The New General Medical Services (GMS) Contract
for General Practitioners Comments from the Royal College of
General Practitioners
Introduction
1.We are pleased to
offer our preliminary comments on the draft GP GMS contract
framework. The quality basis of the framework provides an
opportunity for the College to offer constructive and helpful
debate to the development of the contract. We readily acknowledge
the role of the General Practitioners Committee of the BMA (GPC) in
negotiating the framework. We have been very pleased to work
closely with GPC over the last few years on a range of issues,
particularly those which focus on quality of work, educational
support and helping to shape and influence the way in which general
medical services are delivered in the UK. We understand that the
GPC welcomes this contribution to the debate on the contract as a
way of gathering further and wider opinion in what is an extremely
complex set of issues. This response indicates various ways in
which we stand ready to offer advice and guidance as the framework
develops.
2.
The range of services which GPs are expected to deliver today means
that developing a contract framework that is acceptable and
satisfactory to all is an extremely difficult process. We therefore
applaud GPC for the huge strides it has made in developing this
framework. We note that there will be two votes on the process and
that the first will be around this framework. Whilst this is likely
to raise questions in the minds of a number of GPs as the framework
is as yet unpriced, we agree that the principles must be settled
before the detail can be filled in. We hope that every GP will take
this opportunity to express his or her opinion.
3.. In order to focus our
comments, this response has been developed around a number of
themes and topics as set out below: -
- a general overview on the structure of the
framework
- "patient centredness"
- the evidence base for the contract
- the quality aspects of the new contract
- aspects to do with health and inequalities
- a group of issues around careers, skills
development, family friendly policies and other workforce
issues
- out of hours issues
- ethical issues
General Overview
4.
We have long held the view that the current GMS contract
is no longer fit for purpose and has long outlived its
effectiveness. It has become overly complex and anachronistic.
Making any change towards a new contract framework was inevitably
going to be a complex and difficult task. We therefore feel that as
a basis for discussion and development into a fully priced new
contract, the new draft framework is an impressive document. It is
timely that the new framework is being discussed just when the new
European Society of Family Medicine/General Practice Definition of
General Practice has been published. We were pleased to endorse the
definition very recently and look to the framework being very
strongly linked to its principles. We do however, have some
significant concerns which are set out in the following
sections.
5. The new contract needs to
recognise and map onto the new European Society of Family
Medicine/General Practice definition of General Practice which is
now being promulgated. It is extremely helpful that the new
contract and the new definition have coincided.
6.. There is a very
large question mark regarding the resourcing of the new contract
and the ability of GPs to deliver quality services within it. There
is also the major issue of how workload is to be capped. Medicine
evolves swiftly and what starts as a new issue ends up as a
commonplace and part of everyday work. Good examples are
HIV-related illnesses and the treatment of infertility in primary
care.
7.. Workload is
inevitably linked to patient demand and how that can be
accommodated. In dividing work into three groups, the framework
offers room for flexibility and choice and for practices to allow
for local initiatives and the development of new ideas and
innovative ways of working as set out on page 9 paragraph 16.
However, it is being introduced at a time when there is little or
no spare capacity in the system. Primary care organisations may
well struggle to provide in their area services which some
practices may have chosen to opt out of.
8. We are already extremely
concerned about the way workforce planning generally has been very
highly fragmented in England. UK bodies such as this College and
the General Practitioners Committee have not been able to engage in
the new workforce structures (despite strong representations). We
therefore have little opportunity to express our views and
concerns, or offer practical help in trying to make the new
arrangements work.
9. One of the major burdens on
GPs is that of bureaucracy. At present the framework does not make
any reference to that and how that might be dealt with.
10.. If the new contract
has the desired effect of improving recruitment and retention in
general practice then some of these issues may not be such a
problem. The indication that salaried, part time and locum posts
will be much more easily available and will have opportunities for
continuing medical education and pension rights is likely to make
general practice a much more attractive option for many younger
doctors. The ability to opt out of the out of hours responsibility
may also help.
11. However, it
is notable that welcome as they are, provision for pensions and
support for continuing medical education will still in no way match
those in other branches of medicine. We do not see any
disincentives as yet to GPs retiring at 60. This is not to
underestimate the achievements so far, but we hope that this
framework is only the start of such changes otherwise it might come
to be viewed as a missed opportunity. It is also imperative that
the negotiators should press the Government not to see the contract
as a proxy for ensuring proper resourcing and increasing the
numbers of general practitioners and others in the primary health
care team.
12. We have
major concerns that there is a danger the contract could fragment
general practice. A good example is the entrenchment of out of
hours work outside of general practice. Another aspect of
fragmentation that worries us is the idea that patients should need
to possibly attend a variety of practices other than their own for
different primary care services - we see that as dangerous and
undesirable. If this has to be a pragmatic solution, then we urge
it is employed only as a very short-term measure to support
practices during particularly difficult circumstances (such as the
ones outlined in Scenario 2). There is no incentive aimed at
continuity of care
13. The
introduction of the quality markers in the framework is to be
applauded. Perhaps understandably, those specified so far are
significantly bio-medically orientated. Such examples do not
necessarily represent the strengths of general practice. We look to
the framework as it is developed to focus on broadening the range
of quality makers. The College has recently prepared its position
statement on the use of Quality Indicators in primary care, and we
attach a copy of this document as Appendix I. We would be very
happy to assist both parties in the negotiations with this
particular aspect of the contract development.
14. The need to
avoid too many targets is obvious given the target-based approach
to the delivery of services at present. Although it is appropriate
to incentivise hard work on specific targets with financial
rewards, care must be taken to avoid the creation of perverse
incentives and undue distortion of clinical priorities. It has been
demonstrated that an incentive for GPs to meet certain targets
could lead to them spending a disproportionate amount of time on
that activity and divert them from other patient care activities.
This tends towards fragmentation of healthcare and is counter to
the holistic approach that we would always advocate. It is
important that every effort is made to avoid adverse outcomes (and
these may not always be foreseen) and also that the targets do not
inappropriately concentrate on one part of a person's healthcare at
the expense of the totality of the patient experience.
15. We question
how chronic disease management is to be defined. Will this include
mental health and drug misuse for example? We disagree with the
categorising of menopause as an illness in the examples given.
Overall we have a concern that the approach in the framework will
medicalise aspects of life far more than is desirable and this
would only exacerbate an unwelcome trend.
16. We have a
fear that the Essential Clinical Services envisaged are too
narrowly drawn and GPs may well view this category as not being
representative of general practice as they know it. If most
practices are expected to provide Additional Services, then it may
be wise to make these core but permit some exceptional opt out. It
is difficult to see how the majority of services listed as
Additional can be so considered. This is an area where we see a
danger that general practice could be viewed in a reductionist
light. Again this might be needed as a temporary measure but we
would want to ensure that it did not adversely affect patients in
accessing locally the range of services they need.
17. We
recognise also the practicality of the primary care organisations
having to deal with local issues by local negotiations within the
framework. Particularly in England where the fledgling Primary Care
Trusts have had so many new responsibilities thrust on them, many
appear under resourced and may not have the range of skills to
carry out these tasks. It would be unfortunate if they performed
badly and undermined the sound concepts that are being
promulgated.
18. Inevitably
perhaps, as a document which aims to provide a framework that will
lead to a scheme of remuneration for GPs, it appears to be much
more profession centred than patient centred. We suggest some ways
in which this might be addressed.
19. One of the
key issues here is the move away from personal doctoring and
holistic and longitudinal care with a known doctor. We accept the
reality that with a more fluid society, the desire to have "my GP"
may not be so clearly demonstrated from recent surveys (see British
Journal of General Practice issue of June 2002 p459). However, we
have already argued the dangers of simply meeting an access target
for general practice and the counterproductive effects it can have
on quality of care.
20. Patients
may well have a legitimate concern that the cessation of personal
lists could lead to a dilution of responsibility. It might well
lead to lower levels of patient satisfaction. The presentation of
this change should particularly have in mind the multiple audiences
for the new contract.
21. It is vital
that patients retain the option of consulting the doctor of their
choice. We would however like the negotiators to point out that the
government may be misguided in its interpretation of the public's
wishes. The need for long term, holistic care is especially notable
particularly amongst elderly people and/or those who have chronic
conditions. With an ageing population and the ability to manage
more chronic conditions in the community, it could be viewed as
perverse to turn away from this key attribute of general
practice.
22. As we refer
in our overview, the fragmentation of services is not in the
interests of patients. We point to the example in New Zealand where
deconstructing general practice has had dire consequences. We would
prefer to see more about personal continuity of care. We question
also, in terms of patient centredness, the formalising of the
fragmentation as regards out of hours care. We accept that the new
contract should assist in the delivery of consistent out of hours
services.
23. Patients
are however likely to be well served by the quality aspects of the
new contract. The way in which targets are being handled is much
more intelligent than has been the case in the past. The test will
be that standards are maintained in the changes that will ensue
from the new contract. We question the use of patient satisfaction
measures as a quality measure which is fraught with problems for
obvious methodological reasons. However, the principle is worthy of
further research.
24. We fear
that the locally enhanced services that are subject to local
discretion could worsen existing "post coded" fund
limitation.
25. Patient
commentators on these proposals highlight the possible risk to
single-handed practice. In many areas, particularly in rural
locations, single-handed practice is the only practical and
appropriate way of providing GMS services. We would be concerned
were this important aspect of patient need to be
undermined.
26. We would
also be concerned if in an attempt to fulfil all needs, GPs found
it necessary to produce statistics for meeting payments, targets,
and quality standards at the expense of time being spent with
patients.
27. There is a
concern also that the ability to opt out of services, despite the
incentives there are to provide them, will exacerbate existing
health inequalities. It seems to be an unwritten rule that areas
which already are providing good quality care are likely to be able
to develop their services more readily than those who are starting
from a lower base.
28. In our
view, a primary care organised basis of delivery of service should
enhance opportunities for patients and public to express views if
this is effectively linked into the patient and public involvement
mechanisms which are being developed for primary care
organisations. . We suggest that this is an important positive
aspect of this framework.
29. Other
positives for patients we feel are flexibility and choice in the
first point of contact in primary care; funding towards better
premises; and incentives to provide a wider range of services
within primary care including enhanced teamwork and national
standards. Against this, we would strongly resist moves to make it
more difficult to access the GP as the first point of contact where
patients wish this to be the case.
30. On a
presentational point, we suggest the list of benefits for patients
should have higher priority and appear further up the
page.
31. We welcome
the agreement that the new requirements in the contract will be
supported by good evidence. This should help reduce the sense of
cynicism of the government and its intentions.
32. However,
paragraph 50 makes a statement that the quality and outcome
framework is still being developed. We accept that generally,
general practice is a difficult discipline to measure objectively
in all its complexity.
33. The
evidence base that guides the quality framework may well be sound,
but the evidence base used tends to suggest that workload dominates
thinking about the future of general practice. Whilst many workload
concerns are genuine, there is a fear that development of the
contract might have over-emphasised these. In order to have
overcome this, it might have been helpful to look in further detail
at what "workload" actually consists of and to think of ways of
helping general practitioners with the really difficult parts of
that. There might have been a different approach to imposing
complex quality ladders on strictly clinical topics. For example,
evidence exists about the length of the consultation and the
College would be happy to help in this area if invited to do
so.
34. There may
be perverse performance markers such as access targets which are
not fully evidence based. There is also no critical evidence base
examining how a different balance of financial incentives will
affect activity, as it simply does not exist. We question therefore
on what basis a decision to reduce weighted capitation based
payments has been made.
35. As stated
at the outset, we welcome the emphasis on quality in the contract.
We congratulate GPC on separating payments for quality from the
general pool. The ability to have money up front to establish
quality is welcomed. However as we have also pointed out, many
aspects of quality care will not be addressed by the contract. It
shows the difficulties of applying uniform quality standards across
a diverse market. This suggests the nature of what is and what is
not considered as part of the quality payment scheme will need to
be reviewed constantly. Inevitably this will rest on measuring only
what is measurable which will ignore other matters that might be
very important to patients. Quality in some areas does not
necessarily imply quality throughout. It is hugely helpful that GPs
are being invited to take control of the drive to ensure quality
standards continue to rise even if there is no certainty that that
will actually happen. We are pleased to see that paragraph 56
recognises that quality delivery may struggle if workload is
high.
36. Some of the
skills which are all about the quality of the consultation which we
feel are overlooked include communication, listening to the
patient, and empathy. The lack of ability objectively and easily to
measure such important attributes must be acknowledged in the
contract.
37. There is
also a public health basis of most quality marker payments. There
is a fundamental conflict between population-based public health
objectives which are centrally controlled and with a strong
emphasis on cost-effectiveness and equity and the individual focus
of patient care.
38. One
consequence of the reduction of the out of hours commitment should
be to improve the quality of daytime consultation and if this is
the result then that may mitigate some of the disadvantages of
fragmenting responsibility for care between daytime and out of
hours.
39. The concept
of "informed dissent" is one that we welcome. But quality standards
and quality calculations may well need to be different for deprived
areas. For example, the table below level 2 shows very high final
targets which may be difficult or time inefficient to meet in
populations with low education, particular ethnic groups, transient
populations with homelessness etc. There may be diminishing returns
and time might be much better spent on other, less easily
quantifiable, issues such as sexual health, domestic violence, care
for the chronically ill, care for people with multiple illnesses
and palliative terminal care. Further, in deprived areas to exclude
patients from quality markers may involve considerable bureaucracy
which may not be the best use of doctor or nurse time.
40.In the College we
stand ready to assist the negotiators in helping to define quality
as it evolves and how College quality awards can be relevant and
meaningful within this new framework.
41. The fact
that access is not rewarded because it is not evidence based is in
our view not a sufficient argument as some of the suggested
clinical markers, such as the annual thyroid function tests, also
have no evidence base. Again, we are concerned that there is
nothing about personal care in the quality markers. We would hope
that over a period the strengths of general practice and its
ability to manage complex patients with co-morbidity, co-ordinate
care and offer care over a considerable period of time can be
recognised. We do have some concerns that distortions in clinical
priorities could well result from the contract.
42. Whilst
understanding the reasons for introducing local targets, we suggest
that care be taken to ensure that these will not unnecessarily
introduce new burdens or distort healthcare access.
43. The
progress in the quality levels from infrastructure to process to
proxy outcomes (e.g. actual control of hypertension) is a logical
and major advance and we applaud this aspect of the proposals. This
should ensure that we head for what matters clinically not just
identification but modification of risk factors.
44. The
reference to the patient perspective is clearly positive but if it
is to rely on the national patient satisfaction surveys, we will be
very concerned that GPs might lose out by substantial amounts if
there is a failure to achieve a certain level of "satisfaction".
This appears potentially arbitrary and at variance with the rest of
the scheme which rewards practices for factors that they can
control.
45. We suggest
also that patient enablement, on which much work has been done in
Edinburgh by Professor John Howie's team, should also be included.
What might be needed is evidence that practices have sought the
opinions of their patients in a systematic way and then responded
appropriately, for instance by altering hours of availability to
suit those who are seriously deterred from consulting.
46. As we have
stated elsewhere, concentration on chronic disease management
leaves a danger that the core task of general practice in caring
for people who are or believe themselves to be ill will be
overlooked in the assessment of quality. This is not sufficiently
mentioned. It is notable that none of the College quality awards
restrict themselves to chronic disease management and are very much
in tune with Good Medical Practice for General Practitioners and we
feel are closer to the concerns of patients.
47. We are
pleased to see the promise to include updating payments based on
deprivation. Allowing proper recognition of rural deprivation will
be a major step forward.
48. Rural
doctors in particular are interested in equality of access. We see
an intriguing illustration suggesting that patient transport to
primary care might be available. That would be a major change and
potentially very helpful and we look forward to further
details.
49. Paragraph
51 suggests that new funding will be found to support practices in
under doctored areas. These are often located in socially deprived
pockets and recent poor recruitment to general practice has only
served to emphasise a very real problem. One of the successes of
the NHS has been its ability to distribute healthcare to all
corners of the UK irrespective of
50. It is
pleasing to see that GPs who have very large lists through no fault
of their own, such as those in some inner city areas, will not be
penalised for not reaching quality standards. It is also notable
that in city areas, language difficulties and other cultural issues
might make it difficult to hit the high quality targets and it
might be possible to recognise such factors within the
framework.
51. We are
pleased to see the capitation formula to allow for deprivation,
patient turnover and refugee access allowing adequate resources to
go to under doctored areas. However, depending on the relative
gearing of quality payments, GPs in inner city areas who may
struggle to attain the same standards serving more mobile
populations could remain financially disadvantaged. There is also
the question of how primary care organisations will choose to
prioritise the needs such as refugees, asylum seekers, the homeless
and the mentally ill, and how they are prepared to supplement
traditional general practice to address those needs.
Careers, Skill Development, Family Friendly Policies and
other Workforce Issues
52. Efforts are
needed to improve the career structure of general practice although
many doctors are more concerned with coping with service demands.
The contract framework attempts to draft a longer time plan for
doctors. We have long wished to ensure that there is opportunity
for educational support, protected time and career development
opportunities for GPs so the developments here are welcomed. We
suggest though that there is more that could still be done and we
would hope that further negotiations will yield developments in
this area.
53. The
contract appears determined to offer flexibility in work patterns.
It also seems concerned about retaining the services of older GPs.
We suggest that skills development in paragraphs 111-114 could be
more specific in explaining how general practice could help
secondary care given the facilities for training and
infrastructure. We do not see the reason why the vital challenges
surrounding skill development should be tied to discussion on
salaried options. Doctors about to start their careers have often
been tempted by the potential of taking the choices provided by the
salaried options. We are concerned for the growing number of GPs
whose pensions are small because of their work arrangements in the
past. Doctors should be made aware of the advantages that self
employed status offers rather than simply the perceived
disadvantages.
54. Under the
present contract, practices bear the bulk of the cost of activities
such as those listed under paragraph 13 on page 46, a list which it
is recognised is not comprehensive. Many GPs find it difficult to
sustain some important activities which involve payment to an
assistant during their absence from the practice. Not only is this
a financial hazard to the practice, but in many areas of the
country, ad hoc assistance is unavailable. There are great
advantages in the system that addresses this problem of under
funding and poor supplies. It is strongly recommended that
reimbursement is for "assistants" rather than "locums" and that
these assistants are included in the new pension
scheme.
55.The framework at
present has not fully developed the idea of the "mixed portfolio"
for GPs which is becoming more and more important. We suggest there
is an evidence base for this which shows that providing clinical
placements linked to sessions in academic departments has a
positive effect on the recruitment and retention of young GPs,
particularly in inner city environments. We are keen to see this
aspect of the contract developed and it is an area where we stand
ready to offer advice if needed.
56. Overall,
this section gives the sharpest focus for the document which is not
surprising. It also recognises the workforce has a finite capacity
and capability. There are also opportunities to move from job to
job and the salaried option is particularly welcomed.
57. Improved
childcare is a real plus to the contract framework as is help with
premises. However, it may be a difficult matter for the primary
care organisations to address and the profession, through the
contract negotiations, must highlight the crucial importance of
this issue to general practice and primary care.
58. In addition
to childcare, we suggest that more creative ways of parental
support are needed. For a start, improved remuneration would give
parent GPs the opportunity to buy the support that they wished.
There always remains the problem of remote childcare facilities
such as crèche and other day clubs being in the wrong location and
requiring further effort and stress on family life. Support for GPs
with older children, such as across summer holiday periods, might
be possible especially given that the NHS is such a major employer
in the UK.
59. Whilst
career development in many of the ways sketched out in the contract
framework is helpful, the horizontal approach to GP practice is
still important in our view because of longitudinal care and
continuity of care. It might also suggest that a career in the
front-line is going to be unrewarding for GPs - but that is the
reason that so many doctors take up general practice.
60.We suggest further
thought is needed on the way that non-principals are taken account
of in the contract framework. It is clearly important that
non-principals are included and helped to participate in the
necessary auditing and monitoring work towards meeting quality
targets - they could well have a key role to play in a practice's
performance. This could suggest that non-principals should look for
enhanced rates of pay but it is quite clear that primary care
organisations will want to control costs particularly through
non-principals. This might lead to provision of more salaried
doctor posts rather than self-employed non-principals, although
this would not support the flexible options the framework aims to
introduce.
61. We
recognise however that too great an emphasis on encouraging
portfolio careers could take away GPs from frontline generalist
work which is something this College would be extremely loathe to
see happen.62. Overall, the workforce aspects undoubtedly
strengthen the position for more flexible arrangements for
individual doctors even if workforce shortages in the short term
limit what is actually achieved. Improving training with initial
salaried options is a very worthwhile development.
63. We have
commented on both the advantages and the dangers of the change as
regards out of hours services. This is an area that will need
careful monitoring to see how the dynamics of the pricing of the
contract, the incentives it gives and the level of opt out from out
of hours actually pans out in practice. What is important is that
consistency and quality of care should be available out of hours
and the contract should not add to any problems that might arise in
these regards.
64. It has been
suggested that rather than simple opt outs which the contract
framework envisages at present, a tapering commitment to out of
hours might have been more appropriate providing this had linked in
with appropriate family friendly policies. The advantage would have
been however that out of hours co-operatives or other services
would continue to have been staffed largely by doctors who were
familiar with the patients in the locality as they worked in that
location during the day.
65. One of the
key issues in delivery is the ability of primary care organisations
to fund the out of hours provisions. The options for primary care
organisations appear to be to sub-contract the out of hours care to
providers in the same way that practices currently do or employ one
or two full time GPs to provide out of hours care with holiday and
sick leave covered by other conventional providers.
66. There
remains the issue that the contract does not include provisions for
the professional aspects for out of hours employed GPs. Their
continuing professional development, clinical governance, appraisal
and other matters will all have to be accounted for. It is
important to ensure that recruitment to these posts is not made
more difficult because of this lack of provision and support. We
would be happy to offer help and guidance in developing the support
for out of hours doctors if invited to do so.
67. Other
issues to consider are whether GPs may no longer drive the out of
hours service, and if this might lead to variable standards. It
remains to be seen whether existing GP co-operatives might become
un-viable.
68. As with
other areas of the contract, the ability, capacity and resources of
primary care organisations to deal with this issue is as yet
untested and so has to be an area where we have
concerns.
69. We have
identified a number of potential ethical issues arising from the
new contract framework although perhaps these are not of undue
concern. There does need to be a degree of transparency in all
transactions involving patients. The implied changes notably
regarding out of hours care need to be understood by patients in
case they are perceived as being totally doctor orientated with
less than acceptable patient concerns. It is important that trust
in the medical profession is not altered by the contractual
change.
70. The
contract will demand honesty in reporting on quality levels.
Patient confidentiality of the individual should be respected. The
NHS ensures probity at the doctor-patient interface but doctors are
still obliged to take care in their claims for payment to their
executives. It is only right that the contract will expect evidence
if requested on a range of quality items trusting the GP to ensure
movement to ongoing improvement. The difficulty will be in
identifying the minority of GP for whom a "high trust" model of
assessment will not be appropriate.
71. We believe
there are ethical questions around the possibility that patients
will have to go to different primary care locations to access the
full range of care they want, particularly because of opt out
arrangements. This is based not on the question of the special
levels of care they might need but for routine care.
72. There are
ethical issues about excluded parts of the population and high risk
parts which could lead them to be potentially disadvantaged and
worse off than they currently are.
73. It is
important ethically to ensure that the arrangements for patient
care under the new contract if introduced comply with the new
European definition of general practice which is now being
promulgated.
74. It is
unfortunate that the opportunity to make more fundamental changes
in the "incentive schemes" of vaccinations and immunisations has
not been taken up. These schemes have brought about the potential
for misunderstanding and loss of trust between doctor and
patient/parent and change is long overdue (reference paragraph 26
on page 48). These should be included in the exception
reporting.
75. It is
recognised however that patients do have right to exercise their
autonomy and refuse treatment or review their condition. It is not
clear whether such patients will be identified in the practice's
reporting data or whether the data is to be anonymised as ought to
be the case.
76. Overall, we
support the new contract framework as it could be an effective
enabling mechanism. Inevitably, it is not perfect and the ability
to deliver it in full will rely on proper resourcing over a
sustained period. Further, delivery will rely on the ability of new
primary care organisations - and we have commented on the possible
problems there. Importantly it needs to be firmly linked with the
new European definition of general practice. With reasonably
favourable conditions the framework could provide a positive way
forward for general practice but it needs to be developed in the
ways we have suggested.