Dissecting GMS contract changes
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2130 (Published 08 April 2011) Cite this as: BMJ 2011;342:d2130
Abstract
Helen Jaques looks through the changes in the 2011-12 GMS contract
Earlier this month NHS Employers and the BMA’s General Practitioners Committee announced the 2011-12 changes to the general medical services (GMS) contract for general practice.
Pay and expenses
The big headline in the 2011-12 GMS contract is that there will be no uplift to the net pay of general practitioners (GPs),1 “in recognition of the general state of public finances and the efficiency contribution expected of general practice,” says the BMA’s General Practitioners Committee.2
“The rest of the NHS has had a pay freeze, and most of the acute trusts have been asked to make 5% of efficiency savings, so in this time of financial crisis it’s unrealistic to expect a pay rise for GPs,” admits Nigel Watson, chief executive of Wessex Local Medical Committees and a general practice partner in Hampshire.
“In this pay deal there is some easing of some of the more facile parts of the job, though,” says Michelle Drage, chief executive of Londonwide Local Medical Committees and a GP in west London. “Although there is a greater amount of clinical work, by and large GPs tend to want to do that type of work and reduce their bureaucratic or political burden.”
Practices will, however, receive a 0.5% increase in the overall value of GMS contract payments to cover increased expenses, most notably the £250 pay award that practices are expected to give all staff who are earning less than £21 000 a year. This uplift will be delivered entirely through a 2.53% increase in the value of a quality and outcomes framework (QOF) point from £127.29 to £130.51. There will be no increase in baseline contract, direct enhanced service (DES), or global sum payments for 2011-12.
This minor increase is unlikely to be enough for many practices and could mean a clear reduction in pay for some GPs, says Richard Vautrey, deputy chairman of the General Practitioners Committee. “I think such a small amount won’t be enough to meet all practices’ anticipated expenses rises, so what’s likely is that GPs will see a pay cut even with a 0.5% expenses rise,” he says.
Paying the expenses increase via a QOF point is an interesting way to deliver the cash, but this route is the only way to guarantee a rise for all practices, adds Dr Vautrey. “If we were to put it in to the global sum it would mean that PMS [personal medical services contract] practices weren’t guaranteed anything at all,” he points out. “Also if it went into the global sum it would probably be redistributed through the global sum correction factor pool, so it would mean only a very small number of GMS practices would get an amount.”
Quality and outcomes framework
Retired indicators
In England a total of 116.5 QOF points, equivalent to roughly £130m, will be released—58.5 will be freed up by ditching the patient experience of fast access and booking indicators; 32 will come from retiring clinical indicators for coronary heart disease, diabetes, and stroke, as recommended by the National Institute for Health and Clinical Excellence (NICE); two from losing a couple of record keeping measures; and 24 from reductions in points for existing indicators.3
These indicators have been retired or revalued essentially because it was thought that GPs no longer needed to be incentivised to do these things. The General Practitioners Committee, however, says that GPs could well continue to perform these functions solely for the benefit of their patients, despite no longer receiving payment for them.
NICE’s role in the QOF process is nominally to make the indicators evidence based, although some GPs would argue that practice has always been done this way. “I think the profession wouldn’t necessarily say that; I think there was quite good evidence beforehand, but NICE is there and it’s contributing to the debate,” says Dr Watson.
“I think there were mixed feelings about NICE taking over the role from what was then an independent professionally led group,” agrees Dr Drage. “But I think so far NICE has actually delivered on the promise, which is they’ve kept to clinical areas, and that has helped keep out the non-clinical. So I think that while some people, or some of us, me included, might have had views on NICE coming in, probably it’s ‘so far, so good.’”
New indicators
Twelve of the retired points will be used to fund new clinical indicators for epilepsy, learning disability, and dementia, as recommended by NICE, and a further eight will be used to support NICE’s recommendations for changes to existing indicators. The remaining 96.5 points, equivalent to £108m, will be used to pay for new, one year quality and productivity indicators designed to encourage responsible and cost effective use of NHS resources.
The aim of these new “Improving Quality and Productivity in the NHS” indicators is to reduce emergency hospital admissions associated with long term conditions, to reduce inappropriate hospital outpatient referrals, and to promote cost efficient prescribing. A recent inquiry into the quality of care in general practice reported considerable disparities in the rate of referrals—for example, an eightfold variation in the rate at which practices urgently refer patients with suspected symptoms of cancer—and in the quality of prescribing,4 suggesting that these areas do indeed need attention.
In England practices will receive full payment in the emergency admission and referral areas through reviewing current practice in their surgery, with the help of external peers, and identifying where their practice differs considerably from national averages provided in the Better Care, Better Value indicators developed by the NHS Institute for Improvement and Innovation.5
GPs should then implement new or alternative care pathways that are intended to reduce outlier performance in referrals and admissions, and in the fourth quarter of the year they should review their practice data again to see whether they’ve made any improvements. “Not every practice has to do the same thing: what matters is that you come up with your list of things you want to do and in a year’s time you look to see whether you’re making the difference or not,” confirms Laurence Buckman, chairman of the General Practitioners Committee.
Payment for the cost effective prescribing element will likewise depend on change in performance reported by external and internal audits, but this will be measured by a range of as yet unconfirmed national and local indicators.
The BMA is keen to emphasise that achieving these QOF points isn’t about hitting numerical targets, such as a 10% reduction in the number of outpatient referrals. “There will be no payment linked to any numerical reduction in referrals or emergency admissions, but it will be linked to practices working within pathways,” says Chaand Nagpaul, negotiator for the General Practitioners Committee.
The purpose of this new set of indicators seems largely to save money. “If the new Improving Quality and Productivity in the NHS scheme takes hold in the way we hope,” says Stephen Golledge, negotiator for NHS Employers, “our calculations suggest that if all practices can mirror the same level of performance as the top 25% of practices in the way they refer patients to consultants, manage emergency admissions, and prescribe, this would generate savings of up to £800m a year.”
Dr Vautrey disputes that this is the sole aim of the new indicators, however, arguing that they are mostly aimed at improving quality. “They’re not primarily about cost cutting or efficiency savings, they’re about trying to identify good care pathways and to ensure that practices are wherever possible following pathways intended to improve the quality of prescribing and referral patterns,” he says.
This new set of indicators isn’t about cutting care so as to earn some cash either, the General Practitioners Committee empasises. “This isn’t some number cutting process—patients might think that we’re withdrawing a service and as a result we get paid,” says Dr Buckman. “It’s not about withdrawing service, it’s about looking at the cost effectiveness of what you’re doing using an agreed set of indicators.
Dr Watson agrees: “If you look at emergency admissions, something like 70% of them come from outside of general practice—they come from out of hours, they come from ambulance calls, they come from accident and emergency, so the incentivisation isn’t to deliver ethically unsound things.” It does put the gatekeeper role of GPs in sharp focus, though, says Dr Drage, and will make people think carefully about who they refer to secondary care.
Direct enhanced services
The ethnicity and first language direct enhanced service (DES) is the only one on the way out for 2011-12, with practices expected to record patients’ ethnicity and first language as a matter of course.6
Three clinical DESs—one for reducing harmful drinking, one a health check for people with learning disabilities, and the third for diagnosing and preventing osteoporosis—will be recommissioned for an extra year, as will the extended hours DES. Crucially, the extended hours DES will be more flexible—for example, any healthcare professional, not just GPs, will be allowed to see patients during extended hours, and the extended hours can be as little as 30 minutes, as long as the overall additional hours still meet the target for the DES payment.
For this increase in flexibility, however, there is a decrease in payment, from £3.01 per registered patient to £1.90. “Practices are getting paid less, but they’re doing less for it,” says Dr Buckman. “The key changes are freedom of operation in a variety of respects. Practices won’t be so straitjacketed as they were. This is what we wanted when we started all this, and we’ve now got it; we’re now back to where the conference of local medical committees wanted us to be. All the things that annoyed GPs about this have gone.”
The £60m saved by cutting back on funding for the extended hours DES will go towards a new two year patient participation DES. Practices will be paid £1.10 per registered patient if they promote the proactive engagement of their patients through reference groups and undertake local patient surveys.
“I think that this is a positive move,” says Dr Watson. “Some practices have established patient participation groups but are really struggling to know what to do with them. I think the DES gives a really clear idea and mandate of where you go forward with it.”
Conclusions
The general view seems to be that the 2011-12 contract agreement is an essentially good one, given the context of funding cuts. “I think this is as good as we were likely to get in the current climate,” says Dr Drage. “And it has steadied the ship, because the good news is that there’s not dramatic change in this review, which allows practices to get on with the job they’re supposed to be doing.”
Footnotes
Competing interests: None declared.