10 September 2015

The best GP surgeries are facing the biggest cuts – and the NHS knows it

Up and down the country, GP surgeries have been yelping in pain.

How much is a GP service worth? The question has been on my mind over the past few weeks as my senior partner and I have been preparing our appeal against the 17 per cent cut in our surgery’s core funding recently mandated by NHS England (NHSE). As far as NHSE is concerned, a GP service is worth about £2 per patient per week – a smidge less than the cost of an annual international subscription to the New Statesman. NHSE has been conducting a nationwide review sizing up each surgery’s funding against this yardstick, and it believes my practice is being paid over the odds.

Up and down the country, GP surgeries have been yelping in pain. For some, the cuts will entail reductions in services; for others, forced mergers, or even closure. On our patch of 27 practices, two look in danger of going to the wall and others are considering amalgamating in order to survive.

What’s noteworthy is the profile of the surgeries affected. The funding cuts are falling disproportionately on practices that serve deprived communities. Also hard-hit are small practices, the ones that often provide the most personalised care to their patients. The third group particularly affected is surgeries with unusually young patient populations, such as university health centres. Our practice, with a list of just 4,400, located in one of the poorest neighbourhoods in our area, and with large numbers of child and young adult patients, scores badly on all three counts.

Why does our funding appear to NHSE to be profligate? The answer lies in something called the Carr-Hill formula. That idea that a GP service should cost £2 per patient per week is a huge generalisation. The elderly and the very young use their GP surgeries frequently, accounting for a lot of health-service spending. By contrast, a fit and active 25-year-old bloke probably won’t darken his doctor’s door from one end of a decade to the other.

Carr-Hill attempts to “weight” practice populations in order to take account of these variations, supposedly diverting more resources to those surgeries with the highest workloads. The “weighting” applied to a practice list with lots of elderly patients, for instance, works well. But the formula fails in several important regards. The “weighting” for deprivation has proved woefully inadequate, failing to come anywhere near to adjusting for the burden of ill-health our society tolerates today among its poorest. The formula also appears to rate young adults as healthier than they actually are, allowing too few resources for their care. And although it makes some attempt to adjust for “unavoidable smallness” in practice size, the criteria are restrictive. Thus, many dedicated doctors with valued personal services are facing ruin (among the surgeries worst affected on our patch are the two smallest, both of which have enviably high rankings in performance and patient satisfaction).

We were told about our funding cut at the beginning of summer, and met with NHSE in July to discuss grounds for appeal. I looked our area team’s head of primary care square in the eye and asked whether NHS England believed that the Carr-Hill formula weighted adequately for deprivation. The unequivocal answer was: “No.” Indeed, NHS Employers and the British Medical Association are working together to refine the model to address the problems with deprivation and atypical populations. Their results, however, are not expected before 2017.

In the meantime, NHSE seems determined to press on with adjusting practices’ funding. We, like many others, are lodging an appeal, but the experts on our local medical committee – who have been through the process with dozens of other surgeries – have warned us that we are unlikely to succeed. Everyone accepts that Carr-Hill is flawed, but until there’s an agreed alternative in place an appeal won’t be allowed simply on the grounds that Carr-Hill isn’t up to the job. We are trapped, it seems, in a classic catch-22. It’s not a comfortable place to be.