GPs in Scotland vote to accept new contract
BMJ 2018; 360 doi: https://doi.org/10.1136/sbmj.k297 (Published 22 January 2018) Cite this as: BMJ 2018;360:k297All rapid responses
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Only 28% of eligible GPs actually voted for this, in a poll marred by misinformation, biased presentation and many reports of doctors unable to vote, as well as a high-handed approach to any who questioned the process. This is a disaster for practices in deprived or rural areas and displays a shocking naivety, being predicated on the assumption that "magic pixies" will appear from nowhere to do all our work.
Competing interests: No competing interests
I can say as a rural GP I was having to think about 'what now' when I heard the details of the new contract.
Next year I need to recruit an associate again, but I wasn't sure from the lack of detail and Deloitte assessing my practice as needing less than 1 GP whether I was able to afford it. Even if I was being assured that there would be the 71K a year ( less than 1 GP) there was no detail on dispensing, out of hours, or more to the point - associates.
Now I pay my associate 60K for 26 weeks of he year. That would leave me 11K. Why would I carry on with such risks to my pension?
And whats more, assessed as needing less than 1 GP to cover the 168 hours a week that we cover, how was that to work? Deloitte assessed this without setting foot in my practice and not so much as a phonecall.
What a shambles.
At 60 the obvious thing would be to reitire now, not that I want to, or hand the practice over to my board, with the risks to the practice that entails.
The whole thing was making me ill. What about my patients? my staff?
Then I discovered that as a 17C practice we can really ignore the new contract and carry on as we are.
Phew.
What a relief for us.
But not a relief for the rest of the small practices who are not 17C.
What about them?
We didn't need a contract that reduced workload.
We didn't need a contract that fragmented our small teams.
We needed a contract that supported the economies of generalism. .
We needed a contract that would help us recruit.
We needed a contract that would support those of us doing our own OOHs.
We needed a contract that strengthened the existence of our small practices, and our small tight teams.
We needed a contract that helped integrate DNs within our teams.
We needed a contract that would help us (with locums) when we are ill or when our staff are ill.
We needed a contract that would strengthen our associates, and ensure time off.
We needed a contract that would support rural GP
We didnt get that.
Hopefully the working group will address some of our issues. But surely these issues should have been looked at before the contract went to press?
Competing interests: I am a very Rural GP
This new contract has certainly caused great dismay amongst rural doctors. There are several reasons for this. Firstly and most importantly the contract is perceived as a step on the road to incorporating general practice fully into the NHS, removing independent contractor status and GPs becoming salaried employees. The setting of a base salary of ~ £80k, the insistence that attached MDT colleagues be HB employees rather than be recruited and employed by practices and the progression towards all GP surgeries being in NHS premesis all point towards the loss of the autonomy which makes general practice so efficient and innovative.
Secondly the removal of areas of core work continues the fragmentation of general practice which started with the removal of our 24/7 responsibility in the 2004 contract. This erodes the ethos of holistic cradle to grave care which is at the heart of many GPs' love for their profession.
Thirdly most urban colleagues are getting a rise in resource allocation, a reduction in workload and the offer of additional staff (i.e. pharmacists, etc). Most rural practices are getting none of those things because
1. The workload allocation formula does not give them an uplift as it takes no account of rurality, meaning that most rural practices have to exist on subsidies. This erodes our morale and makes it even more difficult for us to recruit or retain doctors.
2. There is no one else to do the work which urban colleagues will shed, but no mechanism to resource rural doctors for doing this work, and
3. There are few additional staff available in rural areas so rural GPs will not benefit from MDT colleague support and again there is no mechanism for this to be compensated for.
Rural doctors have been left feeling that this contract was negotiated without adequate thought being given to how to support us to continue to provide the holistic, person centered, realistic medicine to the patients we serve in the communities where we live and work. We feel let down by our BMA negotiation team. The promised short life working group looking at rural practices should have reported before the contract poll, not as an afterthought and only after intensive lobbying by RGPAS, Highland LMC and others. We urgently need active collaborative engagement with the rural general practice community to restore trust and reassure us that we will be able to continue to provide first rate care for our patients.
Competing interests: No competing interests
Only 28% of Scottish GPs voted to accept the new contract. The extremely low turnout reflects the fact that neither the status quo nor the new contract is an acceptable option.
The main cause for concern about the contract is the damaging effect of the Deloitte Scottish Workload Allocation Formula (SWAF) on patient care and on general practice as a whole in Scotland. The methodological weaknesses of the SWAF relate to modeling based on an outdated and unrepresentative sample of practices, and the model itself relies simply on consultation numbers (or Read codes) per patient as the driver for allocation of funds to practices. Funding allocations will be simply calculated on the basis of patient numbers, age and area deprivation scores, and the cost of supply of medical services (higher in rural areas) is now excluded from the formula for reasons that have not been made clear. Practices in areas with more doctors (hence more consultations) will gain from the formula and those in under-doctored areas will lose out.
SWAF will lead to 63% of Scottish practices obtaining extra resource – amounting very roughly to £10,000 per partner on average. There is no doubt that GPs need a substantial increase in remuneration if they are to approach consultant salary levels (thus making general practice a more attractive career option for students) so this is good news. The 37% of practices who will enter the income support mechanism may however have good reason to resent their non-preferred status even though there has been a promise that basic practice income will be protected at current levels without any increase.
Impact on rural areas
Arguably it is patients in rural and remote areas that are most reliant on their practices to deliver health care. They have no option to register with a nearby practice or attend an A&E department if their practice collapses. Over 90% of practices in the northern Health Boards will be in the income support category. It is rural practices that have the biggest problems recruiting GPs and there are already large swathes of Caithness, Sutherland and the Scottish Isles where patients cannot access a doctor without travelling huge distances. The problem in recruitment not only relates to GP partners and salaried GPs but also to locum doctors. There are simply not enough GPs in Scotland. Urban practices with increased funding will now be able to make more generous offers to potential partners, salaried doctors and locums and consequently it will become increasingly difficult to attract any doctor to work in the remote regions. Rural doctors earn less on average than urban doctors so the allocation of more money to urban doctors will exacerbate GP income inequality between rural and urban areas.
The primacy of age over SIMD in the SWAF formula exacerbates a problem that a new funding formula was designed to solve. Areas which have the lowest life expectancy will lose out – so the practices in the most deprived urban areas that deal with patients in the poorest health will also be placed in the income support category and will have to face the same recruitment challenges that remote practices do. This does a profound disservice to our sickest populations.
The depth of division within the profession should not be underestimated and it is disappointing that our BMA representatives did not draw back from supporting a contract that relies on SWAF as it stands. Waiting until the next phase of negotiation for a fair funding solution will be too late: irreversible damage will already have been done if the contract is enacted.
Competing interests: No competing interests
The BMA in Scotland having spinning this result furiously and claiming it as some kind of ringing endorsement when nothing could be further from the truth.
They claim "some rural GPs " voted No when in reality the vast majority voted No along with many in deprived urban practices - the so-called Deep End practices.
But BMA Scotland refuses to realease the vote by LMC. Why is that? Are they frightened it will show a clear rural urban divide?
They talk about the "vast majority" of Scottish GPs supporting the proposals when in reality the turnout was 39% and about two thirds of them voted Yes. So in reality only 28% of Scottish GPs have openly endorsed the proposals.
My no vote was my means of telling OUR trade union reps that I feel they have not done a good enough job.
It's not a trade union's job to produce a deal with which a significant proportion of members (both rural and Deep End) disagree with profoundly.
The promised £250 million is NOT going directly to practices. Past experience tells me that whenever health boards get more money for "primary care" very little filters through to practices.
With health and social care integration I think we will be even less likely to see our fair share of the "new money".
This contract puts almost every rural practice (and many Deep End) on income support which is in its own way a destabilising influence.
It fails to redistribute in favour of Deep End deprivation and inequality.
It does not recognise rural deprivation at all or the significant extra level of responsibility taken on by rural GPs.
It does nothing to support, enhance or promote fragile rural practice.
It makes promises about services been taken off the hands of GPs much of which is simply not going to be feasible in rural areas.
It enshrines a situation where rural GPs consistently earn about 20% less than urban colleagues despite broader responsibilities and higher expenses and living costs. We are de facto the poor country cousins. How does that help recruitment and retention?
We are told they well get round to sorting rural in 3 to 5 years when it needed sorting in 2004.
Throughout the last 2 months the legitimate concerns of Deep End and rural GPs have been met with what stuck many of us as a patronising and condescending response from BMA Scotland. They have certainly not done themselves any favours with many rural and Deep End GPs and they will lose members as a result.
These proposals are a proverbial curate's egg and I for one don't want something that's "good in parts"
Competing interests: No competing interests
Re: GPs in Scotland vote to accept new contract
The 2018 Scottish GP Contract document suggests “Generalism, by definition, is a form of care that is person- not disease- centred.” However, the fundamental thought processes behind this contract remain largely unchanged from every contract in the history of medicine. It continues to be driven by a system- not person-centred focus and resourcing. This sets the whole profession up for yet another decade of living in the deluded belief that we can improve the quality and safety of healthcare by just tweaking the delivery a little bit. Primary Care resourcing will continue to be defined by what the system thinks it can provide rather than what the people and communities truly need. Whilst SGPC have acknowledged that a formula is not a good way to allocate resources across such a complex, heterogeneous system, yet another formula (the Workload Allocation Formula, WAF) has been devised and sold as a ‘methological improvement’ over the previous 2004 allocation formula. This continues despite clear indications from the widely publicised allocation map(1), basic comparisons between practice WAF calculations and SIMP deprivation data(2), and concerns from both Rural and Deep-End GP groups, that the WAF rewards demand, not need, and will further reinforce the inverse care law from the outset of Phase 1 of the new contract.
SGPC have continuously repeated that “... no practice in Scotland will see any reduction in nationally agreed funding as a result of this contract “(3). On the surface that sounds great, but in reality a freeze in income translates to a loss when tax changes and inflation are taken in to account. The new formula takes even less account of the very real higher costs of providing core GP services in geographically challenging and widely dispersed practice areas. This includes higher fuel usage and prices, acquisition (delivery surcharges), locum and permanent GP recruitment, and much more. Even the costs of a basic CPD course sky rockets when you factor in ferries, fuel, flights, hotels, and extra cover for the additional travel time needed.
And then, if you were looking for a partnership, would you be more likely to go for a practice with an income boost or income protection? Essentially it has a similar psychological effect as a landlord comparing tenants in paid work vs on social security. So what will that do for recruitment and retention? It widens the gap and makes it harder to recruit to some of the hardest areas to recruit to already.
These are all very real prospects for Remote and Rural GP practices and their communities, right from day 1 of Phase 1. They need to be addressed now, or many rural areas may lose their medical services before Phase 2 ever emerges out of the negotiating chambers.
1) New GP contract uplift heatmap. Available at: https://fusiontables.google.com/DataSource?docid=13SLV8fjU8S5LvhiMcmbUWp...
2) Scottish Index of Multiple Deprivation (SIMD) 2016 Map. Available at: https://jamestrimble.github.io/imdmaps/simd2016/
3) A. McDevitt, BMA SGPC Chair. Proposed GMS contract and its impact on remote and rural areas. Letter, undated. Available on https://www.bma.org.uk/-/media/files/pdfs/collective%20voice/committees/...
Competing interests: No competing interests