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New GP contract deal: a game changer for primary care?

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l531 (Published 01 February 2019) Cite this as: BMJ 2019;364:l531
  1. Gareth Iacobucci
  1. The BMJ

A landmark deal that will boost practices’ core income and incentivise them to work together in networks has been hailed as a turning point for general practice. Gareth Iacobucci looks at the detail

This week the BMA’s General Practitioners Committee and NHS England announced with much fanfare that they had agreed on a new contract deal for general practice in England, amounting to an extra £2.8bn over the next five years.1

The deal has been described by some as the most important change to the GP contract since 2004 and a potential “game changer” for practices that have been struggling to cope with an unsustainable workload, a shortage of GPs, high demand, and a decade of constrained funding.

The multifaceted agreement is significant for several reasons, not least because it spans five years rather than the traditional one year. This longer timeframe was enabled by the commitment in the NHS Long Term Plan, published last month,2 to boost investment in primary and community health services as a share of total NHS spend over the next five years.

GP leaders hope the extra certainty will stabilise and support practices under pressure and improve services for patients. The BMA has provided a summary of the changes online.3

Core practice funding and pay

The new deal will increase core practice funding by almost £1bn over the next five years. In 2019-20 practices in England will receive a 1.4% increase to core funding through the global sum. In the four years after this, global sum payments will continue to rise each year until 2023-24 in line with predicted inflation. The BMA said that this funding, when coupled with additional income to support practices’ participation in primary care networks (see below), will guarantee a minimum 2% uplift for GP and staff pay and expenses this year, and uplifts to core practice pay and expenses each year.

Richard Vautrey, chair of the General Practitioners Committee (GPC), said, “After years of derisory pay uplifts for staff and tightening financial pressures on practices, we have been able to negotiate a five year deal guaranteeing investment that covers pay and expenses and at least matches predicted inflation.”

The news that NHS England will also invest £20m in the global sum for practices to cover the costs of dealing with subject access requests by patients, after the ability to cover costs was removed by the General Data Protection Regulation, is likely to be warmly welcomed. The profession may be less pleased that any GPs whose NHS earnings are more than £150 000 (€170 000; $197 000) will have to make this public from 2019-20 as part of an NHS England transparency drive. There are no exact figures on how many GPs will be affected, but Vautrey told a joint GPC and NHS England press conference that he expects it to be a “modest” number.

Indemnity

The agreement confirms that the much anticipated state backed indemnity scheme for all GPs will begin in April 2019. This big step means that all GPs (including partners, salaried GPs, and locums, and those working out of hours) and practice staff (including nurses and allied health professionals) will no longer have to personally fund clinical negligence cover. Helen Stokes-Lampard, chair of the Royal College of General Practitioners, said that the college was “particularly pleased” at this announcement. “Escalating indemnity costs have become a huge burden for GPs at all stages of their careers, and some GPs have even cited this as their reason for leaving the profession,” she said.

Primary care networks

Close to two thirds of the deal’s extra funding (£1.8bn over five years) will be tied to practices’ participation in primary care networks. The funding is designed to help neighbouring practices develop collaborative networks across an area covering 30 000 to 50 000 patients.4 This arrangement was trailed in the NHS long term plan, and the new contract deal sets out the detail, taking an approach described by Nuffield Trust chief executive Nigel Edwards as “the carrot, not the stick.” The carrot is a new “network contract” that will operate alongside GPs’ existing practice contracts.

A new directed enhanced service (DES) will distribute additional funding via several avenues. Full details are online,3 but included are additional direct payments to practices for engaging with the network, recurring annual payments of £1.50 a patient to all networks to support their work, £31m for a GP clinical lead for each network, and the moving of all current funding for extended GP access to the networks.

In line with the aims in the NHS long term plan, the DES will eventually require practices to meet specified requirements in seven clinical areas: medicines reviews, enhanced support to care homes, anticipatory care for patients with complex comorbidities, personalised care, supporting early cancer diagnosis, cardiovascular disease detection, and tackling inequalities at neighbourhood level.

Workforce

Through the DES, each network will be funded from 2019-20 to employ at least one social prescribing link worker and one clinical pharmacist. By 2023-24 funding will be available to employ an extra 22 000 members of the primary care workforce across England, including physician associates, practice based physiotherapists, paramedics, and others.

With the exception of the social prescriber workforce (which will be 100% recurrently funded for five years), the rest of the expanded workforce will be 70% recurrently funded by NHS England, with networks funding the remaining 30%. NHS England’s Ian Dodge, who led the negotiations with the BMA, told the press conference that adding extra support staff was a “pragmatic” solution to easing the workload and workforce issues in general practice. “We know that there is supply, but there is also demand,” he said. But as the Nuffield Trust’s Edwards pointed out, finding these extra staff won’t be easy. “We need to hear more about where these staff are coming from,” he said. “After all, many other parts of the NHS have their own serious shortages.”

Quality and Outcomes Framework

From April this year, 28 “low value” QOF indicators will be retired, worth 175 points in total. These include annual cholesterol checks for diabetes, dementia blood tests, annual FEV1, osteoporosis, and peripheral artery disease indicators. A total of 101 of the retired points will be recycled into 15 more clinically appropriate indicators, covering key areas such as aligning blood pressure control targets with NICE guidance, reducing iatrogenic harm and improving outcomes in diabetes care, supporting age appropriate cervical screening, and offering pulmonary rehabilitation (where available) for patients with chronic obstructive pulmonary disease.

The remaining 74 points will be allocated to a new quality improvement domain split into two modules. In 2019-20 these modules will focus on safe prescribing and care at the end of life. Vautrey told the joint press conference, “This is to try to move away from the box ticking process to a more professionally empowering and appropriate focus.”

IT and digital

The GPC will work with NHS England to develop a “standard specification” for IT systems in primary care that helps to increase patients’ digital access.

From April 2019 practices will have to provide new patients with full online access to prospective data from their patient record. They will also be expected to allow NHS 111 to book patients directly into their appointments systems. This will be permitted at a rate of one available appointment a day per 3000 patients on the practice list and will happen only after triage.

All practices will be expected to make at least 25% of appointments available for online booking by July 2019 and to offer online consultations by April 2020, subject to further guidance.

After a consultation last year,5 the deal also confirms that core practice funding will be revised to ensure fair payments for digital first providers and avoid “unwarranted redistribution” from other practices.

Pensions

The government has agreed to fully fund the increases in employer contributions that will arise from its plan to increase the contribution rate from 14.3% to 20.6% from April 2019. “General practice will not have to bear any additional costs,” it confirms.

Separately, the BMA and NHS England have asked the government to explore a new “partial pension” option for GPs, under which they could choose to halve the rate at which their pension builds up, and in return to pay half rate contributions. The local government pension scheme already has a 50% pension option. It is hoped that introducing a similar scheme could tackle the current problems with the annual allowance cap, which creates an incentive for GPs to cut their hours or quit the NHS pension scheme.

What’s the initial verdict?

When placed in the context of the past decade of underinvestment in general practice, the deal has generally been well received. The indemnity scheme will provide a huge fillip for practices; and while a 1.4% uplift to core funding is modest, when added to the indemnity funding and the extra money for networks, for many it represents a better deal than GPs have seen in a long time.

The formation of primary care networks is a trickier proposition. The principle of collaboration is hard to argue against, and the extra funding will be welcome, but how the networks will form, develop, and operate will be determined by the strength of relations between local practices. There is scepticism about the workforce targets, which is perhaps understandable, given that the government is struggling to meet its target to boost GP numbers by 5000 by 2020-21.

The chief executive of the King’s Fund, Richard Murray, said, “The timetable for implementing these changes looks extremely challenging, and it will be important that general practice and community services are supported to put these plans into practice.” Stokes-Lampard said that her college hoped the new contract would help general practice “finally turn a corner.” But while welcoming the extra staff, she added, “Now we need the forthcoming NHS England workforce strategy to deliver viable measures to continue recruitment efforts into general practice, and initiatives to keep more GPs working in it.”

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