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Is scrapping the square root formula fair?

Dr Tim Scott says for far too long the formula has penalised practices in areas of high disease prevalence. But Dr Adam Pringle argues that although it is not ideal, scrapping it wholesale will make things worse

Dr Tim Scott says for far too long the formula has penalised practices in areas of high disease prevalence. But Dr Adam Pringle argues that although it is not ideal, scrapping it wholesale will make things worse


Since the introduction of the QOF, my practice of 13,300 patients has been denied about £120,000 as a result of the square root correction factor. Three years ago, GPC member Dr Andrew Dearden claimed it was 'artificial' to say practices lost out because of the formula (Pulse, 16 July 2005). However, the experience of my practice is grounded in hard fact.

The formula seems to have been deliberately designed to work against practices with high disease prevalence.

For example, a practice with double the average prevalence will have had its raw figure for QOF income reduced by 30% (the square root of 2.0 is 1.4). Conversely - and almost unbelievably - any GPs with disease prevalence of less than 1.0 will have seen their raw figures boosted; the square root of 0.5 is of course 0.71, an increase of 40%! GPs with lower prevalence will receive twice the income per patient of their high prevalence colleagues - 140% of average compared with 70%.

The QOF is really just another item of service fee - the achievement of a clearly defined objective results in a payment. The difference, of course, is the unprecedented square root 'correction'.

I am sure that there have been major inter-practice variations in other IOS fees in the past. But I don't recall those GPs with higher claims ever being asked to subsidise the others.

At its introduction, the view of the Department of Health was that this correction was necessary to 'narrow the national range of disease prevalence' and therefore the payments. The rationale given was that all practices have costs in setting up disease registers, training staff and buying equipment in order to do the extra QOF work.

I can't see much merit in that argument for the following reasons:

  • QOF work is optional and additional to core GMS/PMS activities
  • disease registers take no real time to set up - assuming the practice is computerised and uses Read codes
  • staff training is a one-off cost
  • the vast majority of QOF indicators do not require the purchase of equipment
  • even if you do attach weight to the reasons given, none of the costs is recurrent
  • the amount of work involved in providing chronic disease care to a practice population is directly proportional to the number of patients and not to the square root of that number.

Also let's not forget the extra non-QOF workload generated by these patients with chronic disease, which isn't reflected in any income stream: the chest infections, leg ulcers, immobility, blindness and so on.

We, like many practices, invested in extra staff when the QOF was introduced. So far, our experience has shown that if 10 patients can be seen in one clinic then, unsurprisingly, we do actually need two clinics to deal with 20 patients and not 1.4 (the square root of 2).

The most disaffected among us have been those GPs with very high disease prevalence struggling to cope with their workload and receiving far less than their fair share of QOF income. I'm sure there are practices out there who will have been 'corrected' downwards far more than us. The QOF enables the redistribution of some resources according to health need but its effect is blunted by this adjustment.

The correction factor is an emollient to practices with low disease prevalence who presumably feel somehow cheated. A raw calculation based around relative prevalence is sensible, logical and just, but the square root correction is unprecedented and unfair. It is a snub to the concept of equity and I, for one, shall be delighted to see the back of it.

Dr Tim Scott is a GP at Staffa Health, Tibshelf, Derbyshire


I'm not arguing that the square root formula is great. At its simplest, nobody would argue that four patients are only twice as much work as one - but scrapping it solves little, and adds to a sea of other problems facing general practice.

The history of primary care is littered with attempts to create funding formulae. Yet any formula leaves some better off and some worse off and every change leaves general practice as a whole a little poorer.

Somebody far cleverer than I am demonstrated that the square rooting saved the Government money and I've little doubt they will abolish it in a way that saves them a little more.

The post-war contract lasted 50 years, Ken Clarke's version lasted 10 and this century's new contract was sold to us as a 'once and for all change'. It was closely followed by a 'once and once only revision of the QOF', followed (inevitably) by changes every year that add work and remove funding in a random and capricious way.

This endless change creates endless uncertainty. How can anyone make a sensible business plan, train staff, expand a practice or take on partners, when such a large part of a practice's income depends on the whim of the health secretary?

Or now, God save us all, on the whim of NICE - an organisation that alternates between teaching us to suck eggs and producing guidance at odds with specialist bodies such as the British Hypertension Society. It certainly has little contact with the reality of general practice.

So, scrapping the square root formula can be seen as just another bit of largely pointless fiddling around. But it also creates perverse incentives to create work of little value.

We will see rapid rises in prevalence as diagnostic thresholds fall. Occasional inhaler users will become asthmatic and patients with impaired glucose tolerance classified as diabetic. And I'm sure some will come to harm through overtreatment.

We will create lots of work - and then the Government will create another layer of hoops to jump through which will create yet more work.

Assume for a moment that we scrap the square root and everyone is coded and treated properly, and the average practice is better off. Do you really think you will keep a penny more? It will all be clawed back next year twice over - every change is an opportunity to take money away from general practice.

If we really want a sensible change, what exactly is wrong with flat-rate capitation? For all the complexities of the old Red Book, most practices had pretty similar income per head. If you have a young list, you have lots of children who attend frequently; if you have lots of elderly you don't have the children; if you have high morbidity and mortality you don't have as many elderly.

Just imagine how much we would all save in administration costs, which would offset any losses for most practices.

Even better, why not a series of five contracts, with slightly different terms and conditions - a rural practice model, (with dispensing and on call included), an inner-city model (with security guards) and three steps in between - all paid the same, but with different trade-offs?

We could do high-demand easy access healthcare for the unemployed and refugees, but only between 9am and 5pm.

Or I might agree to be on call 24 hours a day, but would need 14 weeks respite a year, for example.

My plea to the Department of Health and the GPC is this: stop buggering about with the contract or - if you must - start from scratch and keep it simple.

Dr Adam Pringle is a GP in Telford, Shropshire

Is scrapping the square root formula fair? yes quote

GPs with very high disease prevalence receive far less than their fair share

'no' quote

If we really want a sensible change, what is wrong with flat-rate capitation?

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