PCTs told how to axe GP contracts

The DoH has sent instructions to PCTs outlining how best to drive up practice performance and terminate contracts of under-performing GPs.

Dr Tony Grewal: PCTs now see themselves as there to performance manage every aspect of the contract
Dr Tony Grewal: PCTs now see themselves as there to performance manage every aspect of the contract

The guidance, called Raising the Bar, tells PCTs 'it is essential to take an aggressive approach' and provides a template letter for threatening practices with contract termination.

Fifteen key clauses in the GMS contract have been picked out in the guidance that can be scrutinised and used to declare that practices are in breach of their contracts.

The guidance comes a month after the NHS Confederation called for a new GP contract 'with stronger contractual levers to deal with unresponsive practices'.

Produced by the DoH's Health Inequalities National Support Team, it offers PCTs advice on how to improve standards across primary care in England.

Raising the Bar acknowledges that 'many PCTs believe the current GP contract is too vague for (improving performance)'. 'However, greater and earlier use of contract breach notices can encourage quality improvements,' it says.

The document recommends that PCTs call upon relevant experts, such as health and safety inspectors or data protection teams, to scrutinise practices' adherence to key contractual clauses (see box, below).

GMS Clauses under scrutiny

GMS clauses identified by the Health Inequalities National Support Team as routes to target poor practices - GP leaders say their 'wooliness' may leave practices vulnerable.

  • Clause 25: The contractor should carry out its contractual obligations with reasonable care and skill.
  • Clause 27: Contractors shall ensure premises are used for the provision of services that are suitable for the delivery of those services and meet the reasonable needs of patients.
  • Clause 40.2: All refrigerators in which vaccines are stored must have a min/max thermometer with readings taken on all working days.
  • Clause 41: The contractor shall ensure it has appropriate arrangements for infection control and decontamination.

It adds that 'appraisal and reviews' should also be used to build a body of evidence against practices.

The report found placing practices in performance 'league tables' was an effective way to drive up performance in even the best practices.

'Seventy per cent QOF achievement means 30 per cent failure,' the document states. It backs the use of 'QOF plus' or locally negotiated 'quality improvement frameworks' to improve standards beyond the remit of the QOF.

PCTs are urged to 'stretch targets in PMS contracts without extra costs'. 'Funds can be redistributed once behaviours change,' the guidance adds.

Londonwide LMCs medical director Dr Tony Grewal said it was the 'formalisation' of a change in PCT attitudes towards practices.

'They no longer see themselves as there to support and advise and control rationing while letting practices get on with it.

'They now see themselves as there to performance manage every aspect of the contract,' Dr Grewal said.

He said vague wording of contract clauses often meant it was a 'matter of judgment, not precision' whether practices met these requirements.

It was unfair to target practices with poor premises, as the guidance suggests, he added.

'GP premises are a major constraint to delivering quality primary care. Cash-strapped PCTs have not been supporting practices to improve for a number of years,' he said.

GPC deputy chairman Dr Richard Vautrey said PCTs should only use contractual levers as a last resort to force failing practices to improve.

'We don't support poor performance either, but contractual levers should be used as a last resort. There should be a greater emphasis on encouraging and supporting good performance.'

The 'unhelpful tone' of the document failed to appreciate the high level that most practices are performing at, said Dr Vautrey.

'Practices will always try to improve but there is a limit to their resources and the time in the day,' he said.

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