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Brief analytical summaries or syntheses #15

Do quality improvements in primary care reduce secondary care costs ?


The introduction in 2004 of the Quality and Outcomes Framework (QOF) in general practice in the United Kingdom represents one of the most ambitious efforts to measure and incentivise quality improvements in primary care. The report takes advantage of a database of over 50 million English citizens to determine whether quality and outcomes efforts in general practice have led to improvements in two major outcomes: mortality and the costs of hospital inpatient and outpatient use. The study finds that primary care performance improvements are associated with some modest but measurable improvements in outcomes and costs.


The report seeks to determine whether the levels of QOF attainment in general practice have led to quality improvements in two major indicators: mortality and the costs of hospital inpatient and outpatient care. The NHS faces significant financial challenges over the next few years as demand is expected to increase even as funding remains constant. It is more important than ever to understand how resources are used and where costs can be reduced.

There is a widespread belief and hope among policy-makers that, over the long term, timely intervention, in the form of behavioural change, preventive medicine and disease management, can both reduce demands for healthcare expenditure and improve health outcomes in the form of length and quality of life. However, the current research evidence is equivocal: most such preventive interventions increase costs, and many are not even cost-effective when compared to more conventional clinical interventions. Research suggests that if resources are to be used wisely, there is a need to focus on preventive interventions that are carefully targeted at relevant at-risk groups.

The Quality and Outcomes Framework (QOF) introduced in 2004 seeks to reward general practitioners with a range of incentives (including financial incentives) to introduce preventive interventions into their practice. Considerable effort was made to ensure that these interventions were aligned with best contemporary clinical practice.

Analysis and results

The main finding of this study is that there is an association between achievement of QOF indicators and some measurable reduction in costs for hospital care and mortality outcomes. This association is stronger for some QOF indicators than others and is particularly strong for stroke care. The results demonstrate that QOF attainment in one clinical area could have a positive impact on hospital costs in other clinical areas.

However, these findings should be interpreted cautiously. The higher achievement of QOF scores is associated with, but does not necessarily cause, the reduction in hospital costs.


The Health Foundation intends to continue its work to better understand a complicated but fundamentally important issue for the health service and for policy makers. It hopes to contribute to the debate and enable evidence-based decision-making that will improve the quality of patient care.

Implications and recommendations

This research makes an important contribution to a number of policy initiatives, including the merits of prevention and early intervention. As new models of commissioning services are introduced in the United Kingdom, such new evidence will help determine resource allocation at a national level.

The study did not seek to evaluate the QOF initiative, or to offer estimates of the cost-effectiveness of QOF interventions. Rather, it gives an indication of the extent to which the initiative may have affected hospital costs or mortality outcomes. In both respects, the QOF appears to be associated with material but limited gains. The authors caution against drawing inferences of causality from the work, but feel that the results do offer solid grounds for believing that QOF improvements are contributing to the gains. The stroke score dominates the models, ostensibly because it is an indicator of overall primary care quality. It is highly correlated with overall QOF attainment. However, its dominance, and the role it plays in the model of circulatory disease costs, suggests that the stroke quality metrics are capturing specific aspects of preventive care that do have a measurable impact on outcomes.


Do quality improvements in primary care reduce secondary care costs?

Gouvernement du Québec
© Gouvernement du Québec, 2018