Strengths and limitations
Findings from a complete national health system are presented, comprising 956 general practice populations, all of which could be characterised by age, sex, and deprivation, based on postcodes and deprivation scores for all patients. The present assessment of practice resources based on practice funding is an improvement on previous studies of the inverse care law comparing whole-time equivalent (WTE) numbers of practitioners.5 The most recent complete data on GP WTE numbers pre-date the new GMS contract and are increasingly out of date. Practice funding provides a better indication of the total resource available for general practice services, including the employment of GPs, nurses, and other staff, premises, and other running costs.
The present estimates of multimorbidity and consultation rates are based on data from samples of 314 (31%) and 60 (6%) practices, respectively. Their combined list populations are large and representative of the general Scottish population in terms of demography and deprivation. To measure multimorbidity, 40 morbidities were used including several that are not generally included in multimorbidity studies but have a major impact on a patient’s quality of life and feature prominently in the work of general practice.10 Although different deprivation measures were used to categorise multimorbidity (based on the Carstairs score) and consultations (based on SIMD), there is a strong correlation between these scores. Only a small number of practices change decile using either scoring system and the results would be similar in either case.
Multimorbidity levels are calculated from 2007 and applied to practice populations in 2012, when data on consultation rates and practice funding also were available. The resulting estimates of multimorbidity prevalence in 2011–2012 may be imprecise, but it is unlikely that the observed social gradients changed sufficiently to have a significant effect on the findings. This study presents a pragmatic, composite picture, describing the realities of general practice in Scotland.
Comparison with existing literature
The authors are not aware of similar data elsewhere to allow comparison between health systems. The principal findings of the present study are that neither general practice funding nor the amount of clinical activity, in terms of number of consultations, are closely aligned with social gradients in multimorbidity and mortality.
In the UK general practices receive income via the GMS contract, with separate funding streams for essential services, the QOF, and ES.14 Although a significant proportion of practices have alternative locally negotiated contracts (personal medical services in England and Wales, section 17c and section 2c contracts in Scotland), these are usually based on the GMS model unless the practice serves a particular population such as homeless people.
About two-thirds of general practice funding in the UK is provided via the global sum, which is similar in design but differs in detail across the UK jurisdictions.14 In Scotland, the Scottish Allocation Formula (SAF) determines how the global sum is distributed between practices.15 Payments per registered patient under SAF are determined by the age and sex structure of the practice population (with weightings determined by estimated consultation rates, based on PTI data from 2004–2005); additional needs of the practice population (morbidity and deprivation); and rurality and remoteness of the practice population. Other weights, taking account of the workloads generated by care home patients and new registrations, are set at a UK level but have a smaller effect. A further adjustment allows for differences in staff costs between Scottish health board areas.
Despite weighting for deprivation, practice funding remains broadly flat as deprivation increases in the population. A possible explanation is the weighting given in the SAF for rurality and remoteness, to ensure the viability of small practices serving sparsely populated areas.13 Rural and remote practices are generally located in less deprived deciles (for example, decile 2) and receive around twice as much funding per patient than practices located in primary cities in Scotland. Rural and remote practices only make up a small proportion of all Scottish practices, however, and if these practices are excluded, the analysis produces similar results (Table 2).
Changes to the way the global sum is allocated were proposed in the UK in 2014–2015,16 including the removal of the MPIG. Removing such payments from this analysis (Table 2) reduces the funding to all practices, especially practices in affluent areas, but makes little difference to the overall results (although some individual practices will experience very large changes). Similarly, although QOF payments increase with deprivation, because the prevalence of chronic disease is higher in more deprived practices, the overall effect on practice income is small.
Recent changes to the global sum in England have increased the weighting given to older patients, in response to the increasing numbers of such patients and their higher use of services.16 Government proposals to drop the weighting for deprivation, thereby enhancing the effect of weighting by age, were rejected by NHS England, however, in favour of a funding formula with the aim of targeting unmet need in deprived areas.17 Critics of the new formula questioned whether it will achieve that effect.18,19 Evidence from this study shows that although practices in more deprived areas have younger populations, they also have higher levels of multimorbidity, occurring at a much younger age, and will be disadvantaged by allocation formulas where age is given such prominence.
These issues reflect the difficulty of assessing and comparing the clinical needs and demands of patients with and without longevity. Practices in more affluent populations have higher numbers of frail older patients (Table 1), who are less mobile, have multiple medical and care needs, and are more likely to require coordinated care, including home visits. Practices in very deprived areas have larger numbers of patients with combined physical, mental, and social morbidities, particularly in younger age groups, who need more time for engagement, and for steadily working through their problems. All practices are busy with different combinations of needs and demands, with different implications for population health and longevity.
Crude comparisons of consultation rates do not capture these different aspects of practice.20 The consultation data in this study include patient encounters with GPs and practice nurses, and home visits, but provide no information on the variable duration, content, and quality of encounters, the extent to which they reflect needs and/or demands, nor the increasing amount of administrative work required before and after consultations.
However, it is noteworthy that the social gradient in consultation rates is less steep than the social gradients in multimorbidity and mortality. With a flat distribution of funding, deprived practices can only generate increased consultation rates by having shorter consultation times, or working longer hours. A study of 3000 consultations in general practice in the West of Scotland described the practical consequences for patients and practitioners. Consultations in deprived areas involve higher levels of multimorbidity and social complexity, shorter duration, lower expectations, less patient enablement, especially for patients with mental health problems, and higher practitioner stress.21 Basing funding on consultation rates simply institutionalises the inverse care law, to the detriment of the most vulnerable patients with complex problems.22–24
Implications for practice
Universal healthcare coverage provides access to care, but does not in itself equip front-line practitioners to respond proportionately to patients’ clinical needs. On average, GPs in more deprived areas have a higher workload, with more consultations with patients who are more likely to be multimorbid with both physical and mental conditions, but do not receive additional funding to address these complex needs.
When needs are partially met, the heath service underachieves in reducing the severity and slowing the progression of health and social problems. Until allocation formulas in Scotland and the rest of the UK take into account the earlier onset of morbidity in more deprived areas and the wide deprivation-related differences in multimorbidity and chronic illness between age groups, such funding systems will remain inequitable, and continue to be part of the problem of health inequalities, rather than part of the solution.
