The new GP contract
pharmafile | October 28, 2003 | Feature | |Â Â GP contract, NHS, healthcareÂ
The new GP contract was supported by a massive 79 per cent of those GPs who voted for it, despite previous predictions of a 'no' vote. Why was there such support, and what are the implications for the industry?
The basic idea of the contract is somewhat contradictory. On the one hand it is about containing and controlling the workload in primary care, but it is also about driving up standards with rewards for those who achieve targets, and the chance to gain extra income from providing extra services. The strong yes vote was probably based on promises of a substantial rise in average GP income coupled with the right to drop out-of-hours care – always a painful bit of the job with unsociable hours, often spent dealing with anything other than genuine emergencies.
The new contract is divided into four key areas:
- the global sum
- additional services
- the quality framework
- enhanced services.
The global sum represents much of traditional funding to general practice including many item of service payments. It also includes out-of-hours services (which most GPs will probably give up) and basic traditional GP care. Additional services include things like family planning and child health surveillance things most (but not all) practices did and will probably continue to do. Funding for these is included in the global sum but doctors can opt out of providing them (and lose income pro rata).
Enhanced services will mainly involve low volume, high-need patients, varying from minor injuries to blood-clotting monitoring in warfarin patients and a number of other services. There is probably no great impact here for pharma sales as the patients will either be in shared care with a secondary care team who will continue to determine treatment (for example, in rheumatoid arthritis) or they will involve small items of pharma interest only (for example, minor injuries services).
There may be some mileage in all of this for the pharma industry but the obvious gains will be around the quality framework. The way this is written offers endless opportunities for increased sales – indeed, so much so that if the ABPI had written the contract I doubt they could have done much better themselves.
The contract was negotiated between the NHS Confederation and the BMA's General Practitioners Committee. My immediate thought is had there been more civil service input (especially with Treasury liaison) the quality framework would have been very different.
There is a long history of civil servants scrutinising health policy with a firm hold on the financial implications. The ladies and gentlemen, GPs and managers who wrote the new contract clearly have either not thought about the financial implication or hoped that the whole thing would go through with no-one else noticing. It will have massive implications for NHS funding with escalating prescribing costs for chronic disease management.
As it is numerical targets for disease management, it will drive desperate clinicians to strive for the best figures for their best personal income by pouring drugs down more patients' gullets.
Numbers people
We might not be surprised that the NHS managers with the Confederation saw the process as one of number crunching. What is perhaps less obvious is why the GP negotiators colluded in this. They are called representatives, but of course they can't be: no more than an MP is typical of his or her constituents, a GP negotiator is no ordinary GP.
The GP negotiators are a special self-selected group of doctors. Inevitably workaholic, their success in medical politics reflects a crisp and business-like approach to clinical medicine, much as the new contract envisages.
There are other GPs who are holistic in outlook and perhaps embody the concept of medicine as an art rather than a science. But they were frozen out because by nature their personalities would militate against taking on such a role as negotiating financially-based contracts.
Quality framework
The quality framework equals profits for pharma. There are several reasons for this, but it might first be worth considering a bit of the history here. Since the NHS started, GPs have derived most of their income from capitation fees; receiving so much for each patient on the doctors list. Obviously the more that was done for these patients the more work the doctor did, but for no extra income. Indeed, doing more for patients could incur extra costs. For example starting an ACE inhibitor or statin involves certain blood-test monitoring that will require the use of a nurse or phlebotomist who is partly funded out of the GP's pocket.
Therefore, the traditional culture of British general practice has been built around minimalism: diagnose as little as possible and treat those you must diagnose only as little as possible, and at your personal financial peril. These lessons of 'minimal practice' were reinforced in the 1990s with GP fundholding, where GPs could save money on prescribing to invest elsewhere (like in expanding their privately-owned premises, to their ultimate personal financial gain). Since then PCOs have run incentive schemes usually based on limiting prescribing costs with some sort of kick-back for the benefit of the practice.
The quality framework turns these traditions upside down with financial incentives for more diagnoses being made and further Brownie points for management to achieve largely numeric goals. The framework covers several chronic diseases, notably (for pharma purposes) coronary heart disease, hypertension, diabetes, COPD, asthma and stroke. In all these areas there will be vastly increased prescribing volume and/or greater use of newer drugs.
The number of the beast
Quality payments will relate to the practice-based disease register. This is a double-whammy for the minimalists. Obviously the more patients on the register the greater the potential income, but also with numerical targets (for example, the percentage of patients with a certain blood pressure), roping in more mild or marginal patients will help massage the target figures towards those low ideal figures.
There is a great incentive for GPs to make more new diagnoses and expand the number of patients in chronic disease management mode. This will mean more patients embarking on drug therapy.
Getting to target
There are many numerical targets in the new contract and getting patients to reach these will be a golden opportunity for increased prescribing. Traditionally (and I would argue rightly), when simple interventions did not work, or patients were awash with polypharmacy, taking a simpler line with pragmatic targets made sense. There tends to be a law of diminishing returns on interventions, with the first incremental improvement (say in blood-pressure lowering) producing greater benefit then the subsequent ones.
Similarly with cholesterol, there is good evidence that patients with heart disease, or at high risk of it, benefit from a fair whack of statin (40mg of simvastatin in the original work). I would favour just doing that: 'Keep it simple, stupid.' But the targets are based on doing an annual cholesterol test (a total waste of time, I would argue) and having targets for total cholesterol of 5mmol or less.
There are lots of opportunities here to encourage the use of newer on-patent drugs to get patients to target levels. My suspicion is the health gain from much of this will be marginal but pharma's profit margins certainly won't be.
Or just because they're there
Some chronic disease areas look less attractive for increased prescribing but just having targets that involve annual review may generate new opportunities.
Take COPD. It's incurable and only two interventions are proved to improve outcome: stopping smoking and oxygen in the severely hypoxic. But there are quality points for seeing them every year and checking their spirometry (which we already know will just keep getting worse). So as they get worse, and as they are seen, there well be temptations to tweak the medication. Good news for COPD drug manufacturers.
Am I bitter?
In some ways, yes. Simpler treatment strategies might be more cost-effective and there is a gross lack of R&D work to substantiate both the practicality and outcome benefits of this approach. But readers need not worry. There is a fine tradition in British general practice that even the impossible can be achieved if there are enough used £5 notes attached. The 1990 contract was greeted with shrieks of impossibility yet all those 'impossible' targets were met by the vast majority of doctors.
A golden future for pharma
Prescribing volume for chronic-disease management should rise steeply as more patients are diagnosed or, perhaps more accurately, have their diagnosis conceded.
At the same time striving to reach maximum income on the quality framework will involve increased use of polypharmacy and increased uptake of newer drugs to drive the incremental improvements in numerical indices necessary to get patients to target.
Here is something readers of Pharmafocus should feel very happy about – even if I don't.
Stephen Head is a GP principal based in New Ollerton, Nottinghamshire, and is also a Medical Advisor for North Derbyshire Health Authority
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