Rapid Responses to:

EDITORIALS: Richard Lewis and Stephen Gillam A fresh new contract for general practitioners BMJ 2002; 324: 1048-1049 [Full text]

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Rapid Responses published:

New Contract seems stale not fresh

Mark Oliver, Stafford ST16 3AT   (4 May 2002)

New GP Contract

James P Bell   (4 May 2002)

The failings of the new GP contract

Prit Buttar   (4 May 2002)

GP contract does not address real concerns

Anthony B Lamb   (4 May 2002)

New contract will make rural GPs'lives even harder

G Rhys   (5 May 2002)

Problems with the GP Contract

Stephen J Shepherd   (5 May 2002)

I salute the King's Fund

Ahmad Risk   (5 May 2002)

Editorial contradictory and incomplete

Trefor J Roscoe   (6 May 2002)

Conflict of interests in the new "contract"

Martin J Heath   (6 May 2002)

new gp cpntract

Mark C Rogers   (6 May 2002)

A triumph of hope over experience?

Janet Menage   (6 May 2002)

Think again on contract

Paul Attwood   (6 May 2002)

Naivety of the negotiators

Tony le Vann   (6 May 2002)

Proposed new GP contract

Jeremy R Paterson, Braintree Essex CM7 9BY   (6 May 2002)

Impossible situation for GPs

James Cave   (6 May 2002)

GP Contract

Stephen Jerrett   (6 May 2002)

A few more tweaks required.

William R.G. Hynds   (6 May 2002)

Proposed new contract

david baker   (7 May 2002)

Counting beans

Craig A McArthur   (7 May 2002)

New Con-trick

John A Glasspool   (7 May 2002)

GPs need a contract with their Patients, not this!

Robin N Barber   (8 May 2002)

Ive Bought a New Car to Celebrate the Proposed New GP Contract

Simon M Fellerman   (8 May 2002)

Volte face by the GPC

G Michael Leuty   (10 May 2002)

Contract proposals are fatally flawed.

Peter Davies   (14 May 2002)

Anxieties about new contract proposal

Michael J Curry   (14 May 2002)

All roads lead to Private Practice

Trevor Alan Underwood   (16 May 2002)

Patient demands

John R harrison   (16 May 2002)

The proposed GMS contract: requesting decisions without key facts

Brian A. Ferguson   (26 May 2002)

Encouragement for GPC but Humility please

David B Rance   (26 May 2002)

Proposed New GP Contract

Andrew I Williams   (28 May 2002)

one more voice for the chorus of disapproval

dougal j jeffries   (4 June 2002)

New Contract seems stale not fresh 4 May 2002
Mark Oliver, GP Browning Street Surgery, Stafford ST16 3AT Send response to journal: Re: New Contract seems stale not fresh	My impression of the new contract is that elements resembling NSFs will be incorporated into a new system of data collection with 5 levels, turning the doctor into a data processor.I am not sure of my future pay.I am certain my workload will rise.GPs will remain the only group in the NHS who will not have pensions accurately reflecting earnings.Allocation of patients to practices remains unresolved.The contract is still able to be unilaterally altered by the government after 12 weeks consultation. A redistribution of resources between practices is planned with no guarantee of current income. Seniority payments are to change but how? Negotiations continue on funding flows, but what will result.The talk is of quality replacing capitation but how will GPs be retained or recruited in areas where patients are uninterested in being compliant with government plans, or rural areas when dispensing has gone and out of hours remains ? Practices will be able to withdraw from providing some services after a notice period of 3 to 9 months if the PCO can find an alternative.At 9 months the Strategic HA may prevent shedding of work if “one of the parties has not pursued the process properly”. Immunisation targets remain with no concession on MMR.Paragraph 28 envisages a shift of hospital services into some general practices. Loss of out of hours is a sweetener for some, but we do not know the resulting loss of income, so do not know if it's practical.Contingency plans must be in place however. Will a rescue be compulsory for local GPs? In “rural, remote and specific geographical circumstances” (para 36) there may be no alternative OOH provision.Home visits remain only potentially resolved by a home visiting service, but run by who? Extraordinarily, para 48 contains reference to the government preventing charging for some non-NHS services! The quality and outcome payments outlined in paras 50 to 63 are Kafkaesque in complexity, threatening practices with a system where they have to run faster every two years or lose money, collect data on a massive scale, produce an annual return, and endure a one to three yearly PCO visit at which all clinicians and the practice manager must attend. This is described as a high trust, low bureaucracy system! Targets are set for number and frequency of invitations, blood tests, and drug therapy with time limits set for risk factor control.Acceptable excuses are detailed, but presumably each case will have to be documented and explained. Appraisal will be compulsory, but will PCTs have the personnel or resources. I am intending to vote against this contract which tastes stale rather than fresh.
New GP Contract 4 May 2002
James P Bell, GP Principal Sunderland SR£ 4DX Send response to journal: Re: New GP Contract	Lewis and Gillum write as if the new contract has been accepted by General Practice. This is not the case, and indeed there is a preliminary vote as to whether this framework is acceptable to General Practice. The framework as stated is by no means complete, pensions have not been adequately addressed, the contract has not been priced, and the government will still retain the right to unilateral change in any contract. I hope tht the BMJ will not threaten its integrity by allowing those who are opposed to this contract an equal chance to portray their views as Lewis and Gillum have. Competing Interests - Wife and Children
The failings of the new GP contract 4 May 2002
Prit Buttar, Partner, General Practice Abingdon Surgery, OX14 3LB Send response to journal: Re: The failings of the new GP contract	Sir, The brief summary of the new GP contract in this article is somewhat misleading. Although the proposals to allow GPs to reduce 'additional' services in order to reduce their workload, this option already exists - if I choose, I can already stop doing cervical smears, vaccinations, and I can pay others to do my out-of-hours work. There is nothing new in the contract about this. Furthermore, most of the pressure on my time comes from what will be defined in the new contract as 'essential services' - therefore, the pressure will not change. There is nothing in this contract that will reduce demand. The proposals are incomplete, and completely unpriced. The new quality targets appear interesting at first glance, but a study of the examples given suggest that they will be a bureaucratic nightmare, and will swiftly degenerate into a vast data collection exercise. This move to 'medicine by numbers' will strike at the heart of the doctor-patient relationship. Far from addressing the concerns of GPs about workload, pensions, the ability of the government to alter the contract unilaterally, etc, the proposals will do nothing to make general practice an attractive career prospect in future. Consequently, the recruitment crisis in general practice will continue, and the profession will decline. By contrast, the Independent GPs Association (www.igpa.org.uk) has proposed alternatives that are clearly priced, and would address concerns about workload. The proposals would also establish a far clearer link between what GPs do, and what they are paid. I am increasingly concerned about the relentlessly positive spin about the new contract. A close study of the proposed framework finds nothing to justify such spin. Prit Buttar
GP contract does not address real concerns 4 May 2002
Anthony B Lamb, GP Stafford ST16 3AT Send response to journal: Re: GP contract does not address real concerns	Sir, I was disappointed that the editorial about the new GP contract by two members of the King's Fund was not counter-balanced by an opposing view. Many GPs, myself included, regard this contract framework as a complete failure, which will do nothing to raise morale and help with recruitment and retention. For example, there is nothing to help with one of the biggest sources of discontent, namely demand management. This point is completely ignored in the editorial. I hope that you will follow this up with a more critical view next week. To do otherwise would damage the reputation of the BMJ for impartiality.
New contract will make rural GPs'lives even harder 5 May 2002
G Rhys, GP Principal Ty Doctor, Nefyn, Gwynedd, LL53 5BL Send response to journal: Re: New contract will make rural GPs'lives even harder	The new contract threatens rural general practice, at a time that rural General Practice is in crisis. Rural GP's have been moving practices to avoid the stresses of our small out of hours rotas. The new contract on first reading, offers some solace for out of hours. Unfortunately, the dearth of registrars and locums will mean that the implementation of a new system will be difficult. Some rural areas are also to be excluded from an out of hours opt out. The income of rural GP's is also under threat. A capitation based system will threaten the income of GP's, who hold smaller patient lists. Additional staff is needed to run rural branch surgeries, which restricts our ability to employ secretaries and administrators. As a result, the practice infrastructures of rural practices are less able to deal with the demands of a quality based alternative contract. Any new staff needed for the new contract, will apparently need to be shared with other practices, and will possibly be employed by the Primary Care Groups. This threatens our independence. Income from dispensing is explicitly at risk. This is a major source of revenue in many rural areas. Our income from temporary residents is also under threat. We see increasing demands from a growing number of the wealthy elderly, which live a significant portion of the year in holiday homes. The realities of the recent BSE crisis, and its effect last year on rural tourism seem to have escaped the notice of those drafting this contract. Basing our income from this work on historical data is therefore not in our best interest. The new contract offers major concessions by rural GP's to change our funding arrangements, but unfortunately so far offers us nothing concrete in return. Competing interests Paying my mortgage
Problems with the GP Contract 5 May 2002
Stephen J Shepherd, Salaried GP The Surgery, 30 North St Ashby-de-la-Zouch. LE65 1HS Send response to journal: Re: Problems with the GP Contract	Sir Your editorial concerning the proposed new GP contract failed to comment on its major defciency. It is not priced. Without some figures it is impossible to draw any conclusion from the new framework. If, as is likely, the pot of money for Primary Care only gets a little larger then GPs will have to carry on working at the current level just to maintain their income at the current level. All that will change is the name under which the fees are claimed and the hoops needed to be jumped through in order to get reimbursed. No one will be able to opt out of services if that will lead to a massive drop in their income and why should we take a drop in income, we have been doing more and more work over the last few years without proper reimbursement. It is only fair that our basic salary increases in line with our increased workload. Without pricing, particularly of the essential services part of the contract, we will be unable to see how we can 'control our own workload' There are also other important matters which have not been clarified, most disturbingly that of pensions. We are being asked to trust that the Government will come up with the money to make this new contract reasonable and unfortunately successive Governments have failed to fund Primary Care properly. That is surely the reason why so many GPs are dissatisfied with their lot. Stephen Shepherd MRCGP. MB, ChB (Birmingham)
I salute the King's Fund 5 May 2002
Ahmad Risk, eHealth Consultant Brighton BN3 2JD England Send response to journal: Re: I salute the King's Fund	I salute the King's Fund for doing an excellent and spinful PR job for the General Practice Committee (GPC) of the BMA. It is astonishing that this institution would allow Lewis and Gillam to try and sell a 'contarct' to the profession, which is: a) Has no price b) Damages the doctor-patient relationship c) Does not address workload or demand management d) Introduces managed care and 'medicine by numbers' by the back door e) Does not deliver the uplift in the quality of care badly needed by the citizens of Britain Shame. Shame. Shame. Ahmad Risk IGPA Http://igpa.org.uk
Editorial contradictory and incomplete 6 May 2002
Trefor J Roscoe, GP INformatics Tutor - North Trent Institute of General Practice, University of Sheffield Send response to journal: Re: Editorial contradictory and incomplete	I am afraid I have to take issue with some of the inherent confusions in the editorial about the new contract (http://bmj.com/cgi/content/short/324/7345/1048) and would like to point out a major deficiency. The authors state, "In future, general practitioners should be better able to control their workload and trade leisure for income." I am afraid that this has always been the case. My colleagues and I chose to reduce our average list size to less than 1700 in 1992 when a larger practice divided into two. My accountant and I have estimated that this cost the four of us between £5000 and £10,000 each per year for the next 3 years until the list size rose again. For every GP earning over the intended average, this is one earning under. They go on to say" The perverse incentive for general practitioners to manage large lists with a limited range of services should reduce." but in the next few sentences state that "The new capitation formula should be welcome for deprived areas because funding will be delivered regardless of whether general practitioners are already in post." These two statements are mutually exclusive. If it is possible to manage large lists with a limited range of services in deprived areas because of a lack of staff, with money still flowing in despite GPs not being in post, then it must be possible to have a very large list and not have the partners to do other than the basics as a deliberate ploy to earn more. I would be interested to be shown which bits of the proposed new contract make this unlikely. I accept that they then go on to say that all incentive schemes encourage gaming; I would be surprised, given current morale, if this contract was not seen as a good game to play against the fledgling PCOs who may not be able to cope with the complexities. I am disappointed that there is no mention in this article of the information issues that the contract generates. A recent paper and accompanying editorial on the Coronary Heart disease NSF pointed out the virtually impossible workload implications of secondary prevention. (Hippisley-Cox J., Pringle M. BMJ 2001; 323: 269-270. Toop, L., Richards, D. BMJ 323: 246-247). The new contract requires recording of large amounts of information to prove basic quality standards are being met and will multiply the work involved in data collection and implementation of care by several times. General Practice IM & T may benefit from new money under these proposals but only if the quality standards are met. How this money is spent and how the people are found to do the necessary information management will in my view be crucial to the success of the contract.
Conflict of interests in the new "contract" 6 May 2002
Martin J Heath, GP principal School Hill Surgery, Lewes, BN7 2LU Send response to journal: Re: Conflict of interests in the new "contract"	The new contract still exposes a conflict of interest for GPs. Whereas the patient who comes to see us wishes to enter into a patient- centred arrangement with a doctor, we are being asked to behave in the interests of a State-driven agenda. If a patient wishes not to have his or child immunised after I have councelled appropriately, then that should be an end to the matter, and the State can take other sanctions against the parent if it so wishes - but not against the doctor. The history of doctors working in the interests of the State rather than their patients is not a happy one
new gp cpntract 6 May 2002
Mark C Rogers, gp principal 19 esplanade ryde isle of wight po33 2eh Send response to journal: Re: new gp cpntract	dear sir, in your editorial you state that general practitioners will be able to control their workload. the new contract proposals do not contain any information on the crucially important issue of patient allocations. unless the current system changes general practitioners will not have any control over their workload. our negotiators tell us that discussions continue on this subject. on the basis of past performance there is no evidence to suggest that the government have the slighest intention of giving up this right. we should reject this contract and the gpc should return to us when all of the outstanding issues have been resolved so that we can make an informed judgement about our future and not make a decision based on a wish list which politicians are very unlikely to honour
A triumph of hope over experience? 6 May 2002
Janet Menage, GP principal Bulkington Surgery CV129JB Send response to journal: Re: A triumph of hope over experience?	Lewis & Gillam are optimistic about the proposed new GP contract. Some of us who work at the coal face are less enamoured by its string vest -like qualities. They maintain that GPs,"can reduce some of their current committments". Do they know something we don't? Unless the contract is priced, those of us with mortgages and offspring to educate have no idea whether we can afford to opt out of any services.Even if some do reduce workload, given the national GP shortage, the offloaded burden will simply fall onto the shoulders of other doctors in the area. They claim a,"major victory" in that new resources are promised for extra workload. This belief is naive on several fronts: firstly, the quantum of resources is not specified in the contract; secondly, workload is not specified, so any additional effort can be hidden in the small print, (eg. attempts to reach a 90% target but just missing would result in payment at the lower target level despite increased output); and thirdly, given that Primary Care Organisations already struggle to balance even their drug budgets, faith in the Treasury's willingness to pour money into practices is misplaced. No other trade union would dare to offer an uncosted contract to their members for approval. GPs sign this blank cheque at their peril.
Think again on contract 6 May 2002
Paul Attwood, GP 1, CT11 8AY Send response to journal: Re: Think again on contract	As a GP, my "representatives" - the BMA and the GPC - are proving disgracefully supine in their negotiations for a new contract with the NHS. They are putting forward a draft which does nothing to alleviate the problem of unconstrained demand and nothing to restore doctors' morale. They appear to believe that they have a responsibility for the NHS as an organisation, rather than towards enabling their members to practice good medicine. I can see nothing to stop doctors continuing to leave NHS General Practice in droves and I suspect it will include me, a GP with 18 years experience and potentially another 18 to go.
Naivety of the negotiators 6 May 2002
Tony le Vann, GP The Scott Practice, Doncaster DN4 0TG Send response to journal: Re: Naivety of the negotiators	All the new contract is based on the goodwill of the government. We therefore have to look for signs of government flexibility and see none. Perhaps they could have been reasonable about the pension problem of general practice which the GPC have been trying to achieve fairness for two years. Maybe they could have helped their own immunisation policy by taking the MMR out of target pay, so that GP advice could be seen by parents to be objective and not a scource of payment. This is not a contract until it is an agreement by two parties which is legally binding on both parties. It is legally binding to GPs but the government can alter it at will by changing the rules as and when they require - just like "The New Contract" in 1990. This is a contract limited by statute, which means that it is anything the government of today or tomorrow wish it to be. It is a contract of slave labour until it is a contract of employment just like any other NHS employee has. Of course the negotiators will say they have been tipped the wink by the other side and there is all the goodwill in the world for us. Have we seen any sign of it in the last 40 years? Is there any sign of it now? Finally, it will be priced by the DDRB. It decided our value last year. For it to suddenly say we were worth £x last year and suddenly to be worth £x +16% this year does not really look real, does it?
Proposed new GP contract 6 May 2002
Jeremy R Paterson, GP Principal Mount Chambers 92 Coggeshall Rd, Braintree Essex CM7 9BY Send response to journal: Re: Proposed new GP contract	The proposed GP contract offers no solutions to the present and increasing problems in General Practice. The "Essential Clinical Services" covers services initiated by patients who are ill, or believe themselves to be ill. This covers the overwhelming majority of the work that GPs perform. The "Additional" and "Enhanced" Clinical Services then covers screening, prevention and chronic disease management, areas where a lot of genuine medicine is involved. The latter two areas, are areas where most GPs would love to be involved, as they represent areas of real and potentially exciting medicine. However, there is not the slightest possibility of GPs coping with these two areas, whilst "Essential Clinical Services" remains as an unrestrained patient led service. Demand management is absolutely critical at this stage, otherwise the rest of the contract aspirations are fairy tales. This clearly presents a major political problem, as the British public (voters) have great expectations as far as their health care is involved. This includes their "right" to instant medical attention for all problems great and small. This has also been the great challenge for the GPC and NHS Confederation negotiators. Unfortunately it is quite clear that the NHS Confederation has "won" hands down over the GPC. The political considerations have clearly been victorious over the aspirations for a first class "Health" service. Sweeteners, such as the ability to give up out of hours (even if there is no-one else to do it !)at an unknown cost, is simply a ruse to beguile GPs. It is often thought that politicians view GPs as failed "cough and cold" doctors. This contract will simply confirm our role, and once again, the genuine patient will lose out. This is not a contract that can be supported by any forward looking doctor.
Impossible situation for GPs 6 May 2002
James Cave, GP Downland Practice, Newbury RG20 8UY Send response to journal: Re: Impossible situation for GPs	Perhaps I am unlucky, having a father that remembers the contract negotiations in the 1960s, for it seems to me that GPs are about to be ambushed. The headlines look great but this contract is nothing but spin until it is priced. (Have you every tried to build a new kitchen or bathroom without knowing the prices??) However more important than price is the structure this contract imposes on General Practice. A look over one's shoulder at the state education system demonstrates how unfocused on individuals a system can make professionals. Worse the new contract will do nothing to reduce demand on its services, instead there will be a complex and confusing series of electronic mail from all kinds of subcontractors each morning demanding the surgery acts on patients that accessed other care during out of hours. Meanwhile a practice based contract will leave the few GPs willing to invest in the service carrying the can and increasingly looking for a way out whilst the "new" profession (doctor and nurse alike) act like grazing gazelle moving from one salaried post to the next, unhampered by the need to be patient focused or community centred. We will be damned if we vote yes and criticed as luddite if we vote no. Perhaps it is understandable that I have a good friend moving into private practice in the Summer and another emigrating to Tasmania.
GP Contract 6 May 2002
Stephen Jerrett, GP Principal Talbot Green CF72 8AJ Send response to journal: Re: GP Contract	The article on the proposed new GP contract states there will be a reduction in workload for General Practitioners. This would only be the case if there was a limit on demand but this is not part of the deal. This contract will only benefit the NHS at the expense of Primary care which will continue to carry the responsibility for an under-resourced and over-burdened service. A further leading article pointing out the faults of the proposed contract would restore balance and the BMJs credibility. yours Stephen Jerrett
A few more tweaks required. 6 May 2002
William R.G. Hynds, Locum GP County of Cornwall (30 practices) Send response to journal: Re: A few more tweaks required.	As a young GP I suppose my hope for a new contract was to provide a promising and sustainable direction for general practice and my career ahead. In the simplest terms I think this boils down to a very minimal core contract (essentially "first aid") combined with the ability, like our consultant colleagues, to provide private services for our NHS patients including the use of FP10's. This would allow our patients to continue to receive "for free" what they consider to be the important part of what we do. At the same time it would allow them to have a genuine choice in the other areas of their health. Furthermore it is crucial that any changes to the way we work incorporate some form of demand limitation formula. I would favour a £5-£10 pound charge for a consultation which could possibly be waived if the GP suggested follow up appointments for the same problem. In the current proposals I can see a lot of the government's agenda and none of mine. Although many of the opt out areas have a slightly Alice -in-Wonderland quality I think there are some very clever hooks to reel in different factions of the GP population. Certainly income will increase and possibly for the next 3-4 years life might be a little better for some GPs. However once the initial sweeteners have been eroded we will be left in much the same position as now except that 30-50% of our income will be dependent on leaping through ever narrowing hoops. In fairness there are some positive aspects to the contract proposals but a few more tweaks are required before any sane, independent and forward thinking GP can accept it.
Proposed new contract 7 May 2002
david baker, gp principal Canford Heath Surgery Poole bh17 8ue Send response to journal: Re: Proposed new contract	The proposed new contract is a shambles. Clearly, the only way GPs can achieve any degree of autonomy & control over their working lives is to follow the example of the dental profession & leave the NHS.
Counting beans 7 May 2002
Craig A McArthur, GP Partner Tweeddale Medical Practice, Fort William, PH33 6EU Send response to journal: Re: Counting beans	The proposed framework attempts to claim that GPs can limit increased demand by not taking on additional responsibilities, and this is fine as far as it goes. However it still proposes an open ended core contract. This leaves the major cause of workload problems completely un-addressed. I have never fully understood our current contract, but I believe that the Government has, through non cash limited funding, an unlimited commitment to funding the NHS, which mirrors our unlimited commitment to serving patients. It would be an incredible achievement for the government to negotiate a situation where it no longer has an open ended commitment but GPs do. Successive governments have been trying to move towards this already and have moved most GPs into a situation where they are not just gate keeping but rationing treatment - particularly regarding drugs budgets. Accepting the rationing role for drugs, secondary care referrals and PAMs referrals while retaining open ended and ultimate responsibility for each patient as an individual is going to squeeze and squeeze GPs. We do not only ration other services but also we ration ourselves. This is hidden rationing. We have appointments which are too short, squeeze in extras at the end of surgeries, have a waiting time for routine appointments. When we work like this we must cut corners - essentially rationing patient safety. However, the contract and the law on negligence are unforgiving - we must provide good treatment for each individual patient. One mistake at any time could mean life or death for a patient and a career shattering complaint for the GP. For example, just brushing over a possible altered bowel habit mentioned in passing at the end of a consultation while running late in surgery with urgent visits to do while having been up half the night before, could falsely reassure the patient with bowel cancer. They might not return for months. By accepting responsibility for all our patients' needs or demands, we compromise not only the patients’ safety, but we also increase our own medico legal risk. Each new treatment that becomes available and each new standard that is set has resource implications in terms of doctors and staff time and responsibility as well as the cost of the prescription. Doctors time is usually seen as a free resource by third parties and, over the years, we have taken on many new commitments without funding for our time - there is a catch up exercise needed here. This part of our responsibility - to see patients presenting with their problems, represents the great majority of our workload and is likely to rise inexorably over the years. The new framework leaves us with this open ended responsibility but, paradoxically, only about half our income will now come from this part of the contract - and it seems likely to be fixed. To get the other half, we must be prepared to increase our activity further to meet the quality standards. We will be under great pressure to ignore the patients agenda and “tick boxes.” (We will have to tick the box whether the patient opts in or out.) This is not only top down micromanagement at its worst but will take further time away from seeing patients and meeting their agendas. They are worthy goals but this is clearly a system for us to collect lots of (previously confidential) data on behalf of the government so that ministers can quote statistics in sound bite format to the media. Or worse, so that GPs can be ranked into league tables and compete with each other for resources. At a time when GPs are in increasingly scarce supply, when doctors remain the most trusted profession, when we have a monopoly on our services, when we are incredibly cost effective and when we have shown our willingness to resign in the survey last year, the negotiators should be in a position to negotiate a more advantageous framework. The contract should put quality first - but not in the form of bean counting which is proposed. The quality should be in the form of longer appointments for patients, safe limits on doctors working hours, dedicated time for education and letting doctors get on with the job as if we were independent professionals and patient advocates. Leave it to our professional integrity or to our professional regulating bodies or to the law on negligence to ensure quality. We don’t need to send in every patient’s weight and height to the Trust every year in order to prove we are good doctors do we? The contract should also clearly link income to workload. This could be simply done by claiming an item of service fee for each patient contact, thus giving the government a responsibility to pay us which matches the open ended responsibility we have. Or it could be done by limiting our responsibility to see patients to match the limited funding and time which is available. This would have to be compulsory and enforced by law and professional indemnity because doctors will always go the extra mile to deal with their patients despite it being obviously unsafe due to tiredness, personal illness or many other factors. Doctors have traditionally been highly driven by “internal motivators” such as ethical values, professional concern for patients and self image as a doctor. With each new imposition of an “external motivator” by an untrusting government - such as having to prove how many cholesterol samples you have taken in the last year - the internal motivators wither away. Not everything that can be counted counts, and the public through the government run the risk of getting exactly what they ask for - and losing much more. With the continuing commitment to unlimited personal services to patients combined with the commitment to ration our time and the time of the rest of the NHS, GPs will be in an impossible position and will continue to bear the burden at the expense of our personal and family life and at the expense of patient safety and quality where it matters, and where patients want it - in the consultation. Voting no to this framework will lose GPs nothing. It will give our negotiators a stronger hand and a mondate to return to the negotiations and get a better deal for doctors , patients and the NHS. If we accept this framework, we will be politically unable to reject the final, costed contract later - even if the pricing is too low and there will be no prospect of change for at least a generation.
New Con-trick 7 May 2002
John A Glasspool, GP Principal Victor St Surgery, Shirley Southampton SO15 5SY Send response to journal: Re: New Con-trick	Dear Sir, The proposed new contract framework does nothing for many GPs. The main problem is that money does not follow workload-that of "core" services. There is no item of service fee for home visits, for example, and no extra payment for the high demand patients in residential care. As ever, those that benefit will be doctors who look after low-demand professional groups in leafy suburbs and new housing areas. It will do nothing to address the dearth of GPs in the inner city. It will do nothing to address the recruitment and retention issue. It also seems to assume that we can rely on the goodwill of the government for many of its positive aspects to happen. Readers can judge for themselves on that one. I urge my colleagues to ignore the positive BMA "spin" and to vote "No" in June. Yours sincerely, John A Glasspool
GPs need a contract with their Patients, not this! 8 May 2002
Robin N Barber, GP Principal Ilminster Somerset TA19 0BN Send response to journal: Re: GPs need a contract with their Patients, not this!	In my opininion the proposed new GP contract is fundamentally flawed, unethical and unprofessional. The only contract a doctor needs is that with the patient., Of course fees do need to be regulated but what goes on in consultations is confidential, patients themselves are the best determiners of quality and will soon vote with their feet if dissatisfied. I am more than happy with INDIVIDUAL patients to discuss the merits of getting a few more mm. of Hg off their BP, a few more mmols off their LDL, not eating fish and chips etc. and will endeavour to treat and monitor progress accordingly if that is what they request. We must however recognise that not everyone wants their health micro-managed with the rest of the herd, many just want to make informed judgements and not to be coerced by a GP whose livelihood depends on manipulating their biochemistry.
Ive Bought a New Car to Celebrate the Proposed New GP Contract 8 May 2002
Simon M Fellerman, GP Principal Leeds LS17 7BE Send response to journal: Re: Ive Bought a New Car to Celebrate the Proposed New GP Contract	I would like to inform all your readers that I have gone out today and bought myself a brand new Mercedes car to celebrate our proposed new GP contract. I also bought one each for my wife and son. The car dealer wouldn't tell me the price of any of his stock so I said to him 'never mind about the price I'll just take those three over there.' Do the GPC really think GPs are stupid enough to vote for a completely unpriced contract? Dr Simon Fellerman (Leeds)
Volte face by the GPC 10 May 2002
G Michael Leuty, GP principal Victoria Health Centre, Glasshouse Street, Nottingham NG1 3LW Send response to journal: Re: Volte face by the GPC	Sir, On 9th April 2001, John Chisholm wrote to me saying that the GPC recognised that there was a "serious workload and morale crisis within general practice". He went on to say that "the development of National Service Frameworks (NSFs) whilst laudable in their intention to raise the standards of care for patients, has been accompanied by demands on general practice to systematise, monitor, and report on the delivery of that care. This has placed an unsustainable burden on GPs and their practices and risks diverting already over-stretched resources away from direct patient care... We are therefore advising family doctors to... stop taking time away from patient care to meet the associated requests for information from health authorities and PCTs". At a "Roadshow" which I attended last night, the GPC negotiator informed us that there are now only 18 more GPs than there were twelve months ago. He then went on to promote a contract framework under which a significant proportion of GPs income would depend on a large amount of systematised, monitored and reported care delivery. There seems to have been a complete change of policy by the GPC over the past twelve months, and I am not sure that this is wise. I find the massive emphasis on systemised and meticulously recorded activity in the proposed framework, along with the similarly bureaucratic appraisal and revalidation procedures being introduced concurrently, to be "challenging". At the tender age of 45 I have little choice but to face these challenges, but I don't think that they will help retention among older GPs. No matter how it is priced, I think the proposed contract will worsen the current manpower crisis. Mike Leuty
Contract proposals are fatally flawed. 14 May 2002
Peter Davies, GP Mixenden Stones Surgery,Halifax,HX2 8RQ Send response to journal: Re: Contract proposals are fatally flawed.	Sir, The editorial by Lewis and Gillam is very optimistic about the future of general practice under the proposed new contract. The fact that two detatched academic observers are in favour of it should not be taken as evidence that anyone else is impressed by it.The unanimity of opposition to this contract in the twenty three preceeding posts is noteworthy in itself. Also the deafening silence about this contract from academic primary care sends out a loud message. I feel that the prosed new contract really fails to deal with the key concerns of general practitioners. John Chisholm rightly described the old red book contract as being flawed as it basically says that "A GP's gotta do what a GP's gotta do." This new contract fails to sort this problem. Doctors are still to be expected to deal with all manner of symptoms washing up in their consulting rooms (Essential services). Consumerism adds an injunction to see everyone within 48hours whether they are ill or not, just because they want to be seen. GPs currently feel swamped by demand. The metaphors used speak of "trench warfare" and "being bombarded" and "poor bloody infantry". We need reinforcements and this proposed contract does not look like providing them. Indeed it will do little to help recruitment into our speciality. At present there are GP principal posts going begging. These are well paid jobs, and no-one seems to want them. Also full time principals at the height of their powers are leaving partnerships and emigrating or working as locums. What is so structurally wrong with general practice that people are leaving partnerships? Start dealing with these problems and we might get to a contract that will allow good doctors to work well at a reasonable pace to deliver good quality care to patients. This proposed contract really does not tackle this. It will not deliver enough doctors on the ground to enable delivery of high quality general practice and so will not deliver Mr Blair's promises on NHS improvement. Ther must be a better alternative waiting to be discovered.
Anxieties about new contract proposal 14 May 2002
Michael J Curry, GP Bicester, Oxon OX26 5HT Send response to journal: Re: Anxieties about new contract proposal	I have 3 main problems with the new proposals 1. The pay for essential services will be on a weighted capitation basis. Will this be a pay cut for those doctors in the SE where GP numbers are higher and morbidity is lower? 2. How is workload addressed by the new contract? While it may be possible to opt for low rates of quality payments, who wants to offer a publicaly second class service? 3. The proposal is basically PMS negotiated nationally. The whole point of PMS is that it is negotiated locally to meet the needs of the patients and professionals. My worries about out-of hours provision are unabated too. I hope you have some answers. Yours, Mike Curry
All roads lead to Private Practice 16 May 2002
Trevor Alan Underwood, GP Principal Reading RG2 7BW Send response to journal: Re: All roads lead to Private Practice	The negotiators have misread the mood of their electorate. They have not resolved the unrestrained demands from patients, nor the relentless guidance, bureaucratic systems and political interference from government. The negotiated contract framework has dispensed with the Red Book. This may be bureaucratic and inflexible but that is the essence of a contract. To be otherwise is complete folly, and it is wrong to promote the concept of flexibility and loads of money to GPs before the fine detail is signed off. They have traded the jewels of the current GMS contract. The Doctors List and all the applicable Red Book rules serve to protect the interests of Doctors and Patients. There is also an unwritten contract of mutual trust and continuity of care. In the new contract all confidential data will be centrally shared. The Doctors will spin off into corporate Practice Contracts and patients will drift between Doctors without constraint. Doctors may move further to sole practitioner status, selling their skills in part time locum style contracts for the NHS and setting up their own private practices based on traditional values. As Principals leave, NHS General Practice as we know it would become a quaint memory. The Primary Care trusts will be left with drop in centres akin to their community dental services. The negotiators have moved a step too far. The status quo is better than this. Plan B is Private Practice. Vote NO.
Patient demands 16 May 2002
John R harrison, GP Rowlands Castle Surgery Hampshire PO9 6BN Send response to journal: Re: Patient demands	This new contract doesnt address the needs of the "supermarket mentality" of our "customers". It has been devised between Doctors who think they know what the patient needs and the government who know how much they want to spend. The Customer/ patient has been left out of the equation. There is nothing in the essential part of the new framework to kerb the patients percieved needs. Untill this is addressed the current situation in the NHS will continue to deteriorate.
The proposed GMS contract: requesting decisions without key facts 26 May 2002
Brian A. Ferguson, Professor of Health Economics Nuffield Institute for Health, University of Leeds, 71-75 Clarendon Road, Leeds LS2 9PL Send response to journal: Re: The proposed GMS contract: requesting decisions without key facts	The proposed GMS contract Having read all of the recent correspondence on this1 2, I simply had to find out what all the fuss was about. Having tracked down the new proposals3, I took them along to my Swedish solicitor, Björn Yesterday, to ask what advice he would give me. I decided that I would gain his advice through the subtle ruse of asking him how he would react in the following circumstances. Here were my questions: Me: “What would you do if all of your future income depended on the characteristics of your client base?” BY: “It would depend on what those characteristics looked like”. Me: “Suppose you didn’t know?” BY: “Then it could be difficult”. Me: “Ok, but I have some good news: demand out there is absolutely unlimited”. BY: “Excellent, so my partners and I can increase charges to constrain excess demand – I like it”. Me: “Well not exactly, but what if you could choose how hard you worked”. BY: “Ah, now I like the sound of that; of course I would need to be able to place some kind of valuation on work and leisure time, so I would need to know, for example, the price attached to different types of work that I might undertake”. Me: “Ah, ok; so, moving on, say those things couldn’t be resolved – but I offered you a good pension deal?” BY: “Well, again, it depends on the nature of the deal?” Me: “Mmmm, tricky one that. Now what about quality - surely it would be good to link that to payment?” BY: “Certainly, I would like to think I do that now. What exactly did you have in mind?” Me: “Well I can’t give you much detail, but there would be several different levels – and you could choose year-on-year which level you aspire to”. BY: “Ok, so how do I do that if supply is fixed? There aren’t many unemployed solicitors you know!” Me: “Ah, now I’ve thought of that one – as a last resort you could move into the private sector and charge a high price because no-one else could provide the really high-quality services publicly!……..Oh, you are in the private sector”. Like all complex issues, there is no ‘black’ and no ‘white’, only shades of grey. The proposals for a new GMS contract at least have some potential to address concerns in primary care. However, Lewis and Gillam’s article1 at this stage is over-optimistic. They point out, for example, that the national pricing of the new contract “will take into account the changing demands on primary care” (p.1048, emphasis added). But the devil will be in the detail; at this stage there are no firm proposals for how this will be done. In future GPs will “be better able to control their workload and trade leisure for income” (p.1049). Roscoe2 has already pointed out the logical inconsistency in Lewis and Gillam’s analysis here – but this work/leisure trade-off is central to the proposals on which GPs are being asked to vote for the future of their profession. All GPs must provide essential services, “envisaged as a tightly defined core” (1, p.1049). Note the following text from the proposals: “Essential services will constitute the management of patients who are ill or believe themselves to be ill, with conditions from which recovery is generally expected, for the duration of that condition, and the general management of patients who are terminally ill” (3, para. 18, p. 12). And later: “It will be mandatory that all practices provide the full range of essential services and it is expected that they will normally provide the full range of additional services” (3, para. 20, p. 12). Essential services hardly constitute a "tightly defined core". And can we expect a queue of practices lining up to be known as “Practice incomplete range of services” or “Practice not quite up-to-scratch”? How is demand going to be constrained? How is the supply of appropriately trained doctors, and other health care professionals, going to be tackled? How is low morale going to be tackled? What resources are going to be available to fund the proposals? How are the proposals going to ‘minimise bureaucracy’ given the transaction costs they imply in terms of data collection and monitoring of quality? In many circumstances it would be quite reasonable for many of these questions to remain unresolved pending further analysis, discussion, negotiation etc. It is, however, quite ludicrous for all of these key issues to be unresolved and yet ask the whole of a profession to sign up to ‘the framework’. I’ve just passed a turkey carrying a ‘yes’ vote for Christmas 2002. On a positive note, attempting to link incentives to quality improvement is to be welcomed. So too is the move to practice, rather than GP, based contracts. A needs-based resource allocation formula at primary care level will task the best modellers but if it improves the quality of morbidity data in primary care then that in itself will be a significant step. Unfortunately, presenting proposals to the GP community that aim to deal with everything inevitably means that some of these important potential benefits risk being lost. Brian Ferguson Professor of Health Economics, Nuffield Institute for Health University of Leeds LS2 9PL e-mail: hssbaf@leeds.ac.uk Lewis R and Gillam S. A fresh new contract for general practitioners. BMJ 2002; 324:1048-9. Electronic letters published in BMJ. http://bmj.com/cgi/letters/324/7345/1048, 4-16 May 2002. NHS Confederation. The new GMS contract – delivering the benefits for GPs and their patients. London: NHS Confederation, 2002.
Encouragement for GPC but Humility please 26 May 2002
David B Rance, GP principal Boston Lincs Send response to journal: Re: Encouragement for GPC but Humility please	Having gone to the Nottingham consultation meeting I would like to encourage the GPC and reassure them about what must be, for them, the rather scary adverse comments of late. Doctors like taking concepts to bits and criticising them and out of the general moaning will come some good constructive points which I am sure the GPC will listen to. We must have a new contract and there is no other but the present process whereby we shall get one. Unless, of course, we en-masse want to leave the NHS and have no contract at all which seems a rather horrid idea. However, I do sense that the GPC is making the mistake of rather bullishly imagining that they can coerce and outwit the government of the day and I think this is naive. As a profession I do not feel we have ever believed that we are greater than the state and I also doubt very much if our amateur politicians will outfox the real ones. (Indeed, assuming the negotiations drag on past the next election, they may even find ourselves negotiating with a real Fox!). Lastly, I think the GPC's thinking is too far ahead of the profession on the issue of voting on an uncosted contract. I dont think their argument for getting a contract on the table and then daring the government to cost it fully stands even a small chance of working. The GPC say at this point that about 50% of the work is done and I am sure they will absorb the many points being made about the new contract they are generating for us.
Proposed New GP Contract 28 May 2002
Andrew I Williams, Principal general practitioner Portsmouth PO1 4JT Send response to journal: Re: Proposed New GP Contract	Three major aspects of the proposed contract are concerning:- i) At his Portsmouth presentation Lawrence Buckman made it clear that the concept of holistic, longitudinal, family care provided by a named doctor was dead. (“The Government is clear that patients want immediate access to a healthcare professional rather than continuing care with their own doctor.”) Not only does this seem to be at odds with the preference stated by the patients and friends I know, it also seems to run counter to a large corpus of teaching of the Royal College of General Practitioners.It also runs counter to the statement made by Dr Chisholm in his letter of 9th April 2001 when he asserted “When they are ill patients want to be able to see their doctors, not to find that their GP is having to undertake administrative tasks in order to satisfy Government.”About a million consultations take place every day in the UK. Perhaps GPs could consult patients about the value they place on access to their own GP, and suggest Mr Blair be made aware of their views. ii) The contract fails to describe how workload is to be capped. All the existing infinite availability to those who are unwell is to be preserved, (and patients’ satisfaction with this service is to be measured and will become a determining factor in GPs’ pay), and, in addition, GPs will be set on a biennial upward ratchet of contracted tasks.If resourcing of “additional services” is as certain as the framework asserts, better the default position be that these services are voluntary. Practices will leap to carry them out if the resources truly are there. iii) Acceptance of the framework is bad news in practical terms. Credibility will be lost if GPs sign up to a framework with fundamental flaws; to reject it subsequently at the pricing stage will be seen only as quibbling about money. Matters of principle should be voted on at the first, not the second ballot. The negotiating team needs to conduct the debate firstly about the value of the role of “essential medical services”. This is a debate the public will understand, without the subtleties and complexities of the available extra payments. Yours sincerely Andrew Williams Principal General Practitioner Portsmouth PO1 4JT ¹ Lewis R, Gillam S. A fresh new contract for general practitioners.BMJ 2002; 324:1048-9 (4 May)
one more voice for the chorus of disapproval 4 June 2002
dougal j jeffries, GP St Mary's, Isles of Scilly Send response to journal: Re: one more voice for the chorus of disapproval	Dear Sir, I feel duty-bound to add to my colleagues' cris de coeur over the proposed new contract. Quite apart from the specific issues over the absence of pricing and pension arrangements, the extraordinary assumption that the PCOs will somehow find people to do all the work that GPs may choose to opt out of, and the failure to offer any clues as to how patient demand can be managed, I am concerned by the further medicalisation of life implied by the new contract. You recently produced a whole issue on this theme, and from this and many other recently published articles, letters, personal voices etc. it is clear than many of us are becoming increasingly dismayed by the role that has been thrust on us. This involves ruthlessly pursuing people who feel perfectly well until they cross our thresholds, when a finding of any one of a multitude of minor physiological or biochemical variations can lead to a lifetime of medication, repeated blood tests and other investigations, and the adoption of a sickness role that diminishes the overall quality of life. The new contract promises to reinforce this trend, and add a hugely increased burden of measurement and data reporting, with the laughable promise of 'exception reporting' (see para. 103) that will be impossible to manage on the scale required. I quite like the idea of seeing only 'patients who are ill or believe themselves to be ill' rather than those whom epidemiologists, health promotionists and pharmaceutical companies believe to be ill, or at least in need of treatment. But if I do so, I will be regarded as providing a third class service. I know I'm exaggerating, but I do believe the danger is real. Competing interests: defending patients from meddlesome doctors, and doctors from coercive governments. Dougal Jeffries