These draconian contract changes will hurt practices and patients
An imposed deal could significantly damage GP funding, writes Dr Laurence Buckman
The GP contract negotiations are the most important part of the calendar for our profession, and much of the UK’s primary care system relies on us getting it right. Good negotiations are not about “winning” or “losing”. They are about reaching agreement.
However, the Government’s stance on this year’s negotiations has made it difficult for us to reach a sensible settlement. As I wrote in my letter to all GPs last week, the new Health Secretary, Jeremy Hunt, issued a statement that made clear he intends to impose a set of draconian new changes to the GP contract, despite the fact the BMA and NHS Employers had been in sight of a possible negotiated agreement.
In my 16 years as a negotiator I have been threatened by governments twice before – in the case of extended hours, which were imposed, the Government’s decision changed general practice dramatically.
We don’t yet know in detail the terms the Government wants to impose. However, the suggestion that MPIG will be phased out over the next seven years is worrying. The implication is that practices that are perceived to be ‘overfunded’ – that is, many PMS practices and (usually) larger GMS practices that rely heavily on Correction Factor payments – would be squeezed. These practices have a gross resource per head that is greater than average. However, it is impossible to identify which practices will feel the most pain before the Government shapes up its proposals.
The BMA negotiators’ original plans for reducing funding variation between practices would have included detailed modelling of the changes for each practice, and then we would have put these to the profession in a test of opinion. Each practice would have had a chance to see its own seven-year trajectory, meaning no nasty surprises for any partners.
A grand project such as reducing variation in this way needs majority support from the profession, and to get support you need detail so that every GP can work out the implications of new contractual terms for themselves. I couldn’t support a new scheme if I thought GPs wouldn’t support it. The fact that we had carefully crafted a scheme to reduce variation, only to have a key component like consent rejected by the Government, will make negotiations all the more difficult in future.
The argument that every practice should get roughly the same funding for the same work is fundamental for our profession. It fits with the policy discussed at many LMC Conferences and has been in the pipeline for years. But if PMS GPs were to feel that they were being targeted by the project to reduce variation, we would damage the excellent work that they do. There should be changes to per capita funding, but without destabilising any practice. I’d challenge anyone who says any kind of practice is overfunded to strip away all the extra work for which they receive payment and then look at the difference in per capita payments – they’ll find it’s nowhere near as big as the total gross resource would imply.
The Government’s proposed changes to the calculation for the Global Sum risk interfering with the very formula that keeps practices afloat. Under these never discussed and undefined changes, GPs will fall victim to being funded for the population they look after, rather than how hard they work to look after those patients. However, given that this has not been part of any negotiation, I have not been privy to the detail of how the Government proposes to write this into our contracts.
The DH suggests reducing the number of points in QOF by removing the entire organisational domain, bar the QP indicators and some public health structures. They also plan to raise thresholds and reduce time limits in achieving those points. Then they try to offset this enormous loss of funding by offering a number of, yet to be defined, DESs.
Under these proposals most practices will lose much of the funding attached to the 139 points to be taken out of the QOF. We expect some practices would be able to maintain some of this funding but those who struggle to achieve current thresholds because their patients are very sick or not able to change their lifestyles, or because the practices are workload saturated, will lose big swathes of income from their QOF income stream.
Changing thresholds and cutting QOF points is defunding by another name. Take hypertension for example: under DH proposals GPs will be forced to chase up a larger number of the most hard-to-reach cases, and asked to recommend treatments – such as anti-hypertensive drugs for elderly patients – that they wouldn’t normally. The evidence shows how over-tight control of certain conditions, such as diabetes, actually harms patients, but the DH is still promoting this approach. Moreover, if you are going to undertake treatments that are genuinely clinically beneficial, you need proper funding to meet these requirements – not the reduction I have been talking about. When you have accountants and politicians deciding what GPs should do, it’s never as effective as asking GPs themselves.
As I have already mentioned, we are still awaiting the full detail of the government’s plan. The BMA is carefully examining what we know already and what this will mean for GPs, and their patients, before we decide our future course of action.
It is clear though, that GPs are dealing with this imposition off the back of a rough few years. Given the deeply unpopular NHS reforms in England and the assault on our pensions, I’m not surprised when people start to talk about taking early retirement. At the moment general practice isn’t a terribly attractive specialty. I hope that the Government takes the time to consider the greater impact that enforced changes will have on the contract this year.
Dr Laurence Buckman is a single-handed GP in north London and chair of the GPC.
To follow the contract negotiations, go to http://www.pulsetoday.co.uk/home/gp-contract-2013/14/