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Weighting of GP practice funding is 'inequitable', finds study

GP practices in the north of England should be receiving higher funding than they do under current weighting, researchers have suggested.

A University of Manchester-led study, published in BMC Medicine, found that the Carr-Hill formula for weighting GP practice funding based on local health needs was 'inaccurate' and 'out of date'.

The research, partly funded by the Medical Research Council, aimed to examine whether primary care funding in 2015/16 matched healthcare needs in geographical areas with an average of 1,500 people.

Looking at data from 7,779 GP practices in England - covering nearly 57m people or 99% of the GP practice-registered population - the team created a new chronic morbidity index (CMI).

This was calculated as the sum of 19 chronic condition registers in the 2014/15 QOF framework, divided by the total practice population.

The analysis found that London has a median of 0.38 health conditions per patient - the lowest in the country - whilst the highest and second-highest health needs were found in North East and North West of England (at 0.59 and 0.55 conditions per patient respectively).

The paper said: 'Levels of morbidity varied within and between regions, with several clusters of very high morbidity identified. At the regional level, morbidity was modestly associated with practice funding, with the North East and North West appearing underfunded.

'The regression model explained 39% of the variability in practice funding, but even after adjusting for covariates, a large amount of variability in funding existed across regions.

'High morbidity and, especially, rural location were very strongly associated with higher practice funding, while associations were more modest for high deprivation and older age.'

The Carr-Hill formula has been in place since 2004 but has been subject to an on-off review since 2007 (see box). It has frequently been criticised for not sufficiently taking into account deprivation.

Lead researcher Professor Evangelos Kontopantelis, from the University of Manchester, said: 'If as a society we want a healthcare system which is fair, then we must fund it according to need, and ideally account for the impact of deprivation.

'This study shows that the current allocation of resources to primary care does not do that.'

Tim Doran, Professor of health policy at the University of York and co-author of the study, said: 'The present funding formula does not provide an equitable distribution of resources across the NHS. It is especially unfair to the North West and North East of England.

'The Carr-Hill formula, which is used to allocate NHS funding, is based on a range of data, some of which are inaccurate, unrepresentative or out of date. As a result, the formula does not accurately reflect the health care needs of local populations.

'New data sources could provide a fairer allocation of resources.'

NHS England released guidance a year ago saying CCGs should identify which practices were disadvantaged by the Carr-Hill allocation formula and offer them the required support.

Funding allocations and atypical patients

The Carr-Hill funding formula, which weights practice funding based on patient population characteristics, has been subject to review for over a decade but to date no changes have been agreed or implemented.

Criticisms have included that it fails to sufficiently take into account deprivation and rurality, with the issues coming to the fore since the phasing out of the minimum practice income guarantee since 2014/15, as well as reviews to PMS funding.

To counter this, NHS England published guidance in December 2016 instructing CCGs to support 'atypical' practices.

This defined an atypical practice as:

  • Unavoidably small and isolated;
  • University practices;
  • Practices that have 'a significantly high ratio of patients who do not speak English including those services designed to address the needs of migrants'.

Readers' comments (4)

  • Open Exeter statements set out
    1, Weighted lists
    2. Total payment Units (which take into account Distance from Surgery, Deprivation wards etc)
    Some Surgeries are paid only weighted list sizes while others are paid the Total Payment Units.
    Have a look at your Open Exeter statements and see which one do you get. In some cases there may not be a difference due to your location and circumstances but in others it is a matter of criminal behaviour and discrimination by the NHSE Managers.

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  • Healthy Cynic

    Newsflash: The Carr-Hill formula is not 'out-of-date' - it was always rubbish. Hence the MPIG farce.

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  • Discrimination is second nature to the NHS. Some GPs get 250 others 100 per patient. Of course there are some differences such as higher deprivation etc but not to this degree.
    Anyway, if a GMS practice fails, the Trust inevitably gets 25 to 50% more per patient.
    Carr- Hill might have been OK except it was messed around with.

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  • Carr-Hill formula was accepted by the BMA because it didn’t “rock the boat”, and why would it, it was essentially a measure of what was being given to patients in terms of GP time in the late 1980s/1990s. Didn’t measure what patients wants were, or their needs; consultation times 5-7minutes. And yet it is still being used today. Why?? Is it that good?
    Read what Carr-Hill said himself in his own CV...

    “Last year, I was contracted by the Department of Health to develop a workload formula as the basis of the new contract with General Practitioners throughout the UK. Despite the almost total lack of systematic data, I was able to generate a formula with sufficient credibility for it to be accepted by the British Medical Association.”
    Get the feeling it wasn’t his best piece of work??

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