The general practice contract: Implications for practice nurses

The 2018-19 GP contract was published just days before it came into effect on 1 April. The good news is that it offers some additional resources for general practice – but it still falls well below inflation… Plus, How to get a pay rise

To use a wild over-simplification, you get what you pay for. When it comes to buying motor cars or washing machines, doing things on the cheap can certainly lead to a sense of disappointment, a feeling that a few more quid would result in massively improved smugness and satisfaction. But when what you are buying is healthcare, then the stakes are rather higher in terms of death, disability, pain and lost earnings. This is one reason why, in 1948, the National Health Service was created: some things are just too important to be left to the free market.

The potential benefits of healthcare have always run ahead of the willingness of governments to pay for them. Nye Bevan rather naively hoped that after a few years the NHS would result in a healthier population, and so the expenditure required would reduce. I wonder what he would make of the predicament the NHS finds itself in today. Medical inflation is always more than of overall inflation, as a result of people living longer, having more wrong with them before they die, and because treatment improvements are nearly always more expensive than the treatments they replace; nowadays more can be done for more illnesses. I am unable to recall a time in the last 40 years when people working in the NHS did not think that it would benefit from extra spending.

The few years after 1997 when the government of the day made efforts to increase NHS spending to the level of other developed nations certainly led to a new optimism: waiting lists were falling and a job in healthcare was regarded as a national and professional asset. However, the general feeling over the last 40 years has been of endless stress trying to match the needs of patients and the professional motivations of healthcare worker to do their best for their patients, with a succession of Chancellors of the Exchequer (of all parties) equally determined to cut costs. Remember how we were told that we all needed austerity? Remember the ‘magic money tree’? It is sometimes suggested that the problems of the NHS cannot be solved by ‘just throwing money at it’, but at least such an approach has the novel advantage that no-one has ever tried it. Inadequate funding of the NHS has almost certainly led to unnecessary patient deaths, but because this is a statistical extrapolation it is not possible to identify the patients concerned.

And within all this, General Practice has been the perpetual Cinderella. Despite General Practice dealing with 90% of all patient contacts with the NHS, and the number of those contacts rising year by year, the proportion of NHS funding going to General Practice has been steadily falling. In the six years to 2012 the proportionate spend fell from 11% to just over 8% of the total NHS budget, an issue energetically campaigned about by the Royal College of General Practitioners.¹

General practices in the NHS continue to operate – in the main – as a series of small businesses. Each practice has income and expenses, and anything left over is shared out among the owners of the business – usually the partners in the practice. Part of the expenditure is the wages of General Practice Nurses (GPNs), so that GPNs are also financially dependent for their jobs and wages on the economic viability of the practices that they work in. Therefore all GPNs should be interested in how GPs are paid and, by extension, how they themselves are paid.

April is always an exciting time for GPs. It is the start of the financial year and often the first indication of how the money looks for the next 12 months. The changes for the current year were not published until the end of March.² This refers only to England. Scotland, as well as being another country, could be on another planet as far as General Practice planning is concerned – their agreement is quite different (See The GP Contract in Scotland, page XX) and could represent the start of a radical shift in the way primary care is delivered in the NHS.

THE DEVIL IS IN THE DETAIL

Nearly everyone currently agrees that in order to get the health service that governments and their voters are reasonably entitled to expect from the 5th richest country in the world, more has to be spent. There continues to be some disagreement between those who just see healthcare improvement in terms of money, and those who (with some justification) see services in some parts of the country working better than those in others, and wonder why all parts cannot be equally efficient. But the cost cutters are in decline for the time being.

There would be a good argument for just giving each general practice a chunk of money and asking them to get on with it. Politics is never that simple. People who argue that politics should be kept out of the NHS must have been asleep since 1948 – it has always been political. The negotiations between NHS England and the British Medical Association (BMA) have looked at many areas of general practice income and expenditure and done some tinkering. The bottom line is that General Practice in England is due to get £256m more than last year, a figure which may yet rise further depending on what the Doctors and Dentists Review Body (DDRB) report says for this year.³

Global Sum

This is the money that practices get for existing: it is not dependant on performance or quality indicators. Per patient, the amount for 2018-19 will rise from £85.35 to £87.92, an increase of just over 3%. As long as a general practice has registered patients, it will receive the Global Sum payment. This may be thought of as an unfair advantage compared with other small businesses: it is not likely that a general practice will ever make a financial loss. On the other hand think what would happen to patient care when a general practice goes broke and closes down. During the present period of austerity some general practices have become financially unviable and closed, with all the attendant disruption. Other practices have closed because they have been unable to recruit enough staff to do the job.⁴

GP pay and expenses

An interim uplift of 1% has been agreed, pending the report of the DDRB. BMA evidence to the DDRB suggests an uplift of Retail Price Index plus 2%. An increase of 1% doesn’t sound a lot, and indeed it isn’t as it still falls well short of inflation and so represents a real pay cut. You may think this would not matter to GPs who are loaded anyway, and whose only hardship might be to settle for a smaller yacht. However, keep in mind that GPN pay has not actually fallen in money terms during austerity (even though it has certainly not kept pace with inflation – the RCN estimates a real-terms reduction of 14%). For comparison, GP pay fell in money terms by 8% in the 10 years to 2016 (an inflation-adjusted pay cut of around 30%).⁵ The GP partners get paid what is left over when everyone else has been paid, and it is they who have taken the biggest financial hit from general practice underfunding. Being paid more for a job is not a great motivator,6 but being paid less is a sure-fire de-motivator.

QOF

The Quality and Outcomes Framework has rather gone off the boil in the last few years. Indeed in Scotland it has been abolished altogether as a general practice funding stream.⁷ It has been apparent for some time that the QOF was not having much effect on patient care and wellbeing:8 the only advantage of the billions of pounds spent appears to be that there is now an enormous national database of patient medical information.

The QOF indicators have not changed for the coming year. This will be a considerable relief for the GPNs who over the years since 2004 have been the main QOF drivers. The annual tinkering will not be happening this year. This is not to say, however, that the slimmed-down QOF is now financially irrelevant, and practices continue to rely on the QOF income stream. A QOF point in 2018-19 will be worth £179.26, an increase of 4.7% on last year.

The rest

In the contract some organisational adjustments are to be made with respect to vaccinations, violent patients, electronic hospital referrals and electronic prescribing. There are additional financial changes on things like indemnity cover, premises, and reimbursements for parental and sickness absence: these may not affect GPNs directly, but will contribute to the financial security of general practices and secure GPN jobs for the future.

SCOTLAND IS A DIFFERENT COUNTRY

The running of the NHS in Scotland has been devolved to the Scottish Parliament. Late in 2017, BMA Scotland and the Scottish Government produced a negotiated settlement that will inform the future of general practice in Scotland for several years. There is money attached, but the main difference with England is that there are also some quite radical proposals for how primary care will be delivered in future.⁹

One thing that has not changed between England and Scotland is that the agreements have been negotiated between the NHS and the BMA, i.e. between government and doctors. I have not been able to find mention of nurses or their representatives being involved. Nor indeed could I find mention of patients being involved. I don’t know how you feel about this, but I think it is at best a shame, and at worst an insult.

Two phases

Phase One runs for the two years to 2020, after which there will be further discussions about whether to implement Phase Two. This is a plan that will be current for several years, and should bring some workload security. £100 million will be made available for the first year: general practice in Scotland gets £100m for a population of 5.5 million; England gets £256 m for a population of 56 million. You do the math.

Selected highlights include:

• There will be a new funding structure based on a new workload assessment which estimates the number of patient consultations based on age, gender and deprivation. The QOF was abolished in 2016, and the money is to be rolled into the Global Sum.
• First, patient care will increasingly be delivered by workers who are not GPs. New primary care staff (details unspecified) are to be employed to free-up GPs for their roles in undifferentiated presentations, complex care in the community and whole system quality improvement, and clinical leadership.
• Every practice will have pharmacy and prescribing support.
• Home visits to be done by ‘advanced practitioners’ (nurses or paramedics) who may be shared between several practices.
• Phase Two will only be concluded when the value of the direction of travel has been confirmed, and when the Scottish Government has a better idea of how general practice works.

If this sounds like your idea of fun, then get a job in Scotland. Nurses or unspecified other health workers will be seeing most of the patients either in the surgeries or on home visits. The GPs will be swanning around in the background performing consultative, executive and leadership functions. Unfortunately the contract is not well referenced and so is not clear on whether there is evidence to support the value of such changes: has this model been tried before and what happened? What are the unintended consequences (there are always some)? Nor is the contract clear on whether GPs are skilled up for their new roles. So for the rest of the UK this can be seen as a massive experiment. Watch this space.

CONCLUSION

It is pretty obvious that unless general practice gets a significant injection of cash in the very near future then things will start to go horribly wrong, as opposed to just wrong. This year’s settlement represents a step in the right direction, but possibly only enough to stop the rot. It far from compensates for the accumulated effects of underfunding over the last 10 years.

There is a long-term context. UK healthcare workers have always believed that they could do a better job with more money. Despite the despicable contraction in wages, healthcare workers are still relatively well paid (with the exception of the less skilled workers on the minimum wage). The NHS will pull through, like it always has: this is a weakness as well as a strength as governments may form the view that NHS workers will make things work whatever the difficulties.

Scotland is looking to do so very interesting primary care things in the next few years. The changes envisaged have been discussed in medical and nursing circles for some time, so seeing if they can work in practice will be invaluable for the rest of the UK.

Of course GPNs deserve a substantial pay rise, but then so also does everybody else.

REFERENCES

1. RCGP ‘Put Patients First’. http://www.rcgp.org.uk/campaign-home.aspx

2. NHS England. Outcome of the 2018-19 GMS contract negotiations. https://www.england.nhs.uk/publication/nhs-england-letter-gms-contract-changes-2018-19/

3. BMA England. Important message to all GPs in England on changes to the GP contract for 2018/19, from Dr Richard Vautrey GPC England Chair. https://www.bma.org.uk/collective-voice/committees/general-practitioners-committee/gpc-england/gp-contract-agreement-england

4. Wilkinson E. BMA warns of patient impact amid another spate of GP practice closures. http://www.pulsetoday.co.uk/hot-topics/stop-practice-closures/bma-warns-of-patient-impact-amid-another-spate-of-gp-practice-closures/20036489.article

5. Moberly T. How GP pay has risen and fallen. BMJ 2017;358:j4385 https://www.bmj.com/content/358/bmj.j4385

6. Chomorro-Premuzic T. Does Money Really Affect Motivation? A Review of the Research. Harvard Business Review. https://hbr.org/2013/04/does-money-really-affect-motiv

7. BMA. QOF guidance. https://www.bma.org.uk/advice/employment/contracts/gp-partner-contracts/qof-guidance

8. Spence D. QOF’s post-mortem. BJGP July 2016: 371.

9. BMA. Healthier Scotland. The 2018 Medical Services Contract in Scotland. The Scottish Government, Edinburgh 2017.

10. Highfield R. British sense of fair play proven by science. https://www.telegraph.co.uk/news/science/science-news/3335100/British-sense-of-fair-play-proven-by-science.html