Review of the new General Medical Services contract – podcast transcript

3 July 2008

Simon: I’m here today talking to Claire Sweeney, portfolio manager for Audit Scotland’s latest report Review of the new General Medical Services contract. Claire, what’s this report about?

Claire:  This report is about the new General Medical Services (nGMS) contract which was introduced on the 1st of April 2004.  This is a new contract between a GP practice and the NHS board and the contract was introduced as other contracts were felt to be no longer fit for purpose.  It’s actually a UK-wide contract with minor differences negotiated for each of the four UK health departments.  As part of the work we looked at how the contract was implemented, what it cost and what the impact of the contract has been on patients, GPs and on the wider NHS.  

Simon: And what have you found?

Claire:  We found that the new contract wasn’t well planned and cost more than expected. In the first three years of the contract General Medical Services cost about £160 million more than was allocated to NHS boards for those services.  We found that there’s evidence of improvement for some patients such as monitoring of patients with certain long-term conditions such as diabetes but it will take time to secure wider benefits for patients on the contract.  We found that NHS boards have started to use the contract to tailor services to local need but there’s scope to develop that further.  We also found there’s a lack of basic management data on general practice which will make it more difficult for the NHS to plan effectively or to carry out workforce planning.

Simon:  You spoke there about some of the benefits there have been for patients so far and also about the potential for there to be some wider benefits later.  Have there been any other impacts of the contract on patients so far?

Claire:  Although it will take time to secure wider benefits for patients under the contract there’s already some areas where things have improved for patients for example those with long-term conditions have their health monitored more regularly than before but the Scottish Government must ensure that the new incentive payments scheme known as the Quality and Outcomes Framework moves from a focus on processes to a much greater focus on outcomes for patients.  As part of the new contract GPs are able to opt out of providing out-of-hours care for patients and this is the subject of a previous Audit Scotland report where we found that although patients were largely happy with the out-of-hours care thy received there were risks that the service was unsustainable in its current form.  

Simon: You said that the contract cost £160 million more in the first 3 years than had been allocated to health boards.  Why did it cost so much more than expected?

Claire:  We did find that the new contract was poorly planned and not well costed.  This was largely due to underestimating the cost of implementing the incentive payments scheme for quality, known as the Quality and Outcomes Framework or the QOF and also ensuring that no GP practice lost out financially from the new contract.  We found that poor data on general practice and a lack of piloting or testing the proposed changes led to the underestimation.  Our report recommends that the Scottish Government collects robust data before implementing major schemes so that it can base decision on accurate information.

Simon: Now, under the contract GP practices have seen quite big increases in their income and as you mentioned they’re not doing out-of-hours work anymore and there doesn’t appear to be a big increase in their work load.  Some people might say this contract just sees GPs doing more for earning less.  

Claire:  The new contract was designed to improve GP income and working conditions so that the recruitment and retention of GPs could be improved.  GP income has increased by almost 40 percent between 2003/04 and 2005/06 although GP’s net income tends to be lower in Scotland than in the rest of the UK which is largely due to lowed practice list sizes.  There is a lack of comprehensive data on staff numbers, activity and workload in general practice.  For example, the NHS doesn’t know how many GPs, full or part-time, there are in each NHS board area.  There is some data available though and this suggests that the role of the staff within the practice is changing and that the percentage of contacts with practice nurses that a patient might have has actually increased.

Simon:  So what do you want to see happen now?

Claire:  The Scottish Government, NHS boards and GPs must all work together to build on the initial improvements that the contract has brought.  We highlight a number of recommendations in the report but the mains ones are that the Scottish Government should collect robust data before implementing any major schemes, such as new pay contracts, so that it can base its decisions on accurate information. The new incentive payment scheme the Quality and Outcomes Framework must have a greater focus on the outcomes for patients rather than processes and procedures. The Scottish Government should also monitor NHS boards’ investment in enhanced services to make sure that they achieve value for money and adequately fund services that address particular local needs and also we recommend within the report that there needs to be comprehensive data on GPs and GP practice staff numbers to support work-force planning both at a national and at a local level.

Simon:  OK Claire, thanks very much for your time.