Single-handed general practice in urban areas of Scotland.
PhD thesis, University of Glasgow.
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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.
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.
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.
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 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.
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 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.
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