The provision of additional services in primary care: a cross-sectional study of incentivised additional services, social deprivation, and ethnic group

Abstract

Background: Primary care in England is contracted to provide essential services. Many practices also provide additional services, termed 'directed enhanced services' (DES), for extra income. The optional nature of DES may result in inequitable service delivery.

Aim: To determine the range of DES activity and equity of service provision.

Design & setting: A cross-sectional analysis of data from general practices in England took place from 2018-2019.

Method: DES were defined in terms of activity level and measured as total DES funding per registered patient. Linear regression modelling was used to explore the relationship between DES activity, practice, and population characteristics.

Results: Data were available for 6873 practices providing up to 10 DES in the initial sample. Due to negative funding amounts and a list size of ≤750 registered patients, 24 practices were excluded. Of the final sample (n = 6849), highest DES provision was for influenza and pneumococcal immunisation (99.9%), pertussis immunisation (97.9%), rotavirus and shingles immunisation (99.9%), meningitis immunisation (99.7%), and childhood immunisation (99.6%); lowest provision was for extended hours access (72.4%), violent patient services (2.0%), and out-of-area urgent care (1.3%). Mean DES funding was £6.25 per patient. In deprived areas, DES funding was £0.35 lower (95% confidence interval [CI] = £0.60 to £0.10) per patient (most versus least deprived quintiles); ethnic group-related differences were not significant. DES funding was higher in practices with more GPs or practice nurses per patient. In deprived communities, there was less immunisation activity (including influenza, pneumococcal, meningitis, childhood, and rotavirus and shingles immunisation) and provision of extended hours access; however, learning disability checks provision was greater in these communities.

Conclusion: DES provision is lower in deprived areas (notably for immunisations and some aspects of access) but higher in better staffed practices. Voluntary quality schemes may contribute to widening health inequalities.

Keywords: general practice; health inequality; health status disparities; primary health care.