MSc MA BM BCh MRCGP DRCOG
MRC Health Service Research Fellow, Department of Primary Medical Care, University of Southampton
Chantal trained as a doctor in Cambridge and Oxford, graduating in 1990, before following the Southampton GP training scheme and becoming a fulltime GP in 1995. After having three children, she became a part-time GP in Christchurch, Dorset. Chantal combines clinical work with research and teaching in the Department of Primary Care at Southampton University, where she holds the post of MRC Health Service Research Fellow. Chantal coauthored the Oxford Handbook of General Practice and the Handbook of Practice Management
After the upheaval of the introduction of a completely new General Medical Services (GMS) contract, life had started to settle down and all the new routines to enable us to collect points in the Quality and Outcomes Framework (QOF) had become second nature. Now, just to keep us on our toes, the GMS contract is under review and set to change over the next year. Stage one of the review concerns three areas of revision: changes to the payment arrangements for dispensing GPs; changes to the QOF; and changes to directed enhanced services (DES).
Changes made to arrangements for payment of dispensing GPs
Three major changes to the system for remuneration of dispensing doctors have been made. First, the oncost allowance has been abolished. This removes the direct link between drug costs and remuneration. Dispensing doctors will receive a fee for each item that they dispense. Secondly, as from 1 April this year in England and Wales, the Department of Health will not pay a VAT allowance on dispensed items. This means that practices now need to register for VAT purposes with HM Revenue and Customs (HMRC) if they require VAT reimbursement. Thirdly, dispensing practices are now paid for providing high-quality dispensary services under a new Dispensing Quality Payments scheme. Details about this scheme are still being negotiated and will be published soon.
Changes to the QOF
Under stage one of the GMS contract review process, the QOF was extensively changed. A summary is presented in Box 1. More points have been allocated to the clinical domain, in which several new indicator sets have appeared – smoking, obesity, learning disability, depression, dementia, palliative care, atrial fibrillation and chronic kidney disease.
Organisational indicators have held onto roughly the same number of points. There is just one new indicator: recording the ethnic origin of all patients newly registering with the practice. Additional services and patient experience points remain roughly static, and the conglomerate indicators (holistic care and quality practice) have been the substantial losers, with quality practice points totally reallocated and holistic practice points reduced to just 20. The 50 access points have also been removed (taking the total number of points available down from 1,050 to 1,000) and, in England, the funding for these has been reallocated under the new directed enhanced services (DES) to improve access to primary care services.
Within the clinical indicators, where disease registers have already been set up for the previous version of the QOF, the number of points available for maintaining the register has been decreased. This is meant to reflect the increased workload required to construct a new register and the lower level of input required to maintain it. In addition, the target ranges have generally been moved upwards, with the minimum attainment levels of 40% being the norm, as opposed to 25% in the previous version of the QOF. This is intended to push up quality standards and demonstrate an increase in value for money delivered by the QOF.
Within the organisational indicators, duplication of targets has been removed. Duplicated targets have been amalgamated into single indicators with an increased value, such as recording of smoking status and the combination of the annual appraisal and personal development plan target for practice nurses. Targets that almost all practices achieved, such as noting medication and recording patient contacts, have been removed.
Changes to DES
Target payments within the DES for childhood vaccinations
Prior to the introduction of the penta-valent vaccine (also known as the “5 in 1” vaccine) in September 2004, the target payment scheme consisted of four separate vaccine groups: diphtheria, tetanus and polio; pertussis; measles, mumps and rubella (MMR); and haemophilus influenza type B (HIB).
Achievement in each group contributed equally in determining whether the target had been achieved and the level of payment awarded. The pentavalent vaccine effectively decreased the number of groups to two, giving the MMR vaccine undue weighting. In light of the controversy over the MMR vaccine, this made it difficult for some practices to achieve their targets.
Since April, three groups are used for target calculation purposes: pentavalent vaccine (with a weighting of 50%); MMR (with a weighting of 25%); and meningitis C (also with a weighting of 25%). A further change will be made once pneumococcal vaccination has been included within the routine childhood vaccination programme, but details are not yet available.
Several new DES were announced for England and Wales.
- Access DES. This replaced the current 2005/06 access DES and the 50 QOF access points in April. This DES focuses on four key dimensions of access to general practice for patients: opportunity to consult a GP within two working days; opportunity to book appointments more than 48 hours in advance; ease of telephone access to the practice; and opportunity to be seen by a practitioner of preference. Payments to participating practices comprise two components. Component one (worth approximately £0.69 per registered patient) will be paid to practices for agreeing a written practice plan, demonstrating how the practice will work towards delivery of the first three dimensions of access (50% of payment), and the rest will be paid when a written commitment to continue participation in the monthly Primary Care Access Survey (PCAS) is made. Component two will be paid at the end of the year, based on the practice’s results in a new National Patient Experience Survey (worth approximately £1.37 per patient).
- Choice DES. This one-year-only DES has also been introduced to support the government’s priority to offer patients choice of secondary care provision and to entice GPs and other primary healthcare team members to use the new Choose and Book system. Again, this service has two components; the first is given to practices that commit in writing to offering a choice of available providers when a decision is made. A 50% aspiration payment (worth about 24p per patient) is payable immediately after the practice commits to providing this service. The remainder will be paid if at least 60% of patients who respond via the new National Patient Experience Survey recall being offered a choice, and will be paid in arrears. Component two is a reward for using the Choose and Book system. Again, half (roughly 24p per patient) is payable in advance as an aspiration payment and can be kept by the practice if at least 25% of referrals are made via Choose and Book. The remainder of the payment is made on a sliding scale, with the minimum payment for 50% and the maximum payment for 90% of referrals being made under Choose and Book.
- Practice-based commissioning (PbC). This other one-year DES has been introduced to promote PbC – with an aim to get all practices to participate by December 2006. Practices may participate alone or join together with other practices. The first component is payable to practices that prepare and implement a PbC plan, and is worth about 95p per patient. Where practices achieve their plan objectives, they are eligible for payment of component two (again, 95p per patient, less any savings made under the scheme), which must be reinvested in the commissioning scheme.
- Information management and technology (IM&T) support. This DES is designed to facilitate IM&T adoption to support the delivery of the National Programme for IT. It requires primary care trusts (PCTs) to pay practices specified, nonrecurring payments following successful preparation for, and adoption of, IT systems and processes.
As always, the realities of implementing these changes in practice are yet to be revealed. Full details of all the changes are available from the British Medical Association website (www.bma.org.uk) and the NHS Employers Confederation website (www. nhsemployers.org).