Memorandum submitted by the British Medical
Association
THE VALUE
OF GENERAL
PRACTICE: THE
FACTS
The new UK-wide GP contract was introduced in
full in April 2004 following lengthy negotiations and full agreement
by all parties—the Government, NHS Employers and the BMA's
General Practitioners Committee. Since April 2004 GPs have been
mainly working under two contracts; the nationally negotiated
General Medical Services (GMS) contract or the locally negotiated
Personal Medical Services (PMS) contract. The two contracts are
broadly analogous in terms of how services are provided to patients.
The National Audit Office (NAO) recently issued the report NHS
Pay Modernisation: New Contracts for General Practice Services
in England, a report on the GP contracts in England. This
fact sheet has been produced by the General Practitioners Committee
(GPC) of the British Medical Association (BMA) to clarify the
facts about why and how the contract was introduced and the benefits
to patient care it has delivered.
KEY MESSAGES
"Since 2004 more services are being
provided in GP surgeries and practices are offering structured
management of chronic diseases which has resulted in consistency
of care throughout the UK".
Dr Laurence Buckman, Chairman, General Practitioners
Committee
— Benefits of the contract include
better consistency and quality of care for patients and fewer
problems with recruitment, retention and morale of GPs.
— Although GP earnings have increased
under the contract, this was an intended consequence and the BMA
predicted the level of increase.
— Since 2006-07 GPs have received no
inflationary uplift to the contract and have taken on additional
areas of work through changes to the QOF. Global sum payments
have not increased since 2004.
— Since the introduction of the contract
the number of consultations has gone up, the time spent with the
patient has increased and the work GPs do is more complex.
CONTENTS
Why was the contract introduced?
What are the key benefits of the contract?
How has the GP contract and QOF improved patient
care?
How much does the average GP earn?
How have GP earnings changed since the introduction
of the new contract?
What will happen to GP pay in 2008?
What difference has QOF made to practice income?
Weren't GPs already doing much of the work in the
QOF?
What hours are GPs doing now?
Has productivity fallen since the new contract was
introduced?
What improvements have been made to the contract
since its introduction?
Is it true that GPs are now taking a greater proportion
of gross income home as profit?
Are GPs investing in practice staff?
Did the contract over-deliver funding to practices?
Does the Minimum Practice Income Guarantee (MPIG)
add to health inequalities?
Are GPs still good value for money?
Why was the contract introduced?
The contract was brought in to address the severe
shortage of GPs, to reduce the excessive hours they were working
and to redress the pay imbalance—before 2004 the UK's GPs
were among the worst paid in the developed world.
What are the key benefits of the contract?
The NAO report (England) recognises that the
new national GP contract is delivering benefits:
— Structured management of chronic
diseases has resulted in consistency of care throughout the UK.
— More services are being provided
in GP surgeries.
— Patient satisfaction with access
has improved (84% of patients said they were satisfied with GP
practice opening times in the 2007 national GP patient survey).
— There are fewer problems in recruiting
and retaining GPs.
How has the GP contract and QOF improved patient
care?
The contract delivered benefits to patients
through the improved monitoring and treatment of acute and chronic
health problems and the development of nationally determined and
locally appropriate enhanced services beyond those that GPs traditionally
supplied. For the first time the contract linked increases in
practice resources to delivering proven higher quality care for
patients through the Quality and Outcomes Framework (QOF). The
QOF provides a framework for processes that, if followed, will
ensure a high quality service for patients. The NAO report asserted
that the QOF has not focused enough on health outcomes although
it is important to note that QOF was designed to incentivise GPs
to do the work that would lead to improved health outcomes. A
recent article in the BMJ supported the use of process measures
to monitor the quality of clinical practice.[4]
The clinical indicators, which include disease
areas such as coronary heart disease, stroke, diabetes and asthma,
draw on best research evidence and only those areas for which
there is evidence to underpin their inclusion can be found in
the QOF. The QOF is reviewed and updated as necessary in the light
of changes to the evidence base and advances in healthcare. These
decisions are based on a review of the quality framework by an
appointed expert panel with input from the BMA and NHS Employers.
In 2006 new areas of clinical work were introduced as a result
of this process.
The BMA, during negotiations on revisions to
the 2008-09 contract, was keen to build on the success of the
QOF and had agreed, with advice from the expert panel, to give
over 38.5 points in the QOF to introduce new clinical indicators,
including peripheral arterial disease and osteoporosis, into the
QOF. Unfortunately the Government rejected this proposal and imposed
the use of all these freed up points to just two access targets,
which are already within the contract.
GPs have exceeded the quality targets they have
been set (although the BMA always predicted that this would be
so) and this has resulted in higher pay. The QOF is an important
aspect of the GP contract. Research from the National Primary
Care Research and Development Centre has shown that "quality
of care for asthma and diabetes showed more rapid improvement
after the QOF" and that "patients with controlled blood
pressure increased from 48% in 1998 to 82% in 2005, and the percentage
of patients with controlled cholesterol increased from 17% to
73% in the same period".[5]
The QOF is well-respected world-wide and many other countries
are monitoring its development closely.
How much does the average GP earn?
The most reliable indicator of GP income is
the Information Centre's Earnings and Expenses Enquiry (EEQ).
This recently estimated that, from all professional earnings sources
(including NHS, private and out-of-hours work), self-employed,
non-dispensing GPs working under the GMS contract earned an average
net income of £102,648 2005-06. This is much less
than the £250,000 widely quoted and misinterpreted by the
media (this figure is often based on income before expenses have
been deducted and applies to only a tiny minority of GPs working
in exceptional circumstances). The figure is often inflated by
other contractual arrangements, such as PMS and dispensing practices.
It is therefore not reasonable to suggest that the nationally
negotiated GMS contract changes are solely responsible for the
increase in overall GP pay. This is a UK figure. It should be
noted that the earnings of GPs differ significantly across the
four countries.[6]
In addition, the earnings of salaried GPs are not included in
this figure. On average, salaried GPs earn less than GP principals,
partly as a result of reduced responsibilities, particularly those
to do with running the practice as a business. When taking into
account salaried GPs the average NHS GP earnings figure is currently
approximately £88,000. It is anticipated that the
EEQ figure will fall in 2007-08 and 2008-09 to reflect increases
in practice expenses and lack of uplift to the contract.
How have GP earnings changed since the introduction
of the new contract?
The NAO report stated that the average pay of
GP partners increased by 58% in the first three years of the contract
(this figure includes both GMS and PMS partners). This is broken
down as 18% in 2003-04, 23% 2004-05, and 10% in 2005-06. It is
important to recognise when referring to this pay increase figure
that the rise in GP earnings was an intended consequence of the
new contract with the explicit purpose of demonstrating high quality
general practice, through the delivery of new work including the
Quality and Outcomes Framework and enhanced services, and counteracting
well-recognised recruitment, retention and morale problems. GP
pay was falling behind pay rates for equivalent professionals
and the contract was specifically designed to address this. The
BMA was not surprised at the extent of the increases in GP income
as the BMA repeatedly told the Government's negotiators what the
rise would be.
Since 2006 there has been no inflationary increase
in the value of the contract and GPs have taken on more work through
the QOF. In addition, practice expenses have continued to rise,
so most GPs will actually have seen their real earnings, for an
increased amount of work, fall over the past two years. This is
not widely reflected in press reports as official figures reflecting
what GPs earn now will not be published until Autumn 2009.
What will happen to GP pay in 2008?
The Doctors' and Dentists' Pay Review Body (DDRB)
recommended a zero increase for contractor/partner GP pay in 2007-08.
In an opinion survey by the BMA two thirds of GPs reported that
their personal income had stayed the same or decreased in 2006-07.
Two thirds expected a decrease in income in 2007-08 but official
figures will not be available until Autumn 2009.
In 2008-09 the Department continued to put pressure
on GPs to work harder and longer within the current contract funding
streams by introducing proposals for extended hours. The BMA could
not agree to the Department's proposals which were inflexible
to local patients' needs and so polled all GPs on the options
available. The package that will be implemented for 2008-09 includes
the provision of an additional three hours per week for the average
6,000 patient practice for the same level of funding, and harder-to-achieve
access targets being introduced into the QOF. Any inflationary
rise to the contract terms for 2008-09 will be determined by the
DDRB which has yet to issue its report.
What difference has the QOF made to GP income?
The negotiations on the contract were predicated
on the overwhelming bulk of new money being delivered through
performance-based income streams and 75% of new money was intended
to be delivered via the QOF. Since the introduction of the new
contract, most of the increase in practice income has indeed been
channelled through the QOF as performance-related pay. As the
GPC had anticipated, practices have attracted additional resources
by demonstrating that they deliver high quality care and work
across the range of specific areas identified by the Government.
In 2006-09 practices in England demonstrated top quality services
with an average of 955 out of the 1,000 points available. These
achievements were significantly higher than the Government had
anticipated and are a great tribute to the work of GPs and their
staff.
Weren't GPs already doing much of the work in
the QOF?
The Government wanted rises in GP incomes to
be linked to demonstrating the delivery of high-quality care (see
above). Of course, as all parties were aware, GP practices were
already undertaking some of the work that now falls under the
remit of the QOF. Much of this work had been transferred from
secondary care with increasing specialisation in secondary care.
Unfortunately the resources for the work remained in secondary
care and GP practices were becoming increasingly stretched by
providing the care without resources. While the Government seemed
to doubt that GPs would do well in the QOF, the GPC stated that
it not only expected most practices to earn 750 points, because
they had been delivering quality work for years, but that it fully
expected many to top 900 points. The introduction of the QOF has
indeed incentivised GPs to employ extra staff and invest in even
better services for patients. It has also provided practices with
the resources to identify patients with certain conditions before
these would otherwise have come to light. Both work that had been
initiated prior to the new contract and work undertaken since
the introduction of the QOF have contributed to GPs' excellent
performance in this area and improvements in patient care.
What hours are GPs working now?
The average length of surgery consultations
with GP partners has increased from 8.4 minutes in 1992-93 to
11.7 minutes in 2006-07. The length of appointments is one of
the best determinants of quality of care. GPs are therefore working
with greater intensity during the day, and offering a higher quality
service than they have ever done. The Information Centre's 2006-07
UK General Practice Workload Survey showed that GP partners, who
regard themselves as full time, work on average 44 hours a week.
This figure does not include any out-of-hours work, which was
included in the 1992-93 survey. Further studies have confirmed
that at least 25% of GPs still do out-of-hours work, on top of
this average figure. The out-of-hours work carried out by GPs
now is also more intense as they are no longer "on call"
but tend to work shifts seeing patients almost continuously. The
report states: "Direct comparison of results with the 1992-93
GP workload survey is difficult. However, average weekly hours
for GMS(PMS/PCTMS) activities, excluding out-of-hours work, are
very similar".
Prior to April 2004 GPs were responsible for
the provision of out-of-hours care. Under the new contract, practices
were given the opportunity to transfer responsibility for out-of-hours
provision to the PCO. This was for two reasons; to give doctors
a reasonable balance between their profession and personal life
and to allow PCTs to re-commission out-of-hours services using
a mixture of new and existing providers.
Has productivity fallen since the new contract
was implemented?
The NAO reports that National Statistics show
productivity has fallen since the new contract was implemented.
This conclusion is supported by comparing costs to activity, which
shows that whilst consultations with patients have increased these
are not in proportion with the increase in costs.
GP activity cannot be measured in this way.
General practice has changed and primary care is now provided
by a whole team working in the surgery. The number of consultations
has gone up, the time spent with the patient has increased and
the work GPs do is more complex. An increasing number of conditions
that were once managed solely in hospital are now managed solely
by GPs and their teams. The entire way GPs work has changed so
it is meaningless to talk about productivity in the way the NAO
has done. GP productivity should be measured in improvements in
health, not the frequency of consultations—and the early
evidence is that the contract is leading to improvements in clinical
care. Care for patients with asthma and diabetes has improved,
more cases of raised blood pressure are being picked up and while
it is too early to give exact numbers, this will prevent many
more serious problems like strokes or heart disease.
What improvements have been made to the contract
since its introduction?
For the year 2006-07, in addition to receiving
no inflationary uplift to the contract, the GPC agreed "efficiency"
changes in the QOF, amounting to some 15%, and the introduction
of additional areas of work, on the explicit and publicly agreed
understanding that the Government's perceived value-for-money
issues would not be revisited in future negotiations. This included
the recycling of 138 points from the QOF into new areas of work
that required practices to work harder—this included new
targets for dementia, depression, chronic kidney disease, atrial
fibrillation, obesity and learning disabilities. This work was
undertaken by practices for no additional funding.
Is it true that GPs are now taking a greater proportion
of gross income home as profit?
No. GPs are often cited as taking a greater
proportion of practice income as personal profit and the Government
has said it regrets the fact that GPs have not invested more of
the increase in gross income in patient services. EEQ figures
show a fall from 59.5% in 2003-04 to 54.2% in 2005-06. Although
a small change in the earnings/expenses ratio had been anticipated
during the new contract negotiations, these figures are generally
misleading because raw figures conceal several changes in the
way GPs are paid under the new contract including the fact that
GPs are no longer responsible for certain elements of their business
expenditure, including IT, and that fact that many partnerships
were opened up to non-clinical members, many of whom were previously
employed by the practice.
The suggested present level of expenses does,
in any case, no more than take the percentage back to its level
in 1990-91 when the previous contract came into being. It had
reached its higher level as GPs were prepared to invest heavily
in their practices even when gross incomes were rising more slowly.
Are GPs investing in practice staff?
Contrary to accusations, GPs have increased
investment in their staff and practices since the introduction
of the new contract. According to the EEQ average expenses rose
from £120,064 to £129,926 between 2003-04 and 2004-05.
The increase in staff costs in 2004-05 was 17%, a fairly significant
increase. The areas where expenses grew slowly or fell were business
expenses and car and travel costs together with depreciation on
capital assets. GPs value their hardworking staff and have honoured
the pay increases put forward by the national body that decides
nurse pay. The BMA has always supported paying practice staff
well.
Did the contract over-deliver funding to practices?
The main causes of the overspending in the first
two years was a significant underestimate by the Government of
achievement levels on the Quality and Outcomes Framework (QOF)
and the additional cost to Primary Care Trusts of providing out-of-hours
care. The BMA made the potential QOF scores quite clear on a number
of occasions and the costs of providing out-of-hours services
were also known at the time and were never planned to be covered
completely by the removal of £6,000 from GPs. Government
negotiatiors were fully aware that out-of-hours replacement costs
would be about £13,000. The global sum payment, provided
to practices to deliver basic general practice defined as essential
services, was defunded to increase investment in the QOF. As a
result the Minimum Practice Income Guarantee (MPIG) had to be
created by funds taken from premises, QOF and PCO funds to ensure
that practices would not be worse off under the new contract arrangements.
Had more funding been put into essential services in the first
place, as the BMA wanted, the MPIG would not have been necessary.
Does the Minimum Practice Income Guarantee (MPIG)
add to health inequalities?
The introduction of the MPIG was deemed essential
to the contract proceeding and the alternative would have seriously
damaged the viability of 90% of GMS practices. MPIG is a recognition
that many practices, with the support of their Health Authority,
had invested to a greater extent in practice staff in order to
provide a greater range of services. The MPIG has led to funding
for the contract being based more on historic funding that would
have been ideal. The BMA is keen to work with the government to
address these health inequalities but it is too simplistic to
suggest that removing MPIG from GMS practices would achieve this
aim. If the MPIG were to be abandoned this would significantly
destabilise many practices that are most dependent on it and who
would be forced to make large numbers of their staff redundant
thereby affecting patient services currently provided.
Are GPs still good value-for-money?
The UK Governments expressed some value-for-money
concerns following the introduction of the new contract, even
though it had been negotiated and agreed by all parties, including
Treasury. Although GP income did rise as intended, following the
introduction of the new contract, GPs remain excellent value-for-money.
General practice delivers high quality services with fewer doctors
per head of population than most of our European neighbours. The
Personal Social Services Research Unit at the University of Kent
has calculated that, in 2005-06, the unit cost of each face-to-face
GP consultation was just £214. This figure compares very
favourably with other NHS costs. Increasingly, GPs are providing
services which used to be done in hospitals, eg minor surgery,
diabetic care, preventive treatment of heart disease and strokes
at a much lower cost to the commissioner. In the House of Commons
on 28 November 2006, the Secretary of State for Health, Patricia
Hewitt said that the new GP contract "has led to primary
care services being rated as better in our country than in almost
any other advanced country".
General practitioners are represented by
a UK-wide committee, the BMA's General Practitioners Committee
(GPC), plus three national committees, which work alongside it.
The committees represent all general practitioners whether or
not they are members of the BMA.
March 2008
4 2007;335;648-650 BMJ Richard J Lilford, Celia
A Brown and Jon Nicholl. Use of process measures to monitor
the quality of clinical practice. Back
5
November 2007, National Primary Care Research and Development
Centre; What should happen to the Quality and Outcomes Framework? Back
6
Average net profit for contracted GPs in 2005-06 was £113,614
in England, £98,656 in Northern Ireland, £90,619
in Scotland and £102,194 in Wales. Back
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