|Implemented in this survey?|
The new general medical services contract (2004) introduces a new means of paying primary health care doctors with the aim of paying doctors on the basis of workload, increasing the quality of care and expanding the range of services available to patients.
On 1 April 2004, the vast majority of GPs in the UK started to be paid under a new national contract. The contract is practice-based rather than with individual GPs. The new General Medical
Services contract introduces a range of important new changes, these include: (i)a quality and outcomes framework whereby GP practices will receive payments related to performance in terms of
specified clinical and organisational criteria - these will include performance in terms of, for example, coronary heart disease, stroke, hypertension, diabetes, cancer and mental health (ii); a new
payments system that will allow practices to earn additional income through the provision of extra services - this will offer special payments for GPs who wish to develop specialisms; (iii) the
ability of GPs to relinquish responsibility for out-of-hours cover, in return for reduced payments. This will become the responsibility of PCTs who will need to arrange for out-of-hours services to
be provided for patients within their areas.
Note: A copy of the contract has been attached as a PDF file.
|Medienpräsenz||sehr gering||sehr hoch|
The new contract embodies a number of sensible features designed to improve quality. However, it needs to be viewed alongside the many other reforms taking place in primary care, and the NHS generally.
There have been a series of reform of general practice in the UK over the last 20 years. These have been undertaken by both Conservative and Labour governments. The essential feature of many of these reforms has been to make GPs more accountable for the services they provide - note: GPs are independent contractors not direct NHS employees - and to encourage quality improvements. These reforms have gathered momentum as the role of primary care as both a provider of primary care and as a commissioner of secondary care in the NHS has become more important. Financial incentives through payments for achieving population-based health targets, such as those based upon rates of immunisation or cervical cytology, have been applied with success in the 1990s and now this approach is being extended to a wider range of services.
|Implemented in this survey?|
The origins of the new contract go back to 1990 when the GP contract introduced that year aimed to improve GP services and to make payments more performance-related. Under this contract, practices were expected to produce annual reports, carry out needs assessments and were offered payments for meeting targets on immunisation and cervical cytology. Extra payments were available for running health promotion clinics. The internal market and the introduction of GP fundholding placed primary care in a more important position and generated a more business-like approach among many GPs. An agenda called 'shifting the balance' envisaged a primary care led NHS. In recent years, so called primary medical services pilot sites have been introduced whereby practices contract with PCTs for the provision of services, often involving innovative forms of payment and service delivery. The 2004 contract can be seen as a further extension of all these previous reforms.
Negotiations over the new contract were undertaken by the NHS confederation on the part of the government and the BMA. Bargaining was hard and protracted. Eventually, however, in June 2003 approximately 80% of GPs voted in favour of the new contract. Factors that proved popular with GPs were the freedom to opt out of out-of-hours cover, opportunities for enhanced earnings and a government commitment to increase spending in primary care by 33% over a 3 year period.
The new contract is a complex document. It will be managed by PCTs who will be responsible for the performance and payment of GP practices in their areas. A particular cause of concern is out-of-hours cover. Most GPs have indicated that they will opt out of providing this service (although many of them will join out of hours co-operatives and sell their services back to the NHS). Ensuring that all patients are offered a satisfactory out of hours service is a major challenge facing many PCTs. Beyond this, payments under the quality and outcomes framework will indicate how successful the reforms have been in improving quality standards.
To my knowledge there are no plans for the formal evaluation of these new arrangements, although clearly the monitoring for payment purposes will provide indicators of performance.
As stated above, the proposals are a clear attempt to increase GP accountability and to improve quality and the range of services through financial incentives. Financial incentives (in a more limited sense) have been successful in general practice before and so have prospects for success through the new contract. One possibly undesirable effect is that the ending of out-of-hours cover may signal the end of comprehensive primary care, which has traditionally been seen as a strength of UK primary care. Primary care is likely to become far more episodic in the UK, a trend also encouraged by NHS Direct, the telephone advice line, and walk-in centres. If the reforms succeed, access and quality should improve but costs are also likely to rise.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
Professor Ray Robinson, London School of Economics and Political science