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Practice size 'makes no difference' to QOF achievement

By Lilian Anekwe

The quality of care provided in small and single-handed practices is comparable to that provided by larger practices, an analysis by primary care researchers has shown.

A comparison of the QOF performance of practices by list size by researchers from the University of Manchester found that in the first year of the new GMS contract, small practices had the lowest median reported achievement rates.

Over the next two years performance in practices of all sizes improved, but the smallest practices improved at the fastest rate and had overtaken larger practices by the third year.

Small and single-handed practices have been accused by politicians of providing inferior care and have been singled out in several policy initiatives as candidates either for closure or merger with larger practices.

The researchers analysed data on QOF performance, reported achievement and the levels of exception reporting and population achievement for 7,500 practices with a mean practice list size of 6,226 in 2004/5, 2005/6 and 2006/7.

Over the three years, practices with fewer than 3,000 patients represented one-fifth of all practices but nearly half of the worst-performing 5% in terms of reported achievement.

However, when measuring quality in terms of achievement rates, even though there was more variation in performance among small practices than larger ones, by year three there was little difference in average achievement rates between practices of different size, with only 1.1% separating the median achievement in all groups.

Practices with fewer than 2,000 patients had the lowest median achievement in year one, at 83.8%, but had the highest median achievement in year three, at 91.5%, compared to the largest group of practices with 12,000 patients or more where median achievement was 90.4% in year three.

An analysis of exception reporting rates showed that the smallest practices also had the lowest average rates of exception reporting, ranging from 6.3% to 6.8% for the smallest and largest practices respectively in year one, to 6.5% and 7.7% respectively in year three.

Lead researcher Dr Tim Doran, public health research fellow at the National Primary Care Research and Development Centre, argued in the September issue of the British Journal of General Practice that small practices provide a similar level of performance to their larger counterparts – but added a ‘significant minority' of small practices were providing below average care.

‘Although these poorly performing practices improved at the fastest rate, in year three it remained the case that a significant minority of small practices were apparently providing substantially poorer care than the national average.'

‘The present results suggest that small practices, most of which are single-handed, achieve, on average, similar levels of performance to larger group practices, despite an arrangement that systematically disadvantages them, but a significant minority do have low rates of achievement and the reasons for this require more attention.'

British Journal of General Practice 2010; 60: 643-648.

Researchers compared median QOF achievement in practices of different size

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