Some GP practices are paid substantially more than others, regardless of the number and type of patients they serve, HSJ analysis reveals.
There is no evidence that high earners are successful in reducing reliance on emergency hospital care, although there was some relationship between practice funding and patient experience.
HSJ examined details of the 2011-12 NHS income of more than a third of England’s 8,300 GP practices, in the biggest analysis of its kind. It comes a week after the Department of Health announced a fresh attempt to standardise part of GP income.
We divided the total NHS income of 3,046 practices by the number of patients on their practice lists. Lists were weighted for need using the method employed by the DH in calculating GP contracts, which takes into account factors such as age and the health of the population. Specialist GP practices and extreme outliers were removed. The remaining practices’ income ranged from about £65-£320 per head of needs-adjusted population.
HSJ calculated the difference between the income of practices paid above the average rate, and their income if they were paid the average rate per patient, taking account of need. If income was standardised across England, with practices earning above the average rate reduced to the average, then high earners would potentially see their income fall by a total of £566m a year. This is around 7 per cent of the total GP services budget.
Much of the variation in income is due to performance rewards under the quality and outcomes framework, and practices providing services beyond core contract requirements. Some variation could be explained by arrangements for unusual services such as walk-in centres.
However, even if performance rewards and additional services - known as enhanced services - are excluded from calculations, there is huge variation, with income per needs-weighted patient ranging from about £30-£300.
Practices receive payments for a long list of factors which varies dramatically between practices and areas. They include payments which are national policy but not universally applied, for example for dispensing drugs; reimbursment for payment for their premises; seniority of GPs, IT and premises maintenance.
They also include money attached to generic schemes such as “practice innovation” and “transforming primary care”; practices’ use of locums due to sickness or maternity; and referral management.
In addition, there is significant variation in the “core” income of practices, which largely excludes these factors.
HSJ also compared practices’ income with the rate of emergency bed days related to long-term conditions among their patients; with how patients rated the practice; and with the proportion of patients they had seen in the past six months (see table, below).
In many of the measures there was little apparent link, indicating those paid more may not be providing significantly better services. Unplanned hospital admissions fall into this category. However, there was a positive relationship between practice income and satisfaction with booking appointments for all but the best-paid practices.
Many of the practices earning more per head of weighted population are those holding primary medical services (PMS) contracts, which can be tailored by their primary care trust, as opposed to more nationally determined general medical services contracts.
In some cases they were paid additional sums for providing extra services. But senior figures said many of the additional payments were not justified.
Charles Alessi, chair of the National Association of Primary Care, which represents many PMS practices, told HSJ the additional payments were often justified. “PMS practices are not paid more to deliver the same. If practices want to do more [than core practice services] and it is appropriate for the population, they shouldn’t be held back.”
Dr Alessi called for PMS contracts to be retained and developed, so GP contracts could in future be tailored by clinical commissioning groups.
However, Shane Gordon, a GP and accountable officer for NHS North East Essex CCG, said a move to create a “level playing field” would be a good platform for CCGs to ask practices to improve services.
He said: “It is hard to see how commissioners, working with CCGs, can make big improvements in productivity when you’ve got such basic variation. It is hard to have a conversation with a practice when they can turn around and say: ‘You are paying these other guys four times as much.’”
A DH spokeswoman questioned the scale of variation and said practice income varied “according to the needs and circumstances of their communities”. She said the government’s commitment to introduce “fairer payment systems for GPs” would cut variation.
UPDATED: The piece has been updated: 1) To reflect the fact that Carr-Hill population weighting used here takes account of factors affecting health need, such as age and mortality, but not directly of deprivation. And 2) to make clear that the items included in varying total income includes payments for dispensing GPs, and practices’ premises costs.
|Practice funding per head of weighted population (HSJ research)||Number of emergency bed days for long term conditions, per 1,000 weighted population, among practice population (NHS Information Centre)||Proportion of patients who said their overall experience of making an appointment was good (GP patient survey, weighted)||Proportion of patients who have seen GP in past six months (GP patient survey, weighted)|
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Exclusive: GP practices' huge income variation revealed