GPs FACE RADICAL REFORM

GPs are to be paid for the improved quality of the services that they offer under a radical shake-up of general practice, involving a 33 per cent increase in spending.

The deal, thrashed out between the BMA, NHS Confederation and the health secretary, will widen the services available at surgeries and will lead to a performance-related pay increase for GPs based on patient outcomes.Instead of being paid for the number of patients they have on their lists, GPs will instead receive salary increases for offering a wider range of proactive primary care services, identifying and monitoring conditions before they become serious and life-threatening.

As a result GPs could see pay increases of between 10 and 50 per cent, although many fear that any such increases could be swallowed up by the necessary modernisation of their services because they are self-employed.Each practice will be given a "global sum" to cover their staffing and running costs, based on "a fairer allocation formula which reflects the needs of local patients, not GP numbers". Overall spending is set to rise from £6 billion to £8 billion by 2006.

And in a bid to solve the current staffing crisis, ministers are also to unveil a recruitment and retention package. It will see a new career structure being developed alongside a system of enhanced seniority for long serving GPs. Top earning GPs could see their pay rise to £80,000 under the new deal, although a lack of enhancement of pension provision could proving to be a sticking-point.

The proposals could anger other health service staff, such as nurses and other auxiliary workers. GPs salaries could rise between from an average of £61,218 by an extra £20,202 a year. Nurses, by comparison, have been offered a 10 per cent cost of living increase plus a restructuring deal of 5.6 per cent over five years.

The announcement comes as senior doctors warn that general practice is "approaching meltdown". Recent surveys had shown GPs to be suffering from work-related stress over the long hours, and the lack of time available to spend with individual patients. Ministers had promised to increase GP numbers by 2000 by 2004, but at the last count just under 483 GPs had joined the NHS.

The reforms, which amount to the most radical shake-up of general practice in over 40 years, could see nurses and paramedics taking a greater role in the delivery of practice care. The NHS Confederation said the new contract will "reward GPs for higher quality care, improve GPs' working lives, and ensure patients benefit from a wider range of services in the community"."I hope that the benefits will be recognised by the profession and that they seize this opportunity to work with primary care organisations to revitalise general practice. This needs to be judged in terms of 'will it bring better services for patients?' I believe it will," said health minister Lord Hunt. "At the end of the day it will provide a more accessible and more flexible health service. I am convinced that patients will be the winners here."

However the Tory Shadow Health Secretary, Dr Liam Fox, accused the government of control freakery: "For GPs, as for consultants, the issue will primarily be about professional freedom in the face of a government which seems increasingly intent on telling them how to do their jobs."Gill Morgan, Chief Executive of the NHS Confederation, described the contract as "fair".

"I believe that GPs have now got an opportunity to vote for a major programme of investment and improvement in primary care delivered through a modern, fair and principled contract", she said. "I hope that the benefits will be recognised by the profession and that they seize this opportunity to work with primary care organisations to revitalise general practice and transform services for patients."

Dr Hamish Meldrum of the BMA said the spending increase was a "very substantial" amount, adding that it was "probably the biggest injection of cash into primary care that we will ever have seen".He also welcomed plans to cut working hours. Under the plans GPs are to be allowed to opt out of providing 24-hour care at a cost of £6,000 a year. Until now they have been legally obliged to provide an out-of-hours service, but under the terms of the new contract, Primary Care Trusts could take over responsibility for providing cover over weekends and evenings, employing doctors specifically to do this. "It is really fairly unrealistic to expect a doctor who has been putting in a 10 or 11-hour day to then be on call at night and, even worse, to then be on call the next day when he is tired, and making decisions," Dr Meldrum told the BBC's Today programme. "We wouldn't ask it of lorry drivers or airline pilots, I don't think we should ask it of GPs."However Mike Stone, Chief Executive of the Patients Association expressed concern at the proposal. "I think people are going to be worried about the changes to out-of-hours cover, especially older people. But, at the end of the day, we hope that this contract will still provide out-of-hours cover for those patients who need it," he said.

The Lib Dem Health Spokesman, Dr Evan Harris, was also critical of the proposals. "This is the end of the one-stop shop," he said. "It means less access to some services, which will now be classed as optional. Patients may end up going to one place to see their GP and another for vaccines or baby checks."

Doctors will vote on the proposals in April. If they back the move, it is expected that the new contract will be phased in later this year. The Secretary of State, Alan Milburn, could stand to lose a lot personally, should the deal be turned-down, after losing an earlier battle with NHS consultants who rejected their new contracts last year.

GPs will want to read the small print of this new contract. The government's spin is that they will be offered a 33 per cent pay rise for working fewer hours. But experience shows that what the government does is often very different from what it says. On closer inspection it appears likely that GPs will not be allowed to opt out of 24 hour cover until December 2004, and that this might well depend on securing PCT approval for that."Liam Fox, Shadow Health Secretary

"Patients know that this is a sticking plaster over the fundamental problems of understaffing and lack of access to family doctors. The new contract does not solve these underlying problems, it just hides them. Patients and their families will rightly feel that the government is still failing to provide the doctors and nurses they need.

"The government lost the original battle to include political targets, such as 48 hour waiting or immunisations, as a measure of quality in the contract. But ministers have had the temerity to impose the targets on the Primary Care Trusts who commission the services."Doctors will still not see the sickest quickest. Public confidence in the government's immunisation policy will not be restored because doctors will be paid for the number of vaccinations, not for the consultations they carry out. It is a self-defeating and unethical approach."Dr Evan Harris, Lib Dem Health Spokesman

"We believe it will be good for GPs and good for patients. For the first time we are rewarding innovation and improved patient care."Gill Morgan, Chief Executive, NHS Federation

"Overall, we have to welcome the contract. It provides more money for primary care. And hopefully, it's going to alleviate the loss of GPs from the NHS. The important thing is what patients make of this, and how they will see the changes to their GP service come about,"Mike Stone, Chief Executive, Patients Association"For the past few years GPs have been leaving the profession in droves, and many practising doctors feel deeply demoralised and undervalued. The government has finally recognised that it has to reward family doctors fairly for the work that they and their teams do. Without adequate reward, the workforce crisis will inevitably worsen, and general practice as we know it will disintegrate completely. The general public deserves a consistently high standard of patient care and in offering GPs such a significant pay rise, the government is at last acknowledging the importance of providing such care, and that the future survival of the NHS depends on high quality general practice.

"The new contract proposes quality payments that will reward GPs for delivering quality care with extra incentives to encourage even higher standards. For such a system to succeed, it is vital that GPs from every range of practice take time to consider whether it will work for them."Professor David Haslam, Chairman Royal College of General Practitioners

Proposals

Doctors' concerns