Welcome to The new GMS & PMS Learning Exchange

1. The National Primary and Care Trust Development Programme Welcome to The new GMS & PMS Learning Exchange

2. The National Primary and Care Trust Development Programme New GMS Learning Exchange

3. The National Primary and Care Trust Development Programme New GMS Learning Exchange All support resources can be found at www.natpact/nhs.uk/primarycarecontracting

4. The National Primary and Care Trust Development Programme New GMS Learning Exchange All support resources can be found at www.natpact/nhs.uk/primarycarecontracting

5. The National Primary and Care Trust Development Programme New GMS Learning Exchange New@NatPaCT Our weekly email update, rounds up new postings on all areas of this site, and is sent, free of charge to over 5,000 subscribers, usually on Wednesday afternoon. Occasionally we delay to catch an important announcement, or issue EXTRA editions in between. Subscribe online or at the Modernisation Agency stand.

6. Dr Mohamed Dewji Clinical Director for Primary Care Contracting

7. PCT Strategic Tests • 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?

8. 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.

9. Progress of primary care 1965  1990  1997  2004  Organisational Unit Individual G.P.s G.P. Units (larger practices) PCGs / PCTs + / - Care Trusts Integrated Trusts (NB Kaiser) Mechanism of Delivery The Red Book GP Commissg GP Fundholdg TPP/Multifund Practice Contracts via PMS Various NHS & Private Providers Service Focus Individual Patients Specific Target Groups >75 years etc Practice & geographical communities Communities of interest

10. Primary Care – from April PCT Commissioner Performers -mainly the Principals holding the contract PMS Provider PMS Provider nGMS Provider P P P P P P P P P N N NP N N NP P N NP

11. Demographic Change by 2019

12. Expected numbers of diabetics: now & by 2010

13. Primary Care- future PCT Commissioner Consolidation of sites by GPs or others Contracting out to Commercial Cos. NFP, Vol. Sector, et al. PMS/GMS Provider Interpractice Consortia & Collaboration Integration into Managed Care Organisations P P NP NP P P NP NP N N N SW N N N C

14. Accountability and monitoring • 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

15. Technological Advance • The Internet & access to information • Role Redesign of health staff • The changed role of the ‘professional’ with the ‘patient’

16. Implications • 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

17. 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

18. Where to next? • 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

19. Questions and Discussion

20. QUALITY & OUTCOMES FRAMEWORK Dr Philip Leech Principal Medical Officer Department of Health

21. 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

22. 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

23. QOF Improvement Cycle Planning QOF IMPROVEMENT CYCLE Learning Action Review

24. QOF Activities for 2004/5 Feb 2004 Agree aspiration April 2005 Achievement payments made Apr 2004 Pay QPrep and QuIP DES Oct 04 – Jan 05 Annual review visits take place QOF 2004/5 April 2004 QOF goes live April 2004 DH guidance on review visits August 2004 QMAS system goes live & provides monthly feedback End April 2004 Monthly aspiration payments

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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!)

31. 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

32. CHD

33. 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

34. Target Populations Women aged 25 to 64 years Children aged under 5 years Women aged under 55 years Women aged under 55 years Cervical Screening Child health surveillance Maternity Services Contraceptive Services

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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!

42. 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

43. 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)

44. GP Practice GP Clinical System PC Other Clinical System Achievement Achievement Data Payments Data Achievement Reports (IT Interface) (BACS) (Web) (Web) PCT Payment Agency Centralised IM&T Agreed Achievement (IT Interface) NHAIS Management and Analysis System (MAS) Achievement Reports (Web) PCT PC

45. 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

46. To sum up... • 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!

47. Getting more information • GMS and PMS: helpline - 0845 900 0008 inbox - gmspms.queries@npdt.nhs.uk website - www.natpact.nhs.uk/primarycarecontracting/ • QOF guidance: GMS www.doh.gov.uk/gmscontract/implementation.htm PMS www.doh.gov.uk/pmsdevelopment/ pmsarrangementsdec03.pdf

48. New Contracts in Primary Care: workforce issues Kate Billingham

49. Starting point Nurses 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

50. Improving employment conditions “Primary care professionals need to be: • eligible to perform services • recruited and retained • development needs to be supported • deserve adequate pensions”