Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract

BACKGROUND: The Quality and Outcomes Framework (QOF) of the 2004 UK General Medical Services (GMS) contract links up to 20% of practice income to performance measured against 146 quality indicators. AIM: To examine the distribution of workload and payment in the clinical domains of the QOF, and to compare payment based on true prevalence to the implemented system applying an adjusted prevalence factor. We aimed also to assess the performance of the implemented payment system against its three stated objectives: to reduce variation in payment compared to a system based on true prevalence, to fairly link reward to workload, and finally, to help tackle health inequalities. DESIGN OF STUDY: Retrospective analysis of publicly available QOF data. SETTING: Nine hundred and three GMS general practices in Scotland. METHOD: Comparison of payment under the implemented Adjusted Disease Prevalence Factor, and under an alternative True Disease Prevalence Factor. RESULTS: Variation in total clinical QOF payment per 1000 patients registered is significantly reduced compared to a payment system based on true prevalence. Payment is poorly related to workload in terms of the number of patients on the disease register, with up to 44 fold variation in payment per patient on the disease register for practices delivering the same quality of care. Practices serving deprived populations are systematically penalized under the implemented payment system, compared to one based on true prevalence. CONCLUSIONS: The implemented adjustment for prevalence succeeds in its aim of reducing variation in practice income, but at the cost of making the relationship between workload and reward highly inequitable and perpetuating the inverse care law.     

Practice size: impact on consultation length, workload, and patient assessment of care.

BACKGROUND: Variations in practice list size are known to be associated with changes in a number of markers of primary care. Few studies have addressed the issue of how single-handed and smaller practices compare with larger group practices and what might be the optimal size of a general practice. AIM: To examine variations in markers of the nature of the care being provided by practices of various size. DESIGN OF STUDY: Practice profile questionnaire survey. SETTING: A randomised sample of general practitioners (GPs) and practices from two inner-London areas, stratified according to practice size and patients attending the practice over a two-week period. METHOD: Average consultation length was calculated over 200 consecutive consultations. A patient survey using the General Practice Assessment Survey instrument was undertaken in each practice. A practice workload survey was carried out over a two-week period. These outcome measures were examined in relation to five measures of practice size based on total list size and the number of doctors providing care. RESULTS: Out of 202 pratices approached, 54 provided analysable datasets. The patient survey response rate was 7247/11,000 (66%). Smaller practices had shorter average consultation lengths and reduced practice performance scores compared with larger practices. The number of patients corrected for the number of doctors providing care was an important predictor of consultation length in group practices. Responders from smaller practices reported improved accessibility of care and receptionist performance, better continuity of care compared with larger practices, and no disadvantage in relation to 10 other dimensions of care. Practices with smaller numbers of patients per doctor had longer average consultation lengths than those with larger numbers of patients per doctor. CONCLUSION: Defining the optimal size of practice is a complex decision in which the views of doctors, patients, and health service managers may be at variance. Some markers of practice performance are related to the total number of patients cared for, but the practice size corrected for the number of available doctors gives a different perspective on the issue. An oversimplistic approach that fails to account for the views of patients as well as health professionals is likely to be disadvantageous to service planning.     

Primary care funding, contract status, and outcomes: an observational study

BACKGROUND: The introduction of the Quality and Outcomes Framework (QOF) provides a quantitative way of assessing quality of care in general practice. We explore the achievements of general practice in the first year of the QOF, with specific reference to practice funding and contract status. AIM: To determine the extent to which differences in funding and contract status affect quality in primary care. DESIGN OF STUDY: Cross-sectional observational study using practice data obtained under the Freedom of Information Act 2000. SETTING: One hundred and sixty-four practices from six primary care trusts (PCTs) in England. METHOD: Practice data for all 164 practices were collated for income and contract status. The outcome measure was QOF score for the year 2004-2005. All data were analysed statistically. RESULTS: Contract status has an impact on practice funding, with Employed Medical Services (EMS) and Personal Medical Services (PMS) practices receiving higher levels of funding than General Medical Services (GMS) practices (P<0.001). QOF scores also vary according to contract status. Higher funding levels in EMS practices are associated with lower QOF scores (P=0.04); while GMS practices exhibited the opposite trend, with higher-funded practices achieving better quality scores (P<0.001). CONCLUSION: GMS practices are the most efficient contract status, achieving high quality scores for an average of pound 62.51 per patient per year. By contrast, EMS practices are underperforming, achieving low quality scores for an average of pound 105.37 per patient per year. Funding and contract status are therefore important factors in determining achievement in the QOF.     

The relationship between social deprivation and the quality of primary care: a national survey using indicators from the UK Quality and Outcomes Framework

BACKGROUND: The existence of health inequalities between least and most socially deprived areas is now well established. AIM: To use Quality and Outcomes Framework (QOF) indicators to explore the characteristics of primary care in deprived communities. DESIGN OF STUDY: Two-year study. SETTING: Primary care in England. METHOD: QOF data were obtained for each practice in England in 2004-2005 and 2005-2006 and linked with census derived social deprivation data (Index of Multiple Deprivation scores 2004), national urbanicity scores and a database of practice characteristics. Data were available for 8480 practices in 2004-2005 and 8264 practices in 2005-2006. Comparisons were made between practices in the least and most deprived quintiles. RESULTS: The difference in mean total QOF score between practices in least and most deprived quintiles was 64.5 points in 2004-2005 (mean score, all practices, 959.9) and 30.4 in 2005-2006 (mean, 1012.6). In 2005-2006, the QOF indicators displaying the largest differences between least and most deprived quintiles were: recall of patients not attending appointments for injectable neuroleptics (79 versus 58%, respectively), practices opening > or =45 hours/week (90 versus 74%), practices conducting > or = 12 significant event audits in previous 3 years (93 versus 81%), proportion of epileptics who were seizure free > or = 12 months (77 versus 65%) and proportion of patients taking lithium with serum lithium within therapeutic range (90 versus 78%). Geographical differences were less in group and training practices. CONCLUSIONS: Overall differences between primary care quality indicators in deprived and prosperous communities were small. However, shortfalls in specific indicators, both clinical and non-clinical, suggest that focused interventions could be applied to improve the quality of primary care in deprived areas.     

Chronic disease detection and access: does access improve detection,or does detection make access more difficult?

Background

The recorded detection of chronic disease by practices is generally lower than the prevalence predicted by population surveys.

Aim

To determine whether patient-reported access to general practice predicts the recorded detection rates of chronic diseases in that setting.

Design and setting

A cross-sectional study involving 146 general practices in Leicestershire and Rutland, England.

Method

The numbers of patients recorded as having chronic disease (coronary heart disease, chronic obstructive pulmonary disease, hypertension, diabetes) were obtained from Quality and Outcomes Framework (QOF) practice disease registers for 2008–2009. Characteristics of practice populations (deprivation, age, sex, ethnicity, proportion reporting poor health, practice turnover, list size) and practice performance (achievement of QOF disease indicators, patient experience of being able to consult a doctor within 2 working days and book an appointment >2 days in advance) were included in regression models.

Results

Patient characteristics (deprivation, age, poor health) and practice characteristics (list size, turnover, QOF achievement) were associated with recorded detection of more than one of the chronic diseases. Practices in which patients were more likely to report being able to book appointments had reduced recording rates of chronic disease. Being able to consult a doctor within 2days was not associated with levels of recorded chronic disease.

Conclusion

Practices with high levels of deprivation and older patients have increased rates of recorded chronic disease. As the number of patients recorded with chronic disease increased, the capacity of practices to meet patients'' requests for appointments in advance declined. The capacity of some practices to detect and manage chronic disease may need improving.     

Do the Quality and Outcomes Framework patient experience indicators reward practices that offer improved access?

Background

The Quality and Outcomes Framework (QOF) includes indicators for patient experience, but there has been little research on whether the indicators identify practices that deliver good patient access.

Aim

To determine whether practices that achieved high QOF patient experience points in 2005/2006 or 2006/2007 also delivered good patient access.

Design of study

Use of publicly available data to investigate two hypotheses: practices with more positive access survey findings in 2006/2007 will be more likely to have achieved maximum QOF patient experience points in the same year; and practices with maximum QOF patient experience points in 2005/2006 will have higher access survey findings in 2006/2007.

Setting

Two-hundred and twenty-four East Midlands general practices.

Method

For hypothesis one, binary logistic regression was used, with achievement of maximum QOF points as the dependent variable, and access survey findings, responder variables, and practice variables as independent variables. For hypothesis two, general linear models were used, with access survey findings as the independent variables, and achievement of maximum QOF points and the responder and practice variables as dependent variables.

Results

The findings did not support the first hypothesis. For the second hypothesis, achievement of maximum QOF points was only significantly associated with patient satisfaction with opening hours (positive correlation). QOF points were not associated with any other aspect of access.

Conclusion

The QOF patient experience indicators do not reward practices that offer good patient access. A standard patient survey with financial incentive may be more effective in identifying and rewarding practices that offer better access, including opportunity to book appointments with a particular doctor.     

Patient experience and the role of postgraduate GP training: a cross-sectional analysis of national Patient Survey data in England

Background

Quality indicators for primary care focus predominantly on the public health model and organisational measures. Patient experience is an important dimension of quality. Accreditation for GP training practices requires demonstration of a series of attributes including patient-centred care.

Aim

The national GP Patient Survey (GPPS) was used to determine the characteristics of general practices scoring highly in responses relating to the professional skills and characteristics of doctors. Specifically, to determine whether active participation in postgraduate GP training was associated with more positive experiences of care.

Design and setting

Retrospective cross-sectional study in general practices in England.

Method

Data were obtained from the national QOF dataset for England, 2011/12 (8164 general practices); the GPPS in 2012 (2.7 million questionnaires in England; response rate 36%); general practice and demographic characteristics. Sensitivity analyses included local data validated by practice inspections. Outcome measures: multilevel regression models adjusted for clustering.

Results

GP training practice status (29% of practices) was a significant predictor of positive GPPS responses to all questions in the ‘doctor care’ (n = 6) and ‘overall satisfaction’ (n = 2) domains but not to any of the ‘nurse care’ or ‘out-of-hours’ domain questions. The findings were supported by the sensitivity analyses. Other positive determinants were: smaller practice and individual GP list sizes, more older patients, lower social deprivation and fewer ethnic minority patients.

Conclusion

Based on GPPS responses, doctors in GP training practices appeared to offer more patient-centred care with patients reporting more positively on attributes of doctors such as ‘listening’ or ‘care and concern’.     

A retrospective review of significant events reported in one district in 2004-2005.

BACKGROUND: Patient safety is a key issue in primary care. Significant event analysis (SEA) is a long established method of improving safety. In 2004, SEA was introduced as part of the Quality and Outcomes Framework (QOF) of the new general medical services (GMS) contract. AIM: To review SEAs submitted for the QOF by general practices for a primary care trust (PCT) in 2004-2005. DESIGN OF STUDY: A retrospective review of SEAs. SETTING: St Helens PCT, Merseyside, North West England, UK (185 000 patients), now part of Halton and St Helens PCT. METHOD: Three hundred and thirty-seven QOF-reported SEAs were reviewed from 32 (91%) of a total of 35 St Helens PCT practices (mean 10.5, range 4-17). RESULTS: Practices identified learning points in 89% of SEAs. Twenty-two of 32 (69%) practices successfully performed SEA and required no further support. Four practices identified learning points but needed further facilitation in implementing change or actions arising from SEA. Six practices had significant difficulties with SEA processes and were referred for extra SEA training locally. Ninety (26.7%) of all significant events were classified as patient-safety incidents. Of these, 22 (6.5%) were 'serious or life threatening' and 67 (19.9%) were 'potentially serious'. Ninety-six (28.5%) of the significant events related to medicines management issues; and 63 (18.7%) had key learning points for partnership organisations. Main outcome measures were review of SEA process as a team learning event; QOF significant event criteria; National Patient Safety Agency classification of significant events, and category of patient-safety incidents. CONCLUSION: SEA in general practice is a valuable clinical governance and educational tool with potential patient safety benefits. Most practices performed SEA successfully but there were performance concerns and patient-safety issues were highlighted. This review emphasises the need for primary care organisations to be able to analyse and share SEAs effectively.     

Characteristics of general practices involved in undergraduate medical teaching.

BACKGROUND: The movement of medical education into the community has accelerated the development of a new model of general practice in which core clinical services are complemented by educational and research activities involving the whole primary care team. AIM: To compare quality indicators, workload characteristics, and health authority income of general practices involved in undergraduate medical education in east London with those of other practices in the area and national figures where available. DESIGN OF STUDY: A comprehensive survey of undergraduate and postgraduate clinical placements and practice-based research activity within general practice. SETTING: One-hundred and sixty-one practices based in East London and the City Health Authority (ELCHA). METHOD: Cross-sectional survey comparing routinely-collected information on practice resources, workload, income, and performance between teaching and non-teaching practices. RESULTS: In east London, teaching practices are larger partnerships with smaller list sizes, higher staff costs, and better quality premises than non-teaching practices. Teaching practices demonstrate significantly better performance on quality indicators, such as cervical cytology coverage and prescribing indicators. Patient-related health authority income per whole time equivalent (WTE) general practitioner (GP) is significantly lower among teaching practices. A multiple regression analysis was used to explore the association between teaching status and income. Eighty-eight per cent of the variation in patient-related income could be explained by the combination of list size, list turnover, removals at doctor's request, quality of premises, and immunisation and cytology rates. CONCLUSION: This study demonstrates that practice involvement in undergraduate education in east London is associated with higher scores on a range of organisational and performance quality indicators. The lower patient-related income of teaching practices is associated with smaller list sizes and may only be partially replaced by teaching income. Lower vacancy rates suggest that teaching practices are more attractive to doctors seeking partnerships in east London.     

The reported availability of general practitioners and the influence of practice list size.

BACKGROUND: Combined practice list sizes have increased, but larger practice size may be associated with disadvantage to patients. AIM: The aim of the study was to investigate the availability of general practitioners as reported by their patients and the relationship between reported availability and practice list size. METHOD: A one-week questionnaire survey of 8315 patients attending participating practices in West Lothian, Scotland, was conducted. Patients were asked about the arrangements for being seen at that attendance, their perception of doctor availability following an urgent or non-urgent consultation request, and their social and demographic characteristics. The proportion of respondents reporting they could see a doctor the same day following an urgent consultation request or within 2 days following a non-urgent consultation request was determined for each practice. RESULTS: Eighteen out of 26 practices agreed to participate in the study, and an overall response rate of 61% was obtained in the patient survey. Participating practices were representative of all practices in the area with regard to list size; questionnaire respondents were representative of the age profile of participating practices and were representative of the local general population with regard to car and home ownership. There was a wide variation among practices in the proportion of questionnaire respondents who reported that a doctor was available within 2 days following a non-urgent consultation request [mean 60.7 (SE 7.1%)], but less variation for the reported availability on the same day after an urgent consultation request [mean 81.1 (SE 2.3 %)]. A significant negative association was demonstrated between combined practice list size and reported non-urgent or urgent availability. CONCLUSION: Wide variation exists between practices with regard to patients' perceptions of doctor availability, and smaller practices may have advantages in this regard. The feelings and perceptions of patients should be taken into account when planning or reviewing the delivery of primary health care.     

Primary Medical Care Provider Accreditation (PMCPA): pilot evaluation

Background

While practice-level or team accreditation is not new to primary care in the UK and there are organisational indicators in the Quality and Outcomes Framework (QOF) organisational domain, there is no universal system of accreditation of the quality of organisational aspects of care in the UK.

Aim

To describe the development, content and piloting of version 1 of the Primary Medical Care Provider Accreditation (PMCPA) scheme, which includes 112 separate criteria across six domains: health inequalities and health promotion; provider management; premises, records, equipment, and medicines management; provider teams; learning organisation; and patient experience/involvement, and to present the results from the pilot service evaluation focusing on the achievement of the 30 core criteria and feedback from practice staff.

Design of study

Observational service evaluation using evidence uploaded onto an extranet system in support of 30 core summative pilot PMCPA accreditation criteria.

Setting

Thirty-six nationally representative practices across England, between June and December 2008.

Method

Study population: interviews with GPs, practice managers, nurses and other relevant staff from the participating practices were conducted, audiotaped, transcribed, and analysed using a thematic approach. For each practice, the number of core criteria that had received either a‘good’or‘satisfactory’rating from a RCGP-trained assessment team, was counted and expressed as a percentage.

Results

Thirty-two practices completed the scheme, with nine practices passing 100% of core criteria (range: 27–100%). There were no statistical differences in achievement between practices of different sizes and in different localities. Practice feedback highlighted seven key issues: (1) overall view of PMCPA; (2) the role of accreditation; (3) different motivations for taking part; (4) practice managers dominated the workload associated with implementing the scheme; (5) facilitators for implementation; (6) patient benefit — relevance of PMCPA to quality improvement; (7) recommendations for improving the scheme.

Conclusion

Version 1 of PMCPA has been piloted as a primary care accreditation scheme and shown to be relevant to different types of practice. The scheme is undergoing revision in accordance with the findings from the pilot and ongoing consultation.     

Which factors are associated with higher rates of chronic kidney disease recording in primary care? A cross-sectional survey of GP practices

The prevalence of chronic kidney disease (CKD) at stage 3–5 is estimated at 8.5% in the UK, but the recorded rate of CKD from Quality and Outcomes Framework (QOF) registers in 2007–2008 was 2.9%. This study aimed to identify practice or patient characteristics associated with recorded rates of CKD. Demographic and QOF data for 230 general practices were combined into a database for cross-sectional analysis. Regression analyses investigated factors associated with CKD recording; deprivation, location in Leicester city or Northamptonshire, and low recording of hypertension and stroke were associated with low CKD recording.     

Nurse staffing and quality of care in UK general practice: cross-sectional study using routinely collected data

Background

In many UK general practices, nurses have been used to deliver results against the indicators of the Quality and Outcomes Framework (QOF), a ‘pay for performance’ scheme.

Aim

To determine the association between the level of nurse staffing in general practice and the quality of clinical care as measured by the QOF.

Design of the study

Cross-sectional analysis of routine data.

Setting

English general practice in 2005/2006.

Method

QOF data from 7456 general practices were linked with a database of practice characteristics, nurse staffing data, and census-derived data on population characteristics and measures of population density. Multi-level modelling explored the relationship between QOF performance and the number of patients per full-time equivalent nurse. The outcome measures were achievement of quality of care for eight clinical domains as rated by the QOF, and reported achievement of 10 clinical outcome indicators derived from it.

Results

A high level of nurse staffing (fewer patients per full-time equivalent practice-employed nurse) was significantly associated with better performance in 4/8 clinical domains of the QOF (chronic obstructive pulmonary disease, coronary heart disease, diabetes, and hypertension, P = 0.004 to P<0.001) and in 4/10 clinical outcome indicators (diabetes: glycosylated haemoglobin [HbA_1C] ≤7.4%, HbA_1C ≤10% and total cholesterol ≤193 mg/dl; and stroke: total cholesterol ≤5 mmol/L, P = 0.0057 to P<0.001).

Conclusion

Practices that employ more nurses perform better in a number of clinical domains measured by the QOF. This improved performance includes better intermediate clinical outcomes, suggesting real patient benefit may be associated with using nurses to deliver care to meet QOF targets.     

Does practice size matter? Review of effects on quality of care in primary care

Background

There is a trend towards consolidating smaller primary care practices into larger practices worldwide. However, the effects of practice size on quality of care remain unclear.

Aim

This review aims to systematically appraise the effects of practice size on the quality of care in primary care.

Design and setting

A systematic review and narrative synthesis of studies examining the relationship between practice size and quality of care in primary care.

Method

Quantitative studies that focused on primary care practices or practitioners were identified through PubMed, CINAHL, Embase, Cochrane Library, CRD databases, ProQuest dissertations and theses, conference proceedings, and MedNar databases, as well as the reference lists of included studies. Independent variables were team or list size; outcome variables were measures of clinical processes, clinical outcomes, or patient-reported outcomes. A narrative synthesis of the results was conducted.

Results

The database search yielded 371 articles, of which 34 underwent quality assessment, and 17 articles (13 cross-sectional studies) were included. Ten studies examined the association of practice size and clinical processes, but only five found associations of larger practices with selected process measures such as higher specialist referral rates, better adherence to guidelines, higher mammography rates, and better monitoring of haemoglobin A1c. There were mixed results for cytology and pneumococcal coverage. Only one of two studies on clinical outcomes found an effect of larger practices on lower random haemoglobin A1 value. Of the three studies on patient-reported outcomes, smaller practices were consistently found to be associated with satisfaction with access, but evidence was inconsistent for other patient-reported outcomes evaluated.

Conclusion

There is limited evidence to support an association between practice size and quality of care in primary care.     

The Public Health Impact score: a new measure of public health effectiveness for general practices in England

Background

Health policy in the UK is increasingly focused on the measurement of outcomes rather than structures and processes of health care.

Aim

To develop a measure of the effectiveness of primary care in terms of population health outcomes.

Design and setting

A cross-sectional study of general practices in England.

Method

Twenty clinical quality of care indicators for which there was evidence of mortality reduction were identified from the national Quality and Outcomes Framework (QOF) pay-for-performance scheme. The number of lives saved by 8136 English practices (97.97% of all practices) in 2009/2010 was estimated, based on their performance on these measures, and a public health impact measure, the PHI score, was constructed. Multilevel regression models were used to identify practice and population predictors of PHI scores.

Results

The mean estimated PHI score was 258.9 (standard deviation [SD] = 73.3) lives saved per 100 000 registered patients, per annum. This represents 75.7% of the maximum potential PHI score of 340.9 (SD = 91.8). PHI and QOF scores were weakly correlated (Pearson r = 0.28). The most powerful predictors of PHI score were the prevalence of the relevant clinical conditions (β = 0.77) and the proportion of patients aged ≥65 years (β = 0.22). General practices that were less successful at achieving their maximum potential PHI score were those with a lower prevalence of relevant conditions (β = 0.29), larger list sizes (β = −0.16), greater area deprivation (β = −0.15), and a larger proportion of patients aged ≥65 years (β = −0.13).

Conclusion

The PHI score is a potential alternative metric of practice performance, measuring the estimated mortality reduction in the registered population. Rewards under the QOF pay-for-performance scheme are not closely aligned to the public health impact of practices.     

The impact of NHS Health Checks on the prevalence of disease in general practices: a controlled study

Background

NHS Health Checks is a national case-finding and vascular risk assessment programme in England. No research has been published to assess the impact of NHS Health Checks on the prevalence of chronic disease in GP practices.

Aim

To examine the impact of NHS Health Checks on the prevalence of hypertension, coronary heart disease (CHD), chronic kidney disease (CKD), atrial fibrillation (AF), and diabetes within practices, and compare this with usual medical care.

Design and setting

A non-randomised controlled study in a mixed rural and urban county in England.

Method

Thirty-eight GP practices provided NHS Health Checks over a 3-year period. Forty-one practices that did not provide Health Checks acted as controls. t-tests and multiple linear regression were used to assess the difference in prevalence of disease between intervention group and control group practices, and the impact of NHS Health Checks on this.

Results

Throughout the duration of the study, 1142 previously undiagnosed cases of disease were detected through a total of 16 669 NHS Health Checks. Despite this, there were no significant differences in the change to the prevalence of diabetes, hypertension, CHD, CKD, and AF in practices providing NHS Health Checks compared with control practices. Regression analysis did not demonstrate that there was any significant association between the proportion of the eligible population of a practice having completed NHS Health Checks and changes in the prevalence of the five conditions studied.

Conclusion

In practices providing NHS Health Checks, the change in the reported prevalence of diabetes, hypertension, CHD, CKD, and AF did not differ from that of practices providing usual care.     

What type of general practice do patients prefer? Exploration of practice characteristics influencing patient satisfaction.

BACKGROUND: General practice is currently experiencing a large number of developments. Studies of patient satisfaction are required to guide the changes that many general practitioners are introducing. AIM: A study set out to examine the characteristics of general practices that influence patient satisfaction. METHOD: In 1991-92, a surgery satisfaction questionnaire of demonstrated reliability and validity was administered to 220 patients in each of 89 general practices. A further questionnaire completed by a member of practice staff collected information about practice characteristics including total list size, number, age and sex of practice partners, training status, fundholding status, presence of a practice manager and whether there was a personal list system. Stepwise multiple regression analyses were undertaken to identify those practice characteristics that influenced patient satisfaction. RESULTS: The mean of the response rates of patients completing questionnaires in each practice was 82%. An increasing total list size of patients registered with practices was associated with decreasing levels of general satisfaction and decreased satisfaction with accessibility, availability, continuity of care, medical care and premises. The presence of a personal list system was associated with increased levels of general satisfaction and increased satisfaction with accessibility, availability, continuity of care and medical care. Training practices were associated with decreased levels of general satisfaction and decreased satisfaction with availability and continuity of care. CONCLUSION: The patients of practices in this study preferred smaller practices, non-training practices and practices that had personal list systems. Practice organization should be reviewed in order to ensure that the trend towards larger practices that provide a wider range of services does not lead to a decline in patient satisfaction. General practitioners should have personal list systems and consider the creation of several personal teams within the practice consisting of small numbers of doctors, receptionists and practice nurses.     

Features of primary care associated with variations in process and outcome of care of people with diabetes.

BACKGROUND: There is now clear evidence that tight control of blood glucose and blood pressure significantly lowers the risk of complications in both type I and type II diabetes. Although there is evidence that primary care can be as effective as secondary care in delivering care for people with diabetes, standards in primary care are variable. Previous studies have shown that practice, patient or organisational factors may influence the level of care of patients with diabetes. However, these studies have been conducted in single geographical areas and involved only small numbers of practices. AIM: To determine the standard of diabetes care in general practice and to determine which features of practices are associated with delivering good quality care. DESIGN OF STUDY: A questionnaire survey and analysis of multi-practice audit data. SETTING: Three health authorities in England, comprising 169 general practices. METHOD: This study was conducted with a total population of 1,182,872 patients and 18,642 people with diabetes. Linkage analysis was carried out on data collected by a questionnaire, routinely collected health authority data, and multi-practice audit data collected by primary care audit groups. Practice annual compliance was measured with process and outcome measures of care, including the proportion of patients who had an examination of their fundi, feet, blood pressure, urine, glycated haemoglobin, and the proportion who had a normal glycated haemoglobin. RESULTS: Median compliance with process and outcome measures of care varied widely between practices: fundi were checked for 64.6% of patients (interquartile range [IQR] = 45.3-77.8%), urine was checked for 71.4% (IQR = 49.7-84.3%), feet were checked for 70.4% (IQR = 51.0-84.4%), blood pressure for 83.6% (IQR = 66.7-91.5%), and glycated haemoglobin was checked for 83.0% of patients (IQR = 69.4-92.0%). The glycated haemoglobin was normal in 42.9% of patients (IQR = 33.0-51.2%). In multiple regression analysis, compliance with measures of process of care were significantly associated with smaller practices, fundholding practices, and practices with a recall system. Practices with more socioeconomically deprived patients were associated with lower compliance with most process measures. Practices with a greater proportion of patients attending hospital clinics had lower compliance with process and outcome measures. Being a training practice, having a diabetes mini-clinic, having more nurses, personal care, and general practitioner or nurse interest in diabetes were not associated with compliance of process or outcome of care. CONCLUSIONS: Despite recent evidence that complications of diabetes may be delayed or prevented, this study has highlighted a number of deficiencies in the provision of diabetes care and variations in care between general practices. Provision of high quality diabetes care in the United Kingdom will present an organisational challenge to primary care groups and trusts, especially those in deprived areas.