As the government reviews ways to improve the troubled legal aid system, the profession is casting envious glances at contracts for GPs.

Yet lawyers worry whether they will be able to use such a model to marry their interests in private and publicly funded work, reports Paula Rohan

Stressed? Fed up with low pay and lack of funding in the system? Feel unappreciated by the government and worried about the future? Many legal aid solicitors will be nodding their heads as they read this, but two years ago it could just as easily have painted a picture of morale in high street medical practices.

Reform since has produced contracts for general practitioners (GPs) and left the legal profession looking at the model with more than passing interest as it wrestles with ways to reform the legal aid system.

In its recent policy paper looking at alternatives to the current arrangements, the Law Society argued that a GP-style contract could be just what legal aid solicitors are crying out for (see [2003] Gazette, 16 October, 1).

Chief executive Janet Paraskeva said although more money was still needed for practitioners, 'such a model will enable resources to be targeted on areas of greatest need and give solicitors more flexibility in the use of resources'.

Last week, both the Department for Constitutional Affairs and the Legal Services Commission (LSC) told the Gazette that they were looking at the Society's proposals with interest.

The healthcare revolution began when the government moved to farm much of the primary care done by hospitals over to GPs' practices, but the medics were not happy about the situation as they had more patients without the facilities or budgets to deal with them.

'They had lost a sense of control over their own workload,' explains a spokeswoman for the doctors' professional body, the British Medical Association (BMA).

The BMA knew that things had to change, and two 'difficult' years on, the GPs are getting used to working under new arrangements that will be fully phased in by April 2004.

The new GP contract takes a practice-based approach, and consists of an agreement with the primary healthcare trust (PHT), covering services, quality, the infrastructure needed and the resources required.

Practices are limited to providing the services specified in the contract, but can spend their money how they see fit - for example, one could channel resources into acquiring a new doctor while others might see nurses as a priority.

Funding is based on a formula aimed at achieving comprehensive service provision within the practice and targeting areas of patient need.

The global figure is based on the number and type of patients in each individual practice.

Practices start with a set sum for essential services - dealing with patients who are ill, have terminal illness or chronic disease - which can be topped through the provision of extra assistance such as contraceptive advice or providing vaccinations.

The global figure will be reduced through opting out of services - for example, out-of-hours care.

Where practices opt out, PHTs can channel the extra money into other practices in the area.

Practices will be given extra incentives to achieve certain levels of quality, for example in clinical care (covering a range of illnesses), and organisational standards, including practice management and recruitment.

They will receive a proportion of the quality payment, according to how well they are doing, but the aim is that they will ultimately get 100%.

The contract also pledges investment in infrastructure, flexibility for doctors in a choice of salaried and independent contractor status, enhanced seniority payments, incentives for experience, and rising and flexible pensions.

Perhaps most importantly, the government had given an undertaking that no GP would lose out under the revised arrangements.

In theory, this means that all practices can embark on the contract from at least a neutral position and go on to earn additional income.

There are few who could deny that the medical profession ended up with a good deal.

Solicitor Richard Moorhead, research fellow at Cardiff Law School, agrees that it is something worth examining for legal aid lawyers, even if it only puts the focus on getting an independent measure of quality and setting out pay in accordance with this, rather than sticking to a time-based system.

'The question always seems to be how to specify what is paid for, but at this moment in time it seems clear to me that any new payment system will have to move away from that - and the GP-style contract is one way,' he says.

Legal Aid Practitioners Group (LAPG) director Richard Miller backs the range of different models permitted along with payment for quality standards, combined with flexibility.

'What is also good about this is the deferment to professional judgement, the payments for IT and premises, the "aspiration payments", that is, paying to assist people to achieve improvements rather than - as we had - demanding improvements and then refusing to increase rates even when we have delivered them,' he adds.

However, the GP model cannot be transferred across without being adapted to legal aid lawyers.

GPs are not in competition with private doctors, for one thing.

Mr Miller joins others in asking how the contract might work in practice for solicitors.

'How will the interface between private and legal aid work - or will people have to choose?' he asks.

'How will the differences between ongoing legal procedures and the generally short transactions that GPs have affect payment structures? How will the contract translate across, in other words?'

Rodney Warren, chairman of the Law Society's access to justice committee, also has questions.

'Everyone is talking about GP contracts because they sound good, but it still remains that GPs are general practitioners whereas the legal aid system, through various panels, requires lawyers to be specialists,' he points out.

'I don't see how it can work quite so easily.'

There is also the issue of whether the government would be prepared to invest in such a system.

Some commentators have priced establishing a GP model at 500 million or more.

Mr Moorhead argues that it would be worth it in the long run, if it led to a better system, but not everyone is optimistic about securing the funding.

'I'd like to think it might be managed in some way, but I can see no immediate prospect of that,' laments Mr Warren.

Professor Gary Slapper, director of law at the Open University, suggests that the contract could also have a detrimental effect on clients as it moves the focus further away from access to justice and more towards business efficiency.

'To the extent that GP-style contracts have encouraged doctors to be more circumspect about their use of resources, a good has resulted,' he says.

'But there is widespread concern that a system that always counterpoises budgetary considerations and clinical considerations will produce dreadful periodic errors.'

Mr Moorhead suggests that the model could be more workable if the government rationalises the supplier base so there are fewer providers that are working under the GP model, although he acknowledges that this could be 'painful' for some firms.

'There is a question of whether legal aid is currently provided in big enough units to make it feasible,' he says.

'It probably is in big urban areas, but not in smaller areas.'

However, Stephen Hewitt, managing partner of London firm Fisher Meredith, is not sure it would work for his large practice, which is split 70/30 into private work and legal aid respectively.

He predicts that the LSC would be reluctant or unable to cover the overheads of a firm with such a high proportion of private work.

'But that's the way larger firms like ours are going,' he says.

'There would be difficulties with firms operating with those sorts of percentages.'

One solution - as Mr Miller suggests - could be moving across the clinical spectrum to look at the way dentists operate, as they are allowed to take on that mixture of private and legally aided work.

'That interface between private and publicly funded work will be a very important issue in any new model,' he predicts.

But he adds: 'In practice, no model is likely to translate across exactly, and there will probably be a need to borrow ideas from a range of different sources and to tailor some solutions specifically for the legal services market.'

Simon Pottinger, lead consultant at legal aid consultancy JRS, insists that payment methods - whether through the GP contract or other options such as salaried services or standard fees - will not work unless the government 'stops seeing profit as a dirty word' in the context of legal business.

'Call me cynical and old-fashioned, but you can do all the blue-sky thinking you like and the fact still remains that the government is relying on a private sector market to deliver publicly funded services,' he argues.

'It doesn't matter what other methods of delivery you are looking at - there must be a profit element in there.'

This signifies one of the great similarities between legal aid and GPs practices - the fact that at the end of the day, they are essentially businesses, even if part or whole of their income is funded by the taxpayer.

It was down to the BMA in 2001 to remind the government of this, and to negotiate terms appropriately.

It was by no means an easy task, the BMA spokeswoman recalls.

'[In the beginning] talks with the government were going nowhere,' she says.

'There was no willingness on behalf of the government to move it forward; it simply did not want to listen.'

The BMA got around this by consulting its members and press releasing the results to a hungry national media.

'There was a total impasse so we decided to go public,' she says.

'We balloted all our GPs throughout the UK to see what they thought about starting afresh with a new contract and how they felt about resigning from the existing contract.

We had a huge response and the majority said "yes", so we started off in a very strong position.'

The Department of Health appointed agents in the NHS Confederation - made up of heads of regional health authorities and PHTs - to act as its negotiators, and the BMA consulted all its members to identify the profession's wishes.

'It was a very long questionnaire but around 23,500 - more than half - responded and that gave us the basis on which to negotiate.

That was our strength: we had an absolute mandate and carried the profession with us, and throughout the process, we kept going back to check with them.'

She says that once the government realised this, it was suddenly far more willing to talk about how to throw away the existing contract and start up a new regime.

There were still problems and delays, but in June this year 80% of GPs voted in favour of the new contract.

The BMA spokeswoman regards it as a successful conclusion.

'[The new contract] delivers the government's agenda, which is quality of care, and meets the GPs' agenda because they get fair pay and control over their own workload.'

The government is reviewing the way legal aid services are delivered, and solicitors in the system are finding themselves in the same uncertain boat that the GPs were in two years ago.

The experience of their medical counterparts may provide a ray of hope that - even if the GP-style contract is not adopted - they too might come out smiling.