Do single-handed and single-partnered practices deliver high-quality personalised care?

Problem

Over the past years, there has been a drive to deliver primary care at scale with an increase in practice mergers. Some practices remain “single-handed”, with a single GP, or “single-partnered”, with a single partner. It is unclear whether these practices deliver high-quality, local and personalised care or have missed opportunities to innovate and benefit from working at scale. This study aims to investigate the quality of service offered by single-handed and single-partnered practices compared to practices with multiple GPs and multiple partners, respectively.

Approach

All practices in England with more than 1000 patients were included. Practices were classified as single-handed or single-partnered if, for the preceding 2.5 years, at 6-month intervals, their workforce data reported one GP/ GP partner respectively. A quality control process was applied to practices whose workforce data listed only one GP to remove anomalies: practices were classified as having multiple GPs if their website listed more than one GP, they operated as a syndicate or they catered to more than 4000 patients. The outcomes were: 1. GP patient survey scores measuring access, continuity, confidence and overall satisfaction; 2. QOF data for diabetes and hypertension outcomes; and 3. ED presentation rates and cancer detection (percentage of new cancers treated resulting from a 2-week wait). Direct comparisons were made between single-handed and multiple-handed GPs and single-partnered and multiple-partnered respectively by three sets of generalised linear models for each outcome: 1. unadjusted; 2. controlling for patient characteristics (age, sex and IMD); and 3. controlling for Carr-Hill weights. Sensitivity analyses were performed, including covariates for patient numbers, number of GPs and rurality.

Findings

Across adjusted and unadjusted models, patients reported improved access and continuity in single-handed and single-partnered practices compared to multiple-handed and multiple-partnered practices, respectively. Patient confidence was lower in unadjusted and Carr-Hill-adjusted models for single-handed practices and in all models for single-partnered practices. Single-handed practices had improved overall patient satisfaction in all models, while unadjusted and Carr-Hill-adjusted models found reduced satisfaction in single-partnered practices. There was no significant difference in hypertension outcomes. All models revealed significantly worse performance in cancer detection and ED presentation rates for single-handed and single-partnered practices and diabetes management in single-handed practices. Sensitivity analyses confirmed these findings.

Consequences

Single-handed practices offer better access, continuity and overall satisfaction but have worse performance in terms of cancer detection, ED presentations and diabetes management. Single-partnered practices also have better access and continuity and worse cancer detection and ED presentations but have better diabetes and hypertension management and worse overall satisfaction. Further work is needed to understand what happens to patient outcomes when practices merge.