IN DECEMBER, agreement was reached between the BMA and NHS Employers to develop the GMS national contract, following completion of the first part of a two-stage review. These changes will take effect from 1 April 2006. Negotiations for the second stage are set to follow the publication of the Government’s White Paper in England ‘Our health, our care, our say: a new direction for community services’ (published 30 January 2006, for implementation from 2007), which tells us more about the implications for primary care. These are far-reaching, and will be examined in future issues of Pf. Key elements of the new GMS contract revisions The new GMS contract that was introduced in April 2004 encouraged practices to improve the care of patients with long-term conditions by introducing incentives for systematic follow-up of patients on certain disease registers. The changes coming into force in April 2006 will build on this work, focusing on the existing and nine new disease areas to extend the benefit of improved care to new patient groups with long-term conditions. However, Quality and Outcomes Framework changes are not the only issues tackled by GMS 2006. The key features of the 2006 GMS agreement include:
The GMS Contract changes in more detail
1. Quality and Outcomes Framework (QOF).
A total of 166 points (out of a new total of 1000) is being reallocated to new or existing areas for 2006–07, resulting in a greater focus on:
Clinical areas whose increased priority is supported by robust evidence. This should have a direct impact on the health of patients with long-term conditions.
Areas where more detailed information is needed to tackle recognised health problems, such as obesity and depression.
Nine new areas – totalling 138 points – are being introduced within the three broad areas of mental health, end of life care and cardiovascular disease:
Mental health (new)
Chronic kidney disease
Obesity Disease Register
A further 28 points are being reallocated to existing areas, with higher thresholds for existing indicators to “encourage continuous improvement and to demonstrate value for money in quality patient care”. Details of these have yet to be announced. Points have been shifted to these new areas from the existing ‘holistic care’ bonus and certain ‘organisational’ indicators, as well as by reducing points for a number of disease registers and completely removing the ‘quality practice payment’.
2. New patient experience survey (England only).
A new, independent national patient survey is being introduced to capture patients’ experience of practice services, initially focusing on access and choice. The results will determine the level of practice awards for payments against the new DESs for access and choice (see below). Alongside this survey, practices will still have the opportunity to carry out an in-house survey and earn points through QOF (survey number 2), and will continue to take part in the primary care access survey (survey number 3). So the next time you visit the doctors, beware of people brandishing clipboards...
3. Directed Enhanced Services (England).
Three new Directed Enhanced Services (DESs) and a revised Access Scheme DES are being introduced in England, and will be available to practices that want to expand or enhance the range of services they offer in return for extra payments. Being ‘Directed’, these Enhanced Services must be made available to practices by every PCT, regardless of its financial plight.
4. Choice and booking (‘Choose & Book’) DES.
This DES will reimburse practices for the additional workload involved in discussing all the choices on offer with patients in secondary care when they are referred for their first consultant outpatient appointment, as well as securing a booked appointment for them. The retrospective DES payment, worth 95p per registered patient, will be based on two measurables:
feedback from the new patient experience survey on whether patients recall a conversation about choices
the percentage of patient consultant referrals that are made using the new booking arrangements.
5. Taking on Practice-based Commissioning (PbC) DES.
A one-year DES with a two-part payment is designed to encourage practices that are not yet engaged to get involved in PbC. These practices will receive 95p per registered patient in recognition of the time taken by practice managers, doctors and nurses to develop and manage PbC in their practice. The practices must draft a PbC plan with specific objectives focusing on, for example, demand and referral management. Payment will be awarded to the practices following agreement of the plan with their PCTs.
The second part of the payment enables PCTs to offer an award of approximately 95p per patient if the practice delivers against its plan. This is paid as an alternative, not in addition to any savings made. It is assumed that full PbC will take over after this first year, and any PbC ‘income’ will have to come from savings against budget rather than DES payments.
6. Information management and technology (IM&T) DES.
A one-off DES worth £70m nationally supports practices adopting Connecting for Health’s programme of IM&T reform. These include the electronic prescription service (ETP), electronic transfer of GP records, Choose & Book, and the NHS Care Records Service. The timing for implementation and one-off payments will vary according to the national rollout of these systems.
7. Access DES (England).
A new DES worth £108m combines the 50 access/money points in QOF and the current 24–48hrs DES. This new package focuses on four key areas:
being able to consult with a GP within 48 hours
being able to book appointments in advance
ease of telephone access (this will be interesting!)
being able to wait for a practitioner of preference (no time limit).
Payment of the DES will be based on two components:
an upfront payment with a firm commitment from practices to deliver on the first three access areas (48 hours, advance booking and telephone access) as well as continuing to participate in the existing primary care access survey (PCAS)
retrospective payment based on results from the new patient experience survey on local access.
8. Childhood vaccination and immunisation (UK-wide).
The GMS contract also introduces improved weightings for the current childhood MMR immunisation payments, as follows:
pentavalent vaccine – 50%
measles/mumps/rubella – 25%
meningitis C – 25%.
9. Dispensing doctors (England and Wales).
A new ‘fee per item’ pay system will be introduced from 1 April. This will remove the link between pay and the cost of drugs, and bring improvements to the system of reimbursement for VAT costs on drugs. It will ensure that the reimbursement for VAT incurred is equal to the actual amount of VAT paid. The VAT changes will only apply to dispensing GPs, who will need to consider registering for VAT from 1 April 2006. The ‘container cost allowance’ for dispensing doctors is being abolished. Dispensing doctors will be subject to new proposals to maintain and improve standards in dispensing medicine, in line with the standards for community pharmacists. Guidance will be published shortly on the need to avoid excessive or inappropriate prescribing; this may have major implications for representatives in rural territories, where prescribing may be influenced by good dispensing deals offered on certain products less favoured by the Prescribing Advisors/PCT formularies.
Where are we now and how can you help?
The General Practitioners Committee issued implementation guidance to GPs in late January 2006. Our next article in Pf will provide you with more details about the changes to QOF and how you can prepare your key customers to develop systems for improving registers and management in the new disease areas before and beyond 1 April, and to develop their business plans for managing Practice-based Commissioning within their practice.
Given the wide range of changes facing General Practice this year (all of the above plus new PCTs/SHAs, Revalidation, PbC and the White Paper), you will need to be sensitive to GPs’ busy schedules and sensitivities around change. Understand that communication of these changes and (practicebased) training on implementation by the primary care team will be high on their agenda. Offer any assistance you can to support their practice training needs and provide speakers for QOF-related meetings, using in-house Protected Learning Time where possible to maximise the learning time available and include the whole practice team.
Identify which changes will benefit your products, and prioritise these in terms of educational support. If your product is not in a relevant QOF disease area, look out for opportunities to piggy-back meetings being organised by others to discuss these changes, as there will be a great many meetings around this topic in 2006.