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The new GP contract

Hard-wired GP

Luke Koupparis

Wednesday, 27 November 2013

contracts_shutterstock_163779683.jpgThe BMA have recently concluded a renegotiation of the GP contract with NHS employers. The changes have been publicised to practices as a move away from the “box-ticking” drudgery that has overwhelmed GPs in recent years. Primary care workload has been increasing significantly over the last decade without increased investment in services. Clare Gerada illustrated this point in her final key note speech that primary care carries out 90% of all NHS contacts, for just 9% of the budget. The RCGP has commissioned two major opinion polls and 85% of GPs feel that primary care is in crisis with more than half stating they can no longer guarantee safe patient care. Many GPs are working 11 hour days with between 40-60 patient contacts in that period.

So will the new contract deliver some much needed resuscitation to a primary care service in the UK that is burdened with this unprecedented demand?

Quality and outcomes framework
The Quality and Outcomes Framework (QOF) will be reduced by 341 points of which 238 will be transferred over into core GP budgets and 103 will be moved over into enhanced services. Some of the indicators that had very little evidence have now been removed and those with unnecessarily frequent testing have been relaxed. Full details of all the changes to QOF are detailed in the further reading links.

The proposed imposition of more stringent threshold changes to many indicators that would have resulted in achievement being progressively more difficult to achieve has been deferred for a year. One can only hope that the GPC team continues to work on this area in subsequent negotiation rounds.

A large portion of work from the Quality and Productivity (QP) area has now been removed completely and many practices will see this as a positive step of reducing items that have resulted in clinicians being taken away from direct clinical care with questionable value to reducing referrals or admissions to hospitals.

Unplanned admissions enhanced service
This enhanced service will be funded through the releasing of 100 QOF points from the QP scheme and £42 million funding from the 2013/14 risk profiling enhanced service (which will be discontinued), making a combined total of approximately £160 million.

This is a significant step closer to an outcomes based contract with the onus on a named clinical lead for vulnerable, high risk patients. Practices will need to provide a quick access telephone number for a number of organisations to enable faster decision making processes. In addition, there is responsibility for the development and monitoring of personalised care plans for any patient who is recently discharged from hospital or deemed to be at high risk of admission. There is a requirement for practices to further enhance their reviews of unplanned admissions and readmissions for this group although the requirement for regular multi-disciplinary case meetings will be removed.

Clearly this will result in additional clinical responsibilities for practices and GPs who will be under greater pressure not only to manage this vulnerable group of patients but begin to coordinate care with other healthcare providers such as community nursing teams. They will be expected to know in more detail who is on the caseloads of community nurses and matrons and be active in managing this list. There is also a risk that secondary care providers may discharge patients from hospital earlier than planned into a case management coordination system. However, without a discussion around capacity and additional investment into community services this may merely overload an already overstretched system.

The BMA has stated that this enhanced service is well resourced and its content reflects the actions that practices can realistically take. However, this is not new investment into primary care and community services and without this there is a risk that many patients will end up being referred back into secondary care.

Seniority payments will be removed over six years, starting in April 2014. During the six years those currently in receipt of seniority payments on 31 March 2014 will continue to receive payments and progress as currently set out in the Statement of Financial Entitlements. All funding released from the seniority pot will be added into core funding.

This is concerning for GP retention where many practitioners are unable to cope with the long hours and workload stresses placed upon them. The loss of this age related pay progression may result in many taking early retirement further compounding the recruitment crisis in general practice.

In answer to the question about whether the latest negotiated contract will bring general practice back from the brink of destruction, many will argue that the impact of increased expectation and workload far exceed any minor contractual changes. The latest changes have reduced some of the box ticking that has been entrenched since the introduction of the new contract, but without significant budgetary shift from secondary to primary care this is merely a reorganisation of deckchairs on a sinking ship.

Further reading

Author's Image

Luke Koupparis

Luke is a general practitioner in the Bristol area with interests in men's health, child health, minor surgery, online education and medical information technology. He is the IT lead for Bristol clinical commissioning group, LMC representative and chair of the locality provider group. He also works as the medical editor to OnMedica helping to deliver high quality, peer reviewed information to the wider medical community. In his spare time he is a keen road cyclist and likes to ski with his children.
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