Single-Handed General Practice in Urban Areas of Scotland Ying Ying

Single-handed General Practice in urban areas of Scotland Ying Ying Wang MD, MSc Thesis submitted in fulfilment of the requirements for the Degree of Doctor of Philosophy University of Glasgow Department of General Practice and Primary Care Division of Community based Sciences Faculty of Medicine December 2008 Abstract Background Single-handed practice, a traditional model of general practice, has been an important facet of primary care provision since before the establishment of the National Health Service in 1948, but has increasingly been challenged by the growth of large practices. Now less than 10 % of GPs remain single-handed in the UK, concentrated in rural areas and areas of urban deprivation. This gradual decline of single-handed practice has resulted partly from the continued advocacy of partnership by the government, but is also indicative of NHS modernisation itself focusing on the delivery of high quality of care. However, little is known about single-handed GP today, particularly in urban areas, and what impact the most recent policy changes resulting from the implementation of the 2004 General Medical Service contract has had on them. Aim The aim of this thesis is to explore the current position of single-handed practices in urban areas exploring the quality of care delivered and to develop an understanding of how being a single-handed GP affects their practices in today’s NHS. Methods A mixed method methodology was employed. Quantitative analyses of routine datasets described characteristics of single-handed general practitioners and their practice population, and also examined their quality of care in comparison to that of group practices. A set of qualitative interviews were conducted to explore the experiences of a single-handed GP and their views of the future of this type of practice. Results The data presented in this thesis shows that single-handed practice accounted for 12.6% (n=85) of urban Scottish general practices and had over 150,000 registered patients with a high proportion living in areas of socio-economic deprivation. GPs working single- handedly were more likely to be male, older, qualified in South Asia, and had larger personal list size than their counterparts in group practices. Taking account of practice and ii population characteristics, single-handed practices offered comparable quality of care to large practices but tended to refer more patients with coronary heart disease to secondary care and also attained fewer organisational points in the Quality and Outcomes Framework of the new GP contract than larger practices. The data generated from the GPs interviews shed light on such patterns, suggesting that single-handed practices had little benefit from the economies scale possible in larger practices with regards to employing additional practice staff and sharing tasks within practice teams. Single-handed GPs continued practising on their own as they enjoyed the true levels of autonomy regarding clinical and managerial work within their own practices. However, the increasing accountability associated with the new contract in terms of Quality and Outcomes Framework monitoring may be a greater challenge to their freedom than current Government rhetoric about larger practice configurations. Some, however, had begun to find other ways of supporting themselves, such as sharing facilities with other small practices or using colleagues also from small practices to provide cross-cover when required. Conclusion The findings from the quantitative and qualitative work drawn together in this thesis highlighted that there was a significant group of GPs in urban areas who continue to practice single-handedly, whose quality of care was as good as that provided by larger practices when difference in the socio-economic status of practice populations between practices was taken into account. Although no significant association between practice size and CHD outcome measures (mortality, EMAs, prescribing and operation rates) was observed, there was variation in out-patient referral rates that remained unexplained, suggesting that patient-related factors such as their level of morbidity, may be important. Under the new contract, with little advantage in practice organisation, single-handed practices attained comparable clinical performance to group practices in the Quality and Outcomes Framework, though the underlying distribution of quality scores and percentage achievement for individual indicators in relation to practice size needs to be examined further, incorporating data on exception report to understand the full effect of practice size on QOF attainment. Enjoying their personal autonomy within their own practices, many thought they also provided a good quality of care for their patients, particularly in relation to access and continuity, and would remain as single-handers. However, concerns over the increasing accountability largely associated with the new contract in terms of QOF iii requirements may be a greater challenge to single-handed practices than current government rhetoric about larger practice configurations. The findings of this study indicates that the quality of care provided single-handed practice is at least as good as and, possibly better than that of larger practices. This has implications for service delivery in general practices, because it suggests that a policy drive to the development of large units in general practice may not necessarily lead to an improvement in quality of care as it intended. Despite some limitations, the importance of socio- economic deprivation rather than practice size in explaining the observed differences in quality outcomes emphasises the need to address health inequalities in populations, as well as the need to support practices such as single-handed practices working in the areas of deprivation and with ethnic minority populations, and to value their ongoing contribution to the provision of primary care in such areas. iv Table of Contents Abstract ii Table of Contents v List of Tables ix List of Figures x Acknowledgement xi Author’s declaration xii Definitions xiii Chapter 1 Introduction 1 1.1 Background 1 1.2 Outline of the thesis 3 Chapter 2 The development of general practice in the National Health Service (NHS) 5 2.1 Introduction 5 2.2 "Cottage industry" 6 2.3 The implementation of the Family Doctor Charter of 1966 10 2.4 The Imposition of the 1990 contract 13 2.5 An alternative—the Personal Medical Service Contract 17 2.6 Political attention—Dr. Harold Shipman 18 2.7 A new century, a new contract 18 v 2.8 Future vision 19 2.9 Future in the Scottish context 20 2.10 Summary 21 Chapter 3 Single-handed general practice in the UK 22 3.1 Introduction 22 3.2 Definition of single-handed general practice 22 3.3 UK single-handed general practice 25 3.4 Rural single-handed general practice. 31 3.5 Quality of care in general practice 33 3.6 Practice management in general practice 38 3.7 GP as an independent contractor 40 3.8 Summary 43 Chapter 4 Methodology 44 4.1 Introduction 44 4.2 Epistemological assumptions 44 4.3 Combining quantitative and qualitative methods 49 4.4 Quantitative study 54 4.5 Qualitative study 57 4.6 Summary 59 Chapter 5 The characteristics of urban single-handed general practice 61 vi 5.1 Introduction 61 5.2 Data and methods 62 5.3 Results 64 5.4 Discussion 69 5.5 Summary 72 Chapter 6 Coronary heart disease care and practice size 83 6.1 Introduction 83 6.2 Data and methods 90 6.3 Results 93 6.4 Discussion 96 6.5 Summary 102 Chapter 7 General practice under the new GMS contract 113 7.1 Introduction 113 7.2 Data and methods 120 7.3 Results 123 7.4 Discussion 126 7.5 Summary 131 Chapter 8 Urban single-handed GPs in today’s NHS 143 8.1 Introduction 143 vii 8.2 Method 146 8.3 Results 150 8.4 Discussion 182 8.5 Summary 189 Chapter 9 Discussion 193 9.1 Introduction 193 9.2 Summarising the main findings 194 9.3 Methodological issues 211 9.4 Implications of the study 215 9.5 Conclusion 219 Appendices 221 Appendix 1: A description of selected QOF indicators 222 Appendix 2: Published paper 226 Appendix 3: Sample Framework 233 Appendix 4: Ethical Approval Letter 234 Appendix 5: Interview topic guide 235 Appendix 6: Coding Framework 237 Appendix 7: Participant information sheet 239 Appendix 8: Consent form 242 Appendix 9: A sample of thematic charts 243 List of References 256 viii List of Tables Table 5. 1: Scottish Executive Urban Rural Classification (Scottish Executive, 2004). 74 Table 5. 2: Distribution of general practice by practice size in 12 health boards of mainland Scotland. 75 Table 5. 3: Distribution of practices by geographical location. 76 Table 5. 4: Urban practices' practice activities. 78 Table 5. 5: The distribution of urban practices by deprivation quintiles. 79 Table 5. 6: GPs' characteristics by practice size in urban areas. 80 Table 5. 7: Characteristics of practice population by practice size in urban areas. 82 Table 6. 1: Patient characteristics of urban practices by practice size (2002). 105 Table 6. 2: Prevalence of angina per 10,000 practice population of urban practices by practice size (2001/2002). 106 Table 6. 3: CHD death rates and standardised ratios of urban practices by practice size (2001/2002). 107 Table 6. 4: Emergency admission rates (per 10,000) of urban practices by practice size (2001/2002). 108 Table 6. 5: Age-sex standardised emergency admission ratios of urban practices by practice size (2001/2002). 109 Table 6. 6: Out-patient referral rates and standardised ratios of urban practices by practice size (2001/2002). 111 Table 6. 7: Hospital admission rates and standardised ratios of elective angiography and revascularisation of urban practices by practice size (2001/2002). 112 Table 7. 1: Characteristics of practice and population of urban practices by practice size (2003/2004).

Load more