North Staffordshire Local Medical Committee

The New GMS Contract

A summary consisting of what I consider to be the most important paragraphs from the original document

Categorisation of services

The new contract recognises that your time is finite and that you must be able to control your workload. You will be able to do so in an unprecedented way, enabling you to decide on the range and quality of service you will provide, while patients continue to receive the full range of health care locally. There will be real opportunities to opt out of some current work and responsibility, including out-of-hours work. New work will be properly resourced.

We have moved away from target payments to a fair and carefully graded system of quality payments that will reward GPs for delivering quality care with extra incentives to encourage even higher standards. There will be significant additional investment in resources for infrastructure, new and better opportunities for developing practice premises, and a range of fully funded computers and IT products paid for by your local Primary Care Organisation. A career structure will be put in place so that family doctors can follow an exciting professional path without adversely affecting their income or their workload. The wisdom and experience of more senior doctors will attract additional rewards.

The proposed categorisation divides the medical work in general practice into three groups:
- Essential Clinical Services
- Additional Clinical Services
- Enhanced Clinical Services: National and Local

The first group - Essential Clinical Services - will be provided by every practice. It covers services initiated by patients who are ill, or believe themselves to be ill, with conditions from which they are expected to recover. It also covers the general management of terminally ill patients. Making this category universal ensures that sick and worried patients who come to their family doctor for help will get the continuity of care they seek.

Essential Clinical Services will be agreed and priced nationally and the money for them will be paid directly to practices through the local primary care organisation. Work in this category includes patients who present with new symptoms such as chest pain, upper respiratory infections, fevers and other health problems presenting for the first time.

The second group – Additional Clinical Services– will also be nationally negotiated to a nationally agreed price. Most practices would be expected to provide these services, which would include vaccination and immunisation, contraception, child health surveillance, cervical cytology and chronic disease management.

The default position would be that most practices would provide these services but could opt out if necessary

The third category of medical services will be called Enhanced Clinical Services. There will be National Enhanced Services and Local Enhanced Services.

The default position would be that practices wishing to provide them would opt in to Enhanced Clinical Services.

Out-of-hours care is an example of a service which, after a transitional phase, would fall into the opt in group of Enhanced Clinical Services. During the transitional phase it would fall into the additional clinical service group provided by most practices.

Out-of-hours care

The clear message to emerge from the National GP Survey was that the vast majority of family doctors (83.8%) believe it should be possible for individual doctors to choose whether to opt out of out-of-hours responsibility.

With this mandate in mind, the GPC has negotiated a new NHS contract in which GPs will have a choice whether to provide out-of-hours cover and whether to accept out-of-hours responsibility. Where a practice does not wish to provide this service, the responsibility for patient care in evenings, at night time and weekends passes to the local PCO.

The new GP contract will allow doctors to choose whether they want their practice to assume round-the-clock responsibility for patients or whether to limit care to within normal working hours. The out-of-hours period will be defined as from 6.30pm to 8am plus weekends and bank holidays. Those practices choosing to continue providing out-of-hours cover will be paid for the work at a nationally negotiated and agreed rate.

How the money will flow

The new contract gives family doctors considerable additional earnings potential for delivering high quality care to their patients. Significant resources have also been promised for infrastructure and development. If GPs signal their wish for the contract framework to go forward to the pricing stage, Ministers have said the resources and the appropriate level of reward required for its implementation will be made available.

Money will flow into practices from several sources. A protected global sum will go directly to the practice via the PCO. There will be a guaranteed floor of money in the unified budget of PCOs for Enhanced Clinical Services, and other aspects of the new contract not covered by the global sum, such as career development. This will include "wisdom and experience" payments for the more senior members of the profession. In addition to these, GPs will be able to draw down quality and outcome payments to cover the infrastructure, aspiration and achievement of providing high quality healthcare to their patients. This money will not be pooled and will flow straight through the PCO to the practice.

The Essential and Additional Clinical Services provided by the practice will be paid for from a global sum based on the weighted needs of the practice's patient list. There will be a national allocation formula to determine how much a practice will receive. This global sum will also cover the practice infrastructure costs.

When practices opt in to provide enhanced services, the money will come from the PCO's unified budget. National Enhanced Services will have a nationally agreed price attached to them. Local Enhanced Services will be priced locally.

The money available to pay GPs for the quality of service will not be pooled. It will flow directly through the PCO into practices in a guaranteed stream. There will be money payable in advance for infrastructure costs associated with the quality and outcomes framework explained in this document. There will also be payments for aspirations to deliver higher quality care and for achieving and maintaining that care. The vast majority of practices will qualify for quality payments and the level of payment will be directly linked to the level of quality provided.

Quality and outcomes

In the new contract GPs will be rewarded for the quality of service they offer to patients. In addition to the guaranteed global sum based on the weighted needs of patients in a practice, extra money will be available for quality.

The scheme is based on incentives and rewards. It will be graded so that even modest improvements are financially recognised. The size of the reward will vary from no extra money for the very small percentage of practices who do not obtain any quality level, to large amounts for practices whose patients are benefiting from really high quality healthcare.

GPs will be able to move up the quality ladder at their own pace. Their rewards will not be constrained by a limited pool of money.

On first reading, the scheme will seem complicated. GPs should be reassured that:
- They don't have to do everything at once to receive a reward
- They are already doing a lot of this work, but possibly not recording it
- They will be given the money in advance to enable them to deliver higher quality care and to record their work
- They will be paid for aspiring to better quality, achieving it and maintaining it
- Safeguards will be there to stop practices being penalised if patients refuse treatment or do not take advice
- Where physical constraints prevent practices from achieving a quality marker, exceptions will be made.

The quality and outcomes scheme is based on reaching quality markers. They come in three forms:
- organisational
- tiered clinical
- phased clinical.

Across all three forms of quality marker, money is available for three things: infrastructure, aspiration and reward.

Infrastructure
All quality elements require some infrastructure expenditure. In some cases this is considerable. There may be additional premises, staff or IT costs as well as doctor time to be paid for. This quality scheme provides the money "up front".

Aspiration
Practices will signal in advance the level of quality care to which they are aspiring in the year ahead. This aspiration will be rewarded through funding, with special provision in the first year of the new contract to ensure a level playing field for all GPs. Practices will be able to climb the quality ladder at a rate of their own choosing. However, if a practice can show it has exceeded its aspirations and achieved a higher level, it will be rewarded for doing so at the end of that year.

Reward
If practices meet their aspirations, they will receive a payment at the end of the year. Once they have achieved some level of improved quality, they can either get a maintenance reward for staying at that level, or attract a bigger reward by showing they have reached the next level up. There will be inducements to move up to higher quality levels.

Organisational quality markers

In many ways these will be the easiest to achieve. The markers are banded into three levels – 1, 2, and 3. Each level will have a different set of things to do. Confirmation that you are achieving the levels will be in tick box form.

Examples of markers in this group are:
- The quality of the written records
- The existence of a practice health and safety policy
- The provision of disabled toilets
- The use and quality of the repeat prescription system.

Tiered clinical quality markers
These clinical quality markers are straightforward in design. They are based on clinical conditions such as upper gastro-intestinal disease, epilepsy, palliative care, thyroid disease and the menopause.

Phased clinical quality markers
Some disease areas are much too extensive to be handled as tiered markers. There are many components in them and considerable work will be required to fulfil the full range of markers. The major current example is the large set of indicators in cardiovascular and cerebrovascular disease. In future, we believe that diabetes mellitus and possibly other major disease groupings will need to be handled in a similar way.

Career structure

There has to be enough flexibility in the contract to allow GPs to move between various forms of work without suffering disadvantages in the short or long term – and this must include pension rights. Career flexibilities have to allow doctors to move from place to place, move between different professional contractual arrangements, be sensitive to personal circumstances (for example by not unduly discriminating against those taking a career break or sabbaticals), allow a variety of time commitments and enable a variety of work to be undertaken if the doctor chooses. The current perverse disincentives that mean practices lose money and doctor time when GPs take on work for the wider NHS will be ended

A three module approach to a career in general practice is reflected in the new contract: it provides for a salaried option as an alternative to independent contractor status, it permits the development of special interests, and a system of "wisdom and experience" payments that recognise and reward the growing experience of doctors as they progress through their professional lives.

The three modules are:
- skills development
- special interest development
- clinical leadership.

The provision of accessible child care arrangements by the PCO for the use of GPs and their staff will make a substantial contribution to the recruitment and retention of GPs and other members of the primary care team.

How the contract will affect your pension

There have been considerable problems with pensions for general practitioners over several years. Particular issues have been the pensioning of locum work and the value of the dynamising factor over successive years. The process of negotiations on the new contract have brought some clarity to these issues. In the opinion of the negotiating team these are fundamental issues of principle, the resolution of which still has to be achieved.

Help for providing modern practice premises

In addition to the raft of new measures to increase flexibilities relating to practice premises (and remove the barriers to improving them), under the new NHS contract, money for funding new premises and improvements to premises will be drawn from a budget managed through PCOs. PCOs will bid for funding from that budget and manage the premises allocation locally. They will be encouraged to collaborate together to ensure that funds are available and the most urgent schemes are developed first taking account of the complex nature and year-on-year variability at local level of funding premises improvements and developments.

The new package of flexibilities concerning practice premises development are:

Dispensing

Dispensing doctors provide a valuable service to their local communities which deserves to be properly rewarded. However, the current system creates perverse incentives in relation to the payments for the costs of drugs prescribed, the number of items prescribed and dispensed and the frequency of repeat prescribing and therefore dispensing. The GPC and the NHS Confederation are agreed that reform of the mechanism for payments to dispensing doctors is required.

Safeguarding the new contract against imposed change

One of the factors which has demoralised GPs over recent years has been the imposition of changes to the current GMS contract without proper time for consultation and negotiation.

Under the new contract, in all but a limited number of exceptional circumstances, there will be a minimum consultation period of twelve weeks. The aim is to make sure that any proposed changes are properly negotiated with the GPC. This should avoid the imposition of an additional workload without providing extra resources or making counterbalancing adjustments to the agreed level of workload in GP practices.

Allocations
159. As GPs struggle to meet the needs of their patients at a time of shortage of both doctors and nurses, many practices have had to close their lists to new patients. Everyone has to have access to primary care and at the moment if new patients cannot find a practice which can taken them on, they are allocated to one by the PCO for their area. This is unsatisfactory both for the already over-subscribed practice and for the patient. It has been agreed, in principle, that the current system of allocations will end. It is envisaged the PCO will develop a new system for looking after these patients. The details of this scheme have not been finalised but will ensure that no one is left without access to primary care.

Temporary residents
Sometimes patients need to see a GP when they are away from home, perhaps on holiday or visiting friends. They will continue to be able to register with a local practice as a temporary resident or to be seen if they require emergency or immediately necessary treatment. Under the new contract, following an assessment of the workload, based on historical demand, the resources to provide this service will come from the practice's total resources. Where there are exceptional circumstances – such as the opening of a new holiday facility - practices will get extra resources via contracts for Local Enhanced Services.

Paul Golik

Secretary

North Staffs LMC