The new UK-wide general medical services contract was implemented on 1 April 2004 and changed the way primary health care is delivered. It provides demonstrable benefits to GPs, other primary health care professionals and patients. It allows GPs to manage their workload more effectively and improve the quality of care they deliver to their patients. The contract also enables practices to deliver some high quality services that historically have only been available in hospitals.
The contract, agreed between the BMAs General Practitioners Committee, the NHS Confederation and the four UK health departments, aims to:
- give GPs a better working life and also improve services for patients
- give GPs greater control over their workload without a detrimental effect on patient care
- attract extra funding into general practice
- allocate resources according to patients’ needs
- pay GPs fairly for the work they do
- improve GP recruitment and retention to help to protect patients from the effects of GP shortages
- open up a range of new patient services at local level, and
- build rewards for high quality care into GPs contracts.
If these aims can be achieved, general practice will regenerate and long-overdue improvements in recruitment, retention and morale will at last begin.
One concept that is very much at the heart of the contract is giving GP practices much greater flexibility and autonomy in how they deliver services, allowing them their own choices as to how they organise the care of their patients, whilst judging them on the quality and outcomes of the care they provide.
Primary care and general practice, like the whole of the health service, have been the victims of decades of under-investment. The new contract delivers a step change in investment in primary care and in practice infrastructure – a huge increase that at last reverses the historic underfunding of general practice. Spending on primary care increases from £6.1 billion per year to £8 billion by April 2006, a rise of 33 per cent over three years. General practice has always struggled to get a fair share of NHS resources. This new contract promises huge and historic extra resources for patient care. This will enable practices to improve the quality of their services to patients, leading to better health outcomes.
The contract also offers a better deal for other practice staff such as nurses and practice managers. The flexibility practices will have to decide how high quality care should be delivered to meet local needs will mean better use is made of the skills of other health care professionals such as nurses and pharmacists. Practices should have the resources required to meet the needs of their practice population and will not have to apply to the primary care organisation (PCO) Primary care organisation (PCO) is the generic UK term used to cover primary care trusts (PCTs) in England, local health boards (LHBs) in Wales, local health and social care groups (LHSCGs) in Northern Ireland, and in Scotland it is the primary care trust, unified health board or Island health board. For additional money, for example, for an extra nurse. The contract offers opportunities for mixed partnerships with managers, nurses and pharmacists entering partnership with doctors.
Some of the changes in the new contract:
- The contract is practice-based rather than with individual GPs – the contract is between the practice and the primary care organisation using nationally agreed terms.
- Although patients register with a practice rather than a GP, they retain their right to ask to see an individual doctor, though they might have to wait longer.
- Funding is based on the needs of patients, not the number of doctors.
- For the first time, practices are paid for delivering quality patient care.
- Clinical work is classified into one of three service categories: essential, additional or enhanced. Essential services have to be provided by all practices. Additional services are provided by most practices, and enhanced services only by those contracted to do so by their primary care organisation (see fuller explanation below).
- GPs have the freedom to staff and structure their practices as they want to.
- A Minimum Practice Income Guarantee (MPIG) backs up the contract so that no practice should have lost money by the change.
- A Patient Services Guarantee, which is the responsibility of the PCO, will ensure patients continue to get access to the range of services they currently enjoy.
- Questionnaires in the patient experience area of the Quality Framework mean patients can be consulted about the way their practice runs.
Out of Hours Cover
At the end of December 2004, GP 24-hour responsibility for patient care ended, and responsibility for providing out-of-hours cover in most areas will have transferred to primary care organisations.
Twenty-four-hour responsibility deters many young doctors from pursuing a career in general practice. PCOs now commission, and possibly themselves provide, out-of-hours care. It is envisaged that, as a result, the pattern of service provision will change, with a more multiprofessional response, involving nurses, paramedics, social workers and pharmacists and relying on doctors to a much lesser extent. At all times, patients will continue to have access to an out-of-hours primary health service.
Benefits for Patients
The contract would not be credible or supportable if it did not also deliver substantial and demonstrable benefits for patients. Those benefits include:
- allocating resources to practices according to the needs of their patients
- improved quality of care
- evidence-based indicators in the Quality and Outcomes Framework
- better health outcomes
- the Patient Services Guarantee that patients will continue to be offered locally at least the
range of services that they currently enjoy under the old contract
- consistent services across the UK
- a wider range of primary care services, delivered near where patients live
- the right to ask to see an individual doctor of their choice
- the use of patient experience questionnaires in the Quality and Outcomes Framework.
The evidence-based Quality and Outcomes Framework, which guarantees very substantial rewards to those practices delivering high quality patient care, is likely over time to lead to improvements in health outcomes and reductions in premature deaths, particularly through better chronic disease management. The Framework is unique in the world in its comprehensiveness, and has excited considerable international interest. If it succeeds in levelling up and raising standards of care, it will undoubtedly be imitated elsewhere.
The quality framework also provides a strong financial incentive for practices to consider their patients’ experiences and views about the service they are receiving, through asking them to complete an accredited questionnaire. Practices can then consider and discuss the results of the analysis and implement appropriate improvements. Experience from practices that have already used the questionnaires has shown real benefits – the practical and symbolic benefits of actually asking patients what they think, which in turn both give positive feedback to the practice and allow appropriate change in response to suggestions made and any concerns raised.
Personal medical services contracts
Parts of the new GMS contract are extended to doctors on personal medical services contracts. PMS doctors will benefit by better pensions, the chance to hand over responsibility for OOH and improved pay.
It has been made clear to GPs that the contract is not the final, definitive, perfect version. It is an exemplar, a prototype that can be moulded. Over time and in the light of experience it will be improved, through sensible, evolutionary change.
Out of hours (OOH); responsibility for providing out-of-hours cover has switched to the local PCO. The cost of transferring responsibility to PCOs worked out at £6,000 per full-time GP in an average practice. Special arrangements are available for the few GPs in areas so remote and isolated that they cannot hand over responsibility for OOH in the same way.
The OOH period is defined as from 6.30pm to 8am on weekdays, plus weekends and bank holidays. Practices that want to hold surgeries at other times, eg on Saturday mornings, can still do so. Practices don’t have to be open throughout the in-hours period.
Every practice provides essential services. This covers the day-to-day work of general practice, looking after patients during an episode of illness, the general management of chronic disease and the non-specialist care of patients who are terminally ill.
Most practices offer a range of additional services. These cover things such as contraceptive services, maternity services excluding care during the actual birth, child health surveillance, cervical screening and some minor surgery.
Practices can opt out of one or more additional services either temporarily or permanently. The opting out process involves the local Primary Care Organisation (PCO) and follows set stages within a maximum nine month period. When a practice opts out of an additional service, it loses an amount of money set at nationally negotiated levels.
Enhanced services are optional. They come in three types:
- Directed Enhanced Services (DESs) which PCOs must ensure are provided for patients within their area but no one practice has to do. Many practices will want to provide these as the work is currently done by many GPs. Under the new contract it is explicitly paid for.
The services include flu immunisations, preparation of records for quality, childhood immunisations, minor surgery beyond curettage, cautery and cryotherapy, improved access, care of violent patients. National pricing, terms and conditions apply.
- National Enhanced Services (NESs) which PCOs may seek to commission within their area, include anti-coagulant monitoring, intra partum care, minor injuries, IUCD fitting, drug and alcohol misuse. National pricing, terms and conditions is used as the basis for commissioning.
- Local Enhanced Services (LES). These are commissioned by PCOs and are locally negotiated without national pay rates. They are services provided in response to specific local needs or innovations that are being piloted.