WELCOME TO THE NEW GMS CONTRACT Dr Stephen Newell April 2004

Aims of the new contract - To give GPs a better working life. - To improve services for patients. - To give GPs control over their workload. - To attract extra funding into general practice. - To pay GPs fairly for the work they do. - To improve recruitment and retention in the profession.

What’s different about the new contract? - The Red Book was open-ended whereas the new contract spells out what GPs are expected to do. - It is a practice-based contract – between the practice and the PCT. Individual GP lists have ceased. - Funding is based on the needs of the patients. - Practices are paid for delivering quality patient care. - The current GP 24 hour responsibility for patient care will end. - GPs will have the freedom to staff and structure their practices as they see fit. - A Minimum Practice Income Guarantee (MPIG) backs up the contract.

What services are covered by the new contract? What services are covered by the new contract? 1: Essential services Every practice will provide essential services - the day-to-day work of general practice, looking after patients during an episode of illness, the general GP management of chronic disease and the non-specialist care of patients who are terminally ill. 2: Additional services Practices will offer a range of additional services – covering such things as contraceptive services, maternity services excluding intra partum care, child health surveillance, cervical screening and some minor surgery.

– these come in three types: 3: Enhanced services – these come in three types: Directed Enhanced Services which PCTs must ensure are provided for patients within their area but no one practice has to do. These services include: - out-of-hours care - flu immunisations - preparation of records for quality - childhood immunisations - minor surgery beyond curettage, cautery and cryotherapy - improved access - care of violent patients

National Enhanced Services which PCTs will commission in their area. E.g. - anti-coagulant monitoring - intra partum care - minor injuries - IUCD fitting - drug and alcohol misuse. Local Enhanced Services. Commissioned by PCTs and locally negotiated. They are services provided in response to specific local needs.

Out-of-hours Out-of-hours - Out-of-hours (OOH) is one service that the majority of practices are expected to opt out of. - Responsibility for providing out-of-hours cover will switch to the local PCT 31 December The OOH period is defined as from 6.30pm to 8am on weekdays, plus weekends and bank holidays. - Practices do not have to be open throughout the in-hours period.

How will practices be paid? The new contract changes the way practices are paid. Money will flow into practices according to the weighted needs of patients. The formula used is intended to have a redistributive effect - to increase the money going to areas of highest workload and patient need. The Minimum Practice Income Guarantee (MPIG) protects those practices that would otherwise lose under the formula. The MPIG will ensure that all practices can embark on the new contract from at least a neutral position. There is an 11% uplift attached to the new contract in the first year which means that all practices will see an increase on current income.

How does the money come into the practice? 1: Global sum About half practice income will come in the form of a Global Sum which pays for much of the essential and additional services provided. The amount is based on the weighted needs of the registered list of patients, taking into account things such as the age and sex of the patients, morbidity and mortality, nursing and residential home patients, list turnover and a market forces factor to reflect local staff costs. It replaces income such as the basic practice allowance, deprivation payments, capitation and staff costs. It does not cover seniority, premises or computers. The global sum can go up or down according to the number of patients and their health needs, and is recalculated quarterly.

2: Money for quality A major new source of income lies in the Quality and Outcomes Framework. There are 1050 points on offer each worth income for the practice. For an average practice (5500 patients) the value per point for the year is £75 rising to £120 next year. Points are scored for achieving certain levels of performance within these areas: - Clinical – 550 points available – 10 clinical areas: CHD/LVFStroke & TIA HypertensionHypothyroidism Diabetes mellitusLong-term mental health COPDAsthma EpilepsyCancerProtocols! - Organisational – 184 points available - Additional services – 36 points available - Patient experience – 100 points available

Organisational Areas - Records and information. - Communicating with patients. - Education and training. - Clinical and practice management. - Medicines management.

Other ways to get points If points are scored at a certain level across seven different areas, the practice can qualify for up to 100 points for "holistic care". Up to a further 30 points are available if points are achieved in the other three quality areas. The final 50 points are available to practices that meet access targets for patients. Recognising that it takes time to implement the quality framework, preparation payments will be paid in 2003/04 and 2004/05. Patients who for one reason or another will not accept, or respond to, advice and treatment, can be excluded from the framework. What is NSMC’s aim (aspiration)? 915 points

Payments for Enhanced services With Directed and National Enhanced Services the practice receives payment at nationally agreed rates for services commissioned by the PCT. With Local Enhanced Services, a practice must negotiate the price, terms and conditions directly with the local PCT. Funds are being provided to PCTs specifically to fund enhanced services in their area.

Computers and IM&T - paid 100% by the PCT. Premises - a whole range of improvements and flexibilities have been introduced, with new funding. Other sources of income Sick leave and maternity, paternity and adoptive leave locum reimbursements. The new contract gives a clearer definition of non- NHS services for which the practice may charge. Income from additional work GPs undertake, e.g. hospital work is not affected by the new contract. Improved seniority payments and pension scheme.

Controlling workload - An end to 24 hour responsibility. - Opting out of additional services to cut workload. - An end to the existing system of forced patient allocations. - A series of demand management initiatives including developing expert patient schemes, making more use of pharmacists and nurses. - Moves towards getting rid of sick note certification. - Future-proofing - new work has to be costed and agreed.

Improvements for patients Resources for practices to improve quality of service. A Patient Services Guarantee, which is the responsibility of the PCT, will ensure patients continue to get access to the range of services they currently enjoy. Although patients register with a practice rather than a GP, they retain their right to ask to see an individual doctor, though they might have to wait longer. Questionnaires in the patient experience area of the Quality Framework mean patients can be consulted about the way their practice runs.

In summary Under the new contract, money follows the patient's needs. Practices have total control of their budgets for the first time & can decide the skill mix they want, the quality they aim for and the non-essential services they will provide. The open-ended nature of the old Red Book contract disappears. UK investment in primary care will increase from the current £6.1 billion to £8 billion in The MPIG principle is a guarantee that no practice will lose money under the new contract.

Our strategy Meetings over several months to prepare our response to the challenges of the new contract incorporating the views of partners, management, nursing team and staff. Global overhaul of chronic disease management with re- engineering of our clinic system including appointments (SN). Development and enhancement of clinical audit to identify our Q & O framework weakness (AH). Enhancing the administrative systems – developing new ones where needed and refining current practice (LT). Enhancement of our IM&T system – Guidelines and Tabs (SW). Meetings with the PCT putting our financial case firmly to them (RB).

Weaknesses The new contract is insensitive to variations in patient numbers. Following guidelines to get points seems like bean- counting – is this really quality? What about disease areas not in the Q & O framework? E.g. RA, OA, Parkinson’s disease? IOS have gone e.g. FP1001s, imms and vaccs – were important at NSMC. Exception reporting is difficult – hard to exclude clinically inappropriate measures.

Threats Is this a doctor-centred contract? What about other members of the team? Do they just have to do what they are told? Ethical issues about doing tests “just for points” – cholesterol in very elderly, microalbuminuria test on all diabetics. Enhanced services not costed yet. Practice income may be reduced!

Opportunities Possibility of more money. OOH responsibility will end – but not an issue for NSMC. Quality & outcomes framework chimes with some elements of quality.

Strengths This is North Street with our excellent team. Administrative systems are second to none. IM&T is in an advanced state.