The New GMS

Contract

The New Contract

• The Old Contract

• Background

• Provision of services

• Quality

• Investment

The Old Contract

• Between GP and PCO

– Capitation fees

– Item of service payments

– Rural practice allowance

– Basic practice allowance

– Postgraduate education allowance

– Seniority payment

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

The Old Contract

• Between GP and PCO

– Capitation fees

– Item of service payments

– Rural practice allowance

– Basic practice allowance

– Postgraduate education allowance

– Seniority payment

Background

• Negotiations for new contract began late 2001

• New contract documentation February 2003

• Vote

• Result 20/06/03:

– 70% turnout

– 79.4% yes vote

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

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

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

Provision of services

• Additional services

– Opting out

• temporary ( <1 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

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

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

Provision of services

• Enhanced services

– in response to local need

• ? Services for immigrants

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

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

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

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

Clinical Domain

• Coronary heart disease

including left ventricular

dysfunction

• Stroke and transient

ischaemic attacks

• Hypertension

• Hypothyroidism

• Diabetes

• Mental Health

• Chronic Obstructive

Pulmonary Disease

• Asthma

• Epilepsy

• Cancer

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%)

Organisational Domain

• Records and information

• Communication with patients

• Education and training

• Medicines management

• Clinical and practice management

Organisational Domain

• Example

– The practice has arrangements for patients to speak to

GPs and nurses on the telephone during the working day.

1 point

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

Patient experience domain

• Patient survey

• Consultation length

• Example

– The practice will have undertaken an approved patient

survey each year. 40 points

Investment

• Global sum and MPIG

• Quality payments

• Payments for enhanced services

• Others - premises, seniority, PCO payments (e.g. for

mat leave), dispensing

• Pensions

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

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

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

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

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

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

PRACTICE

GLOBAL SUM

PCO

UNIFIED BUDGET

ESSENTIAL

&

ADDITIONAL

PROTECTED

TIME

DIRECTED AND

NATIONAL

ENHANCED

LOCAL

ENHANCED

GUARANTEED

FUND(S)

ASSURED

QUALITY

MONEY

ALTERNATIVE

PROVIDER

PCO-MANAGED

FUNDS

PREMISES

IT