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Enhanced patients, not enhanced services



One of the frustrating things about general practice, and there are many, is that GPs up and down the country can be offering the same services to their patients but be funded very differently for it. Some CCGs may fund DOAC monitoring or enhanced diabetes care, but many do not. This variation in local enhanced services, combined with an antiquated Car-Hill formula, leads to significant inequity in practice funding.

There are many GPs who wish to scrap capitation altogether and be paid for every patient contact. Although this idea of payment by activity is a seductive concept, in reality, it is overly bureaucratic and open to gaming.

But we clearly cannot carry on as we are. Practices in multicultural, deprived areas like mine are struggling to keep our heads above water, due to the funding shortfalls arising from a younger demographic with significant co-morbidities.

Without doubt, this funding solution needs to be a national one, rather than partners having to scrabble around for different pots of money within local enhanced services. I propose we scrap all local enhanced services and replaced them with extra funding for an ‘enhanced patient’.

A patient on DMARDs requiring long term monitoring would attract a global sum uplift

If we had a national formula for enhanced patients, it would mean extra funding was delivered to core on the basis of individual patient needs. For example, a patient on DMARDs requiring long term monitoring would attract an uplift to the basic global sum, as would patients placed on the palliative care register, or those on long-term anticoagulation.

The obvious advantage to this would be a much-needed boost to core funding which would be equitable and not dependent on a postcode lottery. Crucially, it would also prevent enhanced services being delegated outside the practice, to PCNs or any willing provider. It may also reduce the admin burden for the burnt-out practice manager, submitting claims for multiple enhanced services at the end of the year.

But we all know this is just re-arranging the deckchairs if overall core funding is not increased. We do not want to be chasing points within QOF to achieve performance related pay. We are in desperate need of funding to manage the increasing numbers of patients with four or five co-morbidities, who may also be on ten medications and speak no English.

People are living longer, more work is being shifted from secondary to primary care, and we are still paid through a model established 16 years ago, within the 2004 contract.

My knight in shining armour is supposed to be the new contract in the form of the PCN DES. I’m afraid his horse hasn’t reached my practice yet, so I’m still on my hands and knees collecting all the enhanced service coppers.

Dr Shaba Nabi is a GP trainer in Bristol. Read more of Dr Nabi’s blogs here