Changes to the GP contract threaten general practice in the UK

Last week, the UK government disregarded five months of painstaking negotiations between the BMA and NHS employers to announce a series of wide ranging changes to the general practitioner contract that could potentially damage general practice in the United Kingdom. Some of the changes had never been mentioned before. Extensive and detailed discussions, which had almost led to agreement on a potential package of changes to the GP contract that recognised the need to do as much as possible for patients despite financially austere times, were ignored. The government had been fully informed about negotiations all along, so what happened last week was surprising and distressing.

There is considerable anger among GPs and within the BMA at how this decision was promulgated. Many other sectors of the medical profession are equally taken aback by the government’s autocratic approach. Furthermore, many of the new indicators that the government has decided to implement are simply unworkable.

GPs are under substantial pressure both financially and as a result of high workload. GP practice incomes have been frozen for several years, and this has led to real net incomes dropping by more than 20% since the introduction of the GP contract in 2004. At the same time expenses related to keeping GP surgeries functioning have steadily risen. This financial straitjacket has been slowly and relentlessly tightening to the point where most practices have little or no room for expanding their services without the injection of extra funds. Adding additional workload demands to an already stretched primary care service will simply force a reduction in patient access as practices struggle to cope. Like all healthcare professionals, GPs are seeing rising requests for treatment. Whether from an ageing population with complex health needs or the impact of improved treatments that benefit patients, this increase in patient demand means extra pressure on finite resources.

Tied to the intertwined problems of funding and workload are the government’s controversial health reforms in England. Whatever their merits, the effect is that GPs are now coping with the impact of another huge NHS reorganisation and the rush towards the implementation of clinical commissioning groups. These groups have brought with them an avalanche of paperwork and legal requirements.

Despite this backdrop of financial, workload, and organisational pressure, the BMA went into negotiations on behalf of GPs in June 2012 prepared to make further evidence based changes to the contract. Over the years, general practice has built up a strong track record of efficient working, especially since the signing of the 2004 contract, which introduced the quality and outcomes framework, a system whereby practices are set various targets that partly determine their practice funding. GPs have collectively worked hard to drive up testing and treatment of a range of conditions, such as diabetes and hypertension, despite reducing resources. Doctors’ representatives were confident that, as government ministers requested, changes could be made that delivered more for patients, while at the same time not tipping practices into crisis.

This was a false hope. The government has decided to implement a large set of indicators, some of which may be unachievable. One indicator rewards GPs for referring patients to certain education programmes, even though these schemes are not available in all areas. Another asks GPs to undertake tougher targets when monitoring patients with hypertension. GPs would be willing to do this, yet the resources needed to make this proposal workable are not being provided. Such indicators leave most GPs in the perverse position of being unable to meet difficult targets without resources and then being penalised further for failing to achieve them.

Alongside this wilful “indicator chaos” is an overall intention to raise the achievement thresholds for all indicators within the framework. Practices will now be expected to treat more patients across the 120 plus clinical indicators. This is based on a simplistic assumption that GPs will treat more patients if they are incentivised to do so. However, there is no evidence to show that practices stop treating patients when they reach a certain target, and those that come up short on some targets, despite their best efforts, do so because their patient population often faces more challenging circumstances than others.1 The total cost to practices of these threshold changes alone could amount to £126m (€156m; $202m) (personal communication, Department of Health, 2012).

Coupled with numerous other badly thought out changes, this imposition almost seems designed to exacerbate the underlying problems that are already damaging general practice. More work will be piled on while funding will be stripped away. This kind of conduct by the government should worry the wider medical profession. The threat to the GP contract is a politically driven exercise, unsupported by sound clinical knowledge, and deeply flawed because of the basic failure of its drivers to grasp the funding and capacity problems facing our NHS.

In the months ahead, the BMA will be examining the specific details of this complicated imposition, so as to inform the public and patients about its likely impact. The government still has time to rethink its proposals as it embarks on a “consultation” on these changes shortly. It must see sense, otherwise patients, GPs, and the country will suffer.