Population characteristics, mechanisms of primary care and premature mortality in England: a cross-sectional study

Abstract

Objectives: Health systems with strong primary care tend to have better population outcomes, but in many countries demand for care is growing. We sought to identify mechanisms of primary care that influence premature mortality.

Design: We developed a conceptual model of the mechanisms by which primary care influences premature mortality, and undertook a cross-sectional study in which population and primary care variables reflecting the model were used to explain variations in mortality of those aged under 75 years. The premature standardised mortality ratios (SMRs) for each practice, available from the Department of Health, had been calculated from numbers of deaths in the 5 years from 2006 to 2010. A regression model was undertaken with explanatory variables for the year 2009/2010, and repeated to check stability using data for 2008/2009 and 2010/2011.

Setting: All general practices in England were eligible for inclusion and, of the total of 8290, complete data were available for 7858.

Results: Population variables, particularly deprivation, were the most powerful predictors of premature mortality, but the mechanisms of primary care depicted in our model also affected mortality. The number of GPs/1000 population and detection of hypertension were negatively associated with mortality. In less deprived practices, continuity of care was also negatively associated with mortality.

Conclusions: Greater supply of primary care is associated with lower premature mortality even in a health system that has strong primary care (England). Health systems need to sustain the capacity of primary care to deliver effective care, and should assist primary care providers in identifying and meeting the needs of socioeconomically deprived groups.

Keywords: PRIMARY CARE; PUBLIC HEALTH.

Figure 1

Model of how population and primary care characteristics are postulated to influence population mortality; characteristics of social and secondary care and public health not included. Modified from Levene et al to include Starfield et al's mechanisms: ¹greater access; ²better quality of care; ³greater focus on prevention; ⁴early management of health problems; ⁵primary care characteristics; ⁶reducing unnecessary specialist care.