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Evaluations of pay for performance schemes have found limited impacts on processes of care,1 2 3 including improvements in non incentivised aspects of care for targeted patients.4 However, pay for performance schemes have not consistently reduced costs5 6 and are sometimes associated with unintended consequences and detrimental effects on quality of care for non targeted patients.7 8 Even when improvements in processes of care are shown, they are often modest9 10 and lacking in apparent impacts on patient outcomes.11 Although several studies have found associations between the introduction of pay for performance schemes and reduced hospital admissions,12 13 14 complications,15 16 and mortality,17 a recent systematic review concluded that the effect of pay for performance schemes on patient outcomes was largely uncertain.18 Part of the reason for this uncertainty may be that the impact of pay for performance schemes depends on their context and design,19 20 21 22 and this has led to experimentation with new and more innovative types of contract.23 24The implementation of a major pay for performance scheme the Quality and Outcomes Framework in all family practices in England provides a natural experiment to evaluate the impact of pay for performance on hospital admissions for ambulatory care sensitive conditions (ACSCs).

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