A fresh new contract for general practitioners

The imposition of the 1990 contract by Kenneth Clarke was a blow from which professional morale among general practitioners has never really recovered. For many general practitioners it marked the end of a golden age. The “Red Book” has long been criticised as bureaucratic and inflexible, and the launch of personal medical services pilots in 1998 was an acknowledgment of the need for change. Currently, allocation of resources only poorly reflects patients' needs; the contract is highly focused on the individual practitioner and fails to recognise adequately the role of the practice team; quality measures are sparse and crudely applied; and perverse incentives often serve to reward poor quality services. A recent BMA survey exposed high levels of stress, poor morale, and planned early retirement or exit from the profession.¹ The proposals for a new national contract, announced on 19 April jointly by the NHS confederation and the British Medical Association, mark an important departure.²,³ A new weighted capitation formula will replace the work of the recently abolished medical practices committee. Crucially, the national pricing of the contract will take into account the changing demands on primary care through an annual assessment of workload. If workload rises, new resources will be made available—a major victory for the profession's negotiators.

The new contract will be between a primary care organisation and a practice (rather than with an individual doctor), and services will be categorised as either essential, additional, or enhanced. All general practitioners must provide essential services, envisaged as a tightly defined core, but can reduce some of their current commitments. In particular, an opt out for out of hours care will be introduced, and in future these services will be managed through NHS Direct.⁴ Primary care organisations will have new responsibilities to commission alternative providers (not all of whom will be doctors) to fill any gaps created.

Conversely, those doctors who wish to will be able to offer enhanced services for extra pay. Some of these services will be nationally specified and priced; others will be open to local agreement. An expenditure floor will ensure that resources are available and not diverted to meet other priorities. A new quality and outcomes framework will cover standards to measure clinical and organisational quality and also patients' experiences. Thus, in part, doctors' pay may depend on the surveyed views of their patients.

So how well does the proposed new contract address the concerns of general practitioners? In future, general practitioners should be better able to control their workload and trade leisure for income. Importantly, the new contract proposes significant changes to the incentives facing general practitioners. Quality of care is likely to be a more powerful motivator than it has proved in the past. The perverse incentive for general practitioners to manage large lists with a limited range of services should reduce.

Shifting the contract from individual practitioners to practices introduces new incentives to make greater use of non-medical staff (under current arrangements, many payments are linked to the existence of a general practitioner). In addition, practices may become larger, with subspecialisation among general practitioners. Of course, the prospect of a practice based contract also raises questions about the nature of the contracting organisations, opening the door to new entities, including private limited companies, which have been tentatively tested under personal medical services.

The new capitation formula should be welcome for deprived areas because funding will be delivered regardless of whether general practitioners are already in post. Currently, many deprived areas are denied resources because enough general practitioners cannot be recruited.

The proposed new contract seems to offer much to general practice and to patients—but there are risks attached. All incentives systems encourage gaming. General practitioners will inevitably concentrate on those quality targets that have been specified, at the expense of others. Whether the right standards have been incorporated into the new quality and outcomes framework will be disputed.

By clearly specifying general medical services for the first time the government risks paying for services it currently receives for free. Primary care organisations, too, face risks. The evidence from pilots of personal medical services suggests that active commissioning of primary care requires considerable managerial capacity.⁵ Yet primary care organisations are organisationally immature and overburdened.

The new contract raises important questions about the future for British primary care. Patients may receive services from their own registered practice, from another practice, from staff employed by primary care trusts, or from others such as community pharmacists. In addition, the linkage between daytime and out of hours services seems set to break forever, and domiciliary general practice visiting may be contracted out to a separate organisation. The traditional general practitioner will no longer be the only hub around which primary care revolves.

The negotiators have made much progress and have dealt with many of the profession's concerns, but the nature of the longitudinal relationship between patient and general practitioner, an admired hallmark of the British system, will change.⁶ This ultimately may be the most important consequence of the new contract.