Why do changes to the GP contract in Scotland matter, asks Christine Hoy, the ALLIANCE.
Long ago, nurses thinking about a move from hospital to general practice nursing, were advised “it’s all about taking bloods and cdm”. This was a pretty accurate description, as it was important to master the ancient art of blood letting (no leeches were involved) and understand “chronic disease management”.
Times have changed – “chronic diseases” are now known as “long term conditions” and words like “person centred”, “assets”, integration” and the like are becoming more familiar in health and social care circles across Scotland. There is increasing recognition that the aim of health and social care systems must centre on our whole wellbeing and be less about dispirit interventions and unconnected episodes of care.
General practice has changed little since the NHS was founded in 1948, they remain vital hubs in communities, often play a significant part in our lives and are usually organised around short appointments. The demographic shift in the last 60 years has been simultaneous with improved control of infectious diseases and a dramatic rise in the number of people living with multiple long term conditions. These factors and persistent health inequalities in Scotland has prompted a call for radical change in the design of our caring services.
In primary care this is reflected in the call for a more generalist approach in general practice and is also reflected in the new contract agreed between the Scottish Government and the British Medical Association’s Scottish General Practitioners’ Committee.
This contract is significant as it may affect our experience of attending general practice and the agreement reflects the different priorities north of the border.
The primary focus of the contract is to provide a structured framework for GP practice income. GP practices receive funding through several streams, including a core fund for providing day-to-day (essential) services, Enhanced Services (both local and national) and the Quality Outcomes Framework (the QOF), which includes effective management of long term conditions. The QOF was introduced in 2003 to standardise treatment across the UK and introduce consistent management of a range of long term conditions. Providing a monetary incentive has produced great improvements for certain (not all) conditions in the last 10 years, but the QOF’s single disease approach and the bureaucracy attached to administration has become frustrating, as the framework can’t respond to the context of a person’s whole life. So what’s changing?
Eight per cent of GP practice income comes from the QOF, which is organised around achieving a certain number of points linked to funding. The new agreement has reduced the total number of QOF points and the funding released will be transferred to the practice’s core income. The contract also introduces a focus on quality and safety.
Here are examples of the changes:
- the points rewarded for maintaining individual disease registers has been removed
- the review period for certain long term conditions such as diabetes and epilepsy has been changed from 12 to 15 months. This reversed a change introduced in 2013 following the conclusion by NICE that the decrease to 12 months delivered no clinical benefit, and increased bureaucracy
- Practices will annually assess current demand (met and unmet need)
- Following the annual assessment, practices will submit a ‘Patient Access Action Report’ to NHS Boards and will be encouraged to involve patients in this process
- Practices will nominate a liaison GP to link with their local Health and Social Care Partnership
- Practices will produce an annual Quality Improvement Report and will have a Quality Programme peer review visit once every three years
However – it is not straightforward, the opportunities for re-negotiation of the contract has sparked debate in Scotland’s GP circles. For instance, Glasgow NHS Board is considering adopting a contract called “17C”, which abandons the QOF altogether, while the Scottish GP Committee and the Glasgow Local Medical Committee are more supportive of a national GP contract.
Whatever is agreed, the contract negotiated in Scotland is designed to be more flexible and to improve both our own experience of attending, and staff experience of working in general practice. Without the distraction of meeting numerous targets, there should be more time in consultations for a more personal approach, a focus on prevention, self management and on the most vulnerable people in our communities.
The contract stipulation that practices must nominate a liaison GP to link with emerging Health and Social Care Partnerships, should encourage integration, pooling of local resources and a co-produced response to local need.
The contract has potential to enable GP teams to develop a stronger focus on what really matters to people by adopting a personal outcomes approach. Also for teams to become more “community facing”, with stronger links to local support like informal and formal community groups, libraries, schools, walking groups, lunch clubs – whatever it is that people consider they need to live well.
The reciprocal benefits of strengthening connections between general practices and the communities they serve, has been explored through initiatives such as the GPs at the Deep End Social Prescribing activity, the Links Project, BRIDGE (Building Relationships in Deprived General Practice Environments) and Improving Links in Primary Care. ALISS (A Local Information System for Scotland) is a national system designed to make it easy to find and share local information and the emerging Link Worker Programme will explore the value of Community Links Practitioners in deprived areas.
The contract will influence how primary care operates and may affect our experience of attending general practices in the future. These changes are an important opportunity for joint thinking about how continuous improvement of our wellbeing and the wellbeing of our communities will be measured.
The third sector has valuable expertise to contribute to emerging health care policies in primary care, it’s important that we get involved.