Practice list size, workforce composition and performance in English General Practice: A Latent Profile Analysis

Abstract

Background General practices in England have grown in size from traditionally small, General Practitioner (GP) led practices to large multidisciplinary enterprises. We assessed the effect of practice list size and workforce composition on practice performance in clinical outcomes and patient experience. Methods We linked five English practice-level datasets relating to workforce, list size, age, deprivation, rurality, patient experience and Quality and Outcomes Framework (QOF) and non-QOF clinical processes and outcomes. Latent Profile Analysis (LPA) was used to cluster general practices into groups based on list size and workforce composition. Bayesian Information Criterion, Akaike Information Criterion and deliberation within the research team were used to determine the most informative number of groups. One-way ANOVA was used to assess how groups differed on indicator variables and other variables of interest. Linear regression was used to assess the association between practice group and practice performance. Results A total of 6024 practices were available for class assignment. We determined that a 3-class grouping provided the most meaningful interpretation; 4494 (74.6%) were classified as ‘Small GP-reliant practices’, 1400 (23.2%) were labelled ‘Medium-size GP-led practices with a multidisciplinary team (MDT) input’ and 131 (2.2%) practices were named ‘Large multidisciplinary practices’. Small GP-reliant practices outperformed larger multidisciplinary practices on all patient-reported indicators except on confidence and trust where medium-size GP-led practices with MDT input had favourable ratings. There was no difference in performance between small GP-reliant practices and larger multidisciplinary practices on QOF incentivised indicators except on asthma reviews where medium-size GP-led practices with MDT input performed worse than smaller GP-reliant practices and immunisation coverage where the same group performed better than smaller GP-reliant practices. For non-incentivised indicators, larger multidisciplinary practices had higher cancer detection rates than smaller GP-reliant practices. Conclusion Small GP-reliant practices were found to provide better access, continuity, patient experience and satisfaction with care. Larger multidisciplinary practices had higher cancer detection rates but no effect on other clinical processes and outcomes. As England moves towards larger multidisciplinary practices efforts should be made to preserve high-quality patient experience.