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At the heart of general practice since 1960

Can the GPC avert a contract crisis?

Even set against a backdrop of general economic discontent, it has been a bleak winter for the GPC negotiators.

By Steve Nowottny

Even set against a backdrop of general economic discontent, it has been a bleak winter for the GPC negotiators.

It seems a long time since the GP leaders and NHS Employers announced a revolution in the way practices were to be paid.

Flu and vomiting viruses were accompanied by a rare outbreak of optimism and contentment among the negotiators, who even seemed to be getting on with their Government counterparts.

As part of a major contractual overhaul, the long-derided QOF square root formula was to be scrapped and a complicated new formula unveiled to begin the MPIG phase-out.

The green shoots of spring are not yet upon us and the two main planks of the deal have if not completely collapsed then certainly splintered.

Negotiators had promised not a single practice would close because of the end of the square root formula. Now GPC chair Dr Laurence Buckman admits that dozens, possibly even hundreds, could go.

As for the MPIG, the GPC now admits it signed up to a deal that will be grossly unfair to some practices.

Little wonder that when Dr Buckman was asked at a press conference if there was a case for going back to the drawing board, he said he would if he could – but that he couldn't.

So where has it all gone wrong?

It was always known the prevalence formula shake-up would cause some practices, especially those with younger patients and low chronic disease rates, to lose out.

But although Pulse revealed early on that the worst losers could see £100,000 wiped off their balance sheets, the GPC had maintained it would not prove to be a nail in the coffin.

Dr Buckman's change in tune has left some questioning why the GPC ever agreed to the change. The negotiators argue it is PCTs who have sold practices down the river, by ignoring a call by the Government to bail practices out.

Critics of the October agreement were far from impressed by the flimsy passage negotiated by the GPC to protect losers.

PCOs, it said, ‘should work with practices that identify themselves as experiencing a significant loss in income to understand the impact of the new arrangements on their service provision'.

The GPC negotiators now say many PCTs, including all those in London where practices stand to lose a combined £11m, have done nothing. The picture on the ground, though, seems more complex.

NHS Hull, for example, has already held two meetings with one student practice likely to lose a significant amount, and has started helping affected practices to validate their disease registers and improve case finding for chronic conditions.

Enhanced services and practice-based commissioning initiatives are also being mooted to help practices regain lost funding.

‘The types of work being considered are HIV testing, erectile dysfunction, long-acting reversible contraception and a LES for termination of pregnancy, as well as enhanced services for patients coming from overseas,' a spokesperson said.

Other PCTs are looking at developing or extending local QOFs, perhaps specifically for students. Even in London there have been some moves, despite the GPC's claim.

NHS Barking and Dagenham says it wrote to all practices in December suggesting they review the implications of the changes. It claims only one responded.

But not every trust is being so obliging. Solihull Care Trust is one of several outside the capital yet to begin any talks.

Heart of Birmingham Teaching PCT, which says it expects few of its practices to be ‘significantly affected', has decided ‘transitional support will not be offered'.

Dr Irene Weinreb, a GP at Imperial College Health Centre in central London, says her practice, where 60% of patients are students and a further 20% university staff, has been forced to ask Westminster PCT for help.

She is hopeful the practice will be able to negotiate a support package, perhaps through a student LES or even by going APMS. But if support is not forthcoming, she has no doubt the double whammy of prevalence changes and an MPIG phase-out will send her practice to the wall.

‘Both would make us completely unviable,' she says. ‘We estimated we could lose 60% of our income.'

Unsurprisingly, practices affected are demanding to know why, after years of talking about it, GPC negotiators agreed to such a rapid change to the prevalence formula.

The square root formula will be scrapped from this April, and true prevalence will be used to determine QOF payments from April 2010.

Could there not have been a more gradual phase-out or a hybrid model basing payments both on prevalence and on practice size?

The BMA did apparently discuss some alternatives to a total switch, but Dr David Bailey, the GPC negotiator who originally led on the prevalence discussions, says true prevalence was the only ‘fair' option.

‘There was never any question that they were going to substitute one fudge with another, it was just the duration over which it was done,' he says, adding even the two-year phase-out was a compromise, with the Department of Health originally favouring a one-year switch.

Insiders suggest GPC members who opposed the square root formula had over the past year become more vocal in their calls for change, with many practices having lost out since 2004. As Dr Bailey puts it: ‘It's been LMC policy to get rid of the formula for the past four or five years.'

If anything, there is even greater confusion over the future of the MPIG.

As a first step towards reducing practices' reliance on high correction factors, the GPC and NHS Employers last October announced a ‘differential uplift' formula for the various elements of the GP contract.

Any pay award made by the Doctors' and Dentists' Review Body – due to report any day now to the DH with recommendations for next year – would be spread among global sum, QOF, enhanced services and correction factor payments with percentage uplifts in the ratio 7:5:5:2 respectively.

But early last month, there was another U-turn. The GPC and NHS Employers launched a hasty survey designed to determine ‘historic reasons' behind high correction factors – and warned this year's deal was ‘potentially unfair'.

In an interview with Pulse last August, prior to the agreement, Dr Buckman stressed his determination to prevent ‘another Black Wednesday' and avoid creating ‘a new generation of losers'. ‘The criticism that we didn't model it carefully enough I will not have levelled against me,' he said. ‘That's why we employ a whole department of economists.'

So how did they get it wrong?

Actually, they didn't, according to the man in charge of that department, Jon Ford – head of health policy and economic research at the BMA. He says it was known going into the October agreement that there was no clear link between deprivation and high correction factors. But because only a small minority of practices would suffer from the unfair distribution, it was considered a risk worth taking.

‘Because so few practices are on pure global sum, you can live with that for a one-year solution, if all practices get a minimum pay increase,' he says.

In an effort to come up with a more permanent solution, the GPC and NHS Employers have surveyed, via PCTs, the 500 practices with the highest correction factors.

Initial results obtained by Pulse give a decidedly mixed picture. Several trusts told Pulse they could find no discernible reason for correction factors – ‘happenstance and history' in the words of negotiator Dr Peter Holden.

But other trusts suggested there are patterns linked, for example, to list sizes or deprivation allowances prior to the new contract.

Dr Nigel Watson, chief executive of Wessex LMCs, says he analysed data from all local practices whose correction factor was greater than 20% of global sum – and ‘very clear patterns' had emerged.

‘The ones with high correction factors are generally those with young lists, split sites and high list turnover. Or they are small rural practices propped up because they work in isolated areas,' he says.

The only thing that's clear is just what a muddle it all is as the GPC, now seeking fresh meetings with ministers, attempts to come up with solutions for the funding crisis.

An idiot's guide to the contract crisis

Why has the deal proved so controversial?
The GPC and NHS Employers thrashed out a wide-ranging contract deal last October, which included changing the formula linking QOF pay with disease prevalence, and a differential uplift to kick off the MPIG phase-out. But in recent weeks fears have arisen about the impact of both these changes.

What was the deal on QOF prevalence?
It was agreed the square root formula would be scrapped from this April, with QOF payments based on true prevalence from April 2010. The move will benefit practices in deprived areas, but will also mean big losses for practices with low chronic disease rates. The Department of Health told PCOs to work with those losing practices and consider commissioning new services as a way of keeping them afloat.

So what went wrong – and what next?
Many PCOs have failed to begin talks on helping losing practices, leading the GPC to fear that dozens of practices could be forced to close. The GPC is now to hold emergency talks with ministers to see what can be done.

What was the deal on phasing out MPIG?
The GPC and NHS Employers agreed a ‘differential uplift' would be applied to any 2009 pay award, with the percentage uplifts to the global sum, QOF, enhanced services and correction factor payments in the ratio of 7:5:5:2 respectively. The move was intended as a first step to reduce practices' reliance on correction factor payments.

So what went wrong – and what next?
The GPC now admits the differential uplift could lead to a ‘potentially unfair' distribution of funding, given there does not appear to be a clear national pattern for why some practices have large correction factors. PCTs have just completed a survey of 500 practices with the largest correction factors to understand this better. The results will then be used in the next round of negotiations.

Dr Laurence Buckman: Can he and his fellow GPC negotiators avert a contract crisis? Dr Laurence Buckman: Can he and his fellow GPC negotiators avert a contract crisis?

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