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General practitioners and the new contract: promoting better health through financial incentives
Health Policy, 25 (1993) 39-50 0 1993 Elsevier Scientific Publishers
39 Ireland
Ltd. All rights reserved.
1168-8510/93/$06.00
HPE 00554
General practitioners and the new contract: promoting better health through financial incentives David Hughes Health Economics Research Unit, Department of Public Health, University of Aberdeen, Aberdeen, UK and Department of Social Sciences, City University, London, UK Accepted I3 April 1993
In this paper the changes in payment of general practitioners in the UK, introduced in the 1990 contract, are described in detail. The effects of the changes on the structure of general practitioners’ incomes is discussed. More emphasis on capitation payments may increase preventive activity in general practice, but, depending on the level at which the capitation fee is set, could lead to shifting of patients to other sectors in the health care economy. Target payments appear to have been successful in increasing the numbers of smears taken. It is clear that doctors respond to financial incentives, but what is not clear is whether their responses will always be in the way intended or lead to more efficient practice. General practice; GP contract; Financial incentives; Efftciency
Introduction In 1990, the UK Government introduced the most radical reforms to the funding and organisation of general medical practice since the Pilkington Commission on doctors’ and dentists’ remuneration in 1960 [l]. Previous reorganisations have not been so comprehensive, or explicit in their intentions. The 1990 contract [2] is intended to make general practice more responsive to consumers’ wishes and to change the emphasis from treatment to prevention by using financial incentives. Addressfor correspondence: David Hughes, Square, LONDON, EClV OHB, UK.
Department
of Social Sciences, City University,
Northampton
40
This paper views the Government’s aims and objectives for general practice outlined in the White Paper Promoting Better Health [3]. The changes to the payment system introduced in the 1990 contract are described in detail and their affects on the structure of general practitioners’ income are discussed. The theoretical incentives provided by each of the payment methods are examined and some of the evidence regarding payment systems is reviewed. The paper concludes with a discussion of the implications of the changes for general practice and an attempt to assess whether the changes are likely to be effective in achieving the Government’s aims.
The Government’s changes and their aims The Government outlined its main aims for general practice in the White Paper Promoting Better Health [3], hereafter referred to as the White Paper. These White Paper reforms are consistent with the wider changes introduced for the National Health Service in Workingfor Patients [4] which attempted to secure two broad aims: to provide patients with better health care and greater choice, and to give greater satisfaction and rewards for those working in the NHS who respond to local needs. There are two main thrusts to the new contract for general practitioners. Firstly, they have tried to promote competition between the providers of Family Practitioner Services by allowing advertising in general practice and by ensuring consumers have easier access to information regarding services provided. Secondly, the Government has linked the remuneration of general practitioners (GPs) more directly to their level of performance. In addition to these changes the concept of general practitioner fundholders (general practitioners with their own NHS budgets) was introduced in Working fir Patients. The bulk of this paper concentrates on the changes to the remuneration system and the effect that these will have on general practitioners’ behaviour. Whether the changes are likely to achieve the policy aims that the Government envisaged and whether financial incentives are, in general, an effective means of influencing general practitioners, are assessed. First, however, it is important to consider what the Government sees as the main aims of such changes. The extent to which the incentives general practitioner fundholders face differ from those of non-fundholding general practitioners is addressed by Ratcliffe, in this issue [5]. One of the specific aims of the Government in the White Paper was to improve prevention and control of disease. The Government claimed that health standards in general had been improving and that much of this is due to the progress made in preventing and controlling disease. However, it suggested that there is still much that could be done to reduce the incidence of disease and that it intend general practitioners to play a central role in contributing to health promotion [3, pp. 2-31. The intention was to shift the emphasis from treatment of illness towards
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health promotion. To this end the following were introduced: targets levels of coverage for vaccination, immunisation and cervical cancer screening; health promotion sessions in general practice; and regular health checks for particular sections of the community. General practitioners have been given tinancial incentives to encourage them to undertake these activities. (The main changes to general practitioners’ terms of service and remuneration system are outlined in the next section.) The success of these changes should be judged on whether they achieve the objectives of increasing the levels of immunisation, screening and general health promotional activities, whilst also improving value for money and efficiency [3, pp. l-21. The Government regards prevention through general practice as a cost-effective form of health care. The remainder of this paper concentrates on the encouragement given to general practitioners to achieve these objectives through the payment system, and whether such encouragement is likely to be successful.
The 1990 contract for general practitioners: changes to the payment system Prior to the 1990 contract there had been little change in general practitioners’ contractual responsibilities or remuneration system since the inception of the National Health Service in 1948. The only exception was the change in 1960 from a purely capitation based system to a mixed capitation and fee/allowance based system. The changes introduced in the new contract were intended to adjust the mix between capitation payments, fees and allowances, and to introduce new methods of payment. The intention was to make general practitioners’ contracts more sensitive to the range of services provided and to encourage the specific health care objectives, outlined above, to be met [3, p. 121. Prior to the implementation of the 1990 contract, general practitioners’ income was composed of three main elements: capitation payments; practice and other allowances; and fee-per-item payments. Practice allowances consisted of three main components: basic allowances paid to all general practitioners with over 1000 patients on their list; group practice allowances for practices with three or more partners; and supplementary allowances for out of hours care. Other allowances were paid for seniority, post-graduate training, and for practising in certain areas (e.g. inner city areas). Capitation fees were paid for each patient on the general practitioner’s list in three ‘bands’ - under 65 year olds, 65-74 year olds and 75 years and over. Per-item fees were paid for each course of treatment carried out for services such as maternity care, contraceptive .services, vaccination and immunisation and cervical cytologies. The main changes to the general practitioners’ contract involved new obligations, alterations to the nature of certain payments with the introduction of some new payment methods, and the abolition of some payments.
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The group practice allowance, vocational training allowance, supplementary basic practice allowance and supplementary capitation payments (i.e. payments made with respect to every patient on a general practitioner’s list, except the first 1000) were all abolished. Per-item payments for carrying out cervical cytologies and childhood immunisations were replaced by target payments. Seniority payments, basic practice allowances and night visit fees were also modified. Per-item fees were retained for certain services, such as family planning services, treatment of temporary residents and emergency cases. A summary of the main changes concerning each method of payment is presented in the remainder of this section. Capitation fees The changes were intended to ensure that, on average, at least 60% of general practitioners’ income is derived from capitation payments, compared with 46% before the introduction of the new contract. The Government’s intention in placing a greater emphasis on capitation in the remuneration system was to ‘reward general practitioners who give a high priority to attracting and keeping patients by providing a high quality, comprehensive service’ [2, p. 81. The increase in capitation income was achieved by three main changes. First, capitation payments for patients aged 75 years and over were increased in recognition of the extra duties expected, namely, annual health checks for those aged over 75 - comprising the offer of a home visit and an assessment of physical, psychological and social functioning. This change is discussed more fully by Shackley and Donald, in this issue [6]. Second, a new capitation fee was introduced for patients under 5 years of age to be paid to general practitioners who provide child health surveillance services. These services include monitoring the child’s health, well being and development and calling the child for examinations at specified times (agreed with the District Health Authority/Health Board). Third, a capitation supplement is payable to general practitioners who carry out certain specified procedures for newly registered patients, including basic background information: medical, family and social history and a simple examination (height, weight, blood pressure and urine analysis). Therefore the increase in the capitation payments is intended to compensate for the extra duties that general practitioners are expected to undertake, and hence the extra workload this represents. Target payments Target payments were introduced to encourage general practitioners to achieve higher levels of cover for childhood immunisation and for screening for cancer of the cervix, in line with the specific health care objectives outlined in the White Paper [4, p. lo]. General practitioners receive a lump sum payment for achieving the ‘target’ levels. For immunisation a payment is made to general practitioners
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who achieve 70% coverage of their eligible population, with payment if they reach 90% coverage. For cervical cancer screening levels are 50% and 80%. The wider questions raised, such as why the target levels for the of cervical cytology and immunisation services have been set at chosen, are interesting, but beyond the scope of this paper.
a higher the target provision the levels
Sessional payments A lump sum fee was introduced, payable to general practitioners who provide certain ‘health promotion’ clinics. Examples of clinics which attract this payment are well person, diabetes, heart disease, anti-smoking, alcohol control, diet and stress management clinics [2]. However, the government has recently announced changes to the nature of these payments [7]. The definition of health promotion has been tightened to refer to specific programmes of preventive primary care. Health promotion activities will, from July 1st 1993, receive an annual lump sum payment. These programmes are aimed specifically at reducing the mortality and morbidity of patients with hypertension, coronary heart disease (CHD) and strokes and reducing the incidence of CHD and strokes. To qualify, general practitioners must compile a minimum amount of information about a target percentage of the population and provide care for those considered to be at risk. The payments are in three bands depending on the level of intervention, ranging from advice on smoking cessation to lifestyle intervention. Lump sum payments are also available for the management of chronic diseases, specifically diabetes and asthma. The new payments are effectively target payments. Allowances The group practice allowance and supplementary practice allowance were both abolished and the income released redistributed through capitation payments. The Government believed that the group allowance had largely served its purpose since group practice is now ‘an established feature of the family doctor service’ [2, p .9]. However the change in emphasis from allowances to capitation payments also reflected a more fundamental shift in policy; that is to see general practitioners’ income more directly related to the list size, and to the services provided [p. 91.
The structure of general practitioners’ income The central aim of the changes introduced in the new contract were to ‘make the terms of service more specific to reflect clearly the requirements of good general practice’ and to make the remuneration system more ‘performance related’ [2, p 51. The relative contributions to general practitioners’ income, pre and post
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contract, are shown below in Table 1. It appears that the new contract has been successful in changing the emphasis of the payment system. The proportion of income derived from capitation payments increased by 13% from 46% in 1989/90 to 59% in 1990/91, in line with Government intentions. Allowances accounted for 19% of income in 1990/91 compared with 42% in the last year of the old contract (1989/90). Per-item fees account for roughly the same proportion of total income pre and post new contract. Target payments and sessional fees together account for 11% of general practitioners’ income. In the next section the theoretical incentives that each element of the payment system presents will be examined and some of the existing evidence regarding the effect of different methods of payment will be reviewed.
Incentives and payment systems: theory and evidence Capitation payments It has been suggested that one of main advantages of the capitation method of payment is that it provides general practitioners with an incentive to encourage patients to join their list [9]. Furthermore, general practitioners have an incentive to retain patients on their list and therefore be responsive to patients’ wishes. Competition between practices in other forms something which the Government is actively encouraging through permitting advertising and making it easier to change practices - will strengthen the financial incentives and encourage their operation. However, general practitioners may have an incentive to attract only low-cost patients (i.e. those with a low risk of disease/illness). The capitation payments are only adjusted very crudely for the likely burden to the practice of providing care (the adjustment is made through the capitation age bands
Table 1 Composition of general practitioners’income
Capitation Allowances Per-item fees Sessional payments Target payments
Pre 1990 contract (1989/1990) (“h)
Post 1990 contract (1990/1991) (%)
46 42 13 -
59 19 11 3 8
Source: Scottish Home and Health Department [8]
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mentioned earlier). However, this incentive depends on the cost to the practice of providing care to the patient and the level at which the capitation fee is set. Since the increase in capitation fees has been accompanied by additional contractual obligations, it is not immediately apparent whether the extra payments will compensate for the increased workload - and therefore whether the payments will provide an incentive to general practitioners to attract patients to their lists. Furthermore what patients wish to see their general practitioner providing, and what will actually improve their health, may differ, perhaps substantially. It is often the asymmetry of information that exists between doctor and patient that necessitates the doctor-patient interaction. It may be that patients are looking to doctors to make decisions on their behalf. Therefore it is not obvious that taking full account of patients’ wishes is necessarily and always a good thing [lO,l I]. Another claimed advantage of the capitation system is that it is consistent with the independent status of the general practitioner [12]. That is, it provides minimal interference with medical judgement. Furthermore, potentially at least, it provides a link between the income of the general practitioner and his or her workload - represented by the list size. However general practitioners may respond to a larger list size by reducing the length of consultations. Therefore this link may not prove particularly strong. Indeed one of the criticisms of the capitation-based system is that it may encourage general practitioners to minimise their own input into consultations by reducing the length of consultations, prescribing more, or referring more patients to hospital. A study by Krasnik et al. [13] in Denmark, which investigated the effects on general practitioners’ activities of changing from a wholly capitation based payment system to a mixed fee-per-item and capitation system, found evidence to support this. They concluded from their study that general practitioners whose remuneration was not directly linked to workload (i.e. capitation based) were more likely to refer patients to the hospital sector. It should also be noted that the incentive for general practitioners to keep workload to a minimum with the capitation system could manifest itself through increased preventive activities, as income is not dependent on the number of consultations. Whether this represents more efficient practice is unknown. But, since encouraging the increased involvement of general practitioners in prevention and health promotion is one of the aims of the new contract, the Government’s emphasis on capitation payments may be seen as consistent with this objective. More generally, however, Hughes and Yule [14] have suggested that general practitioners may find it less easy to respond to incentives linked to list size since they may only have limited control over the number of patients on their list, at least in the short run. This questions the overall effectiveness of capitation payments as a means of influencing general practitioners’ behaviour.
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Per-item fees Per-item fees have the advantage of rewarding general practitioners according to the amount of work they carry out and can be used to encourage general practitioners to provide specific services. However, per-item fees have been criticised as a method of payment because they may encourage general practitioners to recommend services to patients that will have little or no beneficial impact on the health of the patient, but will remunerate the general practitioner. The extent to which physicians induce demand for their services has received attention in several North American studies. It has been concluded that much of the evidence is ambiguous since it is difficult to disentangle the various influences on demand and supply to test the hypothesis of inducement [ 151. However some of the North American studies appear to have found stronger evidence of inducement. For example, Rice [16] found that decreasing the reimbursement rate by one percent resulted in an increase of 0.61% in service intensity and a one per cent decrease in the reimbursement rate for surgical services resulted in a 0.15% increase in service intensity. This suggests that physicians respond to changes in fee levels. Culyer [ 171in a similar review of such studies concluded that ‘it seems fairly clear that fee-for-service methods result in both more active treatment and higher incomes for doctors’ [p. 301. Culyer noted that the effect of per-item fees on general practitioners’ behaviour has not received much attention in the UK, or Europe in general, stating that ‘no evidence for Europe exists that is comparable to that for North America’ [p. 301. Nonetheless it has been suggested that the existence of per-item payments for cervical cytology in the UK was one of the influences leading general practitioners to increase by over 400% the total number of smears they carried out between 1966 and 1980 [ 181. In reaching this conclusion the authors did not carry out any statistical analyses. Recent research by Hughes and Yule [19] employed econometric techniques to examine the impact that per-item payments had on general practitioners’ behaviour in the UK over the period 1967-1989. This study considered two services (cervical cytology and maternity care) and incorporated a number of determinants of the level of service provision in addition to fees, including: number of general practitioners, eligible population, and births. They found little evidence to suggest that changes in per-item fees have had an effect on the number of treatments provided by general practitioners. It should however be noted that in a system where the fees are set centrally, as in the UK, the incentive to provide treatments (or induce demand) depends on the level at which fees are set. If fees are set at such a level that they fail to compensate the general practitioner for the cost of providing the service there may be little incentive to provide the service’. ‘The situation is further complicated by the existence of practice allowances and capitation payments such that the general practitioner does not rely solely on fees for their income.
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Furthermore, providing an incentive for general practitioners to provide services should not be considered as bad per se. If the public policy goal is to provide as much of a service as possible (e.g. to maximise the numbers of cervical cytologies or immunisations done) then fees may be the best way of encouraging general practitioners to do this. However this crucially depends on the extent to which general practitioners respond to financial incentives. Target payments and sessional fees
Target payments have the advantage of remunerating general practitioners directly in line with their workload based on their success in achieving particular levels of services. As with per-item fees, they can be used to encourage general practitioners to full3 public policy goals. Such payments have the disadvantage that if a general practitioner cannot reach the ‘target’ level the incentive is not to provide any of that form of care at all. Furthermore once the target level is reached there is no incentive to provide any more care over and above this level, which may lead to individuals who could benefit from a service not being catered for. For example, a target level for cervical cytologies set at 80% requires that general practitioners provide smears for 80% of their list within a predetermined population group. However it is not obvious that the 20% they do not screen would not benefit from the service, or that the 80% they do screen are those who would benefit most. Therefore the concept of targets and the levels chosen for targets are by no means unproblematical. Furthermore whilst the average coverage of the population may be high, this may mask geographical inequities. In some areas it may be much more difficult or even impossible for general practitioners to reach the lower target. Thus there is no incentive to provide the service since they will not be paid for any services provided below the lower target level. Consequently targets set in this way may increase variation between general practitioners and between regions2. Since they are a new form of payment there is, as yet, little evidence regarding the impact of target payments. However, there is some evidence to suggest that they have been effective in increasing the number of cervical cytologies performed. Hughes and Yule [19], using the model they developed to analyse the impact of fees in the period 1967-89, estimated the impact of the introduction of target payments. They found that in the first year of target payments there was a 50% increase in the number of cervical cytologies carried out by general practitioners relative to the level they estimated would have been performed had per-item payments been retained. However, they suggest that these initial findings should be treated with caution since they may reflect a ‘settling in’ period where general practitioners are finding out which target levels they can reach and which they cannot, and the costs to 21nitial evidence in Scotland supports this. The percentage of general practitioners reaching the upper target for cervical cytology range from 100% in the Borders region to 20% in Lanarkshire. The percentage of general practitioners not achieving the 50% lower target level was almost 28% in Greater Glasgow (201.
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the practice of achieving the different levels. Consequently the high levels of numbers of smears observed initially may fall in the future. Sessional fees, as with target payments, reward general practitioners directly in line with the work they carry out. However, at least in the UK where clinics which provide ‘health promotional activities’ attract sessional payments, the incentive may be to undertake ‘clinics’ where previously the work might have been carried out in ordinary consultations. Evidence from a recent study [21] suggested that significantly more patients were being seen by general practitioners in clinics after the new contract than before. Consequently the costs of providing a service may increase without any corresponding increase in health. Furthermore, sessional payments may encourage general practitioners to over-provide health promotional clinics, regardless of the impact on the health of the patients. More evidence is required on the effectiveness of such clinics. As mentioned earlier these payments will be replaced on 1 July 1993. Health promotion activities will in future attract a lump sum payment based on total list size. Eligibility requires that practices compile certain information on a target percentage of patients3, and those on the list considered to be at risk must be provided with a range of ‘health promotion interventions’, effectively making the payment a target payment. The payments, however, are not linked directly to workload. The target levels refer to information about patients and not specifically to treatments carried out. Practices with a very small number of patients considered to be at risk will receive the same payment, for a given list size, as practices with a very high number at risk. Therefore, practices with a low number of ‘at risk’ patients will have a greater incentive to register for the payment than those with a high number, since they will have a lower workload associated with health promotion but will receive the same payment. Furthermore, as with any target payment the incentive is for practices to achieve the minimum level of coverage and no more. More importantly perhaps, the payments are not linked to outcome. The targets do not refer to reduction in the number of smokers or incidence of CHD, they refer indirectly to process, and directly to information. Furthermore, the incentive to register for the payment is inversely related to the number of patients considered to be at risk on a general practitioner’s list. As with clinics, more evidence regarding the effectiveness of advice and lifestyle intervention programmes is required before such a policy can be fully evaluated. Allowances Allowances are paid for fulfilling certain requirements, such as providing a minimum number of surgery hours, or operating with a certain minimum practice list size. They have the advantage of providing a stable income and can encourage general practitioners to fulfil certain policy aims (such as ‘Although minimum levels of coverage initially will not be included in the Statement of Fees and Allowances ‘in recognition of practices’ different starting points’ [7].
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encouraging group practice). They have the potential disadvantage of failing to give general practitioners a direct incentive to respond to patients’ wishes. Furthermore, as with capitation payments, since payment is not linked to workload the incentive may be for general practitioners to minimise their own workload. Although, similar to capitation payments, they may be seen to provide minimal interference with medical judgement.
Conclusion The new contract for general practitioners has altered the payment system in an attempt to fulfil wider policy objectives. Most notably, these objectives are to increase the preventive activities of general practitioners and to increase the influence of the patient in general practice. Underlying these changes is an expectation that financial incentives are an effective means of altering general practitioners’ behaviour. The Government has changed the emphasis of the remuneration system such that capitation payments form the most substantial part of the general practitioner’s income. This is an attempt to make general practitioners more responsive to patients’ wishes. This could, as noted earlier, lead to an increase in preventive activities. But, equally, it may lead to the shifting of patients forward from general practitioners on to other sectors of the health economy. The operation of these incentives depends on the level at which fees are set and whether general practitioners consider they are being adequately compensated for the increased workload associated with the higher capitation payments. Target payments and sessional fees were introduced to encourage general practitioners to provide preventive services. The introduction of target payments appears to have been successful, at least initially, leading to an increase in the number of smears taken. However, the longer term effect may be increased geographical inequities in provision. The fact that sessional payments now account for 3% of general practitioners’ total income could be interpreted as some indication of success in their implementation - but nothing is known about their success in terms of efficiency. It is not immediately apparent that general practitioners have an incentive to provide any extra services. Rather, the incentive is to reorganise existing ones such that they receive a sessional payment for providing them. Crucially, the success of the changes depends on the way general practitioners respond to financial incentives. Some international evidence suggests that doctors respond to changes in fees and payment systems. However, it is not clear whether the response to changes will be in the way intended. Furthermore it may be that the major restructuring of the system, as has happened in the UK, may have more of an impact than incremental changes. The study by Hughes and Yule [19] lends support to this theory, i.e. the changes in per-item payments prior to the implementation of the new contract appeared to have had no real impact, whereas the substitution of target payments for per-item fees appears to have had a substantial impact. The
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study in Denmark by Krasnik et al. [ 131 also supports this interpretation, although it should be noted that the UK system differs from the North American and other European systems. Therefore caution must be exercised when making inferences from studies based in other countries. Until more is known about the incentive effects of payment systems, the impact of policies which alter general practitioners’ remuneration in an attempt to fulfil policy objectives will be difficult to predict. The changes introduced in the new contract will therefore have to be closely monitored to determine their impact on general practice and whether they have been successful in encouraging general practitioners to achieve wider policy goals. References
14 1s 16 17 18 19 20 21
Pilkington Commission, Royal Commission on Doctors and Dentists Remuneration, 1957-60 Report, HMSO, London, 1960. Department of Health, General Practice in the National Health Service: The 1990 Contract, HMSO, London, 1989. Secretaries of State for Social Services, Wales, Northern Ireland and Scotland, Promoting Better Health, HMSO, London, 1987. Secretaries of State for Health, Wales, Northern Ireland and Scotland, Working for Patients, HMSO, London, 1989. Ratcliffe, J., Extra-market incentives in the new NHS, Health Policy, 25 (1993) 169-183. Shackley, P. and Donald S., Prevention in primary care: the annual assessment of elderly people, Health Policy, 25 (1993) 51-62. Scottish Oftice, NHS Circular PCA (M), 1993. Scottish Home and Health Department, Scottish Health Service Costs, Scottish Home and Health Department, Edinburgh, 1990-91. Donaldson, C. and Gerard, K., Paying general practitioners: shedding light on the review of health services, Journal of Royal College of Genera1 Practitioners, (1989) 114-I 17. Lupton, D., Donaldson, C. and Lloyd, P., Caveat emptor or blissful ignorance? Patients and the consumerist ethos, Social Science and Medicine, 33 (1991) 559-568. Donaldson, C., Lloyd, P. and Lupton, D., Primary health care amongst elderly Australians, Age and Ageing, 20 (1991) 280-286. Glass, N., The economics of general practice in England, British Journal of Preventive and Social Medicine, 28 (1974) 203-209. Krasnik, A., Groenewegen, P., Pedersen, P., Scholten, P.V, Mooney, G., Gottshau, A., Flierman, H. and Damsgard, M., Changing remuneration systems: effects on activity in general practice, British Medical Journal, 300 (1990) 1698-1701. Hughes, D. and Yule, B., Incentives and the remuneration of general practitioners, HERU Discussion Paper, University of Aberdeen 02/91, 1991. Donaldson, C. and Gerard, K., Economics of Health care Financing: the Visible Hand, Macmillan, Basingstoke, UK, 1993. Rice, T.H., 1983, The impact of changing Medicare reimbursement rates on physician induced demand, Medical Care, 21 (8) (1983) 803-815. Culyer, A.J., Cost containment in Europe, Health Care Financing Review, Annual Supplement, (1989) 21-32. Horder, J., Bosanquet, N. and Stocking, B., Ways of influencing the behaviour of general practitioners, Journal of the Royal College of General Practitioners, 36 (1986) 517-521. Hughes, D. and Yule, B., The effect of per-item payments on the behaviour of general practitioners, Journal of Health Economics, I I (4) (1993) 413-437. Chief Medical Otlicer, Health in Scotland, HMSO, Edinburgh, 1990. Hannay, D., Usherwood, T. and Platts, M., Workload of general practitioners before and after the new contract, British Medical Journal, 304 (1992) 615-618.
39 Ireland
Ltd. All rights reserved.
1168-8510/93/$06.00
HPE 00554
General practitioners and the new contract: promoting better health through financial incentives David Hughes Health Economics Research Unit, Department of Public Health, University of Aberdeen, Aberdeen, UK and Department of Social Sciences, City University, London, UK Accepted I3 April 1993
In this paper the changes in payment of general practitioners in the UK, introduced in the 1990 contract, are described in detail. The effects of the changes on the structure of general practitioners’ incomes is discussed. More emphasis on capitation payments may increase preventive activity in general practice, but, depending on the level at which the capitation fee is set, could lead to shifting of patients to other sectors in the health care economy. Target payments appear to have been successful in increasing the numbers of smears taken. It is clear that doctors respond to financial incentives, but what is not clear is whether their responses will always be in the way intended or lead to more efficient practice. General practice; GP contract; Financial incentives; Efftciency
Introduction In 1990, the UK Government introduced the most radical reforms to the funding and organisation of general medical practice since the Pilkington Commission on doctors’ and dentists’ remuneration in 1960 [l]. Previous reorganisations have not been so comprehensive, or explicit in their intentions. The 1990 contract [2] is intended to make general practice more responsive to consumers’ wishes and to change the emphasis from treatment to prevention by using financial incentives. Addressfor correspondence: David Hughes, Square, LONDON, EClV OHB, UK.
Department
of Social Sciences, City University,
Northampton
40
This paper views the Government’s aims and objectives for general practice outlined in the White Paper Promoting Better Health [3]. The changes to the payment system introduced in the 1990 contract are described in detail and their affects on the structure of general practitioners’ income are discussed. The theoretical incentives provided by each of the payment methods are examined and some of the evidence regarding payment systems is reviewed. The paper concludes with a discussion of the implications of the changes for general practice and an attempt to assess whether the changes are likely to be effective in achieving the Government’s aims.
The Government’s changes and their aims The Government outlined its main aims for general practice in the White Paper Promoting Better Health [3], hereafter referred to as the White Paper. These White Paper reforms are consistent with the wider changes introduced for the National Health Service in Workingfor Patients [4] which attempted to secure two broad aims: to provide patients with better health care and greater choice, and to give greater satisfaction and rewards for those working in the NHS who respond to local needs. There are two main thrusts to the new contract for general practitioners. Firstly, they have tried to promote competition between the providers of Family Practitioner Services by allowing advertising in general practice and by ensuring consumers have easier access to information regarding services provided. Secondly, the Government has linked the remuneration of general practitioners (GPs) more directly to their level of performance. In addition to these changes the concept of general practitioner fundholders (general practitioners with their own NHS budgets) was introduced in Working fir Patients. The bulk of this paper concentrates on the changes to the remuneration system and the effect that these will have on general practitioners’ behaviour. Whether the changes are likely to achieve the policy aims that the Government envisaged and whether financial incentives are, in general, an effective means of influencing general practitioners, are assessed. First, however, it is important to consider what the Government sees as the main aims of such changes. The extent to which the incentives general practitioner fundholders face differ from those of non-fundholding general practitioners is addressed by Ratcliffe, in this issue [5]. One of the specific aims of the Government in the White Paper was to improve prevention and control of disease. The Government claimed that health standards in general had been improving and that much of this is due to the progress made in preventing and controlling disease. However, it suggested that there is still much that could be done to reduce the incidence of disease and that it intend general practitioners to play a central role in contributing to health promotion [3, pp. 2-31. The intention was to shift the emphasis from treatment of illness towards
41
health promotion. To this end the following were introduced: targets levels of coverage for vaccination, immunisation and cervical cancer screening; health promotion sessions in general practice; and regular health checks for particular sections of the community. General practitioners have been given tinancial incentives to encourage them to undertake these activities. (The main changes to general practitioners’ terms of service and remuneration system are outlined in the next section.) The success of these changes should be judged on whether they achieve the objectives of increasing the levels of immunisation, screening and general health promotional activities, whilst also improving value for money and efficiency [3, pp. l-21. The Government regards prevention through general practice as a cost-effective form of health care. The remainder of this paper concentrates on the encouragement given to general practitioners to achieve these objectives through the payment system, and whether such encouragement is likely to be successful.
The 1990 contract for general practitioners: changes to the payment system Prior to the 1990 contract there had been little change in general practitioners’ contractual responsibilities or remuneration system since the inception of the National Health Service in 1948. The only exception was the change in 1960 from a purely capitation based system to a mixed capitation and fee/allowance based system. The changes introduced in the new contract were intended to adjust the mix between capitation payments, fees and allowances, and to introduce new methods of payment. The intention was to make general practitioners’ contracts more sensitive to the range of services provided and to encourage the specific health care objectives, outlined above, to be met [3, p. 121. Prior to the implementation of the 1990 contract, general practitioners’ income was composed of three main elements: capitation payments; practice and other allowances; and fee-per-item payments. Practice allowances consisted of three main components: basic allowances paid to all general practitioners with over 1000 patients on their list; group practice allowances for practices with three or more partners; and supplementary allowances for out of hours care. Other allowances were paid for seniority, post-graduate training, and for practising in certain areas (e.g. inner city areas). Capitation fees were paid for each patient on the general practitioner’s list in three ‘bands’ - under 65 year olds, 65-74 year olds and 75 years and over. Per-item fees were paid for each course of treatment carried out for services such as maternity care, contraceptive .services, vaccination and immunisation and cervical cytologies. The main changes to the general practitioners’ contract involved new obligations, alterations to the nature of certain payments with the introduction of some new payment methods, and the abolition of some payments.
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The group practice allowance, vocational training allowance, supplementary basic practice allowance and supplementary capitation payments (i.e. payments made with respect to every patient on a general practitioner’s list, except the first 1000) were all abolished. Per-item payments for carrying out cervical cytologies and childhood immunisations were replaced by target payments. Seniority payments, basic practice allowances and night visit fees were also modified. Per-item fees were retained for certain services, such as family planning services, treatment of temporary residents and emergency cases. A summary of the main changes concerning each method of payment is presented in the remainder of this section. Capitation fees The changes were intended to ensure that, on average, at least 60% of general practitioners’ income is derived from capitation payments, compared with 46% before the introduction of the new contract. The Government’s intention in placing a greater emphasis on capitation in the remuneration system was to ‘reward general practitioners who give a high priority to attracting and keeping patients by providing a high quality, comprehensive service’ [2, p. 81. The increase in capitation income was achieved by three main changes. First, capitation payments for patients aged 75 years and over were increased in recognition of the extra duties expected, namely, annual health checks for those aged over 75 - comprising the offer of a home visit and an assessment of physical, psychological and social functioning. This change is discussed more fully by Shackley and Donald, in this issue [6]. Second, a new capitation fee was introduced for patients under 5 years of age to be paid to general practitioners who provide child health surveillance services. These services include monitoring the child’s health, well being and development and calling the child for examinations at specified times (agreed with the District Health Authority/Health Board). Third, a capitation supplement is payable to general practitioners who carry out certain specified procedures for newly registered patients, including basic background information: medical, family and social history and a simple examination (height, weight, blood pressure and urine analysis). Therefore the increase in the capitation payments is intended to compensate for the extra duties that general practitioners are expected to undertake, and hence the extra workload this represents. Target payments Target payments were introduced to encourage general practitioners to achieve higher levels of cover for childhood immunisation and for screening for cancer of the cervix, in line with the specific health care objectives outlined in the White Paper [4, p. lo]. General practitioners receive a lump sum payment for achieving the ‘target’ levels. For immunisation a payment is made to general practitioners
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who achieve 70% coverage of their eligible population, with payment if they reach 90% coverage. For cervical cancer screening levels are 50% and 80%. The wider questions raised, such as why the target levels for the of cervical cytology and immunisation services have been set at chosen, are interesting, but beyond the scope of this paper.
a higher the target provision the levels
Sessional payments A lump sum fee was introduced, payable to general practitioners who provide certain ‘health promotion’ clinics. Examples of clinics which attract this payment are well person, diabetes, heart disease, anti-smoking, alcohol control, diet and stress management clinics [2]. However, the government has recently announced changes to the nature of these payments [7]. The definition of health promotion has been tightened to refer to specific programmes of preventive primary care. Health promotion activities will, from July 1st 1993, receive an annual lump sum payment. These programmes are aimed specifically at reducing the mortality and morbidity of patients with hypertension, coronary heart disease (CHD) and strokes and reducing the incidence of CHD and strokes. To qualify, general practitioners must compile a minimum amount of information about a target percentage of the population and provide care for those considered to be at risk. The payments are in three bands depending on the level of intervention, ranging from advice on smoking cessation to lifestyle intervention. Lump sum payments are also available for the management of chronic diseases, specifically diabetes and asthma. The new payments are effectively target payments. Allowances The group practice allowance and supplementary practice allowance were both abolished and the income released redistributed through capitation payments. The Government believed that the group allowance had largely served its purpose since group practice is now ‘an established feature of the family doctor service’ [2, p .9]. However the change in emphasis from allowances to capitation payments also reflected a more fundamental shift in policy; that is to see general practitioners’ income more directly related to the list size, and to the services provided [p. 91.
The structure of general practitioners’ income The central aim of the changes introduced in the new contract were to ‘make the terms of service more specific to reflect clearly the requirements of good general practice’ and to make the remuneration system more ‘performance related’ [2, p 51. The relative contributions to general practitioners’ income, pre and post
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contract, are shown below in Table 1. It appears that the new contract has been successful in changing the emphasis of the payment system. The proportion of income derived from capitation payments increased by 13% from 46% in 1989/90 to 59% in 1990/91, in line with Government intentions. Allowances accounted for 19% of income in 1990/91 compared with 42% in the last year of the old contract (1989/90). Per-item fees account for roughly the same proportion of total income pre and post new contract. Target payments and sessional fees together account for 11% of general practitioners’ income. In the next section the theoretical incentives that each element of the payment system presents will be examined and some of the existing evidence regarding the effect of different methods of payment will be reviewed.
Incentives and payment systems: theory and evidence Capitation payments It has been suggested that one of main advantages of the capitation method of payment is that it provides general practitioners with an incentive to encourage patients to join their list [9]. Furthermore, general practitioners have an incentive to retain patients on their list and therefore be responsive to patients’ wishes. Competition between practices in other forms something which the Government is actively encouraging through permitting advertising and making it easier to change practices - will strengthen the financial incentives and encourage their operation. However, general practitioners may have an incentive to attract only low-cost patients (i.e. those with a low risk of disease/illness). The capitation payments are only adjusted very crudely for the likely burden to the practice of providing care (the adjustment is made through the capitation age bands
Table 1 Composition of general practitioners’income
Capitation Allowances Per-item fees Sessional payments Target payments
Pre 1990 contract (1989/1990) (“h)
Post 1990 contract (1990/1991) (%)
46 42 13 -
59 19 11 3 8
Source: Scottish Home and Health Department [8]
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mentioned earlier). However, this incentive depends on the cost to the practice of providing care to the patient and the level at which the capitation fee is set. Since the increase in capitation fees has been accompanied by additional contractual obligations, it is not immediately apparent whether the extra payments will compensate for the increased workload - and therefore whether the payments will provide an incentive to general practitioners to attract patients to their lists. Furthermore what patients wish to see their general practitioner providing, and what will actually improve their health, may differ, perhaps substantially. It is often the asymmetry of information that exists between doctor and patient that necessitates the doctor-patient interaction. It may be that patients are looking to doctors to make decisions on their behalf. Therefore it is not obvious that taking full account of patients’ wishes is necessarily and always a good thing [lO,l I]. Another claimed advantage of the capitation system is that it is consistent with the independent status of the general practitioner [12]. That is, it provides minimal interference with medical judgement. Furthermore, potentially at least, it provides a link between the income of the general practitioner and his or her workload - represented by the list size. However general practitioners may respond to a larger list size by reducing the length of consultations. Therefore this link may not prove particularly strong. Indeed one of the criticisms of the capitation-based system is that it may encourage general practitioners to minimise their own input into consultations by reducing the length of consultations, prescribing more, or referring more patients to hospital. A study by Krasnik et al. [13] in Denmark, which investigated the effects on general practitioners’ activities of changing from a wholly capitation based payment system to a mixed fee-per-item and capitation system, found evidence to support this. They concluded from their study that general practitioners whose remuneration was not directly linked to workload (i.e. capitation based) were more likely to refer patients to the hospital sector. It should also be noted that the incentive for general practitioners to keep workload to a minimum with the capitation system could manifest itself through increased preventive activities, as income is not dependent on the number of consultations. Whether this represents more efficient practice is unknown. But, since encouraging the increased involvement of general practitioners in prevention and health promotion is one of the aims of the new contract, the Government’s emphasis on capitation payments may be seen as consistent with this objective. More generally, however, Hughes and Yule [14] have suggested that general practitioners may find it less easy to respond to incentives linked to list size since they may only have limited control over the number of patients on their list, at least in the short run. This questions the overall effectiveness of capitation payments as a means of influencing general practitioners’ behaviour.
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Per-item fees Per-item fees have the advantage of rewarding general practitioners according to the amount of work they carry out and can be used to encourage general practitioners to provide specific services. However, per-item fees have been criticised as a method of payment because they may encourage general practitioners to recommend services to patients that will have little or no beneficial impact on the health of the patient, but will remunerate the general practitioner. The extent to which physicians induce demand for their services has received attention in several North American studies. It has been concluded that much of the evidence is ambiguous since it is difficult to disentangle the various influences on demand and supply to test the hypothesis of inducement [ 151. However some of the North American studies appear to have found stronger evidence of inducement. For example, Rice [16] found that decreasing the reimbursement rate by one percent resulted in an increase of 0.61% in service intensity and a one per cent decrease in the reimbursement rate for surgical services resulted in a 0.15% increase in service intensity. This suggests that physicians respond to changes in fee levels. Culyer [ 171in a similar review of such studies concluded that ‘it seems fairly clear that fee-for-service methods result in both more active treatment and higher incomes for doctors’ [p. 301. Culyer noted that the effect of per-item fees on general practitioners’ behaviour has not received much attention in the UK, or Europe in general, stating that ‘no evidence for Europe exists that is comparable to that for North America’ [p. 301. Nonetheless it has been suggested that the existence of per-item payments for cervical cytology in the UK was one of the influences leading general practitioners to increase by over 400% the total number of smears they carried out between 1966 and 1980 [ 181. In reaching this conclusion the authors did not carry out any statistical analyses. Recent research by Hughes and Yule [19] employed econometric techniques to examine the impact that per-item payments had on general practitioners’ behaviour in the UK over the period 1967-1989. This study considered two services (cervical cytology and maternity care) and incorporated a number of determinants of the level of service provision in addition to fees, including: number of general practitioners, eligible population, and births. They found little evidence to suggest that changes in per-item fees have had an effect on the number of treatments provided by general practitioners. It should however be noted that in a system where the fees are set centrally, as in the UK, the incentive to provide treatments (or induce demand) depends on the level at which fees are set. If fees are set at such a level that they fail to compensate the general practitioner for the cost of providing the service there may be little incentive to provide the service’. ‘The situation is further complicated by the existence of practice allowances and capitation payments such that the general practitioner does not rely solely on fees for their income.
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Furthermore, providing an incentive for general practitioners to provide services should not be considered as bad per se. If the public policy goal is to provide as much of a service as possible (e.g. to maximise the numbers of cervical cytologies or immunisations done) then fees may be the best way of encouraging general practitioners to do this. However this crucially depends on the extent to which general practitioners respond to financial incentives. Target payments and sessional fees
Target payments have the advantage of remunerating general practitioners directly in line with their workload based on their success in achieving particular levels of services. As with per-item fees, they can be used to encourage general practitioners to full3 public policy goals. Such payments have the disadvantage that if a general practitioner cannot reach the ‘target’ level the incentive is not to provide any of that form of care at all. Furthermore once the target level is reached there is no incentive to provide any more care over and above this level, which may lead to individuals who could benefit from a service not being catered for. For example, a target level for cervical cytologies set at 80% requires that general practitioners provide smears for 80% of their list within a predetermined population group. However it is not obvious that the 20% they do not screen would not benefit from the service, or that the 80% they do screen are those who would benefit most. Therefore the concept of targets and the levels chosen for targets are by no means unproblematical. Furthermore whilst the average coverage of the population may be high, this may mask geographical inequities. In some areas it may be much more difficult or even impossible for general practitioners to reach the lower target. Thus there is no incentive to provide the service since they will not be paid for any services provided below the lower target level. Consequently targets set in this way may increase variation between general practitioners and between regions2. Since they are a new form of payment there is, as yet, little evidence regarding the impact of target payments. However, there is some evidence to suggest that they have been effective in increasing the number of cervical cytologies performed. Hughes and Yule [19], using the model they developed to analyse the impact of fees in the period 1967-89, estimated the impact of the introduction of target payments. They found that in the first year of target payments there was a 50% increase in the number of cervical cytologies carried out by general practitioners relative to the level they estimated would have been performed had per-item payments been retained. However, they suggest that these initial findings should be treated with caution since they may reflect a ‘settling in’ period where general practitioners are finding out which target levels they can reach and which they cannot, and the costs to 21nitial evidence in Scotland supports this. The percentage of general practitioners reaching the upper target for cervical cytology range from 100% in the Borders region to 20% in Lanarkshire. The percentage of general practitioners not achieving the 50% lower target level was almost 28% in Greater Glasgow (201.
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the practice of achieving the different levels. Consequently the high levels of numbers of smears observed initially may fall in the future. Sessional fees, as with target payments, reward general practitioners directly in line with the work they carry out. However, at least in the UK where clinics which provide ‘health promotional activities’ attract sessional payments, the incentive may be to undertake ‘clinics’ where previously the work might have been carried out in ordinary consultations. Evidence from a recent study [21] suggested that significantly more patients were being seen by general practitioners in clinics after the new contract than before. Consequently the costs of providing a service may increase without any corresponding increase in health. Furthermore, sessional payments may encourage general practitioners to over-provide health promotional clinics, regardless of the impact on the health of the patients. More evidence is required on the effectiveness of such clinics. As mentioned earlier these payments will be replaced on 1 July 1993. Health promotion activities will in future attract a lump sum payment based on total list size. Eligibility requires that practices compile certain information on a target percentage of patients3, and those on the list considered to be at risk must be provided with a range of ‘health promotion interventions’, effectively making the payment a target payment. The payments, however, are not linked directly to workload. The target levels refer to information about patients and not specifically to treatments carried out. Practices with a very small number of patients considered to be at risk will receive the same payment, for a given list size, as practices with a very high number at risk. Therefore, practices with a low number of ‘at risk’ patients will have a greater incentive to register for the payment than those with a high number, since they will have a lower workload associated with health promotion but will receive the same payment. Furthermore, as with any target payment the incentive is for practices to achieve the minimum level of coverage and no more. More importantly perhaps, the payments are not linked to outcome. The targets do not refer to reduction in the number of smokers or incidence of CHD, they refer indirectly to process, and directly to information. Furthermore, the incentive to register for the payment is inversely related to the number of patients considered to be at risk on a general practitioner’s list. As with clinics, more evidence regarding the effectiveness of advice and lifestyle intervention programmes is required before such a policy can be fully evaluated. Allowances Allowances are paid for fulfilling certain requirements, such as providing a minimum number of surgery hours, or operating with a certain minimum practice list size. They have the advantage of providing a stable income and can encourage general practitioners to fulfil certain policy aims (such as ‘Although minimum levels of coverage initially will not be included in the Statement of Fees and Allowances ‘in recognition of practices’ different starting points’ [7].
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encouraging group practice). They have the potential disadvantage of failing to give general practitioners a direct incentive to respond to patients’ wishes. Furthermore, as with capitation payments, since payment is not linked to workload the incentive may be for general practitioners to minimise their own workload. Although, similar to capitation payments, they may be seen to provide minimal interference with medical judgement.
Conclusion The new contract for general practitioners has altered the payment system in an attempt to fulfil wider policy objectives. Most notably, these objectives are to increase the preventive activities of general practitioners and to increase the influence of the patient in general practice. Underlying these changes is an expectation that financial incentives are an effective means of altering general practitioners’ behaviour. The Government has changed the emphasis of the remuneration system such that capitation payments form the most substantial part of the general practitioner’s income. This is an attempt to make general practitioners more responsive to patients’ wishes. This could, as noted earlier, lead to an increase in preventive activities. But, equally, it may lead to the shifting of patients forward from general practitioners on to other sectors of the health economy. The operation of these incentives depends on the level at which fees are set and whether general practitioners consider they are being adequately compensated for the increased workload associated with the higher capitation payments. Target payments and sessional fees were introduced to encourage general practitioners to provide preventive services. The introduction of target payments appears to have been successful, at least initially, leading to an increase in the number of smears taken. However, the longer term effect may be increased geographical inequities in provision. The fact that sessional payments now account for 3% of general practitioners’ total income could be interpreted as some indication of success in their implementation - but nothing is known about their success in terms of efficiency. It is not immediately apparent that general practitioners have an incentive to provide any extra services. Rather, the incentive is to reorganise existing ones such that they receive a sessional payment for providing them. Crucially, the success of the changes depends on the way general practitioners respond to financial incentives. Some international evidence suggests that doctors respond to changes in fees and payment systems. However, it is not clear whether the response to changes will be in the way intended. Furthermore it may be that the major restructuring of the system, as has happened in the UK, may have more of an impact than incremental changes. The study by Hughes and Yule [19] lends support to this theory, i.e. the changes in per-item payments prior to the implementation of the new contract appeared to have had no real impact, whereas the substitution of target payments for per-item fees appears to have had a substantial impact. The
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study in Denmark by Krasnik et al. [ 131 also supports this interpretation, although it should be noted that the UK system differs from the North American and other European systems. Therefore caution must be exercised when making inferences from studies based in other countries. Until more is known about the incentive effects of payment systems, the impact of policies which alter general practitioners’ remuneration in an attempt to fulfil policy objectives will be difficult to predict. The changes introduced in the new contract will therefore have to be closely monitored to determine their impact on general practice and whether they have been successful in encouraging general practitioners to achieve wider policy goals. References
14 1s 16 17 18 19 20 21
Pilkington Commission, Royal Commission on Doctors and Dentists Remuneration, 1957-60 Report, HMSO, London, 1960. Department of Health, General Practice in the National Health Service: The 1990 Contract, HMSO, London, 1989. Secretaries of State for Social Services, Wales, Northern Ireland and Scotland, Promoting Better Health, HMSO, London, 1987. Secretaries of State for Health, Wales, Northern Ireland and Scotland, Working for Patients, HMSO, London, 1989. Ratcliffe, J., Extra-market incentives in the new NHS, Health Policy, 25 (1993) 169-183. Shackley, P. and Donald S., Prevention in primary care: the annual assessment of elderly people, Health Policy, 25 (1993) 51-62. Scottish Oftice, NHS Circular PCA (M), 1993. Scottish Home and Health Department, Scottish Health Service Costs, Scottish Home and Health Department, Edinburgh, 1990-91. Donaldson, C. and Gerard, K., Paying general practitioners: shedding light on the review of health services, Journal of Royal College of Genera1 Practitioners, (1989) 114-I 17. Lupton, D., Donaldson, C. and Lloyd, P., Caveat emptor or blissful ignorance? Patients and the consumerist ethos, Social Science and Medicine, 33 (1991) 559-568. Donaldson, C., Lloyd, P. and Lupton, D., Primary health care amongst elderly Australians, Age and Ageing, 20 (1991) 280-286. Glass, N., The economics of general practice in England, British Journal of Preventive and Social Medicine, 28 (1974) 203-209. Krasnik, A., Groenewegen, P., Pedersen, P., Scholten, P.V, Mooney, G., Gottshau, A., Flierman, H. and Damsgard, M., Changing remuneration systems: effects on activity in general practice, British Medical Journal, 300 (1990) 1698-1701. Hughes, D. and Yule, B., Incentives and the remuneration of general practitioners, HERU Discussion Paper, University of Aberdeen 02/91, 1991. Donaldson, C. and Gerard, K., Economics of Health care Financing: the Visible Hand, Macmillan, Basingstoke, UK, 1993. Rice, T.H., 1983, The impact of changing Medicare reimbursement rates on physician induced demand, Medical Care, 21 (8) (1983) 803-815. Culyer, A.J., Cost containment in Europe, Health Care Financing Review, Annual Supplement, (1989) 21-32. Horder, J., Bosanquet, N. and Stocking, B., Ways of influencing the behaviour of general practitioners, Journal of the Royal College of General Practitioners, 36 (1986) 517-521. Hughes, D. and Yule, B., The effect of per-item payments on the behaviour of general practitioners, Journal of Health Economics, I I (4) (1993) 413-437. Chief Medical Otlicer, Health in Scotland, HMSO, Edinburgh, 1990. Hannay, D., Usherwood, T. and Platts, M., Workload of general practitioners before and after the new contract, British Medical Journal, 304 (1992) 615-618.