Primary care competition and the effect of new providers on quality of care in England

Abstract

BackgroundHealth system reforms in England have welcomed competition by opening broad areas of clinical practice to new providers of care. As part of these reforms new entrants, including private companies, have been allowed into the primary care market since 2004 under contracting mechanisms known as alternative provider of medical services. The characteristics and performance of general practices working under new alternative provider contracts are not well described. MethodsBetween 2008–09 and 2012–13, we compared performance on 17 established quality indicators that included clinical effectiveness, efficiency, access, and patient experience in all general practices in England by contract type. Data were obtained from the Quality and Outcomes Framework and General Practice Patient Survey. We used linear regression in cross-sectional and time series analyses, adjusting for practice and population characteristics and underlying trends, to compare quality in practices using alternative provider contracts to traditional practices. We created a regression model using practice fixed effects to estimate the effect on performance of practices changing to the new contract type. Findings347 (4·1%) of 8300 general practices in England were run by alternative contract providers. These practices tended to be smaller, and serve younger, more diverse, and more deprived populations than traditional providers. Practices run by alternative providers performed worse than traditional providers on 15 of 17 indicators after adjustment for practice and population characteristics (p<0·001 for all 15), including diabetes and hypertension control, admissions for ambulatory care sensitive conditions, and overall satisfaction with care. Alternative providers had a higher percentage of patients reporting satisfaction with opening hours and higher prescribing of generic medications than did general practices not run by alternative providers. Switching to a new alternative provider contract did not result in improved performance in our fixed-effect models. InterpretationThe introduction of contracts for new alternative providers to deliver primary care services in England has not led to improvements in quality and might have resulted in worse care. Strengths of our study include use of a 5-year national data sample. Limitations include risk of lack of adjustment for unmeasured confounding factors. Regulators should ensure that new entrants to clinical-provider markets are performing to adequate standards and at least as well as traditional providers. FundingThere was no specific funding for this work. FG is funded by London Deanery and the Commonwealth Fund. CM is funded by the Northwest London National Institute for Health Reasearch Collaboration for Leadership in Applied Health Research & Care and the Higher Education Funding Council for England.