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Is the square root formula fair?

Can it be right that practices with the same size CHD register can earn as little as £850 or as much as £25,063 for 100 QOF points

By Lilian Anekwe

Can it be right that practices with the same size CHD register can earn as little as £850 or as much as £25,063 for 100 QOF points

Dr Anthony Lister, who practises in Norwich, typifies the group of GPs researchers have identified as financial losers under the square root formula used to adjust QOF payments.

‘Most people think of Norwich and think it's quite leafy, but it's actually quite deprived,' he says.

‘We have high prevalences in all the areas you would expect of a deprived area – CHD, asthma, mental health, diabetes.'

For Dr Lister the square root formula has meant a tough few years. ‘We have achieved maximum QOF points every year since the beginning and it's been bloody hard work.

‘For the life of me, I don't understand how people in very deprived areas of inner cities are able to provide a high-quality service.'

Dr Lister is one of thousands of GPs affected by massive variations in GP earnings caused by this controversial funding mechanism.

The square root formula, used to adjust pounds-per-point earned by GPs according to disease prevalence, remains a subject of fierce debate.

However, a new report by the NHS Confederation, based on research from the National Primary Care Research and Development Centre, has sparked speculation of a major shake-up.

Alarmingly, it calculates that in extreme circumstances, a small GP practice with very high prevalence can earn £13 per patient for achieving maximum points in its CHD targets, compared with £27,600 that could be earned in a large practice with a very low prevalence.

Dr Tim Doran, clinical research fellow at the NPCRDC and the researcher behind the data, says he has uncovered ‘very real examples' of differences of nearly £3,000 per patient.

‘The square root formula does create an unusual situation where some people are getting overpaid. The problem is, it distorts the extreme ends of the distribution,' he says.

‘This is just one of the problems of having a "one-size fits all" QOF,' Dr Doran adds.

Professor Bruce Guthrie's research has shown the amount paid per patient on a disease register can vary by up to 44 times.


They blew it

Professor Guthrie, a professor of primary care at the University of Dundee, says general practice has always had inequalities of payments, the question that needs to be asked is: ‘Is the inequality a fair one?'

He says: ‘When they created the square root formula it was an opportunity to match payments with workload. But I think they blew it. I think they effectively prioritised the wrong thing.'

NHS Employers says it is keen to negotiate changes that will smooth the kinks the square root creates.

Professor Guthrie's solution is a simple one – pay practices per point achieved, per patient with disease. The problem is ‘there's no straightforward relationship between the two', he says.

‘I can't see any justification for having the formula whatsoever. But adjusting capitation for workload is highly controversial.

'When you try to change from one system to another the winners are happy, but the losers complain vociferously – and rightly so.'

And he warns: ‘The problem is, if you try and change it there will be major losers. The losses from changing it may outweigh the case for change.'

Dr Robin Jackson, a GP in Lancashire, thinks that whatever tinkering is done during current negotiations, the QOF should be based on evidence, ‘which won't change whether you're in Barnsley or Barnstaple'.

Dr Lister describes the GPC's position – that the square root formula is ‘the best compromise' – as ‘just stunning'.

He says: ‘When I started practising in 1979 I could never have imagined how much things would change.

‘Working in a deprived area has a limited shelf life. I think we are in danger of seeing massive movement and a lack of continuity. The picture for inner-city areas is very bleak.'

He adds: ‘The GPC has singularly failed to understand the issues of inner-city GPs. I don't know why the GPC is consistently failing to represent GPs in deprived areas.'

Dr Tim Doran Dr Tim Doran

The square root formula means some people are overpaid

Formula ‘Abolish the MPIG too'

‘Abolish the MPIG too'

As well as calling for the square root formula to be changed, last week's NHS Confederation report also called for the MPIG - which it said ‘prevents equitable distribution of resources' - to be abolished.
Lancaster GP Dr Robin Jackson has particular concerns about scrapping the MPIG. ‘If they do get rid of the MPIG, or part of it, then it would destabilise practices,' he says.‘The concern is the Government will say "so what, they can go bust and we'll just get a private company to run the practice".'

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