The provision of additional services in primary care: a cross-sectional study of incentivised additional services, social deprivation, and ethnic group.

Veline L'Esperance,Peter Schofield,Mark Ashworth

doi:10.3399/bjgpopen20x101141

Abstract

BackgroundPrimary care in England is contracted to provide essential services. Many practices also provide additional services, termed ‘directed enhanced services’ (DES), for extra income. The optional nature of DES may result in inequitable service delivery.AimTo determine the range of DES activity and equity of service provision.Design & settingA cross-sectional analysis of data from general practices in England took place from 2018–2019.MethodDES were defined in terms of activity level and measured as total DES funding per registered patient. Linear regression modelling was used to explore the relationship between DES activity, practice, and population characteristics.ResultsData were available for 6873 practices providing up to 10 DES in the initial sample. Due to negative funding amounts and a list size of ≤750 registered patients, 24 practices were excluded. Of the final sample (n = 6849), highest DES provision was for influenza and pneumococcal immunisation (99.9%), pertussis immunisation (97.9%), rotavirus and shingles immunisation (99.9%), meningitis immunisation (99.7%), and childhood immunisation (99.6%); lowest provision was for extended hours access (72.4%), violent patient services (2.0%), and out-of-area urgent care (1.3%). Mean DES funding was £6.25 per patient. In deprived areas, DES funding was £0.35 lower (95% confidence interval [CI] = £0.60 to £0.10) per patient (most versus least deprived quintiles); ethnic group-related differences were not significant. DES funding was higher in practices with more GPs or practice nurses per patient. In deprived communities, there was less immunisation activity (including influenza, pneumococcal, meningitis, childhood, and rotavirus and shingles immunisation) and provision of extended hours access; however, learning disability checks provision was greater in these communities.ConclusionDES provision is lower in deprived areas (notably for immunisations and some aspects of access) but higher in better staffed practices. Voluntary quality schemes may contribute to widening health inequalities.

Highlights

Of the final sample (n = 6849), highest directed enhanced services (DES) provision was for influenza and pneumococcal immunisation (99.9%), pertussis immunisation (97.9%), rotavirus and shingles immunisation (99.9%), meningitis immunisation (99.7%), and childhood immunisation (99.6%); lowest provision was for extended hours access (72.4%), violent patient services (2.0%), and out-o f-area urgent care (1.3%)
There is a large amount of literature about the Quality and Outcomes Framework (QOF), but very little is published about another primary care performance-related payment, the provision of DES
Since the gradual reduction of QOF funding over the past decade, DES account for a larger proportion of funding than QOF funding

Summary

Introduction

In 2004, the UK government agreed a new contract with GPs that saw the introduction of the Quality and Outcomes Framework (QOF), the world’s largest pay-for-performance system in primary care, viewed as both a vehicle for Childhood vaccination and immunisations 6820 (99.6). Improving the quality of primary care and for allocating additional incentive-based income.[1]. Less widely known is that at the same time, Learning disabilities health checks Minor surgery the contract allocated additional income for the provision of specified additional services in primary care.[2]. Schemes for providing additional primary care services covered services such as immunisations, extended opening hours, minor injury services, and many others.[3] The scheme has evolved and is termed 'directed enhanced services’ (DES), and in 2018–2019 covered 10 services (Table 1).[4]. Many practices provide additional services, termed ‘directed enhanced services’ (DES), for extra income. The optional nature of DES may result in inequitable service delivery

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