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

BMJ 2015; 350 doi: (Published 02 March 2015) Cite this as: BMJ 2015;350:h904
  1. Evangelos Kontopantelis, senior research fellow12,
  2. David A Springate, research fellow23,
  3. Mark Ashworth, senior lecturer4,
  4. Roger T Webb, reader5,
  5. Iain E Buchan, professor1,
  6. Tim Doran, professor6
  1. 1Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK
  2. 2NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester
  3. 3Centre for Biostatistics, Institute of Population Health, University of Manchester
  4. 4Primary Care and Public Health Sciences, King’s College London, London, UK
  5. 5Centre for Mental Health and Risk, University of Manchester
  6. 6Department of Health Sciences, University of York, York, UK
  1. Correspondence to: E Kontopantelis e.kontopantelis{at}
  • Accepted 13 January 2015


Objectives To quantify the relationship between a national primary care pay-for-performance programme, the UK’s Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework.

Design Longitudinal spatial study, at the level of the “lower layer super output area” (LSOA).

Setting 32482 LSOAs (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 QOF for at least one year of the study period, including over 99% of patients registered with primary care.

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.

Results 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.

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


  • We thank the Health and Social Care Information Centre and the Office of National Statistics for the wealth of information they have collected and systematically organised, which made this study possible.

  • Contributors: EK and TD designed the study. EK extracted the data from all sources and performed the analyses, while some sensitivity analyses were performed by DAS. EK and TD wrote the manuscript. DAS, MA, RTW, and IEB critically edited the manuscript. EK is guarantor of this work and had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: EK was partly supported by a NIHR School for Primary Care Research fellowship in primary healthcare; TD was supported by a NIHR Career Development Fellowship. The views expressed are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health. No other relationships or activities could appear to have influenced the submitted work.

  • Transparency: EK 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 have been explained.

  • Data sharing: Most of the data used in this study are freely available, and the authors are happy to share an organised and cleaned final dataset, except for the mortality data, which were obtained under a sharing agreement from the Health and Social Care Information Centre.

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