John Appleby’s briefing (‘Is general practice in trouble?’ BMJ Nov 2014) reminds us that funding for general practice has fallen to 8% of total NHS spending (1).
His analysis of the ups and downs of investment in general practice since 2003 masks the important point that different practice population needs make major differences to practice workload. Recent changes to funding allocations between practices, in particular by removing the minimum practice income guarantee (MPIG) will have the result of increasing health inequalities – apparently under the banner of providing uniform funding for all (2).
In 1983 the Jarman score introduced the first area based weighting for workload associated with deprivation in the allocation of general practice budgets. In 2004 this was replaced by the Carr-Hill funding formula which was introduced with the laudable aim of providing funding to reflect the workload requirements of the population served by each practice. Reliable data on the workload implications of social deprivation were not available at that time, and the resulting formula did not redress the health burden of inequality – which has been amply demonstrated by the Marmot report and others (3,4). Instead some practices required funding top ups through the MPIG, to offset unacceptable losses and practice closures. In 2014, as the MPIG is phased out, once again the underlying problems with the equitable distribution of the global sum are revealed. Twenty two of the worst affected practices in the country come from some of England’s most deprived boroughs in Tower Hamlets, City and Hackney and Newham.
Appleby states that there is a dearth of information about activity outputs in general practice with the latest data on consultation rates being 2008 (1). But this information is not hard to generate. Consultation rates, by deprivation score, are available in nationally representative samples of GP practices. We have examined the 2013 annual GP consultation rates, by age and sex, for the one million GP registered population in east London, and have broken this down by the national quintile of Index of Multiple Deprivation (IMD) based on linkage to lower super output area. Our findings (fig 1) illustrate the excess number of consultations in more socially deprived groups, and illustrate that an individual aged 50 years in the most deprived quintile consults at the same rate as someone aged 70 years in the least deprived quintile. This reflects Marmot’s findings of an 18 year gap in disability free life expectancy (2).
Moreover these additional consultations are not simply brief encounters for minor illness. Analysis of consultations which include one or more of a cluster of common investigative blood tests shows a similar distribution by deprivation, indicting the complexity of these consultations, (data available but not shown).
Using these data we are able to recalculate the age-sex workload index element of the Carr-Hill formula by weighting the population by the observed consultation rates in each deprivation quintile. When we do this for Tower Hamlets, which is one of the top five deprived boroughs in England, we estimate that a fair formula which takes into account the additional workload for this population would provide 33% more funding. If this were to be implemented it is likely that the need for MPIG would disappear.
Finally, the 2007 funding formula review which was convened in response to the perceived shortcomings of Carr-Hill, included deprivation weighting and would have rebalanced funding towards deprived areas which are currently reliant on the MPIG top up (5). We are now on the cusp of a second attempt at resource redistribution in primary care. We have demonstrated it is possible to accurately measure the large effect of deprivation on consultation rates. If the rhetoric of reducing health inequalities is to be meaningful for general practice then calibrating the funding formula for deprivation is an essential first step.
GP, Clinical Senior Lecturer, QMUL
GP, Reader in Primary Care Development, QMUL
GP, Reader in Primary Care Research and Development, QMUL
1. Appleby J. Is general practice in trouble? BMJ 2014;349:g6814.
2. NHS England . Impact of phasing out the Minimum Practice Income Guarantee: ‘Outlier’ GP practices: NHS England, 2014. http://www.england.nhs.uk/wp-content/uploads/2014/02/gp-gms-practices.pd... Accessed 05/12/2014
3. Marmot M, Bell R. Fair society, healthy lives. Public Health 2012;126 Suppl 1:S4-10.
4. Barnett K, Mercer SW, Norbury M, Watt G, Wyke S, Guthrie B. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012;380:37-43.
5. BMA and NHS Employers. Review of the General Medical Services global sum formula. BMA. 2007 http://www.derbyshirelmc.org.uk/Guidance/Review%20of%20the%20GMS%20Globa.... Accesed 05/12/2014
Competing interests: All three are GPs based in Tower Hamlets