New contract for general practitioners
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7387.457 (Published 01 March 2003) Cite this as: BMJ 2003;326:457
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Professor Shekelle’s editorial, written from the perspective of
someone practising in an area with perhaps the most inequitable
distribution of health resources in the developed world is, or should be,
compelling. He has the luxury of providing top quality health care to
those who can afford it through insurance while knowing that many within
the society he serves can and do slip through the health care net.
Recognising his difficulty in squaring his perceptions of quality for the
few against mediocrity for the many I believe his observations are that
more valuable.
So far as most UK general practitioners are concerned, the burden of
his leading article is contained in its last paragraph. There are many
who perceive the aims of the new contract as command and control from the
centre, at the cost of the personal elements of care that are so intrinsic
to UK practice. Shekelle rightly articulates the risk that target
achievement and “bean counting” will be at the heart of any new
arrangements which is possibly to the detriment of the high value we put
on relationships.
Against this risk must be set the fact that many general
practitioners have already moved well up the “quality and outcomes”
gradient despite the perverse incentives inherent in the extant “Red Book”
contract while at the same time maintaining good relations with patients.
There are three factors that can make this new contract work. First,
information technology that has developed out of all recognition within
primary care over the past decade. Second, a welcome injection of
resources into primary care that will increase rewards and/or ameliorate
the effects of rising demand. Finally, and most importantly, the
intrinsic ability of the UK general practitioner to make any system work
for, instead of against the doctor-patient relationship. It is the last
of these that will remain the bulwark against the increasing and
pernicious desire of modern governments officiously to invade that
territory.
Yours etc
Brian D Keighley
General practitioner, The Clinic, Balfron, Stirlingshire G63 0TS
Competing interests:
Member of GPC(UK), SGPC
Non-executive director, BMJ Publications Ltd
Competing interests:
Member GPC(UK) and SGPC
Non-exec Director BMJ Publications Ltd
Competing interests: No competing interests
Sirs
The new GMS contract includes significant payments for quality,
rewarded for meeting very specific standards.
We audited the management of hypertension to the standards specified
in the new contract. We met all the standards except one. Only 51% of
patients with blood pressure recorded in the last 9 months, were below
150/90. This criterion produces the most points and is therefore worth the
most money. The maximum score of 56 points for this one criterion yields
£4200. Our score of 32 points yields £2400.
Audit has always been a means to an end, and results are used with
professional judgement to improve patient care. With significant money now
paid on audit results, there is a subtle change in emphasis. Audit results
will now become an end in themselves.
We discovered a number of perverse incentives and describe here the
financial implications of one.
In the audit sample, if we remove 11 of the patients who had
imperfect control, then we gain maximum quality points. With a 10% sample
size, this equates to the practice omitting to record the blood pressures
of 110 poorly controlled patients and directly gaining £1800 – adjusted by
Carr-Hill weightings. We would lose points from the criterion requiring us
to record every patients’ blood pressure every nine months, but there are
less points produced by this criterion, and this would only lose £600.
This could be regained by recording more blood pressures from well
controlled patients. Therefore, by omitting the recording of 110 poorly
controlled patients and recording 110 well controlled patients instead, we
gain £1800. This is clearly an incentive to target a practice’s limited
resources towards frequent recall and measurement of well controlled
patients rather than the time consuming and difficult task of improving
poorly controlled patients.
This and the other perverse incentives we identified are simply a
matter of diverting resources to do exactly what our contract requires and
are not fraudulent. If we collude with these, we will get more money, the
government will get statistics “proving” that patient care has improved as
a result of the quality framework, and yet the care of the population is
probably poorer. Incentives in the secondary care sector have been well
known to distort patient care and have even lead to outright fraud by
management. Incentive based medicine in primary care may lead to an
historic change in the way we practice.
Competing interests:
None declared
Competing interests: No competing interests
In last weeks Private Eye (sister satirical magazine to the USA's
"The Onion" and France's "Le Canard Enchaine") a solicitor, in a letter
arguing for higher legal aid fees, cited the "fact" that GPs had been
awarded a 30% pay rise.
Most people think GPs have been offered a huge pay rise. This is
false, but will make us seem greedy and uncaring if we vote no.
Today, I discussed the GP contract with a colleague who had attended
a meeting with 400 other GPs and had also taken acountancy advice. She was
advised on both occasions that most GPs would end up losing money if the
contract was implemented. THis is the opposite of the view promulgated by
DoH media men.
There is more to the caring professional life than money, but it
seems that a pattern of systematic deceit is emerging which is death to
trust. It seems as if the government has been acting in bad faith again.
Competing interests:
1)recently quit GP
2)previous contributor to this debate
Competing interests: No competing interests
It is interesting that transatlantic support had to be sought for the
shambolic new GP contract, which would have incurred a 5% or more pay cut
for my partnership in 3 years, by our AISMA accountants reckoning. It is
bizarre in the extreme that the BMA hierarchy commended it, whilst not
officially doing so of course. One wonders what they would have said about
a contract that led to a reward for extra work!
Stick to your ivory
tower, Dr Shekelle, and let the doctor on the ground in the UK judge what
is and is what is not good and ethical for him and his patients. This
muddle is neither, and it is typical of the career-clinging negotiators to
withdraw the ballot rather than let it be deservedly consigned to the
rubbish tip of history.
Competing interests:
A harasssed NHS GP
Competing interests: No competing interests
Sir,
I read Dr Shekelle's editorial (1) with interest. I was surprised that no
one from Britain could be found (or was even asked?) to write on this
topic. Maybe the strength of response to Lewis and Gillam’s editorial (2)
scared British writers away.
Despite my letter of May 2002 (3) I had almost come round to voting
for the contract on grounds that it could help improve chronic disease
management. Achieving this improvement is currently a major public health
goal and primary care teams probably could be and should be leading this
as Shekelle(1), and Martin Roland and team have pointed out
regularly.(4),(5)
Suddenly the Carr-Hill formula appears and patients are magically
made to disappear from GPs lists. Patients suddenly only count for 0.8 or
0.6 of a patient. Do they then suddenly only need 0.8 or 0.6 of a service?
Would you be happy with 0.8 of a service or 0.8 of a vote in an election?
The net result is that practices with 10,000 patients still have to deal
with 10,000 patients whilst only being paid for 8000 of them.
The idea of spreading resources according to need is a good one
assuming it can be done fairly. However nowhere in the NHS is well
resourced so re-distributing existing resources from one area to another
is largely robbing one area to pay another. The Carr-Hill formula appears
unfair and fails to achieve its purpose. It needs to be modified
significantly or abandoned before any progress with a new contract for GPs
is possible.
I suspect the GPC will have to postpone the contract ballot for a
long time which leaves general practitioners and Primary Care Trusts in an
uncomfortable limbo. Just what we need to rejuvenate our speciality.
1. Shekelle,P New contract for general practitioners Editorial BMJ
2003; 326: 457-458
2.Lewis,R and Gillam, S A fresh new contract for general practitioners BMJ
2002 324:1048-9
3 Davies,P Contract proposals are fatally flawed Letters, BMJ 2002
(25/5/2) 324:1275
4.Roland,M New GP contract BMJ rapid response (27/5/2)
http://bmj.com/cgi/eletters/324/7348/1274#22579
5.Marshall,M and Roland,M The new contract: Renaissance or Requiem for
general practice? Editorial British Journal of General Practice July 2002
Competing interests:
Salaried GP so income under no immediate threat from this contract
Competing interests: No competing interests
Given that depression is very common in general practice (it has been
estimated that 5-10% of patients attending the surgery have major
depression (1)), given that outcomes are surprisingly poor (60% of
patients treated with drugs still met criteria for caseness at one-year
follow-up (2))and given that enhanced care of depression can lead to
better outcomes (3), it is surprising that depression does not feature in
the list of quality indicators in the proposed new GP contract. My
experience is that it is possible to set quality targets for depression
management: 1. DSM-IV criteria for major depression should be applied, 2.
antidepressant medication should be prescribed at an effective dosage, 3.
80% of patients should comply with medication and return for follow-up and
4. 60% of patients should complete a 6 month course of treatment. A shared
care approach with the practice nurse was successful in improving initial
patient compliance, with an increase from 45% to 80% of patients attending
for follow-up(4).
My concern is that the list of quality targets has been assembled on
the basis of what is easy to measure rather than what is most important.
By condemning depression to be an "unmeasured" domain, the danger is that
scarce practice resources will be diverted elsewhere and that quality
initiatives designed to provide enhanced care will be stifled. The fourth
most significant cause of suffering and disability worldwide (5) deserves
better.
1.Anderson IM, Nutt DJ, Deakin JFW. Evidence-based guidelines for
treating depressive disorders with antidepressants: a revision of the 1993
British Association for Psycho-pharmacology guidelines. J Psychopharmacol
2000; 14:3-20.
2. Goldberg D, Privett M, Ustun B, Simon G, Linden M. The effects of
detection and treatment on the outcome of major depression in primary
care: a naturalistic study in 15 cities. Br J Gen Pract 1998; 48: 1840-4.
3. Von Korff M, Goldberg D. Improving outcomes in depression. BMJ 2001;
323:948-9.
4. Bland PM. Practice nurse input improves care of depressed patients.
Guidelines in practice 2001; 4: 75-81.
5. World health report 2001: 30.
Competing interests:
None declared
Competing interests: No competing interests
Editor- I do not think the doctor and patient relationship will be
compromised to the extent that Shekelle described in the proposed
initiative by the NHS, to improve quality of care by setting performance
targets for general practitioners accompanied by financial incentives.1
I entrust that general practitioners will continue to value their patients
as individuals and not a series of achievable performance targets. Rather,
I think GPs would consider using these targets as tools for aiming to
improve the quality of their service and the efficiency in which it could
be delivered, irrespective of financial rewards. I expect GPs and any
sincere health professional accepting the need for clinical reform, not to
change their behaviour towards patients on the basis of financial gain
alone. This would reflect badly on the profession, the program and the
very reason for its existence.
I do share Shekelle's sentiments about the usefulness of many new
quality indicators in multiple domains of care. This broadens the focus
into other aspects of care, which may have previously been neglected;
however it does not address the problem of care domains that have yet to
be measured.1
The implementation of the proposal may present to be difficult.
However, good clinical governance, a quest for appropriate changes by GPs
and continual input from all those involved should contribute to the
successful implementation of the program, which strives to improve the
quality of primary care in various clinical settings. Although this bold
new proposal presents as a mammoth task, the benefits and ramifications
from its implementation could potentially ensure better outcomes for all
concerned.
1.Shekell, P. New contract for general practitioners: A bold
initiative to improve quality of care, but implementation will be
difficult.
BMJ 2003;326(7387):457-458.[Fulltext]
Competing interests:
None declared
Competing interests: No competing interests
Professor Shekelle1 recognises that data collection for the new
general practitioner contract will be a huge task, requiring comprehensive
computerisation. However, having a computer is not enough: using it –
consistently and comprehensively– is the key.
To examine the size of the task, we studied one area, that of cancer.
It is proposed that practices establish a register of all cancer patients.
As part of a larger project, we obtained details from the local cancer
registry of all colorectal, lung and prostate cancers diagnosed from 1998-
2002 inclusive who were registered at an Exeter practice at the time of
diagnosis. Histology results were obtained and the diagnosis checked in
those without histology. Only cases with histological proof or a
consultant diagnosis based on strong evidence were studied.
We searched the computers of 19 of the 21 Exeter practices: all store
clinical data in Read code form. The other two practices, although very
willing to help, had important staff absent, and those remaining could not
fathom the search system on their computers. Two other practices are still
transferring patient summaries from paper to computer. We searched for the
four relevant Read codes (B13.., B14.., B2…, and B46..) using the
practices’ computer expert or WH when the computer system was one in which
he is proficient. The results are broken down by year of diagnosis in the
table. In only one practice were all cancers from the registry also on the
practice register.
Year Number on cancer register only (col 2) Number on practice register only (col 3) Number on both (col 4)Total(col 5) Percentage on practice register (col 6) 1998 106 3 45 154 31 1999 93 3 65 161 42 2000 87 8 84 179 51 2001 80 5 82 167 52 2002 94 9 102 205 54
Although the percentage has risen it is clear that sufficient
retrievable information is absent from most practice systems. It is likely
that some of the cancers were given a more generic code (all B…. codes are
neoplasms), and it is also likely that continuing transfer of data to
computer will further improve the figures. Our results should not be
taken to suggest that clinical care is inadequate: on every occasion that
the general practitioner was asked about a case requiring confirmation
they were able to give an immediate, impressive clinical vignette.
However, on this evidence only one Exeter practice would achieve points
under the cancer heading care despite a reputation for quality primary
care.
Yours sincerely,
William Hamilton, research fellow, Division of Primary Care,
University of Bristol, BS6 6JL
Alison Round, public health consultant, Dean Clarke House, Exeter EX1
1PQ
Deborah Sharp, professor, Division of Primary Care, University of
Bristol, BS6 6JL
Tim Peters, professor, Division of Primary Care, University of
Bristol, BS6 6JL
Reference.
1. Shekelle P. New contract for general practitioners. BMJ
2003;326:457-458.
Competing interests:
DS is a part-time GP, and WH will be in the future. The new contract would change their remuneration, though it is unclear in what direction.
Competing interests: Year Number on cancer register only (col 2) Number on practice register only (col 3) Number on both (col 4)Total(col 5) Percentage on practice register (col 6)1998 106 3 45 154 311999 93 3 65 161 422000 87 8 84 179 512001 80 5 82 167 522002 94 9 102 205 54
Among the novel ideas in the New Contract is the concept that one can
assess "holistic care" by adding up points after asking your practice
computer a series of rather complicated questions on different diseases.
According to para 1.28 of the Contract document this means that
"Holistic care will be incentivised ....."
Your readers may, like me, be baffled by any connection between these
"holistic" points and the concept of holism.
The British Holistic Medical Association offers a vision of medical
practice that is centered on people rather than diseases. Holism is about
relationships between people and between humans and our environment.
Of course we all have a relationship with our computers too and this
may involve emotional and even spiritual aspects. Somehow I'm not
convinced this is what the negotiators had in mind.
Competing interests:
Chair
Board of Trustees
British Holistic Medical Association
Competing interests: No competing interests
Are we not ignoring what is important?
Dear Sir,
I believe the GMS contract has produced a health care system more
suited to a third-world socialist state than the fourth strongest economy
and is well overdue for a radical change rather than the sinister
adjustments currently on offer (1).
In a capitalist society customers purchase goods and services from
the supplier of their choice. Although supposedly self-employed, British
general practitioners are tied into a contract that prohibits private
practice. Even when the NHS does not provide a particular treatment the
contract effectively prohibits doctors from offering this directly at any
price (2,3). GPs can have private patients but these must forego the major
benefit of receiving NHS prescribed medicines. It may seem appropriate
that private patients should not benefit from the subsidies that
facilitate a doctor's NHS practice but private patients are frequently
taxpayers and so have contributed to the costs of NHS provision. However,
these same subsidies are considerably reduced if a doctor's private fees
exceed 10% of his total practice income thus reducing the resources
available for his NHS patients (4). It is therefore unheard of for a
doctor to mix NHS and private practice. The majority simply refer rather
than treat. I know of one patient who paid a podiatrist £730 for a simple
Zadek's procedure, which should not be beyond the competence of any GP.
My main concern in the proposals is the total loss of any remaining
autonomy GPs have to act as the patient's advocate. The contract empowers
PCTs to commission and provide medical care by unregistered practitioners.
It prevents list closure and allows PCTs to enforce allocations without
payment. Added to this is the eventual ownership of computer data and the
fact that the contract is binding on one side only. The strategy is
control, allowing the state to recoup whatever this may initially cost.
The difference between GPs and lawyers and other professionals is
that doctors are tied to working only for the state at a rate of pay
determined by the exchequer alone. Others can mix state-funded and private
practice without financial penalty but the taxpayer can never meet all of
society's medical requirements, so until GPs are able to work in a mixed
economy we will always be fighting over our share of a very limited cake
and which is the better of many evils (1).
Is it not time for paragraph 38 etc, and all the falsehood this
implies, to be challenged?
Dr Paul Thomas
Gipping Valley Practice, Barham Suffolk.
1) New contract for general practitioners, Paul Shekelle, BMJ 2003;
326:457-458
2) NHS (General Medical Services) Regulations, 1992, Schedule 2,
paragraphs 38-42
3) NHS (Pharmaceutical Services) Regulations, 1992, Schedule 2, PART III,
paragraph 13(1)
4) NHS Statement of Fees and Allowances paragraphs 51.16, 51.17 and 52.22
Competing interests:
none
Competing interests: No competing interests