Resource allocation & equity in general practice

Professor Azeem MajeedUniversity College London

Outline of talk

Role of general practitioners in the NHS

Allocating resources to GPsGMS & PMS contractsProposed new GP contractGatekeeping & medical practice

variationsMonitoring equity in general practice

Role of GPs in the NHS

Independent contractors (self-employed)Provide primary (first contact) careAround 75% of all medical contactsAct as gatekeepers to other NHS servicesPrescriptions, investigations, outpatient

referrals, hospital admissionsGovernment views gatekeeping as more

important than do many GPs or patients

Allocating resources

Budgets for hospital & community services, mental health, GP prescribing allocated to PCTs

Based on population measuresNo standards for allocation to practicesCreates large variations in practice

budgets, GP income and use of resources

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

General Medical Services 2

Practice allowancesCapitation feesItem of service paymentsSessional paymentsStaff, premises and IT budgets

Personal Medical Services

Optional replacement for GMS contract

Practice-based budgetUsually based on previous GMS

payments‘Locks in’ variations and inequitiesSimplifies contractual arrangementsAllows for salaried GPs

New GP contract

Practice-based contract‘Fairer’ resource allocationNational terms of service with local

flexibilityFocus on quality & outcomesCareer development opportunitiesThree levels of services: Essential,

additional, enhanced

Carr-Hill Formula

Age-sex workload curveNursing & residential homesList turnoverAdditional needs: Standardised long-

term illness and standardised mortality ratios

Unavoidable costsOther factors: practice size & London

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)

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

Why do variations occur?

PatientDoctorGeneral practiceLocal health care systemNational health care system

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

Antibiotic prescribing rates in 211 general practices in 1998

0

10

20

30

40

50

60

70

80

300 500 700 900 1100 1300 1500

Rate per 1,000 patients

No

. o

f p

rac

tic

es

Annual outpatient referral rates per 1,000 in males

Group 1Affluent

Group 2 Group 3 Group 4 Group 5Deprived

Total 131.9 120.4 118.6 120.4 115.9

Medical 20.0 17.3 16.6 17.4 16.8

Surgical 29.2 27.0 27.8 28.1 26.9

Paeds 42.9 31.0 30.5 31.0 27.6

0

10

20

30

40

50

60

70

80

90

0.000 0.500 1.000 1.500 2.000 2.500Comorbidity Score

% P

atie

n ts

Re f

erre

d /Y

ear

UK

US Health Plans

Monitoring equity

Population estimatesRoutine statistics: births, deaths,

censusHealth service use: prescribing,

referrals, admissions etc.Monitoring information from new

contract

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%

Populations estimates for England and Wales 1950-1996

40

42

44

46

48

50

52

54

56

1950

1952

1954

1956

1958

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

Source: Population & Vital Statistics, ONS

Po

pu

lati

on

(m

illi

on

s)

GP-Lists

ONS

Difference between GP-list and ONS resident populations 1996

+3.1%

+1.2%

+0.5%

+1.4%

+9.9%

+4.5%

+0.9%

+2.3%

+2.6%

+2.4%

+0.0% +2.0% +4.0% +6.0% +8.0% +10.0% +12.0%

England and Wales

Northern & Yorks

Trent

Anglia & Oxford

North Thames

South Thames

South West

West Midlands

North West

Wales

Source: Population & Vital Statistics, ONS

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

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

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

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 recordingLarge variation currently in recording of

computerised data

Strengths of primary care data

Population basedMost contacts with NHS take place in

primary careInformation on morbidity, treatment,

outcomes & utilisationIncreasing number of practices now

computerised

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 dataCollected for different objectivesCan be difficult & expensive to access

Comparison of GPRD and HSE diabetes prevalence, 1998

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

10.0

16-24 25-34 35-44 45-54 55-64 65-74 75+

Age group

%

GPRD males

HSE males

GPRD females

HSE females

Death rates by age and sex, 1998

0

50

100

150

200

2500

1-4

5-9

10-1

4

15-1

9

20-2

4

25-2

9

30-3

4

35-3

9

40-4

4

45-4

9

50-5

4

55-5

9

60-6

4

65-6

9

70-7

4

75-7

9

80-8

4

85+

age group

rate

per

1,0

00

khs98 males E&W males khs98 females E&W females

Percentage of CHD patients correctly identified before and after examining medical records in 47 medical practices

0

10

20

30

40

50

60

70

80

90

100

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47

Practice

Percentage

After

Before

Percentage of men with atrial fibrillation prescribed oral anticoagulants in 1994 and 1998

0

5

10

15

20

25

30

35

40

45

0-34 35-44 45-54 55-64 65-74 75-84 85+ All ages

Age Group

Perc

entag

e pre

scrib

ed or

al an

ticoa

gulan

ts 1994

1998

Percentage of men and women with AF prescribed anticoagulants in 1998

0

5

10

15

20

25

30

35

40

45

35-44 45-54 55-64 65-74 75-84 85+ All ages

Age Group

Perc

enta

ge Men

Women

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

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