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Investing in general practice

The new general medical services contract
February 2003

As part of the original contract negotiations, it was agreed that the contract would be reviewed for 2006. Changes have been agreed by NHS Employers, the General Practitioners Committee (GPC) and the health departments of England, Scotland, Wales and Northern Ireland in the first stage of that process, which will come into effect on 1 April 2006.
Access the document outlining the changes here

Chapter 1 : Investing in general practice: summary of changes

1.1 If accepted by the profession, the new GMS contract will:

(i) provide new mechanisms to allow practices greater flexibility to determine the range of services they wish to provide, including through opting out of additional services and out-of-hours care

(ii) reward practices for delivering clinical and organisational quality, through the evidence-based quality and outcomes framework which is in line with professional practice, and for improving the patient experience

(iii) facilitate the modernisation of practice infrastructure including premises and IT, support the development of best human resource management practice and help GPs achieve a better work/life balance, support the development of practice management, and recognise the different needs of GPs in different localities, including GPs in deprived communities and in rural and remote areas

(iv) provide for unprecedented and guaranteed levels of investment through a Gross Investment Guarantee, which replaces the current flawed pay mechanisms. The contract allocates resources on a more equitable basis and allows practice flexibility as to how these are deployed from the global sum

(v) as a result of these mechanisms, support the delivery of a wider range of higher quality services for patients and empower patients to make best use of primary care services

(vi) simplify the regulatory regime around how the contractual mechanisms will work

(vii) be implemented as soon as practicable in all GMS practices, and be revised following consultation and negotiation with the General Practitioners Committee (GPC) of the BMA [1].

The Governments are committed to following good practice on consultation arrangements as set out in the Cabinet Office Code of Practice on Written Consultation which sets out the arrangements and timescale for consultation in normal circumstances. This provides that, where consultation on written documents takes place, the period of consultation should normally last at least 12 weeks, other than in exceptional circumstances.

More flexible provision of services (Chapter 2). Read more here
1.2 A key objective throughout the negotiations has been to address the issues of practice workload and to find ways which this could be managed without a detrimental effect on patient care. The new contract allows practices to control their workload by providing them with the ability to choose the services they will provide.

1.3 This will be achieved through a categorisation of services. All GMS practices will provide essential services. Practices will also provide a range of additional services and have the opportunity to increase their income further through opting in to the provision of a wider range of enhanced services. Where practices are experiencing difficulties such as recruitment problems they will be able to opt out of the provision of additional services, either temporarily or permanently.

1.4 At the same time, Primary Care Organisations [2] (PCOs) will be responsible for ensuring that patient access to services is not compromised. Where practices opt out of services, their global sum will be reduced and the PCO will be able to use this money to secure alternative provision from other practices or primary care providers including PCOs themselves.

1.5 Recognising the current issues with patient assignments, the NHS Confederation and GPC have developed a proposal which aims to prevent a further burden on practices which are already experiencing difficulties, whilst guaranteeing patients access to the services they require.

1.6 The new contract recognises the need for GPs to have a balance between their work and personal commitments. This will be achieved through the opt-out arrangements referred to above and removal of the default position for out-of-hours services. A key message from the 2001 GPC National Survey of GP Opinion was to ensure that GPs were able to retain the option to provide out-of-hours care where this was their desire. In other cases, however, it was recognised that GPs wished to opt out of providing this service. The new contract allows for both.

1.7 By 31 December 2004, all PCOs should have taken full responsibility for out-of-hours. The PCO will be able to exploit a number of models for delivering out-of-hours care using various providers and professions such as NHS Direct/24, GP co-ops, NHS walk-in centres, practice partnerships, paramedics, pharmacists, GPs and primary care nurses in A&E departments, commercial deputising services and social work services. Different models of care will be developed in different areas shaped around local needs and circumstances.

Rewarding quality and outcomes (Chapter 3). Read more here
1.8 The contract provides a major focus on quality and outcomes. Practices will have the opportunity to receive additional funding to support aspiration to and achievement of a range of quality standards. The new quality framework will reward practices for delivering quality care with extra incentives to encourage even higher standards. The quality framework will have four main components focusing on:

(i) clinical standards, covering coronary heart disease (CHD), stroke or transient ischaemic attacks, hypertension, diabetes, chronic obstructive pulmonary disease (COPD), epilepsy, cancer, mental health, hypothyroidism and asthma

(ii) organisational standards covering records and information about patients, information for patients, education and training, practice management and medicines management

(iii) experience of patients covering the services provided, how they are provided and their involvement in service development plans

(iv) additional services.

1.9 The quality standards have been developed by an independent expert group on the basis of the latest evidence and are in line with current professional practice. At the beginning of the year, practices will aspire to achieve a number of quality standards and will receive a proportion of the quality payment, which includes the additional infrastructure associated with the delivery of these standards.

1.10 Once achieved, the practice will receive the remainder of the quality payment - the achievement payment. Separate preparation payments will also be made. In recognition of the increase in workload required to deliver good access at the same time as higher quality, practices will receive additional payments where they are achieving the relevant national access target.

1.11 A system of exception reporting will be put in place to ensure that practices providing a quality service will not lose out on quality payments through factors outside their control.

1.12 The quality framework will be measured within a high trust system developed to strike a balance between monitoring and demonstrating that standards have been achieved. This will be implemented in normal circumstances through an annual review, including a practice report and a visit by the PCO. Effective IM&T systems will be required to implement the quality and outcomes framework and these will be supported through new investment. Implementation will start in 2003/04.

Developing human resources and modernising infrastructure (Chapter 4). Read more here
1.13 Practice infrastructure will be modernised to ensure that patients can have access to high quality services delivered in modern, fit-for-purpose premises. Premises and IM&T will receive a major boost through considerable additional investment.

1.14 A number of new premises flexibilities and revised payment arrangements will be introduced through the new contract to ensure that the quality of practice premises is adequate to provide a quality service to patients and funds are targeted at those areas where premises are most in need of improvement.

1.15 Practices will be incentivised to exploit the use of IM&T both in terms of clinical and management systems. PCOs will fund the costs of practice IM&T systems which have been accredited against UK-wide standards. Each practice will have guaranteed choice from a number of accredited systems with transition from practice to PCO ownership in line with new investment.

1.16 The new contract will recognise the different stages of a GP career and GPs will be able to adapt their career to suit their aspirations. Salaried and independent contractor status will be available with greater flexibility around moving between the two. The new contract will also reflect a three-module approach to the GP career based on skills, knowledge and experience.

1.17 The contract recognises the need for GPs and their staff to have a work/life balance and work is continuing to provide access to NHS childcare facilities as well as cover for those on maternity, paternity and adoptive leave.

1.18 Existing seniority payments will be increased and the scheme improved to help reward experience. The arrangements for appraisal will not change from those recently negotiated and the funding for this has been built into the global sum. The global sum also contains funding to provide for protected time for GPs to undertake a range of activities.

1.19 The function of practice management will be enhanced, recognising the contribution an effective practice management can have on reducing the administrative burden on clinical staff. Practice managers will be encouraged to develop new roles and responsibilities following a new competency framework.

1.20 We recognise that practices in rural and remote areas may not always be able to enjoy the same options as other practices. We therefore acknowledge that practices in these areas require additional support and this will be provided by PCOs.

Investing in primary care services (Chapter 5) Read more here
1.21 The new GMS contract will provide an unprecedented level of investment into primary care to improve services to patients and to revitalise general practice. This investment will form a three year Gross Investment Guarantee which will be monitored by the Independent Technical Steering Committee.

1.22 The new Carr-Hill allocation formula will provide equity, recognise casemix and practice circumstances, and ensure money will flow according to patient need. The particular needs of patients will be taken into account when calculating the amount each practice receives in its global sum allocation to provide a range of essential and additional services. Practices will have the flexibility to use these resources in a way which suits local circumstances and meets patient need. Funding will be provided irrespective of whether or not doctors are in place. A UK tariff, adjusted according to practice circumstances under the Carr-Hill formula, will apply for opt-outs from additional services and out-of-hours care.

1.23 There will be a guaranteed floor of money from the unified budget of PCOs to ensure that enhanced services can be delivered where appropriate and this will help to make the shift of secondary care services to primary care a reality. PCOs will manage the funding for other elements of the contract such as certain HR initiatives, premises, and IT. Spend on many of these elements and the quality framework will be subject to fixed national rules to ensure equity.

1.24 Mechanisms for payments to dispensing doctors will continue but will be reviewed in the light of negotiations on a new pharmacy contract. Funding for dispensing, including some of the costs of dispensers, will be separate from the global sum.

1.25 As a result of the increased investment guaranteed under the new contract, practice income will rise and, together with the new changes to the pension scheme, the total percentage increase in pensions should, over time, exceed the percentage increase in net income. A number of changes will be made to the existing pension scheme including a new definition of pensionable pay, new pension flexibilities to facilitate portfolio careers for GPs who may wish to work at some stage as salaried GPs and independent contractors or in other NHS service and, in line with a practice-based contract, allowing non-practitioner providers into the NHS pension scheme.

1.26 Funding flows to PCOs will change to support these new arrangements, following the introduction of primary legislation.

Better services for patients (Chapter 6). Read more here
1.27 A Patient Services Guarantee, underpinned by new duties on PCOs, will ensure patients continue to get access to the range of primary medical services. New arrangements for the registration of patients with practices will both recognise the need for practices to close their lists as a means of managing workload and ensure that all patients are able to register with providers to receive NHS primary medical services. These will help minimise the need for forced assignment of patients. PCOs will have new mechanisms to ensure that whenever a practice opts out of an additional service, patients will receive the care they need. Patients will also benefit from a wider range of enhanced primary care services. The measures to improve recruitment and retention will enable primary care capacity to expand.

1.28 Although patients will now register with the practice and not an individual GP, they will still retain the choice, where appropriate, to request to see an individual GP. Holistic care will be incentivised through holistic care payments under the quality framework. Rapid access to services will be rewarded through the quality framework and patients will be able to exercise new choices in relation to additional and enhanced services.

1.29 In addition, patients will be empowered to use primary care effectively. Whilst not strictly a contractual issue, improving public education, empowering patients and developing the role of skill-mix across primary care are crucial to the context and environment in which a new contract will work. PCOs will have the opportunity to develop a range of initiatives to improve access for patients and help them to manage their own conditions, learning from pilots already under way such as developing ‘expert patient’ schemes and working with community pharmacies in reducing general practice consultations for over the counter medicines.

1.30 These initiatives will enable services to be designed around patients’ needs. Through the quality framework, practices will be rewarded for surveying patients’ needs and taking account of these. Patients will also be consulted appropriately on decisions that affect the operation of services they receive.

Underpinning the contract (Chapter 7). Read more here
1.31 The new contract will normally be an NHS contract between the local Primary Care Organisation (PCO) and the practice, not the individual GP. Together with supporting documentation it will set out:

(i) what services practices will provide

(ii) the level of quality to which services will be provided

(iii) the infrastructure and support available

(iv) the financial resources to support this.

1.32 The practice-based approach will enable the practice to use the resources available to it, both people and money, to deliver services in such a way as to meet their needs and the needs of their patients. The existing system of statutory vacancies will be replaced by practice flexibility to introduce new partners or employ the staff they need to deliver services. Teamwork will be encouraged and other professionals including nurses and therapists will be able to have extended roles in delivering services and could be co-signatories to the local contract.

1.33 In England and Wales, the existing three separate GP lists - the Medical List, the Supplementary List, and the Services List - will be rationalised and replaced by a single Primary Care Performers List. The Scottish Executive and the Northern Ireland Health Department will announce their respective plans for future listing arrangements in due course. In recognition of the practice-based approach, the Primary Care Performers List will be extended over time to cover other primary care professionals delivering services to patients.

1.34 A national contract will reflect the agreements set out in this document and be used as the basis for contracting between the practice and PCO. The existing primary legislation will be replaced by new provisions, which will underpin the introduction of a new secondary legislative regime by April 2004, subject to Parliamentary agreement.

Making it happen (Chapter 8). Read more here
1.35 If the profession votes in favour, the Doctors’ and Dentists’ Review Body will be asked in joint evidence between the GPC, the NHS Confederation and the four UK Health Departments to endorse the agreement, and primary legislation will be introduced.

1.36 The new contract will be implemented in a phased way, allowing those elements that are not subject to primary legislation to be implemented more quickly. Substantial implementation will occur in 2003/04.

1.37 Future changes to the contract will be consulted on according to existing good practice as outlined in the Cabinet Office guidelines. New work will be recognised and rewarded appropriately.


1. The words ‘negotiated’, ‘negotiation’, ‘consulted’, ‘consultation’ and the expression ‘discussion and negotiation’ were used in the framework document and apply in this document to describe the process of consultation set out below together with the established negotiation process that is part of, and/or may follow, such consultation. Failure to reach agreement would not prevent the Secretary of State or Health Ministers from discharging their statutory obligations or exercising their statutory powers.

2. In Northern Ireland, this will be the Health and Social Services Board.