Impact of primary care funding on patient satisfaction: a retrospective longitudinal study of English general practice, 2013–2016

Veline L’Esperance; Hugh Gravelle; Peter Schofield; Mark Ashworth

doi:10.3399/bjgp21X714233

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Figure 1.
Patient experience and practice funding 2013–2014 to 2016–2017. A) Patient experience (% good/very good). B) Practice funding per patient, adjusted for inflation at 2016–2017 prices: total funding, capitation funding, and performance-related funding.
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Figure 2.
Practice funding by patient experience: a comparison of funding between practices with the highest and practices with the lowest achieving positive experience quintiles (‘good/very good’).
^aP<0.001. Bars illustrate differences in funding. Thus, for ‘overall experience’ the highest achieving quintile had a mean of 94% of surveyed patients reporting positive experience; in these practices mean funding was £154.65. The lowest achieving quintile had 68% positive experience; their mean practice funding was £122.75.

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Decisions about the funding of general practice should be informed in part by the relationship between funding and quality. Patient experience is one of three core components of quality in primary care, alongside clinical effectiveness and patient safety. This large-scale longitudinal study of English general practices finds that increases in funding are associated with improvements in reported patient experience of access, continuity of care, and professionalism of practice staff, and with higher overall satisfaction.

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Table 1.

Characteristics of general practices and their registered populations in England

Variable	2013–2014	2014–2015	2015–2016	2016–2017

	Mean (5th, 95th centiles)

Practices, n	7253	7253	7253	7253

Patients aged 0–4 years, %	6.06 (3.68, 9.16)	5.97 (3.64, 8.95)	5.87 (3.59, 87.74)	5.91 (3.52, 8.56)

Patients aged ≥75 years, %	7.63 (2.49, 12.75)	7.67 (2.50, 12.90)	7.68 (2.51, 12.91)	7.66 (2.46, 13.00)

Index of Multiple Deprivation score	9.22 (0.51, 41.89)	9.22 (0.51, 41.84)	9.23 (0.52, 41.57)	9.25 (0.52, 41.67)

Patients with Asian ethnicity, %	4.02 (0.10, 19.66)	4.02 (0.10, 19.65)	4.03 (0.11, 19.53)	4.04 (0.11, 19.62)

Patients with black ethnicity, %	0.05 (0.00, 19.66)	0.05 (0.00, 14.60)	0.04 (0.00, 13.99)	0.04 (0.00, 13.49)

Nursing home residents, %	0.49 (0.00, 1.47)	0.47 (0.00, 1.46)	0.43 (0.00, 1.40)	0.45 (0.00, 1.35)

Annual growth in patient list size, %	1.34 (−3.79, 7.83)	2.15 (−3.03, 9.15)	2.88 (−3.49, 11.45)	2.70 (−3.21, 10.67)

Patients with ≥1 chronic conditions, %	16.30 (9.24, 24.14)	15.85 (8.86, 24.67)	15.33 (8.57, 23.74)	14.93 (8.29, 23.19)

Contract type, %
Alternative Provider Medical Services	1.0	3.0	3.1	3.1
General Medical Services	55.5	56.4	62.7	69.3
Personal Medical Services	43.5	40.6	34.2	27.6

Dispensing practices, %	15.0	14.8	14.8	17.8

Single-handed practices, %	9.3	8.9	6.1	6.5

Training practices, %	26.5	25.6	24.8	24.4

In receipt of Minimum Practice Income Guarantee, %	35.6	37.1	40.4	37.8

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Table 2.

Association of overall patient experience with total funding per patient

	Model 1	Model 2	Model 3	Model 4	Model 5	Model 6
Practices, n	7253	7253	7253	7253	7253	7253

Overall patient experience^{^a,^b}	2.40^c (2.29 to 2.51)	0.93^c (0.77 to 1.08)	0.83^c (0.65 to 1.01)	0.89^c (0.71 to 1.07)	1.46^c (1.27 to 1.65)	0.88^c (0.52 to 1.24)

Models contain:
Year effects	Y	Y	Y	Y	Y	Y
Patient characteristics^d	N	Y	Y	Y	Y	Y
Practice characteristics^e	N	N	Y	Y	Y	Y
Practice effects	Random	Random	Random	Random	Random	Fixed

Years	2013/2014 to 2016/2017 2013/2014 to 2016/2017		2013/2014 to 2016/2017	2014/2015 to 2016/2017	2014/2015 to 2016/2017	2014/2015 to 2016/2017

Funding year	Current	Current	Current	Current	1-year lag	1-year lag

↵a Percentage change associated with 1 SD increase in funding (±95% CI).
↵b Dependent variable: overall patient experience (Q28, Q29). Calculated from the average of the practice percentages of patients reporting the top two positive responses (‘good’ and ‘very good’).
↵c P<0.001.
↵d Social deprivation, proportion of patients aged 0–4 years, proportion of patients aged ≥75 years, proportion of patients of black or Asian ethnicity, proportion of nursing home residents, and practice morbidity.
↵e Contract type, dispensing status, training practice status, and single-handed. NB. All models account for clustering at general practice level. CI = confidence interval. SD = standard deviation.

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Table 3.

Association of patient experience domains with total funding per patient

Patient experience domain^{^a,^b}	Model 3	Model 4	Model 5	Model 6
Practices, n	7253	7253	7253	7253
Access (Q3, Q15, Q18, Q25)	1.06^c (0.89 to 1.23)	0.90^c (0.69 to 1.10)	1.63^c (0.57 to 0.87)	1.18^c (0.89 to 1.47)
Continuity (Q9)^d	0.12 (−0.23 to 0.47)	0.05 (−0.36 to 0.46)	0.98^c (0.58 to 1.39)	0.86^e (0.19 to 1.52)
Professionalism of GP (Q21)	0.48^c (0.35 to 0.61)	0.54^c (0.39 to 0.69)	0.82^c (0.68 to 0.97)	0.47^c (0.22 to 0.71)
Professionalism of nurse (Q23)	0.70^c (0.57 to 0.84)	0.72^c (0.57 to 0.87)	0.91^c (0.76 to 1.05)	0.51^c (0.24 to 0.77)
Professionalism of receptionist (Q4)	0.66^c (0.53 to 0.78)	0.66^c (0.52 to 0.81)	0.86^c (0.71 to 1.00)	0.51^c (0.24 to 0.78)
Overall experience (Q28, Q29)	0.83^c (0.65 to 1.01)	0.89^c (0.71 to 1.07)	1.46^c (1.27 to 1.65)	0.88^c (0.52 to 1.24)
Practice effects	Random	Random	Random	Fixed
Years	2013/2014 to 2016/2017	2014/2015 to 2016/2017	2014/2015 to 2016/2017	2014/2015 to 2016/2017
Funding year	Current	Current	1-year lag	1-year lag

↵a Results show percentage change associated with 1 SD incr ease in funding (±95% CI).
↵b All models contain year effects, patient characteristics, and practice characteristics.
↵c P<0.001.
↵d Continuity model excluded 695 single-handed practices from the analysis. All models account for clustering at general practice level.
↵e P<0.01. CI = confidence interval.
SD = standard deviation.

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Table 4.

Association of overall patient experience with types of funding per patient

Funding variables	Model 3	Model 4	Model 5	Model 6
Practices, n	7137	7137	7137	7137
Capitation funding^{^a,^b}	0.02 (−0.12 to 0.17)	0.003 (−0.17 to 0.17)	0.20^c (0.06 to 0.34)	0.12 (−0.07 to 0.35)
Performance- related funding ^{^a,^b}	0.36^d (0.26 to 0.46)	0.43^d (0.32 to 0.54)	0.39^d (0.26 to 0.51)	0.18^e (0.04 to 0.33)
Operational funding^{^a,^b}	1.10^d (0.89 to 1.30)	1.08^d (0.86 to 1.32)	1.63^d (1.39 to 1.87)	1.10^d (0.53 to 1.67)
Practice effects	Random	Random	Random	Fixed
Years	2013/2014 to 2016/2017	2014/2015 to 2016/2017	2014/2015 to 2016/2017	2014/2015 to 2016/2017
Funding year	Current	Current	1 year lag	1 year lag

↵a Results show percentage change associated with 1 SD increase in funding (±95% CI).
↵b All models contain year effects, patient characteristics, practice characteristics.
↵c P<0.01.
↵d P<0.001.
↵e P<0.05. All models account for clustering at general practice level. CI = confidence interval. SD = standard deviation.

Supplementary Data

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