A King’s Fund/Nuffield paper recently painted a good picture of the variety of contracts currently available alongside some potential innovations1. One of its conclusions was that an ‘alternative contract’ was required to achieve many of the developments.
However, the examples it quoted demonstrate that these innovations are possible with current contracts. Defining another contract with the inevitable resulting delay is not necessary.
Back in 1994, the current chief executive of the King’s Fund Chris Ham described a bright new future for primary care in a previous publication in a chapter entitled ‘The Future of the NHS Reforms’. The effects of the changes were to ‘consolidate the already pivotal position of GPs and primary care teams within the NHS and move resources and services in the direction of primary care’ and writes about the ‘discretion at a local level to negotiate with GPs for the provision of certain services [that] will include not only general medical services as traditionally understood but a wider range of primary and social care’.2
The fact that similar sentiments are reflected in the recent King’s Fund/ Nuffield document shows a consistency on Hams’ part, but is a sad reflection of how difficult it has been to achieve a vision that is now two decades old.
Further meddling with contracts will do nothing but delay the current set of innovators from implementing their collective visions. Current attempts to prune the untidy organic growth of primary care are likely to preserve the middle-ground mainstream at the expense of the innovative frontrunners.
‘Myth of the minimal’
NHS England’s ‘Call for Action’ asks the question, ‘how could the GP contract develop in ways that better support wider NHS objectives?’.3 But the difficulty is that general practice is so often seen as being defined by the GMS contract (covering only 53% of GPs), which views the world through the wrong end of the telescope.
The resulting minimalist view has bedevilled general practice developments. The ‘myth of the minimal’ is demonstrated further in NHS England’s attempt to establish contract baselines. It too makes the error of trying to define general practice according to the lowest common denominator (GMS baselines). But the reality is that PMS practices have been extending the scope of general practice as it was designed to do for some time.
Virtually all PMS schemes deliver extra services. In my area alone we have what we refer to as ‘Premium Key Performance Indicators’ (KPIs) covering quality practice, anti coagulation, urology, sports medicine, audiology, pharmacy liaison, advanced extended hours, Surestart, acupuncture, heart failure, extended dementia services, reaching vulnerable groups, and reaching 24-39 year olds. Other PMS schemes have covered the homeless and other hard to reach groups (services devised for the needs of particular practice populations). They are not primary care ‘add-ons’ so much as extensions.
Hence the concern that retrenching to the GMS core will reduce the boundaries of general practice. We have not waited for national schemes to be defined but have responded to local need. We also have implemented extensions in quality to core GMS requirements, including more stringent targets for vaccinations and several other areas. Again, removing the funding would require a reduction in quality (the tyranny of equitable mediocrity).
There is now an implication that the work of the past decade should be shovelled into a heap and left at the disposal of CCGs, used to meet short term QIPP targets or redistributed to practices that chose not to take the risk of innovating.
GPs’ experience of PMS reviews demonstrates that, even over a three-year timetable, rapid change has the power to destabilise any practice. At a time when general practice should be expanding to fill the secondary care gap, services should be encouraged and extended – but disruption and destabilisation of practices will prevent that development.
The NAPC has always seen PMS as the complementary contract since GMS lost its vision with its head buried in the Red Book. PMS was achieving change, an attempt to lift some of the elements into ‘new GMS’ was seen as the solution, but PMS has undergone attritional attacks in attempts to gravitate it towards a lowest common denominator, which has not moved forward. The recent GPC suggestions that QOF should be trimmed back would suggest that core funding and QOF have now reached Red Book position. As a complement or alternative to the GMS contract, once again PMS offers a workable solution.
Stop this ‘new contract’ talk
We do not need to wait for the golden dawn of an ‘alternative’ GP contract to create and implement a new vision for primary care. We already have the mechanisms and innovative potential to hand already. What we require is reassurance for primary care providers that they can innovate without fear of their contracts being decimated.
All effective primary care developments have arisen from grass roots primary care innovation, not from imposed national models. Let the thousand flowers bloom and this time, don’t cut them back when they appear.
Keep the PMS contract, but insist on development; develop local contracts for GMS practices with equally stringent KPIS and fund it from CCG baselines. Allow practices to develop new models themselves with further models across PMS and GMS. It will then be in the interest of CCGs very rapidly to encourage population-based integrated models of care that save money by reducing admissions and minimising unscheduled care – for instance, community GP services to cover the housebound patient, services to support patients with early dementia at home, LTC support at home properly resourced, seamless cover across general practice and social care.
Enthusiasm from the innovators is already there; PMS practices are ready and willing to take up the challenge. But meddling with contracts is not the answer. Practices, assisted by CCGs and supported by NHS England should now be given the right and the room to create the future.
Dr Peter Smith is a GP in Kingston and vice-president of the National Association of Primary Care
1 Smith, J et al. Securing the future of general practice: new models of primary care. King’s Fund/Nuffield Trust 2013. http://www.nuffieldtrust.org.uk/publications/securing-future-general-practice
2 Ham, C Management and Competition in the New NHS. Radcliffe Medical Press. 1994
3 NHS England Improving general practice – a call to action. 2013. http://www.england.nhs.uk/ourwork/com-dev/igp-cta/