How far does the global sum uplift go?

‘We’ve listened, we’ve acted and we have delivered’. Those are the words BMA GP Committee chair Dr Richard Vautrey said at the LMC annual conference in March after securing a new GP contract.

A year ago, the same conference called for drastic changes in general practice in light of the increasing number of GPs across the country struggling to deal with rising patient demand and years of underinvestement in services.

And the BMA listened to those concerns: In January, negotiations with NHS England and the Government resulted in a new five-year GP contract, with more than £2.8bn in funding secured as a result.

There is no doubt that the profession has welcomed such investment and, as Dr Vautrey pointed out, ‘these widespread changes are the most significant in 15 years’. But as the saying goes, the devil is in the detail and a closer look at the agreement shows that the reality might not be so glamorous. 

According to official documents, the global sum per weighted patient will increase from £88.96 in 2018/19 to £89.88 in 2019/20, meaning that practices will only get an extra 92p. 

As always with contractual negotiations, the devil is in the detail

Dr Samir Dawlatly

Despite the increase, almost 90% of that is a transfer of funds from schemes the NHS is phasing out. These include 39p for seniority payments and 44p for the Minimum Practice Income Guarantee (MPIG).

Seniority payments and MPIG were introduced in 2004 as part of the then new GMS contract. MPIG was used to top up the global sum payments of some practices, especially those located in rural areas, while seniority payments were paid to practices on behalf of eligible GPs as a reward for their experience.

But the Government announced in 2013 that it would phase out MPIG payments over a seven-year period, starting in 2014/15 – as part of the GP contract imposition – while redistributing the total sum of correction factor payments across all GMS practices. Similarly, the phasing out of seniority payments began in 2015 and will be completed in 2020 so this is recycled money.

The remainder 9p is set to cover the costs of inflation and the extra work GPs will be required to undertake.

The global sum will see a £20m funding boost to cover GPs dealing with patient requests for information – known as subject access requests (SARs) – in relation to GDPR, alongside a £30m pot of funding to cover the costs arising from changes made to the requirements for extended hours access and for offering direct booking from NHS 111.

Based on Pulse’s calculations, the SARs funding amounts to around 33p per patient in England, while funding for NHS111 direct booking and the increased population coverage of the extended hours access requirements amounts to around 50p per patient.

Taken together the overall package decreases expenses and results in a £2.68 uplift per patient 

BMA spokesperson

Although there is no funding cut as such – as the additional funding will actually cover new work and money for MPIG and seniority payments is a ‘reinvestment’ – Pulse estimates that, taking into account the costs of the new work, it amounts to the global sum being effectively cut by around 74p per patient.

There are significant caveats to this, the burden of indemnity payments has now been removed, with the introduction of the new NHS indemnity schemes for GP last month. This means GPs will no longer have to pay for cover for any clinical negligence claims relating to NHS work – a huge financial lift.

Meanwhile, joining the new primary care networks – geographical groupings of practices serving 30,000 to 50,000 patients in size – will automatically unlock £1.76 per patient, an annual average of £14,000 per practice through the ‘practice participation’ additional service. This is alongside the millions coming through the networks themselves.

And England remains more fortunate than its neighbour Wales after the Welsh Government recently revealed its plan to cut the global sum by more than £11m – the equivalent of £2.88 per patient – in order to deliver the state-backed indemnity scheme. 

The BMA said the overall package in England results in a ‘£2.68 uplift per patient at practice level’.

A BMA spokesperson said: ‘This year’s contract agreement delivers significant new investment well above previous years and includes many different elements, including increases to the global sum, via the statement of financial entitlements (SFE), the primary care network DES and a landmark expenses reduction with the introduction of the state-backed indemnity scheme, which will save practices a substantial amount of money.

‘Taken together the overall package decreases expenses and results in a £2.68 uplift per patient at practice level with further funding delivered via the PCN.

‘The recycling of MPIG and seniority is not new for this year, and has been the case since 2013 GP contract imposition but crucially this funding is not removed from the contract but reinvested. Furthermore, the suggestion that responding to SARs is new work is not true. Practices were doing this work anyway, but were not receiving any funding. They are now.’

They added: ‘Similarly, direct booking through 111 will not create additional work as it uses a very limited number of existing appointments, and pilots have shown even these appointments are often not used by 111. To selectively pick out elements of a unified agreement in such a way will inevitably distort the overall benefit of the package.’

We know there is some new money available; perhaps not a lot but there is more to come particularly through PCNs

Dr Greg Place

GP leaders believe that it will take time before GPs can see the full impact of the changes, whether positive or not. 

Nottinghamshire LMC chair Dr Greg Place said: ‘We know there is some new money available; perhaps not a lot but there is more to come, particularly through primary care networks. There is also a substantial change to GP expenses.

‘We haven’t seen all the increase yet: to be honest we will have to look both at the end of quarter statement and the end of year accounts to see the full extent of the change. But for the moment, I think we should thank our team for what they have achieved so far, and work collaboratively together and use the new framework for the betterment of both patient care and the financial state of UK general practice.’

However, Dr Samir Dawlatly, a GP partner at Jiggins Lane Medical Centre in Birmingham, said: ‘As always with contractual negotiations, the devil is in the detail. One could find oneself asking, “When is an uplift, not an uplift?”. Partners are not going to be able to answer that for certain until months after the end of this financial year when they sit down with their accountants and try to balance the books.

‘It looks like some are going to lose out more than others, but it won’t be clear until at least 18 months after the contracts have been signed on our behalf.’

But Dr Vautrey said ‘we are not there yet’ and much more needs to be done to address the current challenges and put general practice back on its feet. 

He said: ‘We are far from complacent. There is much that needs and must be done. But, as GPCs and LMCs together, we will listen, we will act and we will deliver.’