GPs in Scotland have voted for a new GP contract that will change the way that practices are funded and starts the move towards a new pay structure for GPs. Medeconomics explains what the deal means.
Funding and pay
Under the new Scottish GMS contract, GP funding will change in two phases. The recent vote on the contract was on the plans for phase 1, which covers 2018/19 and 2019/20. There will be a second poll on the changes proposed from 2020/21 when plans for this second phase have been finalised (see below for more details).
From April 2018, a new funding formula – the GP Workload Formula – will be introduced. This will replace the existing Scottish Allocation Formula (SAF). This new formula re-estimates the number of consultations per patient based on age, sex and deprivation. GPC Scotland says it more accurately reflects the workload of GPs because it gives greater weight to older patients and deprivation.
The new arrangements will include MPIG and core standard payments (previously QOF payments) in a new consolidated global sum.
The out-of-hours opt-out deduction will end under the new deal. Nationally 6% will be deducted from the 2017/18 global sum prior to the new funding formula being applied. A new opt-in out-of-hours enhanced service will be developed for practices that choose to provide out-of-hours services. Seniority arrangements remain unchanged.
GPC Scotland says no practice will lose out under the deal – practices will be protected from any funding losses and the Scottish government is investing an additional £24m to cover this.
The guarantee to protect GP practice income and expenses continues ‘until there is a proposal acceptable to the profession for the introduction of phase 2’. Any future funding uplifts will apply to all GP practices’ share of the total derived from the new funding formula, including the new income guarantee. Population increases will only apply to the formula sum.
In total, the Scottish government has pledged £100m funding to support the new GMS contract in 2018/19.
As part of the new deal a GP partner whole-time equivalent minimum earnings expectation will be introduced from April 2019. This means that from this date no GP partner should receive less that £80,430 NHS income (including pension contributions) pro-rata. The contract classes a whole-time equivalent GP as working 40 hours a week.
Phase 2 (if agreed) will introduce a standard income range with pay progession for GPs, comparable to that of consultants. See below for more detail.
The GP's role
GPs will continue to run their practices to deliver GP care to their list of patients. However, practices will now be expected to carry less risk compared to previous contracts and be more embedded in the wider health and social care services in their communities.
GPs will play a critical role as expert medical generalists and senior clinical leaders within those services.Training will be available to help support GPs to take on this leadership role.
GPs will focus on three key tasks: undifferentiated presentations, complex care in the community and whole system quality improvement and clinical leadership.
To support this new primary care staff will be employed by NHS boards and attached to practices and clusters.
GP time will be freed up for longer consultations where needed (see workload below)
GP clusters will have a clear role in quality planning, quality improvement and quality assurance.
Instead of the current opt-out arrangement for out of hours a new opt-in enhanced services will be developed for practices that choose to provide out-of-hours services.
There is an agreed principle not to expand the number of enhanced services under the new contract. Locally determined enahnced services will still be agreed between NHS boards and local practices.
Vaccinations will move from GP practices to NHS boards, however the funding previously available for vaccinations will remain with practices.
Every practice will receive pharmacy and prescribing support under the new contract. Additional funding will go twards increasing the number of pharmacist training posts to help achieve this.
Community and treatment care services will provide management of minor injuries, phlebotomy, ear syringing, suture removal and chronic disease monitoring among other services. There will be a three-year transition period to allow the responsibility for providing these services to pass from practices to health and social care partnerships (HSCPs). By April 2021 these services will be commissioned by HSCPs and delivered in collaboration with NHS boards.
Urgent care services will be redesigned to reduce GP workload and free up GP capacity to focus on their new role.This will involve developing more advanced practitioners (nurses or paramedics) who will be first response for home visits. It is likely these practitioners would work across a number of practices.
HSCPs will develop models to embed physiotherapists and musculoskeletal services within practice teams.
Community clinical mental health professionals, based in general practice, will work with individuals and families assessing their mental health needs, providing support for conditions such as low mood, anxiety and depression.
More community link workers will be rolled out in practices - these are non-clinical practitioners who work with patients to help them navigate and engage with wider services.
The Scottish government and Scottish GPC have agreed a National Code of Practice for GP Premises, which sets out how the government will support a shift, over 25 years, to a new model in which GPs will no longer be expected to provide their own premises.
GP partners will be offered interest-free 'GP sustainability loans' worth up to 20% of the 'existing use value' of their premises - even if they are in negative equity, with additional loans from regional NHS boards in exceptional circumstances. These loans will be made available to every partner who owns their premises by 31 March 2023.
The loans will allow partners to release capital without destabilising their practice and reduce the up-front cost of becoming a GP partner. They will be repayable if the premises are sold or no longer used for provision of GP services. The loan will have no effect on notional rent or borrowing cost payments.
The Scottish government plans to end the current model in which many GPs lease premises from private landlords. Regional NHS boards in Scotland will gradually take control of these leases, and will take responsibility for ensuring that GP practices have 'fit-for-purpose accomodation'.
For existing leases due to expire by 1 April 2023, boards are likely to negotiate a new lease for practices' premises naming the board as tenant, or to provide new premises.
For leases expiring after April 2023 boards will take on the existing lease for practices if a series of criteria are met - including suitability of the premises, value for money of the lease, and agreement of the landlord.
All GP practices will transition to new clinical IT systems by 2020. GPs will continue to have the right to choose a clinical IT system from those that have been approved by the government.
The current arrangements for dispensing in Scotland will not change under the proposed new contract.
The challenging behaviour scheme DES will be revised to introduce greater consistency across NHS boards ensuring that practices and staff are protected from patients who have been violent or threatening.
The new contract will clarify how practice areas should be agreed as part of the contract between NHS boards and practices.
Under new regulations around practice list closures if NHS boards have not completed discussions concerning support with practices within three months, a closure notice will be considered as accepted.
The contract will provide a list of certificates which, through primary legislation, GPs are entitled to charge for providing. The regulations will be clear that other work falls outside of the GMS contract.
Phase 2 is still subject to further negotiations between the Scottish government and GPC Scotland, but the agreed direction of travel is towards introducing a standard income range with pay progression for GPs (which is comparable to that of consultants) and direct re-imbursement of practice expenses, covering staff and premises costs.
The current plan is for this to be introduced from April 2020, but any changes would only come into effect if they are backed in another poll of the profession. As mentioned above, the arrangements from phase 1 will continue until phase 2, or another deal, is agreed by the profession.
The changes planned for phase 2 will remove the direct link between the new formula and practice funding. The formula will then be used to guide allocation of primary care resources across the country, but not used to allocate money directly.
The Scottish government and GPC Scotland say that to prepare for this next phase they need to ‘fully understand the current expenses of running a GP practice, the income of salaried GPs and the income of GP partners as well as the hours worked by individual GPs' so that they can establish the total cost of introducing a consultant comparable income scale for GPs. All practices will be required to provide data on earnings, expenses and hours/sessions worked to NHS National Services Scotland Practitioner Services to enable this to happen.