Conclusions and Recommendations
1. The new contract cost some £1.8 billion
more than planned. Incomplete
data on the cost of services provided by GPs led the Department
to underestimate expenditure in the first three years of the contract.
While Primary Care Trusts' funding was increased, they still spent
£406 million more than allocated, largely because of the
additional cost of providing out-of-hours care and higher than
expected levels of payments to GPs under the pay for performance
system. Where practicable, major changes should be piloted before
they are implemented so that costs can be determined with greater
accuracy.
2. Since March 2003, 4,098 more GPs are working
in primary care, an increase of 15.3%.
There are also fewer vacancies for GPs, including in some deprived
areas where recruitment has previously been a problem.
3. General practice productivity has decreased
annually by an average of 2.5%. The contract
was expected to deliver 1.5% productivity gains year-on-year.
The Office of National Statistics' method for estimating productivity
is, however, not accepted by the Department as sufficiently robust.
An agreed method for measuring productivity in primary care should
be developed, which has the support of the NHS, the Department,
the Treasury and the Office of National Statistics. More specifically,
the Department needs to set a clear strategy and timetable for
Primary Care Trusts to report to Strategic Health Authorities
on how their GP practices have improved productivity.
4. Many Primary Care Trusts do not yet have
the capability to make the best use of the contract to maximise
the benefits for patients. The contract
allows Primary Care Trusts to negotiate with GPs the provision
of a range of enhanced services specifically intended to meet
local needs. Very few Trusts have so far done this, and over a
half have not spent to even the minimum level set by the Department
for enhanced services. Primary Care Trusts should use the standards
developed as part of the Department's World Class Commissioning
programme to benchmark their commissioning performance and identify
priority areas requiring improvement.
5. The contract has yet to lead to a measurable
improvement in services for deprived areas.
The needs-based funding formula is intended to reduce inequality
in service provision. The Minimum Practice Income Guarantee has,
however, significantly reduced its redistributive impact, and
failed to address historic funding issues. The Department should
consider replacing the Minimum Practice Income Guarantee with
a redesigned global sum allocation in order to move more money
into areas of greatest need.
6. Access to general practice services has
not improved significantly since the new contract, although the
Department is taking action to address this lack of improvement.
Having to arrange to visit a GP in normal working hours is a significant
cost to the economy in terms of lost output. The Department has
included as part of future Directed Enhanced Services the requirement
that GPs open for longer hours. For this to be effective, Primary
Care Trusts need to commission services that are more clearly
linked to local needs, underpinned by a performance management
framework that enables them to monitor how well GP practices meet
this and other requirements. They must also tackle poor performance
as necessary.
7. The Quality and Outcomes Framework links
GP pay to the quality of patient care they deliver but requires
further enhancement. The Framework concentrates
largely on indicators that are easy to measure, and as such there
is a tendency for it to reflect GP workload, rather than improvements
in population health. The Department should (i) develop the Framework
so that it is better aligned to national health priorities; (ii)
give more weight to achieving health outcomes, rather than clinical
practices which are easy to measure; and (iii) allow Primary Care
Trusts some discretion to agree the content of the Framework to
reflect local priorities.
8. GP partners' pay has increased by an average
of 58% since March 2003 compared to 15% originally expected.
Higher pay has helped improve recruitment and retention, but not
all practice staff have benefited to the same extent as GP partners.
Salaried GPs and practice nurses have only had inflationary rises
in pay over the same period and some practice nurses do not have
appropriate contracts of employment. Primary Care Trusts need
to require practices, as part of their GMS contracts, to have
appropriate contracts of employment in place for all staff and
advise practices on appropriate pay rates. Primary Care Trusts
should also, as part of the contract, require GP partners to provide
annual feedback on how they have used NHS funding to improve practice
productivity.
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