The new GMS contract for GPs contains an evidence-based quality and outcomes framework that is unique. It guarantees very substantial rewards to those practices delivering high quality patient care, and is likely to lead to improvements in health outcomes and reductions in premature deaths. By 2005-06, £1.3 billion per year will be spent on quality incentives.
Practices already provide a quality service, although the existing contract places a greater emphasis on high volume rather than quality of care. For the first time in any health system anywhere, through the new contractÍs quality and outcome framework, practices will be systematically rewarded on the basis of the quality of care they deliver to patients. The clinical indicators within the framework have been drawn up by practising GPs and are based on the best available evidence.
Now that the profession has voted Æ decisively, by four to one Æ to accept the new contract, it will be implemented in full by April 2004. In the current financial year (2003/04), quality preparation payments, worth on average £3000 per GP, will be paid to allow practices to get ready to participate in the framework. From April next year, payments will come in two ways: as aspiration payments in advance of doing the quality work and as achievement payments.
There are four domains within the framework, the largest being the clinical domain. The other domains relate to organisational areas (e.g. records), additional services (e.g. cervical screening), and patient experience, using patient surveys. Each domain contains indicators describing different aspects of performance.
While all domains are important and will deliver rewards for practices achieving the indicators, the most significant in terms of improving health outcomes is the clinical domain. It contains 10 disease areas, each with evidence-based indicators.
The number of indicators has been kept to the minimum compatible with an accurate assessment of patient care. Points are attached to each indicator and the number achieved by the practice determines the sum paid via the framework. In all, 1050 points are available.
Payments for clinical standards will be based on disease prevalence in a practice. Practices will choose which areas to tackle and the number of points to aim for. Linkage payments are available for breadth of achievement. Exception reporting means that practices are not financially penalised if patients do not comply with or respond to advice or treatment.
The disease areas are: coronary heart disease including left ventricular dysfunction; stroke and transient ischaemic attacks; hypertension; hypothyroidism; diabetes; mental health; chronic obstructive pulmonary disease; asthma; epilepsy; and cancer.
Disease categories have been selected for the following reasons: where responsibility for ongoing management rests principally with the GP and the primary care team; where there is good evidence of the health benefits likely to result from improved primary care Æ in particular if there is an accepted national clinical guideline; or where the disease area is a national priority.
Some patients will have multiple diseases; for instance, a significant number of patients with diabetes will also have CHD or hypertension. The separation of disease categories in the quality and outcomes framework will ensure that the hypertensive diabetes patient with developing CHD continues to have his or her diabetes monitored while the clinician focuses on the developing CHD.
The indicators are not intended to cover all the process issues or outcome indicators for each disease category, but are designed to encourage more structured care of patients with chronic diseases.