New GP contract < Influencers contents | Print this page The new GP contract is critical to the future of general practice and both local sales teams and NHS influencers have more than likely now been fully briefed by their companies. What follows is some additional background. The final British Medical Association (BMA) ballot on the new GMS contract eventually resulted in a vote of 79 per cent in favour to accept the new contract, but this was not before many last minute glitches. NHS Alliance chairman Dr Michael Dixon said in response to this vote: ‘The BMA and NHS Confederation negotiators are to be congratulated on achieving such an overwhelming majority for the new contract... This has secured the future for British general practice. It is good news for patients, doctors and primary care organisations. It will bring much needed new resources into primary care, shift the focus towards quality, and offer GPs the flexibility to choose the level of service they provide. It also represents a huge challenge to PCTs and the primary care organisations in Scotland, Wales and Northern Ireland. They are going to need practical support’. National Association of Primary Care (NAPC) chairman Dr Peter Smith commented: ‘This is a historic result for primary care and is all the more remarkable given the early uncertainties surrounding the contract. The quality framework has rightly been hailed as a quantum leap forward for general practice. This is one small step for general practice but a giant leap for primary care,’ But some discontent about the new GP contract did continue up to the very last minute because the numbers did not seem to add up and practices looked like losing money. This was improved by the late introduction of a minimum practice income guarantee (MIPG) to ensure practices did not lose out. But there were also problems with the formula being used to determine practice income. Disgruntled GPC members have also turned their wrath on the quality framework, branding it ‘unacceptable and unfair’. One of the main problems seems to have been that GPs have simply struggled to understand the complexity of global sums, quality markers, additional/enhanced services, out-of-hours-services etc. The NHS Alliance commented: ‘The vote at the LMC conference... demonstrated beyond all doubt that the GPC must give up the Carr-Hill formula now. The answer is to adopt a transitional funding arrangement, based on the current Red Book plus the quality framework from the proposed contract. Payments would then be based on the same methodology as personal medical services. The GPC should look at three key questions — the principles of the proposed contract; commitment to a needs-based allocations formula based on registered lists and not on census populations and a transitional funding formula. The Carr-Hill formula must then be refined, peer-reviewed and validated. Whatever solution is adopted, the new funding arrangements must be demonstrably sensitive to practice workload.’ Richard Smith, previous editor of the BMJ suggested in an editorial that what appeared to have gone wrong with the contract negotiations for GPs (and consultants for that matter) was related to a clash of values, with politicians putting greater emphasis on efficiency, management of performance, and responsiveness to patients, while doctors believed that their main job was to care for the seriously ill, unencumbered with bureaucracy. ‘Doctors don’t want to be good corporate citizens. They want to be valued professionals.’ See ‘The failures of two contracts’ And note that Mike Farrar, NHS Confederation lead negotiator and South Yorkshire Strategic Health Authority CEO told a conference in 2004 that the new contract is ‘incredibly permissive’ but there is a huge responsibility on PCTs to make sure it works. ‘PCTs can take the contract and mould it to deliver the strategic objectives they want’, he told the conference. 'This is a once-in-a-generation opportunity for PCTs to reshape healthcare provision in their localities, he suggests. The new contract is not simply another way of paying GPs and is a ‘fantastic platform’ for managing chronic disease with enhanced services being used as a way of shifting treatment away from the acute sector, he went on to say. The final proposals were set out in The new GMS contract: delivering the benefits for GPs and their patients. In England, the DH continues to publish detailed guidance on the implementation and operation of nGMS. For instance see Delivering investment in general practice: implementing the new GMS contract. Influencers involved in analysing and thoroughly understanding nGMS will find this a rich resource. There is some interesting material about private providers of primary care services following on from comment in Building on the best, which spelt out the DH’s intention to ‘promote new entrants’ into primary care through a new alternative provider medical services (APMS) contract. There is also discussion on PCTs employing their own doctors under a ‘PCT medical services’ scheme and there is some important comment about developing the area of practice management and the role of the practice manager. Certainly the finally approved new general medical services contract marks a radical change for both GPs and primary care but primary care organisations do now face the challenge of ensuring the contract is fully implemented in all GMS practices from April 2005. They will need a lot of support. See the DH’s general medical services section. Quality and outcomes framework For NHS influencers, the most relevant fact concerning nGMS is that there is a new focus on quality and outcomes, and it is intended that the quality framework within the contract will reward practices for delivering high quality care. This is good news for the pharmaceutical industry. One third of GP pay will come from points scored in the quality framework. Practices will have to submit an annual quality report and PCTs will also visit the practice annually to monitor quality achievements, although ‘measurement by high trust’ is mentioned frequently in the documentation. Payments made through the quality framework will allow practices to increase income substantially by achieving a series of quality standards. Other payments will include payments for providing enhanced services over and above the basic range of service. Additional services will include services that are preventive in nature (for example, chronic disease management). At the end of the year the practice will receive an achievement payment where standards aspired to have been delivered. Practices will be expected to progress through each level of the model, achieving the standards in the preceding level before moving up. An agreed data set of evidence-based standards will be defined for each level. The quality framework relates to the achievement of clinical quality standards (for example, national clinical priorities and locally determined clinical priorities). Many of these standards involve the appropriate use of pharmaceutical interventions, for example, statins. The quality framework includes five organisational areas including medicines management, and education and training along with the ten clinical areas. Patient satisfaction outcomes are also in the pot. A big opportunity area here for companies. GP journals continue to be filled with material on nGMS. For example, Pulse has reported a poll on national enhanced services that GPs will bid to provide — 54 per cent said anticoagulant services, 50 per cent depression services and 28 per cent sexual health services. The new contract does signal a radical change for GPs and primary care. See DH press release 2003/0077, which states, ‘Treatments that have previously only been available in hospitals will be available to patients at local GP practices and for the first time GPs will be rewarded for the quality of services they provide.’ There is an interesting focus on new incentives for GPs to treat patients in the community rather than referring them to hospital. The important features
of the new contract are: it is practice-based, not GP-based; it
is inherently multiprofessional and there is a new quality incentives
framework. The proposals spell out 76 quality indicators in 10 clinical
domains of care, 56 in organisational areas, four assessing patients’
experience, and a number of other indicators for additional services.
The medicines management section includes an annual meeting with
PCT prescribing advisers and an agreement on up to three prescribing
actions and medication reviews for patients on repeat medicines.
There continues to be a lot of comment on the likely effect of the nGMS quality and outcomes framework hiking prescribing costs and the knock-on effects this will have. Overspends on prescribing budgets are expected and GPs are being warned to expect cuts in IT, acute care and enhanced service improvements. It seems clear that the Healthcare Commission will performance manage PCTs on the basis of GPs’ performance against the quality and outcomes framework and that this will also go into star rating assessments. There is a lot to take in here and a mass of new acronyms to get used to — QOF (quality and outcomes framework), DES (directed enhanced services), MPIG (minimum price income guarantee), Read codes, aspirations, global sums, three kinds of enhanced services, PMS versus nGMS, MPIGs, OOHs, Car-Hill, practice manager competencies etc. For a BMJ editorial comment see ‘New contract for general practitioners’: ‘The proposed new contract… contains an initiative to improve the quality of primary care that is the boldest such proposal on this scale ever attempted anywhere in the world.’ Health minister John Hutton has said, ‘implementing the new primary care contract is without doubt one of the biggest and most important opportunities and challenges facing primary care trusts in 2004/05.’ Well that’s pretty clear then… another ‘P45 indicator’ for PCT CEOs… By early 2005, PCTs will be totally responsible for out-of-hours (OOH) care, where GPs have decided to opt out. Some PCTs are putting in place cover through non-GP triage although the government has insisted that patients should be able to see a GP, should they so wish. A survey conducted by Pulse magazine found that more than 60 per cent of GPs have concerns surrounding OOH services once responsibility is transferred to primary care organisations. Some 92 per cent predict a rise in A&E referrals, 72 per cent fear patients will receive inappropriate advice, 72 per cent believe patients will receive poor standards of care and 62 per cent state patients will receive inappropriate medication. Having said that, the survey confirms that over 80 per cent will opt out of OOH. Care on call: a mutual approach to out-of-hours primary care services has been published with a foreword by health minister John Hutton. It discusses one possible approach to the development of providers of out-of-hours care based on ‘mutual ownership’ in primary care. See www.out-of-hours.info. The NHS Alliance and the Royal College of GPs (RCGP) have called for a re-think on 48-hour access targets for GPs in their report The future of access to general practice-based primary medical care. The report argues that while rapid patient access to GPs is important, targets have become more important than genuine, patient-centred care. People sometimes need urgent access faster than 48 hours, says the report, while others — seeking a regular check up or lifestyle advice — may want to book appointments several weeks in advance. The report also calls on the government to recognise the complexities in primary care and general practice rather than seeing it as a small-scale version of secondary, hospital-based care. Professor David Haslam, RCGP chairman said: ‘More than 90 per cent of NHS patients are treated entirely in primary care. People visit their GPs for a variety of reasons from the worried to people suffering serious illnesses who need urgent referrals. But the current target system is not delivering according to patient needs and assumes that all patients are the same. Worse still, it puts pressure on GPs to disregard their different needs.’ NHS Alliance chairman Dr Michael Dixon commented: ‘What we are proposing will make life more difficult for NHS planners but better for patients. We have to stop behaving as if patients are all the same square-shaped pegs we can force into the same square hole. Planners should also understand that in a primary care-led NHS, where localism matters, clinicians and their patients must set the agenda.’ The new contract particularly focuses on practice management. Clearly by supporting the professional development of practice managers, PCTs could really enhance their relationship with general practice. One can predict that the role of the practice manager will become much more significant in the future with the roll-out of nGMS. It is with great interest that a number of practice ‘director’ posts continue to be advertised in the Health Service Journal. One group practice has searched for a ‘strategic manager to take the lead in steering the group (12 doctors in three constituent practices) in the future and future NHS environment’ and was offering up to £40K. The National Primary Care Development Team (NPDT) has published a guide to nGMS/PMS for practice managers — this is useful as it is less full of jargon than the GP materials — and a network of practice manager mentors is also to be set up. An information pack for GPs and practices has been compiled by the NPDT jointly with the British Medical Association, Royal College of General Practitioners, NHS Alliance and the National Association of Primary Care. The Nursing Times has suggested that practice nurses should ‘seize the opportunities’ that the new GP contract offers and could set up enhanced services for patients with chronic diseases. The new contract will after all be largely delivered by nurses, and nurses and pharmacists may undertake the majority of patient reviews, altering medications/medicines management. Nurse-led clinics are therefore likely to increase and they could become partners. As nGMS moves forward, a practice in Peterborough has courted publicity where all patients see nurses, only seeing GPs when referred on. The practice is full of nurse practitioners, practice nurses, healthcare assistants and only two GPs. Actually it is a PMS practice! The surgery is quiet, with no waiting despite an open appointment system. Dr Simon Fradd, joint-deputy chairman of the General Practitioners Committee, has waxed lyrically about it. But also note, more than two thirds of GPs in a survey run by the Institute of Healthcare Management would like patients to pay £10 or more for missed appointments. PCTs will take on wide-ranging powers under the new contract regarding commissioning services from alternate providers, including private companies when practices opt out of enhanced services. But there is some worry that this threatens to reduce the independence of practices and clinical freedoms. It will certainly mean some new services in primary care (similar to fundholding) — diagnostic treatment, minor operations, new services for managing CHD and diabetes, new roles for nurses and pharmacists, etc. And the plans to introduce practice-led commissioning in 2005 also needs to be added into the mix. Meeting the quality targets will also have prescribing cost implications and PCTs may need some help to find the cash and to work out what is a fair prescribing scheme. It will apply across the whole of the UK so all four health departments will be involved. The government has decided that PMS is and will remain a permanent option for practices. The NAPC thinks that the availability of the two contracts offers primary care trusts tremendous flexibility and that PMS practices must also become actively engaged in the debate over the new contract. Specialist PMS practices have also been announced, which can offer enhanced services similar to nGMS. Interestingly, a report from the National Primary Care Research and Development Centre (NPCRDC) at the University of Manchester, and published in the British Journal of General Practice, suggested that although GPs have made significant progress in improving patient access and organisation of care, this has had little impact on the quality of clinical care that practices provide. Those practices studied failed to make any significant improvements over a three-year period (1998-2001) in the clinical care of asthma, diabetes and mental health, all areas now covered by the new contract quality framework. There are lots of posts being advertised in the HSJ for PCT nGMS leads with many being sponsored by the national primary and care trust development programme (NatPaCT) and the national primary care development team (NPDT), both part of the Modernisation Agency. NDPT is setting up an nGMS/PMS collaborative with 28 PCT pilots (one per SHA) and NHS influencers might need to find out where these ‘exemplars’ are being set up. This is focusing on service redesign and different models of primary care provision with a particular focus on chronic disease management. Phase three of the NPDT collaborative, run through the 11 NDPT centres, has now moved from CHD to both diabetes and COPD. Finding money for enhanced services (held by PCTs) seems to be creating problems — essential services (provided by all practices) and additional services (provided by most) are centrally funded. In connection with nGMS, Dr Mike Dixon, NHS Alliance chairman has commented on what he thinks primary care’s relationship with the industry should be: ‘Your two big opportunities are the GP contract and the PCT becoming the commissioner of primary care. There will be massive opportunities for the pharmaceutical industry, even sub-contracting to provide services to meet the quality criteria in areas such as cardiology, stroke prevention and diabetes. Sometimes I suspect it may even become an alternative provider, almost in competition with local practices. But I don’t expect to see that very soon.’ Certainly the nGMS contract is potentially fantastic news for some companies. Companies may be able to help in many areas within the contract (eg, patient surveys and practice management). It is worth emphasising again the role of primary care practice management and practice managers. The role will become more complex over time and it may attract more pay and so more professional managers may arrive. Again remember that the new GP contract will not just affect GPs — it really is a GP practice contract. In terms of service development, do companies need a new breed of medical representative working more like PCT teams, but working more closely with practice-based managers? One can certainly be sure that many companies will throw a lot of money at developing offerings around nGMS. But as mentioned earlier, the new contract will focus on the whole team including practice nurses and any practice support pharmacists. So a more multidisciplinary approach might make any such offerings that bit different. This would still allow representatives to get in front of GPs and indeed might make GPs even more interested in seeing the representatives. Companies clearly need to carefully brainstorm the implications of nGMS in their respective therapy areas and NHS influencers must clearly keep up with both national and local developments concerning nGMS. Chronic disease management (CDM) has recently moved up towards the NHS front burner. CDM is at the heart of the new GP contract and many commentators are now suggesting that it has finally come of age with the realisation that better care of chronic disease in primary care settings both reduces relapse and emergency admissions. Much of the emergency pressures faced by acute trusts results from patients with acute exacerbations of chronic illness and so it would seem to be sensible to have a greater emphasis on actively managing the patient and their disease through the lifecycle. The NHS Confederation has long called for a shift away from a focus on elective surgery to chronic disease. But note their warning: ‘if we are to put chronic conditions at the heart of the health agenda, we need a more radical and systemic change in health policy and practice — and a shift in the health debate’. A new emphasis on chronic disease management is central to the process of reforming and modernising the NHS, they say, since patients suffering from chronic disease or its complications use over 60 per cent of hospital beds. The government clearly views the new GP contract as offering major strategic advantages to both PCTs and GP practices in the better management of such chronic disease, leading to fewer admissions to hospital. But what is new is the model being proposed by the DH and now set in stone as regards NHS targets for 2005–08. Many of the ideas being implemented around CDM have been ‘imported’ from US managed care models where using more nurse practitioners and aggressive case management of patients it would seem it is possible to achieve sharp reductions in the rate of hospitalisation in elderly patients. One such approach is the Evercare programme developed by US health maintenance organisation United Healthcare. This programme continues to be piloted in nine English PCTs with each PCT choosing a target population with chronic illnesses to address. Some eight other PCTs are also working on managed care pilots with US-based Kaiser Permanente. Hospitals may also want to start providing chronic disease management as well, especially in areas with high levels of GP vacancies/poor levels of service. GP practices in some areas might also be interested in creating companies to offer their (enhanced) services to PCTs, offering packages of care including pharmacy, diagnostics and therapies alongside the new GMS. Innovative GP practices might also look at service developments aimed at reducing referrals to outpatients in areas like back pain. To cut emergency admissions, the new financial flows regime also offers incentives for PCTs to focus on improving CDM. Finally here, Geoff Rayner, chair of the UK Public Health Association, has written to John Reid, asking him to take a much longer-term view on things — including more investment in public health and stopping patients getting ill in the first place. ‘The big disease time bomb for the future is chronic diseases,’ he warns. The Wanless review for the Treasury also made the same point. The government’s long awaited White Paper on public health will be of interest.
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