For the first time since the inception of the NHS, under the proposed new GP contract1 family doctors will be specifically rewarded for offering higher quality care to their patients.
Many GPs believe that they are already giving their patients a high quality service, although few are receiving any rewards for doing so. Many of their efforts are uncoordinated and some of what they do is not informed by convincing evidence.
To make things even more complex, governments have demanded many additional activities under the old GP contract and funded very few of them. Despite this, GPs have responded by doing politicians' bidding even when the evidence has not been forthcoming. This has resulted in GPs funding the additional staff or technology costs out of their own pockets.
The Government has now agreed with the BMA's General Practitioners Committee that doctors' activity will be stratified into clearly demarcated and evidenced areas. Practices will be invited to deliver 'organisational', 'tiered clinical' and 'phased clinical' quality at their own pace and with appropriate rewards.
Organisational quality markers will be used to look at the efficiency and effectiveness of practices. They will include consultation length, repeat prescribing systems and medicines management, practice facilities, medical records and other markers of good management such as a health and safety policy.
Tiered clinical markers are those based around evidence for fairly straightforward and discrete clinical entities, including thyroid disease, osteoporosis, epilepsy and rheumatoid arthritis. Once negotiations informed by the evidence base have been concluded, asthma will probably be added to this list.
The phased markers are presently all in one group and based on cardiovascular and cerebrovascular disease, although it is likely that another set of markers will be introduced for diabetes. Here the evidence is clear and the workload considerable.
Organisational and tiered markers are each in three tiers, and practices will be able to choose to deliver quality at any of the three levels by completing an agreed majority of the markers at that level. The phased markers are completed by covering a series of criteria along a continuum. This is because there are so many matters to cover that it would be daunting, where a practice had not done so before, to attempt to complete a large series of markers in large steps.
For each of these different activities, the practice will be able to decide how much it wishes to achieve and at what pace. The practice team will measure what they have chosen to do, record it, and then be rewarded at the end of the year.
What makes this scheme unique is that practices will be funded in advance for all the infrastructure costs, including staff costs. Many GPs have for years bemoaned the fact that they could do much better if only they had the nurses or data entry staff. Now they will have staff fully funded 'up front', as well as computers and other necessary equipment. Once a year they will have to provide an annual report that the practice computer will generate.
The challenges of this scheme are immense. We will need excellent information management and technology. We will also need a change in culture to ensure that the evidence is adhered to and that guarantees resources and time for GPs to deliver the higher quality that patients, doctors and the Government want.
- Your Contract, Your Future.General Practitioners Committee, British Medical Association, April 2002.