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New beginnings

24 April 2015

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With the new general medical services contract about to come into full swing, changes that will be encountered need to be outlined and understood

The new year of the general medical services (GMS) contract comes in to force only a few weeks before the general election and, while it may not be helpful to view absolutely everything through a political lens, the pressure on the negotiators this year must have been intense. In that context the changes can be seen as fairly restrained. However, direction of change is towards much more central control. Two optional Direct Enhanced Services (DESs) will become compulsory, other provisions extended and regulations about the publication of practice finances become more stringent.

The general scope of the changes was announced very early but there has been no further detail since then and some of the changes have only been sketched in very broad strokes.

For many practices the biggest change will be the move of the Patient Participation and Alcohol DESs into the core contract. Financial data published in 2013/14 suggests that many practices did not participate in these, with the alcohol service having the higher level of take up of the two.

The payment is due to be transferred into the global sum (without an out-of-hours (OOH) reduction) in 2015/16. These services have been relatively cheap for NHS England where not all practices participated and total funding may need to be increased. However, practices that have looked at these services in the past and found them not to be either financially or practically viable will be compelled to provide the services this year.

The stated aim, however, is to reduce the administrative burden to practices of having to make DES claims, although it seems inevitable that some reporting requirements will remain.

Patient Participation DES
The Patient Participation DES was worth just more than £1 per registered patient and required the setting up or maintenance of a patient participation group (PPG). The Care Quality Commission (CQC) now expects a patient group in each surgery and it is a requirement that this is broadly representative of the practice population. There is no actual requirement for the group to meet and many practices have had very successful virtual patient groups.

This can also be part of a strategy to make the group more representative as it places fewer demands on patients’ time.
The current DES has specific requirements for the reporting of three priority areas and goals agreed with the PPG, as well as the progress made towards these. In 2014/15 the reporting template was 14 pages long. This requirement should be reduced in 2015/16 although we may not know by quite how much for some time.

Alcohol DES
The Alcohol DES requires the use of a screening questionnaire for patients over 16 years old at the time that they register with the practice. The practice should use either the three-question alcohol use disorders identification test consumption (AUDIT-C) or four-question fast alcohol screening test (FAST) questionnaires for the screening. This can be included as part of a more general registration form for new patients. Patients with a high score can then go on to complete the more detailed AUDIT-C questionnaire.[1]

A score of eight or more on the AUDIT-C questionnaire can suggest potentially harmful drinking patterns and patients should be offered brief intervention for alcohol use or, with a score of 16 or more, brief lifestyle counselling may be offered as an alternative. Both of these interventions have a formal definition and, although they may not differ from your normal practice, a familiarity with the concepts would make an excellent addition to a personal development plan come appraisal time.

Patients with very high levels of harmful drinking, represented by an AUDIT-C score of more than 20, should be referred directly to local alcohol services.

There will be very little change in the reporting requirements with practices still expected to code the assessments as before and NHS England will continue to extract the data directly from practices.

Under the previous DES the practice was paid according to the number of initial screenings performed and this would increase with the number of new registrations. From April this will be paid as part of the global sum. The upshot will be that practices with a low list turnover will see an increase in income compared to the old system and vice versa.

Named GPs were brought in last year for all patients over 75 years of age. This has clearly been seen as a success and will now be extended to all patients of whatever age. This takes us back to the situation before the introduction of the 2004 contract. It is not clear what effect this has had for either patients or doctors.

Fortunately, practices do not have to write individually to all patients and can instead simply inform patients when they come for their next appointment. The named GP can be either a partner or a salaried GP and patients’ preferences should be taken into account. All patients should have a named GP by the end of March 2016 and this fact should be published on the practice website. There is no additional funding for this service.

The changes to the QOF this year are fairly small and should not cause too much difficulty for practices. Most of the chronic kidney disease area has gone with only the requirement to maintain a register remaining for six points. The only other indicator to be completely removed is the requirement for prescribing statins, angiotensin-converting enzyme (ACE) inhibitors and beta blockers to patients with a previous myocardial infarction.

There are no completely new indicators. Risk assessment for patients with atrial fibrillation should now use the CHA2DS2-VASc formula with the older CHADS2 formula now considered obsolete. All patients with a score of two or more (on either formula) should be anticoagulated – the use of aspirin is no longer advised.

The risk score should be calculated annually until the score is two or more. The score is unlikely to go down again in the future so it does not have to be repeated. Calculating the scores early in the QOF year remains the best strategy as it will be clear which patients require anticoagulation. You don’t want to find out that warfarin needs to be started in the middle of March.

The final changes are for patients with dementia. The timescale for dementia diagnosis bloods has been increased so there can now be up to 12 months after the blood test (normally this is around the time of referral to secondary care) for the diagnosis to be made.

More significantly is that the annual review is to be beefed up. The wording has been changed to ensure that this is performed face-to-face and now includes a review of the care plan. There will be further guidance in due course but it will be very similar to the care plans used in the unplanned admissions DES. As patients with dementia are likely to be in a group at high risk of unplanned admission to hospital this could often be the same document.

To compensate for the greater work required the number of points available for this indicator have increased from 15 to a whopping 39. For a typical practice this will be nearly one point for each patient with dementia making these reviews very valuable indeed.

Online access
The 2014/15 contract included requirements for patients to have online access to repeat prescription requesting, appointment booking and some access to their medical records. The two latter areas are to be expanded in 2015/16 with a larger number of appointments to be made available online. The minimum level of access to the practice records will also be increased from the previous medications and allergies to full access to all coded information. Information that is in free text can also be shared.

There is a promise that practices will be able to withhold specific pieces of information if there is a reference to a third party or it would be in the patients best interest for that information to be withheld. The technology to allow this should appear during the year.

The money
One of the most contentious areas of the contract has been around the publication of practice profit figures. In February 2015 details were published of the payments made to practices in the previous financial year. These related purely to income rather than profit and passed by with relatively little reporting in the mainstream press.

The next publication may be a little different. The total profit of the practice, net of expenses, should be published alongside the number of full-time and part-time GPs in the surgery. While the current figures for total practice payments are produced nationally these new reports will be produced by the practice and should be published on the practice website by the end of March 2016.

There are many potential issues with this and much will depend on the exact definitions to be used. The status of salaried GPs’ income is not entirely clear. Only nationally defined income will be counted (i.e. not local enhanced services) and individual GP earnings will not have to be declared. Practices may well have accounting year-ends that do not match with NHS England’s financial year end in March. The method of publishing currently described will make comparisons between practices almost impossible, although it is likely that some will try.

The rules, when they arrive, are likely to be complicated and practices could be faced with increased accountancy costs to produce the report in the required format.

Unplanned admissions
There are some changes to the unplanned admissions DES that are due to have a reduced reporting requirement. There will be some changes to recognise that this is a group with a high mortality rate. Production of care plans will be recognised even when the patient dies before the end of the quarter. Combined with a reduction in the number of reporting periods in the year this should mean that there is less duplication of work for practices.

There is a new requirement that practices should monitor the quality of their local OOH service. With no specific resource for this and there is no suggestion that practices have to be proactive. However, where concerns arise as a result of reviewing the information received from OOH providers or patient feedback this should be reported to the CCG.

2015 contract
Overall the changes to the contract in 2015 are relatively light, especially for practices who already take part in the alcohol and patient participation DESs. There is not a large amount of new work but some of the work is just different enough to cause some difficulty to practices.

Gavin Jamie is a full-time GP in Swindon with an interest in health informatics. He runs the QOF database website.

World Health Organization. Screening and brief intervention for alcohol problems in primary health care