Mary McCarthy: Are GPs doing “penance” for the 2004 contract?

mary_mccarthyRecently, Jeremy Hunt said that GPs are undergoing penance for the 2004 contract. To quote, he said: “Labour signed a disastrous contract in 2003 and since then, in penance really, the NHS has not really wanted to put extra money into general practice and it been has starved of resources progressively.”

Is he really saying that general practice has been deliberately starved of resources because GPs achieved more than they were expected to in the years following the new General Medical Services contract for general practice? And if he really believes that GPs and their patients are being punished for a decision a government made 10 years ago, why hasn’t Hunt, as secretary of state for health, done something about it?

The 2004 contract was decided at a time when GPs, as now, were overloaded with a demand that seemed incapable of being quenched. One factor that seemed possible to solve was the provision of out of hours cover. GPs had already realised that the system needed changing and in many areas practices were buddying up to cover larger groups of patients. Some areas, mine included, were beginning to form doctors’ co-operatives where a central triage system, staffed by experienced clinicians, sorted out weekend and evening problems, mostly by telephone advice but sometimes with a visit to a base surgery or with a home visit by a doctor.

Because these systems were doctor heavy, the ambulance call-out rate after a clinical problem was very low—in my area around 3% of encounters ended with an ambulance trip to A&E or a hospital admission. This was effective in managing bed occupancy in local hospitals and in reducing the need for expensive ambulance transfers.

The 2004 contract offered GPs the chance to opt out of out of hours cover and, not surprisingly, a lot of GPs voted for this. The contract also offered a voluntary Quality and Outcomes Framework (QOF) scheme, which aimed to financially reward doctors who achieved predetermined clinical targets. This was truly a “payment by results” project, unlike the secondary care scheme, which is really “payment by activity.”

The government thought that not all doctors would want to take part in this scheme, which would involve more work, and also estimated that about 50% of the proposed targets would be achieved. This assumption proved to be false, as the BMA had warned the government it would be. The BMA pointed out that most GPs were treating their patients with chronic disease to a high standard of care and that the targets were, in most practices, already being reached.

The government was sure its assessment was correct and it was only when the figures started to come in, a year or two later, that it realised it had promised to pay GPs for clinical targets that 90% of them were reaching. The result was that general practice received an injection of funds, which compensated for the years when the money going in had been almost static.

This is the decision that the health secretary is referring to when he tries to explain the restricted funds into general practice by saying that GPs are doing penance for the 2004 contract. Does he realise that it is also the patients who are doing penance, with long waiting times for appointments? Or that it is increasingly difficult to attract young GPs into the profession because they see it as an increased workload—with consultations up from 300 million a year to nearer 370 million a year—with decreased funding?

The proportion of the NHS budget going to general practice has dropped from 10% in 2004 to 7.4% in 2013 and practices are closing because they are financially unviable.
In all established health economies, general practice is seen as the foundation stone.
If the base of general practice is continually chipped away at by restricted funds, bureaucratic barriers to good practice,vilification in the media, and—indeed—by the government, then the whole edifice of healthcare becomes unstable.

An American professor of medicine told me that general practice in the US is defunct and that he thought it could never be revived. We do not want to have the problems of the US’s health system so we need to support and nourish the system we have.

The UK’s general practice system of personal care and clinical continuity used to be copied all over Europe. Now colleagues in Europe tell me that they look to the NHS to try and avoid the mistakes we are making. General practice is the sturdy base of a functioning health service. So will the government please support it?

Mary McCarthy has been a GP, based in Shropshire, for 30 years. She is also a hospital practitioner in diabetes and has the following roles too: elected representative for Shropshire, North Staffs, and South Staffs on the BMA General Practitioners Committee; BMA head of delegation to UEMO (European GP Group); and a fellow of the Royal College of General Practitioners (RCGP) and board member of its Midland Faculty.

Competing interests: The author has no further relevant interests to declare.