COVID-19 has driven workload in general practice to unprecedented levels, with more than 30m appointments in October alone and around two thirds of those carried out face-to-face.
The growing NHS backlog created by the pandemic has pushed waits for hospital treatment to record levels - with practices picking up huge amounts of extra work while patients face long delays for hospital treatment.
RCGP data, meanwhile, shows that clinical administrative work is up by more than a third compared with before the pandemic - compounding pressures on general practice.
But GP leaders have been saying since well before COVID-19 arrived that workload in general practice is 'undoable' - with rising demand from an ever-more complex, ageing patient population heaping more and more pressure on a workforce that remains in decline.
Nearly two decades on from the landmark 2004 GMS contract deal, which saw a shift away from an item of service payment system to a practice-based contract with capitation payments based on a formula, LMCs feel the contract is inadequate and outdated, despite updates through the years.
GPs at the 2021 LMCs 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 consultations per patient has risen dramatically.
But would a move back to item of service payments help - and could it even make things worse?
Item of service
Katie Collin, a partner at specialist medical accountants Ramsay Brown, told GPonline that she recognised the current 'block contract' had left GP practices facing unrestricted workload. However, she warned that there was significant risk attached to moving to an item of service model.
The most significant risk could be that bureaucracy - already a major headache for general practice - would become even more of a drain on time and resources for practices, she said.
'The problem in practice with item of service is the potential for a huge amount of bureaucracy,' Ms Collin said. 'From 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 lot more scrutiny than around a block contract.
'There is a risk that you get more drudge down in terms of administration. The problem is potentially that you move to box ticking for everything, rather than just QOF.'
Although a significant amount of practice activity is recorded in their IT systems, she pointed out that although good use of technology can bring significant benefits, it can also go wrong - pointing to problems with the shift to a centralised primary care support model in recent years.
She added that with contract changes there are always 'winners and losers' - and that larger practices well on top of management and paperwork may be best placed to cope with a more bureaucratic item of service model, while smaller practices already finding themselves overwhelmed with administrative workload could struggle most.
'Changing the contract in this way could really hit a lot of those practices, but not just the really small ones - a lot of our clients have lists of 6,000 to 12,000 patients, and those are the ones that could really start to struggle with that extra administrative work.'
She added that there was already a 'deficit of practice managers out there', with many unable to cope with existing administrative pressure - and warned that a major overhaul could create 'an opportunity to retire' for a further group.
Andy Pow, a healthcare partner at Mazars, said he agreed with the view expressed by LMCs that the current contract was outdated and inadequate. 'It has had its time - I think it needs a refresh,' he told GPonline.
Mr Pow said the intention in 2004 with the so-called 'new GMS contract' was to simplify the funding model for general practice - but that since that time complexity in the contract had increased, with changes to the QOF, growth of local enhanced services based on item of services payments, and a tendency to offer funding in short-term blocks that offered a poor basis for long-term planning of GP services.
Meanwhile, changes linked to austerity had left general practice as 'almost the only show in town' soaking up demand from other services that had been run down - 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 item of service-based system would mean 'too much bureaucracy in terms of claiming payments', he warned.
'You have to have other factors in there,' he said. He pointed out that a simple fee per appointment could encourage getting patients through in five-minute blocks rather than genuinely improving access, for example.
'If it went to purely claims for everything you did that would be a nightmare,' he said. 'Ideally you need to work out the true cost of providing the service, for the service you want to provide.'
In areas where the current Carr-Hill formula reflected workload relatively accurately, the existing contract worked well, he said. But he argued that the existing formula had never worked for everyone - and that the allocation model 'needs looking at'.
He said if item of service is the direction of travel, a blended system with improvements to the existing funding formula to improve funding for those currently denied the funding they need could be a way forward. But he warned: 'What you don't want is to replace the thing with even more bureaucracy.'