Horizontal equity in primary care financing: An assessment of payments to general practices in England, 2014–2022

Objectives

Previous studies of equity in primary care financing have only considered deprivation as the benchmark for need and focused on specific funding streams. We assessed inequity in payments to primary care providers in England, considering alternative definitions of need and comparing different schemes and changes over time.

Methods

We used data on annual payments to 7765 general practices between 2014 and 2022, linked to patient characteristics. We measured need as: (i) demand for care, based on patient appointment attempts; (ii) expected utilisation based on a primary care needs index; (iii) diagnosed morbidity, based on prevalence of 20 chronic conditions; and (iv) expected care burden from diagnosed morbidity, based on a hospital care needs index. We ranked practices by average patient neighbourhood income in 2019, and calculated concentration indices of need and need-standardized payments. We then decomposed the concentration index into need, socioeconomic (income, education, ethnicity, economic activity, rurality), and supply-side factors (practice region, dispensing status, contract type).

Results

Need was concentrated among poorer populations for most measures: expected utilisation (concentration index (CI) = −0.0169), demand for care (CI = −0.0102) and expected burden from diagnosed morbidity (CI = −0.0097). The concentration of diagnosed morbidity varied across conditions. Total payments were consistently pro-rich, with the highest inequity when defining need by expected utilisation (horizontal inequity index (HI) = 0.0224), followed by diagnosed morbidity (HI = 0.0039). Inequity varied substantially across payment schemes, from pro-rich (HI = 0.03993) for the Minimum Practice Income Guarantee to pro-poor (HI = −0.0938) for the Personal Medical Services expenditure. Socioeconomic and supply-side factors contributed to pro-rich inequalities in payments in all years.

Discussion

Payments to NHS primary care providers do not fully reflect healthcare need. Clear objectives for resource distribution should be defined and harmonized across different schemes to reduce horizontal inequities.