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Letter to the profession - GP GMS contract negotiations

20 December 2007

Dear Colleague

GP GMS contract negotiations
I am writing to update you on the position we have reached in the GMS contract negotiations for 2008/09. Whatever your own contractual arrangements, it is inevitable that the outcome of these negotiations will affect you and your practice.

As you will be aware, the Prime Minister has given an undertaking that GP surgeries in England will be open in the evenings and on Saturday mornings. This commitment has been reinforced by the detail of the Darzi interim report, which stated, ‘our aim is that at least half of all GP practices will open each weekend or on one or more evenings each week’. It is clear that this issue has become a major political imperative and the top NHS priority for the governments in England and in Scotland (following the publication of Better Health Better Care).

From the survey of GP opinion that we conducted in the summer, we are aware that a significant majority of GPs do not consider such extended opening hours to be a good use of NHS resources, but around half would be prepared to offer such services if the circumstances and resources were reasonable.

Since early October, an outline of a UK agreement for practices to have the option to provide extended opening in the evenings or at weekends has been the subject of detailed negotiation between the GPC negotiating team and NHS Employers. In conducting these negotiations, the GPC negotiators have been intent on reaching a deal which balances the competing demands of offering extended hours whilst preserving a good service to the large majority of patients who want to attend during normal hours. We have also been determined to protect existing practice funding, ensuring the safety of GPs and their patients and preserving a reasonable work/life balance for GPs and their staff.

It was part of a package that we had hoped would lead to an inflationary uplift to all elements of the existing contract, on which all parties have submitted oral and written evidence to the Doctors’ and Dentists’ Review Body. The DDRB will produce their report in the new year.

The potential national agreement on which the GPC was prepared to progress discussions with NHS Employers included the following elements as set out below and all were contingent upon GPs being treated no differently from other doctors by the Doctors' and Dentists Review Body (DDRB) and the DDRB report being fully implemented without interference.

Access
In England, all monies from the current Access and Choice and Booking DESs would be reinvested into a new Extended Access DES to build on the existing Access DES and also include new extended access arrangements for patients. Practices that wished to do so would be funded through the Extended Access DES to offer their patients 20 minutes of appointment time (outside existing core hours) per 1,000 registered patients per week. This would include 5 minutes per 20 minute block for essential administration time. This would be applied flexibly to allow practices to provide hours that would best meet the needs of their local population.

The DES would enable practices to offer extended opening hours for approximately £2.80 per registered patient per annum. The remaining payment of approximately £0.34 per registered patient would be paid for offering convenient access paid based on the results of the relevant current QOF survey questions. In addition, the 20 points currently found in section PE5 of the QOF would be used to reward practices for continuing to meet 24/48hr access arrangements and advance booking. Doctor of choice and telephone access would no longer be monitored other than through the QOF survey, but we believed that practices would want to maintain as good arrangements as possible for the benefit of their patients.

Any changes to the QOF patient survey and the Access DES for the Devolved Administrations would be dependent on agreement being reached between Scottish GPC, GPC Wales and Northern Ireland GPC and their respective departments. The Devolved Administrations would be free to negotiate their access arrangements with their respective GPCs.

Quality and Outcomes Framework
Up to 38.5 points from the organisation and holistic domains were identified as points the government no longer wished to purchase and were to be allocated to new clinical areas or to enhance existing areas. This would have included delivering two new clinical areas – osteoporosis and peripheral arterial disease – plus expanding the scope of ethnicity monitoring, a new indicator covering the treatment of heart failure, enhancing the point value of chronic kidney disease and changes to existing areas in line with the recommendations of the Expert Panel. This work was developed in line with the agreement that the QOF is an evolving scheme and should be updated to reflect changes in evidence and good clinical practice, as advised by experts.

IT DES in England
The DES would continue for those practices that had already agreed to participate but had yet to complete all of its components.

Inflationary resources rise
All parties have submitted evidence to the Doctors and Dentists Review Body (DDRB) and are awaiting its conclusion. However the final agreement of any deal between the GPC and NHS Employers on Access and the QOF would have been dependent on the availability of suitable additional resources introduced into the contract in 2008/09.

The GPC negotiating team has done its utmost to reach an agreement with the NHS Employers on these issues. The team believes that the package that it had been prepared to agree to would have protected practice income in an atmosphere where government was determined to claw back resources from practices at the same time as making extended practice hours a political priority. The QOF changes would have led to improvements in patient care. Whilst the GPC had significant concerns about the package, it recognised the political reality of the current situation and it was prepared for the GPC negotiators to continue with discussions with NHS Employers and the departments of health. This was on the basis outlined and would demonstrate that General Practice is responding to governments’ views about the need for more flexible access to primary care, whilst being able to maintain a good quality in-hours service. Practices would have provided this increased level of service for the same level of funding.

Unfortunately NHS Employers, having taken further instructions from the government, was not prepared to proceed on this basis and insisted on seeking 30 minutes of clinical time per 1000 registered patients per week. Extended sessions would have to be provided in blocks of no less than 1.5 hours in the evening or one hour in the morning. Extended hours surgeries would be offered in a way that was in line with the way in hours services operate. Practice opening arrangements would be determined by asking patients what they want and then a practice plan would need the approval of the PCO.

The government stated that the 38.5 points identified in the organisation domains and the holistic points of the QOF should all be given to support these new access arrangements, bringing the total of QOF points related to access to 58.5. This, in fact, would be sacrificing evidence-based potential new areas of work (for example osteoporosis and heart failure) that would have saved lives and provided improved quality clinical care to patients, in exchange for non-evidence-based government-driven politically-motivated access targets. Finally they have given an undertaking that should the profession accept this deal, they would agree to a minimum of 1.5% additional new investment in to the contract. We are however unclear how this would be allocated.

We have been informed that if the GPC is not prepared to accept this offer, the government will impose changes to the GP contract, which will be worse than the final offer that has been made. We expect that the government will give notice tomorrow of a 13 week period of consultation about plans to impose changes.

In the face of this threat, the Committee believes that it is essential that it maintains its stance and does not agree to being coerced into accepting something which it considers will be fundamentally unacceptable and unfair to GPs and their staff and lead to a worse service for patients. We believe that GPs throughout the UK would not wish the GPC to give in to threats in place of a properly negotiated deal.

The GPC’s decision and what is likely to happen now
At its meeting today, the General Practitioners Committee has concluded that it does not accept the government's current contract proposals and that we should attempt to gain further improvements in the flexibility and appropriateness of the arrangements. Once we have gained further clarity about governments final proposals we will seek the opinion of all GPs. The Committee believes that the NHS Employers’ offer on behalf of the governments places undue emphasis on the politically-driven agenda of extended opening hours, to the detriment of evidenced-based quality care that practices already provide to their patients.

If, as we expect, the government proceeds to impose changes on Friday 21st December, the procedure requires a 13 week consultation before implementation. We accept that the move to impose can be stopped at any time in the event of a satisfactory deal. We will write to you again as soon as we have further details.

Yours sincerely

Dr Laurence Buckman
Chairman, General Practitioners Committee