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
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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)