The New GP Contract

1
The New GP Contract

• Investing in
• General Practice

2
A few things to remember...

• Utterly different
• Total flexibility for practice
• No carry-over from Red Book or Terms of Service
• Ability to say no
• Formula-based global sum
• Money for primary care goes from 6.1bn per annum
  in 2002-03 to 8bn in 2005-06

3
No more...

• Over 75 or 3 year checks
• Availability rules
• Applications for partners
• Staff reimbursement
• Health promotion

• CDM
• PGEA
• Lists
• Claim forms
• Saturday mornings
• Out of hours
• Individual Terms of Service

4
The Contract...

• Has UK-defined terms
• Remains predominantly nationally negotiated
• Will have appropriate flexibility to meet local
  needs

5
A contract between whom?

• Contract between a practice and a PCO
• all practice partners will enter contract with
  PCO
• Terms of individual practice contracts from
  national menu

6
The contract menuFive types of service

• Normal services
• Essential
• Additional

• Supplementary services
• Directed Enhanced
• National Enhanced
• Local Enhanced

7
Essential Services 1

• MANDATORY - common to all practices
• 1) 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

8
Essential Services 2

• 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

9
Additional Services

• Normally expected of all practices but OPT-OUT
  possible
• These will mainly include services which are
  preventative
• CHS
• Non-IUD contraception
• Non-intra partum maternity
• Childhood vaccinations and immunisations
• Cervical screening
• Curettage, cautery and cryocautery

10
Opting-out of Additional Services

• 2 types-
• temporary (to cover emergencies)
• permanent (to cover longer term problems)
• PCO and practice must come to agreement within
  maximum of nine months
• Where no agreement, appeal possible

11
Directed Enhanced Services

• 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
• Quality information preparation
• Improved access

12
National Enhanced Services

• 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

13
Local Enhanced Services

• OPT-IN
• Response to specific local requirements
• Local terms, conditions and standards
• Possibly, innovative services for piloting and
  evaluation

14
Out of Hours

• End of current 24 hour responsibility
• PCO responsible for ensuring provision for OOH
  period
• 6.30pm - 8am weekends and bank holidays
• PCO to have contingency plans to cover unexpected
  failure of OOH service
• Default option lies with PCO, not practice

15
Arrangements for OOH opt-out

• PCOs can start NOW to aid recruitment
• Opt-out legislation from April 2004
• Must be able to opt out by 31.12.2004
• Price for opt-out is 6000 per average GP

16
In-hours home visiting

• Clarification of definition
• Essentially will mean that the GP will decide
  whether and when a home visit is necessary on
  clinical grounds
• PCO may commission area-wide service

17
Remote and Rural 1

• How has the lack of choice been rewarded?
• Supported time off
• Supported OOH cover
• Flexible work within hours - supported by PCOs
• Salaried option

18
Remote and Rural 2

• New funding flows
• Rural weighting in global sum
• QO framework
• Enhanced service payments
• OOH package

• Current funding flows
• IP scheme
• Chapter 10.5
• Mileage payments

19
The Formula

• Assesses the relative workload between practices
  and the costs of delivering that workload
• Distributes resources on a weighted patient needs
  basis not per GP
• Produces a fixed sum per notional patient
• Practice with 10,000 patients may have 10,893
  notional patients
• Practice paid for notional patients and the total
  the global sum, which contains some profits
  and some expenses
• Takes account of regional cost differences
• Global sum includes temporary patients

20
How items get into the Formula

• Consider factors relevant to generating workload
• Analyse the influence of these on total
  consultation time per annum
• Survey of 99m consultations show that boys 5-14
  have the shortest total consultation time per
  annum
• The Formula will be refined over time as more
  data are collected

21
Factors in the Formula are

• Age
• Gender
• List turnover
• Morbidity and mortality
• Nursing home/residential home consultations
• Rurality
• Market forces

22
Notional Population

• 10,000 x 1.07 x 0.98 x 1.06 x 0.98 10,893
• List
• Age/sex weight
• Additional need
• MFF
• Rurality
• Notional
  population

23
Global Sum Replaces

• BPA
• Assistants
• Deprivation
• Capitation
• OOH
• PGEA
• Staff costs
• Appraisal
• Unregistered patients (last 5y levels of T/Rs)

• Cytology (partly)
• Vaccs imms (not targets)
• Contraceptive - non-IUCD
• Rural practice payments
• Some minor ops
• Maternity except i/p
• Arrest of dental haemorrhage
• Employers contribution to superannuation

24
Global Sum does not include

• Structured health promotion
• CDM (diabetes asthma)
• Dispensing
• Premises
• Computers
• Maternity i/p
• Seniority
• Sustained quality payments
• Golden hellos

• Some minor ops
• Cytology (partly)
• VI targets
• Geographical payments
• Inducement
• Rural locum
• Associate
• Initial practice
• Designated area

25
The Money

• Global sum may go up or down
• Calculated each quarter, paid monthly
• Enhanced services pay us for transferred work
• QO pays for higher quality
• Seniority increased by average 30 over three
  years

26
Transitional protection

• On individual practice basis
• Based on 2003/04 income
• Adjusted for quality preparation and aspiration
  payments
• 100 points (2004/05), 150 (2005/06), 200
  (2006/07)
• Not adjusted for quality achievement
• Adjusted for opt-outs
• Continues until 2007

27
GLOBAL SUM
UNIFIED BUDGET
ASSURED QUALITY MONEY
ESSENTIAL ADDITIONAL
PROTECTED TIME
LOCAL ENHANCED
PCO-MANAGED FUNDS
DIRECTED AND NATIONAL ENHANCED
PCO
PREMISES
GUARANTEED FUND(S)
IT
ALTERNATIVE PROVIDER
PRACTICE
28
Rewards for Quality

• 1.3bn for the UK for quality in GMS PMS
• No quality pool
• Non-discretionary
• In addition to the global sum
• Payment for what many already do
• All work converts to points
• 1000 maximum points
• Value 75 in 2004/5, 120 in 2005/6 for average
  weighted population

29
Aspiration Achievement

• Money in advance for equipment and staff
• Aspiration payment
• In advance monthly
• Rising as you aspire higher and 1/3 total
• Reward dependent on level of achievement
• Over-achievement paid in full

30
The four domains of quality

• and linkage payments
• Holistic care - clinical
• Quality practice - organisational
• 50 bonus points for access target achievement
• additional to the QO Framework

• Clinical
• Organisational
• Patient experience
• Additional services

31
Balance of 1000 Points

• Clinical 550
• Organisational 184
• Additional services 36
• Patient experience 100
• Holistic care 100
• Quality practice 30

32
Clinical Areas

• Epilepsy
• Asthma
• COPD
• Mental health
• Cancer

• CHD and LVD
• Hypertension
• DM
• Stroke or TIA
• Hypothyroidism

33
Organisational Areas

• Records and information
• Communicating with patients
• Education and training
• Clinical and practice management
• Medicines management

34
Additional services

• Cervical screening
• Child health surveillance
• Maternity services (not intra partum care)
• Contraceptive services

35
Patient Experience

• Standardised approved patient questionnaires
• Voluntary within the Q O Framework
• Three levels
• Length of consultation

36
Breadth v Depth

• Holistic care payments
• across clinical domain
• performance in 3rd lowest area
• Quality practice payments
• across other three domains

37
Principles

• Evidence-based
• Indicators fair
• Clinical indicators are measurable
• Not disruptive to consultation

38
CHD - the biggest marker set - 101 points

• register
• patients with newly diagnosed angina who are
  referred
• patients with record of smoking
• patients who have been offered smoking cessation
  advice
• patients with record of BP
• patients with BP lt 150/90
• patients with record of cholesterol
• patients with total cholesterol lt 5
• patients on anti-platelet therapy or
  anti-coagulant
• patients on beta blocker
• patients on ACE inhibitor
• patients with influenza immunisation

39
Exception Reporting you dont have to count
them if

• Patients refuse to attend three times
• New patients or recently diagnosed
• It is not clinically appropriate
• They have given informed dissent
• They cannot tolerate medication / therapy
• They are taking the maximum medication
• They have another supervening condition
• Secondary care service not available

40
High Trust Reporting

• Data entry as you see patients
• Audit data generated by normal workload
• Annual report on computer
• Almost no claim forms to fill in
• Very little paperwork
• Visit from PCO to verify annual report
• Appeals if you think PCO is unfair

41
Quality Preparation Delivery

• Preparation payments 2003/6 - 3000 per ave. GP
• Count data for all the markers you can
• Decide where you are
• Decide how high you wish to aspire
• Discuss this with PCO
• Receive aspiration payment monthly
• Do the work
• Receive achievement payment at standards achieved

42
Quality points hypertension

• INDICATOR
• register of patients
• smoking status
• smoking advice
• BP recorded in last 9 months
• BP lt or 150/90

• COVERAGE POINTS
• yes/no 9
• 25-90 10
• 25-90 10
• 25-90 20
• 25-70 56

43
Smoking status - BP2

• No on register 100
• Smoking status recorded 70
• Exception reported 10
• No on register after exceptions 90
• Achievement 70/90 77.78

44
Smoking status - Achievement

• Points for 90 threshold 10
• There is also a minimum achievement threshold of
  25
• Practice points achieved (77.78-25)/(90-25) x
  10
• 0.812 x 10
• Therefore achievement 8.12 points

45
Smoking status - cash value yr 1

• Achieved points x value of point x practice
  notional list 55001 8.12 x 75 x
  5700 5500 631.151 5500 average
  practice notional list

46
Smoking status -cash value yr 2

• Achieved points x value of point x practice
  notional list 55001 8.12 x 120 x
  5700 5500 1009.831 5500 average
  practice notional list

47
Access

• Defined in each country
• In addition to Framework
• 50 access target achievement points
• Providing improved access
• Whilst maintaining quality

48
Information Management Technology

• Vital
• Existing systems can cope
• Guidance on Read codes

49
Review

• Expert group
• GPC
• Departments or their agents
• Unspent quality money remains in GMS (Gross
  Investment Guarantee)

50
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

51
New flexibilities of pension

• New options
• treating income from pre-practitioner service as
  GP income
• treating salaried service concurrent with GP
  service as GP income
• pre-GP added years purchase uprating
• Uprating practitioner pension when self-employed
  GP becomes salaried
• Active non-practitioner providers (eg practice
  manager partners) in NHS pension scheme

52
Pensions the accrual rate and dynamising factor

• Accrual Asked for 1.6 from 1.4 - No shift but
  the way pre-GP hospital practitioner work treated
  just under 1.5
• Dynamising Asked for 11 because of 1990-2003
  exclusions - No shift but...

53
Dynamising Factor

• Anticipate pensions will rise by minimum of 25 -
  30 over next 3 years
• Agreed dynamising factor will not decrease when
  OOH transferred
• Succeeded in all GP locum work / NP work
  pensionable from April 2002
• Agreed proportional to actual NHS income

54
Regulatory Framework

• Practice-based contract from 1.4.2004
• Subject to primary legislation
• All payments will then go to the practice
• Practice can choose whether disputes go to
  arbitration or court
• Remedial notices for breach of contract
• Present discipline procedures go

55
PCO powers to commission services

• Subject to primary legislation PCO will have new
  powers to commission and provide services e.g.
  OOH, allocations and support
• GPs have one shot at preferred provider status
  for additional services
• Instead of opt-out seek subcontracting or
  collaborative working

56
Preferred Providers

• GPs are preferred providers for essential and
  additional services
• PCOs can provide GMS themselves
• PCOs can commission GMS subject to value for
  money and probity

57
Choice of practice

• No restriction on maximum list size
• Patients free to register with any practice
• which has an open list
• if they live within the declared practice area
• Patient Services Guarantee
• All patients have statutory right to services

58
Patient removals from the practice list

• Right to remove patients remains
• New obligation to give a reason to patient
• Right to remove violent patients to be extended
  to safeguard
• staff
• other patients
• bystanders

59
Enforced Patient Allocation 1

• Principles
• PCO upholds the principle of list closure
  wherever possible
• Process of allocation is a top-level decision
• Allocation is a last resort process AND PCO has
  to support the practice with resources
• Fast- track appeals process is final stage

60
Enforced Patient Allocation 2

• Stage 1 - 28 days max
• Practice gives PCO notice to refuse patient
  allocations
• Discussion and review with PCO
• Checklist of matters for PCO consideration
• Try to stay open with help
• Stage 2 - 14 days max
• Formal closure notice by practice
• PCO
• either approves 12 month closure or allows list
  to drop to agreed range
• or rejects

61
Enforced Patient Allocation 3

• Stage 3 - 28 days max
• Assessment panel of PCO
• LMC rep, HA director, PCO CE, patient rep
• If list stays open, it must remain open for 6/12
• Right of appeal - fast-track system to StHA/SoS
• Can reapply after 3/12
• If forced allocation then support from PCO
• No special funding for allocated work
• Panel decisions reported to StHA/SoS and must be
  in annual reports and star ratings

62
Partnerships

• No change now
• Major revisions for 2004
• GPC will issue guidance in 2003 after primary
  legislation
• Rolling contract
• Vacancy rules stay only for single-handers
• Single-handed doctors can arrange succession
• Salaried option - model contracts for PCO and
  practice employment

63
Non-NHS Work

• Ministers determined to maintain NHS medical
  services free at the point of use
• Clear definition of services for which the
  practice may charge
• RTA/criminal assault reports
• drugs, supplies, travel kits for foreign travel
• reports and certificates for organisations
• reports for compensation claims
• reports about fitness to fly

64
LMCs in the new world 1

• Analogous to existing role
• Existing legal arrangements will continue in
  respect of
• s44 recognition
• s45 functions of local representative committees
• Levy arrangements continue

65
LMCs in the new world 2

• Involvement in
• Contract review procedures
• Dispute resolution procedures
• Contract variations
• Practice splits
• Breaches and failures of contract
• Commissioning of enhanced services
• Re-provision of additional services

66
Demand Management

• Government recognition
• National body in England
• 10 million
• Promote initiatives
• Evaluate
• Roll out programmes

67
Specific Initiatives

• Self-care - education
• Skill mix - pharmacists and nurses
• Minor illness management
• Expert patients
• to help patients look after themselves
• Patient use of services - DPP
• Changing public behaviour
• Medical certification
• National Curriculum

68
IT

• PCO owns new software and equipment
• PCO pays 100 of all IT costs from 1.4.2003
• Present systems can do quality framework
• Training funded
• Summarising funded
• Service Level Agreements

69
Premises 1

• PCO District Valuer to ensure equity between GP
  developers and third party developers
• Development of new premises and upgrading current
  premises a priority
• New funding available, 200 million for England
  and matched in UK

70
Premises 2

• New flexibilities from 1.4.2003
• New method of funding
• Lead PCO in any area with StHA (or equivalent)
  holding the ring
• Existing funding guaranteed to continue
• Development funding to be bid for by PCO against
  submitted development plans
• Only then will it enter the unified budget

71
Premises 3

• Improved premises quality standards
• Subject to PCO funding DDA compliance where
  possible
• Clear guidance about branch surgeries
• Improvements to cost rent schedule based on need
  for provision rather than size and number of rooms

72
Career Structure

• Modular not linear
• Valuing traditional skills and experience
• Developing skills
• Developing special interests
• Clinical leadership
• Salaried options - practice and PCO
• Seniority payments - new scale from year 1
• No compulsory retirement age

73
Human Resources

• Protected time
• Appraisal
• Good employment practice
• Childcare
• Maternity, paternity and adoptive leave
• Review of sick leave arrangements
• Possible sabbaticals - earliest 2006

74
Salaried Option

• Contract between
• salaried doctor and PCO
• salaried doctor and practice
• Model contracts
• National terms and conditions
• Minimum pay rate and pay scales set by DDRB
• Can enhance but not diminish Ts Cs

75
Seniority

• Begins from start of NHS service
• Annual increments
• Curve gets steeper and smoother over the next
  three years
• Many GPs will jump several increments
• No losers
• 30 uplift by year 2005/06

76
Implications for PMS

• Return ticket for practices
• Single contractual framework by 2004
• Enhanced services funding available for PMS
• Out-of-hours opt-out open to PMS
• Pensions
• Possible use of Carr-Hill formula
• Possible use of quality framework
• Negotiating rights not fully resolved

77
We have obtained...

• Money
• Quality rewards
• Workload management
• Categorisation
• Core/non-core Split
• Improved seniority
• Practice flexibility
• Reduced bureaucracy
• Future-proofing
• Recognition for unpaid work
• Improvements to PMS

• New resources for new work
• End of OOH
• Flexible careers
• Salaried options
• Free IT
• All NHS work superannuated
• Limits on PCO powers
• Transitional payments
• Demand management

78
We have not obtained...

• Full dynamisation factor uplift on moving to new
  contract
• Absolute end to forced allocations
• Compensation for small practices
• Negotiating rights for PMS
• Informed dissent for VI targets
• Practice IT ownership
• Complete change to para 38
• End-of-career retention payments

79
Timetable if we vote yes

• HDs, NHSC and GPC give joint evidence to DDRB
• Money backdated to 1.4.2003
• Practice and PCO preparation and planning
• New contract implemented in full from 1.4.2004
• Enhanced schemes, new seniority scheme and
  preparatory funding for QO - 2003
• IMT modernisation begins

80
Gains in Year 1

• Uplift 3.225
• Quality preparation payments 5.5
• Directed enhanced services
• Change to seniority scales 1.5
• Write-off of overpayment of GPs
• 2.4 in this year

81
This is our New Contract

• Our future
• We all decide

82
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83
Further slides

• These need not be used unless you want to.
  London slides should be shown at a London Roadshow

84
Take practice population

• Weight them for age and gender
• Add uplift for list turnover ( of list)
• Add uplift for residential/nursing homes per
  patient

85
Weight for additional need

• Ill health is the best proxy for clinical
  workload
• Standardised Limited Long-Standing Illness (SLLI)
  and Standardised Mortality Ratio (SMR) the best
  variables at explaining workload variations over
  and above age and sex
• Continuous Morbidity Recording (CMR) in Scotland
• Needs index is derived from this

86
Unavoidable costs

• Market forces factor reflects geographical
  variation in staff costs related to where you
  practise

87
Rurality

• Derived from population density dispersion
• Measures influence of relative rurality on costs

88
Practice population and weighted age/sex
consultation rates
89
Take population after adjustment for census
lists - Attributable data

• Take list numbers x age-sex weightings
• Add per-patient uplift for list turnover
• Add per-patient uplift for residential/nursing
  homes
• Result 35,492
• Normalise actual UK ONS population/total UK
  notional population x result
• Normalised 10,723 age/sex weight of 1.07

90
OOH when no choice

• Retention of agreed OOH abatement
• Further support through the OOH development fund

91
Help for London

• Market Forces Factor
• List turnover adjustment
• Off-formula adjustment

92
London adjustment

• Special provision required
• 53 million per annum
• Distributed on basis of ONS projected practice
  populations
• unweighted for age, sex, additional need

93
Partnership working

• Contract emphasises importance of doctor /
  patient partnership working
• Use of other professionals to reduce workload -
  pharmacists, WICs
• Use of expert patient schemes
• Teaching of minor illness in National Curriculum

94
Negotiating statistics since July 2002

• 8 versions of final document, 140 pages annexes
  
• 2245 documents
• 105 topic areas
• 9 working groups and 60 working group meetings
• 22 joint negotiating meetings
• 47 contract domestic negotiating meetings
• 8 negotiating weekends
• 525 e-mails, 70 with attachments, since 25
  January
• Only 6 days without meetings since 10 January

95
New contract- some of the key principles

• GP time is a finite resource
• No new work without new resources
• Control of working life
• Recognition of the value and cost of providing
  high quality care

96
Workload

• Present contract
• doesnt allow practices to control workload
• delivers insufficient reward for additional
  workload
• inhibits development of new services
• makes general practice less attractive

97
Control of working life

• The new contract will enable GPs
• to take on manageable levels of work
• to obtain necessary resources
• to use resources as they see fit

98
Funding the practice

• Funding will follow the patient
• Practices patients health needs will be
  weighted
• Consequence - resources always available to
  practice, for the practice to decide how to use
  them

99
Dispute Resolution and Appeals

• All contract matters dealt with by dispute
  resolution
• Statutory or similar arbitration procedure
• Very few appeals anticipated
• Appeals include right to practise

100
Workload control and management

• Needs-related practice resources
• New work attracts new resources
• Opt-out provision
• PCO responsibility for out of hours
• Changed allocation arrangements
• Demand management initiatives
• Career development opportunities

101
Dispensing

• Dispensing separated from GMS
• Dispensing payment arrangements preserved
• Addition for transfer of dispenser costs
• Dispensing rights unaltered