New contracts could see GPs opt out of services to social care clients

While the new GP contract has been heralded as “the most ambitious
attempt to reform primary care services since 1948”, professionals
are not optimistic the new working practices will bring benefits
for social care service users.

Despite the contract not being implemented until next April, fears
have already been raised that older people, vulnerable children,
substance misusers and the homeless could come out worse off than
under current arrangements.

Presently, a GP has to see anyone who walks into a surgery needing
treatment. Andrew Dearden, chairperson of the British Medical
Association’s community care committee, explains that this has led
to GPs being “emotionally blackmailed” to provide treatment because
if they don’t, no one else will.

This has resulted in an intense workload, fewer doctors becoming
GPs and a new generation of doctors who do not want to work under
the traditional conditions.

The new contract – the result of 18 months of negotiations between
the BMA and NHS Confederation – defines essential work that GPs
must provide and certain additional duties. GPs have to “opt-in” to
provide these additional “enhanced services”. If they decide not to
it will be the responsibility of primary care trusts to ensure
these services are provided either in other practices or
elsewhere.

One area of work GPs are likely to not to opt into is out of hours
work. “No one would let a truck driver or pilot work an eight or
nine hour day, then go on to a night shift until 7am in the morning
and start again at 9am,” says Dearden, who was on the negotiating
team.

He also highlights that current out-of-hours services are too
“GP-dominated”, whereas a truly responsive service would have GPs,
nurses, paramedics, social workers and community psychiatric nurses
all being available to provide out-of-hours services.

“At the moment, patients receive a rough deal,” he says. “GPs are
very good at being GPs, but not very good at being social
workers.

“I hope primary care organisations develop out of hours services to
reflect the patient’s needs rather than just having one group of
professionals available,” he adds.

A spokesperson for the National Association of General
Practitioners Co-operatives explains that current out of hours work
is usually covered by doctors all going into a co-op and one doctor
taking a turn once a week rather than working every night.

“Co-ops as we know them won’t be in existence,” he adds. More
integrated services will be put in place and social work would
“definitely” be part of the environment.

This proposal has triggered alarm bells among the sector. Frank
Ursell, chief executive of the Registered Nursing Home Association,
fears the plan will move towards schemes that are already in
existence in some areas with primary care units based in hospitals
providing an out-of-hours service.

He believes a patient would “have to be dying” to get a GP out and
patients would usually have to travel to the centre.

“Our concern is that in care homes there are times when we need GPs
to come out,” he says. If a resident has suffered a mini-stroke, it
is not appropriate for them to travel.

While some patients in the community may need to speak to a nurse
to get reassurance rather than “treatment”, this would not apply to
older people in care homes as they already have access to nurses.
“If we need anyone, it would be a GP and we are concerned there
will not be enough available.”

Requiring social workers to provide 24-hour services could also
have a dramatic effect on an already overstretched workforce in the
same way that it has affected doctors.

Ian Johnston, director of the British Association of Social
Workers, believes social workers would “vote with their feet”,
exacerbating the situation.

GPs will also be given the option to cherry pick which “enhanced
services” they want to opt-in to provide. These include services to
many social care client groups such as homeless people and
substance misusers.

Dearden explains that if a patient with substance misuse problems
has a sore throat, he would provide the treatment. But if that
patient requires help to come off drugs, this would be seen as an
enhanced service, which Dearden could opt out of.

The primary care trust then has the choice to commission that drug
treatment work to another practice, hospital or elsewhere in the
NHS. However, those GP practices that want to specialise in drug
treatment would opt-in, and would need to be funded and resourced
to provide the work.

Dr David Jenner, the professional executive committee lead for the
NHS Alliance, which represents PCTs, warns that GPs are unlikely to
be attracted to providing drug and alcohol services, particularly
if the funding is minimal, because “both services can be
time-consuming and involve patients with challenging
behaviour”.

But Dr Clare Gerada, a government adviser on drugs, says she would
not like a system where drug users are managed by one or two
doctors. “I don’t think patients would want to go to the ‘drug’ GP
because of the stigmatisation,” she warns.

But Dearden argues: “It has got to be better to see someone who is
trained to see you, has got the time and does not see you as a
burden.”

However, there remain serious questions over the whole funding
issue and whether cash-strapped PCTs can fund the enhanced services
– some of which GPs have previously been providing. Dearden admits
that money tends “to go where the horror stories are”, such as
people waiting on trolleys in corridors. The main horror stories
tend to be in hospitals “because primary care and community care
just get on with it”, he adds.

But providing enhanced services in hospitals would not be
cost-effective, he warns, as hospitals have huge overheads and
therefore the treatment would cost more to be provided there. “If
the money isn’t spent in primary care and community care, the real
flexibilities won’t be used and patients won’t be better off,” he
warns.

Also there are concerns that child protection services could be hit
by the new contract. Delegates at a conference on health
professionals and child protection organised by the Royal College
of General Practitioners warned that none of the 1,050 quality
indicators in the GP contract cover child protection (news, 4
December, page 12).

GPs and their practices are rewarded according to how many points
they get in each of the areas covered by the indicators, meaning
they will have no incentive to deal with the issues not
covered.

Tink Palmer, principal policy officer at Barnardo’s, says this is
“extremely worrying” as GPs are on the front line and “in a good
position to pick up on issues”.

“GPs are not the best at coming forward about child protection
because of issues of confidentiality,” she adds. Because of their
relationships with families, “they tend to put families first
rather than children,” and this will do nothing to incentivise
them.

Jane Held, co-chairperson of the Association of Directors of Social
Services children and families committee agrees, and warns that
social services are reliant on people such as GPs to warn them if
they have concerns about a child. “We are not a universal service
so if the universal services don’t identify concerns, we don’t get
to know,” she says.

GPs hold “a vital piece of the jigsaw, and if it is not put in the
right place, you can’t complete the picture”, she adds. However,
Held feels optimistic that the government will put measures in
place in the forthcoming Children’s Bill “to ensure GPs cannot
avoid their responsibilities to protect children”.

This would address one of the elements of concern, although there
are many more outstanding. It is early days as according to Dearden
the contract will “take four to six months to bed in”.

He believes that things have “got to get better”. But in a climate
of tight PCT budgets and GPs having the freedom to drop the more
peripheral parts of their work, it is difficult to envisage how
some of the neediest clients will benefit.