GP funding and contracts explained

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The way general practices are contracted and funded is complex and very different from other parts of the health and care system. This explainer sets out how general practices are contracted and paid in England, looking at the services they are contracted to deliver, and the different streams of funding they receive.

What are general practices?

General practices are the small to medium-sized businesses whose services are contracted by NHS commissioners to provide generalist medical services in a geographical or population area. While some general practices are operated by an individual GP, most general practices in England are run by a GP partnership. This involves two or more GPs, sometimes with nurses, practice managers and others (as long as at least one partner is a GP), working together as business partners, pooling resources, such as buildings and staff, and together owning a stake in the practice business. GP partners are jointly responsible for meeting the requirements set out in the contract for their practice and share the income it provides.

Some GPs work as salaried employees of a practice without owning a share in the overall business (so they are not GP partners). The British Medical Association (BMA) has a model salaried employment contract for these staff and practices with a General Medical Services (GMS) contract are required to offer this contract or an equal alternative to salaried GPs.

Who commissions general practice?

Responsibility for commissioning primary care services, including general practice, sits formally with NHS England. However, over time clinical commissioning groups (CCGs) have increasingly taken on full or partial delegation of these commissioning powers for primary care. This now means most CCGs have at least some responsibility for commissioning general practice in their local area, while keeping to national guidelines to ensure consistency.

What types of GP contracts are there?

Every individual or partnership of GPs must hold an NHS GP contract to run an NHS-commissioned general practice. These set out mandatory requirements and services for all general practices, as well making provisions for several types of other services that practices may also provide, if they so choose.

There are three1 different types of GP contract arrangements used by NHS commissioners in England – General Medical Services (GMS), Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS).

The GMS contract is the national standard GP contract. In 2018/19, around 70 per cent of GP practices operated under it2. This contract is negotiated nationally every year between NHS England and the General Practice Committee of the BMA, the trade union representative of GPs in England. It is then used by either NHS England and/or CCGs (depending on delegated powers) to contract local general practices in an area.

The PMS contract is another form of core contract but unlike the GMS contract, is negotiated and agreed locally by CCGs or NHS England with a general practice or practices. This contract offers commissioners an alternative route with more flexibility to tailor requirements to local need while also keeping within national guidelines and legislation. The PMS contract is being phased out, but in 2018/19, 26 per cent of practices held one.

The APMS contract offers greater flexibility than the other two contract types. The APMS framework allows contracts with organisations (such as private companies or third sector providers) other than general practitioners/partnerships of GPs to provide primary care services. APMS contracts can also be used to commission other types of primary care service, beyond that of ‘core’ general practice. For example, a social enterprise could be contracted to provide primary health care to people who are homeless or asylum seekers. In 2018/19, 2 per cent of practices held this type of contract.

All types of contract are managed by the NHS commissioner (either NHS England or CCGs). Where contracts are negotiated locally, Local Medical Committees representing GPs may advise or participate in discussions alongside regional BMA representation.

  • 1. A new Integrated Care Provider (ICP) contract has recently been made available to allow for greater integration of services. This can offer an additional contracting route for general practice but there has been no uptake so far.
  • 2. Figures do not add up to 100 per cent because in 2018/19 101 practices were listed with an unknown contract type.

What’s in a GP contract?

The core parts of a general practice contract:

  • agree the geographical or population area the practice will cover
  • require the practice to maintain a list of patients for the area and sets out who this list covers and under what circumstances a patient might be removed from it
  • establish the essential medical services a general practice must provide to its patients
  • set standards for premises and workforce and requirements for inspection and oversight
  • set out expectations for public and patient involvement
  • outline key policies including indemnity, complaints, liability, insurance, clinical governance and termination of the contract.

In addition to these core arrangements, a general practice contract also contains a number of optional agreements for services that a practice might enter into, usually in return for additional payment. These include the nationally negotiated Directed Enhanced Services (DES) that all commissioners of general practice must offer to their practices in their contract and the locally negotiated and set Local Enhanced Services (LES) that vary by area.

What services can practices be contracted to provide?

General practices are contracted to perform broadly five types of service for the NHS, although some are optional.

  1. Essential services are mandatory for a practice to deliver to registered patients and temporary residents in its practice area. They include the identification and management of illnesses, providing health advice and referral to other services. GPs are required to provide their essential services during core hours, which are 8.00am–6.30pm Monday to Friday, excluding bank holidays.
  2. Out-of-hours services are those provided outside core working hours. A practice is assumed to provide these by default but can opt out. Where a practice opts out, as most practices do, commissioners have the responsibility for contracting a replacement service to cover the general practice area population.
  3. Additional services include specific other clinical services that a practice is assumed to provide but can opt out of, for example, minor surgery.  
  4. Enhanced services are nationally agreed services that holders of almost all GP contracts (GMS/PMS/APMS) can also provide if they choose to opt in. Services specified for 2020/21 include some vaccination programmes and a health check scheme for people with learning disabilities. Primary care networks (PCNs) (see box below) have also been established via an enhanced service agreement.
  5. Locally commissioned services are locally set services that practices can also opt in to. Unlike other GP services, these might also be commissioned by non-NHS organisations such as local authority public health departments. Examples include services for people who are sleeping rough or mental health support programmes.

Almost all general practices in England are part of a PCN, a small group of practices usually within the same geographical area that work together under the PCN DES contract to gain some of the benefits of working at scale and access to additional funding.

How does the money flow?

The funding a general practice receives depends on a complex mix of different income streams. Much of a practice’s income comes from its core contract agreements – meeting mandatory requirements, running essential services and operating additional and out-of-hours services where they have been agreed. This is known as the global sum payment. However, a sizeable amount of a typical practice’s income comes from other NHS sources such as the Quality and Outcomes Framework scheme (see below) or payments for providing enhanced services. Practices may also top up their NHS funding with fees for limited private services, such as sick certifications and travel prescribing. Most practice income is paid to the general practice rather than individual GPs.

Global sum payments

About half the money a practice receives is from the global sum payment – money for delivering the core parts of its contract. This includes payment for out-of-hours and additional services; if a practice opts out of these, percentage deductions are applied to the global sum payment to account for this. Global sum payments are based on an estimate of a practice’s patient workload and certain unavoidable costs (eg, the additional costs of serving a rural or remote area or the effect of geography on staff markets and pay), not on the actual recorded delivery of services. The global sum payment for each practice is based on a weighted sum for every patient on the practice list. The Carr-Hill formula is used to apply these weightings, which account for factors such as age and gender. The global sum amount is reviewed quarterly to account for changes to the practice’s patient population.

Figure 1 summarises how the global sum payment to a practice is calculated.

Figure 1 Calculating a practice’s global sum payment
GP contracts explainer figure 1

Quality and Outcomes Framework payments

The Quality and Outcomes Framework accounts for around 10 per cent of a practice’s income. The Quality and Outcomes Framework is a voluntary programme that practices can opt in to in order to receive payments based on good performance against a number of indicators. In 2018/19 more than 95 per cent of practices took part. The framework covers a range of clinical areas, for example, management of hypertension or asthma; prescribing safety; or ill health prevention activity. Each area has a range of indicators that equate to a number of Quality and Outcomes Framework points.

Example indicator from The Quality and Outcomes Framework 2019/20

RA002 – The percentage of patients with rheumatoid arthritis, on the register, who have had a face-to-face review in the preceding 12 months. Achievement threshold 40–90 per cent. Points: 5

If 40 per cent of patients with rheumatoid arthritis have had a face-to-face review with a health professional, the practice will receive 1 point. If 90 per cent of these patients have had a face-to-face review, the practice receives 5 points. Points are awarded proportionately for percentages between these boundaries.

At the end of the financial year, the practice receives an amount of money, based on points achieved in the Quality and Outcomes Framework.

Premises payment

If a practice is leasing its premises, rent is generally reimbursed in full in arrears. If a partnership owns its premises, it is mortgage payments that are reimbursed, although most practice premises are leased. Some practices sub-let rooms to other providers (for example community health services providers) but there are rules on what a practice can use its building for, which affect reimbursement.

Primary care organisation (PCO)-administered payments

PCO-administered payments refers to payments by the local ‘primary care organisation’, ie, the CCG or NHS England depending on delegation of powers. Payments in this category include, for example, locum allowances and appraisal costs.

What do GPs spend their money on?

Figure 2 Practice income, outgoings and partner share

GP contract explainer figure 2

Source: GP income streams based on NHS payments recorded in NHS payments to general practice – England, 2018/19

Paying its workforce – including salaried GPs, nurses, health care assistants and administrative staff – accounts for the majority of a practice’s costs. These staff are usually employed directly by the GP practice and not by the NHS and so are not subject to Agenda for Change arrangements.

Partners pay themselves from the money that remains after other expenditure has been accounted for. Part of this personal income is used to pay their pension contributions, tax, indemnity, General Medical Council and other subscriptions. Partners may also decide to reinvest some of the remaining income into the practice. It is important to note that partners in GP practices are also personally liable for any losses made by the practice.

What does it all mean?

GP partners are not just clinicians but also small business owners and employers. This comes with a number of challenges, for example, the need to manage and optimise complicated income streams and personal liability for financial risks. It also means partners have a strong vested interest in maintaining and developing their practice.

Historically, the major levers for setting national or local priorities and implementing service improvements across general practice have been contractual, for example, the Quality and Outcomes Framework, rather than based on national guidance. This is still the case, although rapid transformation in the services GPs are providing in response to Covid-19 is challenging this assumption.

If local health systems are to achieve their full potential, a shared understanding of the differences between funding and contracting models for the different parts of that system will be important if partners are going to work effectively together.

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Comments

Peter Barnshaw

Position
Retired,
Comment date
15 October 2021

Many GP practices appear to be run as professional partnerships but as they are not incorporated either as LLPs or limited companies there is no transparency to taxpayers on the use of public funds and whether GPs are making excessive profits or syphoning off funds for their private use that should be spent on patient care. And who is auditing these organisations?
The whole system appears open to fraud and financial abuse as financial accounts are not available to the public, unlike almost every other public body.

Tom Mac

Position
Retired,
Comment date
14 October 2021

I was amazed to hear on the TV today, the Minister of Health being blammed for spreading disatisfaction with GPs.

I personally warned my GP Practice many weeks ago that the public where falling out of love with GPs whom they previously looked upon with respect. I did not dream up this message; literally every person I talked to asked the same questions; where have the GPs disappeared to and why can I not get an appointment ?

I was also amazed to hear a GP state that all GPs were snowed under with work and appointments. How can that be true.?
Before Covid the car park at my GP Practice was always full to the brim and one often had to park on the access roads. When you got to the waiting room it was inevitably full and one often had to stand until called. At no time since Covid has their car park been than one third full and the last time I got as far as the waiting room, there was only one other patient waiting.

If you want an appointment you must be ready poised over the phone at their opening time and re-dial as needed every few seconds just to get into the queue. Only to have to listen to basic messages we all learned a year ago and then only to be told.... "We no longer give out face to face appointments".

Sorry but GP Practices are no longer fit for purpose and GPs themselves seem to have forgotton their Duty of Care for those who supply their income.

RC

Position
GP,
Comment date
12 October 2021

This is an incredibly useful article, thank you for making it. I've learnt quite a bit from it. Reading the rest of the comments is pretty interesting, because it signals the power of the media in increasing the negativity towards healthcare professionals. We as humans hold onto negative experiences & news much more than positive ones.

My hope for the general population is that they read and collate information from a variety of accurate sources (not the daily mail...!) and note that this situation almost mirrors that of the petrol crisis - supply has actually increased (GPs are offering 30% more appointments compared to 2019) but the demand outstrips this. We need to ask why, with our expanding and more elderly population, and the wave of GPs about to retire, this wasn't a government focus a decade or more ago. It takes at least 10 years to train a GP from medical school to GP training. Please consider lobbying your MPs and focusing on pressuring our elected government to work on this because the situation will not improve much otherwise. We're all in this together.

R Burroughs

Position
Retired,
Organisation
member of the public
Comment date
08 October 2021

I live in Shrewsbury coverd by the worst hospltals in the contry , Both hospitals are under special measures by NHS England and being investigated by the Police . Trying to get a appointment with my GP is almost impossable. One reason is that none of the Senior partners have been working in the practic for a long period leaving the work load to fall on locoms. The local hospital have been blaming GP as the reason for so many people turning up at A&E .Now the hospital have started telephone consultations not face to face .Is this tit for tat or plain stupidity

George Kingston

Position
retired mechanical engineer,
Comment date
04 October 2021

GP's do not have a formal regulatory body that demands them to produce results for what they do. The result is they get paid for doing nothing.Boris Johonson need's to act on this and make GP's answerable to an authoritative body. "no work ,no pay.--well Boris?

W. Richardson

Position
Retired senior manager,
Comment date
02 October 2021

GPS are letting down their patients. I have tried on 3 occasions to get an appointment to discuss my prescribed medication. 1st call at 8:10 am , this lasted 45 minutes before it was answered. I was told there were no appointments left and to ring again at 8:00 am the following day. I did this and the call was answered after 20 minutes but again all the appointments had gone. I explained the problem was due to my diabetes and asked what I should do. I was told to ring again at 8:00am but to wait two days as both doctors dealing with diabetes were off. I rang two days later but gave up after waiting 40 minutes for someone to answer.
Surely these gps are NOT providing any service and should have some funding withdrawn. They obviously have too many patients and should be investigated as to why they are unable to provide a basic service

Marcus Taylor

Position
Director,
Organisation
Health and Social Care support services
Comment date
18 September 2021

The answer to funding and capacity issues in general practice is staring us in the face with the model used for dentistry where you pay for all basic services unless under 16, pregnant or those with certain disability. All can opt for more expensive private treatment. This model is directly transferable. Short term public would of course shift to visiting A+E but this is solvable by a tougher triage system at reception. Good example recently of a family friend on holiday who twisted ankle badly and went to A+E that refused to see her and instructed her to wait for minor injuries unit the following week. We need more of that. There will be a cry about National Insurance etc and ‘paying twice’ but anyone who thinks that NI contributions are ringfenced must still believe in the tooth fairy.

Danny O'Leary

Position
Retired,
Organisation
Business Owner
Comment date
15 September 2021

I ended up on this Site/Page whilst trying to find out how GP surgeries are funded and operated so that I might be able to understand why it is almost impossible to get a face to face appointment with a GP. Using the excuse that they are just trying to protect the public and their staff just does not wash any more. Seeing sick people is what they signed up for.
While doing this I have been listening to the Jeremy Kyle radio show which strangely enough is discussing the very same thing. I could not believe my ears when I listened to the { not one but multiple cases } of people who have had a loved one not able to get a face to face appointment with there GP and been palmed off with a telephone consultation with a Doctor who does not know their history or a nurse or receptionist. And then gone on to die from stage 4 cancer. What the hell is happening in this country. I can not remember a time in my life when things were as bad as they are now with the Health Services. We can't keep blaming everything on the covid virus. Something needs to be done about this as a matter of urgency.

Linda

Position
Retired,
Organisation
GP's
Comment date
15 September 2021

We are mostly double vaccinated, but GP's still don't want to see you, even when my GP phoned me yesterday he couldn't get if the phone fast enough. I used to have great respect
For GP's. Not any more. Covid has been used to change the structure of how GP's work, it's a total scandal, people have died because they haven't been able to see a GP. When will the Government put a stop to this, or maybe they don't care either, it's gone on for far to long.
I fully agree with vaccinations, most people have had their vaccinations, what are the GP's scared of, if the vaccines work why won't GP's see you, a question that needs answering don't you think. The most unbelievable part of this is that last year my husband and myself were seen
Face to face by a GP who gave us our flu jabs, I wonder why. Gone are the days when GP's gave
The reassurance and time that was needed to keep their patients safe and healthy.

Evelyn

Position
Retired,
Comment date
11 September 2021

The phrase that comes to mind is to many chiefs and not many indians. Ive heard of partients going to A and E rather than their GPs. ( costs to their GPs is approximately £200.) As for appointments not being kept, why not reverse back to the queue system. It would certainly get most in need of help attended to. I remember the day when the doctor made my medicine in the surgery. I was 8 when NHS came in and I'm grateful for it. But back to my original quote " too many Chiefs"

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