No change to global sum formula

The delayed global sum review may mean private providers can afford to take patients GPs can't. By Nick Bostock

The global sum formula review will not be complete in time for changes to be implemented in 2007/8, the GPC has admitted.

GPC chairman Dr Hamish Meldrum says the timetable has ‘slipped’ and that the time needed to model any new formula and for the DoH to assess its cost implications mean it would not be ready for April.

The DoH and the GPC are desperate to get rid of the MPIG, the global sum top-up mechanism, but in the absence of an alternative it is likely to be retained.

Contract negotiations are at a standstill because NHS Employers negotiators are resisting GPC demands for an inflationary pay rise.

But the review offered hope that some of the contract’s inequities might be ironed out and that negotiations could get back on track.

MPIG undermines GPs

The delay means there is unlikely to be any real change for another year. In the meantime, GPs say the MPIG’s side-effects are undermining the profession.

The MPIG creates a disincentive to list growth and freezes historical inequities in the levels of core pay that practices receive.

Practices are discouraged from taking on more patients because the MPIG is made up of a global sum, based on £54 per patient, weighted according to need, plus a correction factor.

The correction factor tops up practices’ formula-generated global sum to ensure core income is not less under new GMS than that earned under the Red book. More than 90 per cent of GMS practices require correction factors which, on average, account for some 20 per cent of core income.

But the amount in the correction factor is fixed - only the global sum element of pay increases when new patients join the list. So practices receive less per patient for new arrivals than for existing patients.

Areas like Milton Keynes, where the population is rising fast, are hit hardest by this anomaly.

Cleveland LMC chairman Dr John Canning said: ‘There is huge variation in the funding practices receive per patient, and much of this is historic. ‘How practices at the bottom of the scale are expected to provide a service when they receive half as much as practices at the top is difficult to see.

‘It’s often about whether practices invested under the old arrangements. If you received a lot of staff investment under the Red Book, this is maintained.

‘But practices that perhaps had an older partner who didn’t want to invest because they were about to leave, are stuck in amber. They are stuck with relatively low core pay and can’t get out of this position.’

Dr Canning warned that the longer general practice remained frozen by the MPIG, the longer private providers would have to fill the service gap.

‘There is a danger that if practices don’t take on new patients and they can’t register with a GP, there will be a demand for an increasing number of APMS contracts,’ he said.

He added that because private providers may be guaranteed set levels of funding when they open practices they may be able to use spare pay to develop additional services that then draw patients away from existing providers.

‘Patients may feel pressure to move to these practices if they offer extra services. The risk to patient-focused general practice will grow while the status quo is maintained,’ Dr Canning warned.

Perverse incentive for PCOs

Oxfordshire LMCs chief executive Dr Paul Roblin said the current pay system created perverse incentives for primary care organisations (PCOs).

‘PCOs have an enormous incentive to dissolve practice lists and not put them out to tender. It’s much cheaper to put patients into existing lists, because that way they don’t attract an MPIG payment,’ he said.

Despite the common ground between GPC and NHS Employers negotiators over the need to ditch the MPIG, the two sides may never see eye to eye .

The GPC favours increasing the basic payment per patient in the global sum, to end reliance on MPIG. But the DoH is reluctant to release more funds.

Dr Canning said the DoH may seek to transfer all correction-factor pay into the global sum pot, a move that would increase the basic global sum payment from its current £54 per patient.

But he said this would be ‘unacceptable’ because it would create winners and losers.

Dr Meldrum has confirmed the review team is looking at the way money is allocated for essential and additional services but has refused to reveal any detail.

Some LMCs say they would prefer a solution that  is well thought out rather than rushed. However, it is needed soon or the promise of MPIG ‘in perpetuity’ may start to turn sour.

Effects of delay

Continuation of funding inequalities.

Practices earn less for taking on new patients.

PCO forced allocations.

Opportunities for private providers.

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