The UK-wide GP contract: still fit for purpose?
Authors: Kathy Oxtoby
Publication date: 11 Apr 2012
As NHS reform in England removes working lives ever further from those in Wales, Scotland, and Northern Ireland, will a UK-wide general medical services contract for GPs look increasingly redundant? Kathy Oxtoby reports
Ever since 1911, when David Lloyd George, then chancellor of the exchequer, set out doctors’ terms and conditions under the Insurance Act, general practitioners have had a UK-wide contract.
Over the years differences have emerged between the four nations in how they deliver healthcare, shaped by individual governments’ visions of what form it should take. In Wales and Scotland, for example, it is policy for GPs not to commission services, but in Northern Ireland they do. In England, GPs were encouraged to embrace practice based commissioning. And the enhanced services that GPs are expected to deliver, such as those for obesity and diabetes, vary between the four nations, with the aim that they should be based on local healthcare needs.
Despite differences between individual governments’ health policies, the principle that the GP contract should be negotiated on a four country basis has remained. In 2004, when GP negotiators agreed a new contract, it was on the understanding that it would ensure the same standards of care for patients across the United Kingdom. “This contract strengthened the equitable provision of general practice through the introduction of a quality and outcomes framework. This has meant patients with a range of clinical conditions can expect equivalent standards of care, no matter where they reside in the UK,” says Chaand Nagpaul, a negotiator for the BMA’s General Practitioners Committee and a GP in north London.
But healthcare reforms in England could be about to dramatically change the role of some GPs, prompting a debate as to whether a UK-wide contract is still relevant. The passing of the Health and Social Care Bill means that GPs and other clinicians will be given more responsibility for spending the budget in England; and greater competition with the private sector will be encouraged—a policy at odds with some GPs’ views on how they want to deliver care. For these practitioners the reforms highlight a growing divide between how GPs in the four nations want to, or are able to, practise, to the extent that they believe a UK-wide contract to be no longer fit for purpose (box).
Pros and cons of a UK-wide contract
Why GPs support the contract
The bigger the collective for bargaining, the greater ability that GP negotiators have to bargain on behalf of their members
At times of economic uncertainty it is better to negotiate nationally rather than locally
It ensures the same standards of care for patients across the UK
It has inbuilt flexibility to deal with local needs
Why GPs reject the contract
The contract is too England-centric
GPs living in rural areas—many of whom are in Scotland, Ireland, and Wales—earn less under a UK-wide contract
Extended hours are relevant only to GPs working in the commuter belt, not in rural areas
It lacks flexibility to deal with local healthcare needs
Contract is too “London-centric”
For Sandy Sutherland, a GP based in Midlothian, Scotland, these latest reforms are yet another reason why UK-wide terms and conditions for GPs are not viable. He says that when the new GP contract came into force in 2004 it meant that practitioners in Scotland lost money because their income was calculated on the basis of how many people they could potentially treat. As Scotland has more rural areas, GPs inevitably lost out under this contract, he says.
Sutherland has regularly called for a separate GP contract at the conference of Scottish local medical committees because he believes that a UK-wide contract does not serve the interests of Scottish GPs.
“We only get short term funding for enhanced services, and the amount of money we receive for new patients in no way adequately recompenses us for the work involved.
“We’ve been totally stitched up, but the General Practitioners Committee is reluctant to accept that or discuss the idea of a separate contract,” says Sutherland.
Richard Williams, chairman of Lothian Local Medical Committee, believes the GP contract to be “very London-centric.” He says that the extended hours part of the contract is geared to the needs of London commuters, who have difficulty accessing services during working hours, and is not relevant to most Scottish GPs whose patients live in rural areas and so find it easier to get to their GP during normal working hours.
Alcohol and drug misuse, smoking, and obesity, though covered by the enhanced services aspect of the UK-wide contract, would be better dealt with by a Scottish GP contract that focused on areas of deprivation and need, rather than list size and activity, he says.
This March Williams’s proposal for a wholesale renegotiation of the UK-wide general medical services deal for Scottish GPs was rejected at the Scottish local medical committees conference. Speaking at the conference, Dean Marshall, chairman of the BMA’s Scottish General Practitioners Committee, warned delegates that renegotiating a separate contract for Scotland would be “suicidal.”
Marshall told BMJ Careers that any moves to alter the GP contract would be a reaction by the Scottish government to changes taking place to healthcare in England. He describes the current contract as “world leading and incredibly successful” and says it has meant that “GPs have been able to withstand attempts by politicians to bring in policies where there is often little evidence that they are either required or beneficial to patients.
“Our position is that until someone comes up with a proposal that delivers a better contract than the one we have got, we choose to stay as we are,” he says.
Change in Scotland
Delegates at the conference, however, overwhelmingly backed the call from the Scottish health secretary, Nicola Sturgeon, for a “tartanisation” of the GP contract north of the border. The move indicates that Scottish GPs believe that their contract does not fully reflect the healthcare needs of their patients.
In her keynote speech to the conference Sturgeon said, “We’ve got a health service in England that is barely recognisable. We don’t want to get dragged along in the slipstream of that; we need to be thinking now about what’s right in our interests. It’s not about ripping it up and starting again, but there are aspects we can do better. That’s the discussion I want to have.”
GPs were in favour of using flexibilities in the current UK-wide contract to make it more appropriate to the Scottish population, such as focusing on the scale and nature of the country’s public health priorities.
England, Wales, and Northern Ireland
Governments from the other three nations seem not to have ruled out changes to the GP contract that would make it more flexible to individual nations’ health needs. A spokesperson for the Department of Health for England told BMJ Careers that the government is “happy for officials to explore how best to ensure that we create greater flexibility for each government to deal with issues of particular concern in each country.”
Asked whether a UK-wide GP contract was still fit for purpose, a Welsh government spokesperson said that given “the differences in health policy and priorities between the four countries, further flexibility within the contract to address issues specific to Wales is currently being explored.”
In Northern Ireland a spokesman for the Department of Health, Social Services and Public Safety acknowledged the advantages of a four nation contract, adding that “moving away from that model would require careful consideration.”
However, all governments emphasise that changes to the contract are matters for the BMA’s General Practitioners Committee.
Backing from BMA
BMA leaders are united in their belief that a UK-wide GP contract is the best way to represent GPs’ and patients’ interests. Laurence Buckman, chairman of the General Practitioners Committee, says that being able to speak on behalf of GPs across the UK, rather than from individual countries, enables the BMA to have more bargaining power to represent clinicians and the needs of patients. “Having a UK-wide contract means we can negotiate on a bigger scale,” he says.
Although healthcare policy varies in different countries, this should not detract from the need to have consistency in general practice, which a UK-wide contract can help deliver, says David Bailey, chairman of the General Practitioners Committee in Wales.
“The benefit of having a UK-wide contract is that patients can be certain that they will be given the same kind of service from their GP wherever they are,” he says.
Tom Black, chairman of the Northern Ireland General Practitioners Committee, says that one of the benefits of the current contract is that it still allows GPs to respond to specific health needs of different areas, through local enhanced services.
GPs on the ground have also voiced their support for a four country contract. Andrew Deardon, a GP in Cardiff, says that there is “overwhelming backing” for the contract in Wales and warns that any move to negotiate country specific terms and conditions by GPs would be “throwing the baby out with the bathwater.”
“We need to be careful not to sacrifice something that makes us relatively secure. There is an assumption that having more local contracts would mean GPs get a better deal for their local areas. But given the current economic situation there is not a lot of money around for everyone. At times of economic uncertainty it is better to negotiate nationally rather than locally,” he says.
Flexibility is needed
But some GPs, while supporting the UK-wide approach to negotiating GPs’ terms and conditions, would like to see more flexibility built in to the contract so that they can better serve the needs of their local communities. “What we need is a nationally negotiated framework with local sensitivities to take into account local needs, which isn’t happening at the moment, as the contract is not nearly sensitive enough,” says Sam Everington, a GP in Tower Hamlets, east London.
Although he believes that the current contract is still “fit for purpose,” Mike Dixon, a GP principal in Devon, can envisage a time when commissioning GPs in England who are working within integrated care organisations may require a local rather than a national contract that best serves their interests and those of the communities they serve.
For the present, it seems that many GPs still recognise the benefits of having a four nation approach to negotiating their terms and conditions, and they will continue to back this approach, because it is in their best interests and those of their patients.
As Buckman puts it, “While we’re not complacent about it, the UK-wide contract has stood the test of time. I believe that the bigger the collective for bargaining, the greater the ability you have to bargain on behalf of your members. And what unites us is bigger than what divides us.”
Kathy Oxtoby freelance journalist, London, UK