Signed, Healed, Delivered

Written by: Mark Kelvin, Programme Director, the ALLIANCE

Mark explores the detail of the newly agreed GP contract and considers what it might mean for people accessing primary care services.

When Dr Finlay cared for the population of Tannochbrae in the 1920s, he did so under a General Medical Services contract. This contract has evolved substantially since then but GPs have (with few exceptions) continued to be individual contractors with the NHS. The contract has at times been agreed and at others imposed, but it has always guided what services are provided by GP teams and sets out the terms of their remuneration.

Today, the long awaited 2018 General Medical Services contract was approved.

Since the proposal of the new Scottish GP contract was announced in November 2017, GPs have been voting on whether they think the new contract should be accepted. Today, the Scottish GP Committee agreed that the contract should be implemented. This means that April 2018 marks the beginning of a three-year transition period which will see potentially the biggest transformation of General Practice since the Thatcher-imposed contract of 1990. That contract, which was imposed after it was voted down by BMA members, introduced targets and competition to general practice and remained in place until the 2004 contract was introduced.

The 2018 contract, which is heralded as ‘an historic joint agreement between the Scottish Government and the BMA’ is ambitious. It aims to improve our access to GPs, address health inequalities, and improve population health (with mental health gaining a specific mention). Alongside these benefits for the general population, the contract aims to offer many benefits to GPs. These include providing financial stability, reducing GP workload, reducing financial risk, and an increase in peer support in quality assurance activities. So how will this be achieved?

Alongside additional financial investment, the reorganisation of multidisciplinary teams aims to ensure that where safe and appropriate, people receive care and services from the professional most suited to meeting their needs, no longer will the GP be the main provider of all general medical care. Instead, as an example, by the end of the transition period all acute and repeat prescriptions will be undertaken by a General Practice pharmacist. ‘Additional services’ will also be provided by the expanded general practice team. These include acute musculoskeletal physiotherapy services, community mental health services, and community link worker services. As I said, it’s ambitious and at first sight appears to be very positive. I have a couple of anxieties though.

Whilst the use of Barbara Starfield’s “four C’s of primary care” (contact, comprehensiveness, continuity, and coordination) as guiding principles throughout the development of the contract offer reassurance, I have concern for the unintended consequences. Just as the 2004 contract was seen by many to improve clinical care, the side effects outweighed the benefits and the letter of the contract became more important than the spirit. I fear that the same mistakes could be repeated here.

The aim of the 2018 contract is to ‘provide the very best of care’, and the intention is for this care to be person-centred, holistic, and co-produced. Our experience in coproducing and delivering the Links Worker Programme has been that finding the balance between delivering an enhanced person-centred relationship-based service that can also meet the demand created by being part of a general practice team is incredibly nuanced. It is possible but there are barriers that will need to be overcome.

Firstly, staff delivering new services will need to establish relationships of trust with their new colleagues very quickly. Establishing successful relationships between new colleagues and existing practice staff is critical in embedding new roles, and our research (this link will take you away from our website) showed that this has a direct impact on how much new staff members are utilised by people accessing primary care.

Secondly, and related to the first point is the physical space required to host the expanded team. GP premises are notoriously struggling for space but for the above relationships to be created, colocation is critical. Colocation also aids sharing of information and access to medical systems. This leads to another barrier, the sharing of information.

Staff are increasingly aware of data protection issues, and the new GDPR legislation could present further challenges to this. Whilst the new contract aims to be both facilitative and protective for GP practice’s data responsibilities, there are often other barriers to it being shared. People are already having to repeat their story with their existing care providers and pertinent information isn’t always shared. Increasing the number of potential providers could exacerbate this existing issue.

There’s also the public reaction to consider. For the expanded team to be most efficiently used, people presenting to primary care will need to be triaged at reception. Reception staff will need to enquire as to the reason for the appointment so that the most appropriate professional can be identified. Will people be happy to share this information with reception staff and will they understand the reason for asking?

As I read the new contract offer I can’t help but picture the GP practices of the future as mini hospitals. Indeed, some of the services being brought in to General Practice are currently based in secondary care. And here’s my main anxiety.

Dare I say it, I don’t see hospitals as providers of long-term, relationship-based care. Don’t get me wrong, the staff that work within each department do an amazing job and aim to treat the whole person despite enormous pressures, but they are based within their specialist department. My bones are cared for in a separate part of the hospital to my eyes. My acute ill health as an infant is managed by a different team to my health as an older person. General Practice is the last part of the NHS that takes all comers. It has no exclusion criteria, and this enables a depth and duration of relationship that secondary care, with all the will in the world, cannot replicate.

The 2018 contract aims to provide the very best of care for the people of Scotland, but does it take away our ability to actually care. Can 10 highly-skilled staff caring for one person offer the same level of care as one generalist practitioner who, like Dr Finlay, has been a person’s GP from cradle to grave? Is it possible to contract for care, and if it is, does the new GMS contract cut it?

The Scottish Government are keen to hear your views on the contract and have asked the ALLIANCE to facilitate a series of workshops across Scotland. For more information on an event near see our events calendar or  contact gregory.hill-oconnor@alliance-scotland.org.uk.

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