A FAIRER FUNDING FORMULADr Kambiz BoomlaSenior Lecturer and General Practitioner

Clinical Effectiveness Group

Queen Mary University of London

Chrisp Street Health Centre E14

k.boomla@qmul.ac.uk

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Minimum Practice Income Guarantee• nGMS contract came into force in April 2004• All GMS practices have Global Sum for looking after their

patients – their share of total national amount allocated for general practice

• Also PMS practices and APMS practices with a more locally determined funding stream

• Other funding streams going into GMS practices such as the Quality and Outcomes Framework

• Global Sum Share of the national pot is determined by the Carr-Hill formula devised by Prof Carr-Hill

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Carr-Hill formula• Idea is to model GP workload so practices are funded fairly for the number of

consultations they are expected to need to offer• So a practice with mainly elderly patients may have a higher workload than one

dealing mainly with commuters• So a practice given a Carr-Hill weighting of 1.1 will get 10% more money than a

practice with the same number of patients that has the national average of 1.0• Practices working in areas of deprivation expected to get Carr-Hill weightings of

greater than 1, when they voted to accept the new contract.• But when practices got their allocation, many were very surprised that their

weighting was less than the national average• So many practices found their income dropping in April 2004 that a top up was

agreed, a correction factor, that guaranteed their previous level of resourcing. This was the minimum practice income guarantee – MPIG

• If MPIG is withdrawn, 24 of the 100 worst affected practices are in Tower Hamlets, Hackney and Newham, demonstrating that Carr-Hill did not succeed in producing a formula that accurately dealt with the issues in many of the deprived parts of the country with greater health needs

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How Carr-Hill was calculated

• Factors included in the Carr-Hill formula • patient age and gender (used to reflect frequency of home and surgery

visits)• additional needs: Standardised Mortality Ratio and Standardised Long-

Standing Illness for patients under the age of 65 years • number of newly registered patients (generate 40% of work in 1st year) • rurality • costs of living in some area (i.e. South East - reflecting higher staff

costs)• patient age/gender for nursing/residential consultations.

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But are all 65 year olds the same• Age is the biggest

factor affecting practice resourcing in Carr-Hill

• Yet illness and need for a GP depends not on how far you are away from your birth

• Rather it depends how close you are to your death

• Professor Marmot illustrated this very well in his government report

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Healthy Life Expectancy

Healthy life expectancy at birth by deprivation decile, England, 2009-11

Note: Decile 1 is the most deprived decile within England, Decile 10 is the least deprived.

Males Females

Former area

Current area

Area name

Deprivation

Healthy life Expectancy

95% Confidence

interval

Healthy life Expectancy

95% Confidence interval

code code   decile (years)lowe

rupper (years) lower upper

  E92000001 England 152.1 51.6 52.5 52.5 52.0 53.0

  E92000001 England 255.8 55.3 56.4 56.1 55.5 56.6

  E92000001 England 358.4 57.9 58.9 59.7 59.1 60.2

  E92000001 England 461.2 60.6 61.7 61.7 61.1 62.2

  E92000001 England 563.5 63.0 64.0 64.3 63.7 64.8

  E92000001 England 664.9 64.4 65.4 66.0 65.4 66.5

  E92000001 England 766.8 66.3 67.3 67.7 67.2 68.2

  E92000001 England 867.7 67.2 68.2 68.6 68.0 69.1

  E92000001 England 968.4 67.9 68.9 69.8 69.3 70.3

  E92000001 England 1070.5 70.0 71.0 71.5 70.9 72.0

Source: ONS

• 18 year gap between richest 1/10 of the population and the poorest 1/10

• 19 years for women

• So very unlikely that a 60 year old from rich area will consult their GP anywhere near as often as a 60 year old from one of the poorest areas

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Need for a new formula• So if MPIG is to be done away with, then a fair formula is needed• Age is still be best indicator of need for a GP

• Problems with language and ethnicity – poorly recorded, could be resourced off formula

• But chronological age needs to adjusted by “Healthy Life Expectancy at Birth”, so that a 52 year old living in the poorest tenth part of the country receives the same weighting as a 70 year old in the richest tenth part of the country

• Multimorbidity – those with many illnesses – recent Lancet paper shows this happens 10-15 years earlier in deprived areas

• Epidemiology of multimorbidity and implications for healthcare, research, and medical education: a cross-sectional study• Karen Barnett, Stewart W Mercer, Michael Norbury, Graham Watt, Sally Wyke, Bruce Guthrie• Published Online May 10, 2012 DOI:10.1016/S0140-6736(12)60240-2

• Data exists at Lower Super Output Area to allow this adjustment to be easily calculated

• They both are the same number of years away from their death, and are likely to consult the same number of times

• If the Department of Health modelled this variation on Carr-Hill, the need for MPIG would most likely disappear