Crisis and possibly closure for some of our best GP practices

NHS England has ordered that some of the ways in which GPs are funded has to be changed. Over the last few months we have seen practices all over the country, including Devonshire Green Surgery in Sheffield fighting the abolition of the Minimum Practice Income Guarantee. Now NHS England has ordained that another form of funding, PMS, should be phased out over a much shorter time putting 11 practices at risk in Sheffield.

Since the foundation of the NHS GPs have been independent practitioners working for the NHS on a contract basis. Following the abolition of Primary Care Trusts in 2012, contracts have been overseen by NHS England, although CCGs have recently been encouraged to get involved in co-commissioning. Traditionally these contracts have been for GPs to provide General Medical Services (GMS). The terms of the contract are set nationally and have undergone significant revisions at different times, most recently in 2004. However since about 1997 and more so since 2004 many practices have been on a more flexible contract called PMS (Personal Medical Services) which was intended to allow practices to tailor their services more specifically to local needs and priorities and which made it easier to employ salaried GPs. Also in 2004 there were changes to the basis on which GP core practice income was calculated; these were intended to make the income more sensitive to practice needs (including deprivation) but when the calculations were delivered to practices there was a huge outcry because nearly every practice would lose money and many would be made financially unviable. As a result the formula was revised during a heavy week of negotiations and an emergency correction factor was introduced, the Minimum Practice Income Guarantee (MPIG) to save practices, especially those most at risk. The NHS is full of such measures which are introduced because some other decision has had unintended consequences, which is partly why NHS funding is so complicated - and often unfair.

Over the last 10 years there have been significant changes in the expectations of and demands on General Practice, especially the services they provide within surgeries and NHS England has been looking for savings or reallocations. A study they commissioned suggested that these days there is far less practical difference between GMS and PMS surgeries and that PMS practices are actually receiving a premium (i.e. extra money which is not reflected in extra services) put nationally at £260m. Whether this is correct or not is open to argument. In addition NHS England decided that the MPIG was having less and less effect overall and that it should be phased out, although it admitted that this would seriously affect the practices which MPIG was originally introduced to help, among them Devonshire Green Surgery. MPIG is already being phased out over 7 years and this is what Devonshire Green has been protesting about. Other surgeries which have been vigorously campaigning include the Limehouse Practice in Tower Hamlets. See this facebook page

NHS England has now also instructed that the PMS system should be abolished but within a much shorter period. Local CCGs have been told to distribute the savings around local GPs in whatever they determine to be an equitable manner. A report to the CCG Governing Body meeting of 2nd July recommended that this surplus ( the estimated local premium totalling around £2.9m) should be redistributed equally around local practices, subject to certain adjustments for deprivation weighting and the possibility that practices at risk could apply to the CCG for special consideration because of the services they provide.

The report said that 62 out of the 87 practices in Sheffield would lose out, with 11 practices losing more than £20 per weighted patient – a potential loss of more than £200,000 per year. Without special help, these practices may not be able to survive so that thousands of Sheffield patients, including many from vulnerable groups, face the possible closure of their General Practice during the next 18 months. The full list has not been made public because of confidentiality issues but it includes Devonshire Green Surgery and Page Hall Medical Centre. Doctors from both these surgeries attended the successful SSONHS meeting last Thursday.

The CCG had to deal with this in an extraordinary way. GPs were excluded from the decision making (because of their financial interest) leaving the CCG inquorate, so it had been decided in advance to run a contiguous sub committee of non-executive directors, CCG officers and the co-option of regular participant observers. They were told that the decision had to be taken fairly quickly or more problems would arise.

In the public questions part of the meeting the paper had been challenged by Dr Graham Pettinger from Devonshire Green Surgery and by a representative of Sheffield Save Our NHS on the basis that it contained no Equality Impact Assessment and that the criteria for special help seemed far too rigid.

Also in the preliminary discussion Dr Mark Durling from the Local Medical Committee representing all GPs said that general practice faced a catastrophe. Demand, stress, financial pressures and bureaucracy were causing many middle aged doctors to leave. The historical system of GP funding does not work properly but the current proposals, as they stood, would severely affect practices with dedicated doctors and staff who were putting all their resources into the care of their patients. The implication of Dr Durling's remarks is that these are practices which really are using their PMS money for extra services, and now risk being put out of action because of this. The notion that these practices are receiving an undeserved premium is quite wrong.

In the formal discussion on the paper the CCG officers apologised for not including an EIA and said that some of the criteria for special help could be adjusted as could the sum set aside from CCG funds. However they said that a decision was needed urgently as further uncertainty might lead doctors in some of the non PMS practices to start withdrawing services such as phlebotomy which they are having to meet out of their own core funding and sending patients to hospital instead. Board members seemed to accept during the meeting that there was not an agreed interpretation of word 'equitable' which is required by NHS England as a criterion for this redistribution. In this case we are talking both about effects on health inequalities and equity as fairness for practices. They were also troubled by the lack of information especially the EIA and decided to defer the decision for a fortnight.

SSONHS members have been supporting Devonshire Green from the start of their campaign; we alerted practices about the impending decision; and since the meeting we have been liaising with some of the GPs from the practices at risk. We want to see doctors working together to find the best way of supporting the varied need of patients across Sheffield. We do not want to see those doctors who have made huge efforts to connect with their local communities and meet their needs being hung out to dry.

There is also a further risk to practices consisting of salaried GPs and run by the Sheffield Health and Social Care Trust. These contracts are due to expire soon meaning that the practices may be put out to competitive tender and fall under the control of private companies such as Virgin. Independent research has shown that GP services run by private companies are less effective than NHS GPs on 14 out of 17 measures.

The doctors have been discussing the best way to campaign; it's not easy because the interests, needs and finances of all the practices are different making common ground more difficult to establish in detail. What's more they are forced to compete with each other for survival - which would not be happening if the overall funding to GPs was not being reduced by the Government. It is also obvious that any practice closures or service reductions will put far more financial pressure on other parts of the system.

Devonshire Green has had its own campaigning site for some months, and this will be regularly updated. See here Other practices may set up their own Save Our Surgery campaigns but will, we hope, also link up to provide a more concerted public presence.

SSONHS supporters who are patients of the practices at risk are urged to offer direct support when they identify themselves and to support any more centralised protests - see our website for updates. Things may develop quite rapidly unless the practices receive adequate assurances from the CCG. Already in the last 6 months NHS England has been forced to abandon threats of practice closure in both Sheffield and Goldthorpe when local patients have organised to protest.