Much of the terrain for this year’s GMS contract negotiations was set out in a White Paper implementation ‘road map’ published last week by the DoH.
‘Our Health, Our Care, Our Say: making it happen’ sets out plans for more accessible primary care, more community-based services, better links between healthcare and socialcare, and an expansion of the self-care agenda.
A desire to increase the NHS’ focus on health and well-being means the that DoH will push for smoking, obesity and alcohol indicators to be added or expanded in the quality framework by 2008 (GP, 20 October).
Elements of the core contract will also need to change and the indications are that negotiations will not be plain sailing. GPs have adopted a defiant stance over many of the changes that they will be pushed to adopt.
The DoH wants practices to expand patient lists, open for longer and allow patients to register at practices with opening hours that are convenient for them. Creating the right conditions for this will be a key goal for NHS Employers negotiators representing the DoH.
The DoH also wants a review of the MPIG as part of a drive to ‘explore incentives for practices to expand’.
Under the current system, the more than 90 per cent of practices that require MPIG receive less money per patient for additions to their practice list than they receive per existing patient.
This is because correction factors that top up practices’ global sums are fixed. If a new patient is registered, the practice’s global sum increases, but the correction factor does not. This creates a potential disincentive to expand.
GPC leaders are adamant they will not accept a change to MPIG that creates winners and losers — they want a ‘levelling up’.
GPC negotiator Dr Richard Vautrey said: ‘MPIG is there in perpetuity, unless a formula can be introduced to ensure practices are levelled up, and it seems unlikely the DoH would do that.’
Another lever to push list growth will come from DoH plans to remove the option for practices to declare patient lists ‘open but full’.
DoH national clinical director for primary care Dr David Colin-Thomé wants patients to be able to join any open list from 2007/8.
‘You can’t have an open-but-full list — you are either open or closed. Open but full is not a legal entity,’ he said.
The GPC believes ‘open but full’ is a contractual right and has vowed to defend it, but if the DoH gets its way, GPs may have to choose between losing income and being unable to control list size. This is because practices that close their lists lose the right to offer enhanced services.
Dr Vautrey said practices depended on open but full status.
‘Many have staff and building constraints, and need to operate at a steady level’ he said. ‘They may be able to take patients allocated by the PCT but not want to actively expand lists.’
Expanding practice allowance
An ‘expanding practice allowance’ features in the road map as another option for incentivising practices to take on more patients. Dr Vautrey said this could be useful in areas with fast-growing populations. But he said there was little detail.
‘How much money would it involve? How long would payments last, and would they be in addition to global sums?’ he asked.
He said it was not clear at this stage whether it offered a potential alternative to a review of MPIG.
The DoH document also sees GPs being heavily involved in improving joint working between healthcare and social care.
The practice-based commissioning (PBC) framework will be updated to help GPs achieve this. By 2007/8 all patients with long-term healthcare and social care needs are to have ‘integrated care plans’. The same applies to all patients with long-term conditions by 2010.
‘If we are proactive about community and social work together with GP practices, consultation rates will fall,’ argued Dr Colin-Thomé.
But GPC member Dr Trefor Roscoe said: ‘Attempts have been made to integrate health and social care, but the benefits are difficult to see. The money would be better spent on more social workers or care homes.’
Incentives for longer opening hours may be easier to devise. But Dr Roscoe said: ‘Whatever the incentives, only a small proportion of practices will take that on.’
The proposed quality framework changes will encounter opposition. GP leaders say there is little evidence that primary care interventions make a difference for alcohol and obesity.
GPC chairman Dr Hamish Meldrum recently said negotiations were at a delicate stage — the road map may have led them down a dead-end street.
GP fears over White Paper plans:
MPIG review impossible with no extra cash.
Ban on ‘open but full’ lists.
PBC undermined by demand to integrate with social care and individual patient budgets.