The New General Medical Services Contract for General Practice An

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The New General Medical Services Contractfor
General PracticeAn Enabling Contract Nigel
McFetridgeHead of clinical governanceHampshire
and Isle of Wight Strategic Health Authority

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Outline of Presentation

• The current contract
• Why change?
• The new contract
• - Extra Services
• - Quality and Outcome Framework
• Role of PCT Public Health function

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Primary Care

• General Practice
• New GMS contract
• Primary Care Nursing
• Liberating the Talents
• Oral health
• Ready for PCT commissioning Dentistry - April
  2005
• Pharmacy
• A Vision for Pharmacy
• Vision and eye care
• Vision 2020
• chronic eye disease management - care pathways

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Features of current GP contract

• Most GPs are self-employed independent
  contractors
• GPs own the capital required to practice their
  craft
• Patients register with individual GPs
• Provide all necessary and appropriate personal
  medical services of the type usually provided by
  general medical practitioners
• Daily Public Health work
• health advice, primary, secondary and tertiary
  prevention, immunisation, cervical screening,
  sexual health and contraception, occupational
  health, prevention of infection, monitoring of
  patients health, collection of data

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Some Problems

• Not enough doctors
• 13 staff near retirement age, more part-time,
  recruitment too low
• Poor work-life balance
• Wide variations in quality - Inverse care law
• Oxfordshire has twice as many GPs as S.Derbyshire
• Money follows doctors investment decisions, not
  patients needs
• 10 premises are sub-standard
• Patient access and choice
• Contract rewards volume, not quality
• Contract too rigid
• More could be done in Primary Care - technology /
  skills
• Good care requires more multi-disciplinary
  team-work
• PCTs have little power to shape general practice
  to meet patients requirements
• Younger people less satisfied with service

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The new contract is a strategic tool to

• Give PCTs more ability to shape services
• Expand primary care capacity to meet local needs
• Deliver wider range of services close to patient
• Improve the quality and range of services for
  patients
• Improve convenience and choice to patients
• Reduce pressure on acute services
• Make General Practice a more attractive and
  family-friendly place to work
• new career structure, protected time for skill
  development, family friendly working practices

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• Key Features -1
• Negotiated between the BMA and the NHS
  Confederation
• Maintains independent contractor status of GP and
  preserves existing practices as providers
• Over 8 billion UK investment over three years
• (33 increase between 2003/04 and 2005/06)
• making primary care the biggest growth area in
  the NHS
• PCTs responsible for securing the provision of
  primary medical services
• So much greater flexibility in boundaries between
  primary, intermediate and secondary care
• GMS
• PMS
• Alternative Providers
• (eg voluntary sector, commercial providers, NHS
  Trusts, other PCTs)
• Direct PCT provision

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• Key Features -2
• Contract is practice-based
• Patients register with a practice not a GP for
  essential services
• (but can choose who they see)
• Allows greater flexibility in staff skill mix -
  so will affect all staff
• Practices have greater flexibility to determine
  the services they provide
• Reinforces multi-disciplinary nature of primary
  care
• Encourages new services and GPs / Nurses with
  special interests
• Practices can control workload
• Practices paid by simplified Global Sum
• PLUS additional resources/reward for
• Extra services - Enhanced Services
• Quality - Standards of care in contract
• - Quality and Outcomes Framework

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Extra Services
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• Essential Services
• ALL PRACTICES MUST PROVIDE
• Management of patients who are ill or believe
  themselves to be ill
• General management of patients who are terminally
  ill
• Management of chronic disease
• Additional Services
• ALL PRACTICES EXPECTED TO PROVIDE
• Cervical screening
• Contraceptive services
• Childhood vaccinations and immunisations
• Child health surveillance
• Maternity services excluding intra-partum care
• Minor surgery

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• Enhanced Services
• 1. Essential or Additional services specified to
  a higher standard
• e.g. minor surgery
• 2. New Primary Care Services
• Optional
• Range of providers
• Directed Enhanced Services
• PCTs must commission
• Minor Surgery
• Staff support for dealing with violent patients
• Quality information preparation (patient medical
  records)
• Influenza immunisation
• Childhood Immunisations
• Access (achieving national targets)

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National Enhanced ServicesPCTs may commission if
not currently provided

• Drug misuse services
• Alcohol misuse services
• Specialised sexual health services
• Enhanced care of the homeless
• Specialised depression services
• Specialised services for patients with multiple
  sclerosis
• Intra-partum care
• Immediate care and first response care services
• Minor injury services
• Near-patient testing
• Anti-coagulation monitoring
• Intra-uterine contraceptive device fitting

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Local Enhanced ServicesExamples

• Enhanced co-ordinated care for older people in
  residential care / nursing homes
• Diabetic care
• Services for Asylum Seekers
• Cardiology care

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Quality and Outcome Framework(QOF)
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• QOF - Principles
• Voluntary system of additional funding
• Major funding stream for new money
• Rewards participation in an
• annual quality improvement cycle
• based on a quality points system
• Adjusted for practice size and disease
  prevalence
• Requires high data quality and IT support
• QOF will be updated

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Quality and Outcomes Framework

• Comprises indicators grouped into areas within
  the following four domains
• Clinical - 10 disease areas
• Organisational
• Patient experience
• Additional services

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Principles for selecting disease areas

• Indicators based on the best available evidence.
• The number kept to the minimum number compatible
  with an accurate assessment
• Only data which are useful in patient care should
  be collected.
• Data never collected twice
• Diseases selected if
• responsibility for ongoing management rests
  principally in primary care
• there is good evidence of the health benefits
  likely to result from improved primary care
• disease is a national priority (eg NSFs)

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• Clinical Domain - 10 disease areas
• Coronary Heart Disease and Left Ventricular
  Disease
• Hypertension
• Diabetes
• Stroke or TIA
• Hypothyroidism
• Epilepsy
• Asthma
• COPD
• Mental Health
• Cancer

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Indicators grouped into three Levels - e.g.
Hypertension

• Level 1 Records
• The practice can produce a register of patients
  with established hypertension (9)
• Level 2 Diagnosis and initial management
• The percentage of patients with hypertension
  whose notes record smoking status at least once
  (max 10)
• The percentage of patients with hypertension who
  smoke whose notes contain a record that smoking
  cessation advice has been offered at least once
  (max 10)
• The percentage of patients with hypertension in
  which there is a record of blood pressure in the
  last nine months (max 20)
• Level 3 Ongoing management
• The percentage of patients with hypertension in
  whom the last blood pressure (measured in the
  last nine months) is 150/90 or less (max 56)

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• Organisational Domain - 5 Areas
• Records and information about patients
• Communication with patients
• Education and training
• Practice management
• Medicines management
• Patient Experience Domain - 2 Areas
• Patient Surveys
• Length of consultations
• Additional Services Domain - 4 Areas
• Cervical Screening
• Child Health Surveillance
• Maternity Services
• Contraceptive Services

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• Quality Points
• Clinical 550
• Organisational 184
• Patient experience 100
• Additional services 36
• Holistic care 100
• Quality Practice 30
• Access 50
• Total points 1050
• 1 point 75 for an average practice
• (Corrected for practice size and disease
  prevalence)

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Role of PCT Public Health functionQOF

• Support practices and the PCT on issues of data
  quality (e.g. monthly returns, annual quality
  review visits and prevalence adjustment
  arrangements).
• Analysis of monthly data returns from practices
  to support health status and health needs
  assessment work.
• Ensure focus on QOF does not divert activity from
  other public health issues.
• Advise the UK-wide independent expert group on
  changes to the indicators, workload implications
  and aspects of the prevalence adjustment
  arrangements.

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Role of PCT Public Health function

• Ensure that the development of primary care takes
  place within a strategic framework that
• maximises health improvement and minimises health
  inequalities
• promotes integration of primary care with other
  health and social care services.
• Development of a long term primary care strategy.
• Help encourage population based and Public Health
  thinking in general practice.
• Advise on service redesign e.g. commissioning of
  enhanced services.
• Identify and manage possible information holes
  that might be created during the changeover.
• Ensure implementation of NSFs in primary care and
  help improve chronic disease management.
• Ensure appropriate provision of services for
• vulnerable groups
• e.g. homeless people, drug/alcohol abusers
• areas where there are major inequalities
• e.g. sexual health, coronary heart disease,
  cancer, mental health, child health).

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Reference

• New General Medical Services Contract
  http//www.doh.gov.uk/gmscontract/index.htm