Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Transatlantic Spin
- Nick Bunting (28 February 2003)
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Hobsons Choice
- Trevor Alan Underwood (1 March 2003)
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The new GP contract - an opinion from the front line
- Laurence B Slater (2 March 2003)
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New contract for general practitioners
- Toby Lipman (2 March 2003)
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Surprise and the Colonies
- Adrian K Midgley (3 March 2003)
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Targets Discourage Caring for Populations at Highest Risk
- Ted Osmun (3 March 2003)
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Mass Resignation
- L S Lewis (3 March 2003)
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BOHICA!
- Stephen F Hayes (4 March 2003)
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Colonialism and racism
- Akash Samtani (5 March 2003)
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GPs - whining profession with no instinct of self-preservation
- Nick Manassiev (5 March 2003)
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The New Contract and "holistic care"
- Brian J McMullen (9 March 2003)
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Incomes will depend on inputs, and inputs are not there
- William T Hamilton, Alison Round, Deborah Sharp, and Tim J Peters (14 March 2003)
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Re: New GP contract - for better or for worse?
- Tania E Papadakis (14 March 2003)
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Raw deal for depressed patients
- Phillip M Bland (16 March 2003)
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The contract unravels
- Peter Davies (21 March 2003)
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Never mind the shekelles
- Mark D Oliver (21 March 2003)
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Disinformation
- Stephen F Hayes (25 March 2003)
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The New Contract: Quality, Money and Perverse Incentives
- Alistair C. W. Revolta, Dr Craig A. McArthur (18 April 2003)
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A welcome perspective
- Brian D Keighley (21 April 2003)
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Are we not ignoring what is important?
- Paul D Thomas (21 April 2003)
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Nick Bunting, GP Principal Kirton Medical Centre, Kirton, Boston, Lincs, PE20 1LD
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Sir, Why am I not surprised that the official organ of the BMA gives pride of place to an editorial so in favour to the propsed new GMS contract? Although the documents produced so far make for interesting reading, and clearly represent one possible way forward, the process by which they were produced and announced led me directly to resign my membership of the BMA. The documents are incomplete, several key areas are not addressed adequately, and there are inconsistencies; not to mention spelling mistakes. Much important information is "to be published shortly". The Carr-Hill formula has yet to be published. The rules regarding funding for premises are yet to be published. Dispensing payments are not disclosed. The issues of forced allocations, home visits, pensions and private income are inadequately dealt with. MMR targets are to remain. 48 hour access, a government target which is largely thought of as ridiculous by GPs is now apparently a quality issue. Finally, and most ominously, Dr John Chisholm, Chairman of the General Practitioners Committee, in his letter to the profession, clearly states that the GPC is not commending the contract to the profession. I read into this that either the GPC Negotiators have been forced into publishing a half-baked compromise with which they are unhappy, or they, mindful of the Consultants' "no" vote, are looking to save their skins. As a profession, we should demand more substance, we should reject spin, we should reject artificial and reject pointless political targets. We should heed Dr Chisholm's words - we should reject this contract. Competing interests: None declared |
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Trevor Alan Underwood, NHS GP Reading RG2 7BW
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The GP negotiators have worked for a year to reach this point, only to have the proposed contract altered unilaterally at the last moment by the UK government. The positive spin from an American is timely. The current contract is unsatisfactory and to me this looks worse. I feel as empowered as an Iraqi citizen voting against war. It is coming anyway. Competing interests: None declared |
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Laurence B Slater, GP Principal The Surgery, 15 Brook Green, London W6 7BL
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I enjoyed reading Prof Shekelle’s article, which I did with interest and not a little curiosity as to why a Professor of Medicine from Los Angeles was asked to lead the opinion on the matter of a contract for general practice in the UK. Given his distance from the line of fire, his erroneous conclusion as to the cause of the initiative is forgiven. The contract was of course demanded, with the threat of resignation, by GPs in response to their poor working environment. I share his concerns about the potential difficulties in implementing the contract and also his recognition of the profound effect it may have on our relationship with out patients. There are however, one or two other points which are worth attention.
A proper assessment of the new GP contract 1 cannot be made without the pricing and disappointingly this information will not be available in time for the first road shows 2. The contract paints a picture of GPs being increasingly answerable to a government bent on documenting interventions many of which are not evidence based and are of dubious benefit to our patients’ health. GPs are manacled to 48 hour access and this target is just as open to manipulation as are waiting list figures. This is widely perceived by the profession as being meaningless and unhelpful and regardless of whether the target is met, it will be very bad for morale. MMR targets which are difficult both to justify and to implement will remain in place. The personal list (and the concomitant continuity of care) has gone. There is no concession on pensions. Cash limited quality payments fall back on hamster wheel working principles (run faster to get a proportionally larger slice of a fixed size cake). There are many hoops to jump through in order to acquire “points” to maintain our income which will inevitably generate more paperwork. There are concerns that patient satisfaction questionnaires may do no more than fulfil a government agenda to pay lip service to the electorate. GPs cannot close their surgeries to new registrations without first obtaining permission from PCTs, who also retain the ability to forcibly allocate patients. They will of course now have the option of allocating to themselves. We are to lose control of the IT systems which underpin the delivery of healthcare, but not the legal responsibilities which depend on these systems being operational. The scope of the IT implementation in the contract is unrealistically ambitious and the underlying Orwellian trend towards the centralisation of patients’ records has very serious repercussions for our society (of which our American Professor may well be aware), which merit further debate. 3,4
These unpopular inclusions have not been tempered by many concessions. Of fundamental importance is the matter of rising patient expectation which remains unfettered and this contract has thrown petrol on the flames. A national shortage of GPs is expected to deliver high standards of care working in a crumbling health service. Increasing demands are placed on general practice directly by implausible diktats from NICE, pie in the sky NSFs and prescribing budgets which are frequently not in our patients’ interests. Reaccredidation and revalidation will be procured internally from within an already overstretched system. Government pressure on secondary care also has a significant indirect effect and there are a plethora of plans from within health care trusts to transfer work which was previously their remit into primary care. More worrying still is the fact that the implementation of this complex contract will fall to our PCTs, who are not yet out of intensive care following their recent traumatic birth. They are already failing to cope in an environment where the system of delivering healthcare is at least defined and understood. What hope do they have of being able to successfully manage another reorganisation of this magnitude?
It was a masterly piece of PR by the government to inform the public that GPs will be getting up to 50% pay rises 5 . An overall 30% is the amount going into the PCTs and the majority of GPs can expect to see a very much smaller slice of this. I have heard preliminary estimates ranging from 3-15%, or even pay cuts if we choose to opt out of some services. Quite how opting out of OOH will be implemented when GPs are the only people qualified to deliver this is unclear. However, it may be that GPs who vote NO to this contract in light of such propaganda will be perceived by the public as being ungrateful and greedy.
It was the GPs who demanded an overhaul to their terms of service, so it would be churlish to be dismissive of any change. But when the new contract emerges looking like the introduction of HMO style managed care and appears centred around bean counting, one wonders who it was who was calling the shots during the negotiations. Demos, the government sponsored thinktank, warned the government last year that that its NHS reforms would fail if ministers persist with a centralised regime of target-setting from Whitehall 6. Why has this not been heeded? Morale is low and GPs who have made significant personal sacrifices to their profession feel undervalued and let down. This is especially so in the light of the empowering mandate which was handed on a plate to our negotiators. No other profession would tolerate the level of control being proposed in this contract. Our consultant colleagues did not accept terms which left them over-managed. A groundswell of anti-contract opinion implies that GPs may feel the same way. Historically general practice has been a great asset to the NHS and I believe it still can be, but not in this form. I for one wish to be able to exercise a degree of professional choice in my working environment and my response to the contract is a resounding NO. Even if the pay turns out to be better than it appears, money is not enough.
Dr Laurie Slater Principal in general practice The Surgery 15 Brook Green London W6 7BL laurie.slater{at}nhs.net
1) New GPcontract. BMA site http://www.bma.org.uk/ap.nsf/Content/NewGMSContract 2) Update on GP contract. BMA site http://www.bma.org.uk/ap.nsf/Content/__Hub+GPC+contract 3) Security of Medical Information Systems http://www.cl.cam.ac.uk/users/rja14/#Med 4) NHS Confidentiality Consultation: FIPR Response document http://www.cl.cam.ac.uk/users/rja14/fiprmedconf.html 5) Times Article: GPs could get 50% increase in new pay deal http://www.timesonline.co.uk/article/0,,1-586268,00.html 6) Guardian Article: NHS hindered not helped by targets http://www.guardian.co.uk/guardianpolitics/story/0,3605,718677,00.html Competing interests: None declared |
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Toby Lipman, General Practitioner Westerhope Medical Group, Newcastle upon Tyne, NE5 2LH
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It is curious that the BMJ has gone to a professor of medicine in California rather than a general practitioner (GP) in the UK for a favourable comment on the new GP contract (1). The contract, based on a large number of quality indicators, is designed to improve performance, narrowly defined as achieving certain clinical markers of outcomes - blood pressure, glycaemic control in diabetics, and so on. I have doubts in three main areas. The first (and least important) is whether monitoring so many parameters will place an unnacceptably heavy administrative burden on general practice, despite the disclaimers in the contract. I suspect that we have the IT capability to overcome this problem. The second, is whether pursuit of clinical markers for their own sake (particularly if achieving them is linked to remuneration), will result in unnecessary medicalisation of a large proportion of the population. There is a danger that our practice, instead of being evidence-based, will be evidence-driven rather than linked to patients' values and wishes. As Shekelle himself points out, "Measuring the values placed on outcomes and how these change over time is complex" (2). The contract, by emphasising the importance of outcomes, risks driving out values. It takes a population rather than individual view and fails to recognise that, while a 5% absolute risk reduction of a cardiac event over five years might be wonderful from a public health viewpoint, an individual might wish to forego a medication from which he has a 95% chance of not benefiting. The last, and most important point, is that the contract utterly fails to address the professional role of GPs (3). Are we to be essentially administrators of public health inspired disease management and prevention programmes? Or are we to build on our established professional skills and role, which are based on the idea that our primary function is to interpret whatever problems patients bring to us and find solutions for them? I fear that the former role may drive out the latter, and that would be a great loss both for the profession and for our patients. 1. Shekelle P. New contract for general practitioners . BMJ 2003;326(7387):457-458. 2. Shekelle P, Eccles MP, Grimshaw JM, Woolf SH. When should clinical guidelines be updated? BMJ 2001;323(7305):155-157. 3. Lipman T. The future general practitioner: out of date and running out of time. British Journal of General Practice 2000;50:743-746. Competing interests: None declared |
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Adrian K Midgley, GP, Exeter Exeter EX1 2QS
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I'm not surprised. UK doctors have a clear interest. You need at least 3000 miles to get enough perspective on this mess to write a BMJ leader. Good one, on the whole. Competing interests: I'm a UK GP and the contract proposals may affect my income and happiness |
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Ted Osmun, Assistant Professor, Family Medicine, University of Western Ontario N0L 1W0
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I read with interest the British GP's response to this proposal. Here in Canada our governments' are keen to round GPs up in an effort to meet population based targets. After years of liberating ourselves from 'paternalism', it now seems ok to be coercive, providing it satisfies the agenda of the bureaucrats. Sadly, it will be those GPs that are working with the disadvantaged who will suffer most for not meeting targets, further hampering recruitment and retention to inner city practices. Competing interests: None declared |
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L S Lewis, General Practitioner Newport, Pembrokeshire, SA42 0TJ
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Sir, This contract is a pitiful response to a major urgent problem - that of rescuing British General Practice - once the shining example - from collapse. WE few - we UNhappy few - are ready to throw in the towel .. What we needed was an immediate injection of morale - and throwing money at us would have helped. Instead we are met with a breathtakingly computer-intensive 'point- scoring' set of quality measures which will exercise an army of 'health police' and 'governance gooks' for years to come. I assume that these turncoats would be recruited from our own ranks, further depleting the battle-weary troops. I cannot discern what will be my pay, nor any other practice income, yet I am expected to vote on this contract within weeks. Let the BMA lead a Mass Resignation Campaign, else resign, en masse - UNLESS:- 1: guaranteed PAY rise 10% now
We GPs will resign in disaffected droves anyway, if they don't. Competing interests: A Life AND a Practice |
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Stephen F Hayes, Hospital Prctitioner Dermatology Isle of Wight
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The taxi drivers and others with whom I discussed the New GP contract since it was announced have, along with Newspaper leader writers and radio 4 commentators gained the impression that it will mean a massive pay rise for GPs and the end of their responsibility to work nights and weekends. My impression of what I have read of the new contract is that after GPs had a couple of away days to help us understand it, the main priority will then be to input data into the organisations' IMT system so they get paid and the organisation gets its happy stats. As there will be the same number of GPs and raised public expectations, time will have to be stolen from elsewhere to allow this increased level of data processing. The unhappy tendency to look at the computer not the patient will increase 2 Specifics. On the problem of forced allocations and violent and abusive patients, after several paragraphs of complex proposals, the final sentence states that even offlisted violent patients must be seen immediately if they say it is urgent. So no change there. I have been forcibly re-allocated a patient who had tried to kill me, and was told I would be "making a decision about my career", effectively resigning, if I refused to have him back. This will continue under these regulations. Also, written consent will have to be recorded for the most trivial of procedures even the freezing of warts. This is annoying in itself, but even more telling as an indicator of the tendency of this centralising government to control minutae. No wonder Dr Chisholm is not going to reccommend we vote for this. BOHICA? An internet acromym, Bend Over, Here It Comes Again. This contract should be called "Working for Patients 2" after the title of the disastrous 1990 Tory reorganisation. What usually happens with NHS reorganisations is that doctors objections are ignored, we work harder (like Boxer in Orwell's Animal Farm) to try to make it work, but it eventually becomes clear that the reorganisation (their preferred term is "reform") didn't succeed because it was the wrong answer to the wrong question. Eventually there is a change of government, and another reorganisation-and so it goes. What is different this time is that many middle aged and older GPs are in a state of decompensation. They can't take any more. Some have planned exit unless the new contract brings relief. Many of the younger GPs are female and will not work full time or nights, and the males are taking their cue from them. The GP workforce of today and tomorrow has a reduced willingness to plod on like Boxer. A growing number of patients have had positive experiences of healthcare systems in other countries where healthcare is not run as a central state monopoly. Moving from our NHS to a different system is becoming less unthinkable. Could this be the moment when we finally accept that Nye Bevans' brave experiment of 1948 has run it's course? The NHS was conceived in a time of rationing after the Hitler war by politicians many of whom admired believed Stalin was creating a workers paradise through central planning. Central state control is not the only way to run Primary Care. Competing interests: recently quit GP |
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Akash Samtani, GP Byford Family Practice, Australia
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Targets, data collection, optimal diabetes and hypertension management etc are unrealistic goals for a lot of inner city GP's. Any inner city GP who visits a house bound, elderly patient living on the 10th floor of a council block without a working elevator in between morning and evening surgeries of 30 people each is hardly going to be able to data chase/achieve targets. Basically the entire NHS system is deeply racist and is based on colonialism. The ethnic make-up of most inner city GP's is that of the old colonies. They earn the least, their patients tend to have more social/drug/violence problems, they have to live in the most expensive parts of the UK, they have very little political representation hence most NHS contract changes are not in their favour. Most GP's in the rural, small town UK are white, have massive incomes, live very well in affordable luxury housing, and have loads of time for data collection/achieving targets(and committee work!!) Competing interests: former (London) NHS GP |
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Nick Manassiev, GP The Wand Medical Centre, 279 Gooch Street, Highgate, Birmingham, B5 7JE
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The answer to the current problems GPs are facing is simple - to dispence with the current middleman ( Govenrment of the day) and to have a new middleman. The current middleman is in enviable position - not directly responsible to either patients or GPs, yet manipulating both. In true British spirit, most GPs and patients I have discussed the matter with, whine about this but do not have the guts to initiate any change. I am disappointed to see calls for mass resignation - this betrays a truly low self esteem and lack of spirit. Since when GPs have been Government employees, so to have to resign? It is far better re-iterate their self- employed status and move to a different system - insurance system/benevolent society/non-profit health funds - whatever name or mixture it may be. There will be a need for a period of grace (perhaps a year) to set it up and then finally deliver ourself from the increasingly meddlesome and dangerous grip of the current middleman. No room for manumission here - God helps those that help themself. Or even better put by I Ilf and E Petrov: The task of saving the drowning is task for the drowning. So far the profession has been lacking organisation or instinct of self-preservation, but as the screw seems to be tightening, these will appear and will inevitably lead to the fall of the current middleman. Then the current problems will be replaced by new ones, but at least those will be of our making. No need to waste time to go into the fine detail of the new contract - the idea is stillborn - the system needs changing. The system that was fit for the grandparents of this generation is not fit for the society of today. This is time to be modern, innovative and radical and not incremental, conservative and constipated. I beg all GPs to start working for the change of the middleman. Competing interests: None declared |
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Brian J McMullen, Chair, Board of Trustees, BHMA 59 Lansdowne Place, Hove BN3 1FL
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Among the novel ideas in the New Contract is the concept that one can assess "holistic care" by adding up points after asking your practice computer a series of rather complicated questions on different diseases. According to para 1.28 of the Contract document this means that "Holistic care will be incentivised ....." Your readers may, like me, be baffled by any connection between these "holistic" points and the concept of holism. The British Holistic Medical Association offers a vision of medical practice that is centered on people rather than diseases. Holism is about relationships between people and between humans and our environment. Of course we all have a relationship with our computers too and this may involve emotional and even spiritual aspects. Somehow I'm not convinced this is what the negotiators had in mind. Competing interests: Chair Board of Trustees British Holistic Medical Association |
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William T Hamilton, research fellow Division of Primary Care, University of Bristol, Cotham House, Bristol BS6 6JL, Alison Round, Deborah Sharp, and Tim J Peters
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Professor Shekelle1 recognises that data collection for the new general practitioner contract will be a huge task, requiring comprehensive computerisation. However, having a computer is not enough: using it – consistently and comprehensively– is the key. To examine the size of the task, we studied one area, that of cancer. It is proposed that practices establish a register of all cancer patients. As part of a larger project, we obtained details from the local cancer registry of all colorectal, lung and prostate cancers diagnosed from 1998- 2002 inclusive who were registered at an Exeter practice at the time of diagnosis. Histology results were obtained and the diagnosis checked in those without histology. Only cases with histological proof or a consultant diagnosis based on strong evidence were studied. We searched the computers of 19 of the 21 Exeter practices: all store clinical data in Read code form. The other two practices, although very willing to help, had important staff absent, and those remaining could not fathom the search system on their computers. Two other practices are still transferring patient summaries from paper to computer. We searched for the four relevant Read codes (B13.., B14.., B2…, and B46..) using the practices’ computer expert or WH when the computer system was one in which he is proficient. The results are broken down by year of diagnosis in the table. In only one practice were all cancers from the registry also on the practice register. Year Number on cancer register only (col 2) Number on practice register only (col 3) Number on both (col 4)Total(col 5) Percentage on practice register (col 6) 1998 106 3 45 154 31 1999 93 3 65 161 42 2000 87 8 84 179 51 2001 80 5 82 167 52 2002 94 9 102 205 54 Although the percentage has risen it is clear that sufficient retrievable information is absent from most practice systems. It is likely that some of the cancers were given a more generic code (all B…. codes are neoplasms), and it is also likely that continuing transfer of data to computer will further improve the figures. Our results should not be taken to suggest that clinical care is inadequate: on every occasion that the general practitioner was asked about a case requiring confirmation they were able to give an immediate, impressive clinical vignette. However, on this evidence only one Exeter practice would achieve points under the cancer heading care despite a reputation for quality primary care. Yours sincerely, William Hamilton, research fellow, Division of Primary Care, University of Bristol, BS6 6JL Alison Round, public health consultant, Dean Clarke House, Exeter EX1 1PQ Deborah Sharp, professor, Division of Primary Care, University of Bristol, BS6 6JL Tim Peters, professor, Division of Primary Care, University of Bristol, BS6 6JL Reference. 1. Shekelle P. New contract for general practitioners. BMJ 2003;326:457-458. Competing interests: DS is a part-time GP, and WH will be in the future. The new contract would change their remuneration, though it is unclear in what direction. |
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Tania E Papadakis, Medical Scientist Melbourne 3000
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Editor- I do not think the doctor and patient relationship will be compromised to the extent that Shekelle described in the proposed initiative by the NHS, to improve quality of care by setting performance targets for general practitioners accompanied by financial incentives.1 I entrust that general practitioners will continue to value their patients as individuals and not a series of achievable performance targets. Rather, I think GPs would consider using these targets as tools for aiming to improve the quality of their service and the efficiency in which it could be delivered, irrespective of financial rewards. I expect GPs and any sincere health professional accepting the need for clinical reform, not to change their behaviour towards patients on the basis of financial gain alone. This would reflect badly on the profession, the program and the very reason for its existence. I do share Shekelle's sentiments about the usefulness of many new quality indicators in multiple domains of care. This broadens the focus into other aspects of care, which may have previously been neglected; however it does not address the problem of care domains that have yet to be measured.1 The implementation of the proposal may present to be difficult. However, good clinical governance, a quest for appropriate changes by GPs and continual input from all those involved should contribute to the successful implementation of the program, which strives to improve the quality of primary care in various clinical settings. Although this bold new proposal presents as a mammoth task, the benefits and ramifications from its implementation could potentially ensure better outcomes for all concerned. 1.Shekell, P. New contract for general practitioners: A bold initiative to improve quality of care, but implementation will be difficult. BMJ 2003;326(7387):457-458.[Fulltext] Competing interests: None declared |
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Phillip M Bland, GP 92 Market St, Dalton-in-Furness, Cumbria, LA15 8AB
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Given that depression is very common in general practice (it has been estimated that 5-10% of patients attending the surgery have major depression (1)), given that outcomes are surprisingly poor (60% of patients treated with drugs still met criteria for caseness at one-year follow-up (2))and given that enhanced care of depression can lead to better outcomes (3), it is surprising that depression does not feature in the list of quality indicators in the proposed new GP contract. My experience is that it is possible to set quality targets for depression management: 1. DSM-IV criteria for major depression should be applied, 2. antidepressant medication should be prescribed at an effective dosage, 3. 80% of patients should comply with medication and return for follow-up and 4. 60% of patients should complete a 6 month course of treatment. A shared care approach with the practice nurse was successful in improving initial patient compliance, with an increase from 45% to 80% of patients attending for follow-up(4). My concern is that the list of quality targets has been assembled on the basis of what is easy to measure rather than what is most important. By condemning depression to be an "unmeasured" domain, the danger is that scarce practice resources will be diverted elsewhere and that quality initiatives designed to provide enhanced care will be stifled. The fourth most significant cause of suffering and disability worldwide (5) deserves better. 1.Anderson IM, Nutt DJ, Deakin JFW. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psycho-pharmacology guidelines. J Psychopharmacol 2000; 14:3-20. 2. Goldberg D, Privett M, Ustun B, Simon G, Linden M. The effects of detection and treatment on the outcome of major depression in primary care: a naturalistic study in 15 cities. Br J Gen Pract 1998; 48: 1840-4. 3. Von Korff M, Goldberg D. Improving outcomes in depression. BMJ 2001; 323:948-9. 4. Bland PM. Practice nurse input improves care of depressed patients. Guidelines in practice 2001; 4: 75-81. 5. World health report 2001: 30. Competing interests: None declared |
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Peter Davies, GP Mixenden Stones Surgery, Halifax,HX2 8RQ
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Sir, I read Dr Shekelle's editorial (1) with interest. I was surprised that no one from Britain could be found (or was even asked?) to write on this topic. Maybe the strength of response to Lewis and Gillam’s editorial (2) scared British writers away. Despite my letter of May 2002 (3) I had almost come round to voting for the contract on grounds that it could help improve chronic disease management. Achieving this improvement is currently a major public health goal and primary care teams probably could be and should be leading this as Shekelle(1), and Martin Roland and team have pointed out regularly.(4),(5) Suddenly the Carr-Hill formula appears and patients are magically made to disappear from GPs lists. Patients suddenly only count for 0.8 or 0.6 of a patient. Do they then suddenly only need 0.8 or 0.6 of a service? Would you be happy with 0.8 of a service or 0.8 of a vote in an election? The net result is that practices with 10,000 patients still have to deal with 10,000 patients whilst only being paid for 8000 of them. The idea of spreading resources according to need is a good one assuming it can be done fairly. However nowhere in the NHS is well resourced so re-distributing existing resources from one area to another is largely robbing one area to pay another. The Carr-Hill formula appears unfair and fails to achieve its purpose. It needs to be modified significantly or abandoned before any progress with a new contract for GPs is possible. I suspect the GPC will have to postpone the contract ballot for a long time which leaves general practitioners and Primary Care Trusts in an uncomfortable limbo. Just what we need to rejuvenate our speciality. 1. Shekelle,P New contract for general practitioners Editorial BMJ 2003; 326: 457-458 2.Lewis,R and Gillam, S A fresh new contract for general practitioners BMJ 2002 324:1048-9 3 Davies,P Contract proposals are fatally flawed Letters, BMJ 2002 (25/5/2) 324:1275 4.Roland,M New GP contract BMJ rapid response (27/5/2) http://bmj.com/cgi/eletters/324/7348/1274#22579 5.Marshall,M and Roland,M The new contract: Renaissance or Requiem for general practice? Editorial British Journal of General Practice July 2002 Competing interests: Salaried GP so income under no immediate threat from this contract |
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Mark D Oliver, GP principal Stafford St16 3AT
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It is interesting that transatlantic support had to be sought for the shambolic new GP contract, which would have incurred a 5% or more pay cut for my partnership in 3 years, by our AISMA accountants reckoning. It is bizarre in the extreme that the BMA hierarchy commended it, whilst not officially doing so of course. One wonders what they would have said about a contract that led to a reward for extra work! Stick to your ivory tower, Dr Shekelle, and let the doctor on the ground in the UK judge what is and is what is not good and ethical for him and his patients. This muddle is neither, and it is typical of the career-clinging negotiators to withdraw the ballot rather than let it be deservedly consigned to the rubbish tip of history. Competing interests: A harasssed NHS GP |
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Stephen F Hayes, Hospital Practitioner Dermatology Isle of Wight
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In last weeks Private Eye (sister satirical magazine to the USA's "The Onion" and France's "Le Canard Enchaine") a solicitor, in a letter arguing for higher legal aid fees, cited the "fact" that GPs had been awarded a 30% pay rise. Most people think GPs have been offered a huge pay rise. This is false, but will make us seem greedy and uncaring if we vote no. Today, I discussed the GP contract with a colleague who had attended a meeting with 400 other GPs and had also taken acountancy advice. She was advised on both occasions that most GPs would end up losing money if the contract was implemented. THis is the opposite of the view promulgated by DoH media men. There is more to the caring professional life than money, but it seems that a pattern of systematic deceit is emerging which is death to trust. It seems as if the government has been acting in bad faith again. Competing interests: 1)recently quit GP 2)previous contributor to this debate |
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Alistair C. W. Revolta, Final Year Medical Student Tweeddale Medical Practice, Fort William, PH33 6EU, Dr Craig A. McArthur
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Sirs The new GMS contract includes significant payments for quality, rewarded for meeting very specific standards. We audited the management of hypertension to the standards specified in the new contract. We met all the standards except one. Only 51% of patients with blood pressure recorded in the last 9 months, were below 150/90. This criterion produces the most points and is therefore worth the most money. The maximum score of 56 points for this one criterion yields £4200. Our score of 32 points yields £2400. Audit has always been a means to an end, and results are used with professional judgement to improve patient care. With significant money now paid on audit results, there is a subtle change in emphasis. Audit results will now become an end in themselves. We discovered a number of perverse incentives and describe here the financial implications of one. In the audit sample, if we remove 11 of the patients who had imperfect control, then we gain maximum quality points. With a 10% sample size, this equates to the practice omitting to record the blood pressures of 110 poorly controlled patients and directly gaining £1800 – adjusted by Carr-Hill weightings. We would lose points from the criterion requiring us to record every patients’ blood pressure every nine months, but there are less points produced by this criterion, and this would only lose £600. This could be regained by recording more blood pressures from well controlled patients. Therefore, by omitting the recording of 110 poorly controlled patients and recording 110 well controlled patients instead, we gain £1800. This is clearly an incentive to target a practice’s limited resources towards frequent recall and measurement of well controlled patients rather than the time consuming and difficult task of improving poorly controlled patients. This and the other perverse incentives we identified are simply a matter of diverting resources to do exactly what our contract requires and are not fraudulent. If we collude with these, we will get more money, the government will get statistics “proving” that patient care has improved as a result of the quality framework, and yet the care of the population is probably poorer. Incentives in the secondary care sector have been well known to distort patient care and have even lead to outright fraud by management. Incentive based medicine in primary care may lead to an historic change in the way we practice. Competing interests: None declared |
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Brian D Keighley, GP Principal The Clinic, Balfron, Stirlingshire G63 0TS
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Professor Shekelle’s editorial, written from the perspective of someone practising in an area with perhaps the most inequitable distribution of health resources in the developed world is, or should be, compelling. He has the luxury of providing top quality health care to those who can afford it through insurance while knowing that many within the society he serves can and do slip through the health care net. Recognising his difficulty in squaring his perceptions of quality for the few against mediocrity for the many I believe his observations are that more valuable. So far as most UK general practitioners are concerned, the burden of his leading article is contained in its last paragraph. There are many who perceive the aims of the new contract as command and control from the centre, at the cost of the personal elements of care that are so intrinsic to UK practice. Shekelle rightly articulates the risk that target achievement and “bean counting” will be at the heart of any new arrangements which is possibly to the detriment of the high value we put on relationships. Against this risk must be set the fact that many general practitioners have already moved well up the “quality and outcomes” gradient despite the perverse incentives inherent in the extant “Red Book” contract while at the same time maintaining good relations with patients. There are three factors that can make this new contract work. First, information technology that has developed out of all recognition within primary care over the past decade. Second, a welcome injection of resources into primary care that will increase rewards and/or ameliorate the effects of rising demand. Finally, and most importantly, the intrinsic ability of the UK general practitioner to make any system work for, instead of against the doctor-patient relationship. It is the last of these that will remain the bulwark against the increasing and pernicious desire of modern governments officiously to invade that territory. Yours etc Brian D Keighley General practitioner, The Clinic, Balfron, Stirlingshire G63 0TS Competing interests: Member of GPC(UK), SGPC Non-executive director, BMJ Publications Ltd Competing interests: Member GPC(UK) and SGPC Non-exec Director BMJ Publications Ltd |
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Paul D Thomas, GP principal (single-handed) Gipping valley Practice IP6 0DJ
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Dear Sir, I believe the GMS contract has produced a health care system more suited to a third-world socialist state than the fourth strongest economy and is well overdue for a radical change rather than the sinister adjustments currently on offer (1). In a capitalist society customers purchase goods and services from the supplier of their choice. Although supposedly self-employed, British general practitioners are tied into a contract that prohibits private practice. Even when the NHS does not provide a particular treatment the contract effectively prohibits doctors from offering this directly at any price (2,3). GPs can have private patients but these must forego the major benefit of receiving NHS prescribed medicines. It may seem appropriate that private patients should not benefit from the subsidies that facilitate a doctor's NHS practice but private patients are frequently taxpayers and so have contributed to the costs of NHS provision. However, these same subsidies are considerably reduced if a doctor's private fees exceed 10% of his total practice income thus reducing the resources available for his NHS patients (4). It is therefore unheard of for a doctor to mix NHS and private practice. The majority simply refer rather than treat. I know of one patient who paid a podiatrist £730 for a simple Zadek's procedure, which should not be beyond the competence of any GP. My main concern in the proposals is the total loss of any remaining autonomy GPs have to act as the patient's advocate. The contract empowers PCTs to commission and provide medical care by unregistered practitioners. It prevents list closure and allows PCTs to enforce allocations without payment. Added to this is the eventual ownership of computer data and the fact that the contract is binding on one side only. The strategy is control, allowing the state to recoup whatever this may initially cost. The difference between GPs and lawyers and other professionals is that doctors are tied to working only for the state at a rate of pay determined by the exchequer alone. Others can mix state-funded and private practice without financial penalty but the taxpayer can never meet all of society's medical requirements, so until GPs are able to work in a mixed economy we will always be fighting over our share of a very limited cake and which is the better of many evils (1). Is it not time for paragraph 38 etc, and all the falsehood this implies, to be challenged? Dr Paul Thomas Gipping Valley Practice, Barham Suffolk. 1) New contract for general practitioners, Paul Shekelle, BMJ 2003; 326:457-458 2) NHS (General Medical Services) Regulations, 1992, Schedule 2, paragraphs 38-42 3) NHS (Pharmaceutical Services) Regulations, 1992, Schedule 2, PART III, paragraph 13(1) 4) NHS Statement of Fees and Allowances paragraphs 51.16, 51.17 and 52.22 Competing interests: none |
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