Building a case for equitable resources for practices serving high need populations

Many practices in socioeconomically deprived areas will be experiencing pressures on their funding arising from the general decline in primary care funding, removal of Minimum Practice Income Guarantee and redistribution of PMS funding.

As you will be aware, the Carr Hill Formula is currently used to determine how much funding GP practices receive. This gives weighted list size for your practice, which is then multiplied by the GMS capitation rate. The formula currently takes account of the following factors:
• patient sex and age for frequency and length of surgery and home visit contacts
• nursing and residential home status
• morbidity and mortality
• newly registered patients
• unavoidable costs of rurality
• unavoidable higher costs of living through a staff market forces factor applied to the costs associated with employing practice staff. In particular, this compensates for those additional costs involved in delivering services in high cost-of living areas such as the south east of England.

You will notice that deprivation is not included as a separate item. Whilst it is indirectly accounted for through morbidity and mortality and newly registered patients, it is now widely accepted that the current iteration of the Carr Hill formula does not adequate take account of the increased demand in Deep End practices.

One of the key reasons for this is that the onset of multimorbidity is 10-20 years sooner in the more deprived populations (Barnett et al, 2012) and sicker younger patients do not benefit from the age weighting applied in Carr Hill. Boomla et al (BMJ, 2014) showed that practices in Tower Hamlets caring for the most deprived quintile of the population would need 33% more resources to meet demand than those practices serving the least deprived quintile.

More recently, McLean et al (BJGP, 2105) highlighted the same issue in Scottish general practice, demonstrating that GP funding and GP to patient ratios are (at best) flat across deprivation quintiles whilst markers of need such as physical-mental health comorbidity and standardised mortality rates rise rapidly with increasing levels of deprivation. For example, practices serving the least deprived quintile received approximately the same funding as practices serving the most deprived quintile but had half as many patients with 5 or more chronic conditions, half as many patients with mixed mental and physical health conditions, 20% fewer consultations per annum and a standardised mortality ratio of 62 versus 149.

There are myriad other factors also influencing workload and demand:
• Fragmented mental health and social care
• More work around child safeguarding
• Use of interpreters for many patient encounters
• Inequity in health literacy (and actual literacy)
• Higher rates of substance misuse
• Patients have fewer financial and social resources to cope with crises

Mercer and Watt (2007) showed that it is not just a quantitative difference in demand, but that the content on consultations in “Deep End” practices is also more challenging because of social complexity and psychological stressors. They found that:
“The increased burden of ill health and multimorbidity in poor communities results in high demands on clinical encounters in primary care. Poorer access, less time, higher GP stress, and lower patient enablement are some of the ways that the inverse care law continues to operate within the NHS and confounds attempts to narrow health inequalities.”

Finally, the inverse care law is amply demonstrated by the fact that deprived areas have fewer GPs per head of population (National Audit Office, 2010) and GP access is poorer (RCGP, 2014).

Building a case for your practice:
• Analyse your local area to determine how well your practice is funded using the HSCIC data on payments to GP practices: http://www.hscic.gov.uk/catalogue/PUB16847
• Use the Public Health Fingertips data to demonstrate the healthcare needs of your population: http://fingertips.phe.org.uk/
• Liaise with your public health department to explore the public health implications of proposed funding changes
• More “political” approaches: CCG (Council of Members and Governing Body), Local Medical Committee, Healthwatch, GP specialist media, local politics (Councillors may have powers to pull in proposals for scrutiny), local or regional press, national politics (your MP, Health Select Committee)

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