How the Darzi review will affect general practice

In the wake of the much anticipated review, Jonn Elledge looks at the changes that will occur and how they affect GPs.

Polyclinics, it seems, were a red herring. For months now, practices have been bracing themselves for the Darzi review and the radical reorganisation of general practice it would mean. In the event, though, last week's report didn't use the 'P' word once.

Nonetheless, the report could still have a big impact on GP finances. And it seems to point the way towards new contract negotiations. If this year's theme was access, next year looks like it will be all about MPIG.

Funding systems
The report's key mantra is patient choice. In theory, patients can already choose their GP, of course, but in reality many practices just don't have the capacity to take on new patients.

And because 90 per cent of practices rely on the MPIG, funding for new patients can be worth as little as half of that for existing patients. In other words, MPIG means practices have little incentive to grow their lists.

The review makes clear the government wants to change all that. It promises 'a fairer funding system, ensuring better rewards for GPs who provide accessible and high quality services'. That means the MPIG is going to go, says National Association of Primary Care chairman Dr James Kingsland. 'It's not if any more, it's when and how.'

To be fair, few defend the MPIG, or the 'unfair' way it distributes funding. And GPC policy is that it should be phased out. But it wants to see this happen through the 'rising tide' of increased funding for general practice as a whole.

If the MPIG were simply removed without time to adjust, they argue, practices that rely on it would face a catastrophic loss of funding.

Battle over MPIG phase-out
What's more, the GPC is confident it has the law on its side. GPC chairman Dr Laurence Buckman points out that letters which accompanied the original contract promised that the MPIG would remain 'in perpetuity until it is no longer needed'.

On this basis, any attempt by the government to remove it would effectively be in breach of the contract.

The result of all this is that next year's negotiations look set to see a pitched battle over when and how the MPIG will be phased out.

Prevention better than cure
The MPIG isn't the only thing likely to be on the table next spring, however. Another of Lord Darzi's themes is shifting the health service from care to prevention.

To that end, each PCT will be asked to commission 'well-being and prevention services', while more joined up services across health and social care are promised to tackle conditions such as diabetes.

It'll also mean more quality framework funding will be directed from administrative processes to services that prevent illness: the DoH's national primary care director Dr David Colin-Thome says the DoH hopes to triple the share of points spent on prevention, from 5 per cent to 15 per cent.

Changes need funding
The government is also targeting the complex formula that links quality funding to disease prevalence. Because many practice costs are fixed, the variation in funding it creates was 'damped down', by square-rooting the figures and rounding the practices with the lowest prevalence up.

Now, says Dr Colin-Thome, the government wants to remove these damping mechanisms because they 'work against getting money to where it's needed'.

Here, too, says Dr Buckman, there's 'universal agreement' that the formula needs rethinking. But any change that isn't accompanied by a funding increase will create losers - and a cut in income will mean a cut in services.

With public finances getting squeezed, the government seems unlikely to willingly offer the kind of funding increase that would enable these changes to happen without any practices losing cash.

The removal of the MPIG, in particular, is likely to mean losers. 'I don't see how you can do it so that no one is disadvantaged,' warns Dr Kingsland. NHS Employers and the GPC have a lot to talk about.

Lord Darzi's vision in numbers

Practice lists - 50%
The proportion of PCTs where some practices have open-but-full lists. The government says that this works against patient choice, and wants to encourage greater competition between practices for patients.

MPIG - 90%
Proportion of practices whose incomes are subject to MPIG. The government wants to scrap the guarantee, so that practices receive equal funding for new patients, and have an incentive to grow their list.

Quality framework - 15%
Proportion of quality points the government wants to dedicate to preventive medicine, up from 5 per cent today. It also wants to remove the 'damping down' mechanisms from the prevalence formula.

Training - 50%
Minimum proportion of doctors entering specialist training in each region that should be GPs, according to the new Workforce Strategy. The government wants to expand GP training programmes from 2009.

Clinical outcomes - 100%
Proportion of NHS providers required to publish 'quality accounts' detailing safety and clinical outcomes. Details of practice hours and services will also be published on the NHS Choices website.

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