General medical services

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.

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. 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'.

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.

The contract changes for 2015/16 in England were announced in September 2014 and formulated in the National Health Service (General Medical Services Contracts) Regulations 2015 (SI 2016/1862). Main changes included a named, accountable GP for all patients, publication of GPs' average net earnings and expansion and improvement of online services. Practices have to help anyone who wants it to sign up for patient facing services. All practices were required to have a patient participation group According to Jeremy Hunt the right to a named GP turned into a tick box exercise as there were not enough GPs.

GP practices in England will receive £85.35 per weighted patient under the 2017 Contract, an increase of 5.9% from 2016/17.

The 2019 contract will run for 5 years. £405 million of funding has been confirmed for 2019/20. The contract provides changes to the rurality index payment and London adjustment payment, so that rurality index payments will only apply to patients living inside a GP's catchment area and the London adjustment payment will only apply to patients actually living in London. Babylon Health complained that this penalised their GP at Hand operation which had invested in technology in order to serve patients over a wide geographic area. According to the BMA the deal will guarantee a minimum 2% uplift for GP and staff pay and expenses this year. There is an incentive of £2 a patient for practices to join geographically based primary care networks. There will be funding for pharmacists, physiotherapists, paramedics, physician associates and social prescribing support workers to support practices. Practices will be obliged to make one appointment per 3,000 patients available per day for direct booking by NHS 111. Richard Vautrey described the changes as the most significant in 15 years. For the first time State indemnity is extended to GPs and practice staff. Practices are banned from advertising or hosting private services.

Apart from GPs in the GMS, primary care is also provided through Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS) contracts. Personal Medical Services (PMS) were first tried in April 1998 and became a permanent option in April 2004. The health care professional/health care body and the primary care trust (PCT) enter a local contract. The main use of this contract is to give GPs the option of being salaried. Alternative Provider Medical Services (APMS) are primary care services provided by outside contractors (like US health companies). A study, published by the Journal of the Royal Society of Medicine in 2015 found that 347 of the 8,300 general practices in England were run by under 'alternative provider medical service' contracts. The study found the introduction of the alternative contract had not led to improvements in quality and may have resulted in worse care. The results showed that APMS providers performed significantly worse across 13 out of the 17 indicators (p=<0.01 in each) in each year from 2008/09 and 2012/13, and were significantly worse than traditional general practice in three out of the five years for a further two indicators.

In 2013/4 the average gross earnings of a single handed GP was £107,200. In practices with six or more GPs the average was £99,100.