Investment and evolution: A five year framework for GP contract reform to implement The NHS Long Term Plan

A five year framework for the GP services contract Summary of agreement Addresses workload issues Brings a permanent solution to indemnity costs and coverage Improves the Quality and Outcomes Framework Introduces a new Network Contract DES Helps join-up urgent care services Enables practices and patients to benefit from digital technologies Delivers new services to achieve NHS Long Term Plan commitments Gives five-year funding clarity and certainty for practices Tests future contract changes prior to introduction Published in January 2019 by NHS England and the BMA General Practitioners Committee in England Five year framework: 2019/20 GMS Contract changes and joint proposals for the four subsequent years The Framework sets direction for primary care and seeks to address the core challenges facing general practice. 2

Investment Resources for primary medical and community services will increase by over £4.5 billion by 2023/24. Funding for the core practice contract is fixed for each of the next five years, and increases by £978 million in 2023/24. In 2019/20, indemnity expenses are removed and there is a 1.4% uplift to practice contract funding. This includes: Pay uplift Expenses uplift, including £20m for subject access requests 1% linked to 2018/19 pay uplift and contract agreement in 2019, via SFE £105m Funding for practices to engage in establishing networks, via the SFE £30m into GS as part of extended access changes and NHS 111 direct booking £5 per patient MMR catch-up Uplift to S7a immunisation programmes (e.g. flu) in line with other immunisations Up to £1.799 billion will flow nationally through the Network Contract DES by 2023/24. This will include funding for the new additional role reimbursement scheme, network support and access 3

Primary Care Networks

Primary Care Networks Practices will be offered a new Network Contract – this is a Directed Enhanced Service (DES). The DES will provide funding for practices to form and develop networks, as well as for additional workforce and services to be delivered by the network. Networks will cover a typical population of 30-50,000 patients. There will be flexibility if required over or below this (for rurality). Networks can be structured in a number of ways depending on how the network members wish to employ staff and work together All Networks will have a Network Agreement. It will outline how the practice will work together, how funding will be allocated and how services and workforce will be shared. A template will be provided for this. CCGs and Integrated Care Systems will play a role in approving the formation of networks and commissioning services they will provide as well as providing ongoing support. CCGs to provide £1.50/head in cash to support PCN development from the general allocation 19/20 is a set up year. 11

New network workforce “£4.5 billion of new investment will fund expanded community multidisciplinary teams aligned with new primary care networks based on neighbouring GP practices” NHS Long Term Plan Through a new Additional Roles Reimbursement Scheme, Networks will be guaranteed funding for an up to estimated 20,000+ additional staff by 2023/24: Clinical pharmacists (from 2019/20) Social prescribing link workers (from 2019/20) Physiotherapist (from 2020/21) Physician associates (from 2020/21) Community paramedics (from 2021/22). The scheme will meet a recurrent 70% of the costs of additional clinical pharmacists, physician associates, physiotherapists, and community paramedics; and 100% of the costs of additional social prescribing link workers. Each network appoint a Clinical Director, chosen from within the network. Funding will be provided for this role based on the network size; 0.25 WTE funding per 50,000 population size. Funding will be set nationally based on Agenda for Change scales, but there is no requirement locally to employ on the AfC contract The network can agree how the new workforce is employed and deployed across practices.

New network services Seven new services will be introduced in line with the NHS Long Term Plan primary care goals, and phased into the DES over the coming years. The specifications for these will be developed with stakeholders during 2019/20 and negotiated with GPC in annual contract negotiations. 2019 Extended Hours access integrated into networks – same requirements as the DES, for 100% of network population 2020 Structured medication review Enhanced health in care homes Anticipatory care (with community services) Personalised care Supporting early cancer diagnosis 2021 Cardiovascular disease prevention and diagnosis, through case finding Action to tackle inequalities

Timeline for establishing PCNs Date Action Jan-Apr 2019 PCNs prepare to meet the Network Contract registration requirements By 29 Mar 2019 NHS England and GPC England jointly issue the Network Agreement and 2019/20 Network Contract By 15 May 2019 All Primary Care Networks submit registration information to their CCG By 31 May 2019 CCGs confirm network coverage and approve variation to GMS, PMS and APMS contracts Early Jun NHS England and GPC England jointly work with CCGs and LMCs to resolve any issues 1 Jul 2019 Network Contract goes live across 100% of the country Jul 2019-Mar 2020 National entitlements under the 2019/20 Network Contract start: year 1 of the workforce funding ongoing support funding for the Clinical Director ongoing £1.50/head from CCG allocations Apr 2020 onwards National Network Services start under the 2020/21 Network Contract

Network investment Up to £1.799 billion will flow nationally through the Network Contract DES by 2023/24. This will include funding for the new additional role reimbursement scheme, network support, access and new Investment and Impact Fund. (£ millions) 2019/20 2020/21 2021/22 2022/23 2023/24 1. Additional Roles Scheme 110 257 415 634 891 2. Network Support £1.50 per head from CCG general allocation 90 91 92 GP PCN leadership (0.25 WTE per PCN, starts July 2019) 31 42 43 44 45 3. Access Extended Hours Access DES 66 87 Improving Access to General Practice at £6 per head 367 376 385 4. Investment and Impact Fund 75 150 225 300 TOTAL PCN FUNDING 296 552 1,153 1,457 1,799

Indemnity

Indemnity The new Clinical Negligence Scheme for General Practice will start from 1 April 2019. It will be operated by NHS Resolution. From 1 April 2019 everyone working in general practice will be automatically covered for all liabilities from clinical negligence in general practice. There are no membership or registration requirements. Coverage of the scheme will extend to all GPs and all other staff working in delivery of primary medical services. This covers all GPs (including salaried and locum) and all other staff working in general practice (including the new network workforce) All NHS work is covered. This includes out-of-hours, local authority, public health etc. Individuals will still need MDO cover for private work, professional services and additional advice. There will be a one-off permanent adjustment to the global sum figure that takes account of the existing contributions from general practice for indemnity. Investment in the practice contract overall will still rise by 1.4% in 2019/20, accounting for the indemnity change. As per last two years, payments will be made direct to practices to fund the increase in fees for the previous year (i.e. via SFE on an unweighted per patient basis). 5

QOF

QOF indicators removed In line with the findings of the QOF review (published July 2018), 28 indicators will be retired from April 2019. These account for 175 points and 31% of QOF: COPD (annual FEV1 and O2 stats) Dementia (test results) Diabetes (middle HbA1c target, see next slide) Mental health (cervical screening test, lithium) Osteoporosis (both indicators) Stroke and transient ischaemic attack (record of referral) Palliative care (3 monthly MDT case review meetings) Peripheral arterial disease (BP, anti-platelet) Smoking (providing literature and therapy) Contraception (removed in full) Cervical screening (protocol and audit) 1313

QOF indicators introduced In line with the findings of the QOF review (published July 2018), 15 indicators will be added or amended, accounted for 101 points: Blood pressure (CHD, HYP, STIA) – split for ≤79 (140/90), ≥80 (150/90) Diabetes indicators amended to account for moderate and severe frailty cholesterol target replaced by prescription of statin Mental Health indicator to record BMI instead of alcohol consumption COPD – offer of referral to pulmonary rehabilitation Cervical screening – split for ages 25-49 and 50-54 – in line with 3 and 5 year recall frequency. The QOF point value will increase by 4.7% to £187.74. This is to reflect increased list size and population growth. 1414

QOF personalisation and quality improvement Personalised care adjustments will be introduced, replacing exception reporting. This will allow practices to differentiate between five reasons for adjusting care and removing a patient from the indicator denominator. Practices will be required to use more personalised correspondence with patients when sending invitations for care, including using the patient’s preferred method of communication. Practices will be required to send two invitations for care, rather than three as presently (except for a few exceptions). 74 points will be used to create a new Quality Improvement domain. For 2019/20, the modules will cover prescribing safety and end of life care. These topics will change on an annual basis. 1515

Digital

Digital – requirements and support all patients have online access to their full record, as the default position from April 2020 with new registrants having full online access to prospective data from April 2019. at least 25% of appointments available for online booking by July 2019. all patients to be able to access online correspondence by April 2020 no longer use fax machines for NHS work or patient correspondence by April 2020 offer and promote electronic ordering of repeat prescriptions and using electronic repeat dispensing for all patients for whom it is clinically appropriate by April 2020 have an up-to-date and informative online presence by April 2020 Support Changes to the GP IT Operating Model, including provision of Data Protection Officers from CCGs GP IT Futures will replace the current GP Systems of Choice (GPSoC) framework from December 2019. This will include capability for digitisation of records, cyber security and transfer of patient records.

Digital-first “Digital-first primary care will become a new option for every patient improving fast access to convenient primary care ” NHS Long Term Plan All patients will have the right to online and video consultation by April 2021. Amendment to rurality index so that it applies to only those patients within the practice boundary Amendment to London Adjustment so that it applies to only those who are resident in London (rather than those who are registered with a London-based practice) Out of Area registrations and digital first access will be reviewed in 2019.

Access and other changes

Improving access The current Extended Hours Access DES will continue until 30 June 2019. From 1 July 2019, the funding will transfer into the Network Contract DES and PCNs’ constituent practices will deliver extended hours access to their collective registered population. By April 2021 we intend that the funding for the existing Extended Hours Access DES and for the wider CCG commissioned extended access service will fund a single, combined access offer as an integral part of the Network Contract DES, delivered to 100% of patients including through digital services such as the NHS App. NHS England will work with stakeholders including GPC England on a single coherent access offer that PCNs will make, for both physical and digital services. This will deliver convenient appointments ‘in hours’, reduced duplication and better integration between settings such as 111, urgent treatment centres and general practice. The review will start in 2019, for full implementation by 2021/22, but we expect local Integrated Care Systems and their Primary Care Networks to go faster and we encourage them to do so. In addition in 2019/20, 1 practice appointment per day, per 3,000 patients will be made available for direct appointment booking by NHS111. 20

Other contractual changes From 2019 it will no longer be legal for any NHS GP provider, either directly or via proxy, to advertise or host private paid for GP services that fall within the scope of NHS-funded primary medical services. A review of Vaccination and Immunisation procurement, arrangements and outcomes will take place in 2019 with its output implemented through the 2020 and 2021 contracts. From 2019-20 GP practices will be required to support six national marketing campaigns on an annual basis, where the GP contractor will be required to put up and display in their premises, campaign materials six times every 12 months. From October 2019, where GPs choose to apply the NHS primary care logo in relation to their NHS provided services, they will be required to adhere to the NHS Identify guidelines and apply the NHS primary care logo to all information and materials about their NHS services. Transparency of Earnings: GPs with total NHS earnings above £150,000 per year will be listed by name and pay (NHS income before tax) in a national publication, starting with 2019/20 income. Shared parental leave will be added to the SFE reimbursements for locum cover The contraceptive services Additional Service will cease and its requirements rolled into Essential Services

GP Contract documentation By the end of March 2019, NHS England and DHSC will have published: A new Statement of Financial Entitlements amendment covering the global sum, QOF £ per point and the network participation payment New DES directions including the new Network Contract DES Network Contract DES service specification and Network Agreement Revised V&I service specifications GMS guidance covering all of the contract agreement for 2019/20 Guidance to commissioners on implementing changes in PMS and APMS contracts Technical guidance on coding Regulations and Directions will come into force in October 2019, and new contract documentation will be published afterwards.

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