Analysis

 

In this section of the briefing, we report our main findings in order of the four areas of general practice set out in the approaches and methods section. We prefix this with a brief explanation of population need.

Population need

Data from the ONS show that the total population in England has been growing by almost 1% a year, and the number of registered patients has been increasing at a similar rate across all levels of deprivation. As set out in the Appendix, need adjusting patient populations increases the effective population in more deprived neighbourhoods and decreases the effective population in more affluent neighbourhoods. This is because patients in more deprived areas have higher needs, and so each patient is ‘equivalent to’ more than one patient in an affluent area when it comes to GP workload.

Funding

The total amount of money available to practices to invest in staff and equipment to meet this population need is largely determined by the practice’s funding per patient.

Before need adjusting the population, payments per registered patient are very similar for practices serving populations across the deprivation gradient. Once weighted for need (GP workload), we found that in 2018/19 practices serving more deprived populations – who on average have greater need for primary care – received around 7% less funding per weighted registered patient than those serving more affluent patient populations. This is shown in Figure 1.

Figure 1: Trends in GP practice payments per patient by neighbourhood deprivation

Figure 1

Supply

Practice characteristics

In recent years, a view from policymakers that in general practice bigger may be better, more efficient and more sustainable, has driven practices towards agglomeration and mergers., However, our analysis shows that this has not happened equally, and practices serving patients living in the most deprived areas are typically smaller, employing fewer GPs than practices serving less deprived populations (see Figure 2).

Small practices, and particularly single-handed practices (those run by a single GP), are over-represented in the most deprived areas, while large practices are over-represented in the least deprived areas.

Figure 2: Practices run by single GPs by neighbourhood deprivation

Staff numbers

Increasing the number of GPs is seen as an important way to improve the amount and quality of care that can be provided in general practice, and remains a focus of policy. However, our analysis shows that more deprived neighbourhoods have fewer GPs and more practice nurses per patient than less deprived neighbourhoods (see Figure 3).

This means that after accounting for different levels of need, a GP working in a practice serving the most deprived patients will on average be responsible for the care of almost 10% more patients than a GP serving patients in more affluent areas. Conversely, a practice nurse working in a practice serving more deprived patients will on average be responsible for the care of fewer patients than a nurse working in a practice serving more affluent patients (although their workload may be higher due to there being fewer GPs, or because of increased complexity of patient need). This may imply a substitution of nurses for doctors in practices serving more deprived populations, which may or may not be consistent with patient needs. These differences are not narrowing during the period covered by the data examined.

Figure 3: Trends in general practice workforce supply per 100,000 population by neighbourhood deprivation

Trends for administrative staff seem to closely track those for nurses, with proportionately more administrative staff in more deprived areas. This may reflect the typically smaller size of practices in more deprived areas, with each practice – however small – needing an administrative function to be fulfilled. Direct patient care (DPC) staff, such as health care assistants and pharmacists, appear to be concentrated in practices serving more deprived populations, while others such as dispensers (who perform administrative duties, and dispense prescription medication under direction of a pharmacist) are concentrated in the more affluent areas. Taking the overall total clinical general practice workforce (GPs, nurses and DPC) we found that even taking into account differences in skills mix, more deprived populations appear to be underserved as compared to more affluent populations.

Table 1: Workforce full time equivalent per 100,000 need adjusted population in 2018/19

IMD group

GP

Nurse

Admin

Direct Patient Care

Health Care Assistants

Pharmacists

Dispensers

Physio­therapists

Phlebotomists

Physician Associates

Other

Most deprived

45.07

28.81

114.48

16.9

11.98

1.62

0.58

0.04

0.89

0.18

0.76

2

45.78

27.04

106.69

17.57

10.62

1.4

2.52

0.02

1.02

0.18

0.66

3

46.76

26.83

102.68

20.21

10.08

1.28

5.38

0.03

1.2

0.13

0.7

4

47.83

26.62

101.27

19.83

9.89

1.26

5.34

0.04

1.16

0.1

0.62

Least deprived

48.81

25.62

99.18

17.74

9.02

1.09

4.24

0.03

1.09

0.08

0.56

Source: General Practice Workforce data – 31 March 2020

Breaking down the GP workforce further by age and sex (shown in Figure 4), there are a disproportionate number of older GPs, particularly those aged 65 and older, working in the most deprived areas. Younger GPs tend to be working in the most affluent areas. If left unaddressed, this trend risks further exacerbating existing inequalities in GP supply as these older GPs working in areas of high deprivation eventually leave the workforce.

Figure 4: GP supply per 100,000 need adjusted population by neighbourhood deprivation

Access

Access to general practice, and patients’ experience of how they access it, depends not only on the absolute number of staff working in a practice but on how many appointments are available, which varies across practices. Practices also vary in the proportion of different types of appointment offered (the ratio of telephone versus face-to-face consultations, for example), and the duration of those appointments. Since March 2020, GPs in England have changed the ratio of face-to-face and telephone consultations in response to the COVID-19 pandemic. Sufficient data are not yet available to enable us to factor the effects of COVID-19 on consulting patterns into our analysis.

Our analysis of appointment data predating the COVID-19 pandemic shows that there are very similar numbers of appointments overall (per 100 patients), regardless of the level of neighbourhood deprivation. Patients who live in more deprived neighbourhoods are more likely to be seen by a practice nurse (two extra appointments per 100 people) and are less likely to be seen by a GP (one fewer appointments per 100 people) than those who live in more affluent neighbourhoods (see Figure 5). This mirrors the workforce supply figures, which show that more deprived neighbourhoods tend to have more practice nurses and fewer GPs.

Figure 5: Trends in primary care appointments carried out by GPs or other practice staff by neighbourhood deprivation

We know that people in more deprived areas generally experience worse health, and we might therefore expect to observe higher numbers of appointments for people living in more deprived neighbourhoods. The fact we do not may indicate a supply constraint (as the number of appointments is limited by the number of staff available, or the time by practice staff allocated to direct patient care). Alternatively, this may be due to a difference in health-seeking behaviour, with people living in more deprived neighbourhoods being less inclined to visit a GP for any given ailment than those living in more affluent neighbourhoods.

The COVID-19 pandemic has required general practice to shift to a ‘remote by default’ consultation approach. Pre-pandemic, practices serving the most deprived populations were doing more face-to-face consultations per 100 patients per month than practices in more affluent areas (see Figure 6). This is reversed for telephone appointments, which occur at greater frequency per head of population in more affluent areas. It is too early to know whether changes in appointment type made by practices in response to COVID-19 will follow the same patterns as face-to-face and telephone consultations pre-COVID-19.

Figure 6: Trends in face-to-face and telephone appointments by neighbourhood deprivation 

There are higher rates of patients not attending their appointments (‘did not attends’ or DNAs) in more deprived areas, where around 6.5% of appointments are not attended compared to 4.5% in the least deprived quintile.

Quality

In addition to assessing the relationship between population deprivation and the amount of care provided by general practice, we assess the relationship between quality of care and population deprivation. We use three publicly available measures to do so: performance on the QOF, overall CQC practice ratings, and satisfaction scores from the GP patient survey.

The QOF is a voluntary incentive scheme for practices (see Box 1). It awards points, and subsequently payments, to GP practices for performance based on a number of indicators. QOF scores follow deprivation scores linearly (see Figure 7). Practices serving patients in the most deprived areas have the lowest QOF scores and those serving patients living in the most affluent areas achieve the highest QOF scores (five more points on average), and therefore larger payments.

Figure 7: Trends in QOF points by neighbourhood deprivation

Assessments of GP practices by the CQC, which result in a rating from ‘inadequate’ to ‘outstanding’, provide another measure of quality. We found that practices serving patients living in the two most deprived quintiles are more likely to receive CQC ratings of ‘inadequate’ and ‘requires improvement’ than those serving patients who live in the most affluent areas (which are more likely to receive ratings of ‘good’ and ‘outstanding’ – see Figure 8). It is important to note that the vast majority of practices – more than 75% – are rated as good, regardless of deprivation level. Practices rated as good are not represented in Figure 8.

Figure 8: Trends in CQC rating by neighbourhood deprivation

The GP patient survey provides an insight into patients’ experience of general practice. Approximately 2 million questionnaires are sent out every year, with a response rate of around 35% (740,000 responses).

Overall patient satisfaction is high, above 75% in all quintiles. But Figure 9 shows that practices serving patient populations living in the most deprived areas have the lowest overall patient satisfaction scores and that practices serving patients living in the most affluent areas have the highest patient satisfaction scores. Patient satisfaction scores appear to be falling over time (2015/16 – 2018/19) in all areas, and the observed deprivation gradient in patient scoring appears to be consistent over time.

Figure 9: Trends in patient satisfaction score by neighbourhood deprivation

Across all three measures of quality analysed, our analysis suggests that more deprived patient populations seem to receive a lower quality of care.


In 2018/19 the value of a QOF point was £179.26 and the total number of points available was 559.

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