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Do PMS GPs get too much money?

The extra money spent on PMS practices may be wasted on reports and renegotiating contracts, says Dr Hank Beerstecher. But Dr Jane Lothian says if there is evidence PMS practices get too much money, let's hear it - if not, let them get on with tailoring services to local need

The extra money spent on PMS practices may be wasted on reports and renegotiating contracts, says Dr Hank Beerstecher. But Dr Jane Lothian says if there is evidence PMS practices get too much money, let's hear it - if not, let them get on with tailoring services to local need

Yes

Practices in England have been able to switch from GMS to PMS contracts for over 10 years now. By doing so practices lose their right to national negotiation of terms and conditions but usually gain an increase in practice income in the form of 'growth monies' to pay for additional services.

Lately PMS practices have come under pressure as PCTs are trying to recoup the extra funding that flows to PMS. It seems some PCTs now question the usefulness of this extra funding.

The evidence on whether the higher cost of PMS is justified is sparse1,2. In 2005 a PMS evaluation study by the NHS Information Centre found PMS practices on average cost more to the taxpayer, but they also seemed to be more productive.

The study was probably slightly biased as the PMS practices were selected and their GMS controls were not. Plus the differences were not large and both GMS and PMS improved over the duration of the study.

It reported that the take-home income of PMS GPs was higher, but they didn't look to see if the doctors worked harder for this money and therefore whether it was deserved.

We compared PMS and GMS practice costs in 2006 and looked to see if PMS produces higher QOF scores3. We did not find much objective difference.

A slightly more sophisticated method is to compare QOF score as output and deprivation-related workload and cost as inputs. Doing this (unpublished data) reveals the expected - PMS and GMS do not differ much in deprivation-related workload or QOF score, so the higher average cost of PMS always means that, in this model, PMS practice pay seems undeserved.

There are, however, some other snags. One is that PMS doctors probably spend more time creating reports and negotiating their contracts with the PCT. Such work would have to be paid for but does not show up in measures of clinical care. From a clinical care point of view this extra money may be wasted on unnecessary administrative chores.

Another snag is that not all PMS practices are paid equally. There are wide variations in pay for, on the face of it, similar services to similar populations - just as there are under GMS.

We even found some PMS practices were receiving less than their global sum, even without any MPIG at all. These practices hadn't struck a good deal and were in fact underfunded compared with their GMS neighbours.

There may be some embarrassment in Government circles about the inequities in GMS and PMS payments and this may be behind the attacks on PMS pay and the MPIG for GMS practices.

I suggested to the consultation exercise on the MPIG last year that it would be little use rearranging the deckchairs in GMS or PMS if APMS providers still carted off disproportionate amounts of taxpayers' money. Imagine, for instance, giving a million pounds to a practice, up front, before any work is carried out. And yes, I'm talking about Darzi centres here.

There is little doubt in my mind that funding of practices in the UK is grossly inequitable and I would support the rooting out of that unfairness. All practices - be it GMS, PMS or APMS - should receive the same fair funding for patient care and infrastructure. Call it a national tariff for primary care.

This would probably mean PMS losing more income than GMS, but PMS practices should be able to drop their extra work or transfer this into an enhanced service. Such a change in funding would not only level the playing field between GMS and PMS but also for private providers.

Dr Hank Beerstecher is a GP in Sittingbourne, Kent, who has researched the differences between GMS and PMS pay

No

There have been many proponents of PMS initiatives in the decade since they started and equally there have been many attempts to shoot them down. PMS was developed to escape the rigid rules of the old GMS contract and allow practices to provide personal medical services driven by and appropriate to local clinical need. Now where have we heard that recently?

Primary care was allowed to develop organically, focusing on quality and outcomes rather than process. Differential investment was encouraged.

Critics say PMS practices are overfunded, but where's the evidence? To prove it would need sophisticated research that has simply not been done. Evaluation of overfunding is on a national value of cost per patient and also on a crude assessment of GP remuneration. No attempt has been made to look at the complexity of GP remuneration, the contribution of private healthcare to the services available to patients nor availability of non-NHS work.

What does primary care actually consist of? Essential and additional services are not defined. The QOF is essentially a data-gathering exercise and for many areas does not necessarily reflect the activity of the practice - only its ability to accurately record it. Enhanced services with tight specifications are potentially a double-edged sword, reducing adaptability and responsiveness. What PMS contracts allow is valuable additional flexibility.

If the presumption is that PMS is overfunded, the implication is that it is either inefficient or fraudulent - but can we prove it? But if it is efficient, then by definition it is providing a needed service. Why then must we level down?

Every GP knows quality in primary care does not equate to saving money. Improving quality is often a metaphor for shifting activity. I can ethically, legally and morally give my patients a service where I see them once or twice and refer, or 10 times and not refer. Which is right? Both are totally defensible contractually. We must assume that PMS practitioners are equally as moral and as efficient GMS colleagues.

The Department of Health would like us to deliver an all encompassing primary care service for the global sum of £54.72 per patient; recently inflated to £56.20. In the past five years, the amount of work primary care can do has expanded dramatically.

So can primary care be reduced to an undefined soup of services that is infinitely expandable at the whim of the Government - all for £56 per patient?

The nGMS contract places no local or specific obligations on GPs, compared with the original ethos of PMS, which had very high expectations.

GPs in Northumberland - where 85% of practices are PMS - solved a recruitment crisis in the late 1990s. Innovative jobs, attractive to young practitioners, were developed along with services for a highly deprived area. Large groups of practices worked closely together, akin to the proposed federated model.

Under the 2008 PMS review, a decision was made to withdraw a substantial proportion of our income from April 2008 to 2010, which has already resulted in redundancies of skilled clinicians.

If the DH wants to get rid of PMS then I believe it is doing a very good job. Flexibility underpins true innovation.

The degree of flexibility for non-standard populations, even within nGMS, is far inferior to that in PMS. If you specify widgets you will get widgets; if you specify outcomes you will encourage innovation.

My plea to the DH is simple. If you truly believe PMS is overfunded, come up with robust evidence of the type you demand in every other branch of healthcare.

Dr Jane Lothian is a PMS GP in Northumberland

References

1 Do Personal Medical Services contracts improve quality of care? A multi-method evaluation. J Health Serv Res Policy 2005;10:31-9

2 GP Earnings and Expenses. Enquiry 2005/6 Final Report, The Information Centre. www.tinyurl.com/5srzxl

3 Morgan CL and Beerstecher HJ. Primary care funding, contract status and outcomes. BJGP 2006;56:825-9

yes quote

All practices should receive the same fair funding for patient care

'no' quote

If the DH wants to get rid of PMS then it is doing a very good job

Do PMS GPs get too much money?

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