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Time to tear up GPs’ UK-wide contract

Scottish GPs work in a fundamentally different health service to their English counterparts' market-based system, says Dr David Bell, and they deserve their own contract.

We are living in interesting times. GPs have reputedly got a single UK contract, but it certainly doesn't seem like that when I – as a Scottish GP – am talking to an English one. I honestly feel I have more in common with friends who are GPs in Holland or Denmark. I'm sure the same could be said even more emphatically (and probably with an even stronger accent) by a GP from Northern Ireland.

Why do I say this? The whole context is different. The health service in Scotland remains united, sees patient care as central and rejects a market vision.

It has been said to me, and it was meant as more of an insult than as praise, that Scotland remains a basically socialist country. I take that as a compliment, as I read it as saying that we care what happens to our folk, and don't think about money first.

Scotland has no real truck with private medicine; APMS is not allowed. There is no market in healthcare as health boards keep primary and secondary care working together, and we actually speak to each other. Some of my best friends are consultants.

For these reasons alone I believe that there is a de facto separate contract already – and that there will be an actual, explicitly separate, contract soon. And that is why I will be making the case for a separate contract at the Scottish LMCs conference this week.

So what do I think this contract would look like? Well, if I've anything to do with it, what it won't be is anything like a market economy. The waste created by fundholding was to some extent overcome by the benefits, but setting primary and secondary care against each other is largely counterproductive.

The plans for GP commissioning in England have their strengths, but the opportunity costs are high. I want to free up GPs to treat their patients fairly and equally with as little bureaucratic supervision as we can get away with.

Remember the mantra in 2004: ‘High trust, low bureaucracy'? I happen to think that it is possible (although perhaps accountants and auditors won't agree).

It would not be so different from where we are now, perhaps similar to the best 17c (or in England, PMS) contracts, with a specified list of outcomes, freedom to work in a way that makes local sense, but with a nationally agreed set of evidence-based measures like the best bits of the QOF, designed for patient benefit.

I cannot see that this is too difficult.

I am not discounting the amount of hard work and hard-headed negotiation that would be required upfront to safeguard income and so on, but I do believe that a country of 5m is the right size to make it happen. This might appear to be a daft time to be looking at structural change, but what's new?

We need to get back to using clinically relevant measures of performance that tell us how we are doing in comparison with our peers.

This has been repeatedly shown to be one of the most potent ways of modifying GP behaviour, and we should go back to it as a way of influencing clinical practice.

There would be a need for financial auditing; no modern system could be imagined without it. It would be very possible for this to be done as part of the routine work of the practice. Anonymised data would be used, of course.

Freeing up GPs and practice staff from the present round of accountability would foster a professionalism that I fear is becoming lost, and creating such a Scottish contract could demonstrate to the whole of the UK that trusting us to do our job is more effective than micromanagement.

Dr David Bell is secretary of Grampian LMC and a recently retired GP in Aberdeen.

Dr David Bell


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