Overview of General Practice (GP) Funding in England – Organizations Involved and Sources of Funding
Introduction
The landscape of general practice in England is a complex web of organizations and funding mechanisms, each playing a vital role in ensuring that GP practices can deliver high-quality, patient-centred care. This article provides an overview of the intricate workings of these entities.
Key Organizations
GP clinics are typically small businesses owned and operated by General Practitioners (GPs). They receive funding from NHS England (NHSE) through Integrated Care Boards (ICBs), which are responsible for commissioning services at both national and local levels. The services provided by these clinics are overseen by various committees and are subject to strict regulation by quality assurance organizations such as the Care Quality Commission (CQC). The key organizations are summarized below:
Funding of GP:- HM Treasury - Allocates overall government budget, including healthcare funding. Source of funding: Government revenue (taxes).
- NHS England (NHSE) - Commissions primary and secondary healthcare services, allocates funds to Integrated Care Boards (ICBs). Source of funding: Department of Health and Social Care (DHSC).
- Integrated Care Systems (ICSs): Formalized as statutory bodies by the Health and Care Act 2022, ICSs coordinate healthcare services and strategic planning across regions. Source of funding: NHS England, ICSs allocate budgets to ICBs.
- Integrated Care Partnerships (ICPs): Work alongside ICSs to address broader health, public health, and social care needs. Develop integrated care strategies but do not commission services directly. Source of funding: Indirectly funded through NHS and local authorities.
- Integrated Care Boards (ICBs): Plan and commission local healthcare services, manage GP contracts, oversee quality and improvement, and support community health initiatives. Source of funding: Funded by NHS England.
- Care Quality Commission (CQC) - Independently reviews and rates healthcare services, ensures quality standards are met. Source of funding: Government funding and fees from registered services.
- GP Clinics - Small businesses usually run by GPs, heavily regulated by NHSE, CQC, and ICBs. Employ various staff to provide services. Source of funding: NHS England.
- Primary Care Networks (PCNs): Collaborative groups of GP practices working together to provide integrated care locally. Source of funding: NHS England, ICBs, additional funding mechanisms like DES and ARRS schemes.
- Local Medical Committee (LMC) - Local representative body for NHS GPs, addresses local issues, provides support, and ensures GP voices are heard. Source of funding: Statutory levies on GPs and NHS contributions.
- General Practitioners Committee (GPC): Part of the British Medical Association (BMA), focuses on GP contract issues, negotiates contracts, advocates for GPs. Source of funding: Funded by the BMA.
- The King’s Fund: Independent charity, conducts research, provides analysis, and policy recommendations to improve healthcare. Source of funding: Donations, grants, and endowments.
Key Functions of ICBs
Managing GP Contracts
ICBs are responsible for the contractual compliance of General Practitioner (GP) contracts, which include General Medical Services (GMS), Personal Medical Services (PMS), and Primary Care Network (PCN) contracts. Ensuring adherence to these contracts is essential for the smooth operation of GP practices.
Quality and Improvement
ICBs monitor the Quality and Outcomes Framework (QOF) and other health outcomes, such as screening programs. Additionally, they encourage innovation and research to improve healthcare delivery and patient outcomes.
Community Health
ICBs identify local health needs and involve patients in service delivery through mechanisms like Patient Participation Groups (PPGs). This engagement ensures that services are tailored to the specific needs of the community.
Digital/IT Infrastructure
ICBs commission and fund digital NHS services through Commissioning Support Units (CSUs), maintaining and enhancing IT systems that support healthcare delivery and improve service efficiency.
Examples of Locally Commissioned Services (LCS)
- Severe Mental Illness (SMI) checks
- Learning Disability (LD) checks
- POD services (Pharmacy, Optometry, and Dentistry)
Sources of GP Funding
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| Sources of GP income |
Core Contracts provide about 50% of overall funding to GPs and include NHS Essential services and OOH (Out of Hours) work. Payments are made on the basis of number of patients registered (patient list) with Capitation calculated using ‘Carr-Hill’ formula. Anyone who has a health need or thinks they have health need should have access to care is the fundamental principle of core contract.
Types of NHS GP Contracts
General Medical Services (GMS)
GMS contracts cover core medical services with payments agreed upon nationally, accounting for 70% of all NHS GP contracts. Providers under GMS are GPs or qualifying health professionals/companies, which must be 100% owned by qualifying persons. The contracts are nationally registered and include essential services along with optional additional services. GMS contracts are open-ended, terminated on notice, and paid via a global sum with a Minimum Practice Income Guarantee (MPIG). The majority of GP practices in England operate under GMS contracts.
Carr-Hill Formula: This formula adjusts funding based on factors like patient age, gender, morbidity, and deprivation to ensure fair allocation of resources to GP practices.
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| Componenents of Carr-Hill formula |
Personal Medical Services (PMS)
PMS contracts cover core services with the option to include additional services tailored to meet local health needs. Representing about 30% of NHS England GP contracts, these contracts are locally negotiated by ICBs with flexible payments. Providers under PMS are also GPs or qualifying health professionals/companies owned by qualifying persons. PMS contracts are typically five years, renewable, and often result in higher incomes compared to GMS. However, PMS contracts are phasing out, with higher incomes likely to be clawed back.
Alternative Provider Medical Services (APMS)
APMS contracts address gaps in service delivery, especially in areas with high need, recruitment challenges, and specialized services. Providers can include Non-Profit Organizations (NPOs), voluntary sectors, and charity organizations. These contracts are locally negotiated, typically lasting three to five years, renewable. APMS contracts cover services that go beyond core services, such as clinics for homeless people in high-need areas.
Additional Sources of Funding
Infrastructure Payments
Infrastructure payments cover various costs associated with maintaining GP practices, including ‘premise’ payments (notional rents agreed upon through district valuer assessments), IT and digital services provided by ICBs and CSUs, Items of Services (IOS) payments on a per-item basis (e.g., vaccines), and other reimbursements like Care Quality Commission (CQC) registration fees.
Enhanced Services
Enhanced services provide additional funding to GP practices to deliver healthcare services beyond their core contract, based on regional and local health needs. These services are categorized into Direct Enhanced Services (DES), PCN DES (Primary Care Network Directed Enhanced Services), and Locally Commissioned Services (LCS). DES are NHS-funded and standardized nationwide, involving services like flu vaccinations and minor surgery. PCN DES focus on collaborative efforts among networks of GP practices to provide integrated care, including weight management and extended hours access. LCS are tailored to local health needs and vary by region, offering services such as minor surgeries and complex wound care, often funded by ICBs or local authorities.
Performance-Based Incentives
Performance-based incentives aim to enhance the quality of care provided by GP practices. The Quality and Outcomes Framework (QOF) accounts for 10% of total funding, rewarding practices for meeting specific quality and performance indicators. The Investment and Impact Fund (IIF) provides financial incentives for Primary Care Networks (PCNs) to achieve performance targets aligned with national health priorities. About 30% of the IIF is allocated for meeting these targets, emphasizing improvements in care quality and patient outcomes.
Extra Sources of Income
GP practices can access additional income through various sources beyond their standard funding mechanisms. Locum payments assist with hiring locum GPs to cover sick or maternity leave, with a fixed allowance capped at £1,752 per week. Discretionary payments are available for attending optional ICB meetings. Private work generates income from non-NHS services like medical reports and private vaccinations. Collaborative projects provide payments for participating in healthcare initiatives with secondary care providers or integrated care pathways.
Other sources of income include research grants for participating in clinical studies, training funds for serving as training sites for medical students or physician assistants, and income from federations or GP Forward View initiatives. Health promotion campaigns funded by local authorities or public health bodies support practices in leading initiatives focused on smoking cessation, healthy eating, and physical activity. These diverse income streams help practices enhance their services and maintain financial stability.
Conclusion
The organizations and funding mechanisms involved in running GP practices in England ensures that high-quality, patient-centred care is consistently delivered. From overarching bodies like HM Treasury and DHSC to localized entities such as ICBs and PCNs, each plays an role in maintaining and improving the healthcare landscape. Understanding the various types of NHS GP contracts, the Carr-Hill formula, and additional sources of income helps to appreciate the comprehensive support system that underpins general practice. As healthcare continues to evolve, these collaborative efforts will remain essential in addressing the diverse and ever-changing needs of communities across England.
Disclaimer: Healthcare funding policies and regulations are ever-changing and region dependent. The content of this presentation reflects the status as of June 2024.
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