The July 2010 white paper 'Liberating the NHS', which trailed many of the changes introduced under the Health and Social Care Act, seemed to herald a major reform of GP contracts in England. It promised a move to a ‘single contractual and funding model’ for general practice, signalling the end of the existing mixed economy of PMS, GMS and APMS deals.
Perhaps more significantly, the white paper promised to ‘support free patient choice and remove unnecessary barriers to new provision’.
It was widely predicted that the single contract would resemble APMS, open not just to the doctors and nurses who make up the ‘NHS family’, but also to private providers.
Plans to remove barriers to new provision were also interpreted as meaning practice boundaries would be scrapped, with time-limited contracts replacing the contracts-for-life that current practices generally enjoy.
But experts now say such fundamental reforms are unlikely to go ahead in the current parliament.
NHS Alliance GMS/PMS lead Dr David Jenner says: ‘Major contractual change is not immediately on the agenda – there is no sense that will happen before the next election.’
NHS reforms depend on stable practices
Clinical commissioning groups (CCGs) are ‘dependent on GP engagement’ Dr Jenner argues, and the DH is wary of destabilising practices just as clinical commissioning beds in.
A Conservative election victory in 2015 could see an emboldened administration press ahead with a GP contract overhaul, he says. But in the event of a Labour victory, he believes a major contract reform is less likely, given recent pledges from shadow health secretary Andy Burnham to repeal parts of the Health Act that relate to fostering a market-based approach to the NHS.
Another factor that complicates contract reform at this stage is that, unlike in 2004 when the new GMS contract took effect, there is very little money around to sugar the pill.
The BMA has argued for contract changes on a ‘rising tide’ basis – meaning all practices see a rise in income, but some more than others. In times of financial constraint, any reforms are likely to be redistributive, creating losers as well as winners.
However, even if fundamental contract reform looks like it is off the agenda for now, contract changes are happening – and for some practices these have been and will be as fundamental as any national reform.
The hunt for £20bn in efficiency savings across the NHS has driven up pressure on PMS contracts in particular. PCTs have sought to move locally-negotiated PMS contracts closer to the terms of the national GMS deal.
Some practices have suffered six-figure cuts in annual income as PCTs cut back PMS funding to match average GMS funding per patient.
Senior GPs are convinced that when the NHS Commissioning Board (NHSCB) takes over from PCTs as the holder of both GMS and PMS contracts, this process of bringing the two streams closer together will accelerate.
In fact, Dame Barbara Hakin, commissioning development lead at the NHSCB, admits it is working ‘to ensure fairness for practices on GMS and PMS’, and that it will be ‘an advantage that all the contracts will be held by one organisation’.
So, strangely, general practice is moving closer to a single contract although the white paper reforms have been shelved for the time being.
Wessex LMCs chief executive Dr Nigel Watson says: ‘Early on we thought we might move to a single contract. But after PMS reviews in a lot of areas, PMS looks remarkably similar to GMS.
‘In a lot of areas when they looked there was a lot of commonality between the two – in some areas they gave extra money to employ extra doctors or nurses, but in our area few practices were offering services above and beyond GMS.
‘So I don’t think at the moment there appears to be a need to negotiate a new contract.’
Impact of CCGs
GMS practices have not escaped the effects of austerity – income at all practices has fallen too as enhanced services have been slashed in recent years, compounding the effects of repeated pay freezes.
But from 2013, CCGs will be able to commission these services in England. If CCGs are willing and able to use this freedom to build general practice and support the shift of work out of hospitals into primary care, this could yet prove the most important aspect of contract change in the coming years.
Dr Watson says that ‘the intensity and complexity of what we are doing is not reflected in the price of the core contract’.
Rising expenses and the likelihood of a public sector pay freeze continuing for the foreseeable future mean that enhanced services investment could be the only potential source of funding to tackle this.
It has been suggested that there should be separate negotiations of the GMS contract in each of the four countries. However, earlier this year Scottish LMCs rejected a bid to negotaite a seaprate contract with the Scottish government. Instead GP leaders decided to continue to support the 'tartinisation of a UK GP contract ratehr than a wholly Scottish contract'.
GPC Scotland chairman Dr Alan McDevitt has said that the BMA believes the UK contract 'is sufficiently flexible to accommodate the Scottish differences'.
'Most enhanced services are negotiated and agreed separately in Scotland and reflect Scottish priorities and there is no point reinventing the evidence base for clinical indicators in the quality framework which are the same for every GP and patient wherever they live and work in the UK,' he said.
Other changes that could yet come before the next parliament include further moves to tie practice contracts in England to CCGs’ agendas. Meanwhile, the QOF is likely to see further points diverted to targets like the ‘quality and productivity’ ones introduced in 2012.
Pay-wise, contract negotiations will involve the GPC arguing for an uplift to combat rising expenses and allow GPs to maintain their income rather than seeing it continue to fall. The government will likely demand any ‘rise’ comes in part from an efficiency gain as in previous years.
So ultimately, although blockbuster contract reforms are on ice, GPs can expect turbulent times. Plus ça change.