General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland

Gary McLean; Bruce Guthrie; Stewart W Mercer; Graham CM Watt

doi:10.3399/bjgp15X687829

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RE: General practice funding
Alan James Wilson McLauchlan

Published on: 04 January 2016
RE: General Practice funding underpins the inverse care law
Graham Watt, Gary McLean, Bruce Guthrie and Stewart Mercer

Published on: 23 December 2015
RE: General practice funding underpins persistence of the inverse care law.
Alec Logan and Chris Johnstone

Published on: 17 December 2015
RE: General practice funding underpins persistence of the inverse care law.
Alan James Wilson McLauchlan

Published on: 16 December 2015
RE: General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland
Louis Levene, Richard Baker, Catherine Honeyford, Andrew Wilson and Nicola Walker

Published on: 15 December 2015

Published on: (4 January 2016)
Page navigation anchor for RE: General practice funding
RE: General practice funding
Alan James Wilson McLauchlan, Retired GP,, FRCGP
Thank you for the opportunity to respond to the reply of Prof Watt et al. The Scottish Index of Multiple Morbidity used in the study divides the population of Scotland into 6505 postcode areas and ranks each postcode area by deprivation score by using a formula. Every patient in each postcode area is then deemed to have the same deprivation score, irrespective of their actual deprivation status. A tightly zoned practice of 8000 patients might have 800 patients in each of 10 adjoining postcode areas, or a practice in a large city such as Aberdeen might have an average of 25 patients in each of 320 adjoining postcode areas. SIMD is an average area deprivation ranking tool and cannot be used to form conclusions about deprivation in general, indeed the authors specifically state that it must not be used for that purpose. Practices in Aberdeen with populations in the most deprived quintile in Scotland (as measured in 1998 by individual patient deprivation scores) are now allocated a less deprived score as their small numbers of more deprived patients in each postcode area as allocated area average scores. In most cities and towns in Scotland a postcode area contains a mix of more and less deprived patients living side by side, and postcode areas have for that reason previously been considered inappropriate to measure deprivation.

Watt et al have identified poor contract performance in certain areas but have not provided any data to link that to...
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Thank you for the opportunity to respond to the reply of Prof Watt et al. The Scottish Index of Multiple Morbidity used in the study divides the population of Scotland into 6505 postcode areas and ranks each postcode area by deprivation score by using a formula. Every patient in each postcode area is then deemed to have the same deprivation score, irrespective of their actual deprivation status. A tightly zoned practice of 8000 patients might have 800 patients in each of 10 adjoining postcode areas, or a practice in a large city such as Aberdeen might have an average of 25 patients in each of 320 adjoining postcode areas. SIMD is an average area deprivation ranking tool and cannot be used to form conclusions about deprivation in general, indeed the authors specifically state that it must not be used for that purpose. Practices in Aberdeen with populations in the most deprived quintile in Scotland (as measured in 1998 by individual patient deprivation scores) are now allocated a less deprived score as their small numbers of more deprived patients in each postcode area as allocated area average scores. In most cities and towns in Scotland a postcode area contains a mix of more and less deprived patients living side by side, and postcode areas have for that reason previously been considered inappropriate to measure deprivation.

Watt et al have identified poor contract performance in certain areas but have not provided any data to link that to contract terms and conditions. Practice income in 1998 would have allowed a comparison but the use of averages and standardisation is inappropriate. Individual practice figures would be more meaningful, especially if the study concerns different contract performance in different practices. The current contract should result in an increase in income for practices with more deprived populations, and a decrease in income for practices with less deprived populations, based not on deprivation score but on the presence of more and multiple chronic disease conditions in more deprived populations. A qualitative study to identify the barriers to implementing the contract in Glasgow would also have been more meaningful for future contract arrangements. What were the problems relating to recruitment of doctors and nurses, and premises issues? Actual numbers of doctors and nurses working in the practice and actual numbers of patients to be seen would again be more appropriate when considering service funding, and not age standardised populations and not WTE staffing levels.
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Competing Interests: None declared.
Published on: (23 December 2015)
Page navigation anchor for RE: General Practice funding underpins the inverse care law
RE: General Practice funding underpins the inverse care law
Graham Watt, Professor of General Practice,, University of Glasgow
Other Contributors:
Gary McLean, University of Glasgow

Bruce Guthrie, University of Dundee

Stewart Mercer, University of Glasgow
We are grateful to Dr Mclauchlan (e-letter, 16th December) for the opportunity to clarify several points.

The calculation of deprivation scores for practices was not based on the practice postcode but on the average of the deprivation scores of the postcodes of every patient registered with each practice.

It is true that the majority of patients living in the 15% most deprived Scottish data zones (the Scottish Government’s target population in addressing health inequalities) are not registered with the most deprived general practices. However, they comprise 42-88% of patients in the 120 most deprived general practices (decile 10 in our paper). These patients comprise about a third of all patients living in the 15% most deprived data zones. The other two thirds are registered with about 500 other general practices in Scotland, in which their prevalence ranges between 42% and 1% (i.e. ranging from “blanket” to “pocket” deprivation). About a third of general practices in Scotland have fewer than 1% of their patients living in the 15% most deprived data zones

Our paper does not focus on a minority of extreme practices. Tables 1 and 2 show that over 2 million people in Scotland in the 4 most deprived population deciles have 47% more complicated multimorbidity (whether ensured by 5+ conditions or the combination of a mental and physical health condition) b...
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We are grateful to Dr Mclauchlan (e-letter, 16th December) for the opportunity to clarify several points.

The calculation of deprivation scores for practices was not based on the practice postcode but on the average of the deprivation scores of the postcodes of every patient registered with each practice.

It is true that the majority of patients living in the 15% most deprived Scottish data zones (the Scottish Government’s target population in addressing health inequalities) are not registered with the most deprived general practices. However, they comprise 42-88% of patients in the 120 most deprived general practices (decile 10 in our paper). These patients comprise about a third of all patients living in the 15% most deprived data zones. The other two thirds are registered with about 500 other general practices in Scotland, in which their prevalence ranges between 42% and 1% (i.e. ranging from “blanket” to “pocket” deprivation). About a third of general practices in Scotland have fewer than 1% of their patients living in the 15% most deprived data zones

Our paper does not focus on a minority of extreme practices. Tables 1 and 2 show that over 2 million people in Scotland in the 4 most deprived population deciles have 47% more complicated multimorbidity (whether ensured by 5+ conditions or the combination of a mental and physical health condition) but received £9.79 (8%) less GP funding per head. It is fanciful to suggest that QOF funding (an additional £1.13 per head in the most deprived 40% of the population) provides a mechanism for employing more staff in these practices.

We agree on, and pointed out, the limitations of consultation data as a proxy measure of need. We recognise that a modest prevalence in a large practice population can involve more deprived patients than a higher prevalence in a small practice. A pro rata formula, based on multimorbidity, is the equitable solution to both issues.

Our paper presents a gross aspect of NHS funding which disadvantages large numbers of general practice populations, is backed up by similar data from England (Levene et al, e-letter, 15th December), and cannot be dismissed by arguments in the small print.
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Competing Interests: None declared.
Published on: (17 December 2015)
Page navigation anchor for RE: General practice funding underpins persistence of the inverse care law.
RE: General practice funding underpins persistence of the inverse care law.
Alec Logan, GP, Houldsworth Centre, Wishaw, Lanarkshire
Other Contributors:
Chris Johnstone, General Practitioner, Paisley
We congratulate Graham Watt and colleagues on their article in the December BJGP highlighting yet again that general practice provision in poorer parts of Scotland, and elsewhere in the UK, exacerbates health inequality.¹To be poor is to die younger. This is not a novel idea.² The RCGP, nationally across the UK, has a long and proud tradition of striving to reduce health inequalities.³ The BJGP study was widely reported across Scotland on the day of publication, displacing Andy Murray’s heroics at the Davis Cup from the front page of The Herald, and leading every news bulletin on BBC Scotland throughout that day.

The very next day after publication the Scottish Parliament hosted a reception for RCGP Scotland. An opportunity, buoyed by formidable evidence, to raise the spectre of health inequality and poverty across both urban and rural Scotland. Three of Scotland’s Cabinet Secretaries were in attendance and at least two of them were fully acquainted with the BJGP study.

An opportunity grasped?

Not according to last week’s emailed newsletter to members of RCGP in Scotland. There is mention of ‘gumption’, optimism, new contractual negotiations, and integrated health and social care. But not a single reference to health inequality.

The newsletter does cite a brief presentation by the chair...
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We congratulate Graham Watt and colleagues on their article in the December BJGP highlighting yet again that general practice provision in poorer parts of Scotland, and elsewhere in the UK, exacerbates health inequality.¹To be poor is to die younger. This is not a novel idea.² The RCGP, nationally across the UK, has a long and proud tradition of striving to reduce health inequalities.³ The BJGP study was widely reported across Scotland on the day of publication, displacing Andy Murray’s heroics at the Davis Cup from the front page of The Herald, and leading every news bulletin on BBC Scotland throughout that day.

The very next day after publication the Scottish Parliament hosted a reception for RCGP Scotland. An opportunity, buoyed by formidable evidence, to raise the spectre of health inequality and poverty across both urban and rural Scotland. Three of Scotland’s Cabinet Secretaries were in attendance and at least two of them were fully acquainted with the BJGP study.

An opportunity grasped?

Not according to last week’s emailed newsletter to members of RCGP in Scotland. There is mention of ‘gumption’, optimism, new contractual negotiations, and integrated health and social care. But not a single reference to health inequality.

The newsletter does cite a brief presentation by the chairman of RCGP Scotland’s patient participation group who wondered aloud whether his new grandson should ‘expect a shorter lifespan now that he has moved from England to Scotland’.

More pertinent questions could be asked. The grandson risk is greater as he moves around Scotland itself.

Why is lifespan longer in Aberdeenshire than Lanarkshire? Why is life expectancy 30 years longer in adjacent Glasgow postcodes: adequately doctored Bearsden and inadequately doctored Drumchapel?

The answers, staring us all in the face, are about delivering health care equitably and addressing poverty.

Why is RCGP Scotland ignoring a central public health issue of our time?

Other signatories Khairat Al-Habbal (Beirut, Lebanon), Dee Mangin (Christchurch, New Zealand) David Braley (Ontario, Canada), Paul Ryan (Cork, Ireland), Ronnie Burns, Niall Cameron, Peter Cawston, Margaret Craig, Lynsay Crawford, Maria Duffy, Susan Langridge, Stephanie Maguire, John Montgomery, Anne Mullin, Petra Sambale (Glasgow), Alanna MacRae (Greenock), Louise Hallam (Paisley), Steve McCabe (Portree), Janice Crofts, Elizabeth Jane Peak (Wishaw), Jack Kildare (Glasgow), Fiona Morrison (Dundee), Kerrie Stevenson (Edinburgh).

References

1. McLean G, Guthrie B, Mercer SW, Watt GCM. General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland. Br J Gen Pract 2015; DOI: 10.3399/bjgp15X687829.

2. Hart JT. The inverse care law. Lancet 1971; 297(7696): 405–412.

3. Royal College of General Practitioners. Health inequalities. http://www.rcgp.org.uk/policy/rcgp-policy-areas/~/media/Files/Policy/A-Z-policy/2015/Health%20Inequalities.ashx (accessed 17 Dec 2015).
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Competing Interests: None declared.
Published on: (16 December 2015)
Page navigation anchor for RE: General practice funding underpins persistence of the inverse care law.
RE: General practice funding underpins persistence of the inverse care law.
Alan James Wilson McLauchlan, Retired General Practitioner,, FRCGP
There are several problems with methodology in this study that invalidate the conclusion. The practice deprivation index used is based on practice area and independent of the number of patients involved. In a city with small exclusive practice areas, such as Glasgow the index is representative, but in cities with larger practices all covering the major part of the city, all practices are allocated the same deprivation score despite different practices having the full range of practice populations with some in the most deprived national quintile, some in the least deprived and others in between. The large population in most cities are therefore allocated to the middle range of the analysis by deciles, with loss of individual practices with most deprived data and least deprived data.

Educational attainment is measured by area but school data is also available. General practices are not afforded this information in Scotland. Previous research in Glasgow and elsewhere demonstrates that most patients in Scotland who are more deprived do not live in the more deprived areas. The 2009 deprivation index used in this study confirms the same with some individual elements being particularly pronounced, such as only 33% of poorest educational attainment being in the overall most deprived areas, and large parts of Aberdeen representing the nationally poorest performing 15%. This is all lost in analysis by the averaging go general practice deprivation sco...
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There are several problems with methodology in this study that invalidate the conclusion. The practice deprivation index used is based on practice area and independent of the number of patients involved. In a city with small exclusive practice areas, such as Glasgow the index is representative, but in cities with larger practices all covering the major part of the city, all practices are allocated the same deprivation score despite different practices having the full range of practice populations with some in the most deprived national quintile, some in the least deprived and others in between. The large population in most cities are therefore allocated to the middle range of the analysis by deciles, with loss of individual practices with most deprived data and least deprived data.

Educational attainment is measured by area but school data is also available. General practices are not afforded this information in Scotland. Previous research in Glasgow and elsewhere demonstrates that most patients in Scotland who are more deprived do not live in the more deprived areas. The 2009 deprivation index used in this study confirms the same with some individual elements being particularly pronounced, such as only 33% of poorest educational attainment being in the overall most deprived areas, and large parts of Aberdeen representing the nationally poorest performing 15%. This is all lost in analysis by the averaging go general practice deprivation scores. If schools can be provided with individual and area data then why can't ISD provide similar data for general practices ?

Consultation data from the reporting practices does not appropriately represent busy city practices and is also invalid in this context.

The important factors introduced in this contract were the ability of each practice to independently hire more doctors and nurses with requiring Health Board approval. Practices with more deprived populations had the potential to appropriately review their more numerous patients with chronic diseases and accumulate points. At the end of each year total points achieved by all practices were divided into the annual budget and allocated to practices. This allowed money to flow from less deprived practices to more deprived practices, provided they employed additional doctors and nurses.
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Competing Interests: None declared.
Published on: (15 December 2015)
Page navigation anchor for RE: General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland
RE: General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland
Louis Levene, Honorary Lecturer, Department of Health Sciences,, University of Leicester
Other Contributors:
Richard Baker, Professor, Department of Health Sciences,

Catherine Honeyford, Research Associate, School of Public Health, Dr Foster Unit,

Andrew Wilson, Professor, Department of Health Sciences,

Nicola Walker, Research Fellow, Department of Health Sciences,
The findings of McLean et al are not unique to Scotland¹. We examined the relationships between NHS payments, deprivation and multi-morbidity in English general practices.

The Global Sum Allocation Formula addresses workload by weighting payments to practices with adjustments including age, sex, morbidity, mortality, list turnover, and patients living in nursing/residential homes²; however, specific measures of deprivation are not included in this formula.

Data with details of NHS payments to individual practices in England for 2014-2015 were published recently³. We used the most recent Index of Multiple Deprivation (IMD) 2010 scores for individual practices⁴ and QOF register data for 2014-2015⁵. Each practice’s multimorbidity index was calculated from the total number of patients on nine QOF registers divided by the number of patients in the denominator of QOF indicator SMOK002 (CE Honeyford et al, unpublished data, 2015).

Of 7959 practices, we excluded those without an IMD 2010 score or with fewer than 500 patients, leaving 7895 practices. Total NHS payments per weighted patient had a positively skewed distribution, median £131.10, (q1 £117.93, q3 £150.79). The Spearman correlation coefficients were: payment and IMD 2010 score rho –0.2161, payment and multimorbidity index rho –0.0447, and IMD 2010 score and multimorbidity index rho 0.4282 (all...
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The findings of McLean et al are not unique to Scotland¹. We examined the relationships between NHS payments, deprivation and multi-morbidity in English general practices.

The Global Sum Allocation Formula addresses workload by weighting payments to practices with adjustments including age, sex, morbidity, mortality, list turnover, and patients living in nursing/residential homes²; however, specific measures of deprivation are not included in this formula.

Data with details of NHS payments to individual practices in England for 2014-2015 were published recently³. We used the most recent Index of Multiple Deprivation (IMD) 2010 scores for individual practices⁴ and QOF register data for 2014-2015⁵. Each practice’s multimorbidity index was calculated from the total number of patients on nine QOF registers divided by the number of patients in the denominator of QOF indicator SMOK002 (CE Honeyford et al, unpublished data, 2015).

Of 7959 practices, we excluded those without an IMD 2010 score or with fewer than 500 patients, leaving 7895 practices. Total NHS payments per weighted patient had a positively skewed distribution, median £131.10, (q1 £117.93, q3 £150.79). The Spearman correlation coefficients were: payment and IMD 2010 score rho –0.2161, payment and multimorbidity index rho –0.0447, and IMD 2010 score and multimorbidity index rho 0.4282 (all P<0.01). A regression on the log of payments, with IMD 2010 and multimorbidity as explanatory variables, produced an adjusted r² of 0.0146, with both IMD and multimorbidity having little predictive effect although significant due to the large sample size. Payments declined from £138.13 and £133.00, respectively, in the lowest deciles of IMD and of multimorbidity to £129.49 and 131.52, respectively, in the highest deciles.

Populations with higher levels of deprivation and multimorbidity are less well served by the current funding formula, which makes it challenging to help reduce the health consequences of deprivation and to address health inequalities.

References

1. McLean G, Guthrie B, Mercer SW, Watt GCM. General practice funding underpins the persistence of the inverse care law: cross-sectional study in Scotland. Br J Gen Pract 2015; DOI: 10.3399/bjgp15X687829.

2. Health & Social Care Information Centre. Appendix A: Global Sum Calculation Process. http://systems.hscic.gov.uk/ssd/downloads/newgpcontractpay/ngms-contents/appaglobalsum (accessed 6 Nov 2015).

3. Health & Social Care Information Centre. NHS Payments to General Practice, England, 2014–2015. 2015. www.hscic.gov.uk/article/2021/Website-Search?productid=18806&q=practice+payment&sort=Relevance&size=10&page=1&area=both#top (accessed 6 Nov 2015).

4. Health & Social Care Information Centre. Dataset: Estimates of Index of Multiple Deprivation (IMD) 2010 for GP practices. 2011.
https://indicators.ic.nhs.uk/webview/index/en/MyServer/NHS-Information-Centre-indicators.c.MyServer/GP-Practice-data.d.48/Demography.d.77/Deprivation.d.202/Estimates-of-Index-of-Multiple-Deprivation-IMD-2010-for-GP-practices/fStudy/P01112 (accessed 6 Nov 2015).

5. Health & Social Care Information Centre. Quality and Outcomes Framework (QOF) — 2014–2015. 2015. www.hscic.gov.uk/searchcatalogue?productid=19196&topics=0%2fPrimary+care+services&sort=Relevance&size=10&page=1#top (accessed 6 Nov 2015).

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Competing Interests: None declared.

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