House of Commons - Public Accounts

Select Committee on Public Accounts Forty-First Report

3 Getting more out of the new contract

21. The new contract has not yet delivered all the benefits that the Department expected it to achieve.[42] In particular, the contract has been less successful in redirecting funds to areas with the greatest need and has had mixed success in incentivising improved access to general practice services. Whilst recruitment of GPs in deprived areas has improved, it is still worse when compared to more affluent areas.[43] The average expenditure on general practice care in relation to need is lower in some of the most deprived areas of the country (Figure 6). For many patients, the contract actually led to a decrease in GP provision through the removal of the GP's responsibility for out-of-hours care, loss of Saturday surgeries and reducing the times that a patient can make an appointment.[44]

22. The new contract successfully increased the types of services that are available in general practice, but has not yet led to the development of as many new services as the Department had expected. Many of the new services reflect national directions, rather than services responding to specific local needs. In 2006-07, 71% of Primary Care Trusts did not spend their allocation for locally enhanced services. These allocations were expected to be the minimum level that a Trust would spend on enhanced services.[45]

23. One of the key objectives of the new contract was to increase access to GP services but efforts to improve access have been mixed. The contract allows Primary Care Trusts to increase provision of GP care by negotiating locally with GPs to extend hours using local enhanced services payments, or to commission new general practice services through competitive tendering. These options have not been used effectively by Primary Care Trusts in commissioning services to address local need.[46]

24. As part of the new contract, the Department negotiated a national enhanced service to incentivise GPs to offer appointments to patients within 48 hours. Currently, 90% of patients are seen within this target. However, this has also had a perverse effect for patients, as GPs reduced the amount of appointments that were available to be booked in advance. The Department has now allocated some of the points available under the Quality and Outcome Framework to measure patient satisfaction against this access target. In addition, the inconvenience of not being able to see a doctor in the evening or at weekends has been highlighted as an issue in patient surveys.[47] The Department has responded to patients' concerns about being unable to see a doctor in the evening and at weekends by issuing a national directive to extend opening hours using directed enhanced services.[48]

Figure 6: Average GP expenditure per head of population adjusted for need

Source: C&AG's Report, Para 2.14 and Department of Health PFR1 Data Returns 2006-07

25. Under the new contract, access to a GP outside of normal hours is the responsibility of each Primary Care Trust, which is expected to commission sufficient out-of-hours services. A previous report by this Committee[49] highlighted that the Department underestimated the cost of out-of-hours care and that the quality of out-of-hours care is not consistent.[50] The Department now believes that the NHS has improved its monitoring and quality assurance of out-of-hours care. The Department does not believe that there is a relationship between a rise in emergency admissions and access to out-of-hours care, although the C&AG's Report showed that the number of emergency admissions has increased since the new contract was implemented.[51]

26. Another factor that affects access is the location of general practices. More deprived areas tend to have the least number of doctors working in them per capita.[52] Since the new contract has been introduced, there has been an increase in the number of doctors working in more deprived areas but still not enough to meet the under provision, nor to reduce the imbalance compared to affluent areas.[53] Primary Care Trusts had mechanisms within the new contract arrangements, such as the Alternative Provider Medical Services (APMS) contracts, to attract new general practices into under-doctored areas but had failed to use them to the extent that the Department expected.[54]

27. In 2008, concerned at the lack of progress, the Department announced the provision of an additional £250 million which it expects most Primary Care Trusts to use to commission a new practice in their most deprived area. At least 100 new practices will be obtained through competitive tendering using APMS contracts, but this process will not exclude current GP practices from making bids to operate the service.[55]

28. Indeed, the Department is investing some £1 billion over five years (including the £250 million in paragraph 27) to develop more accessible and responsive services. In London, following Lord Darzi's London review,[56] this involves the development of polyclinics that bring primary care and secondary care closer together. For the rest of the country, Primary Care Trusts are expected to commission new services using the best model of care that meets their local needs. As a minimum, the Department expects each Primary Care Trust to invest in a GP led health centre that will be open from 8am to 8pm. Polyclinics and health centres will introduce a range of services into primary care which are currently delivered in hospitals. This is an attempt to increase the access and breadth of services provided in primary care.[57]

29. The lack of progress in increasing access to, and the provision of, new services in the areas of most need is largely explained by Primary Care Trusts not being sufficiently proficient in commissioning, as well as a lack of reliable information on which to base commissioning decisions. In addition, they lack sufficient people with the requisite skills to commission new services effectively. The reorganisation of Primary Care Trusts may help address this by enabling more experienced staff to be redeployed to areas of greater need. There is a risk, however, that such staff will initially have less detailed knowledge of local needs.[58] The Department is taking steps to tackle this through its World Class Commissioning initiative.

42 C&AG's Report, Figure 4 Back

43 C&AG's Report, paras 2.15, 4.10-4.11, 4.16 Back

44 C&AG's Report, paras 4.16, 4.18 Back

45 C&AG's Report, para 4.24 Back

46 C&AG's Report, paras 4.10-4.15 Back

47 Q 18 Back

48 Qq 18, 51, 71, 81, 155 Back

49 Committee of Public Accounts, Sixteenth Report of Session 2006-07: The Provision of Out-of-Hours Care in England,
HC 360 Back

50 Qq 30-35, 48 Back

51 Qq 36-37, 80-81 Back

52 Q 14 Back

53 Q 24 Back