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Saving the Surgery

4 December 2014

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If you look on Tower Hamlets’ Jubilee Street Practice’s website one of the first things you’ll notice is the proud advertisement for the success it has had in saving the practice from imminent closure through its ‘Save Our Surgeries’ campaign.

The campaign was spearheaded by Jubilee Street’s formidable practice manager and partner Virginia Patania just under a year ago when she developed a detailed spreadsheet to work out what the Government’s proposed removal of the Minimum Practice Income Guarantee (MPIG), along with the cutting of certain 

QOF points and global sum income streams, would mean for the practice’s future – and realised the stark truth that the withdrawal of MPIG meant the practice could not survive.

MPIG was introduced in 2004 to protect GP practices which lost out financially as a result of other contract changes, and is worth £219,508 a year to Jubilee Street. Patania says the loss of quality and outcomes framework (QOF) income, enhanced services and MPIG funding combined means the practice will be down £77,263 by the end of 2014-15. It had already lost £30,000 of QOF income from last year and will lose its £219,508 a year MPIG allocation incrementally over the next seven years – the accumulated loss due to MPIG alone amounting to over £903,000. To make up for the MPIG loss the practice would need to sign up 1,000 new patients every year – something which is simply not feasible or sustainable.

Patania explains that when the announcement was made about the abolition of MPIG last year, NHS England started off by reassuring practices that under the new contract formulae those that lost out would still be ok.

“I asked for the finanicial modelling for this from NHS England, I wrote to them a number of times and got no response,” she says.

“We were told not to worry but our financial forecast told us that we would have to close; we were faced with a 23% decrease in income year-on-year so we as a practice made the decision to go The Guardian with our information.”

The media interest generated by the publication of The Guardian’s article in April led the practice to set up the ‘Save our Surgeries’ campaign, which in turn was backed by other local GPs, the Royal College of General Practioners (RCGP) and the British Medical Association (BMA).

GP partner Dr Naomi Beer says that Jubilee Street’s figures were repeatedly tested for accuracy.

“Over seven years they showed that we were going to lose anywhere between £650,000 and £1 million; or up to two thirds of our annual turnover.

“We have always done a long-term forecast and it was clear that we would have to close the practice, we couldn’t fund it out of our own pocket,” she adds.

So the practice partners decided to fight to save the award-winning practice. The 12 GPs (not all full timers), three practice nurses, two healthcare assistants and a physician’s assistant could not understand why a practice with the highest immunisation rates in London, that has won the RCGP’s Quality Practice Award and has a 95% patient satisfaction rate should be forced to close, not least because before announcing the removal of MPIG, NHS England had failed to hold any kind of consultation.

The practice meets all the government’s quality targets, has introduced internet-based consultations, appointments, repeat prescriptions, and while-you-wait phlebotomy. 

It has managed this in an area where demand is very high. The population has increased by 25% over the last 10 years – the largest increase in England, according to official census figures – and the growth is mostly in the under-35 age group.

So the practice decided to mobilise against closure. The partners first met with Tower Hamlets MP Jim Fitpatrick who Dr Beer describes as “fantastic”. They then met with junior health minister Dan Poulter and then were finally granted an audience with health minister Earl Howe and NHS England’s head of primary care commissioning, Dr David Geddes, to explain their situation.

After many months of waiting and uncertainty, the practice finally learnt of their reprieve in September when NHS England announced that funding would be provided under section 96 of the 2006 NHS Act, which allows commissioners to provide discretionary financial assistance to primary medical service providers.

Initially it was estimated that 98 practices across the country risked closure due to the loss of MPIG, 36 of which were in London. However, alongside the emergency funding came a strict qualification criteria which has meant that so far only 17 practices have got their hands on the cash. The criteria stipulated that no doctors at practices applying for the two-year support package should have declared pensionable earnings in excess of £106,100, the Doctors and Dentists Review Body’s calculated average pay for GPs in 2011/12.

Practices also had to show they have expenses greater than the average 63% of revenue and have no contract breaches since April 2013.

In a letter to London practices, NHS England’s London head of primary care commissioning Neil Roberts said: “This support will apply where there is evidence of extenuating circumstances within the practice population, related to patient demographics, that have an impact on practice workload. We have decided that this will be defined as an Index of Multiple Deprivation (IMD) score of 35 or higher (the upper quintile) for the practice. Among other factors, this measure is designed to take account of health inequalities.”

Patania says that that NHS England have also promised a review of the Car-Hill formula introduced over a decade ago, which links funding to the age of the practice population. Critics have always said this punishes inner-city areas where the average age of patients is younger but the burden of illness is higher.

“They have promised a revision of the new funding formula by March 2016 but if they just fiddle with Car-Hill it won’t work. What would be very helpful would be to introduce local comissioning budgets,” says Patania.

“People have known about the affects of deprivation for years,” says Beer. 

“In the absence of new core funding, some practices (in relatively affluent areas) may need to face redistribution of some of their resources as a proportion of the whole core funding allocation as funding should follow evidence-based need.”

“This is not a battle that is in any way won yet – we’ve managed to secure our future for two years in order to carry on fighting,” she adds.

And while they await a visit from NHS England chief executive Simon Stevens next month, Patania is frank about what she has learnt and what other practices should be doing.

“In 2014 you better know your numbers. I have no sympathy for those practices that don’t know their numbers because viability is not guaranteed.”

“Evidence moves everything. In general practice we need to build a much stronger corporate presence