Funding in General Practice Dr Andy Withers www.bradfordvts.co.uk Grange Practice Allerton, Bradford

Aims & Objectives Aims Objectives Increase understanding of how General Practice is financed Objectives Know how :- Practice income is calculated and received Budgets are set The difference between NHS & Private income

Questions How do GPRs get paid in practice? How do salaried GPs get paid? How do GP Partners get paid? What is the difference between a GMS & PMS practice? Are all my earnings pensionable? What is PBC? How can I earn more?

What do we get paid for? Core General Practice(= Essential Services) Additional Services Enhanced Services QOF

NHS Income

GP Funding Budget BAtPCT Essential Services 42027354 63.6 Additional Services 1879730 2.8 QOF 10174089 15.4 LoQOF 1118611 1.7 Enhanced Services 7481849 11.3 Other 3429216 5.2 66110849

Premises Budget Brought forward 66110849 Premises 8453145 74563994

Essential Services (63.6%) MANDATORY - common to all practices The management of patients who are ill or believe themselves to be ill, with conditions from which recovery is generally expected, for the duration of that condition, including relevant health promotion advice and referral as appropriate, reflecting patient choice wherever practicable 2) The general management of patients who are terminally ill 3) Management of chronic disease in the manner determined by the practice, in discussion with the patient

Essential Services (63.6%) Either paid as “Global Sum” or MPIG in GMS practices (MPIG = GS +correction factor) Government want to get rid of MPIG Basic Contract in PMS practices

Additional Services (2.8%) Normally expected of all practices but OPT-OUT possible Cervical cytology Child health surveillance Maternity services (not intrapartum care) Contraceptive services

Enhanced Services (11.3%) 3 types Direct National Local

DES (2.8%) Obligatory for each PCO National specifications No one practice has to do: Services to violent patients Childhood vaccinations and immunisations financial incentives Minor surgery Flu immunisations Improved access IMT Choice & Booking (PBC) “New clinical DESs” Heart Failure, Osteoporosis, LD, Ethnicity, Alcohol

NES (1.7%) OPT-IN - national terms and conditions Anticoagulant monitoring IUCD Sexual health MS Drug and alcohol misuse Terminally ill Depression Learning disabilities Intra partum care Minor injuries Near-patient testing Homeless Immediate/first response care

LES (6.8%) OPT-IN Response to specific local requirements Local terms, conditions and standards Possibly, innovative services for piloting and evaluation

LES (6.8%) Choice & Booking (to 31/3/09) IM&T Sexual Health Minor Primary Services ECG Minor Surgery (various levels) Spirometry

GMS v PMS Little difference now PMS probably slightly higher earning practices due to historic funding. Both practice based contracts GMS nationally negotiated Either global sum via Formula Or Minimum practice income guarantee (MPIG) PMS (potentially) locally negotiated

Range of Practice Funding in BAtPCT

Seniority Begins from start of NHS service Annual increments Soon to be removed

QOF THE FOUR DOMAINS OF QUALITY Clinical Organisational Patient experience Additional services

Total Points 1000 Clinical 650 Organisational 167.5 Additional Services 36 Patient Experience 146.5

CLINICAL AREAS Asthma 45 Heart Failure 20 AF 30 Hypertension 83 Cancer 11 CKD 27 COPD 28 CHD 89 Dementia 20 Depression 33 Diabetes 93 Epilepsy 15 Heart Failure 20 Hypertension 83 Hypothyroidism 7 Learning Disabilities 4 Mental health 39 Obesity 8 Palliative Care 6 Smoking 68 Stroke & TIA 24

Records and information Patient communication Education and training ORGANISATIONAL AREAS Records and information Patient communication Education and training Practice management Medicines management

General Practice Assessment Questionnaire (Manchester) PATIENT EXPERIENCE Standardised approved patient questionnaires General Practice Assessment Questionnaire (Manchester) Improving Practice Questionnaire (Exeter) Length of consultation - 10 mins appts

QOF Changes 2009/10 End of “Square rooting” Move to true prevalence

Pensions All NHS income pensionable delivering GMS / PMS delivering services under delegation including locum work board, advisory and other work for NHS bodies collaborative arrangements work education statutory certification work for GP cooperatives that are NHS bodies All locum pay pensionable from 1.4.2002

PBC Practice Based Commissioning Voluntary Devolved budgets to all practices Virtual Money – you can’t take it home For: Prescribing Secondary care, acute & elective Community Staff Can spend (up to) 70% of Freed up resources (FURs note not savings) on patient care. Pct takes rest. Only get FURs you predict (no serendipitous FUR) Idea is to provide innovations in services to produce FUR Usually done through commissioning alliances

Other Income Teaching & Training Amount NHS Pension? NHS related work GPR £7.5k Y FY2 £10k Y Medical Students £15-20k N NHS related work GPwSI c £10k/session Y PCT Y LMC N DH Y Private N Reports Medicals etc

Getting Paid

Getting Paid 2 (This is real money) Typical Middle sized practice (approx 5500 patients) Total amount £875k Less running expenses (36%) £315k Less Staff costs (including salaried GPs & GPRs) £260k Profit (34%) £300k Divided between partners = income £100k Need to pay 20% superannuation £80k Need to pay Income tax

Premesis Lift PFI variants DIY Guaranteed income stream from PCT About 11% return for developer