Primary care supply and quality of care in England

The European Journal of Health Economics, May 2017

We investigated the relationship between primary care supply and quality of care in England. We analysed 35 process measures of quality of care covering 13 medical conditions using English Longitudinal Study of Aging data linked to area of residence indicators. Greater GP density had a statistically significant and positive association with quality of care, and distance to GP practice had a statistically significant and negative association. The effects were concentrated in indicators of care related to cardiovascular diseases and arthritis, and on specific indicators for diabetes, incontinence and hearing problems. The results suggest that better primary care supply can improve quality of care.

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Primary care supply and quality of care in England

Primary care supply and quality of care in England Laura Vallejo-Torres 0 Stephen Morris 0 JEL Classification I 0 I 0 0 Department of Applied Health Research, University College London , Gower Street, London WC1E 6BT , UK We investigated the relationship between primary care supply and quality of care in England. We analysed 35 process measures of quality of care covering 13 medical conditions using English Longitudinal Study of Aging data linked to area of residence indicators. Greater GP density had a statistically significant and positive association with quality of care, and distance to GP practice had a statistically significant and negative association. The effects were concentrated in indicators of care related to cardiovascular diseases and arthritis, and on specific indicators for diabetes, incontinence and hearing problems. The results suggest that better primary care supply can improve quality of care. General practitioner; Health care supply; Quality of care; Multilevel model; Primary care - Introduction In England, as in many countries, primary care plays an important role in managing the health of the population. Individuals register with general practices that provide a range of primary care services involving the diagnosis of ill health, referral to secondary care services, prescribing, direct management of acute illness and long-term conditions, and health & Laura Vallejo-Torres promotion [1]. These services are coming under mounting pressure due to: higher demand caused by an ageing population and larger numbers of patients with comorbidities; tighter budgetary constraints; and the widening role of primary care to meet the health care needs of the population, in terms of a shift from hospital-based to community-based care and a move towards general-practice-led commissioning [2]. In England in 2014 there were 37,000 full-time equivalent (FTE) general practitioners (GPs), 15,000 FTE general practice nurses, and 73,000 FTE other practice staff working in under 8000 general practices in the National Health Service (NHS), with each practice serving a mean population of 7,000 patients [3]. While sizable, it has been argued that the primary care workforce has insufficient capacity to meet the demands placed on it [4], leading to concerns about the quality of care [5]. The aim of this study was to investigate the relationship between the supply of primary care and the quality of that care (QoC). Our hypothesis was that primary care supply has a positive impact on QoC. We expected that increasing primary care supply should improve access to primary care for patients, and increase the number and length of primary care contacts. Increased contacts with patients ought to improve QoC because GPs can better adhere to appropriate standards of care, communicate better with their patients and improve diagnosis, and can broaden the range of services they provide to patients. Also, in the NHS where patients can switch GPs and health care is free at the point of receipt, GPs are expected to compete for patients on the basis of non-price factors such as QoC. However, it may be that increasing primary care supply has no impact on QoC, because GPs are not perfect agents for patients [6]. QoC can be evaluated using structural measures, process measures, or outcomes [7]. Structural data are characteristics of the health care system; process measures describe what is being done to patients; outcomes refer to patient subsequent health status. Primary care supply is a structural measure, and so these are not suitable QoC measures in our study. It has been argued that outcomes are not appropriate measures of QoC in primary care because they depend on all levels of health care (primary, secondary, and tertiary) and because they depend on factors unrelated to health care such as socioeconomic status. Process measures are generally accepted as the most useful indicators of QoC in primary care [8] and we focus on those here. We use 35 individual level process measures of QoC covering 13 medical conditions, which were derived to assess the care received by older people. Self-reported data on these measures were available at the individual level, and collected at repeated points in time over several years, for participants in the English Longitudinal Study of Ageing (ELSA) [9]. They have also been used in other studies to measure QoC [10–12], though none of these has evaluated the impact of primary care supply. Previous research The relationship between primary care supply and QoC has been investigated in other countries [13–15] with some studies showing a statistically significant and positive association and some showing a non-significant association. To our knowledge, the present study is the first English study. Evidence from several studies suggests that greater primary care supply, usually measured in terms of the number of GPs per capita, is positively correlated with better health outcomes [16, 17]. The (...truncated)


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Laura Vallejo-Torres, Stephen Morris. Primary care supply and quality of care in England, The European Journal of Health Economics, 2017, pp. 1-21, DOI: 10.1007/s10198-017-0898-2