Health CommitteeWritten evidence from Public Health Manchester (ETWP 11)

MANCHESTER CITY COUNCIL/NHS MANCHESTER

The subject of this memorandum is the problem of the inequitable distribution of GPs in England and the importance of tackling this problem. This is relevant to the following element of the committee’s inquiry:

Whether and how the Government’s plans will ensure the right numbers of appropriately qualified and trained healthcare staff (as well as clinical academics and researchers) at national, regional and local levels.

Summary

(i)This paper describes the current severe inequity in the geographical distribution of GPs in England, and suggests some possible remedies. This inequity is likely to contribute to variation in the quality of primary services and to variation in the effectiveness of Clinical Commissioning Groups (CCGs).

(ii)The relative provision of GPs is calculated in the paper using a standard measure of weighted relevant populations used by the Dept of Health.

(iii)In general, better health areas have a lot more GPs per weighted population than do poorer health areas.

(iv)The range of GP provision at SHA level is from 13% above the England average (London SHA) to 13% below (North West SHA).

(v)The range of GP provision at PCT level is from 53% above the England average (Wandsworth PCT) to 27% below (Nottingham City PCT). Wandsworth thus has more than twice as many GPs per weighted population as Nottingham City.

(vi)The range of inequity at CCG level will be worse than that at PCT level because there is additional geographical variation within PCT areas.

(vii)The extra responsibility of GPs in CCGs for commissioning and budgeting makes it even more crucial for this inequity to be tackled.

(viii)It is important to reduce this inequity as part of the drive to reduce health inequalities.

(ix)The proposed centralisation of the budget for GPs under the NHS Commissioning Board (NCB) provides an opportunity to manage initiatives to reduce the inequity.

(x)Possible initiatives to reduce the inequity include additional central funding for new GPs in under-doctored areas, greater incentives for GPs to work in these areas, and introducing a limit to the weighted list size per full time equivalent GP.

Introduction

“At a minimum the health service should ensure that disadvantaged groups have equal access to NHS services”

Marmot Review Economic Framework Report 2009 p. 112

1. The geographical distribution of GPs in England has been problematic since the birth of the NHS.1,2 Many GPs prefer to live and work in desirable areas. Consequently it has been difficult to reduce the inequity in the distribution of GPs which favours areas of better health. This is despite the past efforts of the Medical Practices Committee, the publicised concern of many past Secretaries of State for Health, the transfer of the primary care financial allocations direct to PCTs and the recent Equitable Access3 initiative.

2. The Equitable Access initiative demonstrated that new practices can be set up in under-doctored areas provided start-up funding is allocated from central funds. This initiative addressed not only under-provision at overall PCT level but also variation in provision within the PCT area. This is because in general PCTs will have sought to locate the new practices in areas which are most under-doctored within the PCT geography. However the size of Equitable Access was small relative to the problem of the inequity in GP provision. In addition it has been difficult to make it work in some areas because of the time needed to entice patients away from their usual GP practice, despite such practices usually being very over-subscribed.

GP Distribution at Regional Level

3. After 63 years of the NHS, the inequity in distribution is still severe; Figure 1 illustrates the latest position by SHA. For example the North West has a shortfall of 13% or 620 full time equivalent (FTE) GPs, while London has an excess of 13% or 570 GPs. The figure also illustrates a strong north/south divide in GP provision—the five southernmost SHAs have 22% more GPs per weighted population on average than the five northernmost SHAs.

4. The calculation of relative GP provision uses the standard Department of Health method of counting Full Time Equivalent (FTE) GPs per needs weighted relevant population, with analysis carried out by Public Health Manchester. GPs are counted at September 2010 as sourced from the NHS Information centre for Health and Social Care,4 and the population is the 2010 relevant one from the Department of Health exposition book for 2010–11. The needs weighting uses the latest formulae used for primary care allocations to PCTs5 (2010–11 allocations). The benchmark is taken as the England average and the calculation of the Index of provision (England = 100) and the shortfall and excess of GPs are all relative to this benchmark.

Figure 1

% EXCESS/SHORTFALL GPS FTE BY SHA 2010 DATA

Table 1

GP PROVISION BY SHA

Rank

SHA

FTE GPs per
100k wtd pop

Index
(England =
100)

GP excess/
shortfall

1

London

68.3

113.5

+573

2

South West

67.1

111.5

+352

3

South Central

66.6

110.7

+224

4

East of England

64.5

107.2

+229

5

South East Coast

64.0

106.3

+152

6

West Midlands

56.5

93.9

−213

7

Yorkshire & the Humber

56.2

93.4

−227

8

North East

54.1

90.0

−187

9

East Midlands

54.0

89.7

−283

10

North West

52.5

87.2

−620

 

South (four SHAs)

66.3

110.2

+1,530

North (five SHAs)

54.5

90.7

−1,530

GP Distribution at PCT Level

5. Figure 2 illustrates the situation for PCTs. Very substantial inequity exists with a greater range than at regional level. The range is from 27% under-provided to 53% overprovided compared with the England average and again calculated using weighted relevant populations.

Figure 2

VARIATION IN GP PROVISION FOR PCTS (ENGLAND AVERAGE = 100)

6. Table 2 gives data at either end of Figure 2. The most over-provided PCT has more than twice the provision of the most under-provided PCT. It is clear that it is in general the poorer health PCTs which have the greatest shortfalls in GP provision and vice versa. For example the top ten PCTs all have mortality well below the average and vice versa for the bottom ten. Thus using Standardised Mortality Ratios (SMRs) under 75 years the top ten PCTs population-weighted average is 87.8 ie12.2% better than the England average while the bottom ten average is 128.3 ie 28.3% worse than the England average. The full table of relative GP provision for all 151 PCTs is given in the appendix.

Table 2

TOP 10 AND BOTTOM 10 PCTS FOR GP PROVISION 2010 DATA

Rank

PCT

FTE GPs per
100k wtd pop

Index
(England =
100)

GP
excess/
shortfall

1

Wandsworth

92.3

153.4

+79

2

Kingston

84.4

140.3

+32

3

Lambeth

79.4

131.9

+53

4

Surrey

78.6

130.7

+159

5

Devon

78.5

130.4

+136

6

Camden

77.7

129.1

+40

7

Buckinghamshire

77.2

128.3

+68

8

Swindon

76.8

127.6

+30

9

Richmond & Twickenham

76.5

127.2

+21

10

Wiltshire

75.4

125.4

+60

 

142

Hull

46.7

77.7

−44

143

Sefton

46.7

77.6

−43

144

Hartlepool

46.6

77.4

−16

145

Sandwell

46.4

77.1

−51

146

Blackpool

46.1

76.7

−27

147

Ashton, Leigh & Wigan

45.7

76.0

−53

148

Oldham

45.6

75.8

−39

149

Wolverhampton City

45.2

75.1

−42

150

Halton & St. Helens

44.5

73.9

−60

151

Nottingham City

43.8

72.8

−59

 

England

60.2

100.0

0

7. Figure 3 shows the correlation between relative GP provision and premature mortality (as measured by the under 75 standardised mortality ratio for persons) for all 151 PCTs. The correlation is significant and the slope negative showing that in general premature mortality increases as GP provision decreases. This demonstrates that the inequity of GP distribution is in general strongly to the disadvantage of poor health areas.

Figure 3

RELATIONSHIP BETWEEN GP PROVISION AND PREMATURE MORTALITY (U75 SMR)

The Effect of GP Distribution on CCGs and the NCB

8. The creation of CCGs brings the problem of GP distribution into sharper focus. Under-doctored CCGs and their patients will be starting at a large disadvantage and they will find it more difficult to absorb the new responsibilities for commissioning and budgeting; they will have little control over the situation because the GP budget will be under the control of the NCB. Consequently under-doctored CCGs are likely to be assertive in their demands for a fair share of GPs to serve the population for which they are responsible. The result is likely to be extensive negotiations between CCGs and the NCB.

9. These likely future problems make it important for the NCB to both review the problem of GP distribution and to develop a plan of action which would ultimately produce a fair distribution related to the needs of the population of each CCG. This action will be important to set a level playing field for NCB’s responsibility to hold CCGs to account for health outcomes.

Ideas to Contribute to a Solution to the Problem of GP Distribution

10. This section discusses possible remedies but is inevitably only introductory in what is a complex issue.

(i)The most obvious is for the NCB to commission and provide start-up funding for new practices in under-doctored areas. But fundamental problems remain which could hinder this such as a lack of sufficient financial incentives for GPs to work in deprived areas.

(ii)Gradually introduce a limit in weighted list size per FTE GP in each practice. There is currently no limit to the list size or weighted list size per GP so that there is a financial incentive for practices to maximize list size in under-doctored areas, sometimes rising to 3,000 or even 4,000 patients per GP compared with the England average of about 1,700. This proposal should make it easier for such areas to absorb new practices.

(iii)Educate patients on the service standards they should expect, and on the weighted list size per GP in their practice. This is designed to encourage patients to move to a better practice if their current one has too many patients and consequently offers a poor service.

(iv)Give greater financial incentives to attract GPs to poor health areas. The financial incentive in the Global Sum formula of the GP contract (it excludes the health inequalities factor used for PCT allocations), or salaries offered to salaried GPs, may not be high enough to attract GPs into deprived areas or to offset levels of private income in wealthier areas. Some commentators have also blamed the MPIG “safety net” payment for helping maintain inequity,6 (though this effect should reduce with time), and some suggest that QOF targets are more difficult to achieve in poor areas.7,8

(v)Investigate the possible relationship between where GPs train in practices and where they gain employment as GPs and if this is positive take steps to increase training places in under-doctored areas.

Conclusion

11. The creation of CCGs brings into greater focus the longstanding problem of the severe inequity in the geographical distribution of GPs in England. The chronic shortage of GPs in most poor health areas will serve to further disadvantage deprived communities as their over-stretched GPs are given additional responsibilities for commissioning and budgeting. But the fact that the NHS Commissioning Board will hold the GP budget and contracts centrally presents opportunities for the underlying problem of the geographically unbalanced workforce to be tackled anew.

References

1. Abel-Smith B. National Health Service. The first thirty years. London 1978 HMSO. P 55.

2. Gravelle H Sutton M Trends in geographical inequalities in provision of general practitioners in England and Wales. The Lancet 352(9144) 1998 1910.

3. Department of Health. Equitable Access to Primary Medical Care services (EAPMC)
http://www.dh.gov.uk/en/Procurementandproposals/Procurement/ProcurementatPCTs/index.htm

4. Department of Health. Health Inequalities: Progress and next steps. June 2008.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085307

5. Department of Health Resource allocation exposition books.
http://www.dh.gov.uk/en/Managingyourorganisation/Financeandplanning/Allocations/index.htm

6. Gainsbury S. Huge variation in GP practice pay regardless of size of list. News Item. Health Service J. March 2008 118(6099) 4–5.

7. NHS Confederation. In Sickness and in Health. September 2007.

8. Mclean G Sutton M Guthrie B. Deprivation and quality of primary care services: evidence for persistence of the inverse care law from the UK Quality and Outcomes Framework. J. Epidemiol Community Health 2006; 60: 917–922.

December 2011

APPENDIX

Table App 1 GP Provision for PCTs using 2010 data

(GP SHORTFALL/EXCESS NUMBERS ARE “EXCESS” UNLESS NEGATIVE)

Rank

PCT

FTE per
100,000
wtd pop

GP
index
(England
= 100)

shortfall/
excess
FTE

1

Wandsworth PCT

92.3

153.4

79

2

Kingston PCT

84.4

140.3

32

3

Lambeth PCT

79.4

131.9

53

4

Surrey PCT

78.6

130.7

159

5

Devon PCT

78.5

130.4

136

6

Camden PCT

77.7

129.1

40

7

Buckinghamshire PCT

77.2

128.3

68

8

Swindon PCT

76.8

127.6

30

9

Richmond And Twickenham PCT

76.5

127.2

21

10

Wiltshire PCT

75.4

125.4

60

11

Harrow PCT

75.1

124.8

26

12

Hammersmith and Fulham PCT

75.0

124.7

23

13

Tower Hamlets PCT

73.7

122.6

31

14

Islington PCT

73.7

122.4

27

15

Oxfordshire PCT

72.3

120.2

63

16

Hertfordshire PCT

72.3

120.1

111

17

Cambridgeshire PCT

71.9

119.5

60

18

Sutton and Merton PCT

71.8

119.4

38

19

South Gloucestershire PCT

71.4

118.7

23

20

West Essex PCT

71.4

118.7

26

21

Cumbria Teaching PCT

71.2

118.4

61

22

Croydon PCT

71.2

118.3

33

23

Berkshire West PCT

70.8

117.7

38

24

Haringey Teaching PCT

70.4

117.0

24

25

City and Hackney Teaching PCT

69.7

115.8

23

26

Bath and North East Somerset PCT

69.5

115.5

15

27

Leicestershire County and Rutland PCT

68.9

114.6

52

28

Herefordshire PCT

68.9

114.5

15

29

Enfield PCT

68.8

114.4

22

30

Barnet PCT

67.9

112.8

22

31

Westminster PCT

67.6

112.3

15

32

Worcestershire PCT

67.4

112.0

38

33

Berkshire East PCT

67.1

111.6

22

34

Kensington And Chelsea PCT

67.1

111.5

11

35

Bedfordshire PCT

67.0

111.3

25

36

Lewisham PCT

67.0

111.3

17

37

Plymouth Teaching PCT

66.7

111.0

19

38

Hillingdon PCT

66.4

110.4

14

39

Western Cheshire PCT

66.4

110.3

16

40

Bromley PCT

66.3

110.3

16

41

Mid Essex PCT

66.1

110.0

18

42

Sheffield PCT

66.1

110.0

35

43

Hampshire PCT

66.1

109.8

64

44

Brent Teaching PCT

65.8

109.4

15

45

Somerset PCT

65.3

108.5

26

46

Ealing PCT

65.3

108.5

15

47

Solihull Care Trust

65.3

108.5

10

48

Gloucestershire PCT

65.2

108.5

27

49

Milton Keynes PCT

65.2

108.5

11

50

North Yorkshire and York PCT

65.2

108.3

38

51

Peterborough PCT

65.1

108.3

8

52

Southwark PCT

65.0

108.1

12

53

Norfolk PCT

64.9

107.8

35

54

Suffolk PCT

64.7

107.6

25

55

Northumberland Care Trust

64.3

106.9

14

56

Warwickshire PCT

64.3

106.9

21

57

Hounslow PCT

64.1

106.5

8

58

East Sussex Downs and Weald PCT

64.1

106.5

13

59

Dorset PCT

63.5

105.6

13

60

West Sussex PCT

62.8

104.4

19

61

Newham PCT

62.6

104.0

7

62

West Kent PCT

62.6

104.0

14

63

Shropshire County PCT

62.4

103.7

6

64

Darlington PCT

62.2

103.4

2

65

Bournemouth and Poole Teaching PCT

61.7

102.5

5

66

Greenwich Teaching PCT

61.1

101.5

2

67

North Somerset PCT

61.0

101.4

2

68

Bolton PCT

60.8

101.1

2

69

Bradford and Airedale Teaching PCT

60.5

100.6

2

70

Central and Eastern Cheshire PCT

60.5

100.6

1

71

Cornwall and Isles of Scilly PCT

60.4

100.4

1

72

Bristol PCT

60.3

100.2

0

73

Waltham Forest PCT

60.1

99.9

−0

74

South Birmingham PCT

59.2

98.4

−4

75

Warrington PCT

58.7

97.6

−3

76

Coventry Teaching PCT

58.5

97.3

−6

77

Luton PCT

58.5

97.3

−3

78

South Staffordshire PCT

58.2

96.7

−12

79

Medway PCT

57.6

95.7

−7

80

Leicester City PCT

57.4

95.4

−9

81

Bexley Care Trust

57.1

95.0

−6

82

Torbay Care Trust

57.1

95.0

−5

83

South East Essex PCT

57.0

94.7

−10

84

Brighton And Hove City PCT

56.6

94.1

−9

85

Redcar and Cleveland PCT

56.5

94.0

−6

86

Eastern and Coastal Kent PCT

56.5

93.9

−28

87

Leeds PCT

56.5

93.9

−30

88

Southampton City PCT

56.3

93.6

−10

89

North Lincolnshire PCT

55.2

91.8

−9

90

Hastings and Rother PCT

55.2

91.8

−10

91

Stockport PCT

55.0

91.4

−15

92

County Durham PCT

54.7

90.9

−35

93

Trafford PCT

54.5

90.6

−12

94

Dudley PCT

54.4

90.4

−19

95

South West Essex PCT

54.2

90.2

−22

96

Walsall Teaching PCT

53.7

89.3

−19

97

Bury PCT

53.7

89.3

−13

98

North East Lincolnshire Care Trust Plus

53.7

89.2

−12

99

Great Yarmouth and Waveney PCT

53.6

89.1

−16

100

Northamptonshire Teaching PCT

53.6

89.0

−42

101

East Riding Of Yorkshire PCT

53.5

89.0

−21

102

Wirral PCT

53.3

88.6

−26

103

Barking and Dagenham PCT

53.3

88.6

−12

104

North Staffordshire PCT

53.0

88.1

−16

105

Havering PCT

52.8

87.8

−16

106

North Tyneside PCT

52.8

87.7

−18

107

Derbyshire County PCT

52.4

87.1

−59

108

Stockton-On-Tees Teaching PCT

52.3

86.9

−17

109

Doncaster PCT

52.2

86.8

−29

110

Gateshead PCT

52.1

86.7

−20

111

Nottinghamshire County Teaching PCT

52.1

86.6

−56

112

Middlesbrough PCT

52.1

86.5

−15

113

Isle of Wight NHS PCT

51.9

86.2

−13

114

Redbridge PCT

51.8

86.1

−19

115

North East Essex PCT

51.7

86.0

−29

116

Salford PCT

51.7

85.9

−24

117

South Tyneside PCT

51.5

85.6

−16

118

Newcastle PCT

51.4

85.4

−27

119

Lincolnshire Teaching PCT

51.3

85.2

−68

120

Heart Of Birmingham Teaching PCT

51.2

85.1

−29

121

Kirklees PCT

51.1

84.9

−38

122

Barnsley PCT

50.8

84.5

−28

123

Derby City PCT

50.8

84.5

−27

124

Wakefield District PCT

50.7

84.3

−38

125

Rotherham PCT

50.6

84.1

−28

126

Portsmouth City Teaching PCT

50.5

84.0

−20

127

Sunderland Teaching PCT

50.2

83.4

−34

128

Birmingham East and North PCT

50.2

83.4

−46

129

Heywood, Middleton and Rochdale PCT

50.0

83.2

−25

130

Manchester PCT

49.9

83.0

−64

131

North Lancashire Teaching PCT

49.6

82.4

−40

132

Telford and Wrekin PCT

49.5

82.2

−19

133

Bassetlaw PCT

49.2

81.8

−14

134

East Lancashire Teaching PCT

48.9

81.2

−50

135

Tameside and Glossop PCT

48.7

81.0

−30

136

Knowsley PCT

48.6

80.7

−24

137

Central Lancashire PCT

48.4

80.5

−57

138

Calderdale PCT

48.3

80.3

−25

139

Liverpool PCT

47.7

79.4

−72

140

Stoke On Trent PCT

47.3

78.7

−43

141

Blackburn with Darwen Teaching Care Trust

47.0

78.2

−24

142

Hull Teaching PCT

46.7

77.7

−44

143

Sefton PCT

46.7

77.6

−43

144

Hartlepool PCT

46.6

77.4

−16

145

Sandwell PCT

46.4

77.1

−51

146

Blackpool PCT

46.1

76.7

−27

147

Ashton, Leigh And Wigan PCT

45.7

76.0

−53

148

Oldham PCT

45.6

75.8

−39

149

Wolverhampton City PCT

45.2

75.1

−42

150

Halton and St Helens PCT

44.5

73.9

−60

151

Nottingham City PCT

43.8

72.8

−59

Source: PHM analysis using data from:
(i) GPs FTE at September 2010 from the NHS Information Centre for Health and Social Care.
(ii) Weights and populations: DH exposition book 2010–11.

Prepared 22nd May 2012