Is the GP contract a barrier to integrated care?

The Future Forum recommended that “we need to move beyond arguing for integration … to making it happen”. The benefits of more integrated and co-ordinated care have long been recognised, particularly for a growing proportion of patients who have multiple and long-term conditions, for those with both physical and mental health needs, and for those who are users of both health and social care. Yet the reality is that for many patients their experience of care is of fragmentation and duplication. This lack of integration is wasteful of time and resources but is also likely to deliver poorer clinical outcomes.

At a recent conference organised by The King’s Fund on commissioning integrated care I argued that one barrier to integrated care is the current GP contract. This has provoked some reaction from GPs who argue they already provide integrated care.

While integrated care is the essence of generalism when it provides holistic, family-centred care, it is not always how patients experience general practice. For example, how many practices provide a one-stop service for a person with diabetes in the community where they can get their feet and eyes checked, as well as have their blood sugars, cholesterol and blood pressure monitored, and receive self-management advice and support? If a commissioner wanted to commission for a pathway, package or year of care that included these elements plus appropriate specialist care and the costs of acute admissions for hypo- or hyperglycaemia due to a failure to manage the diabetes, what element could they expect GPs to already be providing under their contract?

The lack of any definition of the “core” services GPs are contracted to provide means that commissioners may find they are paying twice. In moving to define core services more explicitly it is important to avoid the mistakes of the consultant contract which in many cases resulted in paying more for less work.

The current GP contract also constrains aspirations to do things that are better for patients and local communities. The incentives for performance currently reward the recording of individual items of care rather than population outcomes. Our Inquiry into the Quality of General Practice made clear that not everything that matters can be measured, and not everything that can be measured matters. There are many aspects of quality in primary care that are not routinely measured or rewarded, including whether patients feel their care is co-ordinated. The quality premium offers an opportunity to redefine rewards towards the achievement of population level outcomes. These could encourage practices to work together in larger federations to meet the needs of their populations.

There is also a need to encourage closer working between GPs and specialists. General practice needs to embrace integrated care by developing multidisciplinary teams that reach beyond the surgery walls. Multispecialty medical groups that take on capitated budgets have greater flexibility to redesign services, but this is likely to mean GPs walking away from a nationally negotiated deal.

While tearing up the current contract and starting again may be too radical for this or any government, there is a serious need to rethink how we commission and contract with primary care if the ambitions of integrated care are to be realised.