Will the new GP contract lead to cost effective medical practice?

Since the mid 1980s the imprecise nature of the GPs’ contract and the lack of knowledge about what services were provided by general practitioners has created much argument and radical changes in the terms and conditions in the GPs’ contract. The old contract required a general practitioner to render those services to her patients which were normally provided by GPs. This “John Wayne contract” – a GP’s got to do what a GP’s got to do – permitted much discretion which some policy makers welcomed as it enabled them to “advise” the extension of GP practice and regard that as a “normal” service. However the lack of precision such Departmental advice and general ignorance about what GPs did was inevitably challenged by demands for greater accountability and “value for money”. Furthermore some research results – for instance a survey of GP working hours in Manchester and Salford – implied that some GPs might be interpreting discretion as an invitation to consume leisure and apparently work quite short working weeks. Against this background of ignorance about what GPs do and rhetoric from the British Medical Association that asserted, in the absence of appropriate knowledge, that general practice was cost effective, the Government formulated a new contract for GPs which it imposed on the profession from April 1 1990. The purpose of the new GP contract is to identify “core services” which must be provided by all practices and to reward performance by financial incentives. The purpose of this paper is to describe the new contract and analyse critically the cost effectiveness of the core services it requires GPs to offer their patients. The contract requires GPs to provide for remuneration: i) health checks within 28 days of joining a GP’s list for all new patients ii) health checks for all patients aged 16 to 74 who have not seen their general practitioner in the last 3 years or have not had a health check in the last 12 months iii) an annual consultation and a domiciliary visit for all patients aged over 75 years iv) cervical cytology every 5 ½ years for women aged 25 to 64 years of age v) immunisation and vaccination services for children vi) health promotion clinics In addition GPs can provide child health surveillance and minor surgery for additional fees. Is it cost effective to provide these services? This paper reviews the available scientific evidence and concludes that the cost effectiveness of many of the services which GPs are now required to provide is unproven. It is possible that GPs are being induced to practice inefficiently. Such an assertion needs to be tested by careful evaluation of these services. Indeed it would have been judicious to develop the core services of the GPs contract in the light of careful evaluation rather than system-wide reform of unknown efficiency. However, given the contract is in place it is essential to evaluate these new services to determine their effects on patients’ health. Such evaluation is complex and produces new knowledge slowly but it will at least facilities the adjustment of the new contract in a way which is demonstrably cost effective. Like many of the Government’s health care reforms, the new GP contract is an attempt to address problems, such as the imprecise nature of the GPs terms and conditions of employment, with a radical and unproven new policy. Such “shots in the dark” should be recognised as such and evaluated to inform future policy choices. Without such evaluation the “next” reform of the GP contract may be based on hope rather than knowledge in the formulation of health care reforms aimed at using scarce NHS resources more efficiently.