Open Access Open Badges Research article

Changing practice as a quality indicator for primary care: analysis of data on voluntary disenrollment from the English GP Patient Survey

Shobhana Nagraj1, Gary Abel1, Charlotte Paddison1, Rupert Payne1, Marc Elliott2, John Campbell3 and Martin Roland1*

Author Affiliations

1 Cambridge Centre for Health Services Research, Primary Care Unit, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR, UK

2 RAND Corporation, 1776 Main Street, Santa Monica, California 90401-3208, USA

3 Primary Care Research Group, Peninsula Medical School, St Lukes, Smeall Building, St Lukes Campus, Magdalen Road, Exeter EX1 2LU, England

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BMC Family Practice 2013, 14:89  doi:10.1186/1471-2296-14-89

Published: 25 June 2013



Changing family practice (voluntary disenrollment) without changing address may indicate dissatisfaction with care. We investigate the potential to use voluntary disenrollment as a quality indicator for primary care.


Data from the English national GP Patient Survey (2,169,718 respondents), the number of voluntary disenrollments without change of address, data relating to practice characteristics (ethnicity, deprivation, gender of patients, practice size and practice density) and doctor characteristics were obtained for all family practices in England (nā€‰=ā€‰8450). Poisson regression analyses examined associations between rates of voluntary disenrollment, patient experience, and practice and doctor characteristics.


Mean and median rates of annual voluntary disenrollment were 11.2 and 7.3 per 1000 patients respectively. Strongest associations with high rates of disenrollment were low practice scores for doctor-patient communication and confidence and trust in the doctor (rate ratios 4.63 and 4.85). In a fully adjusted model, overall satisfaction encompassed other measures of patient experience (rate ratio 3.46). Patients were more likely to move from small practices (single-handed doctors had 2.75 times the disenrollment rate of practices with 6ā€“9 doctors) and where there were other local practices. After allowing for these, substantial unexplained variation remained in practice rates of voluntary disenrollment.


Family practices with low levels of patient satisfaction, especially for doctor patient communication, are more likely to experience high rates of disenrollment. However substantial variation in disenrollment rates remains among practices with similar levels of patient satisfaction, limiting the utility of voluntary disenrollment as a performance indicator for primary care in England.