In Portugal, for instance, P4P was introduced to newly created primary care models. P4P was not introduced as an additional component to an existing payment model, but rather was part of a broader organisational change to primary care, and a shift from facility-level payment based on salaries to mixed payment including salary, capitation and P4P. This holds also true for Ontario, Canada where the P4P schemes introduced for primary care physicians were been tied closely to organisational changes, notably requirements that physicians work in group models, and that after-hours care be provided. In Norway there was broad involvement of key stakeholders, while in Portugal the initiative started as a pilot in 2005 where the Family Medicine Association and Medical Trade Unions were involved from the beginning as part of a broader primary' care reform and improvement efforts before being scaled up.