The characteristics of the practice and the population by type of contract for the period 2012-2013 are presented in Table 2. Practices that used contracts with other medical service providers tended to have smaller lists, more GPs per 1000 patients, and were in more disadvantageous areas than GMS/PMS practices. The population served by other medical service providers was younger and more likely to come from non-white ethnic groups. These findings are relevant to the debate on the increasing provision of services by non-traditional NHS providers, including the private sector. The study used an open cohort of all general practice practices operating in England between 2008/2009 and 2012/2013. We compared the performance of general practice practices by type of contract in each academic year and examined the impact on the quality of a practice as an alternative provider of medical services over time. We compared the performance of alternative medical service providers with those who hold GMS or PMS contracts together, as these two groups represent the traditional model of general medicine and general medicine. This SE is offered by the Commissioner (NHSE) to all contractors of general medical services, personal medical services and alternative medical services. In total, 4.1% (347 out of 8300) of general practice in England were operated by alternative contract providers. These practices tended to be smaller and served younger, more diverse and disadvantaged populations than traditional providers. Alternative supplier practices performed worse than traditional suppliers on 15 of the 17 indicators after adjusting for practice and population characteristics (p < 0.01 overall).
The move to a new alternative supplier contract did not result in any performance improvements. Alternative Medical Services Contracts (APMS) allow NHS England to order primary care services. We excluded from the study practices with fewer than 1000 patients (n = 195) as they often provide specialized services (p.B a sexual health service) or services to specific population groups (e.g.B. homeless patients). The total number of practices included in our study was 8300 (97.7% of the total number of 8495 practices in England at least one year during the study period). The small number of practices using the primary Care Trust Medical Services contract was also excluded from the analysis in the years they had this contract (413 out of 40,262 or 1% of years of practice) – as primary care trusts were abolished in 2013. For 191 practices, complete data on the characteristics of the practice were missing. These practices were excluded from the adjusted analyses. The strengths of our study are that it involves the first use of a national dataset to examine the performance of new primary care providers in England.
In addition, it uses a wide range of comparable performance measures, collected according to strict standards and able to observe trends over a five-year period. The results of our sensitivity analyses were similar to our main analyses, suggesting that our results are robust. However, our study has a number of limitations that mean our results should be interpreted with caution. As with all observational studies, there is always a risk of residual confusion – although our models have been adapted using available data on practice and population characteristics. Practices that have been advertised as alternative providers of medical services may have been more likely to be practices with a history of poor performance, perhaps due to previous mismanagement. The number of alternative providers of medical practices, at 4.1% of the total, is only a small group that can be compared to the traditional model. In addition, the limited number of practices contracting with other medical service providers – and the use of a statistically conservative fixed-effect model – may have led to a model that was unable to recognize the impact of changes in contract change practices. We are aware that there are differences in the type of provider within practices that use the contract for alternative medical services. Some are managed by groups of GP entrepreneurs, others by multinationals. While we found that the subset of alternative medical service providers operated by limited liability companies also provide lower quality care, more research is needed to assess whether the business model of the provider type affects performance.
There are also limitations in the survey of general practitioners and QOF as performance measures. For many QOF measures, there is little variation and, therefore, little ability to differentiate performance.15 The response rate of the survey among general practitioners means that there is a risk of selection bias. Different types of organisations have had to resort to different types of contracts3, with services provided by private limited liability companies, public companies and voluntary organisations contracted through new contracts for alternative medical service providers (Table 1). These changes provide a unique opportunity to explore the impact of approving the go-to-market of new alternative providers on healthcare performance. We examined how many practices of alternative medical service providers have been introduced into primary care in English since 2004 and whether their characteristics differed from practices that used “traditional” contractual mechanisms owned and managed by general practitioners – general medical services (GMS) and personal medical services (PMS) contracts. We also looked at how alternative medical service providers perform in a variety of quality indicators established for primary care compared to practices with traditional contractual models. In addition, for practices that have shifted from traditional contracts to contracts with other medical service providers, we examined the impact of this change on performance. Unadjusted comparisons of practice performance in a year by contract type are presented in Table 3 […].