Now the Health Bill has finally been passed by parliament, the government needs to find a palatable way of tying England’s GP practices – increasingly disenfranchised by the reforms – to the new clinical commissioning groups (CCGs) that will be driving change in the reformed health service.
Now the Health Bill has finally been passed by parliament, the government needs to find a palatable way of tying England’s GP practices – increasingly disenfranchised by the reforms – to the new clinical commissioning groups (CCGs) that will be driving change in the reformed health service.
But how any new commissioning objectives will be worked into GPs’ core responsibilities and contracts is likely to prove hugely challenging for the government. The BMA’s GP Committee is resisting any changes to the GMS contract at all, aside from perhaps a basic requirement that practices are members of a CCG.
GPC deputy chairman Dr Richard Vautrey says there is no reason to change PMS or GMS at all, despite the scale of the government’s ambitions for the profession.
“The GP contract actually is providing some stability in patient services at a time of great upheaval and change,” he says. “If we continue to tinker with it as the government has done for the last few years, it undermines practices ability to provide quality services for patients.”
Dr Vautrey insists more detailed commissioning objectives should not become part of GP’s core responsibilities – CCGs should have to ‘earn’ the engagement of their member practices in achieving commissioning outcomes, he says.
“At the moment, the only responsibility GPs should have is for the practice to be part of a CCG. It is up to the CCG to win their engagement, and that is how it should be. Compelling people to do something often just leads to perverse outcomes,” says Vautrey.
A leaked draft government ‘risk register’ expresses the very real concern that, among other things, the DH will be “unable to negotiate the necessary changes to the GP contract to incentivise and lock practices into consortia (the former name for CCGs)”. The government document rates this scenario as ‘three out of five’ in terms of likelihood (five being ‘almost certain’) and four out of five in terms of the impact it would have on the success of the reforms in general.
The idea that GPs will not accept commissioning objectives imposed on them is perhaps why think tank The King’s Fund has been mooting the idea of an ‘alternative’ contract, for GPs with a greater focus on commissioning and service design, to opt into.
Nick Goodwin, senior fellow at The King’s Fund, explains how a contract that includes organisations from related sectors, such as nursing and community services, could help strengthen GPs’ commissioning power.
“I don’t think we’ll see the end of the GP contract but there may be an option to move onto an alternative contract with the options available to do something different,” he says.
“GPs may be offered a sort of opt out where you are part of a wider multi-agency contract,” he says. “There has to be new capability built around the challenge of ageing population and increasing spend on long term conditions.” Goodwin admits, however, any optional new contract is likely to be taken up variably around the country. “Any new contract will undoubtedly appeal to GPs working in homogeneous places, where there is perhaps a common issue that needs tackling. For others, GPs working in difficult areas, it might be more threatening,” he says.
For Vautrey, however, the idea of a voluntarily, alternative contract is “unnecessarily complicated” and would stifle local working.
“It misses the point and sees commissioning in contractual terms, when GPs really should have the freedom to work in lots of different ways.”
The GPC believes local agreements between the NHS Commissioning Board, CCGs and practices can incentivise and monitor GP commissioning in a local way, without the need for changes to national contracts. Agreements similar in form to Local Enhanced Services (LESs) could fund GPs’ engagement and activity with their CCG, says Vautrey.
Yet as contracts move from PCT and SHA control to the new NHS Commissioning Board, the nature of contracting will undoubtedly change. LESs, useful tools for bolting on improvements to practices’ core services, could be impossible to develop in the new NHS landscape, says Goodwin.
Moving GP contracts to the NHS board will make the development of localised contracts and services more difficult, he says, and could even spell the end for the PMS contract, which now accounts for nearly half of all GP practices.
“I’m not sure the way the NHS Commissioning Board will run GP contracts, even with regional outposts, will be flexible enough – we may see the end of PMS, especially – it’s part of the board’s general aims to centralize a lot of the financial aspects of the health service.
“DESs and LESs will become a more difficult concept to organise under CCGs. They were often a more successful way of developing local services than practice-based commissioning was, for example.”
But Vautrey is confident GPs can work around the conflicts of interest inherent in the new system.
“Developing enhanced services locally will become more complicated. Contracts will be held by the NHS Commissioning Board but they can be developed by the CCG, who then get sign off by the board. That seems a sensible way to do that.”
Dr Charles Alessi, chairman of the National Association of Primary Care and vocal supporter of the government’s reforms, also thinks LESs and other local contracts will be able to flourish between CCGs and the NHS Commissioning Board.
“I don’t agree it will be more difficult [the creation of LESs and very localised agreements]. The NHS Commissioning Board will have regional outposts and they should be sensitive to the plans of CCGs. It should be able to work and integrate with them.”
And far from the disappearance of PMS contracts, Alessi thinks the reforms will herald a move towards the proliferation of local contracts – and away from GMS.
“If you look at the overall focus of the reforms it’s about moving to a more locallly-determined health service. This points to a PMS contract being more helpful with achieving those aims. I’m not suggesting we scrap GMS, though. The reality, though, is we have a contractual agreement that has taken years to negotiate.”
Another issue that could lead to GPs’ delicately negotiated contract unwinding is the increasing divergence of policy in England with the rest of the countries in the UK. Will the three Celtic countries need their own GP contract if England’s is significantly changed?
Alessi believes such is the pressure on their health systems, the other UK countries will “inexorably” move towards a similar system to England. “Internationally, everywhere is moving towards the idea of clinicians taking fiscal responsibility for the delivery of a population’s health. I think it’s inevitable that whatever happens in England, those countries will have to move to the same place before their healthcare becomes unaffordable.”
So far, it’s all very speculative and there is little in the way of consensus on many of the major issues on the horizon. With contractual changes for 2012/13 already settled, GPs are unlikely to see any details of their new responsibilities on paper until 2014, even later if there is a stalemate between the GPC and the government. In fact the government may have its plate full for the next few years anyway – NHS Employers currently states that its ‘future work’ on the GP contract includes piloting the removal of practice boundaries, work to reduce A&E admissions and a reworking of the Carr-Hill formula – all extremely complex policy commitments.
And there has still been no word from the government on how its ‘quality premium – the fund paid to CCGs for achieving the aims of the Commissioning Outcomes Framework – will be distributed.
What proportion of this payment goes to the CCG as a whole to reinvest in services and what proportion will be paid as a financial bonus to individual practices and GPs?
Despite the BMA’s best efforts to keep these ‘bonuses’ away from GPs making cost-based decisions about patient care, Alessi says some degree of financial reward is inevitable.
“CCGs will receive a quality premium based on their achievements in relation to the commissioning outcomes framework – and I agree the GP contract shouldn’t be full of these commissioning objectives.
“But if practices aren’t completely intertwined with CCGs, then the reforms won’t be working properly. If they aren’t we will end up with a situation where GPs are being told you have to do this or that and that is exactly what we want to move away from.”
It should be left up to CCGs to decide how they distribute their quality premium payments, proposes Alessi.
“That needs to be left to local determination. Local circumstances can be fundamentally different.
You can have a situation where in one CCGs all the practices wish to reinvest all the money in a certain service, and it must be up to them how they do it.”
It seems there is consensus among GP groups on one point surrounding the reforms and primary care contracting: That whatever systems and contracts are drawn up over the next few years, they must be drawn up by the clinicians themselves, locally. This will prove difficult and time-consuming due to the inherent conflicts of interest that comes with GPs developing their own services and the establishment of a brand new management hierarchy.
Unfortunately for GPs, the new role seems unlikely to prove financially lucrative either – if the BMA is opposed to GPs getting paid for all this new work, you can be damn sure the government won’t force it upon them.
