1. Welcome to The new GMS & PMS Learning Exchange The National Primary and Care Trust Development Programme

2. New GMS Learning Exchange The National Primary and Care Trust Development Programme

3. New GMS Learning Exchange All support resources can be found at www.natpact/nhs.uk/primarycarecontracting

4. New GMS Learning Exchange All support resources can be found at www.natpact/nhs.uk/primarycarecontracting The National Primary and Care Trust Development Programme

5. New GMS Learning Exchange New@NatPaCT Our weekly email update, rounds up new postings on all areas of this site, and is sent, free of charge to over 5,000 subscribers, usually on Wednesday afternoon. Occasionally we delay to catch an important announcement, or issue EXTRA editions in between. Subscribe online or at the Modernisation Agency stand. The National Primary and Care Trust Development Programme

6. Dr Mohamed Dewji Clinical Director for Primary Care Contracting

7. Pay GPs or vehicle for strategic change? Replace OOHs or re-shape emergency care? Use QOF to effectively manage chronic disease? Enhanced services – shift treatment or a cross to bear? Feedback on the patient experience and flexibility to progress the choice agenda? PCT Strategic Tests

8. Take opportunities for skill mix and forge effective new partnerships e.g. with pharmacists? Positive impact on Recruitment, Retention and morale? Develop a more entrepreneurial culture in primary care? Use further flexibilities in PMS and PCTMS to tackle local issues. PCT Strategic Tests

9. Progress of primary care Organisational Unit Service Focus Mechanism of Delivery Individual G.P.s Integrated Trusts (NB Kaiser) PCGs / PCTs + / - Care Trusts G.P. Units (larger practices) 1965 2004 1997 1990 The Red Book Communities of interest Practice & geographical communities Specific Target Groups >75 years etc Individual Patients Various NHS & Private Providers Practice Contracts via PMS GP Commiss g GP Fundhold g TPP/Multifund

10. PCT Commissioner PMS Provider PMS Provider nGMS Provider P NNP PP Performers -mainly the Principals holding the contract N P NNP PP N P N PP P Primary Care – from April

11. Demographic Change by 2019

12. Expected numbers of diabetics: now & by 2010

13. Primary Care - future PCT Commissioner PMS/GMS Provider P NN NPP N N P SW P NC NP N Consolidation of sites by GPs or others Integration into Managed Care Organisations Interpractice Consortia & Collaboration Contracting out to Commercial Cos. NFP, Vol. Sector, et al.

14. Data rich society Performance management: changing role of CHAI Performance related incentives e.g. QOF in nGMS Benchmarking Outcome-driven contracting i.e. control v. empowerment Accountability and monitoring

15. The Internet & access to information Role Redesign of health staff The changed role of the professional with the patient Technological Advance

16. Patient demand and individualism: more immediacy & less community spirit Work - life balance - flexibility, etc. IWLs Increased career development with portfolio careers / job variety Networks of providers & covering shifts Reduction of (i) continuity of care over time & of (ii) long-term commitment Implications

17. Self-determination, cohesion of society –Growth in private / pay-as-you-go care –European Working Time Directive Rationing –Equitable distribution of resource / Costs –Proactive or reactive care / prevention –Coordination by PCTs of public & other providers with equity / transparency of corporate governance and contracting Implications

18. Strategic & Progressive Opportunity for Change in Primary Care Reshape Services – Use of OOH / Enhanced Services / QOF Choice & Diversity Skill-Mix – Patient Centred Use of Different Service Models Primary Care Driven NHS Where to next?

19. Questions and Discussion

20. QUALITY & OUTCOMES FRAMEWORK Dr Philip Leech Principal Medical Officer Department of Health

21. Key points The QOF is voluntary - but practices that dont take part are likely to rely on the MPIG PMS practices can opt out of the national QOF - but agreeing local variations will be hard work Non-computerised practices will be at a distinct disadvantage Day-to-day delivery of the QOF will fall more on practice nurses and practice managers than on GPs

22. Contents of QOF Guidance Activities and milestones for 2004/5 Preparatory funding Aspiration calculation and payment Prevalence Annual quality visits Calculation of achievement points and payment Ensuring equity and probity IM&T and data flows QOF review and adaptation

23. QOF Improvement Cycle Review QOF IMPROVEMENT CYCLE Planning ActionLearning

24. QOF Activities for 2004/5 QOF 2004/5 Feb 2004 Agree aspiration Apr 2004 Pay QPrep and QuIP DES April 2004 QOF goes live April 2004 DH guidance on review visits End April 2004 Monthly aspiration payments August 2004 QMAS system goes live & provides monthly feedback Oct 04 – Jan 05 Annual review visits take place April 2005 Achievement payments made

25. Structure of the QOF - 1 Clinical domain - 76 indicators - 10 disease areas (CHD, stroke/ TIA, cancer, hypothryroidism, diabetes, hypertension, mental health, asthma, COPD and epilepsy) - 550 points Organisational domain - 56 indicators - 5 areas (records, information, patient communication, education and training, practice management and medicines management) - 184 points

26. Structure of the QOF - 2 Patient experience domain - 4 indicators - 2 areas (patient survey and consultation length) - 100 points Additional services domain - 10 indicators - 4 areas (cervical screening, child health surveillance, maternity services and contraceptive services) - 36 points

27. Structure of the QOF - 3 Holistic care payments - based on points scored in clinical domain - 100 points Quality practice payments - based on points scored in organisational, patient experience and additional services domains - 30 points Access bonus - based on achievement of 24/ 48 hour access target - 50 points

28. Preparatory funding Quality Preparation Payments (QPrep) –Nov 2003: all receive payment (£9000 for practice with average list size) –end Apr 2004: second payment (£3250 for average practice) for practices participating in QOF Quality Information Preparation (QuIP) DES –to help practices summarise records, depending on list size and amount of work –PCTs offer 2004 QuIP to practices by 1 Jan 2004 –for 2005, schemes agreed before 1 Apr 2004 are paid to practices with next monthly payment

29. Aspiration Payments Arrangements for 2004/5 –practice and PCT agree aspiration points total –practice paid a third of this –not weighted by prevalence but weighted by relative list size Arrangements for 2005/6 –practice paid on the basis of 60% of its achievement payment for the previous year –weighted by prevalence and relative list size Aspiration payments paid monthly

30. Prevalence adjustment Only applies to practices doing national QOF Acknowledges that practices with low prevalence still have costs in setting up registers and regularly checking patients. Provides adequate income protection to practices with lowest prevalence Delivers appropriate rewards to practices with highest prevalence (no cap!)

31. How does it work? Prevalence adjustment is based on the contractors prevalence measured against the national average Contractors prevalence = no of patients on disease register Separate calculation made for each disease area Adjusts the pounds per point available for each disease area

32. CHD

33. Additional Services Adjustment Pounds per point adjusted by relative size of target population Protects contractors with large target populations Rewards for greater workload Relative size of contractors target population is compared to national average

34. Target Populations Cervical Screening Child health surveillance Maternity Services Contraceptive Services Women aged 25 to 64 years Children aged under 5 years Women aged under 55 years

35. Dont panic! For the national QOF, these calculations will be made automatically by the IMT software (Quality and Outcomes Framework Management & Analysis System aka QMAS) PCTs of PMS practices taking part in a locally agreed QOF will need to do their own calculations

36. Annual Review Commissioned the School of Health and Related Research (ScHARR) to develop proposals Separate guidance will be published in April 2004 by DH Current guidance sets out key principles Visits should take place between October and January - PCT should agree and publish a schedule

37. Supporting Information Supporting information to be submitted by contractor one month before the visit Required information set out in New GMS Contract 2003: Supplementary Guidance Must cover all areas for which the contractor intends to submit an achievement claim Will certainly include levels of exception reporting and any anomalous data eg on referrals

38. Annual Review Assessors Selected on the basis of meeting certain competencies Appropriately trained - national training available for a limited number of assessors One assessor will normally be a doctor (or another healthcare professional by agreement between practice and PCT) One assessor will normally be a lay person Bound by a code of practice on confidentiality Visit may involve LMC

39. Outcomes of the Visit Assessment of contractors likely achievement against the QOF Written report, seen in draft by the practice Remedial plan if visit highlights issues around data quality eg Read coding Remedial plan to be implemented by contractor within one month of agreement

40. Annual Review Visit DO Identify the person responsible for visits Start working on a visit schedule now Identify potential assessors, and check availability Wait for publication of national guidance in April before working on the detail

41. Annual Review Visit DONT Get too bogged down in detail: further guidance will be published in April Assume national training will be available for ALL your assessors Ignore everything until April!

42. Ensuring Equity & Probity PCT verification of achievement claims before payment PCTs can re-score contractors achievement claims, in some circumstances Remedial action on data quality if annual review visit generates concerns Random 5% check of achievement claims to deter fraud

43. IM&T and Data Flows Practices do not need new software, just an RFA99 compliant clinical system Reports from QMAS - monthly to PCTs, at least monthly to practices QMAS reports will, in time, have comparative data on achievement and trends (local and national) Consultation on impact of Freedom of Information Act (kicks in January 2005)

45. Review of QOF Process for reviewing QOF will be established this year Will be informed by PMS local QOF experience Major changes unlikely before April 2006 Smaller changes before then to remove errors and take into account groundbreaking new evidence

46. The IMT will do all the calculations for you You need to focus on: - appointing a QOF lead for your PCT - agreeing aspirations (if you havent already) - encouraging practices to get ready for the IMT (Read codes, list cleaning, computerisation) - identifying potential assessors - booking annual review visits You are part of a world first! To sum up...

47. Getting more information GMS and PMS: helpline - 0845 900 0008 inbox - gmspms.queries@npdt.nhs.uk website - www.natpact.nhs.uk/primarycarecontracting/ QOF guidance: GMS www.doh.gov.uk/gmscontract/implementation.htm PMS www.doh.gov.uk/pmsdevelopment/ pmsarrangementsdec03.pdf

48. New Contracts in Primary Care: workforce issues Kate Billingham

49. Starting point Nurses in general practice can experience : – no contracts –less than rigorous scrutiny on appointment [illegal employment!] –limited training opportunities –limited feedback on performance –no consistent professional development –limited integration with other nurses –lack of access to nursing leadership

50. Improving employment conditions Primary care professionals need to be: –eligible to perform services –recruited and retained –development needs to be supported –deserve adequate pensions

51. This will mean... Job descriptions Pre-employment references to be checked Registered with relevant professional body Agenda for Change principles to be implemented

52. Support development needs having a say and being consulted new roles are supported by training access to clinical supervision and appraisal access to CPD and professional advice The regulations say…………..

53. The contractor shall ensure that for any health professional performing clinical services under the contract there are in place arrangements for the purpose of maintaining and updating his skills and knowledge in relation to the services he is performing (para 59)

54. The contractor shall afford to each employee reasonable opportunities to undertake appropriate training with a view to maintaining competence (para 60)

55. The risks Nurses and others will not be competent for their new roles Workforce supply will be inadequate Poor professional engagement Principles of Agenda for Change are not implemented

56. What needs to be done PCT staff need to provide HR support to practices Use and strengthen tools already available e.g clinical governance Monitor the HR elements of the contracts Involve professional bodies Clarify professional accountability

57. New and modified roles

58. Hold discussions with... Other local PCTs Workforce Development Confederations Strategic Health Authorities Local universities

59. In summary Different contractual relationship PCTs will be commissioning primary care –a practice –a group of practices –a PCT employee –an alternative provider Professional advice and input will be crucial

60. Liberate the Talents

61. Delivering Out-of-Hours Services David Carson

62. www.out-of-hours.info My Presentation Policy Framework Who will deliver OOH services? The role of PCTs and SHAs Some cross-cutting issues

63. www.out-of-hours.info Background Policy Framework OOH Review REC NHSD Review nGMS Choice and Plurality

64. www.out-of-hours.info Policy I : OOH Review Standards Clinical Leadership Integrated OOH services Network of providers Joined up planning and commissioning

65. www.out-of-hours.info Policy II: Reforming Emergency Care Same principles as OOH Current focus on A&E headline figure Integrated response to Minor Illness and Injury Solutions may reside outside A&E within network provision Chronic disease management - real opportunities in contract

66. www.out-of-hours.info Policy III: NHS Direct Review Technical Links Capacity in 2004/5 and 2005/6 Clear set of criteria being developed for joint operational arrangements Ensure that developed arrangements are consistent with NHSD direction and key role in emergency care. NHSD commissioning framework out for consultation Must be in the development process - integration of clinical processes

67. www.out-of-hours.info Policy IV : nGMS Opt out is not partial Specific notice periods OOH will provide mechanism to meet in-hours nGMS Challenge Opportunity to build PC capacity and volume

68. www.out-of-hours.info Policy V: Plurality NHS Mutual / Voluntary Sector Private Sector All have a role PCT provision is perhaps backstop choice

69. www.out-of-hours.info Who will deliver OOH Services? GP Opt-Out and re-provision Capacity Information Providers Mutuality Commercial Providers The Ambulance Service NHS Direct

70. www.out-of-hours.info Delivery I: GP opt-out & re-provision. Relevant yes but perhaps not in terms of re-provision 2 Different things Opt out is Practice decision Look beyond this question Services staffed by GPs and others attracted to work in services and providers

71. www.out-of-hours.info Delivery II : Capacity Information Urgent need to collect and collate existing information Should be mapped by: Case mix Geography Time Competencies Use as basis of planning integrated service All data should be shared with all providers (including acute and ambulance service)

72. www.out-of-hours.info Delivery III : Providers Limited view of opportunities by some Providers stop competing on all aspects – cooperate and build on your strengths (none are good at everything) More opportunity for joint development More attention to planning process At scale versus local Provider development process is needed in every area

73. www.out-of-hours.info Delivery IV : Mutuality COOP to COOP Basis of COOP membership changes from those with responsibility to those working within COOP and beyond. Will require support as per guidance from PCTs Working on governance models Provider development Further papers coming Mutual Transfer - January Model Constitution - March

74. www.out-of-hours.info Delivery V: Commercial Providers Strengths Resilience due to size Clinical governance structures Logistics and management capacity Often complementary services to local COOPs

75. www.out-of-hours.info Delivery VI: Ambulance Service Also Strengths Part of network Have increasing role Must be at the table Time to develop effective PC Capacity

76. www.out-of-hours.info Delivery VII: NHS Direct Technical Links Capacity in 2004/5 and 2005/6 Clear set of criteria being developed for joint operational arrangements Ensure that developed arrangements are consistent with NHSD direction and key role in emergency care. NHSD commissioning framework out for consultation Must be in the development process - integration of clinical processes

77. www.out-of-hours.info PCTs Networks Inter-PCT Co-operation Self-provision

78. www.out-of-hours.info PCTs I : Networks Have you achieved contestability and sustainability? A network gives more options than a single preferred provider Yet to see an area in which a single provider has all the answers Support providers (or establish new providers) Support change Give OOH the priority it requires

79. www.out-of-hours.info PCTs II: Inter-PCT Co-operation Potential for one PCT solution to destabilise others Agree on what development activity could be shared Inter PCT process requires proper attention (probably at Board level) Single PCT options will be very rare

80. www.out-of-hours.info PCT III: Self-Provision OOH Volumes within individual PCTs are low - few economies to be gained Enough service volume to have senior professional and operational leadership? Track record? Delivers contract but what next? Aspects of provision at scale do not exclude local initiatives Question the perception that PCT provision is the only way to control costs

81. www.out-of-hours.info Role of SHAs Key role Overview of PCT process Review of plans and hot spots Key role in ensuring plurality and adequate provision Overview of capacity and market No of providers Capacity of providers Assure overall provision is adequate Benchmark and support PCT action

82. www.out-of-hours.info Other Issues Workforce Clinical Leadership Procurement and tendering Accreditation and the Quality Standards

83. www.out-of-hours.info Other Issues I : Workforce Significant number of WF initiatives in Agency and in WDCs Important for SHAs and PCTs to ensure OOH and PC issues are on WDC agenda now No magic bullet but skill mix and flexible roles are key

84. www.out-of-hours.info Other Issues II : Clinical Leadership Effective clinical leadership underpins effective team working Clinical leaders key role in developing brokering network / inter provider operational arrangements Employed skill mix workforce (even GPs may be employed in new OOH organisations) The organisational structure requires capacity and competency to attract, develop and support senior clinical leaders

85. www.out-of-hours.info Other Issues III: Procurement & Tendering Procurement is not the same as tendering It is legitimate to include providers in process Providers should identify strengths / weakness & the benefits of joint working Then working co-operatively We do not have excess capacity We need to build capacity

86. www.out-of-hours.info Other Issues IV: Accreditation & Standards Under review Process of accreditation potentially within contracting Standards will apply to all providers (including practices who do not opt out) Revised Standards in April

87. www.out-of-hours.info A Unique Opportunity Best opportunity in a generation to build on the best of current practice Will require focussed work and investment. More complex but worth the effort

88. Delivering OOHs services David Carson

89. www.out-of-hours.info OOH Challenges Providers Networks Joint operations Clinical leadership Making most of opportunities Short medium and long term arrangements Immediate priority not the enemy of the next stage Workforce

90. The new GMS & PMS Learning Exchange The National Primary and Care Trust Development Programme