An evaluation of a multifaceted, local Quality Improvement Framework for long-term conditions in UK primary care

BACKGROUND: The evidence that large pay-for-performance schemes improve the health of populations is mixed—evidence regarding locally implemented schemes is limited. OBJECTIVE: This study evaluates the effects in Stoke-on-Trent of a local, multifaceted Quality Improvement Framework including pay for performance in general practice introduced in 2009 in the context of the national Quality and Outcomes Framework that operated from 2004. METHODS: We compared age-standardized mortality data from all 326 local authorities in England with the rates in Stoke-on-Trent using Difference-in-Differences, estimating a fixed-effects linear regression model with an interaction effect. RESULTS: In addition to the existing downward trend in cardiovascular deaths, we find an additional annual reduction of 36 deaths compared with the national mean for coronary heart disease and 13 deaths per 100000 from stroke in Stoke-on-Trent. Compared with the national mean, there was an additional reduction of 9 deaths per 100000 people per annum for coronary heart disease and 14 deaths per 100000 people per annum for stroke following the introduction of the 2009 Stoke-on-Trent Quality Improvement Framework. CONCLUSION: There are concerns about the unintended consequences of large pay-for-performance schemes in health care, but in a population with a high prevalence of disease, they may at least initially be beneficial. This study also provides evidence that a local, additional scheme may further improve the health of populations. Such schemes, whether national or local, require periodic review to evaluate the balance of their benefits and risks.