Welcome to The new GMS & PMS Learning Exchange

Welcome to

The new GMS & PMS

Learning ExchangeThe National Primary and Care

Trust Development Programme

New GMS Learning Exchange

The National Primary and Care Trust Development Programme



All support resources can be found at www.natpact/nhs.uk/primarycarecontracting


All support resources can be found at www.natpact/nhs.uk/primarycarecontracting



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Dr Mohamed Dewji

Clinical Director for

Primary Care Contracting

• Pay GPs or vehicle for strategic change?• Replace OOHs or re-shape emergency care?• Use QOF to effectively manage chronic

disease?• Enhanced services – shift treatment or a

‘cross to bear’?• Feedback on ‘the patient experience’ and

flexibility to progress the choice agenda?

PCT Strategic Tests

• Take opportunities for skill mix and forge effective new partnerships e.g. with pharmacists?

• Positive impact on Recruitment, Retention and morale?

• Develop a more entrepreneurial culture in primary care?

• Use further flexibilities in PMS and PCTMS to tackle local issues.

PCT Strategic Tests

Progress of primary care

Organisational Unit

Service Focus

Mechanismof

Delivery

IndividualG.P.s

IntegratedTrusts (NB

Kaiser)

PCGs / PCTs+ / -

Care Trusts

G.P. Units(larger

practices)

1965 2004 1997 1990

The RedBook

Communitiesof interest

Practice &geographicalcommunities

SpecificTarget Groups>75 years etc

IndividualPatients

Various NHS& Private Providers

PracticeContracts via PMS

GP Commissg

GP Fundholdg

TPP/Multifund

PCTCommissioner

PMSProvider

PMSProvider

nGMSProvider

P

N NP

PP

Performers -mainly the Principals holding the contract

N

P

N NP

PP

N

P

N NP

PP

P

Primary Care – from April

0 - 14 15 - 64 65 + 75 + 85 +

B&NES

BristolN Somerset

S Glos

-10.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

Age group

Demographic Change by 2019

Expected numbers of diabetics: now & by 2010

0

500

1000

1500

2000

2500

3000

0 - 4 5 16 17 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65 - 74 75 - 84 85 - 89 > 90Age bands

Primary Care- future

PCTCommissioner

PMS/GMSProvider

P

N N

NPP

N

NP

N

P

SW

P

N C

NPNP

N

Consolidationof sites by GPs

or others

Integration into Managed CareOrganisations

Interpractice Consortia &

Collaboration

Contracting outto CommercialCos. NFP, Vol. Sector, et al.

• Data rich society

• Performance management: changing role of CHAI

• Performance related incentives e.g. QOF in nGMS

• Benchmarking

• Outcome-driven contracting i.e. control v. empowerment

Accountability and monitoring

• The Internet & access to information

• Role Redesign of health staff

• The changed role of the ‘professional’ with the ‘patient’

Technological Advance

• Patient demand and individualism: more immediacy & less ‘community spirit’

• Work - life balance - flexibility, etc. IWLs• Increased career development with

portfolio careers / job variety• Networks of providers & covering shifts• Reduction of (i) continuity of care over

time & of (ii) long-term commitment

Implications

• Self-determination, cohesion of society– Growth in private / ‘pay-as-you-go’ care – European Working Time Directive

• Rationing– Equitable distribution of resource / Costs – Proactive or reactive care / prevention– Coordination by PCTs of ‘public’ & ‘other’ providers

with equity / transparency of corporate governance and contracting

Implications

• Strategic & Progressive Opportunity for Change in Primary Care

• Reshape Services – Use of OOH / Enhanced Services / QOF

• Choice & Diversity

• Skill-Mix – Patient Centred

• Use of Different Service Models Primary Care Driven NHS

Where to next?

Questions and Discussion

QUALITY & OUTCOMES FRAMEWORK

Dr Philip Leech

Principal Medical Officer

Department of Health

Key points• The QOF is voluntary - but practices that don’t

take part are likely to rely on the MPIG

• PMS practices can opt out of the national QOF -

but agreeing local variations will be hard work

• Non-computerised practices will be at a distinct

disadvantage

• Day-to-day delivery of the QOF will fall more on

practice nurses and practice managers than on GPs

Contents of QOF Guidance

Activities and milestones for 2004/5

Preparatory funding

Aspiration calculation and payment

Prevalence

Annual quality visits

Calculation of achievement points and payment

Ensuring equity and probity

IM&T and data flows

QOF review and adaptation

QOF Improvement Cycle

Review

QOF IMPROVEMENT

CYCLE

Planning

ActionLearning

QOF Activities for 2004/5

QOF 2004/5

Feb 2004 Agree

aspiration

Apr 2004Pay QPrep and QuIP

DES

April 2004QOF goes

live

April 2004DH guidance

on review visits

End April 2004

Monthly aspiration payments

August 2004QMAS system

goes live & provides monthly feedback

Oct 04 – Jan 05

Annual review visits take

place

April 2005 Achievement

payments made

Structure of the QOF - 1• Clinical domain

- 76 indicators

- 10 disease areas (CHD, stroke/ TIA, cancer, hypothryroidism, diabetes, hypertension, mental health, asthma, COPD and epilepsy)

- 550 points

• Organisational domain- 56 indicators

- 5 areas (records, information, patient communication, education and training, practice management and medicines management)

- 184 points

Structure of the QOF - 2

• Patient experience domain

- 4 indicators

- 2 areas (patient survey and consultation length)

- 100 points

• Additional services domain- 10 indicators

- 4 areas (cervical screening, child health surveillance, maternity services and contraceptive services)

- 36 points

Structure of the QOF - 3

• Holistic care payments

- based on points scored in clinical domain

- 100 points

• Quality practice payments- based on points scored in organisational, patient experience and additional services domains

- 30 points

• Access bonus- based on achievement of 24/ 48 hour access target

- 50 points

Preparatory funding

• Quality Preparation Payments (QPrep)– Nov 2003: all receive payment (£9000 for practice with

average list size)– end Apr 2004: second payment (£3250 for average

practice) for practices participating in QOF

• Quality Information Preparation (QuIP) DES– to help practices summarise records, depending on list

size and amount of work– PCTs offer 2004 QuIP to practices by 1 Jan 2004– for 2005, schemes agreed before 1 Apr 2004 are paid to

practices with next monthly payment

Aspiration Payments

• Arrangements for 2004/5– practice and PCT agree aspiration points total– practice paid a third of this– not weighted by prevalence but weighted by relative list size

• Arrangements for 2005/6– practice paid on the basis of 60% of its achievement

payment for the previous year– weighted by prevalence and relative list size

• Aspiration payments paid monthly

Prevalence adjustment

• Only applies to practices doing national QOF

• Acknowledges that practices with low prevalence still have costs in setting up registers and regularly checking patients.

• Provides adequate income protection to practices with lowest prevalence

• Delivers appropriate rewards to practices with highest prevalence (no cap!)

How does it work?

• Prevalence adjustment is based on the contractor’s prevalence measured against the national average

• Contractor’s prevalence = no of patients on disease register

• Separate calculation made for each disease area

• Adjusts the pounds per point available for each disease area

CHD

Distribution of £s per point, under raw and adjusted prevalence rates - CHD

0

5

10

15

20

25

30

35

40

45

up t

o £

5

£5-£

10

£10-£

15

£15-£

20

£20-£

25

£25-£

30

£30-£

35

£35-£

40

£40-£

45

£45-£

50

£50-£

55

£55-£

60

£60-£

65

£65-£

70

£70-£

75

£75-£

80

£80-£

85

£85-£

90

£90-£

95

£95-£

100

£100-£

105

£105-£

110

£11

0-£

115

£11

5-£

120

£120-£

125

£125-£

130

£130-£

135

£135-£

140

£140-£

145

freq

uen

cy

Raw

Adjusted

Additional Services Adjustment

• Pounds per point adjusted by relative size of target population

• Protects contractors with large target populations

• Rewards for greater workload

• Relative size of contractor’s target population is compared to national average

Target Populations

Cervical screening Women aged 25 to 64 years

Child health surveillance Children aged under 5 years

Maternity services Women aged under 55 years

Contraceptive services Women aged under 55 years

Cervical Screening

Child health surveillance

Maternity Services

Contraceptive Services

Women aged 25 to 64 years

Children aged under 5 years

Women aged under 55 years

Women aged under 55 years

Don’t panic!

• For the national QOF, these calculations will be made automatically by the IMT software (Quality and Outcomes Framework Management & Analysis System aka QMAS)

• PCTs of PMS practices taking part in a locally agreed QOF will need to do their own calculations

Annual Review

• Commissioned the School of Health and Related Research (ScHARR) to develop proposals

• Separate guidance will be published in April 2004 by DH

• Current guidance sets out key principles

• Visits should take place between October and January - PCT should agree and publish a schedule

Supporting Information

• Supporting information to be submitted by contractor one month before the visit

• Required information set out in New GMS Contract 2003: Supplementary Guidance

• Must cover all areas for which the contractor intends to submit an achievement claim

• Will certainly include levels of exception reporting and any anomalous data eg on referrals

Annual Review Assessors

• Selected on the basis of meeting certain competencies

• Appropriately trained - national training available for a limited number of assessors

• One assessor will normally be a doctor (or another healthcare professional by agreement between practice and PCT)

• One assessor will normally be a lay person• Bound by a code of practice on confidentiality• Visit may involve LMC

Outcomes of the Visit

• Assessment of contractor’s likely achievement against the QOF

• Written report, seen in draft by the practice

• Remedial plan if visit highlights issues around data quality eg Read coding

• Remedial plan to be implemented by contractor within one month of agreement

Annual Review Visit

DO• Identify the person responsible for visits

• Start working on a visit schedule now

• Identify potential assessors, and check availability

• Wait for publication of national guidance in April before working on the detail

Annual Review Visit

DON’T• Get too bogged down in detail: further guidance

will be published in April

• Assume national training will be available for ALL your assessors

• Ignore everything until April!

Ensuring Equity & Probity

• PCT verification of achievement claims before payment

• PCTs can re-score contractors’ achievement claims, in some circumstances

• Remedial action on data quality if annual review visit generates concerns

• Random 5% check of achievement claims to deter fraud

IM&T and Data Flows

• Practices do not need new software, just an RFA99 compliant clinical system

• Reports from QMAS - monthly to PCTs, at least monthly to practices

• QMAS reports will, in time, have comparative data on achievement and trends (local and national)

• Consultation on impact of Freedom of Information Act (kicks in January 2005)

GP Practice

PCT

PCT Payment Agency

OtherAchievement

Data(Web)

NHAIS

PC

Management and AnalysisSystem (MAS)

Centralised IM&T

Achievement Reports(Web)

Achievement Reports(Web)

AgreedAchievement(IT Interface)

Payments(BACS)

Clinical SystemAchievement Data

(IT Interface)

PC

GP ClinicalSystem

Review of QOF

• Process for reviewing QOF will be established this year

• Will be informed by PMS local QOF experience

• Major changes unlikely before April 2006

• Smaller changes before then to remove errors and take into account groundbreaking new evidence

• The IMT will do all the calculations for you

• You need to focus on:

- appointing a QOF lead for your PCT

- agreeing aspirations (if you haven’t already)

- encouraging practices to get ready for the IMT (Read codes, list cleaning, computerisation)

- identifying potential assessors

- booking annual review visits

• You are part of a world first!

To sum up...

Getting more information

• GMS and PMS:

helpline - 0845 900 0008

inbox - [email protected]

website - www.natpact.nhs.uk/primarycarecontracting/

• QOF guidance:

GMS www.doh.gov.uk/gmscontract/implementation.htm

PMS www.doh.gov.uk/pmsdevelopment/

pmsarrangementsdec03.pdf

New Contracts in Primary Care: workforce issues

Kate Billingham

Starting pointNurses in general practice can experience :

– no contracts– less than rigorous scrutiny on appointment

[illegal employment!]– limited training opportunities– limited feedback on performance– no consistent professional development– limited integration with other nurses– lack of access to nursing leadership

Improving employment conditions

“Primary care professionals need to be:– eligible to perform services– recruited and retained– development needs to be supported– deserve adequate pensions”

This will mean...

• Job descriptions

• Pre-employment references to be checked

• Registered with relevant professional body

• Agenda for Change principles to be implemented

Support development needs

• having a say and being consulted

• new roles are supported by training

• access to clinical supervision and appraisal

• access to CPD and professional advice

The regulations say…………..

• The contractor shall ensure that for any health professional performing clinical services under the contract there are in place arrangements for the purpose of maintaining and updating his skills and knowledge in relation to the services he is performing (para 59)

• The contractor shall afford to each employee reasonable opportunities to undertake appropriate training with a view to maintaining competence (para 60)

The risks

• Nurses and others will not be competent for their new roles

• Workforce supply will be inadequate

• Poor professional engagement

• Principles of Agenda for Change are not implemented

What needs to be done

• PCT staff need to provide HR support to practices

• Use and strengthen tools already available e.g clinical governance

• Monitor the HR elements of the contracts

• Involve professional bodies

• Clarify professional accountability

New and modified roles

Hold discussions with...• Other local PCTs

• Workforce Development Confederations

• Strategic Health Authorities

• Local universities

In summary

• Different contractual relationship• PCTs will be commissioning primary care

– a practice– a group of practices– a PCT employee– an alternative provider

• Professional advice and input will be crucial

Liberate the Talents

Delivering Out-of-Hours Services

David Carson

www.out-of-hours.infoMy Presentation

• Policy Framework

• Who will deliver OOH services?

• The role of PCTs and SHAs

• Some cross-cutting issues

www.out-of-hours.infoBackground Policy Framework

• OOH Review

• REC

• NHSD Review

• nGMS

• Choice and Plurality

www.out-of-hours.infoPolicy I : OOH Review

• Standards

• Clinical Leadership

• Integrated OOH services

• Network of providers

• Joined up planning and commissioning

www.out-of-hours.info

Policy II: Reforming Emergency Care

• Same principles as OOH• Current focus on A&E headline figure• Integrated response to Minor Illness

and Injury• Solutions may reside outside A&E

within network provision• Chronic disease management - real

opportunities in contract


Policy III: NHS Direct Review

• Technical Links• Capacity in 2004/5 and 2005/6• Clear set of criteria being developed for

joint operational arrangements• Ensure that developed arrangements

are consistent with NHSD direction and key role in emergency care.

• NHSD commissioning framework out for consultation

• Must be in the development process - integration of clinical processes

www.out-of-hours.infoPolicy IV : nGMS

• Opt out is not partial

• Specific notice periods

• OOH will provide mechanism to meet in-hours nGMS Challenge

• Opportunity to build PC capacity and volume

www.out-of-hours.infoPolicy V: Plurality

• NHS

• Mutual / Voluntary Sector

• Private Sector

• All have a role

• PCT provision is perhaps backstop choice

www.out-of-hours.infoWho will deliver OOH Services?

• GP Opt-Out and re-provision

• Capacity Information

• Providers

• Mutuality

• Commercial Providers

• The Ambulance Service

• NHS Direct

www.out-of-hours.infoDelivery I: GP opt-out & re-provision.

• Relevant yes but perhaps not in terms of re-provision

• 2 Different things• Opt out is Practice decision• Look beyond this question• Services staffed by GPs and others

attracted to work in services and providers


Delivery II : Capacity Information

• Urgent need to collect and collate existing information

• Should be mapped by:• Case mix• Geography• Time• Competencies

• Use as basis of planning integrated service• All data should be shared with all providers

(including acute and ambulance service)

www.out-of-hours.infoDelivery III : Providers

• Limited view of opportunities by some• Providers stop competing on all

aspects – cooperate and build on your strengths (none are good at everything)

• More opportunity for joint development• More attention to planning process• At scale versus local• Provider development process is

needed in every area

www.out-of-hours.infoDelivery IV : Mutuality

• COOP to COOP• Basis of COOP membership changes from

those with responsibility to those working within COOP and beyond.

• Will require support as per guidance from PCTs• Working on governance models

• Provider development• Further papers coming

• Mutual Transfer - January• Model Constitution - March

www.out-of-hours.infoDelivery V: Commercial Providers

• Strengths

• Resilience due to size

• Clinical governance structures

• Logistics and management capacity

• Often complementary services to local COOPs

www.out-of-hours.infoDelivery VI: Ambulance Service

• Also Strengths

• Part of network

• Have increasing role

• Must be at the table

• Time to develop effective PC Capacity

www.out-of-hours.infoDelivery VII: NHS Direct

• Technical Links• Capacity in 2004/5 and 2005/6• Clear set of criteria being developed for

joint operational arrangements• Ensure that developed arrangements

are consistent with NHSD direction and key role in emergency care.

• NHSD commissioning framework out for consultation

• Must be in the development process - integration of clinical processes

www.out-of-hours.info PCTs

• Networks• Inter-PCT Co-operation • Self-provision

www.out-of-hours.infoPCTs I : Networks

• Have you achieved contestability and sustainability?

• A network gives more options than a single preferred provider

• Yet to see an area in which a single provider has all the answers

• Support providers (or establish new providers)

• Support change• Give OOH the priority it requires

www.out-of-hours.infoPCTs II: Inter-PCT

Co-operation

• Potential for one PCT solution to destabilise others

• Agree on what development activity could be shared

• Inter PCT process requires proper attention (probably at Board level)

• Single PCT options will be very rare

www.out-of-hours.infoPCT III: Self-Provision

• OOH Volumes within individual PCTs are low - few economies to be gained

• Enough service volume to have senior professional and operational leadership?

• Track record?• Delivers contract but what next?• Aspects of provision at scale do not exclude local

initiatives• Question the perception that PCT provision is the

only way to control costs

www.out-of-hours.infoRole of SHAs

• Key role• Overview of PCT process• Review of plans and hot spots• Key role in ensuring plurality and adequate provision• Overview of capacity and market

• No of providers• Capacity of providers• Assure overall provision is adequate

• Benchmark and support PCT action

www.out-of-hours.infoOther Issues

• Workforce

• Clinical Leadership

• Procurement and tendering

• Accreditation and the Quality Standards


Other Issues I : Workforce

• Significant number of WF initiatives in Agency and in WDCs

• Important for SHAs and PCTs to ensure OOH and PC issues are on WDC agenda now

• No magic bullet but skill mix and flexible roles are key

www.out-of-hours.infoOther Issues II :

Clinical Leadership

• Effective clinical leadership underpins effective team working

• Clinical leaders key role in developing brokering network / inter provider operational arrangements

• Employed skill mix workforce (even GPs may be employed in new OOH organisations)

• The organisational structure requires capacity and competency to attract, develop and support senior clinical leaders


Other Issues III: Procurement &

Tendering

• Procurement is not the same as tendering • It is legitimate to include providers in process• Providers should identify strengths / weakness

& the benefits of joint working• Then working co-operatively• We do not have excess capacity• We need to build capacity


Other Issues IV: Accreditation &

Standards

• Under review

• Process of accreditation potentially within contracting

• Standards will apply to all providers (including practices who do not opt out)

• Revised Standards in April

www.out-of-hours.infoA Unique Opportunity

• Best opportunity in a generation to build on the best of current practice

• Will require focussed work and investment.

• More complex but worth the effort

Delivering OOHs services

David Carson

www.out-of-hours.infoOOH ChallengesOOH Challenges• Providers• Networks• Joint operations• Clinical leadership• Making most of opportunities• Short medium and long term

arrangements• Immediate priority not the enemy of

the next stage• Workforce

The new GMS

& PMS

Learning Exchange


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Welcome to The new GMS & PMS Learning Exchange