Managers are calling for the power to “fire” GPs and to get rid of small practices to make the huge spending cuts needed in coming years.

A summary of discussions between the Department of Health and strategic health authority directors, seen by HSJ, reveals they are seeking controversial reform of primary care contracts.

GPs should not be paid for poor performance. There are huge variations in the performance of GPs

A summary of the talks about what is needed for the DH’s quality, innovation, productivity and prevention - QIPP - programme, includes the conclusion: “Can’t deliver the productivity improvements required with small practices.”

Smaller, separate practices are considered less able to share administration, host additional services and take on commissioning functions.

Much of the QIPP programme relies on reducing referrals to hospital, better care for long term conditions and moving services into the community: all dependent on primary care services.

The summary says managers “want to be able to ‘hire and fire’” GPs, something commissioners say is very difficult to do.

Commissioners “need transparency in managing primary care performance and need contractual levers to help address this”, they say. “GPs should not be paid for poor performance. There are huge variations in the performance of GPs.”

Policy makers are also looking at how to incentivise GPs to reduce unnecessary spending by strengthening their commissioning role, for example with real budgets, as proposed by the Conservatives.

On out of hours care the summary says: “Primary care is required 24/7. Need to focus on quality and the availability of care.”

Many of the proposals would have to become part of contract negotiations with the British Medical Association on new GP contracts, expected to begin after the election.

However, as well as contract changes, the summary acknowledges there must be “better performance management of existing levers”. Last October HSJ revealed huge variation in the amount different PCTs were paying GPs for similar services.

PCT Network director David Stout said that while some contract changes were needed, dramatic shifts were not likely to come quickly, so should not be relied on.

However, he said: “We cannot exclude general practice from the quality and productivity challenges, and wider than that we need them to operate as efficient and productive clinicians in terms of referrals.”

Royal College of GPs chair Steve Field said it was important for GPs to lead the changes.

He said: “I would call for all doctors to engage in this agenda [of improving quality while making savings]. Both managers and doctors have to take responsibility for this and lead it.”

York University professor of health economics Alan Maynard said: “The GP contracts are going to have to be radically reviewed. We can’t afford to have all these restrictive practices.”

The DH said: “These are notes of informal discussions at a quality and productivity event - these are not official proposals and this is not DH policy.”