Minimum Practice Income Guarantee

Debate between Sarah Wollaston and Tim Farron

Wednesday 26th March 2014 Westminster Hall

[Tim Farron (Westmorland and Lonsdale) (LD)]

It is a huge pleasure to serve under your chairmanship, Sir Roger. I am extremely grateful for the opportunity to raise the problems caused by the removal of the minimum practice income guarantee. The removal of the minimum practice income guarantee is not the sole cause of the crisis facing some of England’s rural surgeries, but it has unveiled the failure over several decades to provide a sustainable basis for funding GP surgeries in rural communities. The coming crisis, which could have the unintended consequence of closing dozens of rural surgeries, will be immensely costly to our communities and to the taxpayer. Taking intelligent, targeted and swift action to prevent those closures will be extraordinarily cheap by comparison.

Over the past few months, I have been working with our communities in and around Hawkshead and Coniston in my constituency, whose surgeries are undoubtedly at risk. Last August, 500 local people filled the school hall at John Ruskin school in Coniston at a public meeting. Five hundred people is an impressive turnout in any community, but when we realise that the total number of patients listed at Coniston is just 900, we see how important the issue is. Those 500 people turned up because they know that it would be impossible for them reasonably to access another surgery, given how remote and isolated they are. My job today is to convince the Minister—I hope it will not take much doing—that my constituents are right and he should take action to help them. Let us be clear: unless a specific decision is taken to provide new and additional support for small rural surgeries, there will be a series of surgery closures that will be hugely damaging to our communities, harmful to patient safety, costly to the taxpayer and utterly embarrassing for Government.

In my constituency, two practices stand out as being in need of immediate aid from NHS England and the Department of Health: Coniston and Hawkshead, two communities in the central Lake district, which are about as remote as one can get in England. Both communities have a GP surgery, and both surgeries are at risk because of unsustainable funding. If you would care to have a look at your Ordnance Survey map of the Lake district, Sir Roger, you will see that if either of those surgeries were to close, the next nearest surgery would be on the other side of at least one lake, not to mention a couple of mountain ranges.

Across the country, there will, of course, be some small practices that should amalgamate with others, predominantly in urban areas where access and sparsity are not such an issue. The number of small rural GP surgeries, such as Coniston and Hawkshead, which are facing up to falling off the funding cliff is relatively small. At the last count, there were 36 in the whole country. Therefore, although intervention is vital, it is manageable and affordable. It is not a big problem to solve if we do it now, but it will become an enormous problem if it is not tackled. The evidence is clear that for that to happen, there will need to be strong and unmistakeable political leadership. In other words, Ministers must state unequivocally that they want NHS England to protect small, strategically vital GP surgeries, and that they expect a formal fund to be set up to make that happen—a small strategic surgeries fund—just as our Government have successfully done to protect small, strategically important schools in rural areas. It will cost little, but it will save a lot.

A couple of weeks ago, controversially, our Government fought to permit the Secretary of State to have the right to intervene in local trust matters when there is a patient safety issue. They were right to do so, because elected Governments should involve themselves to ensure that strategic priorities are met. Here is one such example. It is strategically vital that people in rural areas across the country, including Coniston and Hawkshead, have the same rights to access health care as anyone else.

[Dr Sarah Wollaston (Totnes) (Con)]

As somebody who has worked in a small rural community, where there are high levels of deprivation in an area of relative affluence, the difficulty is that many people cannot access transport to get to services in other locations. I agree with my hon. Friend that we must prioritise access in small rural communities and recognise the problems of rural poverty.

[Tim Farron]

I am grateful to my hon. Friend for making that strong and good point. What counts as poverty in rural areas is often very different from what counts as poverty in urban areas. It is poverty in terms not only of income but of access to services. The average age of my constituents is 10 years higher than the average age of the UK population, so isolation and lack of access to private transport, never mind public transport, make it physically impossible to access another service. That is why we need to intervene.

I have had many conversations with NHS England, our local area teams and the clinical commissioning group. In the nicest possible way, there is a sense that they are all seeking a lead from the top. They are all good people, but they seek direction from the top. To be fair, NHS England has identified some 90 GP surgeries as outliers—practices that will lose more than £3 a patient—and a further 200 or so that will lose more than £2 a patient. However, that process of identifying outliers does not tell us which practices will be sustainable and which will not. Crucially, although outliers have been identified, no resource has been identified to help to protect them. That is why the Government must take a lead and make it clear that surgeries such as Hawkshead and Coniston must be protected, and that funding must be set aside to ensure that they not only survive but thrive. I am concerned that many of the discussions and the media attention have focused around the minimum practice income guarantee when we should focus more directly on funding sustainable general practice in remote rural areas.

In south Lakeland there are vast differences in minimum practice income guarantee payments per patient. Coniston gets approximately £25 a patient, Hawkshead gets less than £1 a patient and Ambleside gets around £15 a patient. By comparison, Slaidburn in Lancashire receives £110 a patient, even though the Slaidburn practice is the same size as the one in Hawkshead. The proposed changes from April will begin to remove those differences. Arguably it is correct to do so, but it is not correct simply to leave it at that.

The process of removing the minimum practice income guarantee and redistributing the funds per capita is a staggeringly blunt instrument. It is the ultimate one-size-fits-all policy, which treats small rural practices the same as large urban ones. It is on a par with making the casual assumption that the local village shop will have the same business model as Tesco. Smaller practices do not have the economies of scale that larger practices do; for example, the core practice management costs are the same whether the practice has 1,000 patients or 5,000.

NHS England’s argument is that, because smaller surgeries are inefficient, they should merge with neighbouring practices to increase efficiency. That works in urban areas, where there are often multiple GP practices operating close together. In that case, it is safe and sensible to consider sharing resources more efficiently. In remote rural areas, however, it is not possible to achieve those savings without sacrificing patient safety. It is not possible physically to merge with a neighbouring practice if it is on the other side of a lake. Merging, say, Coniston and Hawkshead with a larger, more distant surgery in Ambleside or Ulverston will not change the fact that health care still needs to be provided in the heart of those communities.

The only way to get savings is by closing a surgery or downgrading the service significantly in one or more of the villages and asking the patients to travel to another one for their main GP service. That would, in fact, result in no savings at all. Consider the increased cost to the ambulance service, to the A and E units nearby—not that they are particularly nearby, by the way—and to social care that would be triggered by the removal of GP services from the heart of our community. The human costs of closure are immeasurable, but the financial costs are measurable. It would be extreme foolishness to let our surgeries close by accident.

NHS England suggests that the policy does not impact on large numbers of rural practices, and that a greater number of urban practices will lose out. It is correct: there are not a large number of rural surgeries at risk. However, the analysis ignores the fact that, for the rural surgeries, an alternative to the current service provision is simply not available. Patients cannot simply move to the neighbouring practice down the road, because there is no “down the road”.

The changes come on the back of an already diminishing level of income in general practice for small rural surgeries. Hawkshead’s 2013-14 income from the GP contract is down 5% on 2012-13, and that has absolutely nothing to do with the removal of the minimum practice income guarantee. We should therefore be careful not to allow the removal of the minimum practice income guarantee to mask the much wider problem of a lack of sustainable funding streams for a relatively small and very manageable number of rural surgeries.

NHS England states that the removal of the minimum practice income guarantee will be phased gradually over seven years, but only so much can be squeezed out of an ever-reducing funding stream. The core running costs of the premises cannot be cut, so all that is left to cut is staff. If the staff consists of barely a handful of committed professionals, all that is left to do is close.

Hawkshead is already at 50% of the national staffing average, which reflects its historical low level minimum practice income guarantee funding compared with similar practices. At the same time, the surgery has the highest patient satisfaction levels in the country. It is officially the best surgery in England, but, as things stand, its only options are to reduce service provision to a level that would never be tolerated in an urban area, or to close. I am sure that the Minister will agree that such unacceptable choices mean that we must intervene.

Unlike Coniston practice, Hawkshead will gain by a small amount through the proposed changes. However, it will be by only about £1,000 a year, when the historical funding shortfall is about £35,000 to £40,000. Coniston’s income will decline significantly—by around £25,000 to £30,000 a year—and, to put it mildly, both surgeries will be at severe risk.

The minimum practice income guarantee should be removed or phased out. That is not challenged by those of us in rural communities. The wide disparities between surgeries with significant minimum practice income guarantee grants and those that, like Hawkshead, get pretty much nothing, makes the case for us. Nevertheless, the removal of the minimum practice income guarantee provides an opportunity to ensure that, in the wider context of a fairer and more efficient funding model, there should also be an element in the formula that does what the minimum practice income guarantee was originally intended to do, only more efficiently, more effectively and less expensively.

A small strategic surgeries fund could cover the additional cost per patient of keeping the core expenses covered. As a basic need, Coniston must keep its current funding, and Hawkshead must rise to a similar level in order to sustain service provision. NHS England will argue that it has reverted responsibility for the decision-making process to local area teams. However, there is no ring-fenced funding to deal with the problem, so local area teams are limited in what they can do. Our local area team has given its support to ongoing service provision in Hawkshead and Coniston, and I am extremely grateful for that, but so far no additional funding has been identified to support the practices.

The Minister will know that strategic small surgery funds have been established in Scotland and Wales. They are ring-fenced at the centre to ensure that no surgery that needs to remain open is closed by accident. Rural communities in England suffer from poor funding in social care, secondary care and primary care. Far too often, people in areas such as Cumbria are forced to put up with services funded at a fraction of what is required in order to provide care equivalent to that on offer in urban areas.

It is understandable that civil servants in Whitehall and officials in NHS England should come up with funding mechanisms that, in the first instance, overlook the fact that it simply costs more money to provide equivalent care to rural communities. It may even be understandable that officials might be ignorant of the desperate social needs in rural communities caused by poverty, ageing populations and isolation. However, once those problems are made clear, it is not acceptable to shrug them off. Once we have brought them to national attention, it is imperative that we see action.

In summary, I want to make five quick points. First, a small number of small, rural surgeries in England are at risk, partly as a result of the removal of the minimum practice income guarantee. Secondly, Coniston and Hawkshead are two such surgeries, and there is no alternative to having a surgery in either of those communities that is either sensible or safe. Thirdly, rural communities have as much right to decent health care as anyone else. Fourthly, it will cost relatively little to come up with a strategic fund to protect those few dozen surgeries. Fifthly, such a fund will be created only if the Department of Health and NHS England agree that it must be, and then make it so.

My constituents deserve access to good local GP services as much as anyone in London, Birmingham or Manchester. Unless we tackle the problem I have outlined, my constituents will be put at unacceptable risk. On behalf of the people of south Lakeland, and all other rural communities, I ask for the Minister’s help in setting up a small strategic surgeries fund so that we can remove that risk.