The GP Contract

The Road To Here And Beyond

Why the GMS contract had to change• Red Book was ‘John Wayne’ contract

without boundaries• OOH responsibility• Erosion of pay against a pool• Complexity of contractual arrangements• Worsening recruitment/retention within the

profession• Increased use of local PMS contract

nGMS• OOH opt-out of responsibility• Defined core services• ‘No new work without new money’• An explicit pay rise

– to compensate for the unresourced work transferred to General Practice over the previous 15 years

– to encourage recruitment and retention

• Pensionability of all NHS/government work• The end of the GMS/PMS monopoly

Potential problems with nGMS

• Definition of core services• Initial deliberate de-funding of global sum

– Excessive ratio of QOF to global sum

• Inadequate funding of global sum• Still too much discretion for PCOs• Government’s right to alter contract

unilaterally

GMS contract 2006/07

• No increase in global sum• New work and funding delivered through

DESs• New areas of QOF work introduced• Governments’ perception of over-

performance and value for money addressed ‘once and for all’

GMS contract 2007/08

• DDRB recommends ‘0% pay increase’• DoH interprets this as no resource increase

for general practice

2007 – the press campaign

• Constant criticism of GP pay, hours and access

• Linked erroneously with failure of out-of-hours care across the country

• The ‘extended hours debate’• Consistent with political views of all parties

2008-9: The GPC/NHSE negotiated compromise never agreed by NHSE (1)• Funding from Access and C&B DES plus

£11m from Patient Survey to fund extended hours-total £158m– Similar level of funding in Devolved Administrations

• Extended hours - 20 minutes per 1,000 patients– 15 minutes appointments and 5 minutes admin – Flexibly provided and voluntary participation

2008-9: The GPC/NHSE negotiated compromise never agreed by NHSE (2)• Patient survey to determine ‘convenient

access’ using 20 QOF points• Redistribution of 38.5 QOF points to

osteoporosis, PVD, new heart failure indicator and additional points for CKD, small increase in lower QOF thresholds

• Would deliver if reasonable new resources introduced into the contract via DDRB award

2008-9 negotiations process

• NHS Employers, after interference from government, rejected negotiated compromise

• Presented a new (non-negotiated) proposal with worse terms (Imposition A)

• Told GPC to accept Government offer (Imposition A) or a more draconian contract would be imposed (Imposition B)

• GPC negotiators sought the view of GPC• GPC voted not to accept this offer under blackmail

and to consult profession democratically

2008-9: The Government “offer”(Imposition A)• Funding from Access and C&B DES

recycled for extended hours (£158 million = £2.95/patient)

• Extended hours– 30 minutes per 1,000 patients– In 1.5 hour blocks at evenings / weekends– Average 9 appointments per 2 hours– Timings related to patient preference from GP Patient

Survey Results - Saturday morning as default– No concurrence of GP time and GP only appointments

2008-9: The Government “offer”(Imposition A)• Diverts 58.5 QOF points to support access

arrangements • Payment dependent in part on patient survey

results• No new QOF clinical work, thresholds remain

unchanged• Cost of not doing extended hours ~ £6000 per

GP• Guaranteed uplift 1.5% (£100m) in event of

DDRB award for GPs being less – but via yet to be defined new DES

2008-9: The GPC response

• GPC voted not to accept (but did not reject) government offer and to seek the profession’s views because– It was not prepared to accept a deal under threat of

imposition– Opposed to diversion of funds from quality to non-

evidence-based access imperative – Criteria for extended hours DES more onerous-financially

viable for the money on offer?– The 1.5% uplift has too many strings and would require

new work to earn it– Wanted to consult profession in the wider context of

government reforms before proceeding

2008-9: The imposition (B) in England• Funding from Access and C&B DES for extended

hours (£158 million = £2.95/patient) passed to PCOs• Extended hours - terms will be under local PCO

control• QOF 135 points removed and money passed to PCOs• QOF lower and upper thresholds increased by up to

20%• Moves funds from nGMS to local PCO control and

could be used to fund “Darzi” health centres, polyclinics, APMS

2008-9: The Imposition (B) in England

• Diminished value of nGMS unlikely to be reversed

• Diverts funds from quality clinical care to political targets

• Led by No10 and Treasury• Financial loss to average GP £12,000 plus

higher QOF thresholds

What happens next?

• Government believe unilateral change requires 13 weeks ‘consultation’

• Clarification on final offer sought• Poll of GPs’ opinion in mid-February• Imposition B on 1st April 2008 if Imposition

A not accepted

Issues to consider

• More than an issue about extended hours• Profession should view in widest terms • Move towards privatisation• Reality of APMS, Darzi as competitors to G/PMS• Government ignoring views of majority of patients

to deliver own political agenda• Government’s method of negotiation• Profession faced with two ‘imposed’ options

– Extended hours remain voluntary in both options, financial penalty much greater under imposition B

Choices to be made

• Imposition A• Imposition B

• Implications of voting- neither acceptable but must consider what’s best for the profession, patients and longer term future of General Practice

Choice 1: Imposition A

• Financial blow less severe than Imposition B• Retains current level of QOF and DES

funding (prevents passing this to local PCO control which could fund APMS, Darzi centres)

• Retains current value of nGMS and national negotiations

• Providing extended hours (at £2.95/patient) is voluntary and more affordable to “opt out” of DES than imposition B

Choice 1: Imposition A (2)

• QOF will remain at 1000 points, and thresholds unchanged – although access targets could be harder to earn in full

• Government spin about victory would have to be pre-empted and challenged

• A possible precedent for future but will depend on success of our PR battle in coming year

Choice 2: Imposition B

• May instinctively feel right, however…• Greater loss of income from practice

– 135 QOF points lost to local PCO control, initially 75 available to earn back in coming year.

– Increased QOF thresholds– Access and C&B DES monies (£2.95) move to

local PCO control for extended hours– GPs may feel under more pressure to do

extended hours with possible worse PCO deals than Imposition A

Imposition B - consequences

• Will weaken negotiating power– if significant number of GPs do extended hours under

imposition B (very possible)

• Hands significant nGMS funding to PCOs to potentially fund competitor APMS/Darzi health centres/polyclinics

• Undermines future national negotiations / GPC role due to reduction in value nGMS –135 QOF point reduction, loss of £158m DES funding, probably irreversible.

Imposition B – consequences (2)• GP income dependent on local PCO deals• Could open the door for future impositions• Public relations concerns

– Unlikely to win extended hours debate in media– Standing up to government bullying or a political victory

for no. 10??

What we must do either way

• Avoid action which adversely affects patient care

• GPs must respond by being united• Reconsider participation in government

initiatives• Continue with campaign to highlight English

Government’s agenda for primary care– Inform patients– Lobby MPs– Mount coordinated PR campaign (GPC has set up

communications group)– Our patients as allies in our campaign

What to do now

• Study both impositions• Consider long-term implications – this is

not just about extended hours• Talk to partners, colleagues and the LMC• Read messages from GPC• Remain united against wider Remain united against wider

government agendagovernment agenda• Vote when the poll is heldVote when the poll is held