Square root formula for disaster
GPs working in deprived areas have enough to cope with, without the added kick in the teeth
of the square root
formula for adjusting
QOF payments, says
Dr Anthony Lister
When the QOF was first published I was quietly confident our practice would do well and at last all the hard work I and my colleagues and staff had put in over many years might bear fruit.
I work in a small urban training practice of just under 3,000 patients in an area of Norwich that has become increasingly deprived over the past decade. We have good-quality records and were able to produce disease registers perhaps a little more easily than some other practices.
We have remarkably high disease prevalences in many areas; the highest in Norwich for hypertension, heart disease, asthma, diabetes, smoking, obesity, learning disability, severe mental illness and depression. Indeed, the data shows that our antidepressant prescribing rate is the highest in England.
All my hope disappeared when I read – with disbelief – the details of the square root formula for prevalence payments. Once again, urban GPs operating in difficult conditions were kicked in the teeth – only this time it had been approved by our own negotiators. Who can possibly explain how carrying out a year's surveillance on two diabetes patients does not take double the time it takes to carry out surveillance on one?
High prevalence of chronic disease is by its very nature more common in deprived urban populations. The same deprived urban populations thrust upon their GPs more Disability Living Allowance forms, more Department of Work and Pensions IB113DLS forms, more sickness certification, more one-week and sometimes one-day repeat prescribing and higher than average use of interpreter services (and each such consultation takes the time of three normal consultations).
Then there is the additional child protection work, the social services case conference reports, the inadequately rewarded drug dependence work and the frequent contact with poorly organised and fragmented mental health services. Our patients, with perhaps less well developed coping skills, summon more ambulances, turn up more frequently at emergency departments and walk-in centres and use out-of hours centres less appropriately. And we are left to record all these contacts and try to co-ordinate care in difficult circumstances.
Urban deprived areas also have odd demographics with many elderly living alone, high rates of alcoholism, smokers and obesity. Natural turnover of patients
is higher, bringing additional work
from new patient checks, summarising records, printing out and packing up
the voluminous records of patients transferring out of the practice. All this means reduced job satisfaction for the clinicians as patients rapidly come and go.
Our primary care teams are rapidly becoming fragmented by Department of Health initiatives such as Sure Start and community matrons, for which evaluation has shown little or no benefit for public health despite significant investment.
And as reward for all this, the more patients with complex chronic diseases that we have on our practice list, the less additional income we receive to look after each additional one.
Would somebody please explain to me the logic of this? The GPC asserts that no change in the funding formula is possible because some GPs may lose out. This position is grossly unfair to those of us working in deprived urban settings. It is the same urban GPs who have lost out over the past 20 years who seem to suffer further for every change. This year's zero pay increase exacerbates the problem.
The GPC agenda is mighty difficult
for urban GPs with high-prevalence populations to understand. Unless we have a substantial investment in inner-city practices, nobody will want to work there in anything other than a salaried capacity.
Frankly, I don't care if any reallocation of funding creates losers as well as winners. The status quo is not an option
if the profession is truly anxious about private providers in general practice –
and goodness, it ought to be.
The GPC is fiddling while inner cities burn.
Anthony Lister is a GP in Norwich and a
VTS organiser and GP appraiser