GP contract and workload
December 2006
General practitioners - the General Medical Services contract
This briefing paper applies to the UK
Contents
Background
GP resources
Features of the contract
Out of hours cover
Benefits for patients
Quality and outcome framework
Personal medical services
Revisions to the contract
Notes
The current UK-wide general medical services (GMS) contract was implemented on 1 April 2004 and changed the way primary health care is delivered. It provides demonstrable benefits to GPs, other primary health care professionals and patients and allows GPs to manage their workload more effectively and improve the quality of care they deliver to their patients. The contract also enables practices to deliver some high quality services that historically have only been available in hospitals.
Background
The contract, agreed between the BMA's General Practitioners Committee, the NHS Confederation and the four UK health departments, aims to:
- improve services for patients and also give GPs a better working life
- give GPs greater control over their workload without a detrimental effect on patient care
- attract extra funding into general practice
- allocate resources according to the workload associated with practices specific patient populations
- pay GPs fairly for the work they do
- improve GP recruitment and retention to help to protect patients from the effects of GP shortages
- open up a range of new patient services at local level, and
- build rewards for high quality care into GPs' contracts.
GP resources
Primary care and general practice, like the whole of the health service, had been the victims of decades of under-investment. The new contract delivered a step change in investment in primary care and in practice infrastructure. Spending on primary care increased from £6.1 billion per year to £8 billion by April 2006, a rise of 33 per cent over three years.
Practices should have the resources required to meet the needs of their practice population and do not have to apply to the primary care organisations (PCOs) for additional money, for example, for an extra nurse. Unfortunately, transfers of funding immediately before implementation of the contract led to a large shortfall in resources for the provision of essential services, leading to the need for a system of income protection (see below) that remains in place.
Features of the contract
Some of the features of the new contract are:
The contract is practice-based rather than with individual GPs and is between the practice and the PCO using nationally agreed terms. Although patients register with a practice rather than a GP, they retain their right to ask to see an individual doctor though they might have to wait longer.
Funding is based on the workload associated with a practice’s patient population not the number of doctors. Each practice receives its main funding for the provision of essential services via a ‘global sum’ which is calculated using the patient-sensitive allocation formula. To make up shortfalls in funding immediately prior to implementation and to ensure that practice income did not drop in the transition from the old contract to the global sum, a Minimum Practice Income Guarantee (MPIG) was agreed.
Practices are paid for delivering quality patient care via the quality and outcomes framework (QOF). The QOF directly links GP income to patient care. The more points the practice achieves, the more money it earns, although the final sum paid to practices is also adjusted to take account of relative (compared to the national average) list size and relative prevalence of disease amongst the practice population.
Clinical work is classified into one of three service categories: essential, additional or enhanced. Essential services have to be provided by all practices. Additional services are provided by most practices, and enhanced services only by those contracted to do so by their primary care organisation (see detailed explanation below).
GPs have the freedom to staff and structure their practices as they wish.
A Patient Services Guarantee, which is the responsibility of the PCO, will ensure patients are provided with at least the level and range of services they previously received
Questionnaires in the patient experience area of the QOF mean patients can be consulted about the way their practice is run.
Out of hours cover
At the end of December 2004, GP 24-hour responsibility for patient care ended and responsibility for providing out-of-hours cover in most areas was transferred to PCOs.
Having twenty-four hour responsibility deterred many young doctors from pursuing a career in general practice. PCOs now commission, and some themselves provide, out-of-hours care. Practices had the option to retain their of out-of-hours responsibility if they wished. As a result, the pattern of out of hours service provision has changed, with a more multi-professional response involving nurses, paramedics, social workers and pharmacists and relying on doctors to a much lesser extent. At all times patients continue to have access to an out-of-hours primary health service.
Benefits for patients
The contract also delivers substantial and demonstrable benefits for patients. Those benefits include:
- allocating resources to practices according to the workload associated with patient populations
- improved quality of care
- evidence-based indicators in the quality and outcomes framework (the QOF)
- better health outcomes
- consistent services across the UK
- a wider range of primary care services, delivered near where patients live
- the right to ask to see an individual doctor of their choice
- the use of patient experience questionnaires in the QOF
- improved access to services.
Quality and outcome framework
The evidence-based QOF, which guarantees rewards to those practices delivering high quality patient care, is likely over time to lead to improvements in health outcomes and reductions in premature deaths, particularly through better chronic disease management. Research indicates that more than 8,700 patients in England will be saved from potentially life threatening cardiovascular illnesses over the next five years as a direct result of the QOF.
The Framework is unique in the world in its comprehensiveness, and has excited considerable international interest. In the first year of the QOF the average practice score was 91% (04/05), increasing to 96% in the second year (05/06), demonstrating the high quality of care that patients are receiving.
The quality framework also provides a strong financial incentive for practices to consider their patients’ experiences and views about the service they are receiving, through asking them to complete an accredited questionnaire. Practices can then consider and discuss the results of the analysis and implement appropriate improvements. Experience from practices that have already used the questionnaires has shown real benefits – the practical and symbolic benefits of actually asking patients what they think, which in turn both give positive feedback to the practice and allow appropriate change in response to suggestions made and any concerns raised.
Personal medical services (PMS) contracts
Many of the benefits of the current GMS contract are extended to doctors on personal medical services (PMS) contracts. PMS contracts, although locally agreed, have been adapted to include payments for specific services and the QOF. PMS contracts also allow practices the freedom to structure services and staffing how they wish and also allow the option to transfer responsibility for out of hours.
Revisions to the contract
When the GMS contract was introduced in April 2004, a commitment was made to review the contract from April 2006 onwards within the original GMS negotiations. Such a review was implemented in 06/07. The package of agreements protects existing funding levels, provides new earning opportunities and draws a line under the perceived overdelivery of and excessive increases in GP pay. There was no inflationary increase for practices in 06/07 for the global sum payments, QOF points or Directed Enhanced Services (DES) payments.
As part of this review, some of the points in the QOF available for non-clinical areas were redistributed to clinical areas such as mental health, palliative care and kidney disease. In all four countries, the additional investment was available for new country-specific DESs. In England the new DESs were practice-based commissioning, information management and technology, choice and booking and access. The access DES incentivises practices to further improve patient access including advanced booking, telephone access and being able to get a consultation with a GP within 48 hours.
The outcome of the current review of the allocation formula will be considered in future contract revision negotiations. The White Paper 'Our health, our care, our say'on health and care services in the community will have implications for primary care and this may also impact on future contract revisions.
Notes
Primary Care Organisation (PCO) is the generic UK term used to cover primary care trusts (PCTs) in England, local health boards (LHBs) in Wales, local health and social care groups (LHSCGs) in Northern Ireland, and in Scotland it is the primary care trust, unified health board or Island health board.
Out of hours (OOH); responsibility for providing out-of-hours cover transferred to the local PCO. The cost of transferring responsibility to PCOs was estimated to be £6,000 per full-time GP in an average practice. Special arrangements were available for the few GPs in areas so remote that they could not hand over responsibility for OOH in the same way.
The OOH period is defined as from 6.30pm to 8am on weekdays, plus weekends and bank holidays. Practices that want to hold surgeries at other times, e.g. on Saturday mornings, can still do so. Practices do not have to be open throughout the in-hours period.
Essential services: every practice provides essential services. This covers the day-to-day work of general practice, looking after patients during an episode of illness, the general management of chronic disease and the non-specialist care of patients who are terminally ill.
Additional services: most practices offer a range of additional services. These cover services such as contraception, maternity (excluding care during the actual birth), child health surveillance, cervical screening and some minor surgery. Practices can opt out of one or more additional services either temporarily or permanently. The opting out process involves the local Primary Care Organisation (PCO) and follows set stages within a maximum nine month period. When a practice opts out of an additional service, it loses an amount of money set at nationally negotiated levels.
Enhanced services are optional. There are three different types:
Directed Enhanced Services (DESs) which PCOs must ensure are provided for patients within their area but no one practice has to do. Many practices will want to provide these as the work is currently done by many GPs. Under the current contract, it is explicitly paid for. The services include flu immunisations, preparation of records for quality, childhood immunisations, minor surgery beyond curettage, cautery and cryotherapy, improved access, care of violent patients. National pricing, terms and conditions apply.
National Enhanced Services (NESs) which PCOs may seek to commission within their area, include anti-coagulant monitoring, intra partum care, minor injuries, IUCD fitting, drug and alcohol misuse. National pricing, terms and conditions is used as the basis for commissioning.
Local Enhanced Services (LES). These are commissioned by PCOs and are locally negotiated without national pay rates. They are services provided in response to specific local needs or innovations that are being piloted.
To implement the 2004 contract, it was necessary for the Government to introduce primary legislation in a number of areas. The sections are included in the Health and Social Care (Community Health and Standards) Act 2003. Similar primary legislation was introduced in Scotland, Wales and Northern Ireland.
Link to revisions 'Delivering investment in general practice’
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