The New GMS Contract

1
The New GMS Contract
2
The New Contract

• The Old Contract
• Background
• Provision of services
• Quality
• Investment

3
The Old Contract

• Between GP and PCO
• Capitation fees
• Item of service payments
• Rural practice allowance
• Basic practice allowance
• Postgraduate education allowance
• Seniority payment

4
The Old Contract

• No account of practice population demographics
• No reward for quality
• GPs responsible for out of hours cover
• Reduction in practice income if GP left

5
The Old Contract

• Between GP and PCO
• Capitation fees
• Item of service payments
• Rural practice allowance
• Basic practice allowance
• Postgraduate education allowance
• Seniority payment

6
Background

• Negotiations for new contract began late 2001
• New contract documentation February 2003
• Vote
• Result 20/06/03
• 70 turnout
• 79.4 yes vote

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Provision of services

• Essential services - all practices
• Additional services - most practices although can
  opt out under certain circumstances
• Enhanced services - responsibility of PCO, may be
  commissioned from practices
• Out of hours - responsibility of PCO

8
Provision of services

• Essential services
• Management of patients who are ill or believe
  themselves to be ill with conditions from which
  recovery is generally expected
• Management of patients who are terminally ill
• Management of chronic disease

9
Provision of services

• Additional services
• Cervical screening
• Contraceptive services
• Vaccinations and Immunisations
• Child Health surveillance
• Maternity services
• Certain minor surgery procedures e.g. cryocautery
  of warts

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Provision of services

• Additional services
• Opting out
• temporary ( lt1 year)
• permanent
• lack of available skills
• practice struggling e.g. short staffed
• conscientious grounds
• UK wide tariff adjusted by Carr - Hill formula
  will apply for opting out

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Provision of services

• Enhanced services
• Nationally directed
• treatment of violent patients
• improved access
• childhood vaccinations and immunisations
  (provided to higher specified standard)
• flu immunisation
• extended minor surgery
• quality information preparation

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Provision of services

• Enhanced services
• With national minimum standards
• intra partum care
• anticoagulant monitoring
• IUD fitting
• more specialised services for substance misuse,
  sexual health, depression, multiple sclerosis,
  terminally ill, the homeless, those with learning
  disability
• immediate care, first response care and minor
  injuries

13
Provision of services

• Enhanced services
• in response to local need
• ? Services for immigrants

14
Provision of services

• Out of hours
• Defined as
• 1830-0800 on weekdays
• The whole of weekends, bank holidays and public
  holidays
• Practices retain the option provide out of hours
  services
• Routine surgeries possible in evening or at
  weekend but only get extra funding if agreed as
  enhanced service with PCO

15
Provision of services

• Out of hours
• PCOs can use alternatives e.g.
• NHS Direct/24
• Walk in centres
• GP co-ops
• community nursing teams
• commercial deputising services
• In remote areas may be no alternative to practice
  provision

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Provision of services

• Out of hours
• Opting out
• a fixed UK wide tariff will apply - adjusted by
  Carr- Hill formula
• Will cost on average 6000 per GP per year

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Quality and outcomes framework

• Practices awarded points for achieving certain
  standards
• Total of 1050 points available
• 1 point 75 on average this year, 120 next
  year
• Four domains
• Clinical
• Organisational
• Additional services
• Patient experience

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Clinical Domain

• Diabetes
• Mental Health
• Chronic Obstructive Pulmonary Disease
• Asthma
• Epilepsy
• Cancer

• Coronary heart disease including left ventricular
  dysfunction
• Stroke and transient ischaemic attacks
• Hypertension
• Hypothyroidism

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Clinical Domain

• Example
• The percentage of patients with coronary heart
  disease, in whom the last blood pressure reading
  (measured in the last 15 months) is 150/90 or
  less. 70 19 points
• A proportion of the points score will be awarded
  in a direct linear relationship for achievement
  between the minimum (25) and the maximum (in
  this case 70)

20
Organisational Domain

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

21
Organisational Domain

• Example
• The practice has arrangements for patients to
  speak to GPs and nurses on the telephone during
  the working day. 1 point

22
Additional services domain

• Cervical screening
• Child health surveillance
• Maternity services
• Contraceptive services
• Example
• The practice has a system to ensure abnormal
  smears are followed up. 3 points

23
Patient experience domain

• Patient survey
• Consultation length
• Example
• The practice will have undertaken an approved
  patient survey each year. 40 points

24
Investment

• Global sum and MPIG
• Quality payments
• Payments for enhanced services
• Others - premises, seniority, PCO payments (e.g.
  for mat leave), dispensing
• Pensions

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Global Sum

• Payment for essential and additional services
• Staff costs
• Locum reimbursement
• Average UK practice to receive 300,000
• Based on practice population weighted using
  Carr-Hill formula

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Carr-Hill formula

• Six key determinants of practice workload and
  circumstances
• Gender and age for frequency and length of
  surgery and home visit contacts
• Gender and age for nursing and residential home
  consultations
• Morbidity and mortality
• Newly registered patients
• Unavoidable costs of rurality
• Unavoidable higher costs of living

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MPIG

• Minimum practice income guarantee
• Ready reckoner used to calculate global sum
  equivalent
• Many practices found their global sum would be
  lower than what they were receiving under the old
  contract
• If global sum equivalent payment for 100
  quality points is less than income under old
  contract then MPIG comes into force and a
  correction factor makes up the short fall

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Quality payments

• Preparation
• E.g. IT payments
• Aspiration
• Practice estimates how many points it hopes to
  achieve in the next year and is paid upfront for
  a third of these
• Preparation
• Paid at the end of the year for the points
  achieved minus the aspiration payment

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Pensions

• Under old contract not all work was pensionable
• Under new contract locum work and work for out of
  hours co-operatives will be pensionable

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Current issues

• Dispute over payments for flu vaccinations for at
  risk under 65s
• Some difficulty in obtaining quality preparation
  payments
• Problems with enhanced services payments
• -PCTs not making minimum floor payments as
  they claim the money has already been allocated
  this year

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