Measuring and explaining variation in quality across English GP practices.

This thesis contributes to the policy debate on quality variation in English general practices. The first chapter uses spatial mapping methods to describe the considerable geographical variation across practices and shows that its pattern is quite stable over the past 10 years. We find that there are spatial clusters of practices with persistently poor quality. In the second chapter, we analyse the determinants of practice quality as proxied by Ambulatory Care Sensitive Conditions (ACSCs) emergency admissions. We find that practices which improve their clinical quality and the availability of urgent and advance appointment reduce their ACSCs emergency admissions. To understand the impact of relationships between practices, we present in the third chapter an application of the peer effect model to GP practices. We find that after allowing for observable factors and local contextual effects, the quality of a practice varies positively with the quality of a peer group of practices within the same Primary Care Trust. We explore in the fourth chapter if practice quality varies with competition. We find modest effects of competition on clinical quality and patient-reported quality, with larger effects on practices that are producing lower quality. Practices will compete on quality only if patients are responsive to practice quality when they choose a GP practice. In chapter five, we test for this patient responsiveness using data on the number of patients who change practice without a change of address and who are arguably, therefore, more informed about the quality of local practices. Results suggest that changes in practice quality have a significant impact on the number of patients who decide to join or leave a practice without changing their address.