IDEAS home Printed from https://ideas.repec.org/a/eee/jhecon/v104y2025ics0167629625000852.html

Impact of primary care market mergers on quality: Evidence from the English NHS

Author

Listed:
  • Lyu, Yuan
  • Zhang, Zhaocheng

Abstract

The primary care market has experienced a growing trend of provider consolidation through mergers and acquisitions, yet the implications of this concentration remain unclear. This study addresses this gap by providing the first empirical evidence on the effects of provider mergers on quality, using evidence from the English primary care market. Examining all provider mergers from 2014 to 2018, we find that mergers improve certain aspects of clinical quality management, but they do not translate into broader population-level clinical quality gains, and patient satisfaction declines significantly. Importantly, the effects vary by merger motivation and the size of the merging parties, rather than their geographic proximity. Survival-driven mergers help sustain care quality and patient access, whereas efficiency-driven mergers lead to greater quality deterioration. Mergers between larger practices also lead to more negative outcomes than those involving smaller practices. In contrast, we find no significant difference between within-market and cross-market mergers. An exploration of the mechanism reveals that changes in market concentration do not explain the observed quality outcomes. Instead, shifts in workforce composition, driven by the underlying merger motivations, play a key role.

Suggested Citation

  • Lyu, Yuan & Zhang, Zhaocheng, 2025. "Impact of primary care market mergers on quality: Evidence from the English NHS," Journal of Health Economics, Elsevier, vol. 104(C).
    • Handle: RePEc:eee:jhecon:v:104:y:2025:i:c:s0167629625000852
    DOI: 10.1016/j.jhealeco.2025.103050
    as

    Download full text from publisher

    File URL: http://www.sciencedirect.com/science/article/pii/S0167629625000852
    Download Restriction: Full text for ScienceDirect subscribers only
    File URL: https://libkey.io/10.1016/j.jhealeco.2025.103050?utm_source=ideas
    LibKey link: if access is restricted and if your library uses this service, LibKey will redirect you to where you can use your library subscription to access this item
    ---><---

    As the access to this document is restricted, you may want to

    for a different version of it.

    References listed on IDEAS

    as
    1. Schaumans, Catherine, 2015. "Prescribing behavior of General Practitioners: Competition matters," Health Policy, Elsevier, vol. 119(4), pages 456-463.
    2. Gaynor, Martin & Town, Robert J., 2011. "Competition in Health Care Markets," Handbook of Health Economics, in: Mark V. Pauly & Thomas G. Mcguire & Pedro P. Barros (ed.), Handbook of Health Economics, volume 2, chapter 0, pages 499-637, Elsevier.
    3. Gaynor, Martin & Laudicella, Mauro & Propper, Carol, 2012. "Can governments do it better? Merger mania and hospital outcomes in the English NHS," Journal of Health Economics, Elsevier, vol. 31(3), pages 528-543.
    4. Ying Fan, 2013. "Ownership Consolidation and Product Characteristics: A Study of the US Daily Newspaper Market," American Economic Review, American Economic Association, vol. 103(5), pages 1598-1628, August.
    5. Gautam Gowrisankaran & Aviv Nevo & Robert Town, 2015. "Mergers When Prices Are Negotiated: Evidence from the Hospital Industry," American Economic Review, American Economic Association, vol. 105(1), pages 172-203, January.
    6. Walter Beckert & Mette Christensen & Kate Collyer, 2012. "Choice of NHS‐funded Hospital Services in England," Economic Journal, Royal Economic Society, vol. 122(560), pages 400-417, May.
    7. Paul J Eliason & Benjamin Heebsh & Ryan C McDevitt & James W Roberts, 2020. "How Acquisitions Affect Firm Behavior and Performance: Evidence from the Dialysis Industry," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 135(1), pages 221-267.
    8. Ho, Vivian & Hamilton, Barton H., 2000. "Hospital mergers and acquisitions: does market consolidation harm patients?," Journal of Health Economics, Elsevier, vol. 19(5), pages 767-791, September.
    9. Leemore Dafny, 2009. "Estimation and Identification of Merger Effects: An Application to Hospital Mergers," Journal of Law and Economics, University of Chicago Press, vol. 52(3), pages 523-550, August.
    10. Martin Gaynor, "undated". "What Do We Know About Competition and Quality in Health Care Markets?," GSIA Working Papers 2006-E62, Carnegie Mellon University, Tepper School of Business.
    11. Manasi Deshpande & Yue Li, 2019. "Who Is Screened Out? Application Costs and the Targeting of Disability Programs," American Economic Journal: Economic Policy, American Economic Association, vol. 11(4), pages 213-248, November.
    12. Rita Santos & Hugh Gravelle & Carol Propper, 2017. "Does Quality Affect Patients’ Choice of Doctor? Evidence from England," Economic Journal, Royal Economic Society, vol. 127(600), pages 445-494, March.
    13. Papke, Leslie E. & Wooldridge, Jeffrey M., 2008. "Panel data methods for fractional response variables with an application to test pass rates," Journal of Econometrics, Elsevier, vol. 145(1-2), pages 121-133, July.
    14. repec:ecj:econjl:v:122:y:2012:i::p:400-417 is not listed on IDEAS
    15. Martin Gaynor & Kate Ho & Robert J. Town, 2015. "The Industrial Organization of Health-Care Markets," Journal of Economic Literature, American Economic Association, vol. 53(2), pages 235-284, June.
    16. Sun, Liyang & Abraham, Sarah, 2021. "Estimating dynamic treatment effects in event studies with heterogeneous treatment effects," Journal of Econometrics, Elsevier, vol. 225(2), pages 175-199.
    17. Pike, Chris, 2010. "An Empirical Analysis of the Effects of GP Competition," MPRA Paper 27613, University Library of Munich, Germany.
    18. Jens Dietrichson & Lina Maria Ellegård & Gustav Kjellsson, 2020. "Patient choice, entry, and the quality of primary care: Evidence from Swedish reforms," Health Economics, John Wiley & Sons, Ltd., vol. 29(6), pages 716-730, June.
    19. Siciliani, Luigi & Chalkley, Martin & Gravelle, Hugh, 2017. "Policies towards hospital and GP competition in five European countries," Health Policy, Elsevier, vol. 121(2), pages 103-110.
    20. Baker, Andrew C. & Larcker, David F. & Wang, Charles C.Y., 2022. "How much should we trust staggered difference-in-differences estimates?," Journal of Financial Economics, Elsevier, vol. 144(2), pages 370-395.
    21. Goodman-Bacon, Andrew, 2021. "Difference-in-differences with variation in treatment timing," Journal of Econometrics, Elsevier, vol. 225(2), pages 254-277.
    22. Patrick Romano & David Balan, 2011. "A Retrospective Analysis of the Clinical Quality Effects of the Acquisition of Highland Park Hospital by Evanston Northwestern Healthcare," International Journal of the Economics of Business, Taylor & Francis Journals, vol. 18(1), pages 45-64.
    23. Doruk Cengiz & Arindrajit Dube & Attila Lindner & Ben Zipperer, 2019. "The Effect of Minimum Wages on Low-Wage Jobs," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 134(3), pages 1405-1454.
    24. Empel, Giovanni & Gravelle, Hugh & Santos, Rita, 2023. "Does quality affect choice of family physician? Evidence from patients changing general practice without changing address," Economic Modelling, Elsevier, vol. 126(C).
    25. Ying Fan & Chenyu Yang, 2025. "Estimating Discrete Games with Many Firms and Many Decisions: An Application to Merger and Product Variety," Journal of Political Economy, University of Chicago Press, vol. 133(6), pages 1886-1931.
    26. Przemys?aw Jeziorski, 2014. "Effects of Mergers in Two-Sided Markets: The US Radio Industry," American Economic Journal: Microeconomics, American Economic Association, vol. 6(4), pages 35-73, November.
    27. Steven T. Berry & Joel Waldfogel, 2001. "Do Mergers Increase Product Variety? Evidence from Radio Broadcasting," The Quarterly Journal of Economics, President and Fellows of Harvard College, vol. 116(3), pages 1009-1025.
    28. Andrew Sweeting, 2010. "The effects of mergers on product positioning: evidence from the music radio industry," RAND Journal of Economics, RAND Corporation, vol. 41(2), pages 372-397, June.
    29. Gravelle, Hugh & Liu, Dan & Propper, Carol & Santos, Rita, 2019. "Spatial competition and quality: Evidence from the English family doctor market," Journal of Health Economics, Elsevier, vol. 68(C).
    30. Gravelle, Hugh & Liu, Dan & Santos, Rita, 2022. "How do clinical quality and patient satisfaction vary with provider size in primary care? Evidence from English general practice panel data," Social Science & Medicine, Elsevier, vol. 301(C).
    31. Callaway, Brantly & Sant’Anna, Pedro H.C., 2021. "Difference-in-Differences with multiple time periods," Journal of Econometrics, Elsevier, vol. 225(2), pages 200-230.
    32. Leemore Dafny & Kate Ho & Robin S. Lee, 2019. "The price effects of cross‐market mergers: theory and evidence from the hospital industry," RAND Journal of Economics, RAND Corporation, vol. 50(2), pages 286-325, June.
    33. Marco Caliendo & Sabine Kopeinig, 2008. "Some Practical Guidance For The Implementation Of Propensity Score Matching," Journal of Economic Surveys, Wiley Blackwell, vol. 22(1), pages 31-72, February.
    34. Brekke, Kurt R. & Holmås, Tor Helge & Monstad, Karin & Straume, Odd Rune, 2019. "Competition and physician behaviour: Does the competitive environment affect the propensity to issue sickness certificates?," Journal of Health Economics, Elsevier, vol. 66(C), pages 117-135.
    Full references (including those not matched with items on IDEAS)

    Most related items

    These are the items that most often cite the same works as this one and are cited by the same works as this one.
    1. Martin Gaynor & Kate Ho & Robert J. Town, 2015. "The Industrial Organization of Health-Care Markets," Journal of Economic Literature, American Economic Association, vol. 53(2), pages 235-284, June.
    2. Kurt R. Brekke & Luigi Siciliani & Odd Rune Straume, 2013. "Hospital Mergers: A Spatial Competition Approach," NIPE Working Papers 04/2013, NIPE - Universidade do Minho.
    3. Godager , Geir & Scott, Anthony, 2023. "Physician Behavior and Health Outcomes," HERO Online Working Paper Series 2023:3, University of Oslo, Health Economics Research Programme.
    4. Gravelle, Hugh & Liu, Dan & Propper, Carol & Santos, Rita, 2019. "Spatial competition and quality: Evidence from the English family doctor market," Journal of Health Economics, Elsevier, vol. 68(C).
    5. Ambar La Forgia & Julia Bodner, 2025. "Getting Down to Business: Chain Ownership and Fertility Clinic Performance," Management Science, INFORMS, vol. 71(6), pages 5022-5044, June.
    6. Brehm, Johannes & Pestel, Nico & Schaffner, Sandra & Schmitz, Laura, 2025. "From Low Emission Zone to academic track: Environmental policy effects on educational achievement in elementary school," Journal of Environmental Economics and Management, Elsevier, vol. 132(C).
    7. Li, Pei & Liu, Kaihao & Lu, Yi & Peng, Lu, 2025. "Organizing regulatory structure and local air quality: Evidence from the environmental vertical management reform in China," Journal of Comparative Economics, Elsevier, vol. 53(1), pages 139-164.
    8. Chen, Jidong & Shi, Xinzheng & Zhang, Ming-ang & Zhang, Sihan, 2024. "Centralization of environmental administration and air pollution: Evidence from China," Journal of Environmental Economics and Management, Elsevier, vol. 126(C).
    9. Jozef Konings & Aaron Putseys, 2026. "The impact of on-the-job training subsidies on firm-level outcomes: evidence from Flemish SMEs," Small Business Economics, Springer, vol. 66(3), pages 977-1003, March.
    10. Jeannette Brosig‐Koch & Burkhard Hehenkamp & Johanna Kokot, 2023. "Who benefits from quality competition in health care? A theory and a laboratory experiment on the relevance of patient characteristics," Health Economics, John Wiley & Sons, Ltd., vol. 32(8), pages 1785-1817, August.
    11. Tobin, Zachary, 2024. "How do public schools respond to competition? Evidence from a charter school expansion," Economics of Education Review, Elsevier, vol. 99(C).
    12. Brehm, Johannes & Pestel, Nico & Schaffner, Sandra & Schmitz, Laura, 2022. "From low emission zone to academic track: Environmental policy effects on educational achievement in elementary school," Ruhr Economic Papers 980, RWI - Leibniz-Institut für Wirtschaftsforschung, Ruhr-University Bochum, TU Dortmund University, University of Duisburg-Essen.
    13. Hjalmarsson, Linn & Kaiser, Boris & Bischof, Tamara, 2023. "The impact of physician exits in primary care: A study of practice handovers," Health Policy, Elsevier, vol. 135(C).
    14. Gruhl, Henri & Volkhausen, Nicolas & Pestel, Nico & aus dem Moore, Nils, 2025. "Air pollution and the housing market: Evidence from Germany’s Low Emission Zones," Journal of Environmental Economics and Management, Elsevier, vol. 132(C).
    15. Lin, Haizhen & McCarthy, Ian M. & Richards, Michael, 2021. "Hospital Pricing Following Integration with Physician Practices," Journal of Health Economics, Elsevier, vol. 77(C).
    16. Jens Dietrichson & Lina Maria Ellegård & Gustav Kjellsson, 2020. "Patient choice, entry, and the quality of primary care: Evidence from Swedish reforms," Health Economics, John Wiley & Sons, Ltd., vol. 29(6), pages 716-730, June.
    17. Carl Hase & Johannes Kasinger, 2024. "The Pass-through of Retail Crime," Papers 2407.07201, arXiv.org, revised Oct 2024.
    18. Wang, Qianqian & Sun, Xinmeng & Xiong, Haoyang & Wang, Qi & Zhang, Bing, 2024. "Environmental taxes, environmental outsourcing, and pollution abatement: Evidence from Chinese industrial sewage discharge enterprises," Energy Economics, Elsevier, vol. 133(C).
    19. Yadav Anil & McHale John & Harold Jason & O’Neill Stephen, 2026. "Estimating the effects of staggered interventions with count and binary outcomes: a simulation study," Journal of Causal Inference, De Gruyter, vol. 14(1), pages 1.
    20. Neri, Lorenzo, 2024. "Moving opportunities: The impact of mixed-income public housing regenerations on student achievement," Journal of Public Economics, Elsevier, vol. 230(C).

    More about this item

    Keywords

    ;
    ;
    ;
    ;

    Statistics

    Access and download statistics

    Corrections

    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:eee:jhecon:v:104:y:2025:i:c:s0167629625000852. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    If CitEc recognized a bibliographic reference but did not link an item in RePEc to it, you can help with this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: Catherine Liu (email available below). General contact details of provider: http://www.elsevier.com/locate/inca/505560 .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.