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Exploring the impact of dispensing practicing on equity in NHS payments to general practices

Cambridge University Hospitals

General practices serving the most deprived populations receive less funding per weighted patient than those serving the least deprived. Here we show that this inequality is driven by a higher concentration of dispensing practices in more affluent areas.

Published

31/07/2024

Authors

Cam Appel
John Ford
Ian Holdroyd
Liam Loftus

Across all practices, those in the least deprived 20% received £182 per weighted patient in 2023, compared to £166 for those in the most deprived 20% – a gap of £16. When we exclude all dispensing practices from this analysis, the gap is only £1. The gap in payments to dispensing practices is much larger (£32), but this is partly because there are only 6 dispensing practices covering the most deprived 20%.

What are dispensing practices?

Dispensing practices are practices where “at the patient’s request dispensing doctors are allowed to dispense the medicines they prescribe for these patients” (DDA); they are not the same as practices with an on-site pharmacy.

In 2023, there were 944 dispensing covering 9,505,878 patients and 5,537 non-dispensing practices covering 52,628,766 patients in England (dispensing status unknown for 188 practices).

73% of all dispensing practices are in rural areas. One explanation for this unequal geographical distribution is that in order for a dispensing practice to dispense medicine, “the patient must live more than 1.6km from a retail pharmacy or the area must be designated as a ‘reserved location'” (DDE). Therefore, dispensing practices are only likely to dispense enough medicine to be sufficiently profitable in rural areas.

Consequently, dispensing practices tend to be in more affluent areas: 42% of dispensing practices serve patients in the least deprived quintile and 33% serve those in the second least deprived quintile, whereas about 1% cover the most deprived quintile.

How do payments differ between dispensing and non-dispensing practices?

Dispensing and non-dispensing practices receive reimbursement for the drugs they use. For dispensing practices, prescribing payments constitute 27.5% of total payments for dispensing practices, but only 2.84% for non-dispensing practices.

  Prescribing total Total payments received % Total
All dispensing practices £624,136,108 £2,268,785,305 27.5
All non-dispensing practices £244,166,199 £8,589,930,080 2.84

As result, prescribing fees constituted a larger percentage of total payments for more affluent practices (13%) than less affluent ones (2%) in 2023. Excluding prescribing payments from the total reduces the difference in total payments between practices covering the most and least deprived quintiles from £636 million to £371 million (or from a ratio of 1.36 to 1.21).

Total payments by type by IMD quintile, 2023 (England)

Are there differences in patient outcomes or GP salaries?

In 2023, 79.2% of patients described their overall experience with dispensing practices as ‘Good’ versus 71.6% of patients of non-dispensing practices. We do not know how much is because the practice dispenses, which is more convenient for patients, and how much of this a general pattern that practices in more affluent areas tend to have higher patient satisfaction (see more here).

In terms of salaries, in 2022, the average income before tax for partners of dispensing practices was £163,400, versus £151,200 for non-dispensing partners, according to the GP Earnings and Expenses estimates.

Does the number of dispensing practices vary by ICB?

Some ICBs have far more dispensing practices than others, and subsequently receive more of their total payments from prescribing.

Lincolnshire ICB has the largest proportion of practices that are dispensing, with 55 out of 85 (65%). Conversely, metropolitan ICBs – such as those in London, Birmingham and Manchester – have 0 dispensing practices.

In this analysis we demonstrate the impact that dispensing practices have upon the inequality that exists in general practice funding. It is critical that policy makers take this into account when considering how to address this inequality, and how to make future general practice funding more equitable.

ICB Name

Number of practices   

Number of dispensing practices

Practices that are dispensing (% total)

Prescribing payments / Total payments (%)

Average payment per patient (£)

Lincolnshire

85

55

65

27

212

Cornwall and the Isles of Scilly

57

36

63

21

221

Norfolk and Waveney

106

61

58

22

246

Suffolk and North East Essex

93

50

54

18

189

Cambridgeshire and Peterborough

88

41

47

14

203

Humber and North Yorkshire

186

75

40

16

195

Herefordshire and Worcestershire

80

31

39

20

184

Gloucestershire

74

28

38

12

202

Shropshire, Telford and Wrekin

51

18

35

15

203

Somerset

64

20

31

13

194

Northamptonshire

71

22

31

11

202

Bath and North East Somerset, Swindon and Wiltshire

91

28

31

13

170

Buckinghamshire, Oxfordshire and Berkshire West

163

44

27

12

153

Devon

123

31

25

11

197

Kent and Medway

203

50

25

10

203

Dorset

80

17

21

11

191

Bedfordshire, Luton and Milton Keynes

99

20

20

7

192

Coventry and Warwickshire

120

23

19

11

185

Staffordshire and Stoke-on-Trent

146

26

18

8

166

Mid and South Essex

152

27

18

8

170

Sussex

171

28

16

9

186

Derby and Derbyshire

118

17

14

7

180

Leicester, Leicestershire and Rutland

134

19

14

8

174

Hampshire and Isle of Wight

157

22

14

7

161

North East and North Cumbria

367

50

14

6

167

Hertfordshire and West Essex

142

18

13

7

155

Lancashire and South Cumbria

205

20

10

6

169

Nottingham and Nottinghamshire

135

13

10

7

173

Surrey Heartlands

104

9

9

7

171

Frimley

78

5

6

4

187

South Yorkshire

178

11

6

4

156

Bristol, North Somerset and South Gloucestershire

80

4

5

5

162

West Yorkshire

282

12

4

4

184

Cheshire and Merseyside

367

12

3

4

173

Black Country

190

1

1

3

155

Birmingham and Solihull

195

0

0

2

181

Greater Manchester

426

0

0

2

164

North Central London

192

0

0

1

160

North East London

281

0

0

1

171

North West London

351

0

0

2

163

South East London

202

0

0

2

172

South West London

182

0

0

3

154