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Analysis: Contract rewrite looms for out-of-hours care



‘Over my dead body,’ was how one GP put it simply at the LMCs conference. ‘If my husband thought I was in favour of this, he would never speak to me again.’

Her robust response echoed many GPs’ instinctive reaction to the health secretary’s demand that GPs take back responsibility for out-of-hours care.

Many GPs remember the ‘bad old days’ of being on call and then having to work through morning surgery half-asleep. Those memories prompted a near-unanimous rejection of a motion at the conference supporting Jeremy Hunt’s call last month – only one representative voted in favour.

The vote occurred hours after Mr Hunt decided to cross the Rubicon and publicly call for GPs to take back out-of-hours responsibility – a move he said when questioned by Pulse meant the GP contract ‘needs to change’.

The details of his plans remain unclear, with the Department of Health refusing to elaborate on how exactly it intends to implement them.

But after weeks of newspaper leaks and rhetoric about the ‘disastrous’ 2004 GP contract and its supposed impact on A&E departments, Mr Hunt was adamant that the NHS has lost the ideal of ‘the family doctor’.

‘No one is suggesting that GPs should go back to being personally on call during the evenings or weekends – they work hard, they have families and they need a life too,’ he said. ‘But should the quality of out-of-hours care for people on their list really have nothing to do with a GP?’

GP sign-off

Answering questions after his speech, Mr Hunt told Pulse: ‘What I am suggesting in this speech is a change: I want GPs to sign off that they are happy with out-of-hours care. ‘I think that the contract needs to change – but it is not all about the contract.’

The GPC’s official position – backed up by the vote at the LMCs conference – is that GPs will not take back responsibility for out-of-hours care. But negotiators are hedging their bets somewhat.

GPC chair Dr Laurence Buckman told the conference the health secretary was ‘kidding himself’ if he thought GPs would personally provide out-of-hours care, but was less strident on other possibilities.

He said: ‘There were a number of things Mr Hunt said that I didn’t like, but I think we should look at what we could work with.

‘The devil is in the detail, but sign-off may be something that we could develop for the benefit of our patients.’

He added: ‘I believe many CCGs, and GPs, would actually like to change the current provider back to a co-operative of their own making – and I believe that would be quite possible.

‘It would need some legal change, but I don’t believe that is impossible.’

Contract talks

NHS England has confirmed it will take forward the health secretary’s call for a return to out-of-hours responsibility as part of contract negotiations with the GPC this year. While undoubtedly the most eye-catching change, the reintroduction of out-of-hours responsibility is just one of several radical alterations to the GMS contract on the cards next year (see box, below).

Like Mr Hunt, Dr Mike Bewick, NHS England’s deputy director for primary care, insists there will be ‘no return to GPs being personally responsible for evening and weekend on-call delivery’. But he says: ‘We work closely with the Department of Health at all times, and support the principle that GPs take on greater accountability for ensuring appropriate and effective out-of-hours arrangements.

‘We look forward to working with the GPC during contract negotiations for 2014/15 which should bring us closer to this shared goal.’

Opening hours

One GP with some insight into the Government’s thinking is Dr Paul Charlson, former chair and now head of policy at Conservative Health and a close confidante of the previous health secretary, Andrew Lansley.

Dr Charlson, a GP in East Yorkshire, says Government officials want ‘longer and wider’ practice opening hours and contractual responsibility for the care of patients at all hours written back into the GP contract.

‘The details haven’t been worked out as yet,’ he says. ‘Either the CCGs can make practices responsible for the budget, or you can have some contractual arrangement where there is a figure attached to out-of-hours care and GPs can either sell it off, if you like, or keep it.’

He adds: ‘I said to them, and I think they are well aware, that it is not going to go back to the previous thing of GPs getting up in the night, driving around the countryside.
‘Those days have gone. I think it will be much like the out-of-hours co-operatives.’

While full details have yet to be revealed, the proposals have already divided GPs. Dr Robert Morley, secretary of Birmingham LMC, believes the idea is not something GPs should ‘dismiss out of hand’. He says: ‘It is ironic that we constantly bemoan the fragmentation and privatisation of general practice, yet are happy to wash our hands of the GP care of our registered patients for two-thirds of the week.’

But judging by the reaction at the LMCs conference last month, he may be in a minority.

GP contract changes on the horizon

Out-of-hours responsibility
Negotiations could begin within weeks between NHS England and the GPC as part of 2014/15 contract talks

Smaller QOF
Review of primary care due to report in the autumn will consider whether the proportion of practice income linked with QOF should be reduced and tied to other incentives

Equitable funding
The seven-year phase-out of the MPIG begins next year, but exactly how the Carr-Hill formula will be reviewed and how GMS and PMS funding will be moved on to the same baseline has yet to be revealed

Access
GP opening hours are included in a review of urgent and emergency care to be published this month