This year the government took the unusual step of laying legislation before parliament to change the core GMS contract.  Why would they do this, and what does it mean for general practice?

In 2019 a 5 year deal was agreed between the GPC and NHS England.  Pressures on the service, in large part brought about by inflation running at over 10%, meant the GPC has tried to renegotiate this contract (without success) in the last 2 years.  The result has been the negotiated terms of the 2019 agreement have been imposed on the service without agreement.

But this year that is not the only thing that happened.  The publication of the core GMS contract was delayed, and it turns out this was because the government laid legislation before parliament to make changes to the core GMS contract that came into effect on the 15 May.

These changes are in relation to access, and stipulate how practices are to respond to contacts made by their patients.  The GPC have summarised the changes here if you have not seen them.

Why would the government choose to take the unusual step of putting legislation before parliament to change the core GMS contract?

We can only speculate as to the motivation, but it may have been because the only way of the government directing general practice is through the contract.  The GPC had refused to negotiate any changes, but (it turns out) it is within the government’s gift to use parliamentary legislation to make any changes it wants to the core contract.

Of course, changes to the core contract are only meaningful if they are enforced by local commissioners (i.e. the ICBs).  The way that contract management takes place does vary around the country, but generally commissioners try and partner with general practice rather than use heavy handed contract management techniques.  An important question is whether this legislative change will in turn lead to a much heavier handed contract management approach by local ICBs.  Only time will tell if this is the case, but more local disputes seem inevitable.

Meanwhile, the legislative change has already (unsurprisingly) provoked a backlash from the profession.  The GPC response has been to reassert their safe working guidance, which is to move to 15 minute appointments, undertake a maximum of 25 patient contacts per day, and to introduce a waiting list system for appointments.   It says, “any excess demand beyond this being signposted to other settings such as 111, overflow hubs, or urgent treatment centres. This is permitted within the contract which says that patients should be offered assessment of need or be signposted to an appropriate service”.

As ever, the combative BBO LMC have been quick out of the gates in offering guidance to their practices.  You can find it here, and it is unsurprisingly defensive in light of the contractual nature of the change being imposed.   They believe the contractual changes, “will likely result in practices diverting extremely large numbers of patients to 111 and A&E for fear of being held in contract breach, due to the unclear meaning of this clause’.

So it is already clear that imposing contractual changes is not going to lead to service improvement.  This has not happened in the past and it won’t happen now.  It is simply creating bad blood, and a hardening of respective positions, when what the service really needs is support.

Much of the reaction to the Delivery Plan for Recovering Access to General Practice has centred on whether the changes will indeed improve access, and is using that as a marker to determine the value of the paper.  But this misses the fundamental problem that creating a focus on access into general practice deepens the discord between what the government consider the purpose of general practice to be (easy access for patients) and what the profession considers its own purpose to be.  If you haven’t already please read Jonathan Tomlinson’s recent publication The Future of Primary Care – Threats and Opportunities, in which he surmises, “The value of general practice is health gain achieved, illness prevented and, holding-work – the supportive partnerships that enable patients with long-term conditions, especially mental illnesses, to keep going”, which, he argues, is undermined by the detrimental impact on relationship-based care that the ‘taskification’ of general practice work across a team creates.

It also sidesteps (ignores?) the key issue of the pressure created by the funding cuts to the service because of the government’s refusal to at least match inflation.  The document itself is clearly not (as it is sometimes referred to) a recovery plan for general practice.  It is explicitly a delivery plan for recovering access to general practice.  These are two different things, and the concern is that one may be at the expense of the other.

The changes to the GMS contract demonstrate the clear lack of a national relationship between the service and the government, and potentially mark a shift towards a more combative, contract-based style of interaction.  This is not good for general practice.  It will inevitably lead to tensions at a local level.  With the GPC talking about industrial action, and NHS England talking about ‘longer term reform’, my fear is things may get worse before they get better.