Let’s bin the 2004 contract and create a new ‘Red Book’
Dr Christiane Harris argues that to save general practice we may need to reconsider past models
When you see an old copy of the Red Book, what do you think? Good riddance? Glad I don’t have to use that? Probably. But are we really better without it? Today, we have so many initiatives that make earning GP income even more onerous with few obvious benefits to our patients and increased stress for us. At least the Red Book made it clear which tasks were contractual and allowed us to be funded for them.
For the younger reader, we first need to explain a little history. The symbol of the 1990 contract, the Red Book, was a small loose-leaf binder that contained ‘terms and conditions of service’. It wasn’t popular as it was the first iteration of target-driven practice, dressed up as preventive medicine. However, for most tasks we performed, the tariff was clearly set out in the book and we were generally paid for the work we did. We knew where we stood.
A clear tariff is a much better carrot than the clumsy initiatives that grow yearly in number and complexity
Where we are now
Fast forward to the 2004 contract and we enter a dizzy and disorientating world, sadly familiar to us all, where we don’t know what we should or shouldn’t do or get paid for. This is a world of the QOF, which seems to have new areas each year, tighter and higher targets to achieve. We also have the alarming news that ‘retired targets’ are never really retired, it is just assumed that, like Pavlov’s dogs, we will all continue to perform tasks (and the QOF police can slap our wrists if we don’t).
It’s also a world of ever-growing numbers of direct and locally enhanced services. The extended hours DES involves colleagues staggering in to start at 7am, others of us working until 8pm, but if a couple of sessions are cancelled due to staff absences there is no payment at all for the work we have done.
Perhaps even more galling is the avoiding unplanned admissions DES. Even if it actually prevented patients ending up in hospital unnecessarily (and sadly in my experience it doesn’t), writing, discussing and agreeing a care plan takes a lot of time. If, for any reason, we are a few days late in completing reviews or fail to notice the numbers on the register have fallen below the required totals there is not a penny for all that work. When we had the Red Book, at least we were paid for the work we did.
In addition, there is the vexatious issue of the global sum. Lists of core contractual work have been compiled elsewhere, but aren’t formally written in the GMS contract. Meanwhile, individual GPs can’t remember what they have signed up for or what each initiative requires. At least the Red Book spelled out what was contractual work.
I am not naïve enough to believe we should reinstate the old Red Book itself, because even then it was clear that some of the tasks were not evidence based and were often shown to give poor health benefit for the expense. But given the improved use of Read coding in computerised records, we are more able to demonstrate the work we do. All we want is to be paid for it. A clear tariff (which might include a bonus if we managed to reach specific targets) that recognised the work we had achieved is a much better carrot than the clumsy initiatives that grow yearly in number and complexity.
Red Book approach
A ‘Red Book approach’ could involve the money following the patient as care flows from secondary to primary care. The more chronic disease registers a patient appears on, the more funding the GP receives for caring for them, and they could also get a small premium for achieving targets in each group. Admission avoidance and the bulk of the QOF could be swept away in a stroke and pay would more fairly reflect workload.
Those who disagree with me would, no doubt, say that this would be stepping dangerously close to a system such as occurs in health maintenance organisations, with everything having its fixed fee and needing an army of claims clerks. I don’t think that’s necessarily so, with the technology we have now.
A clear statement of fees and a contract that is more specific about what is and is not NHS work would allow overworked and often overwrought GPs to either charge for, or justifiably decline, non-contractual requests. A new Red Book might be the best way to do this.
Dr Christiane Harris is a GP in Luton and chair of Bedfordshire LMC. The views expressed in this article are her own and not necessarily those of Bedfordshire LMC