Ethnic disparities in diabetes management and pay-for-performance in the UK: the Wandsworth Prospective Diabetes Study

PLoS Med. 2007 Jun;4(6):e191. doi: 10.1371/journal.pmed.0040191.


Background: Pay-for-performance rewards health-care providers by paying them more if they succeed in meeting performance targets. A new contract for general practitioners in the United Kingdom represents the most radical shift towards pay-for-performance seen in any health-care system. The contract provides an important opportunity to address disparities in chronic disease management between ethnic and socioeconomic groups. We examined disparities in management of people with diabetes and intermediate clinical outcomes within a multiethnic population in primary care before and after the introduction of the new contract in April 2004.

Methods and findings: We conducted a population-based longitudinal survey, using electronic general practice records, in an ethnically diverse part of southwest London. Outcome measures were prescribing levels and achievement of national treatment targets (HbA1c < or = 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol < or = 5 mmol/l or 193 mg/dl). The proportion of patients reaching treatment targets for HbA1c, BP, and total cholesterol increased significantly after the implementation of the new contract. The extents of these increases were broadly uniform across ethnic groups, with the exception of the black Caribbean patient group, which had a significantly lower improvement in HbA1c (adjusted odds ratio [AOR] 0.75, 95% confidence interval [CI] 0.57-0.97) and BP control (AOR 0.65, 95% CI 0.53-0.81) relative to the white British patient group. Variations in prescribing and achievement of treatment targets between ethnic groups present in 2003 were not attenuated in 2005.

Conclusions: Pay-for-performance incentives have not addressed disparities in the management and control of diabetes between ethnic groups. Quality improvement initiatives must place greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes.

Publication types

  • Comparative Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Africa / ethnology
  • Aged
  • Aged, 80 and over
  • Bangladesh / ethnology
  • Blood Pressure
  • Caribbean Region / ethnology
  • Cholesterol / blood
  • Contracts
  • Diabetes Mellitus / blood
  • Diabetes Mellitus / economics*
  • Diabetes Mellitus / ethnology
  • Diabetes Mellitus / therapy
  • Disease Management*
  • Ethnicity*
  • Family Practice / economics*
  • Family Practice / organization & administration
  • Female
  • Glycated Hemoglobin / analysis
  • Goals
  • Health Policy
  • Humans
  • India / ethnology
  • London
  • Male
  • Medical Records Systems, Computerized / statistics & numerical data
  • Middle Aged
  • National Health Programs / economics*
  • National Health Programs / standards
  • Outcome Assessment, Health Care / economics
  • Outcome Assessment, Health Care / standards*
  • Pakistan / ethnology
  • Physician Incentive Plans / economics*
  • Physicians, Family / economics*
  • Practice Management, Medical / economics*
  • Prejudice*
  • Prospective Studies
  • Quality Indicators, Health Care* / economics
  • Quality Indicators, Health Care* / standards
  • Reimbursement, Incentive* / economics
  • Reimbursement, Incentive* / organization & administration
  • Treatment Outcome
  • United Kingdom / epidemiology


  • Glycated Hemoglobin A
  • Cholesterol