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Scrapping Carr-Hill is long overdue



Ministers are threatening to impose contract changes on us this year, all in the hope of getting rid of funding variation in general practice.

To me, the search for funding equity feels like the search for the Holy Grail: it has long been sought and everyone thinks it’s a lovely idea, but no one can be quite sure it exists. Indeed, all the evidence continues to indicate that Dr Julian Tudor Hart’s ‘inverse care law’ is still very much alive and kicking.

There has been considerable criticism of the allocation formula used to determine NHS funding, and a fundamentally new approach has been developed by a team at the Nuffield Trust that will replace the current formula with a person-based allocation formula (to be released to CCGs on 14 December).

But what about general practice? The Government has announced the phasing-out of the MPIG over a seven-year period from 2014 onwards, but also a change to the Carr-Hill funding formula.

This is long overdue. For those who do not know, the formula is based on a piece of work done in the 1990s that measured the amount of actual time that GPs were recorded as spending with patients. Not only is the data behind the formula now out of date – some is nearly 20 years old – but there were fundamental problems with this approach. Simply measuring the amount of time given to patients is not the same as measuring what patients want or need; a patient seeing a doctor in an under-doctored, deprived area may have received five minutes of consultation, wanted 10, needed 20 and should have come back the week after, but couldn’t get in and went to A&E instead.

The Carr-Hill formula appears to have been accepted by the GPC as it still is, largely on the basis that it didn’t rock the boat too much. Which it didn’t, of course. It literally measured the amount of time that was being given to different groups of patients, didn’t find patients from deprived areas were taking more GP time, and was then used to create a formula that to a large extent reflected the past distribution of resources.

In concentrating its current opposition to the Government’s proposed contractual changes on the measures to remove variation, the GPC is fighting the wrong battle. Negotiators should focus their objections on the radical proposed changes to the QOF, and especially the unilateral removal of the points attached to the organisational domain.

Bringing in a new formula when there is no extra money will make winners and losers of practices, but this is a battle the GPC should concede. Underlying the variations in funding are variations in access to and quality of care. This cannot be acceptable to the profession.

A single contract

Beyond arguments around Carr-Hill and the MPIG, there is a bigger issue. For me, the best way of moving towards equal funding for every GP practice would be to reinstate a single GP contract.

It has long been accepted that the most effective way to reduce health inequalities is to invest in primary care and so, when the new contract came in 10 years ago, PMS was introduced as a way of delivering targeted extra help to deprived areas.

But since then, in many areas PMS practices have been subject to intense scrutiny by PCTs. For instance in Derbyshire, PMS funding has been clawed back and replaced by a ‘basket LES’ system for services such as CV risk assessments, minor ops, and phlebotomy.

At the same time, partners in PMS practices have become better paid – the most recent data from the NHS Information Centre shows that, in 2010/11, PMS GPs earned an average of £113,400, compared to GMS GPs’ average of £99,000.

The lack of equity between PMS and GMS (and between partners and salaried GPs) was not what was intended by the new contract, certainly not to the extent that we now see. We certainly don’t want to reduce overall investment in primary care, but after a decade of problems, I think we should call time on PMS and revisit the basis of the whole contract.

While the GPC is right to raise concerns over many aspects of the proposed contract deal, the DH is right to try and address funding differences which perpetuate health inequalities.

It would be nice to think that it could come about through increased baseline funding in general practice across the board, but that’s not going to happen. A new contract and a new formula will have to emerge regardless, for our patients and the future of the profession.  

Dr John Ashcroft is deputy chair of Derbyshire LMC and a GP in Ilkeston