Relationship between general practice capitation funding and the quality of primary care in England: a cross-sectional, 3-year study

The performance of general practice in the English National Health Service (NHS): an analysis using Starfield's framework for primary care

General practice in the English National Health Service (NHS) is in crisis. In response, politicians are proposing fundamental reform to the way general practice is organized. But ideas for reform are contested, and there are conflicting interpretations of the problems to be addressed. We use Barbara Starfield's "4Cs" framework for high-performing primary care to provide an overall assessment of the current role and performance of general practice in England. We first assessed theoretical alignment between Starfield's framework and the role of general practice in England. We then assessed actual performance using publicly available national data and targeted literature searches. We found close theoretical alignment between Starfield's framework and the model of NHS general practice in England. But, in practice, its model of universal comprehensive care risks being undermined by worsening and inequitable access, while continuity of care is declining. Underlying causes of current challenges in general practice in England appear more closely linked to under-resourcing than the fundamental design of the system. General practice in England must evolve, but wholesale re-organization is likely to damage and distract. Instead, policymakers should focus on adequately resourcing general practice while supporting general practice teams to improve the quality and coordination of local services.

Does workforce explain the relationship between funding and patient experience? A mediation analysis of primary care data in England

OBJECTIVES

To determine whether general practitioner (GP) workforce contributes to the link between practice funding and patient experience. Specifically, to determine whether increased practice funding is associated with better patient experience, and to what degree an increase in workforce accounts for this relationship.

SETTING

Primary care practice level analysis of workforce, funding and patient experience of all NHS practices in England.

PRIMARY AND SECONDARY OUTCOME MEASURES

The link between NHS-provided funding to general practice (payments per patient) and patient experience, as per the General Practice Patient Survey, was evaluated. Subsequently, mediation analysis, adjusted for covariates, was used to scrutinise the extent to which GP workforce accounts for this relationship (measured as the number of GPs per 10 000 patients).

PARTICIPANTS

We included all general practices in England for which there was relevant data for each primary variable. Atypical practices were excluded, such as those with a patient list size of 0 or where the workforce variable was recorded as being more than 3 SD from the mean. After exclusion, 6139 practices were included in the final analysis.

RESULTS

We found that workforce (GPs per 10 000 population) significantly (p<0.001) acts as a mediator in the effect of practice funding on overall patient experience even after adjusting for rurality, sex and age, and deprivation. On average, the mediated effect constitutes 30% of the total effect of practice funding on patient experience.

CONCLUSIONS

The increase in the number of doctors in primary care in England appears to be a mechanism through which augmented practice funding could positively impact patient experience. Policy initiatives targeting improved patient experience should prioritise considerations related to workforce and practice funding.

Review of literature for ethnic minority-led GP practices: impact and experience of CQC regulation

Background/aim

The Care Quality Commissions’ (CQC) recent report into the impact and experience of CQC regulation for ethnic minority-led general practitioner (GP) practices found that ethnic minority-led practices are disproportionately situated in areas of deprivation, working single-handedly and without adequate systems of support. These challenges are not always accounted for in CQC’s processes or methodology (CQC, 2022).

This study summarises a review of literature carried out as part of research by the CQC, which was published in January 2022.

Methods

Search terms included ‘GP’, ‘CQC’, ‘Black and Ethnic Minority GPs’ combined with Boolean operators. Grey literature was reviewed, and searches were undertaken of known authors in the field. Backwards and forwards reference harvesting was performed on identified literature. Limitations included the capacity and subjectivity of the reviewer, as well as the availability of studies with a focus on ethnic minority GPs as opposed to doctors whose place of primary medical qualification was outside of the UK.

Results

20 evidence sources were identified and included. The literature review found that many ethnic minority-led GP practices are in complex cycle of inequality, which starts with recruitment and thereafter followed by deprivation, isolation, poor funding and low morale. The symptom of these factors is often poor regulatory outcomes and ratings. When these poor ratings are received, GP providers often struggle to recruit, which serves to perpetuate the cycle of inequality.

Conclusion

When CQC rates an ethnic minority-led practice as requires improvement or inadequate, this can perpetuate a cycle of inequality.

Policy Analysis for Prevention and Control of Influenza in Aged Care

OBJECTIVE

This study aimed to analyze national influenza infection control policy documents within aged care settings by identifying the consistencies, inconsistencies, and gaps with the current evidence and by evaluating methodological quality. Aged care providers can use these findings to identify their policy documents' strengths and weaknesses.

DESIGN

A quality and content analysis of national level policy documents.

SETTING AND PARTICIPANTS

Aged care settings rely on national agencies' policy recommendations to control and prevent outbreaks. There is limited research on the effectiveness of control measures to prevent and treat influenza within aged care settings. Because of the complexities around aged care governance, the primary responsibility in developing a comprehensive facility-level, infection-prevention policy, falls to the providers.

METHODS

The analysis was conducted using the (1) International Appraisal of Guidelines, Research and Evaluation assessment tool, containing 23 items across 6 domains; and the (2) Influenza Related Control Measures in Aged Care settings checklist, developed by the authors, with 82 recommendations covering: medical interventions, nonmedical interventions, and physical layout.

RESULTS

There were 19 documents from 9 different high-income countries, with a moderately high methodological quality in general. The quality assessment's average score was 40.2% (95% CI 31.9%-44.7%). "Stakeholder involvement" ranked third, and "Editorial independence" and "Rigor of development" had the lowest average scores across all domains. The content analysis' average score was 37.2% (95% CI 10.5%-21.5%). The highest scoring document (59.1%) included term definitions, cited evidence for recommendations, and clear measurable instructions. "Physical Layout" had the least coverage and averaged 21.9% (95% CI 4.2%-37.5%), which shows a substantial gap in built environment recommendations.

CONCLUSIONS AND IMPLICATIONS

Existing policy documents vary in their comprehensiveness. The higher scoring documents provide an ideal model for providers. The checklist tools can be used to assess and enhance documents. Further research on document end-user evaluation would be useful, as there is room for improvement in methodological quality and coverage of recommendation coverage, especially related to physical layout.

Indonesian General Practitioners' Experience of Practicing in Primary Care under the Implementation of Universal Health Coverage Scheme (JKN)

INTRODUCTION

The Indonesian government has been implementing Jaminan Kesehatan Nasional (JKN) as the national universal coverage scheme to help Indonesian citizens affording medical care since 2014. However, after a few years of its implementation, a very limited study has been conducted to explore general practitioners' (GPs) views and experiences of practicing in primary care under JKN implementation.

METHODS

The study applied semi-structured interviews with GPs from January to February 2016, guided by a phenomenology approach in Yogyakarta province, Indonesia. The GPs were recruited using a maximum variation sample design. The interviews were recorded and transcribed, and the data were analyzed thematically.

RESULT

A total of 19 GPs were interviewed. Three major themes emerged, namely: powerlessness, clinical resources, and administration. Transition to the JKN system has improved patient access to primary care without significant economic barrier, however, GP participants experienced a sense of powerless practice during JKN implementation. They also commented on limited clinical resources and claimed that JKN administration was complicated and burdened their practice.

CONCLUSION

This study identifies various perspectives from GPs practicing in primary care under JKN implementation. The JKN improves access to primary care practice, but there are limited supports for GPs to practice optimally and maintain their relationships with patients. Extensive improvements are needed to upgrade the GP practice in primary care.

The Impact of COVID-19 on the Performance of Primary Health Care Service Providers in a Capitation Payment System: A Case Study from Poland

In Poland, as in many other countries, the use of capitation payment schemes in primary health care is popular. Despite this popularity, the subject literature discusses its role in decreasing the quality of primary medical services. This problem is particularly important during COVID-19, when medical entities provide telehealth services to patients. The objective of the study is to examine the effects of COVID-19 pandemic on the performance of the primary health care providers in Poland under a capitation payment scheme. In this study the authors use data from interviews with personnel of medical entities and financial and administrative reports of primary health care providers in order to identify how this crisis situation impacts the performance of primary health care entities, under capitation payment system. The performance indicators include both the financial and quality measures. Selected to the case study primary health care service providers significantly improved their profitability due to considerable costs savings and reduction of services provided to patients in a time of COVID-19 pandemic. Capitation payment system proved to be inefficient, in the studied pandemic period, in terms of the services provided by primary health care service providers to patients and the funds paid to them, in exchange, by the government entities.

Impact of primary care funding on patient satisfaction: a retrospective longitudinal study of English general practice, 2013-2016

BACKGROUND

Providing high-quality clinical care and good patient experience are priorities for most healthcare systems.

AIM

To understand the relationship between general practice funding and patient-reported experience.

DESIGN AND SETTING

Retrospective longitudinal study of English general practice-level data for the financial years 2013-2014 to 2016-2017.

METHOD

Data for all general practices in England from the General and Personal Medical Services database were linked to patient experience data from the GP Patient Survey (GPPS). Panel data multivariate regression was used to estimate the impact of general practice funding (current or lagged 1 year) per patient on GPPS-reported patient experience of access, continuity of care, professionalism, and overall satisfaction. Confounding was controlled for by practice, demographic, and GPPS responder characteristics, and for year effects.

RESULTS

Inflation-adjusted mean total annual funding per patient was £133.66 (standard deviation [SD] = £39.46). In all models, higher funding was associated with better patient experience. In the model with lagged funding and practice fixed effects (model 6), a 1 SD increase in funding was associated with increases in scores in the domains of access (1.18%; 95% confidence interval [CI] = 0.89 to 1.47), continuity (0.86%; 95% CI = 0.19 to 1.52), professionalism of GP (0.47%; 95% CI = 0.22 to 0.71), professionalism of nurse (0.51%; 95% CI = 0.24 to 0.77), professionalism of receptionist (0.51%; 95% CI = 0.24 to 0.78), and in overall satisfaction (0.88%; 95% CI = 0.52 to 1.24).

CONCLUSION

Better-funded general practices were more likely to have higher reported patient experience ratings across a wide range of domains.

The provision of additional services in primary care: a cross-sectional study of incentivised additional services, social deprivation, and ethnic group

Background

Primary care in England is contracted to provide essential services. Many practices also provide additional services, termed ‘directed enhanced services’ (DES), for extra income. The optional nature of DES may result in inequitable service delivery.

Aim

To determine the range of DES activity and equity of service provision.

Design & setting

A cross-sectional analysis of data from general practices in England took place from 2018–2019.

Method

DES were defined in terms of activity level and measured as total DES funding per registered patient. Linear regression modelling was used to explore the relationship between DES activity, practice, and population characteristics.

Results

Data were available for 6873 practices providing up to 10 DES in the initial sample. Due to negative funding amounts and a list size of ≤750 registered patients, 24 practices were excluded. Of the final sample (n = 6849), highest DES provision was for influenza and pneumococcal immunisation (99.9%), pertussis immunisation (97.9%), rotavirus and shingles immunisation (99.9%), meningitis immunisation (99.7%), and childhood immunisation (99.6%); lowest provision was for extended hours access (72.4%), violent patient services (2.0%), and out-of-area urgent care (1.3%). Mean DES funding was £6.25 per patient. In deprived areas, DES funding was £0.35 lower (95% confidence interval [CI] = £0.60 to £0.10) per patient (most versus least deprived quintiles); ethnic group-related differences were not significant. DES funding was higher in practices with more GPs or practice nurses per patient. In deprived communities, there was less immunisation activity (including influenza, pneumococcal, meningitis, childhood, and rotavirus and shingles immunisation) and provision of extended hours access; however, learning disability checks provision was greater in these communities.

Conclusion

DES provision is lower in deprived areas (notably for immunisations and some aspects of access) but higher in better staffed practices. Voluntary quality schemes may contribute to widening health inequalities.