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Beyond QOF: The future of the GP contract

4 March 2014

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With quality and outcomes framework points reducing in certain areas, practices may find they have more time but may need to identify new streams of income  

This coming April will see major changes to the quality and outcomes framework (QOF), which accounts for a significant proportion of practice income, and new requirements for GPs aimed at improving care for vulnerable elderly people. 

But while the media has focused on the impact on GPs, the changes will have ramifications across practices – and practice managers, as ever, will have a key role in implementing them.

The good news is that, overall, the changes look positive for general practice and those working within it. “I don’t think it is transformational but to me it looks like a positive outcome which should result in some workload reductions both for the doctor and the team,” says independent practice management consultant Fiona Dalziel, who is co-lead of the Royal College of General Practitioners’ General Practice Foundation.  

Overall, there will be a reduction of 341 in the number of QOF points practices are chasing, with funding moved into the global sum and to a new enhanced service around emergency admissions, which will encourage the case management of vulnerable patients. More than £50,000 of funding for the average practice will be shifted.  Nick Nurden, business manager for the Ridge Medical Practice in Bradford, says it is early days but one of the most important aspects is likely to be a shift in work which could be done by nurses to work which will need to be done by GPs. 

In the past a lot of QOF points were awarded for work which could be done in chronic condition clinics such as blood pressure checks. Some of these will now be dropped, and other changes to the contract include having a named GP for the over 75s and a greater focus on integrated care, especially for the vulnerable elderly.

The issue for practices may be that they don’t have the right staff in place to quickly accommodate these changes; they may have more nurses than they will need and potential fewer GPs. Over time nurse numbers can change due to resignation and retirement, but GPs can be hard to recruit – the Royal College of General Practitioners (RCGP) recently highlighted a need for 10,000 new GPs by 2022. 

Dr Michael Dixon, chairman of the NHS Alliance, says: “It is quite difficult to recruit practice nurses at the moment so that might be a blessing in disguise.”

Practices may also find they have more time to arrange vaccinations and follow-up reviews, such as for patients diagnosed with cancer and depression. Flu vaccinations done from August 1, rather than September 1, will now count for QOF. This allows practices a longer lead time to get vaccinations done before flu becomes a serious issue. However, it will require vaccine stocks to be made available earlier and practices may struggle to put on extra clinics in holiday time (and indeed to get patients to think about flu in the middle of the summer).

The dropping of some targets which were seen as box-ticking have been widely welcomed. Mr Nurden points out that practices are under pressure and this could lead them to concentrate on QOF points which are easily attainable, provided patient care is not adversely affected. There can be enormous discrepancies in the number of patients a practice needs to monitor to gain QOF points. One recently-introduced indicator around blood pressure measurement – which is being dropped in April – may not be worth chasing because of the low number of points and the high number of patients involved. 

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But one of the most significant changes will take a burden off practice managers. The quality and productivity part of QOF will disappear – and much of this involved practice managers in auditing performance, taking minutes of meetings, and follow-up work. Ms Dalziel says this will have a “huge impact.”

The dropping of the requirement to offer appointments of at least 10 minutes will be welcomed by many practices but may not make a lot of difference to how they can operate. Ms Dalziel points out it is being dropped, not because of any controversy or disagreement about its usefulness, but because it had become embedded in practice.

The opportunities to make changes will be limited as it is difficult to anticipate with any certainty which patients can be given shorter appointments. An area practices are seeing some improvements in is telephone consultations, which are often popular with patient and can save time. But the move away from a system of 10-minute appointments, based on two sessions a day, and nurse-led clinics is a significant change in how patients are managed within general practice.

Mr Nurden suggests that what could emerge is a system of multi-disciplinary clinics where a GP leads a team which will assess patients (who are increasingly likely to have multiple co-morbidities). Appointments for this sort of patient may need to be longer than 10 minutes and end with advice on self-care.  

So what will be the overall impact? Mr Nurden feels the changes are generally for the better and should improve care for elderly vulnerable patients who may be a group who lose out at the moment. This may be as simple as ensuring they can book appointments – they do tend to be quite stoic and won’t push to see the GP like some other patients, he says. The new enhanced service requires practices to offer same-day telephone consultation for high-risk patients, and also allow other healthcare practitioners swift access to the practice to support decisions on admissions. 

‘It does mean that we need to manage access differently and make sure we care for the right people,’ he says.  

However, Ms Dalziel says practices may want to monitor what percentage of over-75s do manage to see ‘their’ GP rather than another member of the team.  

Ray Guy, a practice manager in Liverpool and an executive member of the National Association of Primary Care, says putting more money into the global sum will allow practices to invest because they can take a longer-term perspective. He believes practices will look at having more doctors and also triage nurses (who may be practice nurses given additional training), and will open additional hours. “Proper investment in general practice is key to the improvement of the health service,” he says.

Dr Dixon believes that practices will go “back to the future” with elderly patients having one person responsible for their care. “Some [of QOF] was inappropriate, some was over complicated and all of it was eroding our professionalism,” he says. “It is a signal for the future in terms of less biomedical tick-boxing and a return to continuity of care.”

But the changes will also need to work for hard-pressed practices – and one concern for GPs is that income will need to be maintained. The removal of many of the indicators will reduce work for practices with the income being partly replaced by the increased amount going into the global sum. In order to ensure their income is kept up practices will have to focus their efforts on making sure they meet new requirements, such as the enhanced service around emergency admissions.