The impact of primary care funding on health inequalities- an umbrella review

Abstract

Problem: Funding of primary care in England is subject to intense debate. Approximately half of funding is determined by a capitation model, which uses a 20-year-old funding formula. General practices have additional income through, for example, fee-for-service (e.g. vaccinations or prescriptions) and pay-for-performance (e.g. Quality and Outcomes Framework (QOF)) schemes. Amongst this debate, health inequalities continue to increase. There are several systematic reviews examining changes in GP funding structures on health inequalities, but conclusions vary and debate persists. Method: This umbrella review aims to systematically evaluate existing literature reviews available on the effect of changes to GP funding systems in high-income countries on inequalities in funding, access, outcomes or experience. This review was pre-registered (PROSPERO CRD42024501203) and searched three databases (MEDLINE, EMBASE, Cochrane) and a Living Evidence Map from the Health Equity Evidence Centre (www.heec.co.uk). Reviews in any language, that assessed the impact of changes in primary care funding on inequalities in funding, access, experience or outcomes in a high-income country were included. Abstracts and titles were double-screened, before two authors independently screened full texts, extracted data and performed quality assessments using the AMSTAR2 tool. Results: Emerging findings are that 11 reviews met our eligibility criteria. Only one compared reimbursement systems, finding some evidence that, compared to pay-for-performance, capitation systems were more equitable in measures of primary care access and quality, but less equitable concerning patient satisfaction. Nine studies reviewed the impact of the introduction of pay-for-performance reimbursement. The majority of reviews investigated the introduction of the QOF. These reviews were of varying quality, included 4–27 articles, and conclusions varied considerably. Overall results suggest that QOF's introduction coincided with reduced socioeconomic inequalities in care provision and health outcomes in England, but not Scotland. Inequalities in age, sex or ethnicity persisted or widened. One review found some evidence that targeted funding for minority groups, with poorer health, improved the health of these populations. A further study found that introducing for-profit general practices in Sweden and allowing patients to choose these over publicly owned options benefitted more affluent populations with lower health needs. Implications: Policy changes to general practice funding have a significant impact on access, experience and outcomes. Future changes should ensure that funding changes support the reduction in health inequalities, and do not worsen them. Future research should focus on the impact of capitation models, evaluation of funding changes and the assessment of future funding models which are likely to lead to more equitable funding, access, experience and outcomes. Additional research gaps included the impact of changes in capitation models and changes in the domain of funding (e.g. ICS and PCNs vs GP practice). Underexplored outcomes included equity of funding and causal rather than co-occurring impacts of changes.