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CAMHS won't see you now

This contract is our best chance to rescue general practice

The proposed GP contract for Scotland is the best hope to put general practice back on a firm footing and secure its future, argues Dr Alan McDevitt

10 mc devitt alan power50 2017 10

The proposed new contract for general practice in Scotland is a bold new direction for the profession and one that I believe offers our best hope for a sustainable future.

Taking an innovative new approach to how we deliver community healthcare in Scotland is essential. Practices across Scotland have been struggling to recruit to vacant positions and we have started to see this impact on patient care, with some practices closing their patient lists, handing back responsibility to the health board or in extreme cases having to close altogether.

Demands on general practice are increasing day by day as Scotland’s health needs grow. As people in Scotland live longer, they are more likely to spend a longer portion of their lives in ill-health, with multi morbidities and increasingly complex needs.

This has pushed many practices beyond the limits of what they can sustain and has directly contributed to the difficulties in attracting junior doctors to choose a career as a GP.

More than one in four GP practices in Scotland had at least one vacancy in the most recent BMA practice survey. Every unfilled position means that the remaining doctors at a practice are stretched even further in trying to cover the gaps.

The workload that GPs in Scotland face is punishing and too often it is pushing doctors past the point where they burn out and leave the profession.

GPs need more support and the proposed new GP contact is a step towards delivering that. If implemented, larger multi-disciplinary teams of health professionals will work together in communities, making care more accessible for patients.

For some patients with specific problems that they need help to manage, it may be more appropriate for them to see another healthcare professional. The proposed agreement will see more nurses, pharmacists, physios and other healthcare professionals available in community settings so that patients can see them directly.

That means GPs will have more time to deliver the kind of care that only they can. For patients who don’t know what is making them unwell or who have complex needs, the GP will still be who they need to see.

The proposed new contract also recognises that those practices with higher workloads need more support if their quality of care is to be maintained. The funding formula that underpins general practice will change if the contract is implemented, so that while every practice’s current income is protected, those practices with the highest workloads will receive more support, most notably those practices with higher numbers of elderly or deprived patients.

The contract will also take steps to reduce the business risk that comes with being a GP. That will make it more appealing for younger doctors to become GP partners, helping with the difficulties in recruitment and retention.

The new arrangements proposed in the contract for GP premises, GP information technology and information sharing are significant too. The effect of these arrangements will be a substantial reduction in risk for GP partners in Scotland, and a substantial increase in practice sustainability.

GPs across Scotland will get the chance to consider and respond to these proposed changes to their contract in a poll of the profession, which opens on 7 December.

If implemented, the first phase of the new contract will be delivered over a three-year transition phase, with a second poll of the profession taking place before the second phase of changes are implemented.

The NHS relies on a healthy general practice to function effectively. It is the part of the NHS that the greatest number of people interact with and all of us depend on being able to access primary care services when we need them. We cannot allow the difficulties in our GP surgeries to go unaddressed.

I believe that this new contract offers Scotland our best hope of once again making general practice an attractive career choice in Scotland and ensuring that Scottish general practice has a brighter future.

General practice, and indeed the wider health system, faces major challenges as patient demand increases rapidly. Amid severe difficulties in recruitment and retention, it is clear that the status quo in general practice cannot be sustained any longer.

I truly believe that this proposed new contract will bring stability to general practice and put it on a firmer footing for the years ahead.

Dr Alan McDevitt is chair of BMA Scotland GPC  



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Readers' comments (8)

  • Why not come clean and admit the the ultimate aim is to have a salaried service. The contract says independant contractor status is preserved but there is precious little in the contract that encourages or develops this status. It may appear a broken system but I believe this is down to massive underinvestment in primary care and GMS in particular over the years. The contract offers little development of GMS with the vast majority of investment going to non GMS support.It may be that younger GPs think this is the way to go but be honest about your aims.

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  • Rescue from what?

    from a NHS monopoly employer that its squeezing us by the proverbial?

    Its NOT your job to ''save the NHS''. You are there to protect DOCTORS interests. At present they will be best served if your worked towards allowing a private service to develop so that an alternative source of income is made available..

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  • I can't see anything in the contract to stop the crashing train.
    The over 50s will still plan to retire.
    The under 50s will reduce partnership sessions and top up pay with OOH or locum work.
    The under 40s will look to locum.

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  • I was at the roadshow this week, and although it is not an immediately obvious green and promised land it is clear a lot of hard work on both sides has gone into arriving at this, and a lot of hard work by all is yet to be done.
    As I get older I have less selfish thoughts about my personal income, although it matters, and more selfish thoughts about who looks after me and my family when I am older.
    This has a good chance of attracting young Drs into the profession which clearly is not happening at the moment.
    What is happening in England is shit. What is happening in Northern Ireland is frighteningly shit- and it all boils down to who is governing (or who isn't in the case of NI). I am hopeful for the first time in a while and hopefully the tail can wag the dog.

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  • Dr. Podgorny - what specifically about the contract do you think will attract young doctors? As a scottish GP trainee, I can't really see anything targeted at encouraging recruitment/retention of pre-CCT docs, for me it just seems to further highlight the massive discrepancy between job perks of secondary care vs. primary care, but I'm v. open to hearing your take on it as I've not yet managed to trawl the whole document, and always prefer an optimisic take.

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  • Vinci Ho

    Forgive me for making a comment as an ‘outsider’ (GP in England).

    This contract , typically like Brexit, has raised more questions than answers :
    (1) The intentions of a new contract are understandable and logic to the current political climate. Indeed , one can argue this might not see the living daylights if there was a much stronger government in Westminster.
    (2) Clearly , the distinction between the definition of a ‘partner’ and a salaried has become blurring . What is the relationship of workload and the ‘guarantee’ of minimum earnings of 80,430 per annum? For an old dog like me , the word guarantee only raises more scepticism after these years(remember what MPIG stands for ?)
    If there is a minimum, is there a potential maximum as well ? For being a partner, there should be a gradation of more earnings for doing more on top of a fundamentally sustainable income. This flexibility is exactly what we ,GP partners in UK , had lost as government(s) managed to exploit and abuse the ‘loop holes’ in GMS (also PMS which is becoming history now) contract . It is funny that HMRC was ironically the little child who saw the emperor wearing nothing for his ‘new clothes’. Perhaps , a horse is a horse and a donkey is a donkey ,after all.
    (3) For younger colleagues, my question for you is whether you will just take this as another ‘job’ with a face value ‘salary’ of £80,000 and will attain a balance between life and work in your next 20-30 years?
    If there is ever a desire to work away from the environment in hospitals(which I will argue is equivalent to that in an ever expanding corporate company) , you may not find yourself running too far out?? Ultimately, terms and conditions govern and you are indeed allowed to say ‘No’s to anything in excess . Really ??
    (4) Then this leads to the question who are to be allowed to vote ? For those of my age (52) , a new contract is only meaningful for a few more years(no intention to be a schadenfreude) but it is the 20-30 year future of younger colleagues. I would argue all GP trainees should have a vote on this.
    (5) Amendments should be introduced into this draft before allowing you guys to vote upon . In addition to address the above questions ,indemnity and (to me) continuity of care should have some imprinting on this contract.

    Being a fan of Orwell and Einstein , you have to excuse my philosophical crap :
    The theory of special relativity states , whether you are inside a fasting moving vessel like a rocket (our youngsters) or being slower and stationary on the ground(old fart like me) , the law of physics( the law of caring patients , for us) is invariant..........
    The faster you run , you gain more mass and heavier (E=mc2) . Nobody or nothing , therefore, can be faster than the speed of light........(unless one wants to turn to the dark side where light cannot reach).

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  • @Glasgow Trainee
    Good questions, and because you are near the beginning of the trail as I am much nearer the end I can only tell you what I observe, mixed up with that most dangerous of beasts: assumptions.
    I observe that there are fewer applications for partnerships although salaried posts seem easier locally to fill. Anecdotally I have been either directly told or heard from others that buying into a practice or taking on a lease (which perhaps carries more risk) is no longer attractive so am making a general assumption that this is the wider case. Certainly taking on a residential mortgage these days is hard enough on its own, so I can understand the concern there. What is being offered in the New Contract does go some way to address that, particularly with leases, although a buy-out of owned premises will take up to 25 years.
    I also observe that younger Drs coming through do not wish to work FT so in that respect I am a dinosaur. Perhaps that is an effect on the huge increase in workload that came with QOF which had significant effects on both the workload and intensity.
    I do remain sceptical about how the new teams of PAMS will reduce workload, and indeed where they will come from or when they will arrive. There is at least a definite line in the sand being drawn about what is secondary care responsibility and what is not. (Should have been dealt with ages ago).
    There is an aspiration that in the next 5 years all FT GPs will have 1 session per week, as with consultants, to have protected time for learning.
    There is also a pledge that if the 2nd phase goes through then GPs will be earning the same as consultants.
    I am guilty on occasion of cup half full though. The last contract started very brightly with a significant pay lift (GP pay was hopefully lagging at the time), but then got lost with successive years of wilful political vandalism.
    To my mind, if I was joining now my principal concerns would be risk and workload. I think the negotiations have successfully addressed these problems, but the big unknown is how it will work in practice. Do I trust ScotGov? I don't know. They've managed to make a sow's ear out of a silk purse with respect to education over the last 10 years, but the difference there is resources. A lot of money per annum has been pledged into primary care (ring fenced) if we go with this which has got to be a good thing, even if we may not be the direct recipients.
    I would be interested in your take. Are those your concerns, and perhaps there are others?

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  • Thanks for your comprehensive response - much appreciated. I've now had a chance to read the whole document and agree with all your points. Replaced my cynicism with scepticism and a bit of hopefulness.

    My main concerns are that we're going to be woefully untrained/unsupported in managing a team of noctors employed by someone else, and I also dread the extra work they'll inevitably generate. Just as one example, the roles specified in the document for the pharmacist are completely unrealistic - how can a pharmacist navigate the 50+ special requests, when a lot of them require a nuanced and intimate knowledge of patients (eg. antidepressant or hypnotic prescribing) or an unspoken contract between patient and doctor that comes through mutual history with each other - it's just not practical and obviously a suggestion made by someone who isn't currently a jobbing GP.

    Even if they reduce actual workload by some arbitrary amount, the amount of menial supervision, handover, communication, tasks, extra work to support the uncertainty/portfolio projects/training of ANPs, pharmacists, paramedics etc will just replace the stress of being overworked with the stress of losing job satisfaction and ennui. By being restricted to 'complex' patients as well, we'll lose the satisfying cases (a quick reassurance something isn't a melanoma, that they do indeed have an ear infection, an easily fixed rash, etc etc) and who on earth is going to even determine who is simple and who is complex before they walk in the door?

    I think maybe this is good for others following, but that I've already got one foot out the door at the end of this training and there's not enough specific, defined benefit in this contract to justify staying on unfortunately.

    Thanks again for taking the time.

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