The new funding structure introduced by the nGMS contract has resulted in many changes for GPs. Dr Gerard Panting assesses the impact


   

The nGMS contract celebrated its first anniversary in April. It is too early yet to draw firm conclusions on whether the contract is a good or bad thing for doctors and their patients. However, we have now been able to form a few first impressions.

The idea behind the contract was to restructure the relationship between patients and their GPs, and between GPs and their primary care organisations. Patients now register with practices rather than with an individual GP, and PCOs contract with practices as GMS providers rather than with individual GP principals.

The new legislation that underpins the contract has also enabled partnerships to be broader to include pharmacists, nurses, physiotherapists and other healthcare professionals as well as non-clinical staff such as practice managers.

Under the new contract, money follows the patient. Therefore, reducing the number of doctors in a practice does not adversely affect the practice’s income, presuming that the practice patient profiles and service levels do not change.

The contract also introduced a quality and outcomes framework (QOF), with financial rewards for achievement measured against quality standards. The four domains – clinical, organisational, additional services and patient experience – each have key indicators against which practice achievement is assessed. Quality payments are then determined through a quality scorecard, assigning up to 1000 points for achievement and 50 points for improved access. In this context, points do not mean prizes but pounds.

The details of how final achievement payments are calculated can be found in Box 1 (below).

Box 1: Calculation of final payments2
  • In the clinical domain, the pounds per point in each disease area are adjusted by a separate Adjusted Practice Disease Factor (APDF) for each area. (This factor is based on the prevalence of that disease among the practice population compared with national prevalence figures)
  • In the additional services domain, the pounds per point are adjusted by the relative size of the contractor’s target population
  • In the remaining domains (organisational and patient experience) the pounds per point are multiplied by the points scored, including points for the holistic care and quality practice payments and access bonus
  • The points and pounds in all domains are added up to give a total raw achievement. For Personal Medical Services (PMS) practices, a points deduction is made (168 for 2004/05, 109 for 2005/06) to account for quality payments already in PMS baselines
  • This figure (in pounds) is then adjusted by relative list size (i.e.multiplied by the Contractor Population Index)
  • The practice’s aspiration payment is then deducted from this to give a final net achievement for the year

Impact of the nGMS contract

So one year in, what has been the experience of GPs? On 26 March, BMA News reported that practices were getting ready to reap the rewards with "most” family doctors receiving a big payment boost by the end of April as a result of their performance under the QOF.1

The deadline for primary care organisations to tell individual practices how much they had earned under the QOF was 31 March. Practices able to agree achievement payments with the PCO should have received their money during April. Even those going through the disputes procedure are expected to receive their payments by the end of June; however, relatively few practices are expected to have to do this.

A straw poll of GPs reveals a mixed picture of the nGMS contract. In many respects it has been a success for both doctors and patients. The points system and its ready translation into pounds appears to have been a successful incentive to meet the targets. In one PCT in Hertfordshire, for example, the majority of practices are expected to have reached 1000 quality points.

The importance of good computer systems

Practices that are well organised with good computer systems have an opportunity to do very well, but the new contract can also mean friction in some practices where it is perceived that some partners are not pulling their weight to meet targets. Unofficial internal league tables make it clear who has contributed what.

The cash, however, comes at a cost. One doctor estimated that 20% of every consultation was taken up with ticking boxes or looking at the computer screen. It can be argued that the tick box culture has improved patient care, providing a discipline that might not have been present before – such as identifying patients overdue for their blood pressure check or thyroid function tests. However, the computer is an intrusion in the consultation and undoubtedly creates a lot of work. Consequently, consultations take longer, with many patients having to wait longer for routine appointments.

While IT systems appear to be central to the success of the new contract, one doctor has complained that they present a major problem and are not really fit for purpose, with practices all inventing their own templates and duplicating work. Needless to say, these systems, of which there is a multiplicity, are not all compatible.

The new contract was a real stimulus for practices to go paperless, but the main problem with this appears to revolve around home visits, because not all sources of information are available to the doctor away from the surgery. It is possible to have a download summary and printouts of the last few consultations, but this does not match the information usually available in manual notes. Laptop transfer has apparently not been entirely successful.

This is an obvious risk area where inappropriate decisions might be based on incomplete information.

Focus on patients

The new contract appears to have encouraged a more structured approach to patient management with the introduction of protocols to facilitate multidisciplinary team working and help in meeting targets. Protocols are good for consistency but some GPs are clearly resentful of what they regard as a ‘cookbook medicine’ approach.

Patient satisfaction also appears to be higher on the agenda, as the contract provides an incentive to carry out surveys using structured questionnaires to gain patient feedback. Interestingly, this appears to have highlighted the problems that practices knew about already, for example inadequate telephone systems. At least this information can be used as evidence to support applications to the PCT for improvement grants.

Feedback from patients is very useful for appraisal purposes (and, in due course, revalidation) and it is therefore worth considering asking for feedback about individuals as well as the practice as a whole.

Improvements for GPs?

Under the new contract, PCOs have assumed responsibility for out-of-hours care and this can be provided by GP co-operatives, deputising services or the new innovations such as walk-in centres. Being able to opt out of out-of-hours work is seen as a significant boon, with one GP referring to a "significantly improved quality of life”.

This is just as well as the new contract clearly brings a lot of work. Work during in-surgery hours can be pressurised and difficult to control, allowing little, if any, time to talk to staff and partners. In most practices, this is essential for good communication.

Publication of QOF data

QOF data are to be published on the web so that everyone will be able to compare how individual practices have done. The Health and Social Care Information Centre (HSCIC), the successor to the NHS Information Authority, is set to publish summary QOF data in August.

This has raised concerns because data not only about individual practices but perhaps also about individual patients may be accessible. Is the Government introducing league tables for GP practices by the back door?

Looking to the future

As yet, there does not appear to have been a significant shift in the way that individual practices are organised. Some non-medical partners are in place, but the traditional model of doctor-based partnerships appears to predominate; it will be fascinating to see how this changes over time.

References

  1. Practices get ready to reap the rewards. BMA News. 26 March 2005 p.7.
  2. www.bma.org.uk/ap.nsf/Content/FocusQApayments0205#Thecalculationoffinalpayments

Guidelines in Practice, June 2005, Volume 8(6)
© 2005 MGP Ltd
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