Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study

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The problem

Pay-for-performance programmes have been adopted in healthcare systems around the world and are intended to improve population health by incentivising high quality of care. We aimed to quantify the relationship between a national primary care pay-for-performance programme, the UK's Quality and Outcomes Framework, and all-cause and cause-specific premature mortality linked closely with conditions included in the scheme.

The approach

Design: Longitudinal spatial study, at the Lower Super Output Area level Setting: 32482 Lower-level Super Output Areas (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012. Participants: 8647 English general practices participating in the Quality and Outcomes Framework for at least one year of the study period, including over 99 per cent of registered patients. Intervention: National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators. Main outcome measures: All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality.


All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality.


Higher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not appear to result in reduced incidence of premature death in the population.


  • Evangelos Kontopantelis, NIHR School for Primary Care Research, University of Manchester, Manchester, UK
  • David Springate, NIHR School for Primary Care Research, University of Manchester, Manchester, UK
  • Mark Ashworth, Centre for Mental Health and Risk, University of Manchester, Manchester, UK
  • Roger Webb, Department of Health Sciences, University of York, York, UK
  • Iain Buchan, NIHR School for Primary Care Research, University of Manchester, Manchester, UK
  • Tim Doran