The Scottish Government

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THE NEW GMS/GP CONTRACT

In the summer of 2003 a new UK-wide contract for general medical services was signed - to come into effect from 1 April 2004. This contract would transfer the responsibility for out-of-hours patient care (generally 6pm to 8am weekdays and 24 hours Saturdays, Sundays and public holidays) from GP practices to Primary Care Trusts - and subsequently to Health Boards. Prior to this GP practices, directly or through GP out-of-hours co-operatives, had had 24 hour responsibility for patient care for decades. By 31 December 2004, the contract deadline, nearly 90% of all GPs in Scotland (some 3,500 out of 4,000) had exercised their legitimate, contractual right to opt out of 24 hour patient care. That was always going to present some real challenges for Health Boards. How were Health Boards going to ensure that out-of-hours services were adequate within their local area? How were Health Boards going to cover for some 3,500 GPs? They had had reasonable notice; by the summer of 2003 most indicators pointed to a 70%-90% GP opt out. So Health Boards had 12-18 months to plan and prepare. The response of Health Boards would of course vary but some were clearly relying heavily on the NHS 24 technological roll-out. If that was unrealistic on their part the main reason would be that they believed the confident messages coming from senior NHS 24 representatives.

GPs who "opted out" of out-of-hours responsibility, as allowed under their new contract, gave up a proportion of their remuneration in return. They were able, however, to offer their services back to Health Boards. A significant percentage of GPs have done so and they sign up for and are paid for specific out-of-hours shifts that they are prepared to cover. That meant lots of local negotiation over rates of pay, etc, and several Health Boards made pleas to SEHD for advice and even for central negotiation. SEHD, after consulting other bodies, concluded that it would be inappropriate to set a national pay rate.

In theory, these changes would not call for any significant design enhancement by NHS 24. After all, it had been planned from the beginning to integrate with out-of-hours work and that would not change - although out-of-hours services were not always developed with identical operational roles. NHS 24 did set up a special internal group in mid-2003 to plan for the impact of any changes and that group, led by the Medical Director, regularly reported back quite optimistically. But with hindsight we have to wonder why the Board could remain so confident given the potential for risk that all of these significant and imminent changes might bring. We are told that several Health Boards suggested a pause in the NHS 24 integration roll-out so that all the parties could take stock but that, once more, NHS 24 thought that was unnecessary.

It may be unfair to suggest that this again indicated a focus more on the efficiency of technological process than on the all-important ultimate, on the ground, service delivery. The Board seemed to be impressed by the steady increase in call volumes ("the largest month-on-month increase in our history" etc) - as if those volume increases on their own confirmed success. Given that those increases coincided with a planned month-on-month increase in the population progressively covered by NHS 24 that was hardly surprising. It was not so much the overall monthly increases that were stretching NHS 24 towards the limit but the concentration of high volumes at particular times, eg weekends. So focused analysis of the separate statistics for weekend and midweek volumes - even as far back as 2003 - might have put NHS 24 in a slightly better position to alleviate the challenges thrown up by the new contract particularly perhaps when GP practices withdrew from Saturday morning surgeries.

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