Designing a new GP contract: considerations for policy-makers and the profession

Agreeing the core functions of general practice

The need to revisit and agree the purpose and functions of general practice within the NHS is no less urgent than it was when highlighted in the 1950 Collings report into general practice! Recent policy – enacted through the GP contract – has focused on rapid access to appointments and the digital and workforce developments needed to achieve this, losing sight of GPs as medical generalists (RCGP, 2012) offering continuity of care and a holistic interpretation of patients’ problems (Rosen, 2022). It is medical generalist skills in assessing and managing unclear symptoms, and holding selected clinical risk without onward referral to specialists, that underpin the potential for GPs to improve productivity within general practice (Kajaria-Montag and others, 2021) and in the wider NHS. This calls for a new emphasis on the functions of interpretive general practice (understanding people’s problems, through continuity of care, in the context of their family and social context) and care coordination (described in the first article in this series).

There is also an important function for general practice in addressing inequalities (Fisher and others, 2022) to improve the health of vulnerable populations and those in deprived areas. And the contribution of general practice to preventive services needs clarification, along with how the contract can support policy-makers’ expectations for linking GPs to integrated neighbourhood teams.

With the current financial, workload and workforce pressures on practices, we should think about which functions, along with the working practices and tools needed to deliver them, are core elements of general practice to be specified in a universal contract. And whether some could be seen as the ‘building blocks’ of future models of care to be developed through optional additional contracts held, in the first instance, by practices and primary care networks (PCNs) with the interest and capacity to develop new ways of working.

The concept of ‘building blocks’ for high-performing primary care, set out by Bodenheimer and others in 2014, drew on the characteristics of a cluster of exemplar US primary care practices. They described four ‘foundational’ blocks (leadership, data, empanelment and team-based care) supporting six further building blocks required to deliver high-quality services. Clearly this approach needs adaptation for an English context and updating to accommodate technological and workforce developments since 2014. It is beyond the scope of this article to define the building blocks in detail, as they need to be agreed through consensus between stakeholders, but they could reflect current policy priorities, to include, for example: extended use of digital technology (beyond that specified in the core contract); new models of access, blending speed and continuity; and new arrangements for integrated neighbourhood working (see NHS England, 2023; NHS England, 2024; Palmer and others, 2018; Fuller, 2022). Consideration is needed of whether this kind of modular approach to primary care transformation could underpin new ways of contracting for GP services.  

What lessons can we draw from international contracts?

Drawing on the international contracting examples described in this series, there is useful learning about:

• contracting for complex changes in the organisation and delivery of general practice service
• blending incentive types
• contracting with large-scale organisations with the resources and capabilities to support contract implementation
• phased introduction of the building blocks for future models of care
• using premises development as a stimulus for new ways of working.

The Alternative Quality Contract (AQC) in Massachusetts illustrates contracting for complex objectives, blending improvements in quality and cost containment. (Examples of complex objectives relevant to English general practice include balancing rapid access for acuity and access to continuity of care for complex health problems, and blending practice-level and PCN- or neighbourhood-level service delivery.) The AQC also highlights the detailed creative thinking and resources needed to develop an effective contract.

Blue Cross Blue Shield – the insurer that offered the contract – invested time with clinicians who piloted it, academics, data scientists and others to agree measures and datasets through which to support implementation, monitor performance and determine incentive payments. They did not specify how providers should deliver improvements, leaving discretion to respond to local context and needs. Importantly, in recognition of the varied starting points of different practices, for each improvement area there are five performance target ‘gates’ triggering a proportion of the incentive payment, designed to motivate improvement in the early and middle part of the continuum of care, with less emphasis on getting to the final gates than on the set-up stages (The Commonwealth Fund, no date). The five-year contract allowed time for practices to develop and implement changes to reach the more demanding payment gates and have a steady supply of data. Leadership and organisational development support were also hard-wired into the AQC.

A similar stepped approach has been used in the Netherlands in contracts between some insurers and care groups, some of which now go beyond the original chronic diseases focus to include increasing digital access and improving mental health services. ¹  Up to 10% of contract payments are for locally negotiated improvements, linked either to clinical performance measures or to achieving specific steps towards a service improvement detailed in the contract. Care groups provide various forms of support to practices to fulfil each step and practices are rewarded as a step is reached, allowing them to move at their own pace. A similar breakdown of the actions and infrastructure needed by practices was provided in NHS England’s 2023 Plan for Recovering Access to Primary Care but was not linked to step-wise payments for sequential levels of achievement on access recovery.

The Netherlands’ bundled payments for chronic diseases and Norwegian fee-for-service (FFS) payments highlight how a new blend of incentives in the GP contract can change service delivery, albeit with some unintended consequences. Norwegian FFS payments incentivised increased consultation activity in participating clinics with additional tests undertaken and lower spend on Accident & Emergency (A&E), but at a reported cost of delivering more transactional care that was less well suited to patients with complex needs (Kraft and others, 2024). In the Netherlands, the policy ambition to develop more cost-effective chronic disease management through bundled payments did transform care but did not reduce overall costs.

As PCNs start to develop acute access hubs – aimed primarily at usually healthy patients with acute problems – there is scope to investigate whether FFS payments could appropriately incentivise productivity in a broadly transactional area of GP care or whether perverse incentives to see patients with minor, self-limiting conditions who could self-care would prevail.

The Estonian group practice contract demonstrates how GP estates development, linked to higher payment rates for working in a new way – if undertaken as part of the government’s manifesto commitments to introduce neighbourhood health services– could be linked to a contract for new models of general practice care (see below).

How to ensure there is adequate support for contract implementation

The need for organisational development support to implement GP contract changes is recognised by general practice commissioners and reflected in recent policy on access recovery. But the funding available is often limited. The US Agency for Healthcare Research and Quality describes the kind of skills and support needed by primary care organisations for quality improvement, as an ‘essential infrastructure’, providing staff and resources for assessment, coaching and skilled interventions, to help practices achieve improvement plans while also building their quality improvement capabilities for the future (McNellis and others, 2013). Both the AQC and the Netherlands’ care group contract demonstrate how support was provided to practices from large-scale organisations with more resources to support service development than a typical practice or PCN.

The PCN contract includes limited funding for management support to practices and has created opportunities for peer learning between practices, although an early, small evaluation of PCN leadership and management capacity highlighted its limitations (Smith and others, 2022).

Support is also needed with clinician engagement in service transformation. The AQC drew clinicians into contract implementation through regular meetings in participating clinics, providing individual coaching and maintaining regular communications throughout the intervention. The Dudley vanguard multispecialty community provider (MCP) also highlighted the importance of ongoing communication with all staff involved in developing the MCP to build engagement and trust in the planned transformation. In the Netherlands, it was the care groups that had to engage clinicians in new approaches to chronic disease management. This intensity of support needs to be costed into contracts or progress risks being glacially slow.

How to develop the timely, high-quality data needed for contract monitoring

If GP contracts are to contribute to the evolution of future models of care then progress towards changes specified in the contract will need to be linked to outcome measures, requiring timely, accurate and relevant data. There are well-recognised problems with the quality of general practice data, which need to be addressed alongside agreeing what data need to be collected to enable service improvement and monitor performance against the contract. The AQC illustrates the importance of early investment in time and resources to agree a starting point for outcomes and data collection and to test and refine this over time. Understanding and improving general practice data is a central aim of the 22 pilots projects underway in PCNs, which could provide useful learning for implementing and monitoring future GP contracts (Tilley, 2024).

National or local contracts and the potential role of large-scale GP organisations

A recurrent concern about the GP contract in England, reiterated in the 2023 Hewitt review, is that a national contract stifles innovation and transformation and limits the ability of practices to adjust services to local need. The Hewitt review called for:

• clarity about the outcomes needed from primary care
• a new balance between nationally specified services and local autonomy to address inequalities and population health need
• new expectations around digital services, data and incentives.

Hewitt’s call for contracts that can respond more effectively than the national contracts to local population health needs is already possible through the Personal Medical Services (PMS) contract, which is still held by 26% of practices. It is important to note that in its evaluation of PMS spending, NHS England (2014) was only able to link 20% of the additional £325 million spent on PMS contracts compared with GMS practices to enhanced services and performance indicators. This highlights the challenges of adequately specifying the local services to be delivered, defining suitable measures and collecting and analysing performance data – a shortcoming that must be addressed in future contracts. Here too, the timescale and intensity of support seen in the AQC provides important lessons about having realistic expectations of contracts for local service developments.

Recognising the limited management and organisational development capacity of small practices and of most PCNs to implement such changes, this also raises questions about whether large-scale, but locally embedded primary care organisations such as general practice federations and PCN alliances could act as contract holders, similar to care groups in the Netherlands. The average size of general practices increased 40% from 2013 to 2023 (Pettigrew and others, 2024) and a cluster of practices now exist with over 100,000 patients. PCNs have formed across England alongside large-scale GP support organisations (general practice federations and PCN alliances). The Hewitt review’s call for flexible local contracts to incentivise and support different models of primary care at scale, is already possible given the potential to use existing local contracts and the range of large primary care organisations that currently exist. Although past evidence from PMS contracts Lewis and Gillam, 2002) suggest it needs careful thought in relation to specifying services to be commissioned and defining the relationship between the contract-holding organisation and practices providing contracted services. It also would require clear tests of the support capabilities, financial stability and resilience of at-scale contract holders to ensure contracts were not awarded to organisations unable to provide necessary support or at risk of collapse (Dale, 2024).

Can we link a new contract to estates development?

The Estonian group practice contract, developed on the back of EU structural funds, demonstrates the opportunity to link premises development to new models of care. While the opportunity was rejected by many older GPs reluctant to lose professional autonomy, it was acceptable to some younger GPs keen to provide clinical care without the burden of management responsibilities and therefore interested to work in the new health centres (WHO European Region, 2023). England has some related experience through the development of Darzi centres linked to extended-access clinics and other services. However, the launch of Darzi access hubs duplicated services provided elsewhere, increasing costs, so most were closed or blended into other services (Davies, 2010).

Plans to develop neighbourhood health services form a central part of current policy. This could include building new health centres to tackle current limitations in GP estates or re-purposing existing ‘Darzi Centres. There are lessons available from Estonia on designing and contracting for the services around modern health centres, although learning from the  initial development of Darzi centres highlights that these must compliment services available through mainstream practices if they are to avoid wasteful duplication. And with younger GPs concerned about the risks associated with joining partnerships (Watson, 2019), there is also potential to contract for a medical workforce in new ways.

What role for primary care commissioners?

The above changes are only possible with strong commissioners – who understand local needs, can adapt modular building-block contracts into local contracts (either as PMS agreements or new forms of modular contract) that address local population health needs and can monitor performance and manage providers. Work to adjust commissioning plans in line with local needs was the bread and butter of clinical commissioning groups but the capacity and relationships required to undertake such work have declined with the centralisation of primary care commissioning into integrated care boards (Smith, 2024). Forward-looking GP contracting, which incentivises the building blocks for future models of care, is only possible with a strong and supportive commissioning function, similar to the support provided by Blue Cross Blue Shield for the Alternative Qualtiy Contract. However, this article has questioned whether the commissioner function of supporting contract implementation could be undertaken by large-scale general practice organisations.

Considerations for developing future GP contracts

The linked articles in this series illustrate the strengths and weaknesses of different approaches to GP contracting and highlight work in progress to develop the components of effective contracts. The articles also highlight demands for additional funding for general practice and the persistent problem of a funding allocation formula (the Carr-Hill Formula) that does not reflect the additional health needs of deprived populations. These issues are important and must be addressed to ensure that a new contract emerges in a context with sufficient and fairly distributed funding to support its implementation. In addition to getting the financial context right, consideration should be given to both a new national contract for core general practice services and new ways to contract locally for the ‘building blocks’ of future models of general practice.

National contracts for core functions, and local optional contracts for building blocks for the future

• As a first step, an expert group of policy-makers, practitioners, academics and service users needs to agree the core functions of general practice and the tools and working methods that form the building blocks of future models of care. It is beyond the scope of this article to define these in detail, but they could include: enhanced digital services; data analytics for individual and population needs assessment; blended access to acute and continuity consultations; novel approaches to multi-professional working through integrated neighbourhood teams; and novel approaches to reducing inequalities.
• A new national contract specifying the core functions of general practice could also require basic implementation of essential building blocks for the future to ensure all practices at least start to introduce working practices that can support new and high-quality models of care.
• In addition, local contracts could be developed for advanced implementation of building blocks for the future. The contracts could be optional and modular, such that practices with an appetite and capacity for service transformation could choose from a ‘pick and mix’ menu of modules, building on local needs and professional interests and able to sequence development and pace the changes to suit their local context and resources.

Learning from international contracts

• A carefully crafted blend of financial incentives can help to drive change in different core functions of general practice, although there is a risk of unintended consequences of incentives, which need to be identified and addressed. Drawing on the January 2024 review of incentives for general practice (undertaken by Dept of Health and Social Care but yet to be published) and giving consideration to lessons presented here, the challenge for future contract(s) is to incentivise delivery of all the agreed functions of general practice along with a step change in the quality of data collected in practices. Improved data is essential to support and monitor contracted service improvements.
• A step-wise approach to introducing new ways of working, with iterative design and phased incentive payments, can enable practices to innovate and change at a pace they can cope with, without being overwhelmed. The expert group suggested above could also put forward outcome measures for each building block – to be refined in response to local health priorities – and the datasets needed for contract monitoring. This iterative approach was seen in the development of the AQC and could draw on experience gained in the 22 pilot PCNs exploring new models of care and new ways of collecting and analysing general practice data.
• A step change in the quantity and nature of contract implementation support, as seen in both the AQC and the Netherlands’ chronic disease contract can help with service transformation over time. This raises questions about: whether individual practices and PCNs have the skills and resources to implement ‘building block’ contracts; whether NHS primary care commissioners can effectively support this kind of transformation work; and whether large-scale general practice organisations, acting as lead contract holders, might be better placed to support individual practices with contract implementation. Not all large-scale general practice organisations have the necessary skills, resources or financial stability to take on this role, so eligibility criteria would be needed, and could be informed by the work of the expert group described above.
• Funding for the service development support needed to improve current services and introduce the building blocks of future models of care could be built into the price of optional modular contracts or provided as additional funding or support in kind. Some support would also need to be available to practices holding the national contract to ensure they are supported to implement smaller-scale service improvements.
• There is also an opportunity to consider using the development of neighbourhood health centres as an opportunity to apply learning from Estonia about linking contracts to deliver care in new premises to the delivery of new models of care and new organisational arrangements. These could include testing new employment models for GPs and new approaches to multi-professional team working.