Funding for local enhanced services in England has always been viewed with a degree of suspicion by GPs.
These GP-delivered services, such as phlebotomy, anticoagulation and ECGs, are supposed to be based on population needs, but in reality are dictated by CCG balance sheets.
The 2016 GP Forward View called on commissioners to increase investment in primary care, but many CCGs have struggled to do so, leading GPs to question whether they are getting a fair deal for each service they provide.
For many practices, just receiving funding for procedures that are carried out for free elsewhere is a bonus. But a Pulse Intelligence investigation has found large discrepancies in LES payments where they are being issued – even between CCGs offering the same types of services.
GPs in the dark
GPs warn such disparities are unjustified and say practices are often unaware of the differences.
Kent LMC medical secretary Dr Guarav Gupta says: ‘CCGs are not doing their due diligence to find out what is acceptable to pay for procedures.
‘This is not fair on GPs or on patients. Such a huge disparity in payments across the country means patients will not get a universal offer and practices will struggle to provide some of these services if they are not resourced appropriately.’
Dr Gupta adds: ‘At an individual practice level it is hard for GPs to know what other areas are being paid.’
An analysis of 60 CCGs offering phlebotomy – one of the most common LESs – reveals NHS Ealing and West London CCGs are paying £3.12 per procedure to practices in 2019/20, whereas NHS Berkshire West CCG is offering just £1.25.
There are differences in the specifications (see table, below), but Berkshire, Buckinghamshire and Oxfordshire LMCs chair Dr Matt Mayer says: ‘It is quite clear across the country that there is a postcode lottery with regards to funding in different counties.
‘We see variability between the three counties in our patch down to individual needs of practices, CCG needs and levels of deprivation. There are lots of different variables to take into consideration.’
The CCGs that commission ECG services on a per-procedure basis – 20 in total – pay around £20-£25 (not including 24-hour and seven-day ECGs). NHS Warrington CCG pays £3.84 per ECG – although, unlike in other areas, the local trusts interpret the results.
Merseyside LMC chair Dr Ivan Camphor says the arrangement between the trust and practices should have been an effective workaround for the cash-strapped CCG – but there are problems with system connectivity.
At an individual practice level it is hard for GPs to know what other areas are being paid
Dr Guarav Gupta
He says: ‘Compared with other CCGs, Warrington is under financial constraints, and doesn’t have a lot of money to play with.
‘The issue here is connectivity between practices and Warrington hospital. The machines are there but they’re not connected because of technical issues. So none of the practices is connected to a central point in Warrington hospital where they can look at these ECGs.’
Payments for ear procedures clearly highlight the discrepancies in funding (see box, below).
And these are not just national variations. Kent LMC medical secretary Dr John Allingham says conversations among local practices have revealed stark differences in fees for the same services among the county’s eight CCGs. For example, GPs discovered that while most practices in West Kent received no funding for ECGs, some were paid £25 per procedure.
The LMC has questioned the eight CCGs in the region about the differences, Dr Allingham adds. ‘The LMC has told them “they’re paying this in that area, why won’t you pay that in your area?”.’
The result has been that Kent LMC has bundled LESs together in recent years, in common with many other areas.
Kent put together a ‘basket’ of seven services: 24-hour blood pressure monitoring; 24- and 48-hour/seven-day ambulatory ECGs; community ECGs; complex wound care; phlebotomy; treatment room; and women’s health.
But GPs warn this often results in a cut in funding for practices. Walsall LMC medical secretary Dr Uzma Ahmad says: ‘When these services are in a package, you will find they’re not well paid.’
This is because they are capitation-based, she adds. ‘In order to be more open – and fill the expense to the practice – they need to be activity-based. For activity-based services funding goes up, which is not always acceptable for CCGs.’
For activity-based services funding goes up, which is not always acceptable for CCGs
Dr Uzma Ahmad
The figures bear this out. Practices in NHS North East Lincolnshire CCG can earn as much as £2 per patient for phlebotomy; in Swindon, practices receive only £3 per head to deliver a basket of nine services including phlebotomy.
This ‘basket’ approach can mean patients lose out, says Dr Gupta: ‘If the basket includes a service that is difficult to provide, practices might not have the required capacity or expertise. This might put them off providing the other services in the basket.’
That could be the case in areas such as Bradford City and Bradford Districts CCGs, where the list of services in a basket is long and includes complex procedures, such as spirometry.
But the biggest problem is dwindling LES budgets. In recent months, practices under NHS Cambridgeshire and Peterborough CCG have faced a freeze in LES funding, despite activity increasing. This is because the CCG has had to cut a third of the discretionary element of its general practice budget.
The solution could be for CCGs to fund LESs through primary care networks.
NHS Newham CCG, in east London, plans to funnel all LES payments through PCNs by 2023/24. Over the next five years, the 10 PCNs in the region will gradually take on LES work – with payments eventually only going to those that hit certain targets.
In Kent, the funding for LES baskets will go through PCNs. New arrangements will allow practices to subcontract an LES to another practice in the network.
Dr Allingham says: ‘The contract has to state your patients will have access to a service – but you don’t have to deliver it. Every network will have a service so that if you don’t provide a community ECG or phlebotomy, someone in your PCN does.’
Unless all CCGs start to invest more in primary care, there will continue to be winners and losers across the country.
You can ﬁnd details of all the locally commissioned services in your area – including all your CCG’s service speciﬁcations on a single page – on Pulse Intelligence. You can also look at all the local services offered by CCGs across England, and how much other areas are paying for certain services.
Ear procedures: wide variation in funding
- NHS Leicester City CCG: Ear irrigation – £0.25 per registered patient/year
- NHS Gloucestershire CCG: Ear irrigation – £0.36 per registered patient
- NHS Telford and Wrekin CCG: Ear irrigation – £1 per registered patient
- NHS East Leicestershire and Rutland CCG: Ear irrigation – £8.36 per ear treated
- NHS Birmingham and Solihull CCG: Ear irrigation – £9.53 per procedure
- NHS Croydon CCG: Ear syringing – £14 per patient
- NHS North West Surrey CCG: Ear irrigation – £14.90 per patient
- NHS North East Hampshire and Farnham CCG: Ear irrigation – £16.02 per patient (1 or 2 ears)
- NHS Crawley CCG: Ear irrigation – £16.87 per visit
- NHS Swindon CCG: Ear irrigation – £21 per appointment
- NHS Eastbourne, Hailsham and Seaford CCG: Ear microsuction – £41.39 per ear treated
- NHS North West Surrey CCG: Ear microsuction – £50.58 per patient
- NHS South Worcestershire CCG: Ear canal clearance – £55.94 per episode of care
- NHS Eastbourne, Hailsham and Seaford CCG: Ear microsuction – £62.71 per procedure (two ears)
Some of the more unique LESs
- PSA monitoring (eg, NHS Coastal West Sussex CCG, NHS Newcastle Gateshead CCG)
- Bariatric surgery follow-up (NHS Devon CCG, NHS Telford and Wrekin CCG)
- Fitting ring pessaries (eg, NHS Bolton CCG, NHS Norwich CCG)
- Insulin conversion in type 2 diabetes (NHS Berkshire West CCG)
- Monitoring ADHD medication (NHS Berkshire West CCG)
- Teledermatology (NHS Camden CCG)
- H. pylori testing and other near-patient testing (eg, NHS Liverpool CCG, Buckinghamshire CCG)
- Anticipatory care (NHS East Berkshire CCG and West Berkshire CCG
- Wrist splinting (NHS East Lancashire CCG)
- Ankle/brachial pressure index (NHS Liverpool CCG)
- Services for the travelling community (NHS Liverpool CCG)