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Contract for GPs in England “failed to live up to expectations,” say MPs

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a2025 (Published 09 October 2008) Cite this as: BMJ 2008;337:a2025
  1. Zosia Kmietowicz
  1. 1London

    England’s spending watchdog has delivered a damning assessment of the government’s attempts to modernise primary care through the new GPs’ contract, which came into effect in April 2004.

    Costing £1.8bn (€2.3bn; $3.2m) more than predicted in its first three years, says the Public Accounts Committee, the contract fully achieved just one of its objectives: to attract more doctors into general practice. Since March 2003 an additional 4098 GPs have been working in primary care, an increase of 15%.

    But productivity in general practice has fallen by an average of 2.5% a year since the contract was launched, rather than increase by the expected 1.5%. And patients in deprived areas continue to struggle to access GP services, despite this being one of the goals heralded by the BMA as a top priority in its lengthy negotiations with the Department of Health over the new deal for GPs.

    The committee’s report acknowledges that some progress has been made in linking GPs’ pay to performance. It is critical, however, of the quality and outcomes frameworks (QOF) system, developed to measure performance. With targets set too low it was simply too easy for GPs to achieve high scores, resulting in additional unexpected costs for the government.

    Edward Leigh, the committee’s chairman, said, “The new contract for GPs in England, intended to deliver benefits by linking GPs’ pay to their clinical performance, has so far failed to live up to expectations.

    “Partners in GP practices are now putting in less time, and their productivity has decreased. Only their pay is burgeoning, having increased on average by an eye watering 58% since 2003 [from £73 000 in 2002-3 to £114 000 in 2005-6].” It was originally expected that partners’ pay would increase by 15%.

    However, the report says that some GPs and other primary care staff have had only small pay rises while taking on a larger share of the workload. Pay for salaried GPs, for example, rose by just 3% from 2003 to 2006.

    The report also criticises the fact that patients are still having problems seeing a GP. Mr Leigh said, “The new contract has not led to general practices being opened longer or at more convenient times for patients and has failed to improve services for deprived areas. Recent improvements in opening hours have been paid for out of additional money.”

    For its report the committee took evidence from witnesses, the health department, and the NHS to examine how the contract was negotiated, its cost, and the extent to which the expected benefits for patients and the NHS are being realised.

    Partly to blame for the lack of improvement in GPs’ services are primary care trusts, the report says, very few of which have exercised their right to negotiate with GPs the range of enhanced services they should be providing to meet the needs of the local population. Over half of the trusts have not “spent to even the minimum level set by the Department for enhanced services,” and improved expertise in commissioning is badly needed in trusts, the report says. Commenting on the report Laurence Buckman, chairman of the BMA’s General Practitioners Committee, said, “The GP contract is now quite different to the deal originally agreed in 2003 and much of the criticism in this report is based on an out of date understanding of the current situation.”

    In the report MPs called on the Department of Health to consider replacing the minimum practice income guarantee (MPIG), the needs based funding formula that is intended to reduce inequality in service provision, with a redesigned global sum allocation to move more money into areas of greatest need.

    However, Dr Buckman said that the minimum practice income guarantee was already being phased out. “We want to reduce practices’ reliance on MPIG and create a fairer system, but if it’s done too quickly it will damage practices and the services they provide for patients,” he added.

    Dr Buckman also said that general practices have taken on additional work since the original contract was agreed.

    The main reason for the high extra cost of the new contract was that the Department of Health had underestimated the cost of out of hours care, he said. “It also didn’t listen to the doctors who told them GPs would hit the vast majority of the targets [in the quality and outcomes framework (QOF)].”

    “Hitting these targets has been good for patient care. As a result of the QOF more conditions are being diagnosed and controlled earlier, patients’ quality of life is improving, hospital admissions are reduced, and ultimately deaths are prevented,” said Dr Buckman.

    The BMA also challenges the suggestion that GPs’ “productivity” has decreased, claiming that the way it has been measured does not take account of the more complex consultations and the intensity of the work that GPs deal with.

    Steve Barnett, chief executive of the NHS Confederation, which represents more than 95% of NHS organisations, said, “The new contract brought radical change and, for the first time, linked improvements in patient care to reward GPs in new and innovative ways. While it has taken a while for the contract to become established, we have made substantial progress and patients are seeing the benefits.

    “In 2006, we made significant changes to the contract and this resulted in substantial financial savings and improved patient services. In addition, earlier this year, we provided incentives for practices to provide additional appointment times which increased access for patients.”

    David Stout, director of the Primary Care Trust Network, which represents most primary care trusts (PCTs), acknowledged that trusts needed to improve the way they used the contract to meet local needs. “Having achieved financial and organisational stability, PCTs are in a position to address some of the critiques of the report.

    “They are now setting up long term plans to address the health needs of local people. The GP contract is one very useful tool in helping them do this.”

    Notes

    Cite this as: BMJ 2008;337:a2025

    Footnotes

    • NHS Modernisation: New Contracts for General Practice Services in England can be seen at www.parliament.uk.