Do GPs deserve their recent pay rise?

Health ministers and NHS staff often complain that the media rarely cover any good news about the NHS. The new GP contract, with its quality and outcomes framework, is an exception to the rule.

It is, of course, true that the odd headline about “fat cat” GPs did appear after last month's news that family doctors across the United Kingdom had achieved 90% of the maximum 1050 points for hitting the wide range of targets for care and access set out in the new contract. The new contract was intended to deliver something in the region of a 30% pay rise for family doctors over three years. The quality and outcomes framework was an important part of that. It looks to have more than delivered.

But even a national newspaper such as the Daily Express (Sep 1:2)—not instinctively sympathetic to the NHS—opened its story with the words “most family doctors are providing their patients with a high quality of care that beats expectations.” Local newspapers went further. “Sutton surgeries receive top marks,” declared the Sutton Coldfield Observer (Sep 2:16). “Triumph,” said the Huddersfield Examiner (Sep 1:9).

If there was local excitement, there is international interest too. Healthcare systems around the world are looking for ways to drive up quality. Sheila Leatherman, an executive vice president with the US based United Healthcare group and a member of President Clinton's Commission on Health Care Quality, has described the UK's attempts to do that—not just through the new GP contract but through the National Institute for Health and Clinical Excellence, the national service frameworks, the National Patient Safety Agency, and other measures—as the most ambitious in the world. A mechanism that works, and one that shows without any doubt that GPs respond to financial incentives to improve the quality of care, not just its volume, will be generally welcomed, not least because the new contract potentially provides a database on chronic disease that will underpin research and allow services to be much better targeted.

“Sutton surgeries receive top marks”

(Sutton Coldfield Observer)

Of course, from the point of view of NHS finance officers some news was rather less good, at least in the short term. When the contract was signed it was expected that GPs would, on average, achieve around 75% of the maximum score. The better than expected performance has cost primary care trusts in England around £200m ($352m; €295m) more than planned, and spending in the rest of the UK has been, relative to the population, even higher.

But against that the health department appears to have learnt the lesson of the last serious attempt to use contractual approaches to raise standards: the NHS dental contract of the early 1990s. That was meant to replace “drill and fill” with a more preventive approach. Dentists outperformed, earning far more than expected. The government of the day tried to claw the money back. The result was the wide-spread collapse of NHS dentistry, as disillusioned dentists quit for the private sector.

That risk is lower in general practice, where, unlike in NHS dentistry, there is no tradition of patients paying. But the signs so far are that ministers do not intend to repeat the mistake of their Conservative predecessors. They seem to be looking to take the contract forward, not reclaim the cash.

But although the GPs' scores are good, they are in practice only the earliest and first test of the new approach. The clinical standards in areas such as asthma, diabetes, heart disease, and chronic obstructive pulmonary disease were selected because it was judged that in these areas the evidence was good that better care in the community would produce better health outcomes.

The data are still being tested for that. Mike Farrar, chief executive of the West Yorkshire Strategic Health Authority and one of the lead NHS negotiators for the original contract, said that early figures emerging in Birmingham and the Black Country and in Hertfordshire and Bedfordshire show that hospital attendances among patients in the target groups have fallen.

How far hospital attendances fall and how widely the falls occur will be an important test of whether this new approach does actually deliver the goods: better care in the community, a reduced load on hospitals, improved outcomes, and higher satisfaction for patients.

Criticisms remain. Some commentators feel that other and better standards might have been chosen. Others point out that the targets have, unsurprisingly, proved easier to achieve in the leafy suburbs than in the areas where health inequalities are worst.

And the spectacularly high scores do raise the question of whether the targets were pitched too low, in other words that the exercise was too easy. The answer almost certainly has to be yes. The Daily Express made this point under the headline “Doctors get 20% pay rise just for doing their jobs” (Sep 27:2).

Hospital attendances among patients in the target groups have fallen

But that, as a criticism, is itself too easy. It was always going to be hard to place the hurdle at just the right height the first time around. And the deal was always intended to be an iterative process: what is counted in and what is rewarded will change over time, and work is already under way to revise it.

How effectively the framework evolves—as well as showing that hitting the standards has indeed produced the expected improvement in care—will, in the end, be the acid test of this initiative. GPs' professionalism will have to be played off against their financial self interest. It won't work if every change is accompanied by a new demand for extra payment. What was once innovative will have to become routine—just part of what a good practice provides—and financial incentives will need to be moved to new areas to stimulate further improvements in care.

Negotiating such moves will not be simple. If it is achieved, the new contract will be rated as ground breaking, not just in the UK but internationally. If it is not, it will go down in history as a mighty one-off pay rise that delivered only a distinctly limited gain, rather than continuous improvement.