Understanding general practice business

The way that general practice is funded has a bearing on many aspects of the practice nurse’s working life, not least how much he or she is paid

The way that general practices are funded is distinctly strange. Partners in a practice are the only NHS workers who do not get a wage for their work. They are partners in a small business. Money comes in, and when all the bills are paid the profit goes to the practice partners. It is an anomaly that started with the foundation of the NHS, but an anomaly that has been fiercely defended over the years by the British Medical Association (and others) for a variety of professional, organisational and financial reasons. Many doctors who work in primary care get a salary, for instance trainees and ‘salaried GPs’ (hence the name), but they do not run the practices that they work in. Things may not be like this forever, but for now GP partners are small-businesspersons.

Unlike other small businesses, nearly all practice income comes from one source – the NHS – and there is a very complex system through which practices are paid. Practices also do private work, not paid by the NHS. In some practices private patients are seen. But ‘private work’ is anything that the NHS does not pay for, and so includes medical examinations (e.g. for insurance or vehicle licensing purposes), medical reports for various non-NHS bodies, and the odd letters that patients need about their housing or whatever. This work can only really be done by the patient’s own GP, who has the background knowledge and the medical records, so whether you approve of private medicine or not, it is nearly impossible to be a GP and not do a bit of private work.

WHERE DOES THE MONEY GO?

Before considering where the money for general practice comes from, let us look at what it is spent on. Every practice each year will produce accounts, and what follows is based on my own practice accounts: every practice is different, but I have no reason to think that our accounts differ in any substantial way from other practices throughout England.

• Practice expenses: supplies; instruments; levies; insurances: 1% of expenditure
• Drugs and medical supplies: 1%
• Premises: rent; heating; repairs etc: 19%
• Staff pay and expenses: 73%
• Administrative expenses: 4%

Nearly three quarters of the money that comes into a practice goes straight back out again, and by far the biggest practice expense is on staff wages. That of course includes practice nurses, who (like all the other staff) are worth every penny.

General practice also now (through the Clinical Commissioning Groups - CCGs) has a say in the money spent on their patients in hospital. This money is kept completely separate: if a GP refers fewer patients or prescribes less medication it does not mean that the money ‘saved’ goes into his or her pocket, or vice versa.

WHERE DOES THE MONEY COME FROM?

Not counting any private income, money from the NHS comes from several different directions. Again the percentages given are the proportions that my own practice gets from the various ‘streams’.

Global Sum and Minimum Practice Income Guarantee (MPIG): A sum based on the number of registered patients, weighted according to age and sex. For example, older patients require more GP care and have more illnesses, and this is allowed for: 48%

Quality and Outcomes Framework (QOF): Over the past decade since its inception, we have all become obsessively familiar with this: 13%

Enhanced services: These are the initiatives set locally, or centrally by the Government, to pursue specific health objectives. Current examples include Intrauterine Contraceptive Devices (IUCDs) and Anticoagulation: 8%

Premises: There is a complex system for supporting practices to work from decent premises. 7%

Dispensing: This applies to the small minority of practices, invariably rural, that dispense medication from the practice. N/A

Seniority and other allowances: Seniority allowances are being phased out over the next few years. A Training Grant is paid for a GP who is a trainer. 1.5%

The astute among you will have noticed that this does not add up to 100%. This is because the private income of the practice is not included above, and neither is the ‘income’ from the reimbursement of expenses (I told you it was complicated).

Many of you will be aware that GPs are doing a lot of moaning at the moment about the money available for general practice. We all know that the workload is going up: this is partly due to patient demand, but also due to patient complexity; work being moved from secondary to primary care; and the ‘QOF trick’ that I have reported on before where work previously supported by the QOF is now assumed to be ‘core work’ or required by the Care Quality Commission and so the funding support has been stopped. What is less apparent is the raw deal that general practice is getting compared with the rest of the NHS: in 2005 general practice got 11% of the NHS budget (for seeing 90% of the patients); by 2012 this had reduced to below 9%.

So anyone who works in general practice is getting paid less for doing more. Some practices doubt their continued financial viability, and may close. All the others are feeling the pinch. In most places staff pay rates have not been reduced, but they have probably not kept pace with inflation and staffing levels may well have fallen. Like everyone else, your GPs are also working harder, and the partners are being paid less: since 2006 the pay of a full-time partner in my practice has fallen by 20% in money terms and 40% in inflation-adjusted terms.

NEXT YEAR’S QOF

Many of you will already have started to run the QOF Derby, that time of year when someone looks at the QOF ‘how am I driving’ figures and realises that a big push is required if you are going to get the points in before April Fool’s Day. So you probably have not had a chance to look at next year’s QOF changes. These were agreed in October last year, which in itself instructive as in 2013 it was November, and in 2012 it was not agreed at all, so the Government just imposed it anyway. You will be pleased to hear that the minimum of tinkering has gone on for 2015-16.

There has been a proper messing about with the atrial fibrillation indicators. There are now 29 points available where there used to be 17.

• AF005. The one about reducing the stroke risk in atrial fibrillation using aspirin. This is sensible as the current NICE wisdom is that aspirin or other anti-platelet drugs should not be used alone to reduce stroke risk in AF.¹
• AF004 has been replaced with AF007. The method of assessing stroke risk has been changed from CHADS2 to CHA2DS2-VASc, again in accordance with NICE.¹ Most GP software includes both these calculations, so it is not too tricky.
• AF006 is a new indicator, and requires the assessment of CHA2DS2-VASc every year, except in patients already on anticoagulants. The thresholds are 40% and 90% for full points (12). You may recall that a gripe last year was the shifting of some timings from 15 months to 12 months when an annual assessment was intended – in practical terms this means that there is no leeway and so patients will need their assessments more frequently than every 12 months.

There is a significant change to the Coronary Heart Disease section.

• CHD006 is being retired, with a loss of 10 points. This is/was the one requiring quadruple drug therapy after an MI: ACE-inhibitor; aspirin; beta blocker and statin. NICE still recommends this drug combination, and indeed now recommends adding another anti-platelet drug to the aspirin,² so it is clearly not intended that these medications are no longer used. Here is a clear example of work now being considered as general practice ‘core work’, and so is no longer eligible for funding support. The same work for less pay: how does that affect morale?

Those of you who read the medical press will be aware that the Department of Health was left with metaphorical egg on its face by suggesting that general practices be given a financial inducement to make more diagnoses of dementia. GPs objecting to being given money was quite a surprising sight. There have also been some QOF dementia tweaks:

• DEM002 has been reworded and relabelled DEM004. This requires a face-to-face consultation with all patients coded with dementia once a year to review their Care Plan. The points have gone up from 15 to 39. This suggests that dementia is finally being taken seriously, which is clearly a step in the right direction. On the other hand, there is currently a bit of a fetish that care planning solves all health problems, a belief not supported by the evidence. The anxiety caused by being made to do things that you know are worthless is called ‘cognitive dissonance’.
• DEM005 is a rewording of DEM003 (do try and keep up there at the back). The required blood tests before making a diagnosis of dementia now have to be done from 12 months before the coding (previously 6 months) to 6 months after (unchanged). This probably simply reflects the pressure on the secondary care dementia services, so that it might easily take more than 6 months before a patient can be seen and assessed.

The indicators for Chronic Kidney Disease have been massacred.

• CKD001 has been replaced by CKD005, which is a bit bizarre as it is the only CKD indicator left. The change simply removes mention of the US National Kidney Foundation – we have a reputable local CKD grading system now. The ‘retired’ indicators are the one including a blood pressure target, the one requiring an ACE inhibitor if there is proteinuria, and the one requiring an albumin/creatinine ratio. For the retired indicators there is a loss of 26 points.

On the Obesity front, OB001 has become OB002 as the lower age limit for recording BMIs over 30 goes up from 16 to 18.

And that’s it for the QOF for next year. There is no change in the number of ‘points’ available to practices. A parallel development is that some CCGs are making plans to replace the QOF in their area with local incentive schemes, and NHS England has said that this is OK.³ The QOF has caused work, tears, and heartache for the last decade – how will you feel if this is suddenly deemed irrelevant and an entirely new local scheme replaces it?

CONTRACT CHANGES

The GP contract can affect practice nurse work, in addition to the work for the QOF. This work is equally important to the practice, even though any sums of money concerned are smaller.

• Avoiding Unplanned Admissions Enhanced Service (ES). The reporting template has been cut by 50%, and reporting will be once a year rather than once every 6 months. In the future there may also be a requirement for a patient survey, but if introduced this will be supported by additional money.
• Patient Participation ES. This enhanced service ceased to exist in March 2015. But (surprise surprise) practices will still be required to have a patient participation group by the CQC.
• Alcohol ES. This also ceased in March.
• Named GP. This requirement will be extended to all patients, not just those over 75 as it was last year, and the process will be simpler. It is not clear what effect this will have on patient care and satisfaction. You will be aware that this requirement does not mean that the same GP has to see the patient each time, so the effect on personal continuity of care is likely to be minimal. Older patients and those with long term conditions are happier and treated better when the same doctor sees them each time. On the other hand younger patients without any long term illness are not really bothered about personal continuity of care.
• Records. By July 2016, any patient who applies can have on-line access to the coded parts of their GP records (but not the free-text entries). This may take a bit of organising. But also recall that under the Access to Health Records Act (1990) patients already have access to hard copy of their entire medical record.

CONCLUSION

The vast national experiment that is the Quality and Outcomes Framework appears to be slithering and sliding into oblivion. It does not seem to have worked, in as much that there is little evidence that patient care has improved any faster with the QOF than it would have done anyway. I am not aware of any other nation’s health service that has adopted the same approach, so at least we may have saved our colleagues in other parts of the world some grief.

Managers and clinicians throughout the nation have put in vast quantities of work that has allowed the QOF to happen. What would the NHS be like if that time and effort had been put into something useful?

REFERENCES

1. NICE. Atrial fibrillation: the management of atrial fibrillation. CG 180, June 2014. http://www.nice.org.uk/guidance/cg180

2. NICE MI – secondary prevention: Secondary prevention in primary and secondary care for patients following a myocardial infarction. CG 172, November 2013. http://www.nice.org.uk/guidance/cg172

3. Lind S. QOF to be the first casualty of co-commissioning drive. Pulse, January 2015, 6-8.