Would a generalist contract based on service item payments be beneficial to general practice?
COVID-19 has pushed GP workload to unprecedented levels, with more than 30 million appointments in October alone and about two-thirds of those done face-to-face.
The growing NHS backlog created by the pandemic has pushed wait times for hospital treatments to record highs – practices picking up huge amounts of extra work as patients face long delays for hospital treatments .
Data from the RCGP, meanwhile, show that clinical administrative work is up by more than a third compared to before the pandemic, exacerbating the pressures on general medicine.
General practitioner workload
But GP leaders have been saying since long before the arrival of COVID-19 that the workload in general practice is ‘irreversible’ – with growing demand from an increasingly complex aging patient population putting pressure on it. increasingly strong in a workforce that remains in decline.
Almost two decades after the landmark 2004 GMS contract agreement, which saw the shift from a service element payment system to a practice-based contract with formula-based capitation payments, LMCs believe that the contract is inadequate and obsolete, despite updates through the years.
GPs at the LMCs 2021 conference for England in November argued that the existing contract had “no upper limit” – leaving practices exposed to unlimited work at a time when demand for patient visits has increased considerably.
But would a return to element of service payments help – and could it even make matters worse?
Katie Collin, partner at medical accountants Ramsay Brown, said GPonline that it recognized that the current “global contract” had left general practitioners’ offices facing an unlimited workload. However, she warned that there was a significant risk involved in switching to a service item model.
The biggest risk could be that the bureaucracy – already a major headache for general practice – becomes even more of a waste of time and resources for practices, she said.
“The problem in practice with the article of service is the potential for a huge amount of bureaucracy,” Ms. Collin said. ‘From the experience of what we have seen with things [like QOF] that are similar – the amount of evidence expected adds more administrative workload, and there could be a lot more control than around a blanket contract.
“There is a risk that you will be more of a pain in terms of administration. The problem is potentially that you are passing the checkbox for everything, rather than just QOF. ‘
While a significant amount of practice activity is recorded in their computer systems, she pointed out that while proper use of technology can bring significant benefits, it can also go wrong – highlighting issues with switching to a centralized primary care support model in recent years. .
She added that with contract changes there are always “winners and losers” – and that larger firms far above the management and red tape may be in the best position to cope. to a more bureaucratic service model, while smaller firms already find themselves inundated with administrative tasks the workload could be the most difficult.
“Changing the contract in this way could really affect a lot of these practices, but not just the very small ones – a lot of our clients have lists of 6,000 to 12,000 patients, and they are the ones who could really start to struggle with it. this additional administrative work.
She added that there was already a “deficit of practice directors”, many of whom were unable to cope with the existing administrative pressure – and warned that a major overhaul could create “an opportunity to retire” for one. other group.
Andy Pow, health partner at Mazars, said he agreed with the view expressed by CML that the current contract was outdated and inadequate. “He’s had his day – I think he needs a refresh,” he said. GPonline.
Mr Pow said the intention in 2004 with the so-called ‘new GMS contract’ was to simplify the GP funding model – but since then the complexity of the contract has increased, with the changes. to QOF, the growth of improved local services based on payments for service items, and a tendency to offer short-term block funding which provided a poor basis for long-term planning of GP services.
Meanwhile, austerity-related changes had left general practice as “almost the only spectacle in town” absorbing demand for other services that had been cut back – while the complexity of the patient population had increased massively, while the contract has no mechanism “to reflect the increase in appointments per patient”.
However, a fully service-based system would mean “too much bureaucracy in terms of claiming payments,” he warned.
“You must have other factors in there,” he said. He pointed out that a simple fee per appointment could encourage switching patients into five-minute blocks rather than actually improving access, for example.
“If it was just complaints for everything you’ve done, it would be a nightmare,” he said. “Ideally, you should calculate the actual cost of providing the service, for the service you want to provide. “
In areas where the current Carr-Hill formula reflected the workload relatively accurately, the existing contract was working well, he said. But he argued that the existing formula had never worked for everyone – and that the allocation model “needs to be looked at”.
He said if the element of service is travel management, a blended system with improvements to the existing funding formula to improve funding for those who are currently denied the funding they need could be a way forward. to follow. But he warned, “What you don’t want is to replace it with more bureaucracy.”