The authors do find, though, that introduction of P4P programmes has brought some other important system benefits, amongst them clarification of the goals of providers, improved purchasing processes, better measurement of provider activity and performance, and more informed dialogue between purchasers and providers. In the English QOF, one of the most established P4P programmes which is voluntarily applied to GPs working for the NHS, a number of studies show high initial improvements in process indicators after introduction with little change since. Furthermore, little impact on health system performance beyond the immediate GP-provided care was seen, for instance lower hospital admission rates - which might be anticipated with improved primary care management - or an impact on mortality, could not be observed (Eijkenaar et al.,