Does Pay-for-Performance improve mental health related patient outcomes? The association between quality of Primary Care and suicides in England

Problem

Pay-for-Performance (P4P) policies target improvements in population health by incentives to improve quality of care. In this study we assess and quantify the relationship between general practice performance on two mental health domains (depression and severe mental health) under a national P4P scheme for Primary Care and suicide mortality in England for the period 2006 – 2014. The purpose of this study is to examine for the first time this relationship and assess whether the quality of services provided in the current setting of Primary Care in England has proved beneficial to suicide prevention.

Approach

We performed a longitudinal spatial analysis, at the lowest available geographical level for England. The study design included 32,844 Lower Super Output Areas (neighbourhoods of 1,500 people on average), covering the entire population of England, from 2006 to 2014. Moreover, we extracted data from 7,624 English general practices participating in the Quality and Outcomes Framework (QOF) for at least one year of the study period, including over 99 percent of the registered population.Our main outcome measure is population-structure adjusted number of suicides in each Lower Super Output Area. Negative binomial models were fit to investigate the relationship between spatially estimated recorded quality of care and suicides. Analyses were adjusted for deprivation, social fragmentation, prevalence of depression and severe mental illness as well as 2011 census variables.

Findings

Suicide mortality increased over the study period. Suicides were associated with greater area social fragmentation (1.053 95% CI [1.047 to 1.059]), greater area deprivation (1.015 95% CI [1.014 to 1.016]), increased prevalence of depression (1.012 95% CI [1.003 to 1.021]) and rural location (1.048 95% CI [1.017 to 1.080]). Age and gender were very strongly associated with suicides, with men aged 40 to 44 having the highest risk (1.864 95%CI[1.774 to 1.959], while the risk decreased for older age groups. No significant relationship was found between practice performance on the mental health indicators of the QOF and suicides in the practice locality.

Consequences

Despite the important role that primary care needs to play in suicide prevention, we could not observe a link between higher reported achievement on mental health-specific activities incentivised in the QOF and the population-structure adjusted number of suicides. Although high QOF performance in the mental health domains may have led to positive changes in other outcomes, our findings suggest that the indicators included in the programme would need to be reconsidered, if one of the overarching aims of incentivisation was suicide prevention. These findings have implications for the design and implementation of other similar programmes around the world, aiming towards suicide prevention.