The first Scotland-only GP contract came into force a year ago. BMA Scottish GPs committee chair Andrew Buist tells Jennifer Trueland how implementation is going
On 1 April 2018, GPs in Scotland woke up to the first day of the new Scottish general medical services contract.
Billed as a historic joint agreement between the BMA and the Scottish Government, the contract aimed to set out a distinctive new direction for general practice north of the border.
Anticipated benefits included improving recruitment and retention of GPs, reducing workload and bureaucracy, and creating a new kind of primary care based on multidisciplinary teams with the GP at the centre as an expert generalist.
Dr Buist was intimately involved in negotiating the new contract in his then role as deputy chair of SGPC – he took over as chair of the committee in August 2018 – and believes it is already having an effect, although he cautions that it’s very early days.
‘We’re just one year into a three-year implementation period,’ he says. ‘If you compare it to any major project when it’s only a third done, you’ll know that it might not look much yet, but that a lot of the hard work has been done. It’s those foundations that we’ll be building on in the next two years and beyond.’
So what has changed so far? Arguably one of the most significant planks of the contract process will start to show results next month (April) with the deployment of a tracking tool to measure contract implementation across the country.
The tool will be used in partnership by Scotland’s 31 health and social care partnerships (also called integration authorities) which, following health and social integration, have responsibility for most services delivered outside hospital.
‘One of the most important things [about the contract implementation] is delivering on primary care improvement plans,’ says Dr Buist (pictured below).
‘Every partnership has one, but they will all be at different stages of implementation. The tool means the partnerships can work with the GP subcommittee to track what is being done to reduce GP workload and improve services for patients, close to home.
‘My feeling is that there is a mixed picture across Scotland at the moment, but this will give us the information to see what’s happening, where it’s working, and encouraging people to believe that yes, we can do this – we can make a difference.’
The aim is to run the tool twice a year, in April and October, providing valuable data and useful comparators, and enabling different partnership areas to learn from each other. But it also has another element.
‘I think it’s a great example of collaborative working between the partnerships and GPs, which I think is very positive,’ Dr Buist says.
‘This is a really big opportunity for health and social care partnerships to prove their worth and demonstrate that they are providing more community-based care. The plan is an important part of that – it creates capacity in primary care, for example, physiotherapists and link workers, and practice-based pharmacists which frees up GP time so that they can work as the expert generalists they are.’
A central tenet of the new contract is what former SGPC chair Alan McDevitt (pictured below) always called reducing the risks of general practice. The idea is to make becoming a GP an attractive career choice for young doctors by lessening some of the burdens, such as responsibility for employing a large practice-based team, and the risks associated with owning practice premises.
To this end, the Scottish Government is funding a practice sustainability loans scheme with £50m over three years. Under the scheme, eligible practices can apply for an interest-free loan of up to 20 per cent of the value of their premises to reduce the risks of premises ownership and to support the transition to a model where GP contractors are no longer required to provide premises.
‘Following the first round of applications, 172 have been approved,’ says Dr Buist, adding that legal discussions on the terms of the loans are progressing and we hope they will are expected conclude in the next few weeks.
Work is also under way to optimise GP clusters – groupings of practices which are expected to work together to assure and improve quality in general practice. Essentially, this replaces the explicit ‘quality’ element of the QOF (quality and outcomes framework), which was abolished in Scotland three years ago.
‘We felt that peer-led quality assurance was needed, and clusters are a way for GPs to share data and expertise and learn from the best,’ Dr Buist says.
Although the profession backed the new contract overwhelmingly both at a special conference of local medical committees and in a national survey, there have been concerns expressed about how well it will work for remote and rural practice.
This is something that Dr Buist has been keen to address head on, and he admits that more needs to be done.
‘In this initial phase of implementation, some have felt that they might not benefit as much as some inner city practices,’ he says.
‘We are hoping that we can start to look at flexibilities to help very remote practices to deliver the style of general practice that they want to. I know from having worked on Colonsay and Benbecula [in island practices] that being a very rural GP is different, and that this is to be valued, and I want the new contract to work for GPs and patients wherever they are in Scotland.’
The new contract is only the first phase of Scottish general practice transformation. Longer term, the aim is to ensure a more sustainable financial footing for practices and for individual GPs.
To that end, work will take place to extract data on practice income, expenses and workforce.
‘That information will be highly confidential but will be used by the negotiating partners when they are looking at phase two of the contract,’ Dr Buist says.
‘We want [GP] income to be comparable to consultants’ income, and more consistent. At the moment, earnings vary quite considerably, and we want to bring up the tail.’
The first step of this will happen in April when a new minimum earnings guarantee is due to begin, effectively ‘topping up’ the income of any full-time GP earning below £70,000.
The new contract is about more than money, however, and Dr Buist hopes that it will prove so attractive that Scotland’s current recruitment and retention problems will be alleviated.
‘That will be the acid test – the success of the contract,’ he says. ‘We want to see the graph of numbers of GPs start to rise again. We want the vacancies data to improve. We want young doctors to choose to become GP partners in Scotland, and we want older GPs who were thinking of retirement to decide they might keep going for a few more years.
‘What I really want is to bring the feel good factor back into Scottish general practice – and we’re working incredibly hard to make that happen.’