Inequalities in primary care: an exploration of the causal pathways linking practice funding, workforce and patient experience

Problem

Socio-economic inequalities exist in general practice across workforce, practice funding and quality of care, including patient experience. There is reason to believe that these three variables are linked; and while there have been studies that have aimed to understand their associations, the mechanisms of action are as yet unknown. The aim of this study is to determine whether GP supply explains part of the mechanism through which practice funding affects patient experience at the level of general practice in England, and if it does, whether the chain of effects is patterned by socio-economic deprivation.

Approach

Publicly available practice-level data for funding, workforce, patient experience and deprivation in England were acquired and linked by practice code. Staff categories GPs, nurses and DPC staff were weighted to adjust for patient need according to the Carr-Hill formula, and plotted against deciles of deprivation. Thereafter, a mediation analysis tested the significance of the mediation of GPs per 10,000 patients on the effect of payments per patient, on patient experience. Non-parametric bootstrapping was used to estimate the average causal mediation effect and confidence intervals. Simple models were built and tested before testing models with added covariates.

Findings

We found that practices in more deprived areas on average have fewer GPs per 10,000 weighted patients than practices in less deprived areas, and that the average practice serving more deprived populations receive less NHS funding per weighted patient than the average practice serving less deprived populations. In addition, GPs statistically significantly (p<0.001) mediate the effect of practice funding on overall patient experience even when adjusting for rurality, sex and age, and deprivation. The mediated effect constitutes on average 30% of the total effect of practice funding on patient experience.

Consequences

This study adds to the growing body of evidence on the relationships between workforce, practice funding and quality of care; and moreover, by exploring the mechanism by which practice funding affects patient experience, the results are informative for policy strategies to reduce inequality of practice funding, patient experience and workforce supply.