The new deal for general practice has surpassed expectations, but will it be enough to make a tangible improvement to practice finances? Alice Harrold examines the 2017/18 GP contract to find out what practices can expect in the coming year
The GP contract for 2017/18 gives the first indications that the Government is waking up to the need to stabilise primary care. The consequences for the NHS of an underfunded general practice are finally getting recognition.
The GP Committee (GPC) of the British Medical Association (BMA) negotiated terms of the newest general medical services (GMS) contract with NHS Employers and the amendments came into force on 1 April.
The Government sought to address concerns from GPs about workload and increasing expenses. The GPC successfully advocated that additional work would need additional funding.
There will be a 3.3% uplift in the average general practice income overall, so this will be the second consecutive year that practice budgets increase ahead of inflation.
The deputy chair of the GPC, Dr Richard Vautrey, has stressed that ‘an average 1% pay uplift is something we should expect’ this year.
The average practice with a list of 7,000 patients will receive around £11,000 to cover GP pay increases and the rising cost of expenses.
Because funding for general practice fell 13% in the five years up to 2014/15, there is doubt about whether the current uplift will result in the promised 1% pay increase and a new era of investment.
Last year’s 3.2% budget increase was supposed to lead to a 1% pay raise, but for many practice staff, that did not materialise. Some say much of the new £239m uplift will get consumed by rising expenses and will lead, at best, to an extension of the pay freeze.
GPC chair Dr Chaand Nagpaul says no contract can ever guarantee a pay rise, adding: ‘We have put forward a package projected to enable a 1% pay uplift, but wider issues govern whether GP pay goes up or down, such as locally commissioned schemes and workforce expenses.’
NHS England chief executive Simon Stevens says that the contract is ‘one piece of the jigsaw’. He adds: ‘We’re turning the corner on a decade of underinvestment, but with new cash clearly tied to new ways of working that both improve patient care and support family doctors.’
Reimbursements and new income
For the first time, practices will be reimbursed in full for Care Quality Commission (CQC) fees. The average-sized practice currently pays around £2,500 in CQC fees, which will rise to £4,800 next year. Practices will now submit their paid invoice to NHS England or their CCG and will then be directly paid back the full amount.
Other benefits include higher sickness payments to cover GP absences on a non-discretionary basis, raised value of Quality and Outcomes Framework (QOF) points, flat rate of 51.7p per patient to cover the costs of increases in indemnity fees, and £2m into the global sum from NHS England to account for increases in workload caused by Capita’s new records collection service.
The avoiding unplanned admissions direct enhanced service (DES) has been scrapped, freeing practices from red tape.
The minority of practices that didn’t undertake the unplanned admissions DES will see an income boost. Practices will receive an extra £24 for every health check done under the learning disabilities DES, an increase from £116 to £140.
Practices are now contractually required to complete the workforce census, and £1.5m has been put into the global sum to cover this work.
Flu vaccines will now be provided to morbidly obese patients; however, practices will no longer be required to vaccinate four-year-olds.
Support for general practice
It is obvious that NHS England is starting to understand that GP workload is becoming unmanageable. It is notable that almost all the new responsibilities – such as checking overseas patients’ eligibility for free NHS treatment – have specific funding attached.
Clinical commissioning groups (CCGs) have been told by NHS England to provide £171m of ‘practice transformational support’. Sustainability and transformation plans (STPs) – the local NHS blueprints – have been instructed to ‘increase investment in the out-of-hospital sector’.
Inflation is expected to increase to 2.8% by 2018, which will affect how much practices are able to benefit from the incoming changes.
Those most likely to be disadvantaged are the practices that rely heavily on the Minimum Practice Income Guarantee (MPIG), which is in its fourth year, with the money being redistributed through the global sum.
Similarly, practices that have relied on seniority payments and those suffering from personal medical services (PMS) funding reviews may be disadvantaged.
How practices develop financially during the coming year will partly depend on key areas of expense – predominantly their staff, at a time when staff costs such as locum rates are on the rise.
Despite an agreement to look at scrapping the QOF last year, the system remains, with a slight increase in the value of each point.
However, a working group has been set up to discuss the framework’s future.
l Practices that regularly close for half a day during normal hours will no longer be allowed to qualify for the extended hours DES from October 2017.
l From July 2017, all practices will be contractually obliged to release data to the National Diabetes Audit.
l Practices will be contractually obliged to enable the extraction of data for retired indicators.
l From July 2017, practices will be contractually obliged to allow prisoners to register before they leave prison.
QOF point increase
The value of a QOF point will increase from April this year by 3.6% from £165.18 to £171.20.
As the population grows, it has been decided that the value of a QOF point will increase proportionally to the consumer price index (CPI) and the growth of the average GP practice list. Otherwise, inflation would mean that work related to QOF would automatically become worth less.
In 2014 it was revealed that NHS England would not be increasing the QOF point value for that financial year, which meant practices lost thousands of pounds; however, the GPC has successfully negotiated increases since then.
Prior to 2014, the value of a QOF point had not been a point for negotiation, but instead had been increased automatically.
Sick pay boost
The new contract makes GP sickness cover reimbursement a practice entitlement, as opposed to a discretionary payment. The amount payable has increased to £1,734.18 a week.
It also removes a number of barriers to practices claiming reimbursement, including a qualifying criterion based on list size, which previously only allowed practices to claim reimbursement when the remaining GPs were left with more than 2,600 patients each.
The agreement, which Dr Nagpaul has hailed as ‘one of the most important gains’ in the entire contract deal, also removes the requirement for the money to be spent on locums, so that practices will be able to use their own GPs to cover absences. There will be no ‘medical exclusion criteria’.
Dr Nagpaul said this would mean that many practices would no longer need to take out locum insurance cover.
Practices will be reimbursed to cover GP sickness – including the sickness of salaried doctors – for up to a year (the first six months will be covered in full, then up to half the amount will be paid), the GPC said.
The deal has also secured improvements to maternity payments, which will no longer be on a pro-rata basis. Practices will now be able to submit an invoice, with either the full amount or the maximum payable being reimbursed.
GPs will need to record yearly reviews and assessments for around 0.5% of their practice population under new core GMS work agreed to replace the unpopular avoiding unplanned admissions DES, the BMA has estimated.
The new contractual work comes in from July and funding from the unplanned admissions DES – some £157m – is being absorbed into the global sum to fund it.
In return, all practices now need to fulfil new contractual obligations on frailty.
Practices will need to use an ‘appropriate tool’ – such as the electronic Frailty Index (eFI)– to identify frail patients. They will keep a register of the number of people with a diagnosis of moderate frailty and those with severe frailty, and record the number with severe frailty who have an annual medication review, have fallen within the past year and who have provided consent to a summary care record. It is hoped this will lead to a significant workload reduction. More detailed guidance will be issued closer to the start date.