THE NEW GP contract was backed by 80 per cent of the 31,945 doctors balloted by the British Medical Association. According to the health secretary, it heralds a new era in primary care, giving patients access to a wider range of services and giving doctors greater flexibility in their working lives.
The contract is struck between practices and the primary care trust (PCT), instead of an arrangement between the individual GP and the PCT. Replacing the old system of practices vying with each other for training monies, computer maintenance and variable rent checks, there will be a global sum of money, or minimum practice income guarantee (MPIG). As a result, it appears that some 80 per cent of practices nationwide will have higher incomes from the MPIG. There will also be incentives for practices to work together to make the best of their allocation and share scarce resources. The contract even envisages a group of practices holding the contract with their PCT. This will encourage the better use of skill-mix and multidisciplinary working. It may mean sharing the cost of a specialist nurse with another practice to specifically meet the needs of a particular group of patients – previously, there was no flexibility about this.
Benefits of the contract will include the removal of an anomaly: with the old contract, the money followed the GP in post and a practice could not recruit a new partner. Therefore, it was heavily penalized financially while having to manage the workload. In the new contract, the money follows the patient. National negotiating will install national terms and conditions and local ‘enhanced’ services will be negotiated locally to meet local health needs. Provision of the full range of services will still be mandatory, but not necessarily on the GP site or by the practice.
Out of hours treatment has been radically altered. Removal of the old 24-hour responsibility and the option of opting out is a huge benefit for general practice, with the associated likelihood of improving recruitment and retention in the profession. However, it is a high risk area. The possibilities now available for a more coherent multidisciplinary approach to out-of-hours provision are exciting but still speculative, as there are probably insufficient adequately trained alternative personnel in post to take up the huge challenge at present. The service is likely to remain very GP-dependent for some time. The government has also underestimated the cost of delivering this service, as it was in fact heavily subsidized by GPs in the past. The new service could well be better, will be different down the line with more appropriate professionals dealing with different problems but there may well be public perception problems in that patients may not be seeing a doctor they did in the past.
The quality framework is the first time in the NHS that payment is given for quality as opposed to throughput/ numbers managed or savings made. Even quality prescribing incentives were dependent on reducing a practice’s budgetary overspend. This will have a significant impact on how disease entities are managed, with much striving for better quality of care. Patients who opt out can be excluded from targets so there is some individual choice remaining, but the pressure will be on patients to improve their management of their diseases in partnership with their clinicians. The slight downside of this is that the framework is theoretically optional, although practices would miss out on significant financial remuneration. There is also the potential for practice league tables both locally (or PCT wide nationally) about points scored. Given that primary care does not necessarily follow the laws of market forces and that a highly performing practice may not want to expand its practice population, we may run into the problems of popular schools and sink practices.
The separation of essential and ad-additional services is a core statement and is fundamental to allowing a shift of work from secondary to primary care. The stage is set for areas of work and services to move out of big complex DGHs (or even foundation hospitals) into the community, closer to patients and their homes. The development of GPs with a specialist interest has been happening across the services needed by patients. Enabling them to extend their portfolio of work should also enhance recruitment and retention.
Other professionals can also be involved and broaden their experience and develop specialist interests and skills.
As for concerns about the contract, there is, as usual, too much work to be done in too little time, with ongoing debates about financial issues and budgets with practices. Not surprisingly, each practice has individual queries and questions about its financial allocation given that this reflects an entirely different payment process.
There is also a lack of clarity about exactly where the “line in the sand” should be drawn about what is to be included in normal GP work and what is out. There is clearly a difference in opinion between the different negotiating sides in the debate (NHS Confederation and the GPC negotiators) and this probably reflects the rushed deal that had to be done to meet the deadlines on agreeing a new contract.
Finally, what was supposed to be a light touch/low bureaucracy/high trust contract is rapidly mushrooming into anything but. There is still a need to number count for many of the enhanced services and the plans for the annual visits to practices are still under formation. The financial cost of funding these is likely to run into the £20-30,000 range, let alone the amount of officer time required.
