General medical services

Despite many different contracting arrangements that have been and are being introduced for general medical service in the UK, General Practitioners (GPs) are, in principle, independent contractors with the government.

History of the Contract
National contracting of General Medical (General Practitioner) Services can be traced to the 1911 National Insurance Act which introduced a pool (similar to todayˈs "global sum") to pay GPs on a capitation system. The Beveridge Report of 1942 gave the impetus for White Paper under the Conservative Health Minister Henry Willink that supported the idea of salaried GP services in health centres. The 1946 National Insurance Act under Labour Health Minister Aneurin Bevan, which laid the foundation for the NHS, reduced the clinical role of GPs in hospitals and their involvement in public health issues. The capitation fees was based on the number of patients the GP had on his list. Proposals to make GPs salaried professionals were rejected by the profession in 1948. In 1951 the capitation started to be based on the number of doctors, rather than patients.

A milestone in defining the role of General Medical Services is the 1966 contract. The contract addressed major grievances of GPs and provided for better equipped and better staffed premises (subsidised by the state), greater practitioner autonomy, a minimum income guarantee, and pension provisions. Despite some changes, the capitation principle and the pool survived.

The Conservative government under Margaret Thatcher from 1979 onwards looked for ways of changing the NHS, with a greater role of the private sector, and for limiting health spending and it was not afraid to take on the doctor's trade union, the British Medical Association(BMA). The 1990 contract linked GP pay more strongly to performance. The terms and conditions of primary medical service delivery were closely specified. The 'Red Book' (Statement of Fees and Allowances) detailed the payment tariffs for each individual treatment.

Today, the UK General Medical Services (GMS) contract covers the pay arrangement between the Primary Care Trust (PCT) or the Health Board (in Scotland) and a General Practitioner (GP) practice.

The New GMS Contract
The new GMS contract (nGMS) came into force in April 2004, abolished the 'Red Book' and led to a significant increase in practice income. Every practice gets a share of a total amount of money allocated towards primary care in GMS practices (the "Global Sum"). This share is determined by the practice's list size, adjusted for age and sex of the patients (children, women and the elderly have relatively higher weights than young men because they cause a greater workload). Furthermore, the practice gets an adjustment for rurality (greater rurality causes greater expenses), for the cost of employing staff (the "Market Forces Factor" (MFF), which captures differences in pay rates between areas, e.g., it is more expensive to hire a nurse in London than in Perth), the rate of "churn" of the patient list and for morbidity as measured by the Health Survey for England.

The application of the formula to this reduced "Global Sum" would have resulted in great changes in GP income and income loss for many GPs and through their powerful representative organisations the GPs were able to extract a concession. They received a Minimum Practice Income Guarantee (MPIG), which brought them up to their previous income levels.

At the same time the Government introduced the Quality and Outcomes Framework (QOF) which was designed to give GPs the incentive to improve their work practices and fulfil government-set requirements (146 indicators) to earn points (varying amounts per indicator) which translate into greater income. The money for the QOF was taken out of the "Global Sum".

Participation in the QOF is voluntary but since the standards are not very stretching practically all practices participate and get this money in addition to what they were earning before.

The new contract allowed GPs to opt out of weekend and night (Out-of-Hours) service provision (they have to forego some of their practice income). Most GPs opt out and immediately back in because the compensation they get for providing the service is greater than the opting out penalty.

A revised contract came into force on 1 April 2006. Primarily, the allocation of QOF points was revised and Directed Enhanced Services (DES) were introduced.

Other Primary Care Contracts
Apart from GPs in the GMS, primary care is also provided through Personal Medical Services (PMS), PCT Medical Services (PCTMS) and Alternative Provider Medical Services (APMS) contracts.

Personal Medical Services (PMS) were first tried in April 1998 and became a permanent option in April 2004. The health care professional/health care body and the Primary Care Trust (PCT) enter a local contract. The main use of this contract is to give GPs the option of being salaried. PCT Medical Services (PCTMS) allows the PCT to deliver primary care services directly and Alternative Provider Medical Services (APMS) are primary care services provided by outside contractors (like US health companies).