General medical services (GMS) is the range of healthcare that is provided by general practitioners (GPs or family doctors) as part of the National Health Service in the United Kingdom. The NHS specifies what GPs, as independent contractors, are expected to do and provides funding for this work through arrangements known as the General Medical Services Contract. Today, the GMS contract is a UK-wide arrangement with minor differences negotiated by each of the four UK health departments. In 2013 60% of practices had a GMS contract as their principal contract. The contract has sub-sections and not all are compulsory. The other forms of contract are the Personal Medical Services or Alternative Provider Medical Services contracts. They are designed to encourage practices to offer services over and above the standard contract. Alternative Provider Medical Services contracts, unlike the other contracts, can be awarded to anyone, not just GPs, don't specify standard essential services, and are time limited. A new contract is issued each year.
Normal working hours of 8 am to 6.30 pm Monday to Friday are specified in the contract.
History of the contract National contracting of general medical (general practitioner) services can be traced to the National Insurance Act 1911 which introduced a pool (similar to today's "global sum") to pay GPs on a capitation system building on the traditions of the friendly society.
The scheme was administered by local insurance committees covering counties and conurbations which held a panel of doctors prepared to work under the scheme. The panel doctors were subject to "terms of service" which were later lifted directly into the NHS GP contract. Lloyd George's "nationalisation of club medicine and local insurance in 1912 was the progenitor of the NHS in 1948". Lloyd George, when proposing to increase from 6 to 9 shillings per head the proposed annual payment to panel GPs insisted: "If the remuneration is increased, the service must be improved. Up to the present the doctor has not been adequately paid, and therefore we have had no right or title to expect him to give full service. In a vast number of cases he has given his services for nothing or for payment which was utterly inadequate. There is no man here who does not know doctors who have been attending poor people without any fee or reward at all".
In 1924 agreement was reached between the British Medical Association and the Ministry of Health that capitation fees would comprise 50% of a GPs income but only occupy 2/7 of his time, the remaining income being generated privately.
The meaning of independent contractor in respect of GPs has not always been very clear, but was generally tied to their rejection of salaried status. It has been argued that their behaviour has rarely been that of self-employed entrepreneurs, but rather that of salaried professionals who emphasise and defend the importance of their autonomy.
GPs' contract arrangements were originally made with local executive councils, and then their successors family practitioner committees, family health service authorities and primary care trusts. In England the contract is now between the GP practice and NHS England. In Scotland GP practices are contracted by the health boards. It was agreed in August 2014 that GPs in Scotland would have a separate contract with negotiations taking place which would come into force from 2017/18. It is proposed that they should give up employing practice staff and move 'as far towards salaried model as possible without losing independent status'.
Early years of the NHS
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.
From 1948 to 2004 the contract was an individual one. Virtually every doctor working in general practice had a personal contract with the local NHS and patients were registered with a named doctor. There was a clause which stated "a doctor is responsible for ensuring the provision for his patients of the services referred to … throughout each day during which his name is included in the … medical list".
In 1953, general practitioners were estimated to be making between 12 and 30 home visits each day and seeing between 15 and 50 patients in their surgeries.
The College of General Practitioners was founded in November 1952, and became an increasingly important player in negotiations about the GP contract. It became a driving force in developing postgraduate training for doctors wishing to enter general practice.
1966 GP contract In 1965 GPs demanded a new contract and threatened mass resignation from the NHS. One of their complaints was that there was no provision for improvement of practices. A GP who employed a secretary or nurse was paid no more than others who did the minimum. The main problem, however, was in comparison to the pay and status of hospital consultants. The career earnings of a consultant at that time were 48% higher than those of a GP. The Socialist Medical Association complained that the role of the family doctor as the lynch-pin of the NHS, as intended in the NHS Act had not been fulfilled. The reverse position had gradually developed, and general practice, was now frequently described as a "cottage industry". The BMA formulated a Charter for the Family Doctor Service. It demanded: "To give the best service to his patients, the family doctor must:
Have adequate time for every patient. Be able to keep up to date. Have complete clinical freedom. Have adequate, well-equipped premises. Have at his disposal all the diagnostic aids, social services and ancillary help he needs. Be encouraged to acquire skills and experience in special fields. Be adequately paid by a method acceptable to him which encourages him to do his best for his patients. Have a working day which leaves him some time for leisure".
The resulting 1966 contract addressed major grievances of GPs and provided for better equipped and better staffed premises (subsidised by the state), greater practitioner autonomy, a basic practice allowance for any GP principal with a list of more than 1000 patients, and pension provisions. Fees for service were introduced for interventions related to the prevention of disease. There was considerable pressure from doctors for the introduction of charges to patients but the Minister, Kenneth Robinson and the leadership of the BMA resisted this. Despite some changes, the capitation principle and the pool survived. The new payment system, known as the red book, allowed doctors to claim back from the NHS 70% of staff costs and 100% of the cost of their premises. Maternity Services and contraception were optional services which attracted additional payments. GPs were allowed to practise privately, to hold part-time hospital or other appointments within the NHS, to work in industry or for an insurance company, although few did very much private work.
In 1976 parliament approved legislation requiring doctors who wanted to become principals in general practice to complete vocational training.
1990 GP contract 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 which was imposed by Kenneth Clarke after it was rejected in a ballot, linked GP pay more strongly to performance. More money was attached to capitation and less to the basic practice allowance, in line with the Thatcher government's general enthusiasm for competition – an enthusiasm which was not shared by many GPs. The number of professional members on the family health services authority was considerably fewer than had been the case with the family practitioner committee. 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. Targets were set for cervical smears and immunisations. GPs were required to give health checks to new patients, patients over 75 and those who had not seen a GP for 3 years.
The GP Fundholding scheme gave them a budget for commissioning for the first time. The government also introduced a new locally negotiated personal services contract for general practitioners in 1997, permitting them to be salaried, paid by the session, or work as locums.
The 2004 GMS contract The new GMS contract came into force in April 2004, abolished the "Red Book" and led to a significant but temporary increase in some practices' 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 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"), 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 representative organisations the GPs were able to extract a concession. They received a "Minimum Practice Income Guarantee", which temporarlily protected the previous income levels of those who would otherwise have lost out – that guarantee being withdrawn over time by a combination of inflation and the clawback of pay rises.
At the same time the Government introduced the Quality and Outcomes Framework (QOF) which was designed to give GPs the incentive to do more work 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", so is not really new extra money.
Participation in the QOF is voluntary but since the standards change each year, practically all practices participating have to do more work each year for the same income. However, the substantial additional workload of QOF has led to substantial improvements in the screening for risk factors in the community by primary care, particularly for older patients with cardiovascular disease.
The Working in Partnership Programme (WiPP) was launched under the 2004 contract to support doctors in general practice by providing them with innovative ideas on how to improve services for the public.