Funding in General Practice

1
Funding in General Practice

• Dr Andy Withers
• Grange Practice
• Allerton

2
Aims Objectives

• Aims
• Increase understanding of how General Practice is
  financed
• Objectives
• Know how -
• Practice income is calculated and received
• Budgets are set
• The difference between NHS Private income

3
Questions

• How do GPRs get paid in practice?
• How do salaried GPs get paid?
• How do GP Partners get paid?
• What is the difference between a GMS PMS
  practice?
• Are all my earnings pensionable?
• What is PBC?
• How can I earn more?

4
What do we get paid for?

• Core General Practice( Essential Services)
• Additional Services
• Enhanced Services
• QOF

5
NHS Income
6
GP Funding Budget BAtPCT
7
Premises Budget
8
Essential Services (63.6)

• MANDATORY - common to all practices
• The management of patients who are ill or believe
  themselves to be ill, with conditions from which
  recovery is generally expected, for the duration
  of that condition, including relevant health
  promotion advice and referral as appropriate,
  reflecting patient choice wherever practicable
• 2) The general management of patients who are
  terminally ill
• 3) Management of chronic disease in the manner
  determined by the practice, in discussion with
  the patient

9
Essential Services (63.6)

• Either paid as Global Sum or MPIG in GMS
  practices (MPIG GS correction factor)
• Government want to get rid of MPIG
• Basic Contract in PMS practices

10
Additional Services (2.8)

• Normally expected of all practices but OPT-OUT
  possible
• Cervical cytology
• Child health surveillance
• Maternity services (not intrapartum care)
• Contraceptive services

11
Enhanced Services (11.3)

• 3 types
• Direct
• National
• Local

12
DES (2.8)

• Obligatory for each PCO
• National specifications
• No one practice has to do
• Services to violent patients
• Childhood vaccinations and immunisations
  financial incentives
• Minor surgery
• Flu immunisations
• Improved access
• IMT
• Choice Booking
• (PBC)
• New clinical DESs Heart Failure, Osteoporosis,
  LD, Ethnicity, Alcohol

13
NES (1.7)

• OPT-IN - national terms and conditions
• Anticoagulant monitoring IUCD
• Sexual health MS
• Drug and alcohol misuse Terminally ill
• Depression Learning disabilities
• Intra partum care Minor injuries
• Near-patient testing Homeless
• Immediate/first response care

14
LES (6.8)

• OPT-IN
• Response to specific local requirements
• Local terms, conditions and standards
• Possibly, innovative services for piloting and
  evaluation

15
LES (6.8)

• Choice Booking (to 31/3/09)
• IMT
• Sexual Health
• Minor Primary Services
• ECG
• Minor Surgery (various levels)
• Spirometry

16
GMS v PMS

• Little difference now
• PMS probably slightly higher earning practices
  due to historic funding.
• Both practice based contracts
• GMS nationally negotiated
• Either global sum via Formula
• Or Minimum practice income guarantee (MPIG)
• PMS (potentially) locally negotiated

17
Range of Practice Funding in BAtPCT
18
Seniority

• Begins from start of NHS service
• Annual increments

19
QOFTHE FOUR DOMAINS OF QUALITYClinicalOrgani
sationalPatient experienceAdditional services
20
Total Points 1000

• Clinical 650
• Organisational 167.5
• Additional Services 36
• Patient Experience 146.5

21
CLINICAL AREAS

• Asthma 45
• AF 30
• Cancer 11
• CKD 27
• COPD 28
• CHD 89
• Dementia 20
• Depression 33
• Diabetes 93
• Epilepsy 15

• Heart Failure 20
• Hypertension 83
• Hypothyroidism 7
• Learning Disabilities 4
• Mental health 39
• Obesity 8
• Palliative Care 6
• Smoking 68
• Stroke TIA 24

22
ORGANISATIONAL AREAS

• Records and information
• Patient communication
• Education and training
• Practice management
• Medicines management

23
PATIENT EXPERIENCE

• Standardised approved patient questionnaires
• General Practice Assessment Questionnaire
  (Manchester)
• Improving Practice Questionnaire (Exeter)
• Length of consultation - 10 mins appts

24
QOF Changes 2009/10

• End of Square rooting
• Move to true prevalence

25
QOF Changes 2009/10

• Heart Failure (9 new points)
• One new indicator (which moves the current HF DES
  for England into QOF)
• HF 4 The percentage of patients with a current
  diagnosis of heart failure due to LVD who are
  currently treated with an ACE inhibitor or
  Angiotensin Receptor Blocker, who are
  additionally treated with a beta-blocker licensed
  for heart failure, or recorded as intolerant to
  or having a contraindication to beta-blockers. (9
  points thresholds 40 60)
• Chronic Kidney Disease CKD (11 new points)
• Five additional points will be allocated to
  existing indicator CKD 5
• CKD 5 The percentage of patients on the CKD
  register with hypertension and proteinuria who
  are treated with an angiotensin converting enzyme
  inhibitor (ACE-1) or angiosten receptor blocker
  (ARB) (unless a contraindication or side effects
  are recorded). (5 additional points (so the
  indicator will be worth 9 points in total)
  thresholds 40 80) While this indicator will
  not change, the guidance will be changed.
• One new indicator
• CKD 6 The percentage of patients on the CKD
  register whose notes have a record of an albumin
  creatinine ratio (or protein creatinine ratio)
  value in the previous 15 months. (6 points
  thresholds 40 80)

26
QOF Changes 2009/10

• Sexual Health - contraception (8 new points plus
  2 points from current CON indicators, CON 1 and 2
  which will be removed)
• Three new indicators, as recommended in the 2008
  expert panel report
• SH 1 The practice can produce a register of
  women who have been prescribed any method of
  contraception at least once in the last year. (4
  points)
• SH 3 The percentage of women prescribed an oral
  or patch contraceptive method in the last year
  who have received information from the practice
  about long acting reversible methods of
  contraception in the previous 15 months. (3
  points thresholds 40 90)
• SH 4 The percentage of women prescribed
  emergency hormonal contraception at least once in
  the year by the practice who have received
  information from the practice about long acting
  reversible methods of contraception at the time
  of, or within one month of, the prescription. (3
  points thresholds 40 90)
• Anxiety and Depression (20 new points)
• One new indicator
• DEP 3 In those patients with a new diagnosis of
  depression and assessment of severity recorded
  between the preceding 1 April to 31 March, the
  percentage of patients who have had a further
  assessment of severity 5 12 weeks (inclusive)
  after the initial recording of the assessment of
  severity. Both assessments should be completed
  using an assessment tool validated for use in
  primary care. (20 points thresholds 40 90)

27
QOF Changes 2009/10

• Cardio Vascular Disease CVD Primary Prevention
  (13 points)
• Two new indicators
• PP 1 In those patients with a new diagnosis of
  hypertension (excluding those with pre-existing
  CHD, diabetes, stroke and/or TIA) recorded
  between the preceding 1 April to 31 March the
  percentage of patients who have had a face to
  face cardiovascular risk assessment at the outset
  of diagnosis using an agreed risk assessment
  treatment tool. (8 points thresholds 40 70)
  For the purposes of QOF measurement, at the
  outset of diagnosis is defined as within three
  months of the initial diagnosis.
• PP 2 The percentage of people diagnosed with
  hypertension diagnosed after 1 April 2009 who are
  given lifestyle advice in the last 15 months for
  increasing physical activity, smoking cessation,
  safe alcohol consumption and healthy diet. (5
  points thresholds 40 70)
• Diabetes (7 new points plus 28 current points)
• There are currently two indicators with HbA1c
  targets (DM7 and DM 20) which have been subject
  to changes. We will also introduce a new
  indicator. The three indicators are as follows
• DM 23 Replaces DM 20 (which has a HbA1C target
  of 7.5 or less and is worth 17 points) The
  percentage of patients with diabetes in whom the
  last HbA1c is 7 or less (or equivalent
  test/reference range depending on local
  laboratory) in the previous 15 months. (17
  points thresholds 40 50)
• DM 24 New The percentage of patients with
  diabetes in whom the last HbA1c is 8 or less (or
  equivalent test/reference range depending on
  local laboratory) in the previous 15 months. (8
  points thresholds 40 70)
• DM 25 Replaces DM 7 (which has a HbA1C target of
  10 or less and is worth 11 points) The percentage
  of patients with diabetes in whom the last HbA1c
  is 9 or less (or equivalent test/reference range
  depending on local laboratory) in the previous 15
  months. (10 points thresholds 40 90)

28
QOF Changes 2009/10

• COPD (2 new points)
• One revised indicator
• COPD 13 Replaces COPD 11 The percentage of
  patients with COPD who have had a review,
  undertaken by a healthcare professional,
  including an assessment
• of breathlessness using the MRC dyspnoea score in
  the preceding 15 months. (2 additional points so
  the indicator would be worth 9 points thresholds
  50 90)
• Reallocation of Points
• The following points will be removed
• Indicator Current value New value Points
  removed
• PE2 25 0 25
• PE6 30 0 30
• SMOKING 3 33 30 3
• SMOKING 4 35 30 5
• BP 4 20 18 2
• CHD 6 19 17 2
• AF 3 15 12 3
• CON 1 1 0 1
• CON 2 1 0 1
• Total 72

29
Pensions

• All NHS income pensionable
• delivering GMS / PMS
• delivering services under delegation including
  locum work
• board, advisory and other work for NHS bodies
• collaborative arrangements work
• education
• statutory certification
• work for GP cooperatives that are NHS bodies
• All locum pay pensionable from 1.4.2002

30
PBC

• Practice Based Commissioning
• Voluntary
• Devolved budgets to all practices
• Virtual Money you cant take it home
• For
• Prescribing
• Secondary care, acute elective
• Community Staff
• Can spend (up to) 70 of Freed up resources (FURs
  note not savings) on patient care. Pct takes
  rest.
• Only get FURs you predict (no serendipitous FUR)
• Idea is to provide innovations in services to
  produce FUR
• Usually done through commissioning alliances

31
Other Income

• Teaching Training Amount NHS Pension?
• GPR 7.5k Y
• FY2 10k Y
• Medical Students 15-20k N
• NHS related work
• GPwSI c 10k/session Y
• PCT Y
• LMC N
• DH Y
• Private N
• Reports
• Medicals etc

32
Getting Paid
33
Getting Paid 2 (This is real money)

• Typical Middle sized practice (approx 5500
  patients)
• Total amount 875k
• Less running expenses (36) 315k
• Less Staff costs (including salaried GPs
  GPRs) 260k
• Profit (34) 300k
• Divided between partners income 100k
• Need to pay 20 superannuation 80k
• Need to pay Income tax

34
Premesis

• Lift
• PFI variants
• DIY
• Guaranteed income stream from PCT
• About 11 return for developer