This site is intended for health professionals only

At the heart of general practice since 1960

pul jul aug2020 cover 80x101px
Read the latest issue online

Independents' Day

Why I have voted ‘yes’ to the proposed Scottish contract

Voting yes means a first step to securing investment and tackling the workload crisis facing our profession, says Dr Christopher Mansbridge

dr christopher mansbridge 3 x 2

Discussions around the proposed new GP contract in Scotland reminded me of an ancient parable I am fond of, in which a group of blind men are tasked with describing an elephant by touch alone. None of them have encountered an elephant before. One has a tusk, one has the tail, the other has the trunk and so on. When describing their findings, they are in complete disagreement about the nature of the animal.

Each becomes suspicious of the others’ claims and accusations of dishonesty arise. It ends in coming to blows or, even death in some versions of the story.

The parable intends to show us that with a partial view on a subject, you might be only partially right.

Having read the ‘blue book’ and attended one of the road shows, I felt there was enough there to convince me the proposed new GP contract was a step in the right direction. I had concerns regarding the big ideas of ‘phase two’ of the proposals, but that will be negotiated pending the current poll. My support for phase one was a simple acknowledgement that investment in the profession is needed and the commitment to reducing risk and workload chimes with my own concerns.

I concluded that the best possible chance to understand Scottish GPs in all their forms and safeguard all our futures would be voting ‘yes’ for phase one

Subsequently, discussions of the vote on social media and online pressure groups revealed that some remote and rural GPs are very concerned about what the contract means for them and it is this aspect that has dominated the debate.

I have learned a great deal by simply reading the hundreds of comments from around the remote and rural areas about how this contract proposal is not addressing their concerns. Some have even suggested this is a deliberate attempt to decimate remote and rural GP life. The discussions made me realise I had only a partial view on what a Scottish GP contract should look like, as did all my interlocutors online from around the country.

However, my conclusion remained that the best possible chance to understand Scottish GPs in all their forms and safeguard all our futures would be voting ‘yes’ for phase one.

To explain why, it is worth laying out exactly what a ‘no’ vote means in the phase one poll. It means saying no to £250m investment in general practice – which, at a time of cutbacks in other parts of the NHS, is quite an incredible achievement.

It means saying no to a new funding formula which finally acknowledges the greater resources needed for our most deprived and elderly populations, backed up by income protection for unaffected practices.

It means saying no to moving some of GPs’ workload, such as vaccinations, into the remit of Health and Social Care Partnerships, a simple but welcome move.

It means saying no to the highly innovative premises loan scheme, which I believe most GPs think is an excellent proposal to take the risk and uncertainty of being a premises owner and avoid the last GP standing scenario.

And it means saying no to the expenses survey, which is the best chance we will have of understanding the scale of GP workload across the country, and identify the true differences between urban and rural areas.

I am only cautiously optimistic about the future, as there is so much at stake in the new contract and how my single-handed practice will fare remains to be seen.

But I believe that if phase one is not agreed by the profession, not only will it be a golden opportunity squandered, but it could also herald a long period of uncertainty about the future of Scottish GPs that the profession could have easily avoided.

Dr Christopher Mansbridge is a GP principal in Glasgow

Rate this article  (2.7 average user rating)

Click to rate

  • 1 star out of 5
  • 2 stars out of 5
  • 3 stars out of 5
  • 4 stars out of 5
  • 5 stars out of 5

0 out of 5 stars

Readers' comments (18)

  • Promises, Promises.
    Seen it all before - numerous times.

    Unsuitable or offensive? Report this comment

  • We rural GPs aren't blind men feeling an elephant - we can see all the information clearly and are calling it for what it is. The 'elephant in the room' is that the contract is a mess and should never have got to this stage (and wouldn't if proper consultation had taken place a lot earlier - especially when the Deloitte formula was first released to the negotiators). If the extra money was indeed going to the most deprived populations that would maybe work... but the formula takes no account at all of rural factors in allocating funding. Despite my practice having far more elderly and deprived patients than average I am looking at a massive income protection measure. Deep end practices in our inner cities aren't faring much better, and recruitment is going to be a nightmare as we try and compete with what is starting to look like a far more favorable working situation for urban central belt colleagues.

    Unsuitable or offensive? Report this comment

  • 'rural GP
    You say the contract 'is a mess'. Could you be a bit more specific, as voting for the first part of the new contract will entail nobody losing out(urban or rural).
    The BMA themselves have admitted there are special rural circumstances which will need closer looking at in round 2.

    Unsuitable or offensive? Report this comment

  • "It means saying no to £250m investment in general practice " -It quite clearly is NOT £250m investment in GP, this money will be going to HBs for primary care "to directly support GP". It is £23 for GP, very much less and nothing like what is needed to acheive the 11% of NHS funding needed to sustain GP.

    Unsuitable or offensive? Report this comment

  • There you have it, Drs Mansbridge and Podgorny.
    Surprise, Surprise. It's not £250 million into GP in Scotland, it's £23 per GP (Miles Mack says so - costs nearly twenty times that to insure beloved hound).

    Unsuitable or offensive? Report this comment

  • I quite agree @ Miles Mack. It is made pretty clear by scottish govt it isnt investment in GP but "primary care". It wont come anywhere near us and what investment has already been made has basically been squandered on nothing helpful

    Unsuitable or offensive? Report this comment

  • Sorry but a no vote means telling YOUR trade union reps they have not done a good enough job.

    It's not a trade union's job to produce a deal with which a significant proportion of members (both rural and Deep End) disagree with profoundly.

    A no vote will tell the BMA they need to come up with something better.

    And, as Miles says, £250 million is NOT going directly to practices. Past experience tells me that whenever health boards get more money for "primary care" very little filters through to practices.

    With health and social care integration I think we will be even less likely to see our fair share of the "new money.

    In what way is the contract a mess? It puts almost every rural practice (and many Deep End) on income support which is in its own way a destabilising influence.

    It fails to redistribute in favour of Deep End deprivation and inequality.

    It does not recognise rural deprivation at all or the significant extra level of responsibility taken on by rural GPs.

    It does nothing to support, enhance or promote fragile rural practice.

    I could go on but there's already enough ammunition reasons in these paragraphs above to vote no.

    It's a proverbial curate's egg and I for one don't want something that's "good in parts"

    Unsuitable or offensive? Report this comment

  • I voted no as there is no pay uplift and using the example of NHS lanarkshire's treatment rooms as progress flies in the face of local experience. In the end this is a poll. I'f we give it a resounding yes it weakens our hand in the future.

    Unsuitable or offensive? Report this comment

  • Angus Podgorny - happy to clarify. After years of negotiation, during which I have been struggling to recruit in rural general practice, a promise to look at things in 3-5 years time is (for me) - 'a mess'. Being told that our practice income is going to be held static indefinitely does not count as a success in any way shape or form. The 23million extra going directly to GP practices is pretty derisory... but for almost all of it to be directed to a narrow band of practices in the Central belt just beggars belief. Don't get me wrong - the allocation of this sticking plaster amount of money is not the biggest issue with the contract by any means - but it very much sets the tone as to how this whole negotiation has been approached.

    Unsuitable or offensive? Report this comment

  • Apologies for my Typo. My understanding is £23m for General Practice, rest is for primary care.

    Unsuitable or offensive? Report this comment

  • Dr Mack thanks for your typo correction. The future for those concerned has improved remarkably in ninety minutes.

    Unsuitable or offensive? Report this comment

  • Whilst this proposed contract has some good ideas, for me it is entirely the wrong direction of travel. 82 % of GPs have indicated that they wish to continue as independent contractors but the contract clearly is intended as a step towards a salaried service - premises HB owned, responsibility for holistic patient care removed from the GP and shared amongst the MDT, a salary scale of £80 ish K a rebadging of GP as "expert medical generalist". The fact that all but 23 m of the 250 m promised is not coming to GP but to the HB to support primary care reinforces this. Our ability to recruit and employ MDT colleagues is undermined and with it our ability to see local solutions to local patient need. The fact the fact that the funding formula takes no account of rurality beggars belief, when it can take a rural doctor most of a session to visit a remote patient, and the range of work undertaken in rural practice is much greater thanks urban settings (which is why rural practice is so enjoyable). A no vote at SGPC does not mean that the process ends, it just tells our negotiators (who work for the membership and not the other way around) that they have more work to do to meet the aspirations of their members. Perhaps there needs to be a change in the negotiating team to listen to and engage constructively with members from every kind of practice.
    We all wish to do the best job we can and provide the best care for our patients. This contract dumbs down the general practice I know and love and there needs to be a rethink that celebrates and supports general practice.

    Unsuitable or offensive? Report this comment

  • Well said @ Richard Weekes.

    Unsuitable or offensive? Report this comment

  • Christopher - I admire the fact you have the courage to go public and say why you are a "yes" voter. And you have been clear. I do, however, disagree with your assessment of the offer to the profession, mainly because of the loss of autonomy, the lack of financial guarantees (rural sustainability payments, enhanced services etc)and the "fire-sale" of GPs' best assets (staff, services and premises). The £23M is small (the £250M won't come near our Practices) and is only going to 63% of GP Practices in Scotland - I note you are only getting a very, very small financial uplift (albeit better than the 37% of GP Practices being put on income support). "Yes" voters clearly believe the salaried approach is the way to go. I just wish that "yes" voters could have chosen to opt for salaried contracts themselves (e.g. 2C) and left the rest of us to maintain our full independent contractor status - and not have the rug pulled from beneath us. In the end, it's all about opinions. I respect yours and thank you for being clear in your views. Best wishes, Iain

    Unsuitable or offensive? Report this comment

  • Iain,
    Similar issues and concerns were raised by SGPC members at the 28 October meeting when the contract documents were discussed. These included the lack of local funding stream guarantees, worries about the management of the extended team members and their relationship with GP teams, and uncertainty about Phase 2. Obviously at that meeting, the practices’ letters has not been sent out but committee was told that the new workload formula would be underpinned with an additional £23m investment to ensure that no practice would loss funding.

    Despite reservations, SGPC members were in effect the first “YES” voters. They were asked their honest opinion on the contract proposals and following a lengthy debate, all SGPC members present at the October meeting were in agreement to put the contract out to the profession in Scotland and to support the polling arrangements.

    Unsuitable or offensive? Report this comment

  • As an aside, in 2017 under the old SAF formula, around 50% of practices were on the old practice income guarantee or Correction Factor.

    The new proposed workload formula will take that to 37% of practices on income protection. Also, the new income protection will mean annual uplifts for the whole amount. The existing funding arrangements means only the Global Sum is annually uplifted; correction factor and Core Standard (old QOF funding) payment is not and is frozen.

    Unsuitable or offensive? Report this comment

  • John, it really is irrelevant how many practices used to have an MPIG.

    The old contract didn't drop the entire allocation of new money on a subset of practices that SPECIFICALLY excluded all R+R (every practice back then could at least earn something extra through QOF).

    It didn't come up with a premises windfall that is mainly skewed away from R+R practices (as a greater proportion don't own their premises as you know).

    ...and it didn't suggest that most of the new government money going into primary care would be to fund a panoply of PAM services that will also be hugely skewed away from R+R practices (small islands and rural hinterlands don't have much chance of getting full time physios etc on site).

    Putting all that against a small extra percentage of practice income now getting the derisory DDRB uplift each year... I despair.

    Unsuitable or offensive? Report this comment

  • Well written with some valid points. I do think the loan premises scheme has some merits. Being a retiring gp with a stake in the practice and no gp to replace you would be worrying - as it would be for the younger partners who have to find the money! Hopefully this wont be to the detriment of health board owned premises such as ours. As regards out new title of "expert bla bla", no thanks. Formally leading teams of care managers, district nurses (good luck) etc etc strikes me as a way to make up for the failures of social care. Who's going to be seeing all the patients whislt we discuss the lack of care and nursing home beds. Oh thats right.... physios!!!!

    Unsuitable or offensive? Report this comment

Have your say