Inequalities and practice-level predictors of cancer diagnostic activity: longitudinal study in England

Background: Early cancer detection is aided by timely GP referrals. However, GP practices face pressures, particularly in deprived areas, which may be associated with diagnostic inequalities. Aim: To examine whether within-practice changes in access, workforce, and population income deprivation were associated with diagnostic care indicators. Design and setting: Retrospective longitudinal study of 6,194 practices between 2015-2019 and 2022-2023. Method: Panel fixed-effects regression examined USC referral rates, USC PPV, USC sensitivity, and emergency presentation rates. Predictors were patient-reported access, GP workforce, and practice population income deprivation. Results: Per one SD increase within practices, (i) USC referral rates were lower with better appointment-making experience (-1.4%) and older average GP age (-3.5%), and higher with female GP share (+1.3%); GP FTE showed a small positive association (+0.7% to +0.8%). (ii) USC PPV increased with older average GP age (+2.2%). (iii) USC sensitivity was lower with older average GP age (-1.1%); emergency presentations showed limited association with access or workforce factors. Practices had higher emergency presentation rates when serving the most deprived rather than least deprived populations (+13.7%). There was little evidence that deprivation modified access and workforce associations. Average GP age was an exception: USC referral associations weakened from Q2 to Q5, USC PPV peaked at Q3, and USC sensitivity was significant only in the most deprived quintile. Conclusion: Practice-level access and workforce factors were associated mainly with USC referral activity. Persistent deprivation gaps in emergency presentation suggest monitoring USC referrals alongside PPV, sensitivity, and emergency presentations.