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Investigation: GP practices at breaking point

As GPs face the biggest practice funding shake-up in the history of the new contract, Madlen Davies and Sarah Holmes look at how practices are planning to cope

In three months’ time, practices across the country will face what the GPC has called ‘the most significant quantum reduction in the GP contract’ since the new contract was introduced.

A Pulse investigation reveals accountants are already advising partners to reduce their drawings by up to 10% and urging practices to urgently re-evaluate the services they provide before April in order to cope with an unprecedented rise in workload.

Coming after several years of pay freezes – or small uplifts that have failed to match rising practice expenses – GP leaders are warning practices to prepare for the worst.

Many are already looking at the services their surgery provides, picking and choosing from the new QOF work and even considering making clinical staff redundant – doing whatever it takes to ensure their business survives.

With even a senior GP adviser at NICE warning of a ‘dangerous, unforeseen consequence’ from the multitude of changes, coming on top of the new responsibility for commissioning, is this the point of no return for general practice? Or can GPs weather a perfect storm?

The proposals

The exact terms of the contract changes will vary across England and the devolved nations. English GPs face the most stringent deal, with a raft of new QOF targets, plus raised thresholds, the removal of the organisational domain, and funding reallocated to four new directed enhanced services.

GPs in Wales and particularly Scotland face somewhat better deals, while the Northern Ireland Executive has yet to announce its proposed changes.

But GPs in the devolved nations have still been warned they face a huge hike in workload.

The Department of Health insists many of the changes proposed are ‘already being delivered’ by practices, and that the new deal will improve patient care.

But Pulse’s snapshot survey of 229 GPs reveals many are considering drastic measures to preserve services. More than three-quarters (77%) are planning on reducing partner drawings this coming year and 47% plan to cut extra services offered to patients. Almost one-fifth (19%) say they will cut the number of routine appointments.

Some practices are also looking at whether they can afford the staff they employ. A tenth (10%) expect to make a salaried GP redundant in 2013/14 and a further 13% expect to make other clinical staff redundant. Almost a quarter (23%) fear they will have to let administrative staff go next year.

Cutting GP pay

GP partners’ own pay packets always take the first hit from any practice funding squeeze, and medical accountants are warning that the reduction next year will be particularly acute.

Rosemary Smith, a senior partner at RS Medical Accountancy, is advising her clients to cut their drawings by 5% to 10%.

She says: ‘It is advisable for GPs to cut their drawings after estimating their income for the next year and to make the decision before the start of the year.

‘If they over-estimate, they can pay themselves out at the year-end, but it is easier to cut drawings monthly than find themselves having to put larger sums back into the practice.’

But she adds that reducing income may not be enough and practices will also have to trim extra services they offer.

She says: ‘Unless they cut overheads as well, they will lose money. GPs will have to spread their income streams so they can cushion new proposals.’

Postcode lottery

Dr Tony Grewal, medical secretary at Londonwide LMCs, says practices simply do not have the capacity to absorb extra work and the proposed contract changes will lead to a ‘postcode lottery’.

He says: ‘Anything new means you’ve got to drop something. This applies from the busiest practice to the leafiest suburb.

‘CCGs are not looking at primary care provision. They’re not borough based, they won’t have the information.

‘It’s unlikely the NHS Commissioning Board will have the capacity or inclination either, so it will lead to a postcode lottery.’

Dr Grewal’s practice is planning to reduce diabetes management and health promotion initiatives and stop fitting coils, and has already ceased providing minor surgery.

Similarly, Dr Marie-Louise Irvine,  a BMA Council member and a GP in Lewisham, south-east London, says her practice will cut some diabetes management work, as well as cease using the PHQ-9 to rate the severity of depression.

‘They were not useful to the practice doctors and it was purely a box-ticking exercise,’ she says.

Dr John Grenville, medical secretary of Derbyshire LMC, says practices will probably have to move towards greater triaging, with patients seeing nurses and health practitioners for minor ailments.

But he warns: ‘Occasionally someone will come in seeking assurance for something which they think is a minor problem and it won’t be, and it might be missed and they’ll suffer. Some patients will slip through the net.’

Dr Paul Conley, a GP in Bordon, Hampshire, says chronic disease care for patients with self-management plans and cosmetic skin surgery are the ‘lower-priority services’ his practice will look to reduce.

Picking and choosing QOF targets

More than half (52%) of the respondents to Pulse’s survey said they will have to re-evaluate which QOF work they take on, with some unlikely to tackle some of the new indicators.

Professor Helen Lester, the clinical QOF indicator development lead for NICE, says the sheer volume of QOF changes may overwhelm GPs.

‘GPs will pick and choose what they do under QOF if you make so many changes all in one go,’ she says.

‘Particularly coinciding with changes to commissioning, I think practices won’t have the energy or the capacity to focus in the way they do now. That could be a dangerous, unintended consequence.’

The GPC has already urged practices to consider whether it is financially viable to take on the additional QOF work, and warned that some indicators are ‘unworkable’.

Dr Peter Swinyard, chair of the Family Doctor Association, warns the planned hike in QOF upper thresholds will demotivate practices. He says: ‘If you set a threshold too high people will say “It’s not worth trying for”.

‘They’ll say “We can get blood pressure down to 140/90 but we can’t get them down to 120/90”.

‘Patients won’t take enough drugs, because it makes them fall over, and then we’ll either get tyrannised for high exception reporting, or our drugs bill will go up and we’ll be rapped for over-prescribing. It’s lose–lose.’

Political agendas

The GPC estimates the average practice will lose £31,000 a year by 2014/15 if the Government imposes its plans to remove funding for the organisational domain of the QOF and hike QOF upper thresholds for 20 indicators.

But they will be able to earn part of the money back by taking on four new DESs worth £3,600 each for the average practice.

However, almost a third of respondents to Pulse’s survey said their practice would not take on any of the new DESs proposed, effectively throwing in the towel on a hefty funding cut.

GPC chair Dr Laurence Buckman says: ‘I am not sure actually you could take on all four DESs; the workload is very steep. If I am not going to do some of the DESs because I physically can’t, then I must be losing money, because the money that funds the DESs is 150 QOF points.’

Dr Grewal says practices will not take on the new DESs for case-finding in dementia, risk-profiling, telehealth and rolling out online access to GP services unless they can see clear clinical benefits.

He says: ‘GPs are fed up with dancing to political agendas rather than clinical ones. The DESs are seen as another vote catcher, not for clinical need.’

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Dr Ben Burville: ‘Existing patients are our priority’

Dr Rosemary MacRae: ‘We are worn out’

Others, however, believe GPs will have no option but to take on the additional work. Michael Ogilvie, client service director at OBC The Accountants, says GP partners are facing a 10% to 20% cut in take-home pay next year, thanks in part to pension tax changes, and they will be forced to take on all the work they can.

‘Emotionally, doctors are saying they can’t do the DESs, but in reality they will have to consider how they can take on the extra work because it’s an important source of funding,’ he says.

‘It won’t be pleasant at all, and some may refuse to do it. But I think that young partners, who still have school bills and mortgages to pay, will make more changes than older partners.’

The DH, meanwhile, insists the changes are fair, claiming ‘excellent care and improving the health of patients is a priority for everyone in the NHS and we are committed to giving them the tools to make sure this happens’.

In a few months we will find out who is correct.