2023: The year the BMA gets radical? 

Radicalism is in the air, with strikes in many parts of the NHS. And GPs are suggesting radical solutions ahead of talks on the 2024 contract, the most important in 20 years. Rachel Carter looks at some of the ideas, and asks if we will see a revolution in general practice

Payment by activity

What does it mean? 
General practice is currently funded on a capitation model, with practices paid based on their patient list. Payment by activity would mean a shift to more of a tariff-based system, with GPs paid for the work they carry out, such as the number of patient contacts. Some funding already involves an element of this, such as local and directed enhanced services.

Is there support from LMCs and GPs? 
A key issue with the current contract is that it sets out essential services GPs should deliver, but does not define a level of activity. Past LMCs conferences have voted to lobby for payment by activity. 

But Pulse understands that at the closed session of November’s England LMCs conference, the consensus was to retain a capitation-based model. But the LMCs agreed the contract needs to define activity – and that an activity-based model should be considered for any work over and above that level. 

Grassroots GPs responding to a Pulse survey suggest that defining activity is a priority. One said: ‘We need to define core services and be allowed to say no’; another said: ‘It’s time we got paid per item of service, then we can’t be accused of trying to avoid work.’

Potential drawbacks? 
A risk of moving to payment by activity is excess bureaucracy, with GPs mired in documenting and claiming for tasks carried out. This could further complicate the payment system.  

How likely is it to happen?
The closed-session vote has weakened the potential for the BMA to negotiate for this, and ministers and NHS England are not likely to raise it either.

However, there is still strong support among GPs, and GPC negotiators had hinted they could push for such a move. GPC England’s deputy chair Dr David Wrigley told the Best Practice Show in October the volume of work was ‘never-ending’ and asked for views on item-of-service fees for patient contacts or tasks such as home visits. So don’t rule it out just yet. 

Scrapping QOF

What does it mean? 
This effectively does what is says on the tin and would represent a move away from target-driven initiatives: but how the framework would be replaced is where things get slightly more complex. 

Is there support from LMCs and GPs? 
There was some mention of ditching the QOF at the November LMCs conference. Leeds LMC proposed that any future GMS contract ‘must not include a pay for performance quality scheme such as QOF’ and Hertfordshire LMC called for the next contract to abolish it and ‘other target-driven initiatives’. 

Two key reasons GPs take issue with the QOF are the micromanagement approach it entails and its role in the onerous payment system. Former RCGP chair Professor Martin Marshall told the Commons health select committee last March it was time to replace the QOF with a contract with ‘higher trust’ and less ‘box ticking’. Dr Kieran Sharrock of the BMA GP Committee executive team told the same session the QOF should be ‘simplified’ not scrapped, and include measures to account for deprivation. 

Our survey did find some appetite among GPs to see QOF money go into core funding. 

Potential drawbacks?
There is a worry that scrapping the QOF could see the funding taken away completely – or absorbed into the similar PCN Impact and Investment Fund, which is viewed as even more bureaucratic.

The QOF is also credited with improving management of long-term conditions, and there is concern in some quarters that getting rid of it could put that progress at risk.

How likely is it to happen? 
Fairly likely. NHS England’s primary care chief Dr Amanda Doyle has already confirmed a move away from targets could be on the horizon. Former health secretary – and now chancellor – Jeremy Hunt is a vocal proponent of abolishing the QOF. He told a Pulse conference last year there should be ‘freedom and flexibility’ about how money is spent in general practice – a view he echoed in a later report from the health select committee, which he chaired.

Workload limits

What does it mean?
The introduction of measures to mitigate workload pressures in general practice. This could include a cap on the number of patient contacts GPs have in a day or limiting the number of patients per GP. 

There are different definitions of ‘contacts’. Yet it is telling that the BMA recommends a safe limit of 25 contacts a day, while GPs report as many as 200. A Pulse survey from November 2022 showed an average of 43 contacts a day.

Is there support from LMCs and GPs?
Unsafe workload was top of the agenda at the England LMCs conference. One motion that triggered a lively debate proposed core opening hours of 9am to 5pm. This passed, with 147 GP representatives in favour and 84 against – and unsurprisingly made the front page of the Daily Mail the next day. This is not likely to happen, but the motion did highlight the mismatch between contracted hours and the level of resource. NHS England might not be keen to cut working hours, but perhaps it will see the need for more resources.

A Kensington and Chelsea LMC motion called on the GPC to negotiate a ‘workload sensitive contract [including] a proactive system of monitoring and wellbeing safeguards’. The motion was passed. 

Potential drawbacks? 
Workload limits might lead to an unpleasant surprise for some GPs, if they suddenly find themselves with a contact cap much higher than what they are doing – especially if that later evolves from a cap to a mandate to do more work. 

How likely is it to happen?
NHS England has been more vocal recently about the pressures on general practice. In board papers last October, it warned demand for primary care services had ‘never been greater’ and capacity in some areas, especially rural or deprived locations, was ‘stretched’. And commenting on former health secretary Thérèse Coffey’s two-week appointment target, NHS England’s Dr Amanda Doyle said while it was not ‘unreasonable’, it was ‘really, really clear’ there weren’t enough GPs to deliver it.

So NHS England may negotiate in GPs’ favour. But this seems less likely for a Government hell bent on ‘improving access’ – with successive health secretaries’ proposals ignoring systemic issues. 

Pulse understands options such as practices moving to a cap of 25 contacts a day could be among those the BMA is weighing up for industrial action. 

Withdrawal from PCN DES

What does it mean?
This would involve practices opting out of participation in the PCN DES, for which the current five-year contract cycle is due to end in 2024. 

Is there support from LMCs and GPs? 
There is a high level of opposition to the PCN DES among grassroots GPs but there is more of a split among LMCs. Some have simply found it useful. Many have voiced concerns over the amount of money being funnelled through the network contract – to the tune of £1.8bn by 2023/24 – instead of going into the core contract. This comes with a lot of strings attached, which feeds into the wider discussion on micromanagement. Some have worries around the inflexibility of the additional roles reimbursement scheme and the difficulty of recruiting staff through it. Equally concerning for others is the impact of DES withdrawal on the viability of practices now reliant on networks. 

Most LMCs don’t object to working at scale. But they want to see an approach with fewer conditions attached and which doesn’t see practices penalised. GPs want the freedom to choose who they collaborate with and on what, or at the very least to have some input into what NHS England wants them to deliver, rather than being dictated to.  

Potential drawbacks? 
Many practices are now invested in primary care networks – in terms of monetary and staffing resources. Consequently, withdrawal from the DES could impact practice finances. 

How likely is it to happen?
The BMA has a mandate to organise practice withdrawal from PCNs this year – in June 2022, 61% of doctors voted in favour of leaving networks at its Annual Representative Meeting (12% against, 27% abstained). However, GPC England has not yet indicated how it will approach this and it won’t be popular with NHS England, given that PCNs have been the flagship policy for primary care over the past few years. With ICSs, the national direction of travel is still very much focused on healthcare services being delivered at scale or ‘place’.

Remove a chunk of work

What does it mean?
It could mean dedicated community or secondary care hubs taking on palliative care, paediatric care, urgent, on-the-day care, mental health, contraception, cervical smears or sick notes.  

Is there support from LMCs and GPs? 
GPs responding to our survey in the main disagreed with removing most of these items, saying they were part of core work. One commented: ‘If you drop these, you drop primary care – choose another career.’ There was more of an even split on the removal of urgent, on-the-day care.  

Pulse understands LMCs were asked to vote on a similar set of proposals at the 2022 conference. They found little appetite to stop offering palliative care, or same-day acute care – in part due to the potential impact on continuity. Mental health is slightly more complex; as Pulse revealed last year, many GPs are working beyond their competence to deliver mental health care and struggle to access specialist support for patients. There would inevitably be concerns about dropping this work without a functional alternative available. 

Potential drawbacks?
One of the main concerns about removing at least some of these areas of care is the impact on continuity, and potentially on funding. 

How likely is it to happen? 
Given the views of GPs and LMCs, it seems unlikely. But there is a precedent: the 2004 contract allowed GPs to opt out of out-of-hours care. This was radical and widely seen as perhaps the most significant change in terms of job satisfaction and recruitment. But there were fierce protests from some GPs, who saw it as the end of general practice as they knew it.

The longshots

Privatisation
One of the more radical solutions is general practice making the switch to a charging model. Ideas floated by LMCs at the England conference included a model similar to dentistry. Pulse understands there was limited appetite among delegates for this. However, a third of survey respondents were in favour.   

Removing patient lists 
In a bid to stop GPs being ‘the providers of last resort’, Devon LMC proposed an end to practice lists, allowing patients to go to whichever practice they want for a given problem. This idea wasn’t popular among grassroots GPs, with 69% of survey respondents stating they disagreed with such a move.

The Pulse survey ran from 23 November to 5 December 2022, with questions on a wide range of topics, collating responses using the SurveyMonkey tool.The questions on what should happen in the next contract were answered by 857 GPs in England. The question on contacts per day was answered by 1,013 GPs across the UK. The survey was advertised to our readers via our website and email newsletter, with a prize draw for £250 John Lewis vouchers as an incentive to complete the survey. The survey is unweighted, and we do not claim this to be scientific – only a snapshot of the GP population.