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Does pay for performance affect socioeconomic inequalities in access? Evidence from hospital specialised care in England

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  • Núñez-Elvira, Alberto
  • Feng, Yan
  • Kristensen, Søren Rud
  • Lorgelly, Paula
  • Meacock, Rachel
  • Siciliani, Luigi
  • Sutton, Matt

Abstract

Pay for performance aims to improve quality and efficiency in the health sector but may widen inequalities. We investigate how pay for performance for specialised hospital care in England affected socioeconomic inequalities in access. We focus on two clinical areas: trauma care aimed at reducing delayed discharges from adult critical care; and internal medicine aimed at reducing in-hospital waiting time and length of stay for patients requiring urgent coronary bypass grafting. Both were part of the Prescribed Specialised Services Commissioning for Quality and Innovation. Using patient-level administrative data from Hospital Episodes Statistics in 2012/13–2016/17, we employ difference-in-difference models to estimate the impact of these schemes across socioeconomic status. Our treatment group comprises hospitals that adopted the scheme, and our control group the remaining eligible hospitals. For trauma care, we measure the impact of the scheme on discharge delays and the probability of an overnight discharge. For urgent coronary bypass, we measure pre-surgery inpatient waiting time, length of stay, 30-day and one-year mortality, and hospital-acquired infections. For trauma care we find the scheme widened inequalities by reducing delays that favoured more patients in the least income-deprived quintile (by 2.4 h or 30.4 % at the sample mean) than in the most income-deprived quintile (by 1.3 h). We find no effect or socioeconomic differences across outcomes for patients requiring an urgent coronary bypass.

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  • Núñez-Elvira, Alberto & Feng, Yan & Kristensen, Søren Rud & Lorgelly, Paula & Meacock, Rachel & Siciliani, Luigi & Sutton, Matt, 2026. "Does pay for performance affect socioeconomic inequalities in access? Evidence from hospital specialised care in England," Health Policy, Elsevier, vol. 164(C).
    • Handle: RePEc:eee:hepoli:v:164:y:2026:i:c:s0168851025001216
    DOI: 10.1016/j.healthpol.2025.105365
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    References listed on IDEAS

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    1. Yan Feng & Søren Rud Kristensen & Paula Lorgelly & Rachel Meacock & Alberto Núñez-Elvira & Marina Rodés-Sánchez & Luigi Siciliani & Matt Sutton, 2024. "Pay-for-Performance incentives for specialised services in England: a mixed methods evaluation," The European Journal of Health Economics, Springer;Deutsche Gesellschaft für Gesundheitsökonomie (DGGÖ), vol. 25(5), pages 857-876, July.
    2. Laia Bosque‐Mercader & Neus Carrilero & Anna García‐Altés & Guillem López‐Casasnovas & Luigi Siciliani, 2023. "Socioeconomic inequalities in waiting times for planned and cancer surgery: Evidence from Spain," Health Economics, John Wiley & Sons, Ltd., vol. 32(5), pages 1181-1201, May.
    3. Moscelli, Giuseppe & Siciliani, Luigi & Gutacker, Nils & Cookson, Richard, 2018. "Socioeconomic inequality of access to healthcare: Does choice explain the gradient?," Journal of Health Economics, Elsevier, vol. 57(C), pages 290-314.
    4. Nicolai Fink Simonsen & Anne Sophie Oxholm & Søren Rud Kristensen & Luigi Siciliani, 2020. "What explains differences in waiting times for health care across socioeconomic status?," Health Economics, John Wiley & Sons, Ltd., vol. 29(12), pages 1764-1785, December.
    5. Rachel Meacock & Søren Rud Kristensen & Matt Sutton, 2014. "The Cost‐Effectiveness Of Using Financial Incentives To Improve Provider Quality: A Framework And Application," Health Economics, John Wiley & Sons, Ltd., vol. 23(1), pages 1-13, January.
    6. Feng, Yan & Kristensen, Søren Rud & Lorgelly, Paula & Meacock, Rachel & Sanchez, Marina Rodes & Siciliani, Luigi & Sutton, Matt, 2019. "Pay for performance for specialised care in England: Strengths and weaknesses," Health Policy, Elsevier, vol. 123(11), pages 1036-1041.
    7. Kaarboe, Oddvar & Siciliani, Luigi, 2023. "Contracts for primary and secondary care physicians and equity-efficiency trade-offs," Journal of Health Economics, Elsevier, vol. 87(C).
    8. Miraldo, Marisa & Siciliani, Luigi & Street, Andrew, 2011. "Price adjustment in the hospital sector," Journal of Health Economics, Elsevier, vol. 30(1), pages 112-125, January.
    9. Turner, Alex J & Francetic, Igor & Watkinson, Ruth & Gillibrand, Stephanie & Sutton, Matt, 2022. "Socioeconomic inequality in access to timely and appropriate care in emergency departments," Journal of Health Economics, Elsevier, vol. 85(C).
    10. Milstein, Ricarda & Schreyoegg, Jonas, 2016. "Pay for performance in the inpatient sector: A review of 34 P4P programs in 14 OECD countries," Health Policy, Elsevier, vol. 120(10), pages 1125-1140.
    11. Siciliani, Luigi & Straume, Odd Rune, 2019. "Competition and equity in health care markets," Journal of Health Economics, Elsevier, vol. 64(C), pages 1-14.
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