GMS contract: 2018

1 Introduction

A strong and thriving general practice is critical to sustaining high quality universal healthcare and realising Scotland’s ambition to improve our population’s health and reduce health inequalities.

The 2018 Scottish General Medical Services ( GMS) Contract has been developed by the SGPC and the Scottish Government to re-invigorate general practice and to re-energise its core values. It aims to create a dynamic and positive career for doctors and ensure that patients continue to have accessible, high quality general medical services.

The contract will be supported by a MOU between the Integration Authorities, SGPC, NHS Boards and Scottish Government. The MOU represents a statement of intent from all the parties to deliver the wider support and change to primary care services required to underpin the contract.

For the purposes of this document, we refer to Health and Social Care Partnerships ( HSCP) as delivery agents of Integration Authorities, responsible for the planning and commissioning of primary care services.

Nature Of The Contract

Since the inception of the NHS, general practice has developed as an independent contractor model. Some of the great strengths of general practice exist because of the independent nature of GPs under this model and their ability to prioritise and advocate for their patients.

After consideration and wide discussion, both the SGPC and the Scottish Government have agreed that the GMS contract will continue as an independent contractor model. In the BMA “The future of general practice” survey 2015, 82% of GPs supported maintaining the option of an independent contractor status for GPs. ^[3]

While the majority of general practice is intended to be delivered through the independent contractor model, we recognise there is an important, continuing role for non- GMS contractor GPs, often in salaried positions, in a wide range of circumstances. The new contract will continue to specify that salaried GP contracts should be on terms no less favourable than the BMA Model Contract.

Our vision is that GPs will continue to run their practices to deliver GP care to their list of patients. However, practices will now be expected to carry less risk compared to previous contracts and be more embedded in the wider health and social care services in their communities. GPs will play a critical role as expert medical generalists and senior clinical leaders within those services.

In Distilling the Essence of General Practice, ^[4] following in-depth consideration by RCGP Scotland on the future of general practice, the authors reflect consensus that “contracts should be used to enable rather than limit developments in general practice”. The Scottish Government and SGPC agree with this consensus, and the aim of the proposed new contract is to be just such an enabling contract.

General practice – the context
“General practice provides continuing, comprehensive, coordinated and person-centred health care to patients in their communities.

GP s and GP-led multi-disciplinary teams manage the widest range of health problems; providing both systematic and opportunistic health promotion, diagnoses and risk assessments; dealing with multi-morbidity; coordinating long-term care; and addressing the physical, social and psychological aspects of patients’ wellbeing throughout their lives. GPs are also integrally involved in deciding how health and social services should be organised to deliver safe, effective and accessible care to patients in their communities. 

With general practice carrying out 90% of patient contacts in the health service, it is the bedrock of the NHS.” ^[5]

GPs – Expert medical generalist
“ GPs are expert medical generalists who provide the first point of contact with the NHS for most people in their communities. They may deal with any medical problem, ‘from cradle to grave’, and by providing continuity of care to their patients, families, and communities, they contribute hugely to keeping the nation healthy. 

General practice is a unique discipline. Rigorous scientific and clinical medical training and the ability to apply the evidence appropriately in community settings, places general practice at the centre of the NHS. This knowledge and skill set – when combined with the discipline’s holistic, relationship based philosophy and broad generalist practice, distinguish the discipline in large measure from other medical disciplines.” ^[5]

This document is organised into a further seven chapters that set out the proposed changes to the GMS contract and our vision for the future of primary care services in Scotland.

The Role Of GPs In Scotland – Expert Medical Generalists

Barbara Starfield’s “four Cs” ^[6] of primary care acted as a guiding principle throughout the negotiations:

• contact – accessible care for individuals and communities
• comprehensiveness – holistic care of people - physical and mental health
• continuity – long term continuity of care enabling an effective therapeutic relationship
• co-ordination – overseeing care from a range of service providers

The 2018 Scottish GMS contract is intended to allow GPs to deliver these four Cs in a sustainable and consistent manner in the future.

These four pillars of primary care are also evident in the landmark Royal College of General Practitioners report on Medical Generalism. ^[7] The ethos of generalism described in this report includes comprehensiveness, co-ordination and continuity. Generalism, by definition, is a form of care that is person - not disease - centred. It is precisely the type of medicine needed to meet the challenge of shifting the balance of care, realising Realistic Medicine, ^[8] and enabling people to remain at or near home wherever possible.

The future will see general practitioners in Scotland fulfilling roles supporting a wide range of clinical professionals, working as an expert medical generalist and senior clinical decision maker within multi-disciplinary community teams. The key contribution of GPs in this role will be in:

• undifferentiated presentations
• complex care in the community
• whole system quality improvement and clinical leadership

Chapter two sets out this vision in more detail.

Pay And Expenses

The GMS contract introduced in 2004 served a purpose for that time. No longer did GPs have individual contracts with the NHS. Contracts were with practices who were encouraged to provide a wide range of services outwith those provided directly by GPs. Alongside this came a structured attempt to promote quality improvement, the Quality and Outcomes Framework ( QOF). Over time, QOF has been subject to much examination about whether its intended purpose was wholly achieved or brought about unintended consequences. ^[9]

The 2004 GMS contract also loosened the link between the income received by practices and the number of GPs. This has broadened the range of incomes of GPs in Scotland. While some have benefited from this (often as a result of entrepreneurial skills, hard work and long hours) others, despite all efforts, have found themselves financially compromised with difficulty recruiting new GPs, and keeping their practice viable. This is why underlying all the proposed changes is a key intention to improve the sustainability of practices.

Proposed changes to the way that practices are contracted and funded in Scotland are ultimately intended to re-establish the link between practice income and the provision of GPs to the community. Most of the payments to practices will be intended as income for the right number of GPs, for paying for a core team of employed staff, and for meeting the necessary expenses of running the practice. As change progresses, the intention is that GPs are paid to be GPs rather than to provide a wide range of other services. The proposed changes are also intended to reduce the transactional business elements of the relationship between GPs and the rest of the system. These elements have, at times, worked against the development of the collaborative relationships in health and social care necessary for good outcomes.

Chapter three sets out our proposals around pay and expenses, including a new workload formula and increased investment in general practice.

Manageable Workload

The consultation remains the foundation of general practice. It is where the values of compassion, empathy and kindness combine with expert scientific medical knowledge to the benefit of patient care and mental and physical health. The role of the modern GP, however, is wider than patient consultations. Repeat prescriptions, test results, home visits, telephone calls and other communication with patients and other services can all form a significant part of the GP day.

Chapter four sets out our proposals to provide additional primary care staff to work alongside and support GPs and practice staff to reduce GP practice workload and improve patient care. These additional staff will underpin a transformational service redesign over the next three years with the development of the multi-disciplinary team to support general practice.

Improving Infrastructure And Reducing Risk

As independent contractors running a practice, GPs are exposed to risk in a number of ways. This can be through the ownership and maintenance of practice premises, through acting as a data controller sharing information with the wider NHS, and through the risks of being an employer.

Chapter five introduces a number of significant new measures designed to manage and reduce these risks to GPs.

Better Care For Patients

With a focus on Barbara Starfield’s four Cs, chapter six sets out the benefits the new contract will bring to patients. The proposals will help people access the right person at the right place at the right time, as described in the Scottish Government Primary Care Vision and Outcomes (see annex). In particular the chapter focuses on:

• maintaining and improving access (contact);
• introducing a wider range of health professionals to support the expert medical generalist (comprehensiveness);
• enabling more time with the GP for patients when it is really needed (continuity); and
• providing more information and support for patients (co-ordination).

In addition, the chapter sets out the critical role of meaningful patient engagement in ensuring services are designed in ways that meet the needs of individuals and communities.

Better Health In Communities

Scotland’s health and social care workforce continues to be at the forefront of a wide range of improvements in the safety, effectiveness and quality of care and treatment. General practice in Scotland took a distinctive path on quality improvement through the establishment of GP clusters in 2016/17 - enabling a peer-led, values-driven approach to quality improvement. The proposed new contract further embeds the cluster quality approach.

The Role Of The Practice

The final chapter sets out the wider role of the practice and practice team, including general practice nurses, practice managers and practice receptionists.

Overall, the proposals represent both significant investment in primary care and significant change. At the heart of any change must be the core principle of patient safety. That is why our planned approach is of a three year transition with changes to services only taking place when it is safe, when it is appropriate, and when it improves patient care. By working together in this way we can build a GP service for the future, one that meets the changing needs and demands of the people of Scotland and enables GPs to do the job they train to do.

A range of supporting materials and evidence including the review of the Scottish Allocation Formula, the Premises Code of Practice and the Review of GP Earnings and Expenses will be published on the Scottish Government website. ( http://www.gov.scot/Topics/Health/Services/Primary-Care/GP-Contract).

The next chapter sets out our vision of the role of the GP as an expert medical generalist.