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Why the minimum practice income guarantee is seriously flawed

n the face of it, I should be happy with the minimum practice income guarantee (MPIG). I have supported the view that a system rewarding quality was needed, I supported the framework and in principle supported the contract when it was published, as well as from what I heard at the roadshow. So what has gone wrong?

The Carr-Hill formula and the way it has been presented in terms of the global amount is obviously flawed. Moreover, there is no doubt an allocation formula that somehow results in the majority of practices having a weighted list which is actually less than the definitive number of patients is unacceptable.

Yet the quality framework, which many have welcomed, has a payment structure based on that flawed 'weighted' list. The MPIG completely fails to address this anomaly.

For example, a practice with an actual list of 4,000 and another with a list of 7,000 could end up receiving the same value for quality points as if they had weighted lists of 5,500 patients. In a similar vein, Carr-Hill makes a basic assumption that all practices have the same proportions of patients in different disease areas, so differences in workload in trying to reach the quality targets is not taken into account.

Missing the point

MPIG is designed to ensure no practice loses financially ­ but that was not the point of the contract. The MPIG is the 'transition scheme' made permanent. By necessity, a transition scheme is supposed to be a temporary measure to cushion a change for a few possible losers: it is not designed to be a permanent feature for the majority.

The contract was designed to

pay and reward GPs and practices for an improved service. While the MPIG may ensure no losses, it is not going to ensure much in the way of reward.

There is confusion as to how the MPIG will be calculated and what elements it will comprise.

For example, current Red Book payments which are supposed

to translate into the global amount will be used to determine the value of MPIG.

But there are some factors, such as appraisal, which are not actually costed in the Red Book, and there are others, such as part of the cytology payment or part of the minor operations payment, which quite frankly I think practices will find hard to determine.

In addition, it is said that not all practice staff costs will translate over into the MPIG if a practice undertakes enhanced services or receives high levels of quality payments.

To add insult to injury, MPIG will be top-sliced by 100 quality points in 2004/5 and 150 points the following year! Therefore, quite clearly MPIG is not even maintaining its supposed minimum income guarantee.

Inner-city practices and those with a high proportion of students are just two examples of practices that lose as a result of Carr-Hill. To make the formula 'work' in London, an additional £53 million was required. That sum is still being retained to top up global sums in London. But no similar adjustment is being made for other inner-city losers or student practices.

If the allocation formula had been sensitive enough, the majority of practices would have benefited, and practices with specific patient groups would not have been disadvantaged. MPIG does not address that issue.

The principles around the contract are reasonable; the fact that a 'fix' is now required to allow practices to maintain their basic infrastructure costs is not.

The basis on which the allocation formula has been derived needs adjusting. All MPIG does is prop up a discredited formula.

All MPIG does is prop up a discredited Carr-Hill formula, says Dr Rob Barnett

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