http://bmj.com/cgi/content/full/323/7308/320
BMJ 2001;323:320-323 ( 11 August )
Primary care
Do single handed practices offer poorer care? Cross sectional survey of
processes and outcomes
Julia Hippisley-Cox
a Division of General Practice, University of Nottingham, Nottingham
NG7 2RD, b Department of General Practice and Primary Health
Care, University of Leicester, Leicester General Hospital, Leicester LE5 4PW
Correspondence to: J Hippisley-Cox julia.hippisley-cox@nottingham.ac.uk
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Abstract |
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Objectives: To determine whether there are important differences
in performance between group practices and singlehanded general
practitioners and the extent to which any differences are explained
by practice characteristics such as deprivation.
Design: Cross sectional survey.
Setting: 206 singlehanded practices and 606 partnerships in
Trent region, United Kingdom.
Method: Comparison of process and outcome measures derived
from routinely collected data on hospital admissions and target
payments for singlehanded practices and partnerships. Multivariate analysis
was used to adjust for the confounding effects of general practice
characteristics
deprivation
(Townsend score), percentage of Asian residents, percentage of black
residents, proportion of men over 75 years, proportion of women
over 75 years, rurality, presence of a female general
practitioner, and vocational training status.
Results: Differences in achievement of immunisation and
cytology targets apparent on univariate analysis were not seen after
adjustment for other general practice characteristics. Similarly,
significant differences (>15%; P<0.01) for three types of
hospital admission seen on univariate analysis were not present after
adjustment for other practice characteristics.
Conclusions: This study provides no evidence that singlehanded general
practitioners are underperforming clinically. Our results offer
insight into the structural difference between the two types of
practice and underline the importance of the effect of other practice
characteristics on process and outcome measures.
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What is already known on this topic Patients like singlehanded practices because of good
communication, personal rapport, availability, and continuity of care Concerns have been expressed about professional isolation
and quality standards for singlehanded practice, on the basis of little evidence
What this study adds The results offer insight into the structural differences
between the two types of practice and underline the importance of other
practice characteristics such as deprivation |
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Introduction |
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Ten per cent of all general practitioners are single handed. Patients like
singlehanded practices because of good communication, personal
rapport, and availability and for the continuity of care they
provide.1-3
Small practices are seen by their patients to be more accessible,4 are
preferred by patients,5
and achieve higher levels of patient satisfaction.6
Singlehanded doctors are very satisfied with their solo status and
do not wish to join partnerships. 3 7 However,
the NHS Plan will have a particular impact on singlehanded general
practice through either a negotiated change to the "red
book" or a new national personal medical services contract into
which all singlehanded general practitioners will be transferred by
2004.8
The NHS Plan recognises that the vast majority of singlehanded
doctors work hard and are committed to their patients but comments
that they can work in relative clinical isolation without the ready
support from colleagues enjoyed by general practitioners in larger
practices. The changes are intended to reduce professional isolation
and protect quality standards.8
Like the contractual threat to singlehanded practice,9 these
concerns about quality standards are not new. However, there is
limited evidence on which to base them. Singlehanded general practitioners
tend to work in areas of high deprivation and need,9 and
deprivation is known to affect rates of referral,10
emergency admissions, 11 12 night
visits,13
and patient consultations.14
Our aim was to determine whether there are important differences in
performance between group practices and singlehanded general practitioners
and to assess the extent to which these are explained by practice
characteristics such as deprivation.
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Method |
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We obtained approval for the study from the multicentre research ethics
committee and the local research ethics committee. We identified all
206 singlehanded practices and 606 partnerships existing
in Trent region (excluding South Humber) on 1 April 1998. We
obtained data on practice characteristics and population distributions (Körner
age bands) from the NHS Executive, Quarry House, Leeds. We defined
singlehanded general practitioners as general practitioner principals
who were not in partnership with other general practitioner principals.
General practitioner, practice, and population characteristics
We compared the sex distribution and mean age of singlehanded
general practitioners with those of general practitioners in
partnership. We compared the proportion of each type of practice
that were involved in general practitioner training, fundholding,
dispensing, child health surveillance, and providing personal
medical services and the proportion that were members of the Trent
Focus collaborative research network. We compared the Carstairs
rurality score linked to the electoral ward of the general
practitioner surgery postcode for the two types of practice.15 We
examined the age-sex structure of the practice populations and
compared the list size per whole time equivalent general practitioner and
per whole time equivalent nurse. Given the potential confounding effect
of deprivation on admission rates and other performance indicators
and outcome measures, we collected data for the Townsend score
associated with the electoral ward where the main general practitioner
surgery was located. We chose to use Townsend score associated with
electoral ward for our main analysis as it most closely adheres to
the concept of material deprivation.16 We collected
data for the percentage of black people and percentage of Asian
people in the electoral ward associated with the general practitioner's
main surgery.
Assessment of performance and health outcome measures
We selected performance and outcome measures that were relevant to
general practice and measurable with routinely available data. 17 18 We
identified all relevant hospital admissions between 1 April
1993 and 31 March 1997 by searching the NHS hospital admissions
database for Trent region. We were unable to access data for deaths
linked to general practice other than those occurring during
inpatient admissions. We were also unable to access data for
measures of cost effective prescribing. We grouped the indicators and
outcome measures under five published headings. 17 18
Disease prevention and health promotionProportion
of practices that achieved target payments for immunisations, preschool boosters,
and cervical cytology for three successive quarters in 1998-9.
Chronic care managementAdmission
rates for asthma (international classification of diseases code 493; Office of
Population Censuses and Surveys code J45-6), diabetes (250; E10-14),
and epilepsy (345; G40-1).
Avoidable admissionsAdmission
rates for ear, nose, and throat infections (381-2; H66), urinary tract
infections (590, 599.0; N39.0, N15.1, N15.9), and congestive
cardiac failure (428; I50).
Inappropriate surgeryOperation
rates for dilatation and curettage (Q10.3, Q10.8, Q10.9) in women under
40 years; operation rates for grommet surgery (D15.1).
Health outcomesTeenage
pregnancy rates (ages 13-19 years).19
Statistical analysis
We used Poisson regression to estimate rate ratios with 95%
confidence intervals for the admission rates for singlehanded
general practitioners compared with partnerships (Stata Statistical
Software version 5, Stata Corporation, College Station, TX). A
rate ratio greater than one indicates a higher admission rate in
singlehanded practices, and a rate ratio less than one indicates a
lower rate. We included the following variables in the multivariate
Poisson regression analysis: Townsend score, percentage of black
residents, percentage of Asian residents, proportions of men and
women over 75 years, rurality, presence of a female general
practitioner, and vocational training status. For binary outcome
variables (such as whether or not a practice attained higher targets
for immunisation), logistic regression was used to calculate odds
ratios with 95% confidence intervals (SPSS version 10). We used
multiple logistic regression to adjust for Townsend score,
percentages of black and Asian residents, proportions of men and
women over 75 years, rurality, presence of a female general
practitioner, and training status. We decided that a greater than
15% difference in admission rates would be clinically important. We
selected the 0.01 two tailed significance level.
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We conducted retrospective power calculations for two main
variables of interestachievement
of targets and admissions for diabetes. 20 21 These
were chosen because they represent variables over which general
practitioners are most likely to have control.
Target achievementFor
a comparison of proportions between the partnerships and singlehanded practices
with available data, the study has 97% power to detect a relative
difference in proportions of 15% or more at the 0.01 level for
immunisation under the age of 1 year and a 99% power for cytology.
For preschool boosters, the study has 43% power to detect a relative
difference in proportions of 15% at the 0.01 level or 80% power
to detect a relative difference in proportions of 22% at the 0.01 level.
Diabetes admissionsUsing
a mean rate of 38.1 admissions per 10 000 patients over the four
years, with 606 partnerships and 206 singlehanded
practices, the study has an 80% power to detect a difference in
rates of 
15% at the 0.01 two sided significance
level.
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Results |
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On 1 April 1998, 206 (25.4%) of the 812 practices in
Trent region were single handed. Of the 4.9 million patients registered
with practices in Trent, 9.7% were registered with a singlehanded general
practitioner.
General practitioner, practice, and population characteristics
Table 1 shows the
characteristics of the general practitioners, practices, and
populations. Singlehanded general practitioners were on average
eight years older than general practitioners in partnerships.
Partnerships were more likely to train general practitioners and to
offer child health surveillance. Singlehanded general practitioners
had larger list sizes per whole time equivalent general practitioner
than did partnerships. Data for practice nurses were available for
only 68% (413/606) of partnerships and 59% (121/206) of singlehanded
practices as two health authorities were unable to provide these
data. Where data were available, 14% of singlehanded practices did
not have a practice nurse compared with 3% of partnerships (
2=24.3, df=1, P<0.0001). The
age-sex structure of the population registered with singlehanded
practices was similar to that for partnerships (table 1). Singlehanded
practices served more deprived populations.
Assessment of performance and health outcome measures
Disease prevention and health promotionTable
2 shows the
data for meeting contractual targets for immunisations under the age
of 1 year, cytology, and preschool boosters. Data for
immunisations under age 1 were available from all 10 health authorities,
whereas data for preschool boosters and cytology were available from
only eight health authorities. Although there were significant
differences in the proportions of singlehanded practices achieving
higher targets for immunisations under age 1 and cytology
compared with partnerships on univariate analysis, neither of these
differences persisted at the 0.01 significance level after
adjustment for other practice characteristics. Table 3 shows the mean
hospital admission rates per 10 000 population for singlehanded
general practitioners compared with partnerships for the four year
period 1993-7. Table 4
shows the admission rate ratios before and after adjustment for
other practice characteristics.
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Chronic care managementSinglehanded
general practitioners had 23% higher admission rates for both asthma and
epilepsy on univariate analysis, but these were only 8% and 9%
higher once adjustment had been made for other practice
characteristics (table 4). There were no
important differences in admission rates for diabetes on univariate
or multivariate analysis.
Avoidable admissionsThe
admission rates for ear, nose, and throat infections, urinary tract infections,
and congestive cardiac failure were not significantly different on
multivariate analysis (table 4).
Inappropriate surgeryThere
was no important difference in the surgery rates for grommets on univariate or
multivariate analysis (table 3). Singlehanded
practices had 13% higher admissions for dilatation and curettage for
women aged under 40, although this was reduced to 1% and was no
longer significant after adjustment for other practice
characteristics in the multivariate analysis (table 4).
Health outcomesSinglehanded
practices had 19% higher teenage pregnancy rates compared with partnerships on
univariate analysis but only 3% higher rates after adjustment for
other practice characteristics.
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Discussion |
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This study has important limitations. It is based on routinely collected
data on hospital admissions and general practitioners' target
payments. Although we have adjusted for deprivation as a census
derived variable, we were not able to adjust for more subtle
population characteristics (such as smoking habits) or to link these
findings to clinical activity within the practices. We have no data
on the arrangements for covering patient care out of hours. We were
not able to include private referrals as these data are not
collected systematically and are therefore not routinely available.
We had no data from two health authorities for nurse time, preschool
boosters, and cytology. The link between performance indicators,
including those for outcomes, and the clinical activity of
individual doctors or groups of doctors is unclear, so
interpretation must be cautious.22 However,
given the current debate about singlehanded practices arising from
the publication of the NHS Plan,8 these
findings are worth exploring, albeit with caution.
The demographic characteristics of singlehanded practices shown here match expectations.
Singlehanded doctors are on average older than those in partnerships
and more likely to be male. Singlehanded practices are less likely
to be involved in vocational training or child health surveillance,
have higher list sizes per general practitioner, and are less likely
to have a practice nurse. Singlehanded general practitioners work in
more deprived areas of Trent.
At first sight, screening uptake seems to be lower in singlehanded
practices. We recognise that it is harder for small singlehanded practices
to reach immunisation and cytology targets, as it only takes a few
patients to drop out for the overall percentage to drop considerably
when the denominator is small. However, target achievement does not
differ between singlehanded general practitioners and partnerships
once other practice characteristics have been taken into account.
This is despite the change in the remuneration for health promotion
activity in primary care in 1993, which led to fewer payments
for singlehanded general practitioners and those whose surgeries
were located in electoral wards with high deprivation indices.23
We have found no evidence in this study that singlehanded general
practitioners are underperforming clinically. Rather, our results
offer insight into the structural differences between these two
types of practice and underline the importance of the effect of
practice characteristics on process and outcome measures. For
instance, three types of admission met our criteria for an important
difference (a 15% difference in admission rates significant at the
0.01 level) on univariate analysis. However, after adjustment for
deprivation, the percentage of black and Asian residents, the
proportion of patients over 75 years, rurality, the presence of
a female general practitioner, and vocational training status there
were no remaining substantial differences.
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Acknowledgments |
Andy Nicholson and Howard Chapman from NHS
Executive Trent helped with the extraction of the admissions data, and Maura
Bell helped to process the ethical approval.
Contributors: JH-C initiated and designed the study, obtained ethical approval,
undertook the literature search, designed and carried out the data collection
and manipulation, the data analysis, and interpretation of results, and
contributed to drafting the paper. MP contributed to the study design and
interpretation and contributed to drafting the paper. CC contributed to the
data analysis and interpretation. VH contributed to the study design and data
collection. AW contributed to the study design and interpretation. JH-C is the
guarantor for the paper.
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Footnotes |
Funding: None.
Competing interests: None declared.
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(Accepted 24 May 2001)
© BMJ 2001
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