'It's what we should be doing anyway': using financial incentives to promote relational continuity in Australian General Practice-a nested case study analysis.

Background: Relational continuity is a fundamental component of primary care. The 'Quality in General Practice Trial' (EQuIP-GP), was a 12-month cluster randomized trial, designed to investigate whether financial incentives can improve relational continuity in primary care.

Aim: To examine (i) how financial incentives are perceived and experienced by primary care patients, providers, and practice staff, and (ii) how clinical and organizational routines related to relational continuity are influenced by the introduction of a financial model designed to incentivize relational continuity.

Design and setting: We used a mixed methods case study approach with six of the intervention arm practices participating in the EQuIP-GP trial.

Method: Semi-structured interviews were conducted with patients, providers, practice staff, and intervention facilitators. Intervention facilitators kept structured diaries to capture reflective notes. To contextualize results, practices completed a modified practice attributes survey and patients completed the Primary Care Assessment Tool at baseline and 12 months.

Results: Patient-perceived relational continuity was not impacted by the intervention. Financial incentives were preferred for rewarding, as opposed to incentivizing, quality care; however, they were perceived as a blunt and inflexible instrument. The introduction of the incentive model increased attention to pre-existing organizational routines rather than creating new ones.

Conclusion: Incentive models should be suitably flexible to accommodate diversity in patient and practice needs. Small changes can be made to existing practice routines that will improve awareness and conscientiousness of relational continuity. Further research should examine how feasible these routine changes would be in practices that do not already focus on continuity.