Editorial: Time to look at the whole income picture

One of the great innovations of the new GMS contract was the notion of splitting practice funding into three income streams - essential services funded through the global sum, the quality framework and enhanced services.

The concept was a clever attempt at giving GPs greater control of their workload and practice income as well as allowing NHS cash to follow patients.

However, intentionally or not, it also created a clever piece of sleight of hand by dividing how we think about GP income into separate streams.

Thus we may discuss the effects of the prevalence formula or new indicators on quality income or the problems associated with the pay freeze or indeed the loss of enhanced service income. What we do less often is to consider them all at once.

This point was brought home by a speaker at this year's LMCs conference in London last week. Talking about how the prevalence gap between Wales and England has increased to the point where Welsh GPs must work 15 per cent harder to earn the same quality income those in England, he warned that the loss of directed enhanced services (DESs) worth as much as £18,000 per practice in Wales and the pay freeze could 'push some practices to the edge of viability'.

This triple whammy is not exclusive to Wales. There are prevalence differences between all four UK countries, and most have seen DES changes this year, meaning that there is a cumulative effect on practices which for some could mean a drop in quality scores or an inability to take on enhanced services - creating a downward spiral.

Part of the problem is that information about GMS changes is generally presented in terms of 'the average practice' and by definition that practice is unlikely to see the extreme effects of changes. But practices are not average and it is their very variety which allows patients to find a service that suits them.

If this variety and the service it offers is to continue, everyone, but especially those considering GP income and workload, must think of the contract as a whole and look beyond the average.

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