Paul Midgley of the Healthcare Partnership reviews the impending new GMS contract-related ‘Quality and Outcomes framework’ (QOF) practice assessment visits that every PCT will be making on every practice across the UK during the period October 2004-January 2005. This article outlines the process, the concerns this will raise for practices, and how you can use this as an opportunity to support key practices in their hour of need and boost your credibility and contacts with key target customers into the bargain.

Introduction

The new GMS contract, introduced into General Practices across the UK in April 2004, brings with it a platinum-plated, (voluntary) incentive scheme (QOF) for all practices to earn substantial additional income in addition to their guaranteed patient population-based monthly payments (known as the ‘Global Sum’ for GMS practices). Practices engaging in the QOF scheme achieve points by providing a wide variety of chronic disease management and practice organisation services to nationally prescribed standards (email HCP for details of the QOF scheme – see next page). An average sized practice, achieving full marks in the QOF scheme (1050 points), will earn an extra £78,750 in year 1 (April 04-March 05) and £126,000 in year 2 (April 05-March 06). It is estimated that by the third year of the contract, high achieving practices could derive a third of their income from the QOF! Needless to say, every practice is actively engaged in trying to gain as many points as they can – because as we know, points make prizes . . . With this much money at stake, the Department of Health has insisted that PCTs ‘risk manage’ the process by visiting each practice involved in the QOF scheme, to verify certain aspects of their compliance (including fraud prevention), and to help practices to aim high and achieve good results, as this benefits both patients and practices alike.

Where are we now?

Every PCT has now appointed QOF Assessment visit teams, each team comprising the following roles at a minimum:

Timings around the QOF Assessment Visits

Here are the timelines of the visit process, which all occurs within a 2 month period around the visit date itself. Every practice will be visited within the period October 2005- January 2006.

Outcomes of the QOF assessment visit for every General Practice

Areas of QOF requiring written evidence from the practice for the visit

Practices will be sent a 20-page pro-forma inviting them to submit written evidence of achieving standards against individual QOF indicators under the following headings:

Support required to make QOF Assessment visit process a success

The following areas require training and meeting support:

What can you do?

Does your product help practices meet key targets outside the chronic disease areas where you may well have already been focusing, for example, smoking cessation? Are there any areas above where your company provides training or information that will help practices provide written evidence that they have achieved the required standards? Look carefully at the QOF indicator areas mentioned above (contact HCP for a copy of the full QOF indicators document).

What have you got to lose? Customers will be impressed at your knowledge, delighted that you are taking an interest, and keen that you are helping wherever you can. You in turn will gain better access to key customers, and will sell more as a result . . .

The CONCLUDING CHAPTER to this series of the NEW GMS CONTRACT distills key points for those representatives selling products within therapy areas

Conclusion: CONTRACT FACTS 46-50

OMAR ALI is the Formulary Development Pharmacist for Surrey and Sussex Healthcare NHS Trust and is a PCT Formulary Adviser to 2 PCTs. He is a lecturer on the MSc on Pharmacy Practice at Portsmouth University and is also an adviser to three Drugs and Therapeutics Committees in the South of England. Omar is a National Speaker in the UK (cardiovascular, diabetes, mental health) and is an Executive Board Member for the National Obesity Forum. He can be reached directly on ‘alipha@aol.com’

CONTRACT FACTS 40-45!

40. Selling in Mental Health: There are only 41 points available for mental health as a therapeutic topic but interestingly another 4 points appear in medicines management chapter (identifying non attendees for those who receive regular neuropleptic injections). So pharma companies need to really see where products may be aligned to aid in achieving these. By far the largest weight goes to review of patients with long term mental health problems (23 out of the 41 points). These problems will need a value-added-service approach.

41. THINK POINT PF: I am a little perturbed at the vagueness of mental health in the GMS contract. Of the 41 points, 7 points for creating a register, 11 points for dealing with lithium and the rest on the ‘review’ of the patient. This review covers 3 areas: physical health of the patient, co-ordination with secondary care services and – review of prescribed medication. The maximum threshold is 90% so there is a lot of room to manoeuvre if practices want to take an interest in earning their points this way. But notoriously, dealing with mental health, sorting out medication, trying to improve patients lives is often just too lethargic for primary careto take initiative on. I think that pharma companies are going to really have to consider far more than just ‘product features and benefits’ here. Unless a company has created a serious attempt at ‘branding’ themselves as leaders in mental health with the offer and ability to gear themselves as main players at the primary/secondary care interface then there is a danger that the GMS contract changes nothing for patients in this section of our society. Worryingly, the absence of specifics (for example – why is depression not even mentioned once?) with lots of points created ‘vaguely’ may result in an apathy here (that already exists). Without pharma companies pushing the envelope in mental health I worry for the sanity of all of us! Don’t forget that secondary care is still leading on trends and referrals for new ideas. Primary Care is good at blocking new drugs and cutting budgets, but secondary care is still where leading therapies are tried, new advances advocated and KOLs will still want to do the best for this group of NHS ‘clients’.

42. Selling in Epilepsy: There are even fewer points in epilepsy management as there are in mental health! Of the 16 points available, the creation of a register of patients who are on anti-epileptics (2 points) is the easiest. The rest of the 14 points apply only to 16yr and above and cover 3 areas: seizure frequency and medication review (4 points each) needs to be done within the last 15 months. The % patients convulsion free within the last year is worth an extra 6 points.

43. THINK POINT PF: Come on epilepsy companies! What are you waiting for! Sure there are not many total points for epilepsy but with a little help from you and your company we can get this topic done and dusted. Think about your product – what’s the data like on seizure frequency? Do you have medical information versus another competitor or as an add on showing seizure free in patient groups? Then get this data in front of us! Companies who are not dealing with patient groups here are missing out – it’s the way forward and epilepsy is no exclusion here. One problem I have noticed is that primary care often just wants to ‘refer’ everything. Fair enough – let the specialist organise care plan and juggle treatment. But the patient needs babysitting’ in primary care and with out good review secondary care management becomes more akin to complicated interference. Pharma companies that can smooth out this process will be on to a winner. Tolerability of anti-epileptic medication is a key area for problems and data is often confusing and conflicting. I am yet to meet a company representative that can make this clear! I am as confused as the rest of them! Finally, care for the patient needs. Driving license problems, prejudice in public, weight problems and behavioural interactions are all peripheral to care but often central to the patient. Ask yourself – does my company take this seriously! If not – change their view – or change the company you work for.

44. Selling in Respiratory: Life is very heated here. Lots of strong products. Lots of very committed competitors. Significant and increasingly vocal patient voice and lots of points! Having recently presented at the annual British Lung Foundation patients & carers group I found the whole experience deeply moving. I had to tone down the humour as significant laughter caused respiratory distress. I had never really appreciated how significant that was.

45. THINK POINT PF: There is a total of 117 points in respiratory medicine split unequally between asthma (72 points) and COPD (45 points). This is such a competitive area to sell within. Some companies have significant ‘branding’ in respiratory medicine (Allen & Hanbury’s) which represent almost unparalleled commitment to airways disease. This has led to original and diversified strategies from other pharma companies (ie Altana’s patient initiatives) which are proving impressive. Companies torn between asthma and COPD would do well to see how the new GMS contrasts the 2 diseases. To produce a register of asthma patients is 7 points whereas COPD registers obtain 5 points. Confirming diagnosis with spirometry in asthma patients 8yr+ provides 15 points compared to COPD which provides 10 points if reversibility is also documented. Lesson – spirometers are desirable and so is the avoidance of so-called ‘doctor diagnosed asthma or COPD. It appears that objective measurements are wanted. Ongoing management of asthma provides the remaining 50 points though when examined in detail, the ‘asthma review; will give 20 points. The rest comes from recording smoking status, offering smoking cessation and jabbing with influenza vaccine. Strange in that whilst most of us do not deny the importance of smoking or flu jab, there appears nothing very specific tailored to asthma therapy as has been described. In fact, even if you hit all the above points, anyone treating or selling within the asthma disease area will know that this will not necessarily provide good control of the disease. Ongoing management of COPD provides 30 points (equally provided by 5 areas). Whilst smoking status, smoking cessation advice and flu jabs also feature, here we also see 6 points for recording a FEV1 and another 6 points for checking inhaler technique. I think companies may feel something more tangible to focus on here. Inhaler technique is an onerous task and one that pharma companies will begin to seek out as a service add-on. Just thinking back to my BLF presentation – what if every patient in that room had their inhaler technique checked before entering the room! Just a matter of time before this starts to happen in local areas and surgeries. What’s more – why was inhaler technique left off from asthma? Is it less important that they know how to use inhalers than those with COPD? Also of significance look at the maximum thresholds for achieving the asthma quality indicators versus achieving COPD indicators… surprised? I am.   

A year ago, the leading editorial in the British Medical Journal heralded the opportunities for improving health outcomes with the new GMS contract but predicted that the transition would not be smooth. The new contract begins this month but some important questions remain unanswered. In this article Paul Midgley highlights the help Practice Managers need to seize the opportunities that the new contract presents, in the knowledge that this will boost your access and sales.

BACKGROUND The four key aims of the General Practitioners Committee when they entered negotiations on this contract 2 years ago were:

• Improve (GPs’) working lives
• Attract extra funding into General Practice
• Improve recruitment and retention
• Improve services for patients

The success of the contract from a GP’s point of view will be judged against these aims. Practice managers have a crucial role in managing change in their organisations and will find many opportunities within the new contract to improve things for both patients and staff, and increase income.

KEY CHANGES COMPARED TO THE OLD CONTRACT The fundamental changes are listed here.

• Practice-based contract with PCT - individual lists will cease
• Funding based on patients not doctors
• End to 24 hour responsibility
• Choice of services to offer
• Quality-based incentive scheme
• Enhanced services shifting services from secondary to primary care
• Predictable higher monthly income = improved cash-flow = better business planning

The final point is perhaps the most important driver of change, as the running of the practice business should be facilitated by PREDICTABLE monthly inflows of EXTRA cash. This stability allows for better, longer – term business planning around services, people and premises.

NEW SOURCES OF FUNDING FOR PRACTICESThis is an important chart as it clearly emphasises where changes are most likely to occur – where the greatest amount of new money is available. This highlights the huge importance of the Quality Framework (QOF) to practices. QOF’s value to the practice could rival income from the Global sum once they achieve high QOF points levels. It also highlights the importance of using the Quality Preparation payments and QuIPP payments (for summarising notes) to re-design internal processes to maximise QOF points. These payments are not there to top up the GPs’ income!  Some existing funding pots have been increased significantly (Seniority and pensions for GPs). There is some re-branding of existing monies (Directed enhanced services, Local Enhanced Services). Other new sources of funding other than QOF include a small amount for National Enhanced Services (many PCTs have not commissioned these this year!).

There are new schemes to help repay grants, rent etc on premises. Practices will pay less on IT (responsibility for maintaining and upgrading IT now rest solely with PCTs). If you want to know more about practice funding under the new contract, read the Statement of Financial Entitlements (http://www.bma.org/ap.nsf/Content/Hub+GPC+contract) so you are clear.

WHICH SERVICES WILL PRACTICES OFFER? Practices have agreed with the PCT which services the practices will provide over and above the basic requirements of Essential services in 2004/5. Their PCT will have confirmed which of the Enhanced services the practice will be commissioned to provide in 2004/5. Practices should already be thinking ahead to 2005-6, and discussing internally, and with the PCT, which National Enhanced Services (NESs) to provide in 2005/6, as PCTs will look to increase the range of NESs that are offered in year 2 as they shift funds away from hospital providers.

KEY ROLE FOR PRACTICE MANAGERS – CHANGE MANAGEMENT AROUND QOF A key NEW role for practice managers is to lead the practice to achieve the maximum points possible under the QOF because points mean prizes! Some practices (paperless, ex-fund holding or early wave PMS for example) really do expect to achieve maximum points in 2004-5 and larger practices will benefit from six-figure boosts to their income. A practice’s big incentive to strive for maximum points in 2004/5 is the link to year two’s monthly ‘aspiration payment’. 60% of year one’s ACTUAL points value will be paid monthly over year two at the much-increased pounds per point rate. Even average sized practices, performing to a high level (over 850 points) will benefit from six-figure boosts in income in year two.

Healthcare Partnership’s most popular training workshop this year has been ‘Maximising Practice Income through your Practice Development Plan’ and we expect this to continue throughout 2004.

QOF PAYMENT All QOF points convert into cash. Achievement payments will be paid to practices in April 2005 from a DoH master computer system (QMAS) which reads from all the major practice IT system suppliers (e.g. EMIS, Torex, Vision). This means that practices will only get paid for what QOF work has been done if their IT system faithfully records and reflects this work.

Details of consultations with patients occurring outside the practice also need to be entered onto the practice computer – currently many are not. You could help here – why not provide paper copies of the relevant templates for doctors/nurses/health visitors doing domiciliary visits so they can collect the necessary information relevant to the patient’s condition for the QOF? Finally, for the 10 chronic diseases, the pounds per point will also be determined according to the practice’s disease prevalence compared to national data. Once QMAS goes live (August 2004), practices’ disease registers data will be collated across the UK, and then by dividing the register by the list size, to give disease prevalence. Practices with relatively high disease prevalence compared to national average will need to work harder to achieve the targets set in QOF so will get higher payments per point; those with lower than average prevalence will receive less per point.

LEADING ON LEARNING UNDER NEW GMS – FUTURE OF PHARMA SPONSORSHIP A practice’s ‘Global Sum’ now covers ‘protecting’ time for PDP, PPDP and appraisal preparation. PGEA NO LONGER EXISTS! PCTs may continue to provide Protected Learning Time sessions – if they do, practices will fight to use this time for practice-based sessions wherever possible, though clearly PCTs will still want to run localitywide sessions where essential briefing and training is required.

What do you need to do to continue to support learning events?Work closely with PCT education and training leads, GP tutors and PLT organisers so you know what events are planned for the year ahead. Work closely with Practice Managers in target practices to ensure you know the practice’s learning needs, and support their inhouse training sessions. Help them put together their PPDP (or work with an external supplier, e.g. Healthcare Partnership) so you can really understand their needs and identify solutions. Practices will use their practice-based PLT to plan ahead, to train staff in line with their PDPs, or the practice together on its PPDP/joint learning (e.g. Significant events audits). These events offer sponsors a great opportunity to really understand customers better and develop close joint working.

LEADING IM & TResponsibility for IM&T maintenance, and purchasing of new kit (hardware and software) becomes the responsibility of PCTs under the new contract. For IT-literate practices, this may be viewed as hugely constraining, but for the majority of practices, this will reduce costs significantly and SHOULD still provide as good if not a better level of IT support service. PCTs will enter into pan-PCT service level agreements PHARMACEUTICAL FIELD ISSUE 4 2004 33 Contact Healthcare Partnership on 0870 2413506 or by email at enquiries@healthcarepartnership.com for details of our training and development services, for testimonials from our extensive list of satisfied customers and for opportunities for sponsorship in your area. Copies of the Practice Management Competency Framework can also be obtained from Healthcare Partnership. with IT suppliers providing better service than would be possible for individual practices. For practices with poor IT, this is very good news as they won’t have to pay for a shiny new GMS compliant system. IT is important for 2 reasons – firstly achievement of QOF points depends on it, secondly, as a stepping stone to Patients Electronic Health Records by 2010. Practices are being encouraged to move paperless as soon as possible hence the funding support for summarising through QuIPPS and the target of 60% by 31st March 2005 for a QOF payment.

LEADING RECRUITMENT AND RETENTIONPractice managers face a huge challenge to recruit and retain good staff. With more and predictable monthly income, practices can afford to employ more or better paid staff. This involves a people capability review. Are the right people doing the jobs most suitable to their skills? In the past, it was a catastrophe if a GP left the practice and they couldn’t recruit as it affected practice income. This drove many practices into PMS. Now, this is no longer an issue, and retirements and resignations present an opportunity to review how the same level of service can be provided by utilising other professionals (e.g. nurses) to take on the bulk of minor illness and routine chronic disease management, and freeing up their time by recruiting or training up administrative staff to perform basic health checks, taking blood pressures, etc. Many (PMS) practices in difficult recruitment areas have been forced to innovate along these lines and have developed successful models for a broader-base of service provision. Clearly this requires that there are nurses to recruit or a willingness to be trained, and the funds and training available. Practices need help with this training – PCTs don’t have much funding so it either comes from Global Sum, or an alternative source – Pharma! Are you ready for this?

LEADING PRACTICE MANAGER AND TOP TEAM DEVELOPMENT The new contract heralds the way for a more complex practice organisation with a greater income stream, more staff, certainly more regulated and IT based. nGMS Annex C (practice management competency framework) recognises the pivotal role played by Practice Management team. This framework will help practices benchmark their current performance to systematically plan to develop the skills required to move the practice towards a more corporate business approach. It will help identify what new skills are required in new recruits to senior positions. An integrated management team may involve the practice manager at the centre providing vision and momentum to the rest of the senior managers (which may well include GPs, senior nurses, IT managers and possibly others in a large practice). Clearly, this will be a challenging transition for many practices and external facilitation of Practice Management Competency development is advisable. It also provides an opportunity for you to help. If your company is unable to provide this for practices, contact Healthcare Partnership for help. The importance of non-GP members on the practice leadership team is recognised in the new contract allowing non-GPs to co-sign the contract alongside at least one GP. Some PMS practices are already led by non-GPs – the new GMS Contract allows GMS practices to provide parity for indispensable non-GPs , opening the way to them becoming partners.

PRACTICE MANAGER EDUCATION Practice managers have a big responsibility to develop themselves. PCT-provided protected time, for example for monthly Practice manager forums, should become a standard commitment in their diary. Increasingly these meetings may be extended to incorporate specific training to develop key areas around the competency framework. PCTs, the Modernisation Agency and NHS University will all provide more qualification-based learning opportunities for those practice managers keen to development themselves (but not the funding!). Ambitious practice managers will seize this with both hands and develop themselves. This will increase their bargaining power at salary review and could prompt an invitation to become a partner in the business if they really excel.

CONCLUSION – WHAT HELP DO PRACTICES NEED FROM YOU?Practice managers never have been busier, so if you understand their priorities, you will know where you can help your key practices most. Where should you think about helping?

There has never been a better time to work collaboratively with key customers as their needs change and opportunities beckon. Get help from internal company resources to keep your costs down, but be aware that some practices may have a problem with ‘getting into bed’ with one company, and indeed may not be happy for company personnel to facilitate their business planning due to the sensitive nature of issues that may arise. If this is the case, an external agency such as Healthcare Partnership may be preferable. We can also help your budget stretch further by involving other sponsoring companies to cover the cost. Contact Healthcare Partnership on 0870 2413506 or by email at enquiries@healthcarepartnership.com for details of our training and development services, for testimonials from our extensive list of satisfied customers and for opportunities for sponsorship in your area. Copies of the Practice Management Competency Framework can also be obtained from Healthcare Partnership.

10 Things You (and your customers) ought to know about the Consultant’s Contract - (Part 5 CONTRACT FACTS 31-39)

31. Consultants Contract: Hospital Consultants also have the bane of their life trying to sort and organise their contract. There are many differences not just in structure of the consultants contract but also in the essence of what the implications are. The consultants contract doesn’t have any points nor does it have any prizes. Begs the question – what exactly is in the consultants contract?

THINK POINT PF: The consultants contract is more along the lines of an ‘employment’ contract. It’s more about salary, working hours, on-call and training rather than the new GMS contract which is much, much more than that.

32. Who implements the consultants contract?: The consultants contract was initially pushed nationally by the government. This didn’t work – so the consultants contract needs to be ‘agreed locally’.

THINK POINT PF: This is not good news. The government didn’t get their way. They were unable to push the small print. So what they are now doing is saying ‘agree locally’. What this means is that some poor soul (usually the medical director) now has to push this contract locally in their own hospital trust. This person is not Mr/Mrs Popular right now. They will be facing the brunt of any reprisals, disagreement, discord and anti-contract feeling that may exist.

33. So what is in the consultants contract?: A significant imperative is a much stricter definition of the contractual commitments for the consultant. For example, core contract of 10 sessions is highlighted with fixed sessions to include on-call, all clinical work, teaching & audit!

THINK POINT PF: Consultants will be earning higher salaries (mean starting jump from £55000 to over £80 000) but will be working hard! Any extra work will be remunerated as ‘additional sessions’. However annual job plan review will be linked to appraisal and subsequent adherence to the new contract.

34. Key Points on the Consultants Contract: A significant imperative is a much stricter definition of the contractual commitments for the consultant. For example, core contract of 10 sessions is highlighted with fixed sessions to include on-call, all clinical work, teaching & audit!

• Overall increase in consultants pay
• Consultants expected to be on site when scheduled for NHS duties
• Strict adherence to contract replaces the 10% limit on private practice
• Significant change in working patterns and on-call site residency and accommodation
• Average 48 hr working time directive not to be exceeded
• 5 yearly career development review to allow portfolio career & less on-call later on
• Incremental pay for professional performance rather than short term bonuses
• Provision for sabbaticals, CPD leave and assessor duties
• Increase availability for part-time & flexible working hours
• Measures to retain consultants who seek early retirement

35. So what’s being contested?: Varied grading of consultants (ie junior consultant & senior consultant) has been rejected outright. On-call payments are being thrashed out (the Paris Test) Enforced reduction in private work (significant politics!). Also the way in which consultants receive merit points & discretionary points to their salary is being reviewed and amended.

THINK POINT PF: The Medical Director of the Trust has a significant job here! Some understanding of this conveyed to the medical director will be received compassionately right now. This task is a lonely one and everyone can seem against them. Your rep-friendliness and ability to influence one of the key medical members may pay off later in life! Everyone will be asking for higher on-call (see Paris Test) and working around private clinic commitments. Leave cover & rotas are very hot topics indeed. Also very contentious – the backpay the consultants are demanding for increased salary!

36. What about on-call?: This is interesting. It’s probably the most contentious part of the consultants’ contract currently being implanted. The Paris Test refers to on-call payment scales based on ‘whether or not on call involves visiting the hospital’.

THINK POINT PF: If you really want some sparks to fly at your lunch meeting or a hospital KOL evening seminar bring up the Paris Test! Sure way to get things into a ‘heated debate’ it goes something like this. Consultants receive a % increase on their salary for doing on-call. However, this can range from 4% - 10% + this depends on 2 main factors – how frequent is your on-call rota & when you do get called, do you have to come in. Regarding the rota – a minimum set of 1 in 5 defines criteria for higher payment. However, the wording is ‘rota’ and not ‘cover!’ So most consultants may be down for 1 in 5 rota but due to cover, leave, sickness, etc, end up covering 1 in 4 or even 1 in 3! Well – the contract says – tough. It’s what you are down for the rota not cover! Not friendly! Also – some consultants will be on 2 separate rotas – where each rota is more than 1 in 5 but together leads to very frequent on-call. Yet again – tough.

37. But what about the Paris Test itself?

THINK POINT PF: If you are a consultant on-call do you ‘usually’ have to visit the hospital site. Now – what does this mean? More common than not? (ie over 50% of the time) All the time? Some of the time? Relatively frequently? Hence the Paris Test asks whether or not you could manage the problem from Paris !!! Or – would you have to be on-site!! As you can see – it’s open to perceptions and believe me, these perceptions are being put directly to the medical director demanding ‘higher scales’ of on-call payment. What’s more – the medical director cannot just award based on the each and every argument. For the government has allowed only for 40% of all consultants to claim the ‘busy on-call’ and the rest to take ‘lower scale’!! So the chief executive will not accept the whole of the consultants’ staff to receive ‘higher grade on-call’ remunerations!! I would not want to be the medical director who has to set these limitations… Furthermore – there is room for manoeuvre in the Paris Test which asks ‘does your on-call involve complex telephone conversations’!!! What does that mean? I suspect all consultants will say their on-call involves this!! And hence demand higher scale remunerations!!

38. So what will happen to on-call as a result of this?: Firstly we will see a lot of toys being thrown out of the pram. Secondly – those physicians that are awarded higher scales will probably do what they currently do. But what about those consultants who are forced to accept ‘lower scale’ % for on-call because they do not meet the Paris Test criteria?

THINK POINT PF: Well – it’s obvious. If they do not get the higher pay for complex calls & visiting on site you can be guaranteed 1 thing. They won’t come in to hospital and won’t spend time on the telephone. The Trust can’t have it both ways. I do hope that if I ever have to go to hospital and the junior phones the consultant on-call, that he/she is getting paid a higher scale. Otherwise, not only will they not come in to see me… they may not answer the phone…

39. Views from Questionnaires: Whilst questionnaires are only snapshots at certain time frames they do make for interesting previews. This one is from 195 specialist registrars prospective to be consultants, anonymously responding to set questions.

THINK POINT PF: I have picked out some interesting ones. For example, whilst 70% said they were prepared to be resident on-call consultants (remember extra pay comes in) over ? would not accept the 7-year ban on private practice (initially proposed by the government). In fact over 80% stated they would be prepared to take some form of industrial action when original government proposals were put to them!! Many still feel that the starting salary is not high enough and would want to seek alternative ways of working (retire from NHS and set up ‘chambers’ who would set sessional fees to work. Bit like a GP saying rather than work a full day week with all the politics of the PCT, NICE and NSF, they will forget being a practice partner and do 1-2 days a week locum/oncall – where they could earn far more, with far less hassles!! What a way to run the NHS!

OMAR ALI is the Formulary Development Pharmacist for Surrey and Sussex Healthcare NHS Trust and is a PCT Formulary Adviser to 2 PCTs. He is a lecturer on the MSc on Pharmacy Practice at Portsmouth University and is also an adviser to three Drugs and Therapeutics Committees in the South of England. Omar is a National Speaker in the UK (cardiovascular, diabetes, mental health) and is an Executive Board Member for the National Obesity Forum. He can be reached directly on ‘alipha@aol.com’

There are now dozens of articles in the pharmaceutical and NHS journals describing what the new GP Contracts are and how they will operate post April 2004, this article seeks to examine what the commercial implications might be in relation to field sales activity and the importance of understanding the altered dynamics brought about by the outcomes focused contracts.

Background

Firstly, a reminder as to what the contracts mean. There has been something of a feeding frenzy around the new General Medical Services (nGMS) contract, but remember more than 40% of GPs will be paid under PMS so it is important not to focus exclusively on nGMS but to regard nGMS as part of wider contractual and ways of working arrangements in the NHS and only one of two ways to reimburse GPs. Now all the negotiations are over and the ‘aspirational’ bids are in, just who is “going to make it happen” and what are the worries? Of course, there are many stakeholders in the implementation process, the GPs, Practices, LMC’s, PCTs, SHAs, the Modernisation Agency, to name but a few. But, in respect of the detail that needs to be mobilised before April 1st 2004 there are 3 key groups: the GPs, the LMCs and the PCTs.

From a GP/practice perspective the tasks between last summer and April this year lies around deciding on how they wish their contract with the PCT to shape-up:-

• Do they want to opt out of additional services (eg: Vaccs and Imms, cervical screening)

• Do they want to opt-out of out of hours (OOH) - 1 PCT I spoke to anticipated 85% of practices will opt-out

• Which national enhanced services (eg: depression, drug and alcohol misuse, MS) might they want to opt into

• Which local enhanced services to they wish to opt in to.

There has been a tidal wave of advice to GPs in respect of where their priorities might lie in order to ensure they get the most financial gain from the new contract. For some, delivering on just a few of the possible high revenue-earning priorities outlined in Tables 1 & 2 will be easy because they are already delivering on NSFs, targets, implementing NICE guidance and are fully computerised. For many the new contract represents a highly prescriptive method of payment, which will necessitate significant behavioural change at professional and practice level.

It is the PCTs however, who will face the biggest challenge in respect of implementation. In addition to the existing responsibilities of local health strategy delivery, financial balance and delivering sustainable local health improvement, or even worse an imminent CHAI review, (or recovery from a CHAI review!) they now have to plan the roll-out of the new contract. The pharmaceutical industry therefore must proceed with caution ensuring that PCTs are engaged in the process of driving through initiatives in the name of nGMS and PMS as they remain the payors, and although it will take many months for the new contractual schemes to bed in, there will come a time when the PCT decision makers will take an interest in points generating projects for general practice that increases their infrastructure and prescribing costs.

New General Medical Services (nGMS) Behavioural Changes

Last year HealthGain Solutions worked with industry leaders developing their strategic response to the new contract. Naturally, most have focused on the quality components; some are becoming attracted to the National/Local Enhanced Services component. Michael Sobanja NHS Alignment Director at HealthGain Solutions believes “our clients are developing integrated solutions between PCTs and GP practices, rather than tactical quick fixes at practice level alone. As far as possible we believe solutions should align to the “ payment by results” system. The guiding principle for marketers who really believe in addressing customer need should be to work on initiatives that help the NHS meet its strategic objectives, the contract itself will see dramatic change in local policy and prescribing patterns”

Programmes which PCTs and practices with whom we are working with value, include: -

• Supporting the training and development of GPwSIs

• Project teams undertaking gap analysis of specific quality areas at practice level and developing action plans to address them

• Project managers to develop and implement action plans once LES priorities have been agreed

• Medicines management review strategies and team resource to do the work

• Facilitating patient group meetings to drive the patient agenda.

We asked a number of GPs and PCT PEC or Board members about issues during the implementation phase and have identified a number of common concerns. Dr Tony Brzezicki, a GP, and Prescribing and Cancer Lead from Croydon PCT explains “The clear objective within the new contract is outcomes, the concern for the PCT therefore is that an outcomes focused practice is not necessarily drugs focused, therefore the drugs guidance and formularies may go out the window”. He continues, “An example of my concern will be if a GP wants to get to target quickly in respect of cholesterol lowering then they will go to a higher and more expensive statin dose level earlier than recommended by local guidance, this could lead to a lack of goal congruence between the individual GP, practice and PCT”. Dr Duncan Jenkins, (Specialist in Pharmaceutical Public Health, Dudley PCT) sees the contract creating even more pressure on PA resource for the PCT “..where services such as prescribing support have been commissioned by the PCT, in the future, employment may be secured by the practices, especially as the opportunity for a pharmacist to become a practice partner evolves”

Impact on Field Sales Activity

It is clear then that the nGMS and PMS contracts, whilst creating opportunities for improved care and joined-up services, creates a selling environment that is complex and evolving. GPs and members of the practice are focusing very much on delivery and this presents the pharmaceutical industry with some real barriers. Dr Jace Clarke, a GP and Chair at Horsham & Chanctonbury PCT comments “Everyone in Primary care is totally focussed on the new contract at present so difficult to get anything done unless you are ill”. Dr Clarke’s comment is not an isolated one; many GPs throughout the country will feel the same way. It is also possible that GPs will favour seeing representatives from companies who have valuable information and perhaps initiatives that help them reach their contracted goals in the ten areas of most interest to them. Some local service delivery issues linked to quality and outcomes framework (e.g. CHD, Diabetes, COPD) may determine which companies are more attractive to receive calls from. As a natural progression from this, will the appointment management system in the practice be set up in such a way to allow the practice to earn more points within the outcomes and delivery elements of the contract? Will this mean that practices will prefer to open their diaries only to pharmaceutical companies who have a drug or service that will assist in this endeavour, speculation I know but this is a good time to think the unthinkable.

There are of course many more examples of GP and PCT concerns and indeed opportunities. As an industry, we must continue to measure where PCTs are with the implementation plan and its rollout post April 2004 and ensure we look beyond the obvious alignment opportunities and develop innovative solutions through really understanding the challenges facing all stakeholders, not just the GPs.

21. Enhanced Services: The GPs should have got copies of their enhanced services, particularly DES & NES. These are vital (cost £5 per copy) and are available on the internet. These are important for GPs when deciding which activities will get them payments and which ones won’t.

22. Directed Enhanced Services (DES): The DES represent national benchmark for services that are essential for PCOs to commission. THINK POINT PF: The DES are literally ‘directed’ by the government. Hence there is no question of choosing whether or not to deliver these. They are a national requirement for all PCOs and a national pricing structure for payments will exist. They include services to the populations, improved access, dealing with violent patients, quality information, childhood vaccines and advanced minor surgery. If for example you represent a pharma company selling vaccines for children, these are essential pharmaceutical goods. To a certain extent, they always have been. Consider your self lucky… many representatives are selling good, cost-effective drugs for diseases that are just not high priority at the moment.

23. Enhanced Services: There are 2 types of enhanced services that fall under DES. There are the ‘essential / additional’ services which are at higher standards (ie extended minor surgery and then are the services not provided under the essential services. They will be specialised services delivered by staff who have been trained in that remit. THINK POINT PF: The specialised services will be of significant interest to pharma companies. Why ? Because here lies the remit behind all of that you tout. Working at the interface, treating specialised patients and meeting their needs and of course training of staff to empower them in their newly found speciality. Furthermore, we will find new pilots of interface clinics and specialised services started under this remit. One important point – funding follows the patient, or the service - not the drug- an important distinction.

24. Essential Services: Also under national direction with regards to payment benchmarks, the essential services cover three main areas. Patients who are ill/believe themselves to be ill whereby recovery from condition is expected, patients who are terminally ill and finally patients who have chronic diseases whereby the practices may plan how exactly they will be managed.

25. Additional Services: Covered in last issue : the 6 areas of cervical screening, child health surveillance, contraceptives, vaccinations and minor surgery. THINK POINT PF: The global sum (2/3 of salary) is aimed to deliver the essential and additional services as well as provide some staff costs and locum fees. The remaining 1/3 is the points, prizes, etcetera. So thinking from a GPs workload perspective there is much that can go wrong here. The global sum is ‘calculated’ (using the Carr-Hill Formula) which is then applied to the ‘practice register lists’, So what happens if you have more patients than are officially ‘on your lists’ ? Or what happens if the workload is far greater than the Carr-Hill has calculated in your favour ? Well what happens is the GP receives a fee which doesn’t reflect the workload he/she is doing. In fact, this is exactly what is happening all over the country.

26. Nationally Enhanced Services (NES): Although they have national benchmark pricing schemes they are not ‘directed’. These would include anticoagulant monitoring, IUD fitting, specialisation in depression/sexual health, minor injuries and others. THINK POINT PF: This is very important. Whilst the NES are critical services to patients, the fact they are not directed means that not all GPs will be doing them. In fact they will local contracts to provide these services. This will lead to the development of Local Enhanced Services (LES) which will be locally negotiated and involve some of the opting in/opting out scenarios, described in previous issues..

27. Minor Surgery: These are sub-divided into 2 parts. Almost every practice is doing some sort of minor surgery at the moment. These practices have preferred provider status, hence the PCT has to offer work at least to the volume of current work load It’s is not always easy for practices to evaluate just exactly what services they want to offer and continue with. THINK POINT PF: It’s going to be tricky to get agreement on this all the time. What about services offered by a GP who is off sick – or away ? Does the service just stop for a while ? Or does a partner from the practice provide back up ? What if he/she is not interested in this new service or is not trained up ? Interesting…

28. Paperless Practices: Some practices are already ahead of the game. In fact not only are they going near-paperless, they result halved receptionist times. Hence, receptionists are being trained and used as a nurse assistants. For example – does it take a nurse to ask a patient with COPD if they smoke, if so how many, and whether or not they would like some help stopping. THINK POINT PF: I would be surprised if you are not already seeing receptionists trained up to do blood pressures, simple screening and other tasks. Remember previous issue and points on how staffing will be reimbursed. There is mixed feelings from nursing staff – ask them about it. This new contract is affecting everyone like no other has ever done.

29. Read Codes: GPs need not waste time re-integrating new codes. It will be a waste of time. Systems will now have templates for disease areas related to quality frameworks. These templates allow simple tick boxes for framework and hence allow for simpler management. THINK POINT PF: Many of the GPs seems genuinely confused over this. Re-typing codes, re-stratifying indices. None is required. New system should allow the computer to do the all the work. There are over 150 read codes and to try and refit them all in to the new contract is hefty. However errors are already emerging and some paranoia around the ability of these systems to extract the correct coding (which will eventually lead to subsequent payments) is probably not a bad thing.

30. What about the consultants contract? Interestingly I have received significant requests relating to this. In particular, what are the differences and how do they relate to the GP contract. So frequent this has been that I have decided to cover some elements of this in the next issue of THE MATRIX.

OMAR ALI is the Formulary Development Pharmacist for Surrey and Sussex Healthcare NHS Trust and is a PCT Formulary Adviser to 2 PCTs. He is a lecturer on the MSc on Pharmacy Practice at Portsmouth University and is also an adviser to three Drugs and Therapeutics Committees in the South of England. Omar is a National Speaker in the UK (cardiovascular, diabetes, mental health) and is an Executive Board Member for the National Obesity Forum. He can be reached directly on ‘alipha@aol.com’

CONTRACT FACTS 11-20

11. Out of Hours Services: most GPs are opting out from April 1st 2004. This removes weekends and evenings from terms and conditions. However the new GMS contract has flexibility for extra hours although the politics behind this are not nice.

THINK POINT PF: It is issues such as this that really creates ill feeling amongst dedicated healthcare professionals. Under the current situation, most GPs will opt out of out-of-hours services (OHS) as the monies they will get paid to do it are very poor indeed. Also, one of the requirements of providing an OHS is the ability to store all voice transactions in an electronic format for 3 years (for the obvious reason of legality and claims in a situation where a GP may have refused to come out to see a patient). So given most GPs don’t have this facility they probably will have to opt out or invest into technology. So why is there dissent? Surely GPs would love someone else to do on-call for them ? Well it comes to money (surprise surprise!) Each GP will have 6% of their global sum taken away to pay for the on-call service. This is many, many times higher than the government will pay the GP to do their own on-call. Hence bring up the subject with your customers only if you plan on ruining their day.

12. Enhanced Services Bidding: the consultation exercise is still ongoing. For example, let’s say a GP wants to do minor surgery – the PCT will have to make the final decision, so the GP needs to get in early with their bid. Discussions with both the PCT and the LMC will be imperative in making sure these extra services are paid for. There is a grey area whereby on one hand the PCT will chose who provides what service, but on the other hand, if a GP has been carrying out significant minor op’s procedures to date, they have to offer this work to that GP so that he may continue to provide it if he/she wants.

THINK POINT PF: The GPSIs (GP Specialist Interests) will become specific targets for various pharma & equipment companies. They will be providing minor ops., anticoagulant clinics, dermatology and other specialist services. The PCTs responsibility is to ensure there is availability of the service to the population whereas the GPs responsibility is to provide the care within remits of clinical governance and quality. If an area is lacking a dermatology specialist it is up to the PCT to either convince a GP to take it up or to outsource to an external agency. That in itself is another kettle of fish – external agencies running/providing very specific procedures/diagnostics/treatments either because a PCT doesn’t have the ability or because the agency in question can provide it quicker, cheaper or more reliably.

13. Quality Achievements Software: The GPs are being paid for points. That we have established. But how will they keep track of ‘what they are achieving ?

THINK POINT PF: There are 2 lots of ‘software engines’ which allow GPs to ‘track’ their achievements, points and hence potential/actual salary & payments. The UTILITY SOFTWARE is used for entering figures of quality aspirations to calculate sum of payments. The SEARCH ENGINE SOFTWARE is used to try & see where you are with your current targets. This is useful in calculating how good or bad your payments will be. Not too different from when you attend your national sales conference and see your company predicted targets and how you are ‘tracking’ above/below them. Want to make friends with your practice manager? One of the ‘easy’ quality frameworks is to send out 50 PATIENT SATISFACTION SURVEYS. They get 50 points for doing this! It doesn’t even matter if the patient fills them in! They just need to post them out! You may be able to help them with that…. (p.s. I don’t want practice managers all round the country calling me up with complaints they are being hassled by reps because of me !)

14. Disease Registers: For the 10 diseases within the GP contract, most provide points for creating a ‘register’. Difficult to know how your cholesterol is doing if you don’t have a list of patients who need their cholesterol monitoring !

THINK POINT PF: Disease Registers are easy points– 6 points for each register. Most practices already have diabetes & CHD registers (NSF requirements). As they form other disease registers they will be ‘finding’ new patients and then creating a focus. For example, looking at respiratory medicine, the GP contract encourages ‘spirometry diagnosed asthma’ rather than ‘doctor diagnosed asthma’. I know certain companies that provide practices with spirometers – do you think their products will knocked off formularies ?

15. Population Screening: Practice prevalence of a disease is more important than screening itself. But screening is the buzz word. This activity will find new patients (new diabetics, new hypertensives, etc) who were otherwise thought to be healthy. Interestingly, data from recall of know patients is valid for 15 months. After this, it is no longer valid. Hence too frequent recall is a waste of time and too late a recall will mean you don’t have figures entered into the computer.

THINK POINT PF: Remember there is a difference between incidence and prevalence. The incidence of a disease is the rate of newly diagnosed patients within a population set (ie 5 new cases of diabetes per month). The prevalence of a disease is the total number of patients within a disease set (ie 150 diabetics within a practice). It’s the difference between how many people are jumping into a pool per hour and how many people are in the pool at any given time. Given that there are newly diagnosed patients every day, and there are patients who are diabetic dying every day, the balance leads to incidence and prevalence statistics. Another think point – what happens if people keep jumping into a pool but no-one leaves the pool ? Visualise it. Well this is the problem with treating diabetes (increasing longevity of life) when we don’t have a cure or proper way of preventing diabetes. This is one pool that is becoming very, very crowded indeed.

16. Partnership Agreements: The new GMS contract creates a real need for GPs to plan with partners. Planning whole time/part time equivalents. Planning NHS/non NHS earnings and how it will go through the practice. Much of this accountancy is related to pension protection.

THINK POINT PF: The course of true love never has run smoothly. I am yet to find a practice of 3 or more GP partners who do not suffer from a kind of business paranoia. Am I doing too much ? Am I getting paid to little ? Have I subsidised someone else’s tax rebate ? Why ? Probably because most GPs remember how they shafted junior/new partners who were inexperienced. However, if worst came to worst, GPs could ‘divorce’, move out and take their ‘list’ of patients with them (remember under the current system patients are registered with individual doctors). Interestingly, under the new GMS contract, the patients are registered with the PRACTICE, not with individual GPs. This means, when a disagreement and subsequent dissolving is due to occur under the new system, the GP may move/divorce from the practice, but they will have no patients ! GPs will have to think more than twice before entering a partnership and more than likely, partnerships just can’t afford to break down. Disagreements are going to have to be worked out. Patients are now registered with practices not doctors.

17. Non-Medical Partnership Agreements: Under the new GMS contract, facilities exist for non-medical staff to join and be considered full partners with business share of the running of the practice.

THINK POINT PF: This is quite phenomenal. Never has this been available, possible or even remotely close to being considered. Now, managers, nurses or even the pharmacists can become partners within the practice. Sharing in profits. Sharing in losses. I am still coming to terms with the full implications of this.

18. Opting Out of Additional Services 1: Whilst GPs can opt out of additional services if they want, they will need to think seriously about this. Opting in to do a service does allow option to opt out at a later date. But if a practice opts out of an additional service, changing their mind on this will prove far more difficult.

THINK POINT PF: That is the key. If you opt out you can’t opt back in ! So some wily practices will opt-in, keep an enhanced service, then subcontract it out. Hence the practice holds the core contract, but someone else is being paid to do it… till the time or expertise is right. Then they will take it over. We are going to see a proliferation of ‘service providers’ ranging from dialysis fluid home delivery through to a 1-stop shop for rheumatology patients.

19. Opting Out of Additional Services 2: Certain enhanced services contribute to global sum monies whilst others contribute to quality and enhanced payment services

THINK POINT PF: This is important. For example, take CERVICAL SCREENING –opt out of this and you actually lose monies (ie – money taken away from global sum to pay someone else to do it). However, cervical screening does not appear in the quality & outcomes framework so it’s nothing to do with points or prizes, just hardcore cash !! On the other hand, take a touchy subject like MMR Vaccinations. These are incentivised with ‘bonus payments’. So does the practice opt out ? If they are clever, they may tell the PCT they are ‘opting in’ for ‘CHILD SURVEILLANCE’ , hence hold the contract. Everyone knows that MMR vaccination is very difficult and time consuming. So they may then outsource and pay an external agency to do this. The practice will obviously be responsible for the quality and service provision of the agencies they ‘hire’ (under clinical governance and of course vicarious liability). But what is key here is that they still hold the contract to provide MMR and will take it over themselves ‘when the heat dies down’ as it were !

20. PCT & GP responsibilities under new GMS: NSF targets will be key focal drivers of the PCT and in fact responsibility for achieving these frameworks rests with the Chief Executive of the organisation. The NSF targets, whilst underpinning a number of clinical parameters within the GMS contract, is not in itself included as part of the quality frameworks or incentives.

THINK POINT PF: This is the killer queen ! Look at the cholesterol targets for patients with CHD. The target of reducing cholesterol below 5mmol/L features in both the NSF for CHD as well as the GMS Contract points (see previous issues PF). What is interesting is the fact that the NSF target for cholesterol will drop this year to reflect more aggressive cholesterol reduction. However, the GP contract target of 5mmol/L will not change for a couple of years. So – when a doctor sees a patient, what cholesterol will they go for ? The NSF target or the GP contract target ? Well, once he gets the cholesterol below 5, he/she gets paid. If they reduce the cholesterol any more than 5, the patient benefits, the budget goes up, BUT the GP does not get anymore payments (they have capped the payment at achieving 60% of patients with a cholesterol of below 5). So whilst it is the PCTs responsibility to achieve the NSF target, it is NOT the GPs responsibility ! In fact, I cant see the GP wanting to overspend the budget anymore than what they will get rewarded to do. Lesson in learning – the PCT needs to achieve NSF targets, the GP wants to achieve GMS Contract Points targets. And, low and behold, they are not one and the same.

I love the NHS don’t you?….

The Problem

Practices are faced with clear opportunities with the advent of the new GMS and PMS contracts from 1st April 2004. With demonstrably improved quality of services and possibly an extended range of enhanced services on offer, the opportunity to improve the overall health of both their patient population, and the practice cash flow and income, are clear. As with any period of tremendous change, 2004 also brings with it challenges, and the prospect of winners and losers. The knock-on effect to representatives calling on practices during a time of immense changes will be significant, and again there will be winners and losers here. Representatives who are attuned to the needs of their key practices will be able to work ever closer with them to help achieve mutually beneficial outcomes. Representatives who continue to offer nothing of ‘added value’ and sell only to their own agenda will find increasingly busy practices clamping down on time-wasting activities (such as seeing low-value reps) to refocus on higher value activities.

Quality Practice Development – a key concern for practices

The Quality and Outcomes framework (QOF) in the new contract will encourage all practices to strive to achieve high quality points scores to maximise additional income through this scheme. Achievement of 1000 points is possible for really good practices which will generate an additional £75,000 in 2004/5 then £120,000 in 2005/6 for an average sized practice (5900 patients) – over and above their guaranteed income (‘global sum’).

Given that all practices will strive to maximise their quality points, where do they start and how can you help?

Quality preparation – the story so far……. Quality Preparation Payments

Every practice received a lump sum payment in Q4 2003 to help them prepare for implementing the QOF of £9,000 for the average sized practice. A second payment of £3,250 will be made in April, and a ‘Quality Information Preparation Payment (QuIPP) will be made via a ‘Directed Enhanced Service’ also in April 04 (£2-5,000).

So, what is this quality preparation money intended for? DoH guidance on how to spend it is scant but here are some of the suggestions:

• Upgrading practice IT systems (e.g. with new GMS-compatible software & templates)

• Summarising and ordering notes onto the computer (QuIPP)

• Training staff and doctors on correct use of new Read Codes for the QOF

• Training on use of the computer generally

• Payment of locums to allow staff to attend awaydays on the new contract

• Funding external consultants to facilitate practice business planning around the new contract

The latter point seems logical and between now and the end of the year practices will be either updating their Practice Professional Development Plans (PPDP), or producing their very first PPDP, to ensure they stand the best chance of implementing the necessary changes smoothly. This uses a business planning approach to firstly engage the whole practice in the change implications of the new contract, then following a SWOT analysis, prioritises the issues that need tackling first and creates a SMART action plan to achieve this. This PPDP approach is being actively encouraged by PCTs and LMCs but there is a shortage of professional outside help so your input here may be very valuable. Healthcare Partnership are running a large number of these sessions now at the request of practices, PCTs, LMCs and proactive representatives.

Practice - PCT joint working

Practices are working increasingly closely with PCTs as joint planning for practice and service development is becoming a reality (e.g. the commissioning of ‘enhanced services’). What form will this increasingly close relationship take?

• In many PCTs, Practice Manager groups meet up every month with the PCT Primary Care Development manager to discuss issues and progress.

• Increasingly, these meetings involve an element of PCT-funded training for the Practice Manager group – e.g. Appraisal skills, how to do Practice Development Planning, etc. With the new contract there is a ‘Practice Management Competency Framework’ which provides a standards template for how practices can benchmark their management standards. Future development training for Practice Managers will revolve around this. Know what this entails so you can get involved in training these influential groups (contact Healthcare Partnership for a copy of this Competencies Framework)

• Encouraging production and sharing of Practice Professional Development Plans (PPDP). Good PPDPs help the PCT’s Primary Care Development team allocate ‘develop ment money’ effectively and informs both next year’s Local Delivery Planning and this year’s education and training needs (e.g. what sessions the PCT should be running during Protected Learning Time) as the PPDP identifies resources and training required to support Practice Quality Development.

• Encouraging good practice-based HR and training procedures through PDP and appraisal (see the QOF indicators in this area – contact us for details). This helps the PCT achieve DoH-set targets of NHSwide implementation of integrated planning and HR policies to ensure a skilled and responsive primary care workforce, and should help practices recruit and retain good staff. Strategic Health Authorities will be monitoring this under the ‘Agenda for change’ legislation.

Changing role of the Practice Manager In modern Primary Care, a highly skilled and well-resourced Practice Manager is a must for the efficient running of the practice. PCTs see practice managers as a key way to influence GPs and their practices most quickly. Why? Practice Managers have the ‘HR’ role in the practice, see all the issues in practices (especially around teamwork, skills, and education) and have a responsibility to maximise practice income (and now quality). Practice Managers play a pivotal role in practice communication – a key issue for PCTs as their messages may not always be welcomed by already overstretched GPs, and may not be communicated to the staff without the Practice Managers’ support.

Modern Practice managers need to be a hybrid of business manager, HR manager and IT specialist in most practices – plus negotiators between the GPs, staff and PCT! They are tasked to run increasingly complex, multi-million pound organisations with (usually) insufficient staff and inadequate training (and often with inadequate support from the GP partners), so time, money and skills are in short supply. They need help! Although PCTs are gearing up to provide more support, resources will be limited, so this is where you can come to their rescue! Even if you are not tasked with a call rate on Practice Managers, it can’t have escaped your notice how influential these people are, so time spent getting to understand their needs better, and the needs of your target practices, will be time well spent. If you already working a system of coverage and frequency on key target practices as opposed to call rate, then you will no doubt already be doing this.

Find out what the practice is focussing on for Quality development

You want to spend more time in key practices, selling your products to relevant healthcare professionals. They feel they have no time for ‘nice to do’ things – e.g. seeing reps – indeed they may see your visit as not only a drain on their time but also possibly jeopardising their drug budget. So, how do you address the needs and concerns of the practice, in order to address your needs to see the right customers and spend time selling to them?

Find out what is of concern to the practice. Then see if you can help support them in some way. You, your organisation, or people in your network of contacts may well be able to provide valuable assistance in key areas where help is needed. If so, you have found your way to become a valued resource to the practice. Provide the support (make a commitment to keep up your support, not just a one-off), build a relationship, and reap the rewards of improved access to sell more often to the key practice stakeholders.

Areas of Quality Development in Practice management and chronic disease management are clearly laid out in the QOF template (see headings below and points per area). If you are serious about understanding your key practices better, discuss the QOF with your practice managers and find out where they need help to improve their scores. It may be in relevant clinical areas, but it might just as easily be help in developing the administrative side that is their real need. Be alert to the whole range of possibilities, and first, be aware of areas where you can help them. If you don’t have a copy of the full QOF indicators, contact us for a copy which we can email you. This will allow you to make as many copies as you need to take to your target practices, to show your genuine interest, to find out what they really need, to identify what help you can provide, and to identify opportunities to get a business return.

Areas of ‘Quality & Outcomes Framework’ and potential points

Chronic Disease management
CHD & LVD - 121
Hypertension - 105
Diabetes - 99
Stroke or TIA - 31
Hypothyroidism - 8Epilepsy - 16
Asthma - 72
COPD - 45
Mental Health - 41
Cancer - 12

Practice Organisation
Records and information - 85 (also QuIPP DES)
Patient communication - 8
Education and training - 29
Practice management - 20
Medicines management - 42
Patient experience
Length of consultations – 30
Patient survey – 70

Additional services
Cervical screening – 22
Child Health Surveillance – 6
Maternity services – 6
Contraceptive services – 2
Access - 50

What should I do now?

1. Look at the areas of running a quality practice above. Obtain a copy of the detailed QOF indicators from us. In which areas do you or your company have personal competence? Could you train or mentor a member or members of staff? What about areas where your colleagues, manager, or head-office based staff are skilled in – could they help out?

2. What about bringing in external resources, e.g. clinical speakers, management training consultants, financial advisers, law experts? If you are worried about the cost of doing so, you could share it – e.g. with colleagues, non-competitor companies, the practice (who have had Quality Preparation Payments) or even PCT?

3. Consider supporting the PCT’s ‘Practice Managers Forum’ meetings – again, provide help as well as resources e.g. food/room hire if possible.

4. Use your business plan to document which practices will get your focus of time and budget, get the help you need and watch those sales grow!

Clearly, the better your network of contacts, the better able you will be able to help your key practices, and the better your customer access will be. Not only will you sell more but you’ll also be spending your resources on something that your customers really want that will gain them extra income and their patients a higher standard of quality care– a genuine win-win outcome!

This double special edition of the MATRIX provides a simple checklist of facts about the new GP contract. Given that this is time for New Year’s Resolutions, the new GMS Contract represents a more of a Revolution of Healthcare Agenda’s and implications for the Pharmaceutical Industry.

10 CONTRACT FACTS

1. Every practice will have 2 x signed PROSCRIBED CONTRACTS. One will be kept at the GP practice and one will be kept at the PCT. These contracts finally pin down what GPs will be doing and more importantly what they will be getting paid to do.

THINK POINT PF: Now think about this. Why has the Government brought in a Contract now ? This is as much to do with control as it is to do with care and delivery. Remember that previous to the contract, the GPs working from a red book are acting as self-employed practitioners. Hence, they can pretty much do what they want. Hence when the pressure comes on from the health Authority (or the prescribing adviser) they can to a certain extent say ‘to hell with you !!’ give or take. But now, with a contract, all sorts of declarations, promises and undertakings will be involved. Hence, it is only with the presence and signing of a contract that one can be in ‘breach’ of contract.

2. INR Monitoring will be an enhanced service. Specialist activities such as INR monitoring will be classified as a Nationally Enhanced Service (NES). Hence GPs will not get paid as part of routine work anymore. They will have to choose to ‘opt in’ or ‘opt out’ if this service.

THINK POINT PF: This is 1 example of a change that could make or break the NHS. For example, patients on warfarin (anticoagulation) need regular INR monitoring. Under the new GP contract, GPs will not be paid to do this. So many of them will be ‘opting out’ of this service. Having said that, the PCTs responsibility is to provide INR monitoring to the patient (it’s not the GPs responsibility). So who will do it ? Well at the moment, many PCTs are hoping GPs will just ‘do it’. Many GPs will now be handing in their ‘I withdraw from INR monitoring’ letter and come April 2004 the PCTs will be frantically trying to get someone to do it. 2 Further interest points : PCTs may out source (like out-of-hours) or certain GPs may take up INR monitoring as an enhanced service. Hence patients will be going to different surgeries for different types of blood tests. Interesting.

3. Minimum Investment Guarantee (MPIG). The global sum makes up about 2/3 of the practice finances. The remaining 1/3 comes from infamous ‘points’ to make prizes. To try and ensure no-one loses out, the government have promised a ‘minimum investment’. Hence if a practice is not achieving minimum points they won’t earn anything less than they earned last year.

THINK POINT PF: This minimum investment guarantee was a carrot. It was the final push which led to the ‘yes’ vote which led to where we are today. One key effect of the MPIG is that once the GP contract comes into effect, if practices are scoring poorly on the points, they wont lose all the 1/3 income. The government have promised that overall income will be similar to previous years until they start achieving ‘points’ over and above minimum targets (25%). Once this has occurred, income will vary depending upon ‘points’ scored.

4. How many points ? There are a total of 1050 points. 550 of these are clinical points across 10 disease areas. The remaining 500 points are administrative practice points related to management, audit, practice records and documentation and patient experience related measures. The 10 disease areas are not split equally as can be seen below.

Secondary Prevention of CHD        121 points
Diabetes Mellitus                                 114 points
Hypertension                                      105 points
Asthma                                               72 points
COPD                                                 45 points
Mental Health                                       45 points
Stroke /TIA                                       31 points
Epilepsy                                              16 points
Cancer                                               12 points
Hypothyroidism                                     8 points

5. And what are they worth ? Each point is worth £75 for 2004/5 which goes up to £125 the following year and then up to £300 per point the year after that.

THINK POINT PF: Much fuss has been made about these points – and rightly so. There are some important principals of care here. We know that patients with disease are often showing poor control despite prescribing and management. Hence this system will focus more on outcomes rather than just activities. 3 Specifics : firstly each of the disease points is made up of targets which need to be achieved (ie) cholesterol below 5mmol/L. But the cholesterol target reappears many times (Secondary Prevention CHD, Diabetes, Hypertension and Stroke/TIA). Hence by investing in ‘cholesterol management’ a practice can hit a target ACROSS diseases rather than THROUGH them. This is very important. It’s like writing an essay. The first marks are always the easiest. The same applies for achieving these points. Rather than trying to treat all the targets for 1 disease, GPs will be more efficient if they treat 1 target across many diseases. Secondly, there are minimum and maximum % thresholds. For example, the cholesterol <5 mmol/L target has a minimum of 25% and a maximum of 60%. This means that no payments are made until at least a quarter of the patients in the register have a cholesterol below 5mmol/L But interestingly, once 60% of patients have achieved target, the GP does not get paid for getting more patients to target ! So will it be worth while bothering ? Finally and really a point for us all to bear in mind. The ‘family doctor’ is on the way out. The idea that the GP would understand your problems, look holistically at your circumstances and view you with your illness may be gone. Because the government want targets, targets, targets. This may not be a bad thing. But 1 of the golden rules of medicine is ‘treat the patient not the blood test’. Rightly or wrongly, that’s now out of the window.

6. What if they score too many points ? If GPs get very high outcomes – then they must be paid for achieving them. That’s what the paperwork says. That’s what the government promised.

THINK POINT PF: This is a very real concern. GPs will be asked what their aspirations are (many of them will say ‘to retire’!) So of the 1050 points, how many do you think you will get ? Or how many do you think you want to work towards. It’s just a guide and they don’t get penalised for not achieving them. But they do get some monies up front (and the rest when/if they achieve the points). You will find many practices not going for 1050, but will aim for say 700-900 points. If they don’t get there – no problem. No penalties. Just payment for targets achieved.

7. What about funding for enhanced services ? GPs will be opting in and out of services as we read this paper. The point is, they are being paid for extra services that they may want to do (say minor surgery). Some GPs don’t want to do minor surgery. So they don’t need to. But what happens in none of them want to do minor surgery ?

THINK POINT PF: There is a worry about enhanced services – will there be enough money to pay for this ? There must be otherwise the PCT will have to pay hospitals to do it !! The GPs will really have to stick to their guns when they ‘refuse’ to do work. What is interesting is the fact that the PCT has responsibility for finding and commissioning the delivery of care – not the GP. Hence we are going to see some real fragmentation (and arguably specialisation) of care delivery from primary care levels.

8. What was all the fuss about pensions ? Much of the disgruntled arguing has been over issues such as pensions and premises rather than clinical quality indicators. One thing we will now see is GPs putting all incomes through their practice accounts to prevent monies and funds from being sucked out of their pensions.

9. A Note on the Sick Note ! Demand Management points out the bulk of sick certification should move out of the GP’s remit and to that of occupational health. So you wont be seeing your GP anymore for a sicky!

THINK POINT PF: The problem with this appointment is that the patient would never have come to the GP for their illness unless they wanted the sick note !! Hence we are wasting doctors time for a piece of paper (that we often have to pay for anyway). I think we will still have to pay for it though . . .

10. What about dispensing doctors ? No changes and no funds have been taken away from dispensing doctors. They have kept interference to a minimum. The points and prizes of the quality framework still apply.

THINK POINT PF: The next time you catch up with a GP ask them about premises and work being done to the premises. It’s a sticky point now. If a practice/GP had an improvement grant/work planned which was approved before September it may go through – but some won’t. In fact from now on, GPs will not get rent to pay for this. Money has become very tight for premises. Why ? The government needed to raid premises budget for the MPIG (see above). So they will need my prescribing incentives to help to pay for this now (and also their staff see next)

11. Staffing and the new GP contract ? Arguably one of the most significant changes to the daily finances will be the way in which staffing is budgeted within practices. Until recently the government has reimbursed 75% on staff that practices employ. Well under the new GP contract – this has gone - completely! So now the GP will have to pay for each and every staff member from his own pocket.

THINK POINT PF: Why is this ? Money follows the patient not the staff. So funding is based on patient outcomes whether you have 1 nurse or 10 nurses. What’s more, for every £1 the GP spends on staff they need to add +11p for NI contributions and +14p pension contribution. So they really do need hence to look at what staff are doing. Under a current system, employing 2 x G-grade nurses and 2 X Hgrade nurses just to do BP and urine will be a complete waste of money!! Expect to see receptionists trained to NVQ doing BP,urine, health checks etc and also the employing of medical students (cheap if not free and no NI and pensions to think about). The world is changing . . .