title: Performance of new alternative providers of primary care services in England: an observational study.
abstract: OBJECTIVE
  Health system reforms in England are opening broad areas of clinical practice to new providers of care. As part of these reforms, new entrants--including private companies--have been allowed into the primary care market under 'alternative provider of medical services' contracting mechanisms since 2004. The characteristics and performance of general practices working under new alternative provider contracts are not well described. We sought to compare the quality of care provided by new entrant providers to that provided by the traditional model of general practice.
  
  
  METHODS
  Open cohort study of English general practices. We used linear regression in cross-sectional and time series analyses, adjusting for practice and population characteristics, to compare quality in practices using alternative provider contracts to traditional practices. We created regression models using practice fixed effects to estimate the impact of practices changing to the new contract type.
  
  
  METHODS
  The English National Health Service.
  
  
  METHODS
  All general practices open from 2008/2009 to 2012/2013.
  
  
  METHODS
  Seventeen established quality indicators--covering clinical effectiveness, efficiency, access and patient experience.
  
  
  RESULTS
  In total, 4.1% (347 of 8300) of general practices in England were run by alternative contract providers. These practices tended to be smaller, and serve younger, more diverse and more deprived populations than traditional providers. Practices run by alternative providers performed worse than traditional providers on 15 of 17 indicators after adjusting for practice and population characteristics (p < 0.01 for all). Switching to a new alternative provider contract did not result in improved performance.
  
  
  CONCLUSIONS
  The introduction of new alternative providers to deliver primary care services in England has not led to improvements in quality and may have resulted in worse care. Regulators should ensure that new entrants to clinical provider markets are performing to adequate standards and at least as well as traditional providers.
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK.
authors.forename: Felix
authors.initials: F
authors.lastname: Greaves
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK.
authors.forename: Anthony A
authors.initials: AA
authors.lastname: Laverty
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK.
authors.forename: Utz
authors.initials: U
authors.lastname: Pape
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK.
authors.forename: Anenta
authors.initials: A
authors.lastname: Ratneswaren
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK.
authors.forename: Azeem
authors.initials: A
authors.lastname: Majeed
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, London W6 8RP, UK c.millett@imperial.ac.uk.
authors.forename: Christopher
authors.initials: C
authors.lastname: Millett
mesh_terms: D000368:Aged; D015331:Cohort Studies; D032982:Contracts; D003430:Cross-Sectional Studies; D003695:Delivery of Health Care / Q000592:standards*; D004739:England; D005260:Female; D058006:General Practice / Q000592:standards*; D018166:Health Care Reform; D006296:Health Services / Q000592:standards*; D006801:Humans; D008297:Male; D009313:National Health Programs; D011320:Primary Health Care / Q000592:standards*; D017149:Private Sector; D019984:Quality Indicators, Health Care; D013222:State Medicine
keywords: clinical quality; health policy; primary care