What are the drivers and population health outcomes associated with persistent high GP turnover in English general practices?
Problem
English primary care is in crisis. Previous work highlighted that some practices have persistent high GP turnover. There is a need to understand whether there are specific factors associated with GP persistent high turnover and whether these practices are associated with poorer outcomes. This study aims to identify predictors of persistent high turnover and associations with emergency hospital attendances and admissions.
Approach
Longitudinal study using GP workforce datasets and GPs-by-general practices data, linked with HES data. We examined population and practice characteristics associated with persistent high turnover between 2007-2019. We also investigated the association between persistent high turnover and emergency hospital activity between 2009-2017. Persistent high GP turnover was defined as GP turnover >10% for at least 3 consecutive years. Relevant characteristics examined for association with persistent high turnover included: practice-area social deprivation, size of the practice, rurality, NHS regions, and the Quality and Outcomes Framework (QOF) prevalence of seven serious conditions (coronary artery disease, diabetes, stroke, hypertension, heart failure, chronic kidney disease, chronic obstructive pulmonary disease). Next, the association between persistent high turnover and relevant outcomes was examined, including: emergency hospital attendances or admissions per 100 people. Logistic regression or linear regression models for panel data with random effects were used.
Findings
An average of 374/7525 (5%) practices were classified as having had persistent high turnover each year during 2007-2019, with a maximum of 688 in 2014. Characteristics associated with higher levels of persistent turnover included practice location deprivation (odds ratio of highest deprivation quintile vs lowest, Odds-Ratio (OR) 1.21; 95% CI: 1.01-1.46), listsize (OR of highest listsize quintile vs lowest 18.6, 95% CI: 15.00-22.99), QOF morbidity burden across serious conditions (OR per one unit increase of 1.03, 95% CI: 1.02-1.04). We also found evidence of regional variation, after controlling for the other covariates, with the highest adjusted rates observed in NHS Cumbria and North East, South Central and West Midlands. Persistent high turnover was associated with higher emergency hospital attendance and admission rates. A practice with persistent high turnover will experience on average 27 A&E attendances and 10 emergency admissions per 100 people compared to 25 and 9 for a practice with the same measured characteristics but no persistent high turnover, respectively.
Consequences
One of the factors associated the experience of high turnover over a number of years is deprivation of the area where the practice is located, highlighting the need for more support for these practices. Persistent high turnover practices are independently linked with poorer outcomes such as higher numbers of emergency hospital attendances and admissions compared to practices without persistent high turnover. These problems affect people’s quality of care and contribute to avoidable health system costs. Strategies and policies are needed to support practices facing challenges with GP turnover.