Dr Kambiz Boomla Senior Lecturer and General Practitioner Clinical Effectiveness Group Queen Mary University of London Chrisp Street Health Centre E14 k.boomla@qmul.ac.uk

1. A FAIRER FUNDING
FORMULA
Dr Kambiz Boomla
Senior Lecturer and General Practitioner
Clinical Effectiveness Group
Queen Mary University of London
Chrisp Street Health Centre E14
k.boomla@qmul.ac.uk

2. Minimum Practice Income Guarantee
• nGMS contract came into force in April 2004
• All GMS practices have Global Sum for looking after their
patients – their share of total national amount allocated for
general practice
• Also PMS practices and APMS practices with a more
locally determined funding stream
• Other funding streams going into GMS practices such as
the Quality and Outcomes Framework
• Global Sum Share of the national pot is determined by the
Carr-Hill formula devised by Prof Carr-Hill
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3. Carr-Hill formula
• Idea is to model GP workload so practices are funded fairly for the
number of consultations they are expected to need to offer
• So a practice with mainly elderly patients may have a higher workload
than one dealing mainly with commuters
• So a practice given a Carr-Hill weighting of 1.1 will get 10% more money
than a practice with the same number of patients that has the national
average of 1.0
• Practices working in areas of deprivation expected to get Carr-Hill
weightings of greater than 1, when they voted to accept the new contract.
• But when practices got their allocation, many were very surprised that
their weighting was less than the national average
• So many practices found their income dropping in April 2004 that a top
up was agreed, a correction factor, that guaranteed their previous level of
resourcing. This was the minimum practice income guarantee – MPIG
• If MPIG is withdrawn, 24 of the 100 worst affected practices are in Tower
Hamlets, Hackney and Newham, demonstrating that Carr-Hill did not
succeed in producing a formula that accurately dealt with the issues in
many of the deprived parts of the country with greater health needs
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4. How Carr-Hill was calculated
• Factors included in the Carr-Hill formula
• patient age and gender (used to reflect frequency of home and surgery
visits)
• additional needs: Standardised Mortality Ratio and Standardised Long-
Standing Illness for patients under the age of 65 years
• number of newly registered patients (generate 40% of work in 1st year)
• rurality
• costs of living in some area (i.e. South East - reflecting higher staff
costs)
• patient age/gender for nursing/residential consultations.
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5. But are all 65
year olds the
same
• Age is the biggest
factor affecting
practice resourcing
in Carr-Hill
• Yet illness and need
for a GP depends
not on how far you
are away from your
birth
• Rather it depends
how close you are to
your death
• Professor Marmot
illustrated this very
well in his
government report
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6. 6

7. Healthy Life
Expectancy
Healthy life expectancy at birth by deprivation
decile, England, 2009-11
Note: Decile 1 is the most deprived decile within England,
Decile 10 is the least deprived.
Males Females
Former
area
Current
area
Area
name
Deprivatio
n
Healthy life
Expectancy
95%
Confidence
interval
Healthy life
Expectancy
95% Confidence
interval
code code decile (years)
lowe
r
upper (years) lower upper
E92000001 England 1
52.1 51.6 52.5 52.5 52.0 53.0
E92000001 England 2
55.8 55.3 56.4 56.1 55.5 56.6
E92000001 England 3
58.4 57.9 58.9 59.7 59.1 60.2
E92000001 England 4
61.2 60.6 61.7 61.7 61.1 62.2
E92000001 England 5
63.5 63.0 64.0 64.3 63.7 64.8
E92000001 England 6
64.9 64.4 65.4 66.0 65.4 66.5
E92000001 England 7
66.8 66.3 67.3 67.7 67.2 68.2
E92000001 England 8
67.7 67.2 68.2 68.6 68.0 69.1
E92000001 England 9
68.4 67.9 68.9 69.8 69.3 70.3
E92000001 England 10
70.5 70.0 71.0 71.5 70.9 72.0
Source:
ONS
• 18 year gap between
richest 1/10 of the
population and the
poorest 1/10
• 19 years for women
• So very unlikely that
a 60 year old from
rich area will consult
their GP anywhere
near as often as a 60
year old from one of
the poorest areas
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8. Need for a new formula
• So if MPIG is to be done away with, then a fair formula is needed
• Age is still be best indicator of need for a GP
• Problems with language and ethnicity – poorly recorded, could be resourced off
formula
• But chronological age needs to adjusted by “Healthy Life Expectancy at
Birth”, so that a 52 year old living in the poorest tenth part of the country
receives the same weighting as a 70 year old in the richest tenth part of
the country
• Multimorbidity – those with many illnesses – recent Lancet paper shows
this happens 10-15 years earlier in deprived areas
• Epidemiology of multimorbidity and implications for healthcare, research, and medical education: a cross-sectional
study
• Karen Barnett, Stewart W Mercer, Michael Norbury, Graham Watt, Sally Wyke, Bruce Guthrie
• Published Online May 10, 2012 DOI:10.1016/S0140-6736(12)60240-2
• Data exists at Lower Super Output Area to allow this adjustment to be
easily calculated
• They both are the same number of years away from their death, and are
likely to consult the same number of times
• If the Department of Health modelled this variation on Carr-Hill, the need
for MPIG would most likely disappear
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