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Background: Pay-for-performance policies aim to improve population health by incentivising improvements in quality of care. Aims: To assess the relationship between general practice performance on severe mental illness (SMI) and depression indicators under a national incentivisation scheme and suicide risk in England for the period 2006–2014. Method: Longitudinal spatial analysis for 32 844 small-area geographical units (lower super output areas, LSOAs), using population-structure adjusted numbers of suicide as the outcome variable. Negative binomial models were fitted to investigate the relationship between spatially estimated recorded quality of care and suicide risk at the LSOA level. Incidence rate ratios (IRRs) were adjusted for deprivation, social fragmentation, prevalence of depression and SMI as well as other 2011 Census variables. Results: No association was found between practice performance on the mental health indicators and suicide incidence in practice localities (IRR=1.000, 95% CI 0.998–1.002). IRRs indicated elevated suicide risks linked with area-level social fragmentation (1.030; 95% CI 1.027–1.034), deprivation (1.013, 95% CI 1.012–1.014) and rurality (1.059, 95% CI 1.027–1.092). Conclusions: Primary care has an important role to play in suicide prevention, but we did not observe a link between practices' higher reported quality of care on incentivised mental health activities and lower suicide rates in the local population. It is likely that effective suicide prevention needs a more concerted, multiagency approach. Better training in suicide prevention for general practitioners is also essential. These findings pertain to the UK but have relevance to other countries considering similar programmes.

More information Original publication




Journal article


British Journal of Psychiatry


Cambridge University Press

Publication Date




Total pages



Christos Grigoroglou: SPCR PhD studentship


Mental health; suicide; quality and outcomes framework; financial incentivisation; pay-for-performance.