General Practice: Contract and Context - Principles of the Scottish Approach

4. GP Contract - recent changes and next steps

4.1 The last 18 months in Scotland have seen considerable change in the GP contract. In October 2015, we agreed to move away from the overly complex and bureaucratic QOF to peer led quality improvement. GPs are already telling us they notice a difference in the quality of their consultation with their patients, that consultations are feeling less cluttered.

4.2 The 2016/17 contractual agreement introduced a new approach to improving the quality of outcomes for people - GP practices working together in clusters of 4 to 8 practices covering 20,000 to 40,000 patients (much clearly depends on practice size and the geography of the local area).

4.3 We have worked collaboratively to introduce these changes - and we consciously retain those elements that are core to general practice: contact, comprehensiveness, continuity and coordination. This includes basing teams providing personalised care around the GP registered patient list as it enables fuller knowledge of individual patients and their families; continuity of their care and understanding of the health needs and priorities of the list population - critical for influencing wider system changes to improve care.

4.4 In many ways, these changes - abolishing QOF and the creation of GP practice clusters in every locality - represent the most significant contractual change over many years in Scotland. The pressing issues now are more contextual - delivering the funding plan; the workforce plan and the infrastructure plan the Cabinet Secretary committed to in her March 2016 speech to the Scottish Local Medical Committee Conference ^[1] . Much progress has already been made since March - new maternity and paternity pay rates delivered; single application to the performers list in use; occupational health delivery agreed and support to practices for emergency oxygen underway.

4.5 The nature of changes to the GP contract require careful planning in line with the planned increase of both funding and staff resources, and the need to ensure overall stability. This does not fit well with a making contractual change in one year but represents a measured step-wise approach to changing the GP contract and primary care.

4.6 The two key contractual issues are GP pay and GMS services. On pay, we recognise the picture presented in annual reports of the Review Body on Doctors and Dentists Remuneration ( DDRB) of insufficient evidence on the details of GP expenses for the DDRB to present recommendations to Ministers.

4.7 We agree, in principle, that we need better information and evidence to inform both accurate recompense of expenses and options for the long term trajectory on GP pay in Scotland. To this end, we have agreed to jointly commission a review of general practice funding, pay and expenses to provide a proper, robust evidence base for improved decision making. This will take place in 2017, and inform options from 2018.

4.8 In transforming the role of the GP to be the 'Expert Medical Generalist' in the community - focussing on complex care; undifferentiated illness; and outcomes, quality and leadership - we are making the best use of GP skills - managing uncertainty, holistic person-centred care and clinical leadership of an expanded team. We will have to ensure that the services specified in the GMS Contract are appropriate. A number of the current GMS services would seem better planned and delivered by Health Boards and HSCPs. We will work with those partners to ensure the safe and effective transfer of as many of those services from out of the GMS Contract as possible, leaving the GMS funding in place with practices. It may be that GPs remains involved outwith the GMS Contract. We expect a short national review in early 2017. National Contract negotiations will reflect these changes and any changes will be on the basis of our agreement on financial stability until April 2018.

4.9 There will be further contractual change in 2017 (which we expect to commence in October 2017). We continue to negotiate how to modernise the contract, improve access to general practice and improve the attractiveness of general practice as a career.

4.10 Improved access and better care for people in communities requires all members of the primary care and general practice team working as effectively as possible, on the aspects of care best met by their training, experience and skills.