PBC cash shifting from rich to poor
It is a tough task getting NHS cash to the patients – and doctors – who need it the most.
Practice-based commissioning budgets are the latest to come under scrutiny as the Government looks for an equitable way of dividing up the pie.
Ministers plan to introduce a formula for calculating PBC budgets that give GPs in deprived areas a bigger share. The Department of Health is looking for a team of researchers to draw up a magic formula that rejigs funds without unduly penalising some practices.
The idea is that allocations will be based on 'individual patient characteristics'. Commissioning budgets are likely to be weighted in favour of socio-
economic factors such as unemployment levels and the number of lone-parent families. Budgets are also likely to weight funds so money is targeted towards areas with high mortality, high disease prevalence and high prevalence of associated risk factors, such as alcohol misuse and smoking.
At present money is allocated according to historical referral patterns, which do not necessarily reflect the true picture of patients' needs. Health economists predict that when the formula is introduced, inner-city practices could see uplifts in PBC budgets, whereas those in leafy suburbs could see theirs cut.
Dr Ethie Kong, a GP in Brent, north London, which is one of the 30 most deprived areas in England, says: 'Any increase would be good news. People in deprived areas are needier. They have more complications and more chronic conditions. Patients with not much money do not have the choice about going
private to places such as BUPA.'
She adds: 'If we had more money it would empower practices to redesign services or to commission services nearer home in the community setting. It could help people with long-term conditions and consultants could come to practices so that patients do not have to travel so far.'
Although we might expect patients in deprived areas to be in worse health and therefore use more NHS services, the reverse is often the case.
These patients tend to be less assertive and confident, and have lower expectations about their healthcare, says Dr Elizabeth Barrett, a GP from Shire Brook, Derbyshire. Despite having greater health needs than their more affluent counterparts, they are not skilled in 'navigating' the health system – sometimes because of language difficulties – and as a result do not access the same level of services, she argues.
Dr Barrett says that as GPs in deprived areas are welcoming extra money, their counterparts in leafier areas will be
resentful at seeing their budgets drop. 'It is very difficult to take budgets away from people who have had them for a long time.'
David Barr, clerk for Kent LMC, says: 'You cannot just take money from one area and give it to another. It makes the assumption GPs in better-off areas are overtreating people – there is no evidence of that.'
Dr Philip Razzel, a GP in
relatively moneyed Sevenoaks in Kent, says: 'There is a problem in targeting resources at vulnerable groups. You cannot say that just because an area is leafy that everything is okay.'
The Department of Health acknowledges that one difficulty is how to allocate money covering high-cost conditions. Another complicating factor is that some affluent areas have high populations of older people who may not be experiencing deprivation, but still need a lot of care.
Giving PBC appeal
But there is one factor that makes overcoming these difficulties especially worthwhile for the Department of Health, and that is the prospect of drawing more GPs into PBC. PBC may not be seen as an attractive proposition for many practices in deprived areas because the commissioning budgets awarded are so low.
Dr Bhupinder Kohli is a GP in Newham, east London, which already has a £20m shortfall on the 'fair share' formula for calculating what services should be available for patients.
Dr Kohli is part of a partnership of 42 practices that has a joint PBC budget of £30m. He is keen on developing PBC, but says the changes may still not be enough to encourage
uninterested GPs elsewhere to take part.
'PBC is struggling to survive because most people are not that excited by it – especially with all the GP-bashing going on. It seems like a lot of work for little gain,' he says.
Why deprived areas need funds...
More patients in the Wirral area of Merseyside could get access to the services for cardiovascular and respiratory illnesses that they need, under the Department of Health's changes to PBC budgets, says Dr Jim Bates, a GP in Wirral.
Dr Bates says the formula would benefit patients in his area, which has patches of deprivation. He says heavy smoking and drinking has taken its toll and caused high levels of heart and lung diseases among the population, which urgently need tackling.
'It is true that patients in affluent areas request more services, but it should not be like that,' he says.
'It creates inequities. There are a lot of postcode lotteries around and so we should do something to address this. I think this is part of the Department of Health's plan to have money following the patient.'
He is concerned, however, that GPs may have to help work out who gets what.
'Some poor bugger will have to do the donkey work – and I think I know who that will be.'
... and why affluent ones do too
GPs in the relatively affluent county of Wiltshire will fail to stay within budgets if money is cut from their commissioning budgets, warns Dr Nick Brown,
a GP in Chippenham.
On one hand diverting money to more deprived areas from elsewhere will bring better
care for patients in dire need, he says.
But on the other, this will make life difficult for GPs in more affluent areas where patients are often heavier users of services.
'It is not always patients with the greatest need that demand the most services,' he says. 'Someone in a deprived area may put up with a slightly painful hip, but in more affluent areas patients tend to want to see something done about it.
'That is why we always overspend here. It is simply because the patients demand more than the Government wants them to.'
Many trusts with deficits are in southern England, where budgets are already relatively low, he emphasises.