Intended for healthcare professionals

CCBYNC Open access

Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study

BMJ 2014; 349 doi: (Published 11 November 2014) Cite this as: BMJ 2014;349:g6423
  1. Mark J Harrison, honorary senior research fellow, and assistant professor123,
  2. Mark Dusheiko, senior research fellow, and assistant professor45,
  3. Matt Sutton, professor1,
  4. Hugh Gravelle, professor2,
  5. Tim Doran, professor7,
  6. Martin Roland, professor6
  1. 1Manchester Centre for Health Economics, Institute of Population Health, University of Manchester, UK
  2. 2Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
  3. 3Centre for Health Evaluation and Outcome Sciences, St Paul’s Hospital, Vancouver, BC, Canada
  4. 4Centre for Health Economics, University of York, York, UK
  5. 5Institute for Health Economics and Management, University of Lausanne, Lausanne, Switzerland
  6. 6Cambridge Centre for Health Services Research, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
  7. 7Department of Health Sciences, University of York, York, UK
  1. Correspondence to: M Roland mr108{at}
  • Accepted 14 October 2014


Objective To estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs).

Design Controlled longitudinal study.

Setting English National Health Service between 1998/99 and 2010/11.

Participants Populations registered with each of 6975 family practices in England.

Main outcome measures Year specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs.

Results Incentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11.

Conclusions The introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities.


  • Contributors: All authors were involved in the study design, analysis and interpretation of the data, and drafting and final approval of the manuscript. They accept full responsibility for the research, had access to the data, and controlled the decision to publish. MR is the guarantor of the study.

  • Funding: This study received no direct funding, but it was initiated at a time when the National Primary Care Research and Development Centre at the University of Manchester was receiving core funding from the UK Department of Health. The views expressed are those of the authors and not necessarily those of the Department of Health. The researchers are totally independent of the funders.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; MR served as an academic advisor to the government and British Medical Association, negotiating teams during the development of the UK pay for performance scheme during 2001 and 2002.

  • Ethical approval: Not required.

  • Data sharing: The statistical code is available on request from MH ( The dataset was derived from hospital episode statistics, access to which requires permission from the Health and Social Care Information Centre.

  • Transparency: The guarantor (MR) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

View Full Text