Time is running out for the national GP contract and I can’t say I’ll be sorry to see it go. More than a third of CCGs have made a bid for full responsibility for primary care under co-commissioning in England (see page 27), and the devolved nations have already begun to develop their own versions.
It’s been a decade since the ‘new’ GMS contract was introduced, but a variety of flaws have rendered it unworkable.
Take the QOF. Touted as rewarding practices for the ‘quality’ of their clinical work, it has instead turned consultations into contrived conversations aimed at ticking boxes. This has affected doctor-patient relationships and also distorted clinical priorities. For example, time spent on recalling patients and conducting physical health checks in the mental health domain might have been better used for case management to reduce the risk of relapse and distress.
Already, GPs in some areas are contemplating a future without the QOF. NHS Dudley CCG is looking to offer practices the chance to replace parts of it while NHS Wirral CCG is looking to drop the framework altogether.
Other elements of the contract have been exploited to make GPs implement political gimmicks, rather than to benefit patients. For instance, the resources spent on the patient participation DES, something of dubious value for patients and practices, could have been put to much better use. Of course, local commissioning won’t be completely free from local politics, but it is better suited to the needs of the local health economy.
Local commissioning is also beneficial because it recognises there are ways to improve outcomes other than financial incentives. For example, our CCG is trying to reduce the prevalence gap of long-term conditions like diabetes, hypertension and COPD by improving case-finding by GPs. And Tower Hamlets GPs have demonstrated how commissioning through managed networks has added value to current QOF targets and improved cardiovascular outcomes for patients. Local contracts can also tackle health priorities that are directly relevant to the patients they serve.
We all want to improve the health of our population. Only by dropping the national contract and embracing the powers of local commissioning can we do that with fair and reasonable financial compensation.
Dr Richard Ma is a GP in north London and a doctoral student at the London School of Hygiene and Tropical Medicine
In the current economic climate, losing the protection and benchmark of a national contract would be potentially disastrous for primary care.
Only a national contract can protect the interests of GPs and their patients and it is the solution to the myriad of pressures facing practices.
As CCGs take on responsibility for commissioning primary care, of course the national contract will evolve (I envisage much greater local variation and population-based funding), but it is still a vital guarantee of a unity of provision across the NHS.
Increasing unfettered contract variation with wholly local contracts and performance management risks widening variation in income and workload for GPs, as well as health inequalities for patients. The wise way forward is to lobby for a properly funded nationally agreed core ‘offer’ to all practices, with enhanced, locally commissioned services wrapped around practices or localities.
The core offer would cover day-to-day practice appointments, and we are working hard to make sure this gets much more investment. Local enhanced services could include improving care for vulnerable patients, extending access, and funding extra GPs to ease pressure in practices. CCGs already have the ability to do this but are struggling to make the necessary disinvestment in secondary care needed to fund community services.
Problems with the national contract lie not in the system itself, but in how it has been systematically devalued and underfunded by government and used to micromanage GPs. During last year’s contract negotiations we managed to keep out many unworkable and unacceptable proposed elements the Government may have been able to ram through in local deals, on top of reversing much of the imposed contract changes.
Local contracts will have the same centralised diktats from the Government hanging over them, but with no national negotiating structure to support them; CCGs co-commissioning hasn’t been dubbed a ‘poisoned chalice’ for nothing.
By standing together, we can act against the worst excesses of government policy, rather than risk being picked off one area at a time. National protection alongside local flexibility and enhanced investment is our solution. We lose that protection at our peril.
Dr Beth McCarron-Nash is a GPC negotiator and a GP in Cornwall