What is the cost of ‘outstanding’? A national study estimating the relationship between funding to general practices and Care Quality Commission ratings in England.
The regulation of the quality and safety of care provided by general practices in England is undertaken by the Care Quality Commission (CQC). Given the widening gap between the demand for (and cost of) healthcare, and the ability of the NHS to provide (and finance) those services, it is important to understand whether funding impacts on CQC practice ratings. No previous study has explored the association between practice funding, CQC ratings and potential confounding. This study aims to further develop our understanding of the relationship between general practice funding and CQC inspection ratings in England.
CQC data were gathered from practices with completed CQC reports from November 2014 to December 2017 (n= 7310, 95% of all practices). Data were unavailable for 5% practices with outstanding reports. CQC inspection outcomes are based on five domains: caring, effective, responsive, safe and well-led. Each domain is assigned one of four ratings: outstanding, good, requires improvement and inadequate. Each practice is also assigned an overall rating based on these scores.
Practice funding data were extracted from the National Health Applications and Infrastructure Services and covered the financial years (2013/14 – 2016/7).
A set of practice and demographic covariates which may confound the relationship between funding and CQC ratings were incorporated in the analysis as control variables. The model was also adjusted for the year the inspection was undertaken. The unit of analysis was £/registered patient. Ordered logistic regression models were constructed to test the hypothesis that general practice funding (capitation funding) is an independent determinant of CQC inspection ratings.
Mean capitation funding was £80.66 per patient (5th centile: £63.26; 95th centile: £102.16). Practices rated outstanding had greater mean capitation funding per patient compared to those rated inadequate across each of the domains: caring, £90.14 vs £80.84; effective, £83.43 vs £80.14; responsive, £83.82 vs £78.48; safe, £90.11 vs £77.69; well-led, £87.16 vs £78.48; overall £87.82 vs £78.47.
Based on ordered logistic regression modelling, an additional capitation payment of £10/patient would translate into a 6% (95%CI: 3.4, 9.1) increase in the odds of an overall outstanding rating. For individual domains, values were: caring, 6% (95%CI: 2.1, 9.9); effective, 4% (95%CI: 1.0, 7.4); responsive, 4% (95%CI: 1.0, 7.3); safe, 4% (95%CI = 1.0 to 6.9); well-led, 6% (95%CI: 2.8, 8.6).
The strongest predictors of an overall practice rating of outstanding include: training practice status, dispensing practice status, group practice and lower list size per GP FTE and per employed staff.
These findings demonstrate that higher mean capitation funding per patient was associated with higher ratings across all CQC domains and in the overall practice rating. This work supports the case for increased investment in general practice to enable improvements in quality and safety of care to patients.