This article describes four international examples of how contract and payment innovation and the use of incentives have been used to change and improve general practice services. The examples are purposively selected to illustrate contrasting approaches and to include changes led by health insurance companies and national government. Case studies were identified through a literature review described in the Appendix at the end of this article.
A note on terminology. The term ‘general practitioners’ (GPs) for first point of contact doctors working in community settings is used in England and in two of the international examples in this article – the Netherlands (example 1) and Norway (example 2). The term ‘primary care physicians’ is used in the United States (example 3) and ‘family medicine doctors’ is used in Estonia (example 4). For simplicity, the term ‘general practitioners’ or GPs is used throughout this article.
Example 1: Bundled payments for chronic disease management in the Netherlands
Contract between insurance companies and large operational support organisations (called ‘care groups’) in the Netherlands
Policy underlying the introduction of the contract
National policy to improve the quality of chronic disease management in general practice and promote integrated pathways for complex patients between GPs and specialists.
Contract holders
Netherlands health insurance companies and large organisations called ‘care groups’.
Care groups were formed by groups of general practices serving 80,000–100,000 patients, specifically to hold these contracts and to support practices to deliver bundled chronic disease services. Care groups hold legal and financial responsibility for delivering chronic disease care specified in the contract (diabetes, chronic obstructive pulmonary disease [COPD] and vascular disease). The price for the bundle of services is negotiated between insurers and care groups; fees for subcontracted care providers are similarly freely negotiated and the care group carries full financial risk for overspends against the contract.
Contract requirements or aims
Bundled payments are for care delivered according to standards set in national guidelines for diabetes, COPD and vascular disease. When the bundled payments were introduced, there was an expectation they would improve quality and that integrated pathways linking GP and specialist elements of care would reduce the overall health service cost of the three conditions.
Embedded financial mechanisms or incentives
GPs are paid via care groups in return for delivering specified chronic disease management activities. The contract is designed to incentivise care groups to support GPs practices – and other providers – to meet contract requirements and care groups provide operational and organisational development support to practices to ensure they can fulfil the contract.
Service delivery arrangements
Care groups subcontract the majority of diabetes, COPD and vascular disease services from member GP practices, and from selected other clinicians such as podiatrists and dieticians. They can also provide services themselves.
Support for implementation
- Collaborative relationships have been built between insurers and most care groups, with insurers providing data and guidance to support contract implementation.
- Phased payments for step-wise developments towards agreed service changes allow practices to progress at a manageable pace.
- Some insurers invest money and other resources into care groups to improve their capacity to support individual practices.
Contract monitoring
Contracts are monitored using data returns from general practice computers.
Evaluation of impact
An evaluation one year after bundled payments were launched reported that:
- Nearly all stakeholders thought care had improved due to care groups organising and standardising processes.
- Training improved for care provision and electronic medical record use.
- Attendance at multidisciplinary team meetings improved, as did compliance with protocols.
- Care transparency improved, allowing care groups to spot areas where improvement was needed and to address these issues.
- The price paid per care bundle varied significantly between insurers.
- There were no significant changes at year 1 in clinical outcomes or use of services.
A further economic evaluation reported on the impact of bundled payments on overall costs of care five years after they were introduced.
- Over five years, costs increased for patients included in bundled payments, with higher increases in those with multimorbidity because the cost of care bundles exceeded lower hospital costs.
- There were improvements in care processes and intermediate outcomes over the five years of the evaluation.
- Care givers thought their relationship with the care group was distorted by their market power, and described GP conflicts of interest due to owning the care group and providing care. Some thought that patients lost choice, because practices worked with preferred providers of other services (such as dieticians).
Resources
Relevance to a new GP contract in England
The Netherlands’ chronic disease contract illustrates the role that a large-scale GP organisation can play in supporting individual practices to implement changes required by a novel contract. Anticipating limited skills and capacity in small practices to design and implement fundamental changes in chronic disease management, insurers saw the potential for larger organisations – owned by the GPs themselves – to support the necessary service developments. The contract can include staged payments for step-wise implementation of new models of chronic disease management, allowing practices to develop from different starting points, with care groups supporting them to change at a pace they can accommodate. 1
NHS general practices are currently required to transform care in many ways:
- improving access arrangements (NHS England, 2023)
- introducing digital services (NHS England, 2021)
- developing multi-professional team working.
At a time of significant workload pressures in practices, contracting through an organisation that has the scale and capacity to support contract implementation in individual practices offers an option for providing management support for contract-driven transformational change.
English practices are also required to work at scale through primary care networks (PCNs), building links with other local providers, and over time, to form integrated neighbourhood teams (Fuller, 2022). Two early evaluations of PCNs, by Smith and others (2022) and Checkland and others (2023), highlight their limited management and leadership capacity. And experience from the NHS Vanguard programme – which could be seen as a forerunner of integrated neighbourhood teams – also highlights the extensive organisational development and change management support needed for such changes (Midlands and Lancashire Commissioning Support Group and Strategy Unit, 2016). Care groups have emerged in the Netherlands to provide this kind of support, including:
- employing, training and allocating staff
- collecting and analysing data and providing IT support
- service redesign and operational management support.
Over the years since bundled payments were launched, care groups have evolved in various ways. The majority remain focused on supporting delivery of the chronic care contract in practices, but a small number – such as in Deventer and Drenthe – have grown into substantial organisations providing operational support to practices, delivering a range of clinical services and providing training and education to GPs and other primary care staff. These care groups have similarities with the PCN alliances and general practice federations that have emerged in England in recent years, raising questions about whether contracting some aspects of general practice care through large-scale support organisations similar to care groups in the Netherlands could help to facilitate new models of care in general practice in England.
Example 2: Fee-for-service payment reform in Norway
Revised blended payments in the GP contract to incentivise GP productivity
Policy underlying the introduction of the contract
An initial pilot scheme in 1993–97 aimed to improve GP recruitment and retention after declining GP numbers in municipality salaried GP roles. This led to a new ‘GP scheme’ in 2001, which enabled GPs to work as independent contractors paid through a blend of capitation, fee for service and co-payments.
Contract holders
Contracts are between municipalities and individual GPs.
Between 82% (Norwegian Institute of Public Health, 2023) and 90% (Kraft and others, 2024) of GPs work as independent contractors. The rest are directly employed by municipalities.
The Health Economics Administration (Helfo) administrates and reimburses fee-for-service (FFS) payments.
Contract requirements or aims
The work of GPs is specified and regulated through the terms of the Municipal Regular GP scheme (Government of Norway, 2000), which shapes the obligations of each GP to their registered patients. If GPs work in a group practice with a shared list, there is a shared responsibility to all patients but a requirement for each patient to be linked to a named GP.
Embedded financial mechanisms or incentives
There are three funding streams: capitation payments by municipalities (approximately 30% of total income); fixed payments towards the cost of care by patients (called co-payments); and FFS payments from a list administrated by Helfo for 220 specified activities (Kraft and others, 2024).
An early evaluation in four pilot sites of GPs gaining 50% of income through capitation found it encouraged long patient lists and was unfair for GPs with many complex patients, so the per-capita element of income was reduced from 50% to 30%, topped up by patient co-payments and FFS payments for specified activities. The latter was intended as an incentive to increase activity.
Support for implementation
No specific support was provided for setting up clinics under the new contract.
Contract monitoring
The national GP registries hold extensive data about GP consultations, quality measures and outcomes, while Helfo has comprehensive data on clinical activity and investigations, which are used to generate FFS payments.
Evaluation of impact
An economic evaluation compared activity levels by locum GPs who worked in both FFS and salaried clinics, reporting 26% more consultations in FFS clinics, with a 6.5% increase in services provided as measured through recorded costs of GP consultations. FFS GPs had longer consultations, ordered more tests, did more follow-ups and issued more sick certificates but referred less. Based on lower Accident & Emergency (A&E) attendance, the evaluation concluded that these savings outweighed the higher cost per consultation. However, a qualitative study examined GP views about the impact of FFS on their clinical judgements and behaviours. They explained that FFS payments may be a disincentive for withholding antibiotics and person-centred care since these require longer consultations to explain and discuss with patients, which lengthens consultation time.
Resources
Relevance to a new GP contract in England
A review of incentives for general practice in England started in January 2024. What can be learned from Norway’s experience of changing the mix of incentives in the GP contract and increasing the use of FFS payments? An economic evaluation reported an increase in overall GP activity and tests undertaken in practices and reduced use of hospital services (Brekke and others, 2018). But qualitative research on the new mix of payments showed that these gains came at the cost of more transactional consultations. Doctors receiving FFS incentives were thought by research participants to focus more on income-generating activities and tests and to spend less time on the time-consuming conversations with complex patients needed to personalise care and explore treatment options (Norwegian Institute of Public Health, 2023).
Financial incentives are well established in the English GP contract for specific evidence-based quality improvement activities (Quality and Outcomes Framework [QOF]) and for specific activities such as immunisations, but have not been used to stimulate a general increase in consultations (that is, payments for activity which is not targeted at specific conditions).
The new GP contract framework in England will have to achieve a range of goals from both individual practices and PCNs. This may include contracting for access hubs serving groups of practices or whole PCNs. Much of this kind of acute clinical work is transactional, with the possibility that FFS payments could incentivise activity and efficiency. But safeguards would be needed to avoid perverse effects, such as:
- encouraging treatment of minor self-limiting illness
- discouraging continuity
- reducing the length of consultations for patients with complex illnesses and mental health problems.
A review of incentives for general practice in England started in January 2024. What can be learned from Norway’s experience of changing the mix of incentives in the GP contract and increasing the use of FFS payments? An economic evaluation reported an increase in overall GP activity and tests undertaken in practices and reduced use of hospital services (Brekke and others, 2018). But qualitative research on the new mix of payments showed that these gains came at the cost of more transactional consultations. Doctors receiving FFS incentives were thought by research participants to focus more on income-generating activities and tests and to spend less time on the time-consuming conversations with complex patients needed to personalise care and explore treatment options (Norwegian Institute of Public Health, 2023).
Financial incentives are well established in the English GP contract for specific evidence-based quality improvement activities (Quality and Outcomes Framework [QOF]) and for specific activities such as immunisations, but have not been used to stimulate a general increase in consultations (that is, payments for activity which is not targeted at specific conditions).
The new GP contract framework in England will have to achieve a range of goals from both individual practices and PCNs. This may include contracting for access hubs serving groups of practices or whole PCNs. Much of this kind of acute clinical work is transactional, with the possibility that FFS payments could incentivise activity and efficiency. But safeguards would be needed to avoid perverse effects, such as:
- encouraging treatment of minor self-limiting illness
- discouraging continuity
- reducing the length of consultations for patients with complex illnesses and mental health problems.
Example 3: Targeted micro-incentives for quality and cost containment, with data and implementation support in Massachusetts, US
The Massachusetts Blue Cross Blue Shield Alternative Quality Contract (AQC)
Policy underlying the introduction of the contract
Cost containment by incentivising primary care providers to use fewer hospital services while also improving quality of care. The Alternative Quality Contract (AQC) was introduced in 2009 as a five-year contract in recognition of the time needed to change services enough to achieve cost reductions.
Contract holders
This was an optional contract between Blue Cross Blue Shield of Massachusetts (BCBS) (a health insurance company) and selected primary care orientated health management organisations that chose to sign up to the AQC.
Contract requirements or aims
The contract established a global budget for each AQC provider based on historical health care cost expenditure levels, to cover all services and costs. The contract model included inpatient, outpatient, pharmacy, mental health and other costs. It required a set of changes in activity involving improvements in care for a specified cluster of high-prevalence conditions and a reduction in spend on other health services.
The cornerstones of the AQC were: the financial structure of the incentives linked to evidence-based performance measures; a ‘sustained partnership’ between primary care doctors and insurers through a five-year contract term; savings opportunities for payers and providers; and incentives to support integration across the continuum of care.
Embedded financial mechanisms or incentives
Incentive payments were linked to improvements in 64 agreed measures and to a share of any savings on overall spend (gain sharing). The gain share was adjusted in response to performance on both cost and quality, with a lower share of savings transferred to GPs achieving limited quality improvement and lower quality improvement payments if overall costs increased.
There were five performance target ‘gates’ triggering a proportion of the incentive payment, designed to motivate improvement in the early and middle part of the continuum of care, with less emphasis on getting to the final gates than on the set-up stages (The Commonwealth Fund, no date).
Support for implementation
BCBS recognised that the contract required improved care processes, changes in doctors’ referral behaviours and systems for data collection and analysis. It provided a sustained partnership with contracted providers to support contract implementation. This included: medical management support with regular input from analysts, senior managers and the BCBS leadership team for performance improvement; provision of quarterly financial reports; data on performance measures drawn from national data bases that were evidence based and clinically important; regular data on areas of special interest for change; training in data analysis; support for patient communications; training support and the sharing of best practice; and integration across the continuum of care to support lower referrals to other services.
Contract monitoring
BCBS claims data were used to track overall spend, with quality measured through a mixture of national datasets, claims data and clinical data compiled by providers. In addition, some locally devised ‘developmental measures’ were tested.
Evaluation findings
A time-series comparison of the AQC and other providers reported that at the end of year 1 there was: a modest slowing of spending growth due to changed referral patterns towards lower-cost providers; lower-cost diagnostics; and reduced spend on high-risk patients. Overall referrals were not lower. Quality scores improved for chronic disease management and paediatrics but not for prevention. At year, 1 bonus payments to GPs under the terms of the AQC exceeded savings.
The time-series evaluation continued for eight years, reporting that by year 4, reductions in spending growth exceeded the cost of the programme’s incentive payments and were due to both referral to lower-cost providers and reductions in referral rates. Savings were higher in patients who had been enrolled under the AQC for longer. Quality measures remained comparable to non-AQC practices so the cost reductions were not associated with lower quality of care.
Resources
Relevance to a new GP contract in England
The AQC was introduced at a time of major change in the funding and organisation of US health care, so the association between the contract and changes in costs reported in a long-term evaluation may not be causal. And the different organisational and financial contexts of the US health system limit the generalisability of research findings on cost reduction. However, the contract illustrates the detailed and ongoing negotiation between insurers, providers and other experts needed to develop a contract with complex aims. And the evaluation highlights the length of time and sustained support needed until financial savings outweighed the costs of the initiative. BCBS’s recognition that a long-term partnership, including data and operational delivery support, was essential for success is an important transferrable lesson for England.
The AQC illustrates a novel approach to using blended financial incentives to achieve complex changes in primary care. It has some similarities in its aims to the introduction of GP fundholding in England in the 1990s but with a more sophisticated and supportive relationship between insurers and providers. The AQC also illustrates how incentives could be used to encourage changes in GP referral behaviours while also promoting quality.
It is also useful to note that the AQC was optional. It was entirely up to providers if they wanted to introduce the phased service transformation required by the contract – using the support offered by BCBS – or whether to stick with business as usual. Although only a handful of providers signed up in early years, by 2019 around 80% of doctors and hospitals in the BCBS Massachusetts network were enrolled in the contract. A similar approach in England would require a step change in the support offered by commissioners for contract implementation, but could potentially allow GP providers with an interest in innovation and service improvement to take on a voluntary contract for specified activities and outcomes with linked financial incentives.
Example 4: Estates development as a stimulus for a group practice contract in Estonia
Contract to incentivise the formation of group practice and multi-professional teams
Policy underlying the introduction of the contract
In 2014, Estonia was eligible for European Union (EU) capital funding for infrastructure development, which overlapped with the focus in the National Primary Health Care Development Plan 2009–15 on multidisciplinary team working (Habicht and others, 2023). The Estonian Ministry of Social Affairs linked the development of purpose-built health centres with its strategic goal of incentivising the formation of larger group practices delivering services through a skill-mixed team led by GPs.
Contract holders
The Estonian Health Insurance Fund (EHIF) and GPs working in health centres funded with EU structural funds.
The contract was intended to be with GP groups, but low uptake of the contract meant it was modified to allow single-handed GPs to move into health centres or become affiliate members of a GP group and continue to work independently of other GPs in the health centre.
Contract requirements or aims
- Group practice with at least three GPs (modified to allow groups of independent GPs to work in the same building).
- Multi-professional team working, including three to four nurses, a midwife, a physiotherapist and home nurses (equivalent to district nurses).
- Extended opening hours (10 hours a day rather than eight hours in non-group practices).
- Registered patient list: 5,000–6,000 patients in urban areas and 3,000–4,500 patients in rural areas for group practices (Habicht and others, 2023).
Embedded financial mechanisms or incentives
Bundled payments including FFS payments to midwives and physiotherapists and some FFS items in GP care.
Quality incentives element linked to selected quality measures.
Support for implementation
The group contract included funding for a practice manager and receptionists in recognition of the management and administrative demands of running a larger organisation. The EHIF also offered mentoring to senior GPs considering taking up the group contract and, after signing the contract, to advise contract-holders how to set up a larger clinic.
Contract monitoring
Data from national datasets are monitored on a range of quality measures and a quality bonus is paid.
Resources for monitoring contract implementation are limited, and there is variable compliance with requirements to establish multidisciplinary teams and extend opening hours.
Evaluation findings
By October 2022 there were 60 primary health care centres housing 340 GPs and 43% of the country’s registered patients. Doctors’ concerns over losing professional autonomy limited transfer to group contracts (so rules were changed to allow co-location of small practices in a health centre and ‘affiliate’ arrangements offering management support to single-handed doctors in return for a minimum of four hours a week working in a group).
Revised funding arrangements have allowed new professional roles in group practices, introducing mental health workers, psychologists and speech therapists.
Resources
Relevance to a new GP contract in England
The Estonian group practice contract, which emerged in response to EU infrastructure funding, demonstrates how premises development can be used as a lever for change in the organisation and delivery of GP services. It has driven the formation of larger practices and multi-professional team working, with around 60% of Estonian GPs now participating in group contracts. And it illustrates step-wise modification of the contract in response to various factors affecting its acceptability. For example, GP concerns about loss of professional autonomy and control over their clinical practice left many unwilling to join GP groups, so the contract was modified to allow individual GPs to work within health centres, with the EHIF acting as a ‘steward’ to encourage collaboration between them (Habicht and others, 2023). The contract has also been revised to allow a wider range of additional staff to join the group, including mental health workers and speech therapists, and has drawn a cadre of younger salaried GPs into group practices who are less interested in owning their own practice, and keen to avoid management responsibilities.
There were also concerns about loss of access to GPs in rural areas, so rural GPs are able to become affiliate members of group practices if they work a minimum of four hours a week in the main clinic. Affiliate practices are supported to improve services while also maintaining rural access, which increases uptake of the group contract – it now covers 44% of the population – but does not fully implement the policy goal of large-scale, multi-professional group practice.
England also has experience of linking premises development to service innovation. Darzi centres added high-quality buildings to the general practice estate, with linked policy aims of improving access and increasing service provision in deprived areas (Fisher and others, 2022). The Darzi centres housed innovative models of extended-access GP clinics and a range of community services co-located with general practice. However, the initiative proved to be expensive and duplicated services provided in traditional practices so many of the extended-access services associated with the new buildings were closed (Davies, 2010) In contrast to England’s Darzi centre initiative, the Estonian group practice contract focuses on a multi-professional model of general practice with increased access through extended hours, rather than through stand-alone access hubs.
With plans in progress to develop neighbourhood health services in England, the Estonian group practice contract offers insights about using premises development to ‘unfreeze’ established ways of working, including GP partners as affiliate participants and working with younger doctors, less committed to the partnership model (Watson, 2019), in new ways.
Appendix: Literature search methods
An initial literature review using the search terms presented below from 1947 to the present identified 656 results, of which over 200 related to the Chinese family doctor contract between individual patients and individual GPs. A repeat search excluding Chinese articles and limited to articles from 2000 onwards in English identified 175 papers on contracting for general practice or equivalent (family doctor, primary care doctor or family medicine services).
Abstracts were reviewed to identify papers that described contracting initiatives or initiatives to pay for GP services in new ways, identifying reports from 10 countries including England. A second search to identify evaluations of each of these initiatives found evaluations of eight of them. Four were excluded (France – a public health initiative; Sweden – an evaluation of patient choice of provider; Bangladesh – an evaluation of public–private partnerships; and one international comparative study, which did not clearly describe the contracting initiative in each country under investigation). The Estonian group contract was identified through a library search for a different project and added to the review as a contrasting contracting initiative.
Google translate was used to convert evaluations into English where necessary.
Search terms
1 (“general practice” or “family medicine” or “family practice” or “primary care*” or “primary health care*” or “physician*” or “family physician*” or “general practitioner*” or “gp*” or “care group*”).ti. (151142)
2 *General Practice/ (12601)
3 *Primary Health Care/ (55564)
4 *Family Practice/ (42851)
5 *Practice Management, Medical/ (8044)
6 *Physicians, Family/ (11630)
7 *General Practitioners/ (8817)
8 1 or 2 or 3 or 4 or 5 or 6 or 7 (202746)
9 *contracts/ (1726)
10 *contract services/ (5847)
11 (contract or contracts).ti. (6245)
12 9 or 10 or 11 (11508)
13 *Quality of Health Care/ (39506)
14 *Quality Improvement/ (16416)
15 *Models, Organizational/ (6497)
16 *Program Evaluation/ (11502)
17 *Qualitative Research/ (3482)
18 *organizational innovation/ (5425)
19 (quality* or evaluat* or effective* or implement* or best practice* or good practice* or example* or research or
innovat* or improve* or deliver* or support* or objective*).ti. (2162761)
20 13 or 14 or 15 or 16 or 17 or 18 or 19 (2202679)
21 8 and 12 and 20 (87)
22 *Reimbursement, Incentive/ or *Reimbursement Mechanisms/ (10076)
23 8 and 12 and 22 (21)
24 *Practice Patterns, Physicians’/ or *Physician Incentive Plans/ (42580)
25 12 and 24 (74)
26 ((general practice* or primary care* or primary healthcare* or general practitioner* or family physician* or
physician* or “care group*” or family practice* or family medicine* or gp* or “general practitioner*”) adj5 (incentive*
or pay* or fee*) adj5 contract*).ti,ab. (85)
27 ((general practice* or primary care* or primary healthcare* or general practitioner* or family physician* or
physician* or “care group*” or family practice* or family medicine* or gp* or “general practitioner*”) adj5 innovat*
adj5 contract*).ti,ab. (3)
28 21 or 23 or 25 or 26 or 27 (257)
29 limit 28 to yr=“2000–Current” (175)
Suggested citation
Rosen R (2025) 'What can we learn from international examples of contracting for general practice services?', in The evolution of GP contracting: learning from history and other countries. Article series, Nuffield Trust