Building equity in the NHS: the role of general practice

INTRODUCTION

The NHS promise of comprehensive health care based on need and free at the point of use trips off the tongue, but has been hard to deliver especially in primary care. Formula-driven resource redistribution has worked in the hospital sector, steadily shifting resource according to need as measured by mortality rates, but not in general practice, where the distribution of general practice funding remains out of kilter with social gradients in premature multimorbidity and mortality.^1,2 The metaphor of a level playing field does not apply. Health care is built on a slope. Life and work are easier at the top.

As Levene et al report in this issue of the BJGP,³ the UK GP Contract continues to serve poor areas poorly. By using measures of activity as proxy measures of need, the funding formula rewards the expressed needs and demands which keep practices busy, such as the needs of patients who have acquired longevity and the demands of the worried well.

The unworried unwell, who often censor themselves, need a worried doctor but worried doctors need adequate consultation time, a long view, supportive colleagues, and effective referral links, all of which may be in short supply.

The Care Quality Commission (CQC, www.cqc.org.uk) rates 6947 general practices in NHS England in terms of being safe, effective, caring, responsive, and well-led — 90% are rated as ‘good’ and 5% as ‘outstanding’.The high prevalence of ‘good’ practices provides an explanation of the inverse care law,⁴ not in terms of the difference between …