GP Contract

Understanding the Minimum Practice Income Guarantee (MPIG)

QOF payment

The Minimum Practice Income Guarantee (MPIG) is a piece of core funding that was introduced in perpetuity at the time of the introduction of the new GP contract in 2004.

Where practices were to lose substantial amounts of money from the changes introduced in 2004, the difference between prior and projected income would be paid back to practices through the introduction of a guaranteed income stream: MPIG.

Not subject to inflation, not dependent on activity or list size, MPIG was, to put it simply, a fixed sum meant to buffer any losses incurred by moving to the new contract.

The top-up payments made under MPIG are termed correction factor payments. Details of how they are calculated are outlined in Section 3 of the 2004 Statement of Financial Entitlements.1

As part of the GP contract settlement in 2013, the Department of Health decided to phase out MPIG top-up payments over a seven-year period, starting in 2014/15.2

Since then correction factor payments to eligible practices have been reduced by one seventh each year, with payments to be phased out entirely by 2021/2022.

Impact of phasing out MPIG

In many cases, MPIG payments funded some of the additional workload generated by deprivation, the latter no longer being financially supported in the Carr-Hill capitation formula introduced in 2004.

My own practice suffered hugely as a result – at the time of the MPIG removal, in 2014, we were in the top 10% of the country with our index of deprivation. Our MPIG payment, worth hundreds of thousands of pounds, helped us cover just some of the additional capacity we required to meeting the extra demands brought on by health inequalities.

When MPIG removal began, we were unable to obtain the overall value of the losses at a national level. However, for our practice alone, the total loss over the seven years of withdrawal – at parity of list size and of other financial variables – amounted to just over £875,000. 

To give an example of the impact, deprived populations between the ages of 50 and 60 tend to visit their practice twice as often as the wealthiest ones – but after MPIG removal the two groups would now bring in the same capitated remuneration, as if at parity of deprivation.

MPIG was helping our access, it was helping our patients – and now its withdrawal risked leaving us bankrupt by 2021.

What support is available?

The BMA advises that practices determine the financial impact of their MPIG losses, using NHS England’s ‘ready reckoner’ tool. Other advice is quite simply to maximise income streams and review costs, including through revising provision models, in order to buffer losses and achieve greater financial stability.3

How we survived loss of MPIG – and thrived

In the face of crisis, there is also the opportunity to tap into your deepest resilience. In order to survive the MPIG removal dilemma, we got creative. And it turns out that some of the solutions that we were able to identify translate well beyond our practice, in crisis or in wealth, as they simply represented a way for us to do things better.

So what were our nifty, penny saving, quality enhancing solutions? Here are the biggest ticket ideas that worked for us:

  • Moving to a triage based appointment system: this was probably the greatest winner of all. At parity of investment, the introduction of a telephone triage model (which has now moved to a digital triage model) increased our appointments from 66.2 per thousand patients per week, to 119. Twice the access at the exact same cost.
  • We looked at skill mix in a serious and sustained way – about half of our GP demand is now addressed by loads of other staff – pharmacists, social prescribers, physician associates, administrators, the list goes on. The result, in numbers: one entire whole time equivalent GP less – on a list size increased by over 2,000 patients.
  • We initiated a staff-run management system called ‘Circles’, based on the better known model of holocracy. With staff running each of the practice’s service lines, including managing budgets and having delegated authority to make changes and decisions, we estimate the practice is saving about 80 hours of management time and £5,600 each month (now being reinvested in quality initiatives). These autonomous Circles better serve functions such as chronic disease management, IT, human resources, social media, risk assessment, premises, finance, and health and safety.
  • This time release has also allowed the practice to offer more time and energy to external boards and projects – and the income generated from that is fed directly back into the practice’s financial baseline.
  • We stopped work that didn’t work for us. Stopped it, plain and simple, or changed the process to make it leaner and less resource-intensive. Small wins, but when summed together, the cumulative gain packed a punch. Amongst our areas of process revision we count:
  1. How we process prescription requests
  2. New patient checks
  3. Reducing our efforts around outdated or redundant targets
  4. Communicating tests results digitally
  5. Allowing greater access and ownership to patient digital records
  6. Management of STD (Sexually Transmitted Disease) screening
  7. Call-recall processes for patients with long term conditions
  8. Travel advice
  9. Improved uptake of digital consultation modes
  10. Management of clinical document workflow
  11. Communication of HBA1c results
  12. Launch of a teenage clinic.

None of these things happened overnight – and change was not easy for us, at least initially. We’ve now bought into a collective view that constant change and improvement are the only way to stay financially sustainable, but more importantly, the only way to stay relevant and responsive towards our service users.

Our ability to adapt and flex has no doubt enhanced our staff morale hugely, with a real sense that we have ownership of our shared destiny. The removal of MPIG remains contentious. The fact that deprivation takes on a background role in the allocation of funding goes against the best available evidence. Yet in the face of this, we chose not to lie down and die.  

Virginia Patania is transformation partner at a GP practice in east London

References

1. UK Government Web Archive. GMS Statement of Financial Entitlements for 2004/5.

2. UK Government. NHS, England. General Medical Services Statement of Financial Entitlements 2013. Section 3. Erosion of Minimum Practice Income Guarantee commencing on 1st April 2014

3. BMA. General practice funding. Phasing out of MPIG – how it affects your practice. Updated January 2019.

Guide URL:
https://pulse-intelligence.co.uk/guide/understanding-the-minimum-practice-income-guarantee-mpig/
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