Approach and methods

 

Previous studies of inequalities in general practice,,,, have looked at the relationship between primary care supply (often in terms of the number of GPs), access (eg the number and type of appointment), and quality of care. In order to form a rounded view of general practice we look across the following areas:

  • First, we consider the variation in funding between different providers.
  • This impacts on supply: the number and skills mix of the staff employed in a practice, the infrastructure and equipment available, and information systems used – this also includes the location of the practice.
  • These elements influence access: the number and type of appointments that can be offered, and the staff that provide them.
  • And in turn the quality of services provided to patients, as well as the practice’s ability to coordinate care for their patients.

Due to the limited availability of data, in this briefing we focus on key indicators within each area: funding, workforce numbers, appointments, and quality. For quality, this means focusing on broad composite measures: performance against the quality and outcomes framework (which in turn affects levels of funding), patient satisfaction, and CQC ratings. These are broad measures and hide variation in more narrow domains of quality (such as condition-specific health outcomes). But these measures are consistent, comparable and should include these narrower areas.

Methods

We analysed the provision of general practice between 2015/16 and 2018/19 by combining publicly available data on funding, workforce, appointments and quality from GP practices and clinical commissioning groups (CCG) with demographic and deprivation data at a neighbourhood level. These neighbourhoods are lower layer super output areas (LSOAs) – 32,844 geographical units each with an average of approximately 1,500 residents.

Health need varies a lot between different areas, and we therefore reflect this in our analysis. We applied weights that reflect GP workload to the population of each neighbourhood to produce a ‘need adjusted population’. We acknowledge that workload does not equate to need, however, workload is the proxy for need used in the Carr-Hill allocation formula, therefore meaning it is consistent for use in this analysis. The weights we use are those suggested by the workload adjustment estimates produced by the 2007 Review of the General Medical Services global sum formula published by the British Medical Association and NHS Employers (except for financing indicators, where we use the weighting applied in the funding formula by NHS England, in order to more accurately reflect funding flows). This means that neighbourhoods with characteristics that imply higher health needs (for example those with very young patients, older patients, and worse health indicators) had their populations ‘inflated’ to be larger than their actual population, as each patient requires a higher workload than average. The opposite is true for those with characteristics that predict lower health needs.

We separate these neighbourhoods into quintiles (five groups) from the most to the least deprived, using the index of multiple deprivation (IMD) to rank each neighbourhood in England. The IMD measures deprivation using a weighted average of seven dimensions – income, employment, education, health, crime, barriers to housing and services, and living environment. Each dimension is constructed from a range of indicators that together provide a rich picture of life in the area. Our analysis focuses on these small geographical units, with the size of their adjusted populations reflecting health need, grouped into five by their overall level of deprivation.

The idea of need weighting populations is a standard approach that has been used in allocating health care funding in the NHS for the past 50 years. The weights we chose – the latest GP workload adjustments – are not the only weights for estimating need. But the patterns we describe in this briefing still hold when we apply different methods of weighting.

As a robustness check we repeated our analysis of each aspect of primary care across the country excluding London and found that the results did not change. This was to ensure that our findings were not being skewed by any resource allocation peculiarities associated with London.

For a more detailed description of our methods, data sources and need weights used, see the Appendix.

Box 1: GP funding and contracting in England

Responsibility for commissioning primary care services, including general practice, falls officially to NHS England. In practice, this role has increasingly been delegated to CCGs in a process known as ‘co-commissioning’. Total annual budgets for CCG primary care medical spend are allocated by NHS England, according to a CCG allocation formula.

All NHS GP practices must hold an NHS contract to run NHS-commissioned GP services. The three contracting options used to commission primary medical care services (GP services) are the General Medical Services contract (GMS), the Personal Medical Services contract (PMS) and the Alternative Provider Medical Services contract (APMS). This box briefly introduces each, together with the other major income streams for general practice in England.

Capitated resource allocation

GMS contracts and the Carr-Hill formula

The GMS contract is negotiated annually between NHS England and the British Medical Association’s General Practitioners Committee. In 2018/19 approximately 70% of practices operated under it. The global sum allocation formula (also known as Carr-Hill) forms the basis of core funding for GMS practices. Global sum income typically accounts for over half of the income of practices using the GMS contract.

The Carr-Hill formula attempts to account for variation in practice workload and the relative costs of delivering services between practices, and to divide funding more fairly to reflect local populations. Payments are based on a practice’s population, adjusted for a set of patient factors (age, sex, turnover of patients and additional needs, which includes a measure of mortality and morbidity) and contextual factors (rurality and a ‘staff market forces factor’ to reflect geographical variation in staff costs). Each adjustment generates a practice index, which are applied to the practice list to produce a practice weighted population.

PMS contracts

The key difference between GMS and PMS contracts is that while GMS contracts are agreed nationally, PMS contracts are negotiated locally between NHS England or a CCG and the provider. This is intended to give commissioners and providers greater flexibility to tailor provision to local need, while maintaining a core set of services. As PMS contracts are usually negotiated based on the GMS global sum, Carr-Hill still applies. In 2018/19, around 26% of practices used PMS contracts.

APMS contracts

In 2018/19 just 2.5% of practices in England were on APMS contracts. These are locally negotiated, more flexible and are open to a much wider range of providers, including the independent sector and voluntary and community sector organisations. APMS contracts can be used to provide essential, enhanced, out of hours and/or additional services that GMS or PMS practices have opted out of providing.

Quality payments

The quality and outcomes framework (QOF)

The QOF is a voluntary annual reward and incentive scheme for practices within the GMS contract. Typically accounting for less than 10% of practice income, QOF offers incentive payments to practices based on performance against a range of indicators. These indicators cover three broad domains – clinical, public health and quality improvement. Practices on PMS contracts may opt-in to the QOF.

Extra services

Enhanced services

Enhanced services are commissioned at either a national level by NHS England, or locally by CCGs, and can be contracted from any GP provider (though some only apply to GMS practices).

Directed Enhanced Services (DESs) are nationally negotiated and commissioners are obliged to offer them to practices within their contract. Local Enhanced Services (LESs) are locally negotiated and therefore vary by area.

These are not the only sources of income for general practice. Smaller income streams for practices include fees for specific services such as vaccinations, as well as payments to cover rent or mortgage on premises, to cover IT costs, locum allowances and some training costs.

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