Open access Original research

Relationship between general practice

capitation funding and the quality of
primary care in England: a cross-­
sectional, 3-­year study
Veline L’Esperance,1 Hugh Gravelle,2 Peter Schofield,1 Rita Santos,2
Mark Ashworth ‍ ‍ 1

To cite: L’Esperance V, Abstract

Gravelle H, Schofield P, et al. Objective  To explore the relationship between general
Strengths and limitations of this study
Relationship between general practice capitation funding and quality ratings based on
practice capitation funding ►► A cross-­sectional study covering 3 years of primary
general practice inspections.
and the quality of primary care care data.
Design  Cross-­sectional study pooling 3 years of primary
in England: a cross-­sectional, ►► The definition of primary care quality used in this
3-­year study. BMJ Open care administrative data.
study was multidimensional, based on inspection
2019;9:e030624. doi:10.1136/ Setting  UK primary care.
findings and covering patient safety, patient expe-
bmjopen-2019-030624 Participants  7310 practices (95% of all practices) in
rience, clinical effectiveness.
England which underwent Care Quality Commission (CQC)
►► Prepublication history for ►► The association between the achievement of qual-
inspections between November 2014 and December 2017.
this paper is available online. ity ratings and practice capitation funding was ex-
Main outcome measures  CQC ratings. Ordered logistic
To view these files, please visit plored, adjusted for known confounders.
the journal online (http://​dx.​doi.​ regression methods were used to predict the relationship
►► Although based on a near-­complete sample of gen-
org/​10.​1136/​bmjopen-​2019-​ between practice capitation funding and CQC ratings
eral practices in England, bias may have been intro-
030624). in each of five domains of quality: caring, effective,
duced by data coding and recording errors.
responsive, safe and well led, together with an overall
►► Longer term and prospective studies are required to
Received 22 March 2019 practice rating.
Revised 27 September 2019 strengthen causal inferences.
Results  Higher capitation funding per patient was
Accepted 30 September 2019 significantly associated with higher CQC ratings across
all five quality domains: caring (OR 1.14, 95% CI 1.04 to
1.23), effective (OR 1.08, 95% CI 1.00 to 1.16), responsive in England is currently undertaken by the
(OR 1.09, 95% CI 1.02 to 1.17), safe (OR 1.11, 95% CI Care Quality Commission (CQC), focuses on
1.05 to 1.18), well led (OR 1.13, 95% CI 1.06 to 1.20) and outcomes for patients and has a wide range of
overall rating (OR 1.13, 95% CI 1.06 to 1.19).
enforcement powers, including closure and
Conclusion  Higher capitation funding was consistently
deregistration of services, if essential stan-
associated with higher ratings across all CQC domains
and in the overall practice rating. This study suggests that dards are not met.5
measured dimensions of the quality of care are related to Studies of the relationship between quality
the underlying capitation funding allocated to each general and funding in English general practices have
practice, implying that additional capitation funding may largely focused on the Quality and Outcomes
be associated with higher levels of primary care quality. Framework (QOF), which rewards practices
for higher quality care, as defined by the
achievement of clinical process and outcome
Introduction targets. The QOF has had limited impact on
Improving the quality of care is a major reducing secondary care costs6 or improving
© Author(s) (or their focus of UK government health policy.1 primary care performance.7 8 In terms of
employer(s)) 2019. Re-­use High-­quality healthcare has three main financial incentivisation, the QOF accounted
permitted under CC BY.
Published by BMJ.
components: clinical achievement, patient for approximately 7.8% of funding received
1
School of Population Health and
experience and patient safety.2 There is wide by general practices in England in 2016.9 In
Environmental Sciences, King’s variation between general practices in the contrast, capitation payments represent the
College London, London, UK achievement of clinical care quality indicators largest proportion of funding to general
2
Centre for Health Economcs, and patient-­reported satisfaction.3 4 practice (54% in 2016) and are related to the
University of York, York, UK It is important to understand whether number of registered patients in each prac-
Correspondence to variations in the quality of care provided tice,9 adjusted for factors thought to increase
Dr Veline L’Esperance; across practices are related to variations in the demand on primary care services.10 Other
​veline.​lesperance@​kcl.​ac.​uk their funding. Healthcare quality regulation components of general practice funding

L’Esperance V, et al. BMJ Open 2019;9:e030624. doi:10.1136/bmjopen-2019-030624 1

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include additional payments for postgraduate training, CQC Ratings

the provision of additional clinical services (enhanced CQC ratings are based on publicly available data (such
services) and various reimbursements to cover the costs of as QOF and General Practice Patient Survey19), prac-
premises, computers and for some practices, dispensing tice inspections, interviews with patients and staff,
medication.11 complaints, clinical record reviews, reviews of practice
Greater capitation spending on general practices has documents and policies.15 We used CQC ratings for prac-
been found to be associated with reductions in secondary tices with completed CQC reports first inspected between
care usage and costs, and increased patient satisfaction.12 November 2014 and December 2017 (n=7310, 95% of all
Studies have also shown that leadership within the prac- practices). Practice ratings were obtained from the CQC;
tice organisation plays a key role in the delivery of high-­ these data are publicly available on request. For practices
quality care.13 Until recently, nationally derived metrics which required reinspection only the first inspection
of inspection-­ based primary care quality were unavail- score was included in the analysis. The five domains of
able. Since October 2014, all general practices have been quality described by CQC inspections are summarised in
subjected to inspections by the CQC.5 14 The CQC reports table 1; each is rated on a 4-­point scale.
on the extent to which practices are caring, effective,
responsive to the needs of patients, safe and well led5 15 and Practice data
also combines these five domains to produce an overall Data for all general practices in England were obtained
practice rating. These five domains incorporate compo- from the General and Personal Medical Services data-
nents of clinical achievement, patient experience and base, for 2014/2015, 2015/2016 and 2016/2017 finan-
patient safety.2 In this study, we assess the relationship of cial years.17 These data are publicly available from NHS
practice capitation funding with overall CQC ratings and Digital. Our use of practice based demographic data
with the individual CQC domains. We aimed to examine followed a previously used methodology.20 Patient char-
the relationship between practice funding and the quality acteristics included the proportion of patients aged 0–4
of care as determined by inspection-­based quality assess- years, proportion of patients aged 75 years or older and
ment. Analysis of total practice funding would have intro- proportion of nursing home patients. Deprivation data
duced confounding through inclusion of quality-­related for each general practice was attributed as the mean
payments. We, therefore, used capitation funding as our of the Index of Multiple Deprivation 201518 weighted
measure of practice funding since this financial indi- by the proportion of practice patients resident in each
cator is independent of financial rewards associated with Lower Layer Super Output area (LLSOA). Neighbour-
quality achievement such as the QOF and other national hood ethnicity (proportion Asian or black) derived from
and local incentive schemes. the 2011 national census, was attributed to practices
weighted by the proportion of the practice population
in each LLSOA.21 The following practice characteris-
tics were included: region (North, Midlands, London
Methods and South), contract type (General Medical Services
Data sources or Personal Medical Services), minimum distance from
We linked practice-­level data on National Health Service an acute hospital, dispensing status (whether the prac-
(NHS) payments to general practice identifiers,16 CQC tice dispensed as well as prescribed medication), single-­
inspection ratings,15 NHS administrative datasets, General handed practice status (single-­ handed practices have
and Personal Medical Services Statistics,17 and small area ≤1.0 full-­
time equivalent (FTE) general practitioner
Census and socioeconomic data from Neighbourhood (GP); group practices have >1.0 FTE GPs) and training
Statistics.18 practice status. We did not include practice staffing (GPs,

Table 1  The five key domains for CQC Inspections

Domain Description
Safe Patients are protected from abuse and avoidable harm
Effective Care, treatment and support achieves good outcomes, helps patients to maintain quality of life and is based
on the best available evidence
Caring Staff involve and treat patients with compassion, kindness, dignity and respect
Responsive Services are organised so that they meet patients’ needs
Well-­led The leadership, management and governance of the organisation make sure it’s providing high-­quality care
that is based around the individual needs, that it encourages learning and innovation, and that it promotes
an open and fair culture
Adapted from: CQC. The five key questions we ask.36
CQC, Care Quality Commission.

2 L’Esperance V, et al. BMJ Open 2019;9:e030624. doi:10.1136/bmjopen-2019-030624

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nurses and other staff) as explanatory variables in the urban practices. STATA V.14 (StataCorp) was used for all
model because staffing is likely to be directly affected by statistical analyses.
practice capitation funding and so inclusion of these vari-
able may lead to an underestimate of the full effect of Patient involvement
capitation funding. Moreover, a major change in the way Funding for this study included funding of a dedicated
in which staffing data were collected in 2015/2016 would patient involvement group. Patients were involved in
have resulted in a large reduction in observation number. developing plans for the study design, approving the
outcome measures and commenting on the potential
Practice capitation impact of outcomes. A lay summary was also provided.
Practice capitation funding depends on the total number
of practice patients adjusted to reflect factors affecting
GP workload (age, gender, patients in nursing and Results
residential homes, small area measures of morbidity), Summary statistics for the main characteristics of the
rurality and an index of local staff costs which affect the general practices are provided in table 2. Mean practice
cost of providing services.10 Data were available for the capitation funding per registered patient increased from
financial years 2014/2015, 2015/2016 and 2016/2017.22 £77.49 in 2014/2015 to £83.17 in 2016/2017 (table 3).
We use the mean capitation payment per patient for the The mean capitation funding per patient across the CQC
year prior to inspection and the year in which the practice inspection period was £79.48. The SD of the mean capita-
was inspected. tion funding per patient was £22.00.
The distribution of practice ratings across each quality
domain is shown in figure 1. A total of 79% (n=5774) of
Sample
practices achieved an overall rating of ‘good’, while only
We linked inspected practices (n=7310) with funding
4% (294) achieved an overall rating of ‘outstanding’.
data for their year of inspection. We excluded atypical
‘Inadequate’ ratings varied across the domains, from 1%
practices with ≤750 registered patients (n=10) or ≤500
(caring domain) to 6% (safety domain) and 4% (overall).
patients per FTE GP (n=8) following a previously used
Figure 2 shows the difference in capitation funding for
method.23 Practices with recorded negative (n=2) or zero
practices with the lowest quality rating compared with
funding (n=52) were excluded. The final analysis sample
those with the highest quality rating. In each domain,
consisted of 7238 practices.
‘inadequate’ practices received less capitation funding.
Using an independent group t-­test, this difference was
Data analysis found to be significant for three domains (caring, safe
Analysis was conducted at GP practice level. Since the and well led) and for the overall practice rating.
CQC rating outcomes are ordered categories we used Table 4 reports the ORs on capitation funding per
ordered logistic regression to model the relationship patient estimated from four regression models of overall
between funding and the practice CQC ratings.24 Sepa- practice CQC rating. The OR on capitation funding per
rate models were estimated for each domain. patient is reported in (SD units). In the first model, capita-
The key explanatory variable was capitation funding tion funding is the only explanatory variable (unadjusted
per patient (measured in SD units). We also include model); remaining models are adjusted for inclusion of
patient and practice characteristic covariates, thereby successive additional explanatory variables: year effects,
reducing the risk of bias from the omission of variables patient characteristics and practice characteristics. The
which might affect the CQC rating and are correlated unadjusted model shows an association between higher
with practice capitation funding. The regression models capitation funding and higher overall CQC ratings with
included year effects to allow for inspection year and an OR of 1.09 (95% CI 1.03 to 1.15). Allowing for the year
annual general practice funding uplifts. We accounted of inspection increased the OR slightly to 1.10 (95% CI
for local area effects by adjusting for clustering at clinical 1.04 to 1.16). Additional allowance for patient character-
commissioning group level. Multicollinearity was tested istics (OR 1.13, 95% CI 1.06 to 1.19) and practice charac-
for by calculating the variance inflation factor (VIF) and teristics (OR 1.13, 95% CI 1.06 to 1.19) further increased
variables with a value for VIF >5 were excluded. The the OR. The number of observations in table 4 fell
proportional odds assumption of the ordered logit model from 7168 to 7045 because of missing data. Very similar
was also tested.25 We report the OR from the estimated changes in ORs across the models were observed when all
models. models were restricted to equal sample sizes. A likelihood
We calculated the average marginal effects of funding ratio test demonstrated that the addition of patient and
on the predicted probabilities of achieving overall ratings practice variables create a statistically significant improve-
of ‘outstanding’ and ‘inadequate’ for all practices. We also ment in model fit, confirming that higher ORs were asso-
compared the predicted probabilities of an ‘outstanding’ ciated with the addition of model variables, rather than to
overall rating at different practice capitation funding a change in sample size.
levels for training versus non-­training practices, single-­ The final adjusted model indicates that for a 1 SD
handed versus multihanded practices and rural versus increase in capitation funding, the odds of achieving an

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outstanding CQC rating are 1.13 times greater, given that

Table 2  Characteristics of general practices and their
populations in England other variables are held constant. We have also shown the
estimated changes in the probabilities of achieving ‘inad-
(Fifth, 95th
equate’ and ‘outstanding’ CQC ratings implied by this
Variable Mean centiles)
model in figures 3–7.
Patient-­adjusted Index of 24.5 8.2, 46.1 Table 5 reports ORs for all the explanatory variables
Multiple Deprivation, 2015 in the overall practice quality rating model (model 4,
Proportion of patients aged 0–4 5.9 3.7, 8.8 table 4). In addition to higher practice capitation funding,
years (%) rural practice and training practice status were signifi-
Proportion of patients aged 75 7.7 2.6, 12.9 cantly associated with higher overall practice ratings. For
years or older (%) example, the adjusted OR of a training practice achieving
Proportion of patients: nursing 0.5 0, 1.4 an ‘outstanding’ CQC rating is 2.30 times greater than
home residents (%) for a non-­training practice. Conversely, for single-­handed
Proportion of patients: Asian or 13.1 0.1, 53.1 practices, the odds of achieving an ‘outstanding’ rating is
black ethnicity (%) 0.53 times that for group practices.
List size per full-­time equivalent 1950 1066, 3315 The ORs for capitation funding per patient from the
(FTE) GP full models for each CQC domain are shown in table 6.
List size per FTE non-­clinical 703 392, 1103 Higher capitation funding was significantly associated
employed staff with higher CQC ratings across all five quality domains.
We used the results from the ordered logistic regres-
List size per FTE nurse 7166 2810, 15 507
sion models with the full set of explanatory variables to
Minimum distance of practice 3.8 0.4, 11.8 calculate the probability of achieving an overall prac-
from acute hospital (km)
tice rating of ‘outstanding’ or ‘inadequate’ at different
Proportion of practices by levels of capitation funding. Figure 3 shows the average
rurality (%) predicted probability of achieving an ‘outstanding’ rating
 Urban 85.5 for a range of per capita funding levels. The probabilities
 Rural: hamlet, village, town 14.5 are the average of the estimated probabilities for each
and fringe practice calculated at each funding level using actual
Proportion of practices by values of the practice non-­funding characteristics (year
region (%) effects, patient characteristics and practice characteris-
 North 30.3 tics). Figure 4 shows the average predicted probability of
achieving an ‘inadequate’ practice rating. Higher capi-
 Midlands 29.4
tation funding was associated with reduced probability
 London 18.0 of achieving an ‘inadequate’ rating and increased prob-
 South 22.3 ability of an ‘outstanding’ quality rating. At capitation
Proportion of practices by payments above £100 per patient, practices have a greater
contract type (%) probability of being rated as ‘outstanding’ rather than
 General Medical Services 59.4 ‘inadequate’.
 Personal Medical Services 40.6 We also compared the probability of achieving an
‘outstanding’ rating at different levels of practice capi-
Proportion of dispensing 14.6
tation funding for training versus non-­training practices
practices (%)
(figure 5), for single-­ handed versus group practices
Proportion of single-­handed 13.1 (figure 6), and for rural versus urban practices (figure 7).
practices (%)
At all levels of funding, the probability of achieving an
Proportion of training practices 30.4 ‘outstanding’ rating is higher for training practices than
(%)
non-­training practices, for group practices than single-­
GP, general practitioner. handed practices, and rural practices than urban prac-
tices. In all cases, higher capitation funding is associated
with higher probabilities of an ‘outstanding’ rating.

Table 3  Capitation funding per registered patient for inspected practices

Inspection year N Mean capitation funding (5th, 95th centiles)
2014/2015 2232 £77.49 £59.54, £99.99
2015/2016 3790 £80.86 £66.57, £101.66
2016/2017 1148 £83.71 £67.74, £106.76

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Figure 1  Distribution of CQC ratings by each domain. CQC, Care Quality Commission.

Sensitivity analyses was significantly associated with increase probability of

The Brant test25 assesses the proportional odds assump- achieving an ‘outstanding’ rating (OR 1.14, 95% CI 1.04
tion that the distance between each category is equiva- to 1.25).
lent. Four of the variables included in our model (region,
proportion of patients aged 0–4 years, contract type
and single-­hander status) did not meet the assumption Discussion
of proportionality of the ORs. However, our variable of This study has demonstrated that higher capitation
interest, capitation funding per patient, did not violate funding is associated with significantly higher overall
the proportional odds assumption. A partial proportional practice quality ratings and ratings across all individual
odds model excluding these four variables, estimated by domains.
generalised ordered logistic regression, yielded similar Practice characteristics, such as postgraduate training
results to our main model: higher capitation funding practice and group practice status, were also associated

Figure 2  Practice capitation funding by overall practice rating: ‘inadequate’ versus ‘outstanding. Difference in practice
capitation funding between practices rated 'Inadequate' versus 'Outstanding for each domain. Caring Domain £80.84 vs
£91.14, p<0.001. Effective Domain £80.14 vs MAD, No significant difference. Responsive Domain £78.48 vs £83.82, No
significant difference. Safe Domain £77.69 vs 90.11, p<0.05. Well-­led Domain £78.48 vs £87.82, P<0.05. Overall Domain £78.47
vs 87.82, P<0.001.

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Table 4  Association of capitation funding per patient with overall practice CQC rating: unadjusted and adjusted regression
models
Model 1 Model 2 Model 3 Model 4
Capitation funding OR† 1.09** 1.10** 1.13*** 1.13***
95% CI of OR 1.03, 1.15 1.04, 1.16 1.06, 1.19 1.06, 1.19
Observations 7168 7168 7144 7045
Models contain        
 Year effects N Y Y Y
 Patient characteristics‡ N N Y Y
 Practice characteristics§ N N N Y
*P<0.05; **P<0.01; ***P<0.001.
†ORs based on SD units.
‡Patient-­adjusted deprivation, proportion of patients aged 0–4 years, proportion of patients aged ≥75 years, proportion patients black or
Asian ethnicity, proportion of nursing home residents
§Region, minimum distance to hospital, contract type, dispensing status, training practice status, singlehanded.
CQC, Care Quality Commission.

with higher quality ratings, representing primary care variables which would otherwise tend to underestimate
structures which support higher quality of care. However, the positive association of funding with the quality rating.
some factors related to the registered practice popu-
lation, such as urban location, social deprivation and Strengths and weaknesses of the study
larger proportions of ethnic minority patients, were nega- This is the first study to explore the relationship between
tively associated with the practice quality of care rating. practice-­level capitation funding and practice quality as
Many of these factors are already known to be negatively measured by CQC ratings. The findings are based on a
associated with reported patient satisfaction26 and QOF near-­complete sample of general practices across England.
achievement.27 Including them in the model led to a Using data linkages from a wide range of sources and
stronger association of practice capitation funding with multilevel statistical models, this study has been able to
practice quality rating. The likely reason for this is that demonstrate the independent effects of practice funding
practice capitation funding is positively correlated with and practice characteristics on quality ratings, which
patient characteristics, which have negative effects on the might otherwise be confounded in single-­level analyses.
quality rating. Thus, including these patient characteris- A variety of sensitivity analyses have confirmed the robust-
tics in the model removes a source of bias from omitted ness of the ordered logistic regression modelling.

Figure 3  Estimated probability of overall practice rating of ‘outstanding’ at various levels of capitation funding per registered
patient. Average predicted probability at each funding level (accounting for year effects, patient & practice characteristics) Mean
values displayed with 95% confidence intervals.

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Figure 4  Estimated probability of overall practice rating of ‘inadequate’ at various levels of capitation funding per registered
patient. Average predicted probability at each funding level (accounting for year effects, patient & practice characteristics) Mean
values displayed with 95% confidence intervals.

However, there are several limitations. Routinely In a country-­level European analysis, it was found
collected data are subject to coding and recording errors. that systems relying on capitation funding were more
As with all observational studies, significant associations, responsive than those based on fee for service or mixed
even if large, may not be causal. Although a wide range payment.28 However, analysis of Scottish general practices
of potential confounders were included in the models, suggests that capitation funding may contribute to the
confounding by omitted variables cannot be excluded. persistence of the inverse care law with deprived areas
Comparison with existing literature experiencing lower quality of care, as defined by inspec-
These findings complement those of a previous study tion ratings.29 Consistent with our study, others have
which found that increased general practice capitation found that GP practice funding is negatively correlated
funding was associated with reduced emergency hospital with healthcare need predictors such as deprivation
admissions and Accident and Emergency attendances.12 and non-­ white ethnicity.30 Previous studies have also

Figure 5  Estimated probability of ‘outstanding’ overall practice CQC rating: training versus non-­training practices. Adjusted for
year effects, patient characteristics, practice characteristics & funding Mean values displayed with 95% confidence intervals in
shaded areas. CQC, Care Quality Commission.

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Figure 6  Estimated probability of ‘outstanding’ overall practice CQC rating: single-­handed versus group practices. Adjusted
for year effects, patient characteristics, patient characteristics & funding Mean values displayed with 95% confidence intervals
in shaded areas areas. CQC, Care Quality Commission.

demonstrated that greater GP workload may be associated for overall ‘profit’ per practice are expected to become
with higher levels of social deprivation and with a higher available in due course. Other studies have confirmed
proportion of Asian patients.31 Similarly, practices with a that incentives based on personal income may influence
greater proportion of ethnically diverse patients reported both quality achievement and productivity.34
worse patient experience.32 Our work is also consistent
with a recent study which demonstrated that GPs colo- Implications for policy and practice
cated with other GPs and professionals had improved This work provides further evidence of the association
outcomes compared with single-­ handed GP practices between general practice capitation funding and the
such as broader provision of technical procedures, wider quality of primary care. A causal association is plausible
coordination with secondary care and increased collabo- and supports the argument that increased quality and
ration among different providers.33 safety of patient care may be achieved through additional
Our study was based on funding data for general prac- investment. The recently published NHS Long Term
tices but was unable to study the relationship between Plan35 outlines proposals to offer increases in capitation
quality ratings and individual GP income. However, values payment together with an emphasis on inter-­ practice

Figure 7  Estimated probability of ‘outstanding’ overall practice CQC rating: rural and urban practices. Adjusted for year
effects, patient characteristics, practice characteristics & funding Shaded areas demonstrate 95%CI. CQC, Care Quality
Commission.

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Table 5  Association of capitation funding with overall

Unanswered questions and future research
practice CQC rating: predictor variable in fully adjusted Future research could extend similar analyses to subse-
model quent 3-­year cycles of quality inspection. A longitudinal
approach, relating changes in funding to changes in
Characteristics OR 95% CI
outcomes, is likely to provide more accurate estimates of
Capitation funding per patient (SD 1.13*** 1.06 to 1.19 the effect of funding. Complementary qualitative analysis
units)†
is likely to provide insight into mechanisms underlying
Year 2 0.92 0.80 to 1.05 the link between better funded practices and higher
Year 3 0.76** 0.64 to 0.91 quality rating achievement.
Deprivation 0.99** 0.98 to 0.99
Patients aged 0–4 years (proportion) 1.00 0.95 to 1.05
Patients aged 75 years or old 0.99 0.96 to 1.17
Conclusion
(proportion) Higher capitation funding was consistently associated
Patients in nursing home (proportion) 1.13* 1.02 to 1.26
with higher overall and domain quality ratings yielded by
CQC inspections. This study suggests that measured and
Patients Asian or black ethnicity 0.99* 0.99 to 1.00
inspected dimensions of the quality of care are related to
(proportion)
the underlying funding allocated to each general prac-
Region: Midlands‡ 0.64*** 0.55 to 0.76
tice, implying that additional funding may be associated
Region: London‡ 0.56*** 0.93 to 0.98 with higher levels of primary care quality.
Region: South‡ 0.48** 0.40 to 0.58
Minimum distance to hospital 1.00 1.00 to 1.00 Contributors  VL, HG, PS, RS and MA contributed to the idea and design of the
study. VL and PS led on data analysis with statistical advice from HG, RS and MA.
Rurality (yes/no) 1.50** 1.18 to 1.92 VL produced the first draft of the paper; all coauthors contributed and approved
Contract type (GMS/PMS) 1.08 0.96 to 1.23 the final draft. VL is the guarantor. The corresponding author attests that all listed
authors meet authorship criteria and that no others meeting the criteria have been
Dispensing practice status (yes/no) 1.1 0.88 to 1.38 omitted.
Single-­handed practice (yes/no) 0.53*** 0.44 to 0.63 Funding  The work was funded by the National Institute for Health Research (NIHR)
Training practice status (yes/no) 2.30*** 1.99 to 2.65 who funded a Doctoral Research Fellowship for VL (reference, DRF-2017-10-132)
and for RS (reference, DRF-2014-07-055). HG and RS were funded by the UK NIHR
*P<0.05; **P<0.01; ***P<0.001. Policy Research Programme (Policy Research Unit in the Economics of Health and
†ORs based on SD units. Social Care Systems: Ref 103/0001).
‡Comparator Region: North. Disclaimer  The findings presented are independent from the funders who have
CQC, Care Quality Commission; GMS, General medical had no role in study design, data collection, data analysis, data interpretation,
services; PMS, Personal Medical Services. or writing of the report. The views expressed are those of the authors and not
necessarily those of the NHS, the National Institute for Health Research, the
Department of Health and Social Care or its arm’s length bodies or other UK
cooperation through the formation of primary care government departments.
networks. Both factors are likely to influence the relation- Competing interests  None declared.
ship between funding and the quality of primary care and
Patient consent for publication  Not required.
will require further study. Our findings suggest that revi-
Ethics approval  Ethical approval not required for the use of aggregate practice
sions to the primary care capitation formula are necessary
level data as included in this study.
to ensure that additional funding is provided in urban
Provenance and peer review  Not commissioned; externally peer reviewed.
areas of high deprivation and ethnic minority popula-
tions in order to address quality of care inequalities. Data availability statement  No data are available.
Open access  This is an open access article distributed in accordance with the
Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits
Table 6  Ordered logistic models: effect of capitation others to copy, redistribute, remix, transform and build upon this work for any
funding on each CQC domain rating purpose, provided the original work is properly cited, a link to the licence is given,
and indication of whether changes were made. See: https://​creativecommons.​org/​
Domains OR† 95% CI
licenses/​by/​4.​0/.
Caring 1.14** 1.04 to 1.23
ORCID iD
Effective 1.08* 1.00 to 1.16 Mark Ashworth http://​orcid.​org/​0000-​0001-​6514-​9904
Responsive 1.09* 1.02 to 1.17
Safe 1.11* 1.05 to 1.18
Well led 1.13*** 1.06 to 1.20 References
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