Primary care trusts blame the “weak and clunky” GP contract for slow progress on improving quality in primary care and unacceptable variations in cost.

Primary Care Trust Network director David Stout told HSJ the national general medical services contract was a “fairly clunky and weak instrument”, which meant PCTs risked spending more on scrutinising practice contracts than they stood to gain.

You cannot force them to close. You have to wait for them to retire

“It’s quite hard to take contractual measures” he said. “If there is a performance issue it is hard to take issue with it. For example, you cannot actually tender a GMS contract.”

He said the inability of PCTs to force poor performing practices to close was the main reason for slow progress on reducing the proportion of single handed practices. The minimum practice income guarantee also meant that even if a PCT attempted to open a new practice close by, the poor performer would not go out of business as a significant proportion of its income would be guaranteed even if patients left.

A PCT source told HSJ GPs “basically have to kill someone” to be considered in breach of their contract.

Mr Stout said practices found breaking employment law could also be considered in breach of their contract.

But he conceded: “You cannot force them to close. You have to wait for them to retire.”

On average PCTs visited just over two thirds of their GP practices in a year for contract managing purposes, according to the results of an NHS Primary Care Commissioning survey, shared with HSJ.

But only 38 of the 91 PCTs in the survey answered the question on that, so the results were boosted by the 20 PCTs that visited each of their GP practices.

Phil Grant, interim director of contracting at NHS Devon and former economic adviser to NHS Employers, admitted PCTs often “struggled” to manage their GP contracts well but he said “there is not a single component of the GMS contract which PCTs do not have the ability to manage or negotiate locally to some extent”.

He blamed the “high trust, low bureaucracy” culture underpinning the contract, which he said was sometimes seen as an alternative to “good contract management and appropriate stewardship of public funds”.

PCTs neglect value in general practice