The UK pay-for-performance programme in primary care: estimation of population mortality reduction

Abstract

Background: General practices in the UK contract with the government to receive additional payments for high-quality primary care. Little is known about the resulting impact on population health.

Aim: To estimate the potential reduction in population mortality from implementation of the pay-for-performance contract in England.

Design of study: Cross-sectional and modelling study.

Setting: Primary care in England.

Method: Twenty-five clinical quality indicators in the contract had controlled trial evidence of mortality benefit. This was combined with condition prevalence, and the differences in performance before and after contract implementation, to estimate the potential mortality reduction per indicator. Improvement was adjusted for pre-existing trends where data were available.

Results: The 2004 contract potentially reduced mortality by 11 lives per 100 000 people (lower-upper estimates 7-16) over 1 year, as performance improved from baseline to the target for full incentive payment. If all eligible patients were treated, over and above the target, 56 (29-81) lives per 100 000 might have been saved. For the 2006 contract, mortality reduction was effectively zero, because new baseline performance for a typical practice had already exceeded the target performance for full payment.

Conclusion: The contract may have delivered substantial health gain, but potential health gain was limited by performance targets for full payment being set lower than typical baseline performance. Information on both baseline performance and population health gain should inform decisions about future selection of indicators for pay-for-performance schemes, and the level of performance at which full payment is triggered.