The new contract that will be introduced in 2024 will potentially bring in the biggest changes to general practice in England since 2004.
We have had some clues from the BMA GP Committee and NHS England about the direction they want to go: the GPC has hinted that it is considering payment by activity, and NHS England has suggested moving away from targets.
Now, we are hearing from LMCs. They will play a vital role in shaping the contract, being closest to grassroots GPs, while setting GPC policy.
And we are now seeing the first glimpses into what their strategy will be. A special conference is taking place as part of the annual England LMCs conference on 24 and 25 November in London. In a behind-closed-doors session, LMC leaders will be discussing their positions – some radical and some not so radical.
The agenda for the special conference is a complicated read, but we have distilled the main ideas put forward – which will go a long way to shaping the new contract.
The most radical suggestion is Gloucestershire LMC’s motion: ‘We call on the BMA to commission a study on the feasibility of general practices transitioning to a privatised “dental” model of GP and publish guidance and a roadmap for practices who wish to explore this route.’
A similar move is suggested by Devon LMC, which is calling for a discussion on a ‘fully worked up and viable plan B for a national swap over to private general practice’. However, there is an important caveat: ‘This would include a system whereby those with lower incomes could have state funding in order for them to be able to appropriately access primary care.’
These are simply topics for discussion, but if there is enough support, the GPC could be forced to at least model a scenario of general practice going the same way as dentistry.
Some LMCs also want the new contract to allow practices to offer private services to all registered patients, including Berkshire and West Sussex LMCs.
A move to item-of-service payments is also, not surprisingly, on the agenda. A proposal from Gateshead and South Tyneside LMC ‘requests that the contract be renegotiated to fund general practice by item of service means, in order to reward work done’.
Another topic close to LMC hearts is reducing GP workload, and it has brought some radical suggestions. Among them is an end to practice lists so that ‘the patient goes to whichever practice they want for a given problem’ to stop GPs ‘being the providers of last resort’ – proposed by Devon LMC.
Other suggestions include:
- Limiting the number of patients that each whole-time equivalent GP is responsible for to no more than 1,500 or providing ‘an increase in core funding sufficient to provide adequate services for the
- Ending of home visits, except for the housebound.
- Ending enhanced access, which make GP services ‘unsafe’, decrease patient satisfaction, increase health inequalities and cause ‘practices to close’.
- Defined workload limits with an overspill mechanism such as urgent care centres, as per the GPAS model.
- Pushing forward existing conference policy to include GPs, nurses and ANPs in the ARRS.
LMCs will also discuss how best to supply GP services. A number of LMCs demand GPCE’s ‘unequivocal support’ for the partnership model and condemned suggestions of a new model of hospitals employing GPs. For example, Ealing LMC ‘has grave concern and unequivocally opposes postulated future models for mainstream general practice, in which GPs are either employed by hospitals or by large scale profit-driven commercial healthcare providers’.
But in an alternative take, Hounslow and Hammersmith LMC opens up for debate about GPs becoming ‘a new category of NHS employee’, as an ‘urgent plan B’ for the profession.
LMCs will also propose that the next multi-year deal requires ‘break clauses’ in the case of ‘exceptionalities’.
The future of the PCN DES
One theme is for LMCs to call for all small sources of funding be consolidated into core funding, including PCN funding.
Some LMCs – including Oxfordshire – have called for the core contract to be made ‘viable’ on its own ‘so that the PCN DES remains a genuinely optional “extra”’, as well as other enhanced services and additional contracts.
While the GPC has been given a mandate for the scrapping of PCNs entirely, it last month indicated that a mass PCN DES exodus is not imminent. And LMCs seem divided on whether PCNs should continue beyond the five-year deal that introduced them or not:
- North Yorkshire LMC calls for the conference to ‘[rescind] the policy to withdraw from the PCN DES in April 2023 and [support] those practices and PCNs that choose to continue to provide the DES’.
- Suffolk LMC added that the conference must recognise that ‘many practices are already heavily invested in PCN workforce’ and should ask GPCE to ‘consider that as a result, PCN contract withdrawal may not be a viable mechanism for potential industrial action’.
- But a motion proposed by Mid Mersey LMC countered that ‘conference notes that it is time to reinvent the wheel again! and that the time of PCNs has to come to a much-awaited end’.
LMCs will also discuss the abolishment of QOF, IIF and other target-driven initiatives.
The GPCE executive team was given a mandate to ‘immediately escalate discussions with BMA Council’ on industrial action in response to the GP pay announcement back in July. But the BMA most recently told Pulse that it remains in the early stages of preparations for any GP industrial action and the specific form of GP industrial action will be ‘decided at a later date’.
The thorny issue of industrial action is another that is set to cause controversy at the England LMCs conference, with differing views from local leaders.
Hillingdon LMC said there is ‘not enough appetite amongst the profession for an all-out strike/industrial action due to risk of patient harm’. And Leeds LMC said that its ‘local practices are not calling for industrial action and GP partners would not be willing to take the risk of doing this without trade union protection that is provided to employees’.
But West Sussex LMC said it is ‘disappointed by the lack of progress on implementing a plan for industrial action since the indicative ballot of GPs in November 2021’. Other LMC motions demanded that GPCE progress work to organise GP industrial action. Berkshire LMC proposed that the conference ‘demands that GPC England look at all available options for industrial action in the case that an agreement cannot be reached on a new contract’.
A motion put forward by Tower Hamlets LMC called on GPCE to ‘provide clear guidance to practices on how they close their practice list on the grounds of patient safety’ and the BMA to ballot GPs on their willingness to do so.
Other proposals for both industrial or collective action put forward by LMCs included:
- Adherence to safe working limits with ‘additional demand diverted elsewhere’
- Working ‘strictly’ to the GP contract and ‘ceasing non-contractual work’
- Rejecting workload shift and lowered thresholds for referrals
- Handing back ‘non-profitable LESs’
- Implementing ‘waiting lists’ for different conditions
- Prescribing all branded medications
- Protected time in contracted hours for learning and wellbeing
- Industrial action coordinated with that of other healthcare professionals such as junior doctors or nurses
- ‘Local action’ as determined to be most appropriate locally, but supported and coordinated by the BMA ‘so that in total there is national action’
With the session being behind closed doors, it is unclear exactly how these will be taken forward. But if some of these radical solutions are taken forward, general practice may be a very different profession in two years’ time.