General medical services (GMS) is the range of healthcare that is provided by general practitioners (GPs or family doctors) as part of the National Health Service in the United Kingdom. The NHS specifies what GPs, as independent contractors, are expected to do and provides funding for this work through arrangements known as the General Medical Services Contract. Today, the GMS contract is a UK-wide arrangement with minor differences negotiated by each of the four UK health departments. In 2013 60% of practices had a GMS contract as their principal contract. The contract has sub-sections and not all are compulsory. The other forms of contract are the Personal Medical Services or Alternative Provider Medical Services contracts. They are designed to encourage practices to offer services over and above the standard contract. Alternative Provider Medical Services contracts, unlike the other contracts, can be awarded to anyone, not just GPs, don't specify standard essential services, and are time limited.[1] A new contract is issued each year.
Normal working hours of 8 am to 6.30 pm Monday to Friday are specified in the contract.
History of the contract
National contracting of general medical (general practitioner) services can be traced to the National Insurance Act 1911 which introduced a pool (similar to today's "global sum") to pay GPs on a capitation system building on the traditions of the friendly society.
The scheme was administered by local insurance committees covering counties and conurbations which held a panel of doctors prepared to work under the scheme. The panel doctors were subject to "terms of service" which were later lifted directly into the NHS GP contract.[2]Lloyd George's "nationalisation of club medicine and local insurance in 1912 was the progenitor of the NHS in 1948".[3] Lloyd George, when proposing to increase from 6 to 9 shillings per head the proposed annual payment to panel GPs insisted: "If the remuneration is increased, the service must be improved. Up to the present the doctor has not been adequately paid, and therefore we have had no right or title to expect him to give full service. In a vast number of cases he has given his services for nothing or for payment which was utterly inadequate. There is no man here who does not know doctors who have been attending poor people without any fee or reward at all".[4]
In 1924 agreement was reached between the British Medical Association and the Ministry of Health that capitation fees would comprise 50% of a GPs income but only occupy 2/7 of his time, the remaining income being generated privately.[5]
The meaning of independent contractor in respect of GPs has not always been very clear, but was generally tied to their rejection of salaried status. It has been argued that their behaviour has rarely been that of self-employed entrepreneurs, but rather that of salaried professionals who emphasise and defend the importance of their autonomy.[5]
GPs' contract arrangements were originally made with local executive councils, and then their successors family practitioner committees, family health service authorities and primary care trusts. In England the contract is now between the GP practice and NHS England. In Scotland GP practices are contracted by the health boards.[6] It was agreed in August 2014 that GPs in Scotland would have a separate contract with negotiations taking place which would come into force from 2017/18. It is proposed that they should give up employing practice staff and move 'as far towards salaried model as possible without losing independent status'.[7]
Early years of the NHS
The Beveridge Report of 1942 gave the impetus for White Paper under the Conservative Health Minister Henry Willink that supported the idea of salaried GP services in health centres. The 1946 National Insurance Act under Labour Health Minister Aneurin Bevan, which laid the foundation for the NHS, reduced the clinical role of GPs in hospitals and their involvement in public health issues. The capitation fees was based on the number of patients the GP had on his list. Proposals to make GPs salaried professionals were rejected by the profession in 1948. In 1951 the capitation started to be based on the number of doctors, rather than patients.
From 1948 to 2004 the contract was an individual one. Virtually every doctor working in general practice had a personal contract with the local NHS and patients were registered with a named doctor. There was a clause which stated "a doctor is responsible for ensuring the provision for his patients of the services referred to … throughout each day during which his name is included in the … medical list".[8]
In 1953, general practitioners were estimated to be making between 12 and 30 home visits each day and seeing between 15 and 50 patients in their surgeries.[9]
The College of General Practitioners was founded in November 1952, and became an increasingly important player in negotiations about the GP contract. It became a driving force in developing postgraduate training for doctors wishing to enter general practice.
1966 GP contract
In 1965 GPs demanded a new contract and threatened mass resignation from the NHS. One of their complaints was that there was no provision for improvement of practices. A GP who employed a secretary or nurse was paid no more than others who did the minimum. The main problem, however, was in comparison to the pay and status of hospital consultants. The career earnings of a consultant at that time were 48% higher than those of a GP.[5] The Socialist Medical Association complained that the role of the family doctor as the lynch-pin of the NHS, as intended in the NHS Act had not been fulfilled. The reverse position had gradually developed, and general practice, was now frequently described as a "cottage industry".[10] The BMA formulated a Charter for the Family Doctor Service. It demanded: "To give the best service to his patients, the family doctor must:
Have adequate time for every patient.
Be able to keep up to date.
Have complete clinical freedom.
Have adequate, well-equipped premises.
Have at his disposal all the diagnostic aids, social services and ancillary help he needs.
Be encouraged to acquire skills and experience in special fields.
Be adequately paid by a method acceptable to him which encourages him to do his best for his patients.
Have a working day which leaves him some time for leisure".[10]
The resulting 1966 contract addressed major grievances of GPs and provided for better equipped and better staffed premises (subsidised by the state), greater practitioner autonomy, a basic practice allowance for any GP principal with a list of more than 1000 patients, and pension provisions. Fees for service were introduced for interventions related to the prevention of disease. There was considerable pressure from doctors for the introduction of charges to patients but the Minister, Kenneth Robinson and the leadership of the BMA resisted this.[5] Despite some changes, the capitation principle and the pool survived. The new payment system, known as the red book, allowed doctors to claim back from the NHS 70% of staff costs and 100% of the cost of their premises. Maternity Services and contraception were optional services which attracted additional payments. GPs were allowed to practise privately, to hold part-time hospital or other appointments within the NHS, to work in industry or for an insurance company, although few did very much private work.[11]
In 1976 parliament approved legislation requiring doctors who wanted to become principals in general practice to complete vocational training.[9]
1990 GP contract
The Conservative government under Margaret Thatcher from 1979 onwards looked for ways of changing the NHS, with a greater role of the private sector, and for limiting health spending and it was not afraid to take on the doctor's trade union, the British Medical Association (BMA). The 1990 contract which was imposed by Kenneth Clarke after it was rejected in a ballot, linked GP pay more strongly to performance. More money was attached to capitation and less to the basic practice allowance, in line with the Thatcher government's general enthusiasm for competition – an enthusiasm which was not shared by many GPs. The number of professional members on the family health services authority was considerably fewer than had been the case with the family practitioner committee.[5] The terms and conditions of primary medical service delivery were closely specified. The 'Red Book' (Statement of Fees and Allowances) detailed the payment tariffs for each individual treatment. Targets were set for cervical smears and immunisations. GPs were required to give health checks to new patients, patients over 75 and those who had not seen a GP for 3 years.
The GP Fundholding scheme gave them a budget for commissioning for the first time. The government also introduced a new locally negotiated personal services contract for general practitioners in 1997, permitting them to be salaried, paid by the session, or work as locums.
The 2004 GMS contract
The new GMS contract came into force in April 2004, abolished the "Red Book" and led to a significant but temporary increase in some practices' income. Every practice gets a share of a total amount of money allocated towards primary care in GMS practices (the "Global Sum"). This share is determined by the practice's list size, adjusted for age and sex of the patients (children, women and the elderly have higher weights than young men because they cause a greater workload). Furthermore, the practice gets an adjustment for rurality (greater rurality causes greater expenses), for the cost of employing staff (the "Market Forces Factor"), which captures differences in pay rates between areas, (e.g., it is more expensive to hire a nurse in London than in Perth), the rate of "churn" of the patient list and for morbidity as measured by the Health Survey for England.
The application of the formula to this reduced "Global Sum" would have resulted in great changes in GP income and income loss for many GPs and through their representative organisations the GPs were able to extract a concession. They received a "Minimum Practice Income Guarantee", which temporarlily protected the previous income levels of those who would otherwise have lost out – that guarantee being withdrawn over time by a combination of inflation and the clawback of pay rises.
At the same time the Government introduced the Quality and Outcomes Framework (QOF) which was designed to give GPs the incentive to do more work and fulfil government-set requirements (146 indicators) to earn points (varying amounts per indicator) which translate into greater income. The money for the QOF was taken out of the "Global Sum", so is not really new extra money.
Participation in the QOF is voluntary but since the standards change each year, practically all practices participating have to do more work each year for the same income. However, the substantial additional workload of QOF has led to substantial improvements in the screening for risk factors in the community by primary care, particularly for older patients with cardiovascular disease.[12][13][14]
The Working in Partnership Programme (WiPP) was launched under the 2004 contract to support doctors in general practice by providing them with innovative ideas on how to improve services for the public.
The new contract forced almost all GPs to opt-out of weekend and night out-of-hours service provision – largely because the cost of providing a good quality service was roughly double the funding allocated to it by the patient, but also because the government set standards (all calls to be answered within 60 seconds etc.) that cannot be met by individuals. The inevitable consequences of systematic underfunding of primary care OOH services and their provision by the cheapest bidder came to a head with the Dr Ubani case, although there have been many others. It should perhaps stand as a warning of the risks inherent in the "lowest bid cheapest provider" model of medical care.
A series of amendments have followed each year – each time reducing income for the current workload, and tying existing pay to new targets (adding new QoF indicators, making them harder to meet, extending working hours). This combined with the other workload factors (increasing consultation length, increasing consultation frequency, ageing population (see Office for National Statistics) increasing medical complexity, and transfer of work from hospital means that GP workload is rising 5% year on year as GP income falls – concealed largely by the rise of "half-time GPs" working 40 hours a week which makes pay look artificially high.
The 2015 contract
The contract changes for 2015/16 in England were announced in September 2014 and formulated in the National Health Service (General Medical Services Contracts) Regulations 2015 (SI 2016/1862). Main changes included a named, accountable GP for all patients, publication of GPs' average net earnings and expansion and improvement of online services. Practices have to help anyone who wants it to sign up for patient-facing services.[15] All practices were required to have a patient participation group[16] According to Jeremy Hunt the right to a named GP turned into a tick-box exercise as there were not enough GPs.[17]
The 2017 contract
GP practices in England will receive £85.35 per weighted patient under the 2017 Contract, an increase of 5.9% from 2016/17.[18]
The 2019 contract
The 2019 contract will run for 5 years. £405 million of funding has been confirmed for 2019/20. The contract provides changes to the rurality index payment and London adjustment payment, so that rurality index payments will only apply to patients living inside a GP's catchment area and the London adjustment payment will only apply to patients actually living in London. Babylon Health complained that this penalised their GP at Hand operation which had invested in technology in order to serve patients over a wide geographic area.[19] According to the BMA the deal will guarantee a minimum 2% uplift for GP and staff pay and expenses this year.[20]
There is an incentive of £2 a patient for practices to join geographically based primary care networks.
There will be funding for pharmacists, physiotherapists, paramedics, physician associates and social prescribing support workers to support practices.
Practices will be obliged to make one appointment per 3,000 patients available per day for direct booking by NHS 111. Richard Vautrey described the changes as the most significant in 15 years.[21]
For the first time State indemnity is extended to GPs and practice staff.
Practices are banned from advertising or hosting private services.[22]
The Carr-Hill formula
Capitation payments, which make up about 60% of a typical practice's income,[1] are calculated using a formula developed by Professor Roy Carr-Hill. "This formula takes into consideration, along with other practice characteristics, individual patients' age, gender and health conditions and calculates a "weighted" count of patients according to need. This means that two practices with the same number of patients may have very different weighted patient numbers due to widely varying patient characteristics and health conditions, and as a result, these practices which may seem to be similar in terms of list size, could receive very different levels of funding".[23]
This includes patient age and gender which is used to reflect frequency of home and surgery visits, Standardized mortality ratio and Standardised Long-Standing Illness for patients under 65, the number of newly registered patients, numbers of residential and nursing home patients, rurality and the cost of living, particularly in London.[24]
In 2019 GPs were paid around £150 on average for each patient on their list. In 2018 3.6 million more patients were registered in England than the population. The NHS Counter Fraud Authority is to investigate where registered patients have not visited their doctor for five years. Richard Vautrey said "Some of these will be people that have recently died, or left the country, others may be homeless or simply unaccounted for in government statistics, and we would be concerned at any suggestion that any discrepancies are down to wilful deception by hard-working GPs."[25]
Other primary care contracts
Apart from GPs in the GMS, primary care is also provided through Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS) contracts.
Personal Medical Services (PMS) were first tried in April 1998 and became a permanent option in April 2004. The health care professional/health care body and the primary care trust (PCT) enter a local contract. The main use of this contract is to give GPs the option of being salaried. Alternative Provider Medical Services (APMS) are primary care services provided by outside contractors (like US health companies).
A study, published by the Journal of the Royal Society of Medicine in 2015 found that 347 of the 8,300 general practices in England were run by under 'alternative provider medical service' contracts. The study found the introduction of the alternative contract had not led to improvements in quality and may have resulted in worse care. The results showed that APMS providers performed significantly worse across 13 out of the 17 indicators (p=<0.01 in each) in each year from 2008/09 and 2012/13, and were significantly worse than traditional general practice in three out of the five years for a further two indicators.[26]
Profitability
In 2013/4 the average gross earnings of a single handed GP was £107,200. In practices with six or more GPs the average was £99,100.[27]
Related Research Articles
In the medical profession, a general practitioner (GP) or family physician is a physician who treats acute and chronic illnesses and provides preventive care and health education to patients of all ages. GPs' duties are not confined to specific fields of medicine, and they have particular skills in treating people with multiple health issues. They are trained to treat patients to levels of complexity that vary between countries. The term "primary care physician" is more usually used in the US. In Asian countries like India, this term has been replaced mainly by Medical Officers, Registered Medical Practitioner etc.
Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care that the patient may need. Patients commonly receive primary care from professionals such as a primary care physician, a physician assistant, a physical therapist, or a nurse practitioner. In some localities, such a professional may be a registered nurse, a pharmacist, a clinical officer, or an Ayurvedic or other traditional medicine professional. Depending on the nature of the health condition, patients may then be referred for secondary or tertiary care.
General practice is the name given in various nations, such as the United Kingdom, India, Australia, New Zealand and South Africa to the services provided by general practitioners. In some nations, such as the US, similar services may be described as family medicine or primary care. The term Primary Care in the UK may also include services provided by community pharmacy, optometrist, dental surgery and community hearing care providers. The balance of care between primary care and secondary care - which usually refers to hospital based services - varies from place to place, and with time. In many countries there are initiatives to move services out of hospitals into the community, in the expectation that this will save money and be more convenient.
Family medicine is a medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body. The specialist, who is usually a primary care physician, is named a family physician. It is often referred to as general practice and a practitioner as a general practitioner. Historically, their role was once performed by any doctor with qualifications from a medical school and who works in the community. However, since the 1950s, family medicine / general practice has become a specialty in its own right, with specific training requirements tailored to each country. The names of the specialty emphasize its holistic nature and/or its roots in the family. It is based on knowledge of the patient in the context of the family and the community, focusing on disease prevention and health promotion. According to the World Organization of Family Doctors (WONCA), the aim of family medicine is "promoting personal, comprehensive and continuing care for the individual in the context of the family and the community". The issues of values underlying this practice are usually known as primary care ethics.
Choose and Book was an E-Booking software application for the National Health Service (NHS) in England which enabled patients needing an outpatient appointment to choose which hospital they were referred to by their general practitioner (GP), and to book a convenient date and time for their appointment.
Primary health organisations (PHOs) in New Zealand are health care providers that are funded on a capitation basis by the New Zealand Government via district health boards. They are usually set up as not-for-profit trusts, and have as their goal the improvement of their population's health.
NHS Scotland, sometimes styled NHSScotland, is the publicly funded healthcare system in Scotland and one of the four systems that make up the National Health Service in the United Kingdom. It operates 14 territorial NHS boards across Scotland, supported by seven special non-geographic health boards, and Public Health Scotland.
The Quality and Outcomes Framework (QOF) is a system for the performance management and payment of general practitioners (GPs) in the National Health Service (NHS) in England, Wales, Scotland and Northern Ireland. It was introduced as part of a new general medical services (GMS) contract in April 2004, replacing various other fee arrangements.
Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately.
Healthcare in England is mainly provided by the National Health Service (NHS), a public body that provides healthcare to all permanent residents in England, that is free at the point of use. The body is one of four forming the UK National Health Service as health is a devolved matter; there are differences with the provisions for healthcare elsewhere in the United Kingdom, and in England it is overseen by NHS England. Though the public system dominates healthcare provision in England, private health care and a wide variety of alternative and complementary treatments are available for those willing and able to pay.
A sessional GP is an umbrella term for GPs whose work is organised on a sessional basis, as opposed to GP partners whose contract is generally for 24-hour care. The term was first coined by the National Association of Sessional GPs (NASGP), who at the time were called the National Association of Non-Principals (NANP). After consultation with their membership, it was perceived that the term 'non-principal' was a term that defined these GPs using a negative definition rather than a positive one.
Practice management is the term used in General practice for the person who manages the finance and administration of a doctor's office or an office of a medical professional in one of many types of specialties in medicine. This is distinct from other official titles such as Advanced Practice Manager, which are generally clinical. A practice manager is responsible for the administrative responsibilities of daily operations and development of a business strategy. Most practice managers are responsible for hiring staff, negotiating benefits and personnel policies, ensuring that medical supplies are ordered and equipment is maintained, ensuring regulatory compliance, and the development and marketing of service lines. Practice management encompasses multiple topics including governance, the financial aspects of medical billing, staff management, ancillary service development, information technology, transcription utilization, and marketing. Practice managers handle the business aspects of medicine to maximize provider time and enhance patient care.
Clinical commissioning groups (CCGs) were National Health Service (NHS) organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in each of their local areas in England. On 1 July 2022 they were abolished and replaced by Integrated care systems as a result of the Health and Care Act 2022.
Dentistry provided by the National Health Service in the United Kingdom is supposed to ensure that dental treatment is available to the whole population. Most dentistry is provided by private practitioners, most of whom also provide, on a commercial basis, services which the NHS does not provide, largely cosmetic. Most adult patients have to pay some NHS charges, although these are often significantly cheaper than the cost of private dentistry. The majority of people choose NHS dental care rather than private care: as of 2005, the national average proportion of people opting for private care was 23%. NHS dentistry is not always available and is not managed in the way that other NHS services are managed.
Out-of-hours services are the arrangements to provide access to healthcare at times when General Practitioner surgeries are closed; in the United Kingdom this is normally between 6.30pm and 8am, at weekends, at Bank Holidays and sometimes if the practice is closed for educational sessions.
Private healthcare in the UK, where universal state-funded healthcare is provided by the National Health Service, is a niche market.
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GP Federations became popular among English general practitioners after 2010 as a means to exploit the opportunities—or mitigate the threats—posed by the Five Year Forward View proposals in the English NHS which envisaged delivering primary care at a larger scale than the traditional GP list. It is widely believed that ‘Practices cannot survive on their own – they have to look at ways of making themselves stronger.’ 15 sites were selected in December 2015 to test new enhanced primary care models serving populations of 30,000 to 50,000 patients. Some, but by no means all, clinical commissioning groups have given financial support to encourage the formation of federations.
In England, an integrated care system (ICS) is a statutory partnership of organisations who plan, buy, and provide health and care services in their geographical area. The organisations involved include the NHS, local authorities, voluntary and charity groups, and independent care providers. The NHS Long Term Plan of January 2019 called for the whole of England to be covered by ICSs by April 2021. On 1 July 2022, ICSs replaced clinical commissioning groups in England.
A Primary care network is a structure which brings general practitioners together on an area basis, possibly with other clinicians, to address chronic disease management and prevention. In 2022 the term is used in England, Singapore and Alberta.
References
1 2 Burch, Patrick (19 December 2018). "Funding in primary care". InnovAiT: Education and Inspiration for General Practice. 12 (2): 100–104. doi:10.1177/1755738018805186. S2CID27415227.
↑ McGovern MP, Williams DJ, Hannaford PC, Taylor MW, Lefevre KE, Boroujerdi MA, Simpson CR (2008). "Introduction of a new incentive target based contract for family physicians in the United Kingdom: good for older patients with diabetes but less good for women?". Diabetic Medicine. 25 (9): 1083–1089. doi:10.1111/j.1464-5491.2008.02544.x. PMID18937676. S2CID517824.
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