Title: The relationship between general practice funding, staffing and healthcare outcomes
Funder: Department of Health and Social Care

Abstract: Background Primary care is often described as the cornerstone of a strong healthcare system. It has been demonstrated across a wide range of international settings that greater investment in primary care is associated with improved population health outcomes. At a practice level, healthcare outcomes for patients are determined by a variety of factors including resource allocation (staffing and funding) and registered patient characteristics. Data which are available on healthcare outcomes in general practice include secondary care usage, patient satisfaction, health-related quality of life, Quality and Outcomes Framework achievement, practice-level mortality, vaccination achievement and Care Quality Commission ratings. Primary care funding data was first made available in 2015 for the 2013/14 financial year. Outcome achievement and allocated funding varies widely across practices in England, raising the consideration that healthcare outcomes might be optimised for a given level of funding. Aims Using general practice funding data for the four years 20013/4 to 2016/7, I will address several research questions related to understanding the association between general practice funding, staffing and healthcare outcomes in England. These are divided into three distinct studies: Study 1 1. To determine the relationship between general practice funding, staffing and healthcare outcomes. Study 2 2. To identify the barriers and facilitators to delivering efficient primary healthcare. Study 3 3. By achieving aims 1 and 2, I will develop a general practice Performance Improvement Tool' to measure practice performance based on the difference between expected costs and actual costs of healthcare outcomes. Methods Study 1 will use quantitative methods to address the following research questions: What is the relationship between general practice funding and healthcare outcomes? What is the relationship between workforce mix e.g. the ratio between nurses and general practitioners, and healthcare outcomes? I will construct a dataset containing practice-level data by linking a number of NHS administrative data sets (NHS payments to general practice, General Medical Statistics, Quality and Outcomes Framework, Hospital Episode Statistics and Primary Care Mortality) with small area census and socio-economic data from Neighbourhood Statistics. The sample includes all general practices in England (n=7900). All data are routinely collected and non-patient identifiable. Study 2 will use qualitative methods to identify the barriers and facilitators to delivering efficient primary healthcare. The Normalisation Process Theory may provide a helpful framework in orienting Studies 2 and 3 in the development, implementation and evaluation of a Performance Improvement Tool for general practices. Semi-structured interviews will be conducted with 39 general practice staff members from six practices across two Clinical Commissioning Groups (CCGs). Additionally, I will also complete 24 semi-structured patient interviews. Study 3 includes developing and piloting a Performance Improvement Tool to improve general practice delivery of healthcare outcomes, informed by Study 1 and 2. An individualised practice report will be prepared for each practice previously visited in Study 2. I will also work closely with the two CCGs to test the feasibility of using this tool at CCG-level. Potential benefits to patients The potential benefit to patients includes utilisation of the Performance Improvement Tool in each practice to deliver high quality patient care for a given level of funding. This tool can be used to maximise clinical achievement, patient satisfaction and health-related quality of life scores. The findings from this proposal may be used to shape national policy by contributing to the development of the proposed new funding allocation formula contained in Sustainability and Transformation Plans and included in general practice contract negotiations, therefore promoting cost-effective models of primary care. Furthermore, with the acquisition of practice-level mortality data, this proposal provides the first primary care analysis of the association between mortality reduction and investment in general practice.

Lay abstract: Aims 1. To determine the relationship between general practice funding, staffing and primary healthcare outcomes. 2. To identify the barriers and facilitators to delivering efficient primary healthcare. 3. By achieving aims 1 and 2, I will develop a general practice Performance Improvement Tool to measure practice performance using the difference between predicted costs and actual costs of primary healthcare outcomes.Background Many international studies have shown that increased funding to general practice is associated with improved population health. However, this has never been examined in England. In the last decade, funding of general practices has reduced, there is a shortage of GPs and workload has increased. Also care is being shifted out of hospitals into the community and the proportion of elderly patients has increased. New ways of working are needed to deal with increased demands on general practices and real reductions in general practice funding.General practice funding is based on the number and characteristics of its registered patients. The ways in which each general practice allocates the funding received into patient care is determined mainly by each general practice. For the first time, in 2015, the government has made public the amount of funding given to each practice. Using this information, I would like to find out how the funding provided to each general practice affects patient care. Patients and the public have been involved in the development of my research questions, study design and the outcome measures. This proposal also includes a patient advisory group (PAG) of six members who will provide patient-centred guidance throughout the project.The overall aim of this study is to understand how GP practice funding affects the delivery of patient care. In this proposal, I am using the term patient care' to refer to healthcare outcomes which can be measured. These include long term condition management, hospital admissions, patient satisfaction, health-reported quality of life, the number of vaccinations delivered and the number of prescriptions issued. I have proposed three studies to be completed over 4 years. Design and Methods Study 1 will address the first aim. I will use a large database of all practices in England (approximately 7900) to calculate how practice funding affects the delivery of patient care. This will allow me to produce an estimate of the efficiency of each practice. There are a number of factors which affect the delivery of efficient patient care. These include social deprivation and ethnicity. I will take these into consideration when doing the calculations.Study 2 will determine the barriers and facilitators to improving efficiency in general practice. I will visit six practices, some of which appear to use their funding well and some of which appear to be less efficient, according to my calculations in Study 1. I will speak with the general practice staff and patients to find out their views about how the delivery of patient care might be improved. I will interview up to 39 general practice staff members from six practices across two Clinical Commissioning Groups. I will also interview four patients from each practice to get their views about the efficiency or lack of efficiency in their practice.Study 3 includes the development of a Performance Improvement Tool. I will use the information from the calculations (Study 1), the general practice and patient staff interviews groups (Study 2) to prepare an individualised efficiency rating' report for each of the practices I visited in Study 2. I will also work closely with each practice to suggest improvements based on this improvement tool to improve the delivery of patient care. I will also work closely with Clinical Commissioning Groups and the practice's patient participation group during this study.Dissemination Dissemination of this work will use multiple approaches including publication in scientific journals, presentations at national conferences and local events. Each year a member of the PAG will attend and co-present at three patient-centred events including a local Healthwatch event, local Patient Participation Group and a Clinical Commissioning Group Public Meeting.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE