{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,27]],"date-time":"2026-10-27T03:14:54Z","timestamp":1793070894750,"version":"4.5.0"},"reference-count":28,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,8,29]],"date-time":"2026-08-29T00:00:00Z","timestamp":1787961600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"},{"start":{"date-parts":[[2026,8,29]],"date-time":"2026-08-29T00:00:00Z","timestamp":1787961600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"funder":[{"name":"NHS Resolution"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["J R Soc Med"],"abstract":"<jats:sec>\n                    <jats:title>Objectives:<\/jats:title>\n                    <jats:p>Avoidable harm and variations in quality have remained persistent features of health systems, but the track record of financial incentives in driving improvement is mixed. Based on an evaluation of NHS Resolution\u2019s Maternity Incentive Scheme (MIS), which focuses on safety of maternity care in English NHS trusts, we identify generalisable principles to inform design of financial incentive schemes in healthcare.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design:<\/jats:title>\n                    <jats:p>Qualitative process evaluation based on interviews with those involved in the design and delivery of MIS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Setting:<\/jats:title>\n                    <jats:p>Organisations involved in running MIS and organisations participating in the scheme.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Participants:<\/jats:title>\n                    <jats:p>Thirty-five individuals were interviewed, including 17 involved in the national-level administration of MIS and 18 with experience of MIS at local level.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Main outcome measures:<\/jats:title>\n                    <jats:p>Not applicable.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results:<\/jats:title>\n                    <jats:p>We identified strengths, weaknesses and unintended consequences of the Scheme from the perspective of participants. MIS was seen by national-level stakeholders as having succeeded in elevating maternity safety in organisations\u2019 priorities and consolidating disparate safety requirements into a unified framework. They saw MIS as a clinically credible and system-owned mechanism for prioritisation. However, local-level participants reported significant administrative burdens, opportunity costs and challenges in interpreting and implementing its requirements. The Scheme\u2019s all-or-nothing reimbursement model, while reinforcing parity across the areas it covered, sometimes led to disproportionate focus on marginal issues and created perverse incentives when full compliance seemed unattainable. We identify seven key lessons for the design of incentive systems that might optimise their impact from the findings.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions:<\/jats:title>\n                    <jats:p>Careful design of incentive schemes is vital to minimise unintended consequences. Lessons from MIS are relevant to broader healthcare system reform efforts and initiatives aiming to harness financial levers for quality improvement, such as those in the 10-Year Health Plan for England.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/01410768261476118","type":"journal-article","created":{"date-parts":[[2026,8,30]],"date-time":"2026-08-30T03:44:06Z","timestamp":1788061446000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":1,"title":["Seven lessons for financial incentivisation schemes in healthcare: a qualitative study of NHS Resolution\u2019s Maternity Incentive Scheme"],"prefix":"10.1177","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-1979-7577","authenticated-orcid":false,"given":"Graham Paul","family":"Martin","sequence":"first","affiliation":[{"name":"University of Cambridge, Cambridge, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gizdem","family":"Akdur","sequence":"additional","affiliation":[{"name":"University of Cambridge, Cambridge, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jane","family":"O\u2019Hara","sequence":"additional","affiliation":[{"name":"University of Cambridge, Cambridge, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5915-0041","authenticated-orcid":false,"given":"Mary","family":"Dixon-Woods","sequence":"additional","affiliation":[{"name":"University of Cambridge, Cambridge, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,8,29]]},"reference":[{"key":"e_1_3_3_2_2","article-title":"Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis","volume":"366","author":"Panagioti M","year":"2019","unstructured":"Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, et al. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ 2019; 366: l4185.","journal-title":"BMJ"},{"key":"e_1_3_3_3_2","doi-asserted-by":"publisher","DOI":"10.1377\/hlthaff.2018.0738"},{"key":"e_1_3_3_4_2","doi-asserted-by":"publisher","DOI":"10.1108\/14777261211230754"},{"key":"e_1_3_3_5_2","volume-title":"Fit for the future: the 10 Year Health Plan for England","author":"Secretary of State for Health and Social Care","year":"2025","unstructured":"Secretary of State for Health and Social Care. Fit for the future: the 10 Year Health Plan for England. London: The Stationery Office, 2025."},{"key":"e_1_3_3_6_2","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.39238.890810.BE"},{"key":"e_1_3_3_7_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1467-9515.2007.00580.x"},{"key":"e_1_3_3_8_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1467-9299.2006.00600.x"},{"key":"e_1_3_3_9_2","doi-asserted-by":"publisher","DOI":"10.1093\/jopart\/mun028"},{"key":"e_1_3_3_10_2","doi-asserted-by":"publisher","DOI":"10.1016\/j.socscimed.2017.12.033"},{"key":"e_1_3_3_11_2","doi-asserted-by":"publisher","DOI":"10.1111\/0033-3352.00075"},{"key":"e_1_3_3_12_2","doi-asserted-by":"publisher","DOI":"10.3399\/bjgp17X693149"},{"key":"e_1_3_3_13_2","article-title":"Pay for performance for hospitals","volume":"7","author":"Mathes T","year":"2019","unstructured":"Mathes T, Pieper D, Morche J, Polus S, Jaschinski T, Eikermann M. Pay for performance for hospitals. Cochrane Database Syst Rev 2019; 7: CD011156.","journal-title":"Cochrane Database Syst Rev"},{"key":"e_1_3_3_14_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1467-985X.2008.00557.x"},{"key":"e_1_3_3_15_2","doi-asserted-by":"publisher","DOI":"10.1111\/j.1445-5994.2012.02766.x"},{"key":"e_1_3_3_16_2","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2013-001947"},{"key":"e_1_3_3_17_2","unstructured":"NHS Resolution. Maternity Incentive Scheme. See https:\/\/resolution.nhs.uk\/services\/claims-management\/clinical-schemes\/clinical-negligence-scheme-for-trusts\/maternity-incentive-scheme\/ (accessed 8 July 2026)."},{"key":"e_1_3_3_18_2","article-title":"The state of care in England\u2019s maternity services","volume":"383","author":"Dixon-Woods M","year":"2023","unstructured":"Dixon-Woods M, Barry Z, McGowan J, Martin G. The state of care in England\u2019s maternity services. BMJ 2023; 383: p2700.","journal-title":"BMJ"},{"key":"e_1_3_3_19_2","volume-title":"Reading the signals: maternity and neonatal services in East Kent \u2013 the Report of the Independent Investigation","author":"Kirkup B.","year":"2022","unstructured":"Kirkup B. Reading the signals: maternity and neonatal services in East Kent \u2013 the Report of the Independent Investigation. London: HMSO, 2022."},{"key":"e_1_3_3_20_2","article-title":"Clinical negligence costs: taking action to safeguard NHS sustainability","volume":"368","author":"Yau CWH","year":"2020","unstructured":"Yau CWH, Leigh B, Liberati E, Punch D, Dixon-Woods M, Draycott T. Clinical negligence costs: taking action to safeguard NHS sustainability. BMJ 2020; 368: m552.","journal-title":"BMJ"},{"key":"e_1_3_3_21_2","volume-title":"Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare","author":"Health Services Safety Investigations Body","year":"2024","unstructured":"Health Services Safety Investigations Body. Recommendations but no action: improving the effectiveness of quality and safety recommendations in healthcare. London: HSSIB, 2024."},{"key":"e_1_3_3_22_2","volume-title":"Maternity Incentive Scheme \u2013 an interim evaluation","author":"NHS Resolution","year":"2020","unstructured":"NHS Resolution. Maternity Incentive Scheme \u2013 an interim evaluation. London: NHS Resolution, 2020."},{"key":"e_1_3_3_23_2","volume-title":"A year in the Maternity Incentive Scheme: 2024\/25 annual report","author":"NHS Resolution","year":"2025","unstructured":"NHS Resolution. A year in the Maternity Incentive Scheme: 2024\/25 annual report. London: NHS Resolution, 2025."},{"key":"e_1_3_3_24_2","doi-asserted-by":"publisher","DOI":"10.1177\/1049732315617444"},{"key":"e_1_3_3_25_2","first-page":"8","article-title":"Sample size and saturation in PhD studies using qualitative interviews","volume":"11","author":"Mason M.","year":"2010","unstructured":"Mason M. Sample size and saturation in PhD studies using qualitative interviews. Forum Qual Soc Res 2010; 11: 8.","journal-title":"Forum Qual Soc Res"},{"key":"e_1_3_3_26_2","first-page":"173","volume-title":"Analyzing qualitative data","author":"Ritchie J","unstructured":"Ritchie J, Spencer L. Qualitative data analysis for applied policy research. In: Bryman A, Burgess RG (eds). Analyzing qualitative data. London: Routledge, 1994: 173\u2013194."},{"key":"e_1_3_3_27_2","first-page":"101","article-title":"Social desirability bias in qualitative health research","volume":"56","author":"Bispo J\u00fanior JP","year":"2022","unstructured":"Bispo J\u00fanior JP. Social desirability bias in qualitative health research. Rev Saude Publica 2022; 56: 101.","journal-title":"Rev Saude Publica"},{"key":"e_1_3_3_28_2","doi-asserted-by":"publisher","DOI":"10.1007\/978-1-137-10541-7_7"},{"key":"e_1_3_3_29_2","volume-title":"Review of patient safety across the health and care landscape","author":"Dash P.","year":"2025","unstructured":"Dash P. Review of patient safety across the health and care landscape. London: Department of Health and Social Care, 2025."}],"container-title":["Journal of the Royal Society of Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/01410768261476118","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/01410768261476118","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/01410768261476118","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T05:46:13Z","timestamp":1788327973000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/01410768261476118"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,29]]},"references-count":28,"alternative-id":["10.1177\/01410768261476118"],"URL":"https:\/\/doi.org\/10.1177\/01410768261476118","relation":{},"ISSN":["0141-0768","1758-1095"],"issn-type":[{"value":"0141-0768","type":"print"},{"value":"1758-1095","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,29]]},"article-number":"01410768261476118"}}