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Focus on: The GP contract overhaul

After years of stalemate, major changes to the GMS contract have been thrashed out. The deal has even been hailed as the first signs of peace between ministers and GP leaders. So what does it mean for GPs? The Pulse news team investigates.

By Pulse news desk

After years of stalemate, major changes to the GMS contract have been thrashed out. The deal has even been hailed as the first signs of peace between ministers and GP leaders. So what does it mean for GPs? The Pulse news team investigates.

After several years in which NHS Employers and the GPC have been in virtually continuous conflict, the two sides have agreed to major changes to the GP contract.

It sees the beginning of the end for the MPIG. The controversial square root formula is abolished. The QOF is reduced as a proportion of pay - but at the same time takes on a new set of outcome-related targets.

But will all this go down in history as the beginning of a new dawn, which, as the Government suggests, heralds the start of a new working relationship? Or will it be the profession's equivalent of peace in our time?

Already it's clear that despite the breakthough, huge uncertainty and plenty of tough negotiations still lie ahead. Here Pulse looks in detail at the changes to the contract – and at some of the issues they raise.

The end of the MPIG

Central to any deal is the Government's determination to dispose of the MPIG and the proposals agreed between the GPC and NHS Employers pave the way.

Both parties have agreed to a mind-blowingly complicated new funding formula for this year's pay negotiations - which may or may not be a one off - effectively slashing the money earmarked for MPIG correction factors, on which many GPs rely.

GPs will be paid increases to the global sum, QOF, enhanced services and the correction factor under a ratio between the percentage uplifts of 7:5:5:2, which in the real world means the global sum gets more and QOF is worth proportionately less for practices. At the same time locum and seniority payments are to be frozen.

But how quickly MPIG disappears is still a matter for huge debate. Health minister Ben Bradshaw's initial verdict was that it would be gone within five years. Days later his boss Alan Johnson admitted that based on a theoretical 2% annual pay uplift, 25% of practices would still be reliant on the income guarantee in five years' time.

Mr Johnson says the Government is at pains to avoid another imposed deal, following the outcry of the last pay settlement over extended hours.

‘We would have liked to have done a multi-year deal but didn't get it. We couldn't and we wanted to negotiate a deal,' he says, adding that when it comes to the erosion of the MPIG and the thawing of relations with the BMA ‘there's nothing between us on this'.

He adds: ‘The GPC is obviously concerned to protect practices to give them a softer landing. I appreciate that, that's what we want to do.'

GP negotiators say when it comes to the subject of timeframe, negotiations still have a long way to go.

Dr Richard Vautrey, GPC deputy chair, says: ‘The GPC is very keen that we reach a stage as quickly as possible when the MPIG will be removed completely.'

This suggests that talk of a phase-out over 10 years or longer is highly unlikely.

But any shorter – any the Government will surely want it to be nearer five than 10 -will require either a firm commitment of solid year-on-year funding increases, or the risk that thousands of GP practices will be thrown into a world of financial uncertainty. That's something no negotiator will want to sign up to.

Square Root formula ‘uprooted'

The controversial square root formula for calculating the size of QOF payments is a definite victim of the new proposals. Unlike with the MPIG, the timeframe is almost immediate, as the two sides move to payments directly related to local disease prevalence. From April 2009 the square rooting component will be scrapped. The formula, brought in 2004, has created frequently perverse side effects which have left it open to biting criticism, especially from practices in areas of high disease prevalence who have lost out the most.

But a replacement system of payments based on true prevalence won't be brought in until April 2010 and the GPC admits that a small number of practices may experience a significant loss in their current QOF income.

The Government has agreed to urge PCTs to work with these practices to ‘understand the impact on service provision', but this is unlikely to be of much reassurance. Trusts will also be expected to identify local health needs that can be tackled through the QOF, in order to reduce inequalities.

What's going to be brought into the QOF?

Lord Darzi's Next Stage Review has loomed large over the reshaping of the QOF, which is being toughened up and targeted directly at health outcomes, rather than at measuring process. In April 2009, 72 points will be rejigged and reallocated largely to the major chronic diseases – heart failure, CKD, depression, CVD, diabetes and COPD.

Health Secretary Alan Johnson says the new-look QOF will bring a stronger focus on outcomes that matter to patients. The new COPD indicator, for instance, will rewards GPs for assessing the degree of breathlessness patients experience, as a direct measure of the benefit of treatment on quality of life.

The QOF also has new preventive elements, particularly for CVD, which gets indicators for conducting risk assessments and giving lifestyle advice – in order to support the Government's planned vascular screening programme. There is also a shift to incremental rewards – so GPs are to be paid for every 1% HbA1c level is lowered in patients with diabetes.

The diabetes indicators are also brought in line with NICE guidance, which is another theme dating back to the Darzi review. But the majority of changes are based on the recommendations made in the 2008/9 experts panel report, which were shunted to one side in favour of the Government's expenditure on extended hours. Other changes this year are more procedural. The indicators for adding [beta]-blockers to ACE inhibitors and ARBs for patients with heart failure, and for recording the percentage of patients with CKD who have a record of an albumin:creatinine ratio in the previous 15 months, are generally seen as sensible and evidence-based. But NICE is to take a much bigger role in drawing up the QOF so expect more dramatic changes in future.

What's been kicked out of the QOF?

GPs will no longer be rewarded with QOF points for taking part in the quarterly PCT access survey. Instead, survey duties will be taken on by Ipsos-MORI as part of its GP Patient Access Survey, which was manipulated so effectively by the Healthcare Commission to attack GP access just this week.

Not only do GPs lose any participation in patient feedback, but the two patient experience indicators, which rewarded GPs for their participation in the survey and implementing the changes indentified as necessary, and the 55 QOF points that came with them, have been scrapped.

Along with 17 other points nipped and tucked from indicators elsewhere, they will be recycled to reward the new indicators for chronic disease included in the QOF from April 2009.

Negotiations – what happens next

Despite the positive noises emanating from both camps, the deal will live and die by the Doctors' and Dentists' Review Board's recommendation to the DH as to whether GPs deserve a pay boost - and then of course that ruling being rubber stamped by ministers.

Yet Alan Johnson has been making encouraging comments about the ring-fenced nature of the Government's spending commitments. ‘Our relationship has always been good,' he says of the BMA. ‘I respect people like Hamish Meldrum and Laurence Buckman. I'm a trade union official, I know what it's like to be on the other side of the table, we are critical of each other, but we are grown-ups.'

‘I am critical of the SOS campaign but with issues like accreditation and health inequalities we are absolutely on the same side.'

The figure being banded around for next year's pay rise is 2%, although the GPC is set to push for more. With the backdrop of a global financial crisis, most GPs will not be overly optimistic.

‘The relationship will improve provided he honours what the review body says,' says GPC negotiator Dr Peter Holden. ‘If he wants good relations, it takes two to tango.'

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