Helen Jaques: Expect fireworks over the new GP contract

As a seasoned hack, it’s not often that I’m shocked by medical workforce news. The pensions ballot and industrial action by doctors earlier this year was one point—I genuinely didn’t believe doctors would actually go on strike. This week though my jaw completely dropped, and I almost fell off my chair, when I saw the news about the new GP General Medical Services (GMS) contract.

The Department of Health, acting with NHS Employers, has announced plans to impose on GPs its planned changes to the GMS contract in England for 2013-14, having failed to reach a settlement with the BMA’s General Practitioners Committee. Five months of negotiations with the union have been unfruitful, says the department, so it is putting its plans to “consultation” with the General Practitioners Committee and will then either come to a negotiated settlement with the union or implement its proposals regardless of any agreement.

The General Practitioners Committee is unsurprisingly furious with the way the negotiations have, or have not, panned out. Laurence Buckman, chairman of the General Practitioners Committee, said that GPs will be “stunned and angered” that the government is disregarding the negotiations, which, he says, demonstrates its “contempt for the profession and the negotiating process.”

And why have the government and the General Practitioners Committee not been able to reach a negotiated settlement? Because the committee calculates that Department of Health proposals will ask GPs to do more work for less money.

Granted, the proposals seem quite sensible on the face of it. For starters, a contract uplift of 1.5% has been proposed by the department—1% for a GP pay rise, which is what the General Practitioners Committee asked for; and the rest to cover increases in expenses. Sounds fine, so long as you don’t ask too many questions about the rate at which expenses are rising for general practices.

Another perfectly sensible suggestion: increase the thresholds for quality and outcome framework (QOF) indictors. At present too many practices are getting these payments and they’re not genuinely driving improved performance. Why not correct this? Well the government plans to raise thresholds across the board in line with the upper quartile achievement, which will presumably make some indicators, and the cash they provide, completely unattainable for some practices.
QOF indicators under the organisational domain of the framework, which encompasses things like record management and staff training, are also likely to get the boot. Again, sounds fine, because, as Nicola Smith, chair of Milton Keynes Clinical Commissioning Group, says: “It seems reasonable to me to agree to retire those indicators that are nowadays considered to be standard practice.” These indicators represent 15% of QOF though, which equates to £167m worth of cash that GPs will no longer receive.

The money saved by these QOF changes will be funnelled into new local enhanced services (LESs). OK, but not all practices will be able to implement these new LESs, so some GPs will lose cash for good. And once the thresholds for QOF increase some practices might decide not to bother aiming for certain indicators on the basis of their likelihood of meeting the new thresholds, which means patients could miss out on appropriate care.

Core funding for general practices is going to be made more equitable, largely by ditching the Minimum Practice Income Guarantee (MPIG) over a seven year period, starting in April 2014. The MPIG was introduced in 2004 to make sure practices moving to the then new GMS contract had the same basic income levels as before GMS was introduced and could financially stay afloat. However this payment has been described by some as a “bung” and by my colleague rather wittily as “the MPIG that brings home the MBACON,” so getting rid of cash designed to ease the transition to the new contract eight years ago likewise seems sensible.

Add all these things together though and you’ve got a contract that’s asking GPs to do more work to keep their income at the very least stable, and accept a seven year clawback of cash. No wonder the General Practitioners Committee wouldn’t agree to it.

Practices are already “stretched to breaking point,” Buckman says, plus are “struggling under the weight of a wholesale NHS reorganisation.” As well as adding up to a pay cut for GPs, these changes are “bad news for recruitment and retention in general practice, particularly with so many GPs nearing retirement age,” he adds.

If you think the past six months has been a rollercoaster for doctors’ careers, you better be prepared for fireworks over the next six.

Read the full proposals for the GMS contract 2013-14 here and the BMA’s response.

Helen Jaques is acting editor, BMJ Careers.