Resource allocation & equity in general practice

1. Resource allocation & equity in general practice Professor Azeem Majeed University College London

2. Outline of talk • Role of general practitioners in the NHS • Allocating resources to GPs • GMS & PMS contracts • Proposed new GP contract • Gatekeeping & medical practice variations • Monitoring equity in general practice

3. Role of GPs in the NHS • Independent contractors (self-employed) • Provide primary (first contact) care • Around 75% of all medical contacts • Act as gatekeepers to other NHS services • Prescriptions, investigations, outpatient referrals, hospital admissions • Government views gatekeeping as more important than do many GPs or patients

4. Allocating resources • Budgets for hospital & community services, mental health, GP prescribing allocated to PCTs • Based on population measures • No standards for allocation to practices • Creates large variations in practice budgets, GP income and use of resources

5. General Medical Services 1 • Traditional method of allocating budgets to practices • GPs are self-employed and do not receive a salary • Funded through a complex system of fees and allowances • Payments based on GP and not practice

6. General Medical Services 2 • Practice allowances • Capitation fees • Item of service payments • Sessional payments • Staff, premises and IT budgets

7. Personal Medical Services • Optional replacement for GMS contract • Practice-based budget • Usually based on previous GMS payments • ‘Locks in’ variations and inequities • Simplifies contractual arrangements • Allows for salaried GPs

8. New GP contract • Practice-based contract • ‘Fairer’ resource allocation • National terms of service with local flexibility • Focus on quality & outcomes • Career development opportunities • Three levels of services: Essential, additional, enhanced

9. Carr-Hill Formula • Age-sex workload curve • Nursing & residential homes • List turnover • Additional needs: Standardised long-term illness and standardised mortality ratios • Unavoidable costs • Other factors: practice size & London

10. Quality framework • Aimed at improving primary care services • By year 3 of new contract, £1.3 of £1.9 billion new resources for primary care • Four areas: clinical, organisational, patient experience, additional services • Based on points awarded for achieving targets (maximum 1,050 points)

11. Gatekeeping role of GPs • In the NHS, GPs often control access to other services • These include prescribing, investigations, specialist referrals, emergency admissions • Important to monitor variations in the use of these services at practice level

12. Why do variations occur? • Patient • Doctor • General practice • Local health care system • National health care system

13. Implications of variation • Patients may be denied access to appropriate care • Patients may be at risk of iatrogenesis • Doctors may not be practising ‘evidence-based’ medicine • May be a marker of inefficient use of resources

14. Antibiotic prescribing rates in 211 general practices in 1998

15. Annual outpatient referral rates per 1,000 in males

16. US Health Plans % Patients Referred/Year UK

17. Monitoring equity • Population estimates • Routine statistics: births, deaths, census • Health service use: prescribing, referrals, admissions etc. • Monitoring information from new contract

18. Problems with GP lists • Variations in population size due to deprivation and population mobility • Nationally, 3% difference between ONS and GP-list estimates of population • For regional health authorities, difference varies from 1% to 10% • For health authorities, difference varies from -5% to +22%

21. Area versus practice data • Traditionally, ONS and NHS information systems have generated mainly area-based data • PCTs will be practice based but will also have an ‘area’ commitment • Some agencies will be entirely area based, e.g., social services

22. NHS Activity data • Elective admissions • Emergency admissions • Outpatient referrals • Accident & Emergency Department attendances • General practitioners’ prescribing costs (PACT) • Cash-limited general medical services • Claims data • Community health services • Diagnostic investigations

23. Generating good activity data • Data collection must be complete & accurate • Practice code must be completed correctly • Sharing data to produce complete data for adjacent PCTs • Experience suggests that high-level commitment needed

24. General practice data • Considerable data collection required for new contract • Identification of cases, use of correct READ codes, monitoring process of care • Accurate and complete data recording • Large variation currently in recording of computerised data

25. Strengths of primary care data • Population based • Most contacts with NHS take place in primary care • Information on morbidity, treatment, outcomes & utilisation • Increasing number of practices now computerised

26. Weaknesses of primary care data • Often comes from volunteer practices & hence may not be representative • Quality & completeness of data recording varies widely • Lack of socio-economic & ethnic data • Collected for different objectives • Can be difficult & expensive to access

32. Access to data • Government has suggested it may publish practice ‘quality’ scores • Unclear what other data will be made publicly available • Data needs to be interpreted with socio-economic characteristics of the population being examined

33. Conclusions • Shift from routine NHS data to data from GP computer systems • Considerable improvements in data quality needed • More systematic use of both routine data and GP data • Interpret data with socio-economic information