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Gold, incentives and meh

Square root correction factor is ripping off my practice

I was glad to read your front page a few months ago on the QOF square root correction factor (‘GPs face sweeping QOF pay overhaul'). It was apparent from the word go that the formula was going to cause problems.

Back in 2005, I calculated that it caused my practice to receive £21,059 less than it deserved from the QOF. The following year, the loss was nearly £32,000, and over the past financial year it will again have been about £30,000. These are mathematical facts, yet when the formula's problems first came to light, Dr Andrew Dearden of the GPC claimed such losses were ‘artificial'.

The system seems to have been designed to work against GPs with high disease prevalence – often, of course, those in deprived areas. 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 GP with disease prevalence lower than 1.0 will see their raw figures boosted; the square root of 0.5, for example, is 0.71 – an increase of 40%!

In real terms, this has significant effects. My own practice of 13,300 patients has higher than average prevalence in all but one disease area, giving us the losses detailed above when comparing the raw with ‘corrected' figures. The calculation is based on relative prevalence, so about 50% of practices will have above-average prevalence and the other half below average. This implies there is a practice of similar size to ours, most probably in another area of the country, with prevalence figures significantly below the average that will have gained by a similar amount in relation to its raw achievement.

QOF payment is really just another item-of-service fee – there are clearly defined objectives that attract payment when they are reached. The only difference is the square root ‘correction'. I am sure there has been major interpractice variation in IOS fees in the past; no doubt GPs working in coastal resorts have quite correctly received large amounts in temporary resident income and university practices have probably had above-average registration fees. I have no problem with extra income being earned in these ways, and I don't recall these practices ever being asked to subsidise those GPs such as us who don't see many tourists.

The Department of Health's view, detailed on its website and implicitly supported by the GPC, is that correction is necessary to ‘narrow the national range of prevalence'. The rationale is that all practices have costs in ‘setting up disease registers, training staff and buying equipment' to do extra QOF work. I can only see a tiny degree of merit in this argument, for the following reasons:

• Disease registers take no real time to set up, assuming the practice uses a computer and Read codes.

• Staff training and purchases of equipment are one-off, non-recurrent costs.

• In any case, the vast majority of QOF indicators do not require special equipment – a spirometer is the only item that springs to mind.

Any right-thinking GP will surely agree that, in chronic disease management, the workload is directly proportional to the numbers of patients involved and not to the square root of that number. Let us also not forget the extra non-QOF workload generated by these patients – in terms of chest infections, leg ulcers, immobility, blindness.

We have invested in extra staff to offer chronic disease management clinics on the basis that we will gain extra income from the QOF to cover costs. So far, our experience has shown that if 10 patients can be seen in one clinic then, unsurprisingly, we need two clinics to deal with 20 patients, not 1.4 clinics.

I think the correction factor is an emollient to GPs with low disease prevalence who will apparently feel somehow cheated compared with those with high prevalence. It is unprecedented, unfair and unacceptable to those 50% of us who will lose out. It should be removed forthwith.

From Dr Tim Scott, Tibshelf, North Derbyshire

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