The new UK-wide General Medical Services (nGMS) contract begins in April 2004. This contract affects all practices – whether they are currently working under a GMS contract (about 62% of UKGPs) or a Personal Medical Services (PMS) contract. The goal is to broaden the range and accessibility of patient services in primary care. The implications of nGMS will be far reaching for all parties involved in health care, and will allow practices and PCTs to re-shape the way services and care are delivered.
This article focuses on how a number of services, some of which are currently delivered in secondary care will move into primary care and become the direct responsibility of PCTs. These are known, for NHS commissioning purposes, as ‘Enhanced Services’.
The definition of an enhanced service is
• Essential or additional service delivered to a higher specified standard, for example extended minor surgery (each enhanced service is commissioned according to nationally prescribed standards – see footnote)
• Services not provided through essential or additional services. These include more specialised services provided by GPs/nurses with a Special Interest (Practitioners with a Special Interest - PwSI) and other allied health professionals and other services at the primary-secondary care interface. They may also include services addressing specific local health needs and innovative services at pilot or evaluation stage
Enhanced Services comprise of 3 types:
• ‘Directed’ Enhanced Services
• ‘National’ Enhanced Services
• ‘Local’ Enhanced Services
Directed Enhanced Services (DESs)
DESs are currently being delivered largely by practices, and will continue to be unless practices ‘opt out’ (for example due to workload pressures). Responsibility for DESs lies with PCTs from 1st April 2004 so they must provide the service elsewhere if practices decide to opt out. This means some patents will have to go elsewhere to access certain services described below. The likelihood is that other practices will expand their DES to take in patients from outside their practice, in some cases providing this service for the entire PCT. DESs attract nationally-agreed rates of funding.
The range of DESs covers these areas:
• Access to a GP or healthcare professional within 48/24 hours
• Quality Information preparation – encouraging summarising of patients’ notes onto the practice computer system from the Lloyd George paper system. This is vital for practices wishing to participate in the Quality & Outcomes framework, which will use the practice computer software to audit achievement against the prescribed standards in the incentive scheme.
• Flu vaccinations for all over 65s and under 65s at high risk.
• Services for violent patients (most PCTs already have arrangements in place)
• Minor surgery involving cutting and injections. Smaller procedures such as scraping and freezing minor lesions remain an essential service. Most practices provide the latter services, which will continue. Commissioning of the former will be subject to the standards outlined in the Minor Surgery DES. Many PCTs will want to use this DES to move more minor surgery out of hospitals thereby reducing waiting times. GPwSIs will expand their caseload and become local centres for referral from other GPs.
• Childhood immunisations and vaccinations which are likely to remain services provided by practices as they already have the infrastructure to provide this service.
National Enhanced Services (NESs)
PCTs, in consultation with the BMA’s Local Medical Committees (LMCs), will decide their own service needs and priorities within this category. As a result, levels and range of NESs will vary between PCTs. Once again, rates of pay have been nationally agreed for these services. Existing providers will have to bid to the PCT to continue to provide the service. In some cases NESs are already provided by Practices but outside the existing GMS arrangements. PwSIs will want to bid for these services so work with target customers you know are planning to expand to help them successfully bid for the relevant NESs. You will need to know the standards set out in the contract documentation so you can work out where you can help.
NESs comprise the following:
• Alcohol misuse
• Substance abusers maintenance care
• Shared-care drug monitoring including rheumatoid drugs
• Specialised care of patients with depression including use of rating scales
• Multiple Sclerosis ‘rounded care’
• Sexual Health akin to a locality-based GU medicine service
• IUCDs specialised coil-fitting service
• Minor injuries service largely in areas distant from hospital A+E services
• First response service for life-threatening or trauma incidents particularly in areas where ambulance response times are inadequate
• Services to homeless patients
•Intrapartum care for mothers wishing to give birth at home
• Anticoagulant monitoring e.g. INRs for patients on Warfarin
Local Enhanced Services (LESs)
These services are based on the same principles as the DESs and NESs but tailored to meet specific needs. Payment levels for LESs are agreed locally. The BMA is drafting guidance for GPs who wish to bid for LESs based around the following service areas:
• Asylum seekers
• Non-English speakers
• Patients with learning disabilities
Other areas likely to be commissioned under the LESs could include:
• Neonatal examinations within 24 hours of birth
• Nursing Home patients care
• Area-wide in-hours home visiting schemes
Funding of Enhanced Services There has been considerable unease amongst GPs that these services will not be adequately funded after reports that PCTs have already spent money allocated for Enhanced Services during 2003/4 on other things. The DoH have sought assurances from PCTs, via the SHAs, that the Enhanced Services money allocated will be ring-fenced for enhanced services for the commencement of the new GMS contract in April 2004. The impact of short term budgetary constraints are most likely to be felt in the NESs and LESs as some of these services are not currently provided in Primary Care, so lobbying by the LMC and practices will be less intense on PCTs who will be able to continue with existing suppliers or continue not to provide the service. However, as the majority of a PCT’s annual budget is currently spent on buying secondary care services, in the longer term, PCTs will be keen to move NESs and LESs into the community as this will bring down the cost of providing the same service in a secondary care setting.
The last five issues of PF have examined how the new GMS contract will expand the range, quality and number of services and healthcare professionals working within primary care to provide better patient care closer to home.
The implications for the Pharmaceutical Industry are clear- local knowledge is required to identify how specific services are to be delivered in each PCT under nGMS, and who the key influencers/prescribers are in each area of service.
accessing an ‘Enhanced Service’ then you need to be fact-finding now to understand how that service will be delivered from April 2004, and who will be writing scripts and where they are based. If you are a medical representative, it is no longer appropriate for you to assume that the GP is your key target – GPs may have opted out of providing the service, delegated that role to someone else who now has the power of the pen, or the PCT may have commissioned delivery of some Enhanced Services from providers outside of General Practices (for example nurse-led clinics). From a secondary care perspective, enhanced services commissioning means some specialist representatives will spend more time with customers in community bases, as we have seen over recent years in Mental Health.
The major changes customers face to redesign services in their new community setting will provide a range of opportunities for medical and specialist representatives to work in partnership on projects around patient pathways, team development and sharing best practise. Look at your PCTs’ Local Development Plans to find out what they are doing.
The rapidly changing Primary Care environment created by new GMS is a critical issue to consider when writing your Business Plan for 2004. Make sure you do your research for each PCT and target practice, stay close to your customers and help them develop their services to your mutual benefit. A good business plan will highlight to your manager who you should be calling on to get maximum business, what your key customers’ needs are and what resources you need to support these, and finally what support you need from colleagues – territory partners, your local hospital specialist and healthcare development manager and marketeers. Happy joined-up Business Planning!