Resource allocation

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Resource allocation equity in general practice

• Professor Azeem Majeed
• University College London

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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

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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

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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

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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

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General Medical Services 2

• Practice allowances
• Capitation fees
• Item of service payments
• Sessional payments
• Staff, premises and IT budgets

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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

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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

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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

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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)

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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

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Why do variations occur?

• Patient
• Doctor
• General practice
• Local health care system
• National health care system

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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

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Antibiotic prescribing rates in 211 general
practices in 1998
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Annual outpatient referral rates per 1,000 in
males
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US Health Plans
Patients Referred/Year
UK
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Monitoring equity

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

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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

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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

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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

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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

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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

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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

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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

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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

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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