Quality payments lie at the heart of the proposed new GP contract but good IT systems will be vital to maximise practice income, says Dr Nigel Watson

The framework for a proposed new GP contract was published on 19 April 2002.1 The proposals have been negotiated between the General Practitioners Committee of the BMA and the NHS Confederation, negotiating on behalf of the Department of Health.

The proposed framework covers England, Northern Ireland, Scotland and Wales, and has the approval of the health ministers of all four home countries. It would be the most significant change to general practice since the introduction of the NHS in 1948.

The framework document contains proposals for IM&T, which are:

1 To facilitate the use of IM&T within primary care, practices will no longer be responsible or receive funding for the purchase, maintenance and running costs of integrated IT systems or for landline links between branch surgeries or between surgeries and hospitals.

2 The capital and revenue, initial and ongoing training costs for practice IM&T systems will be met and managed by the PCO. Each practice will have a guaranteed choice from a number of accredited systems. Servers will usually be situated within individual practices unless an alternative agreement is reached to house the server elsewhere e.g. the PCO.

3 Incentives to use IM&T to manage practice workload will be built into the quality framework.

Funding IT in practices

Practices are currently reimbursed 50% or less of the cost of purchase and maintenance of clinical systems. The significant investment required of GPs is now holding back computerisation of general practice.

The prospect of receiving 100% reimbursement will be widely welcomed, but there will be some concern that if 100% of the funding comes from the PCO, the PCO will have greater control over a practice's choice. It will be the task of the LMC to ensure that this does not occur.

The costs of maintaining a landline between a main and a branch surgery can run into several thousands of pounds per year, and the framework will ensure that practices with this facility are not financially penalised.

For practices moving from a system of written clinical records to electronic patient records (EPRs), significant additional work will be created, and training will be required. GPs as well as administrative staff will need to be trained. At present, 70% of the cost of staff training may be reimbursed, but GP training is fully funded by GPs themselves. The contract proposals recognise that anomaly and go a long way towards resolving it.

Where to locate the server?

A server is the hub of a network and may be used for the clinical system or for NHSnet. Many practices have their own server and the advantage of that is that the practice has sole control of it. However, the practice also has the responsibility of ensuring that it is maintained and updated.

Increasingly, practices are finding that they do not have the expertise or time to run their own server, and they have looked at the benefits of locating the server outside the practice, for example in the PCO. The advantage of this is that maintenance and updates can be carried out by experts, so relieving the practice of this responsibility. Some GPs are concerned that locating the server in the PCO will compromise control of, and access to, patient data.

Many practices that have computerised their records have done so at their own expense. There has been little or no financial incentive to use IT, and this has been recognised and addressed in the framework proposals.

However, the framework proposals are more far-reaching in terms of IM&T than merely the section quoted above.

Quality payments

The contract proposals significantly change the way practices would be funded - from a system of capitation, allowances and item-of-service fees to one that places quality at the forefront of patient care by rewarding GPs for reaching quality markers.

It is anticipated that 30-50% of practice income will come from quality payments - the higher the level achieved, the greater the reward.

The quality markers come in three forms:

  • Organisational standards, banded into three levels; these include health and safety, practice management IM&T, clinical governance, medical records and prescribing.
  • Tiered clinical quality markers, banded into three levels; these are based on clinical conditions such as epilepsy, thyroid disease and the menopause.
  • Phased clinical quality markers, banded into five levels; these concern disease areas that are too extensive to be handled as tiered markers.
  • The clinical quality markers will be almost impossible to measure using written health records.
  • The example of a phased clinical quality marker given in the proposal document is that for ischaemic heart disease (IHD).

Level 1 - entry level

Practices will have an accurate computerised disease register of patients with IHD. The register should include information about:

  • Long term drugs for IHD and other chronic conditions.
  • Whether the patient has been reviewed by the practice in the past 12 months.

Level 2

Level 2 includes level 1 plus the eight standards in Box 1 (below). They are all subject to exemptions and excception criteria. The entry standard must be in place before the level can be commenced.

Box 1: The eight standards of the level 2 phased clinical quality marker for IHD

Standard Entry % Final quality standard

Patients will be reviewed or offered review (contacted twice) at least annually (including a medication review)

To be negotiated 90% of those reviewed

Smoking, BMI, exercise status and alcohol consumption will be recorded and appropriate advice offered

To be negotiated 90% of those reviewed

Blood glucose will be measured in all patients (at least once since diagnosis) and treated where appropriate

To be negotiated 90% of those reviewed

Blood pressure will be recorded at least annually

To be negotiated 90% of those reviewed

All patients should be taking regular aspirin except where contraindicated or not tolerated

To be negotiated 90% of those reviewed

All patients with symptomatic IHD should have access to sublingual GTN

To be negotiated 90% of those reviewed

All patients who require regular symptomatic treatment should be treated with a beta-blocker (unless contraindicated or significant side-effects)

To be negotiated 80% of those reviewed
Patients should have their blood lipids measured of those at least annually and prescribed a statin in line with national guidance. To be negotiated 90% of those reviewed

Level 3

Level 3 consists of levels 1 and 2 plus:

  • Patients should have their total cholesterol or LDL reduced according to national guidelines. Optimal standard 95% with exception reporting.
  • Patients should have a blood pressure of less than 150/90 mmHg. Optimal standard 85% with exception reporting.

Level 4

This is the level that is achieved when the highest standards of level 3 have been delivered and maintained.

Level 5 - the premium level

This level is achieved by delivery of every standard to the highest possible level across all three types of quality areas: clinical, organisational and patient perspective.

The factors that will help practices to reach the highest quality levels include:

  • Good organisation
  • Good management
  • Having a below-average list size
  • Use of computer systems:
    • all clinical data entered on EPR
    • all data coded2-3
    • using IT to audit quality of care given
    • ability to run computerised data- bases
    • ability to run complex call/recall systems.

It is clear that all practices will need to move rapidly to using EPRs.4 To demonstrate higher quality levels using a paper system would be very difficult and would not be cost effective.

The annual report

With the abolition of item-of-service fees, the need for claim forms will be reduced to an absolute minimum. In their place will be an annual report that will detail the practice's achievements for quality and its aspirations for the following year.

The report will be complex and will most probably be provided by the main clinical system suppliers. The production of the report will depend on information being added to the EPR and coded in a standard manner that allows it to be identified and extracted.

GPs who thought they could resist moving to full computerisation by maintaining comprehensive written records will need to consider again - the penalty for not modernising will be reduced practice profits.

How can practices prepare?

The practice computer plan5

It is worthwhile looking at the practice's current IT systems and assessing what developments will be required over the next 18 months to help deliver the quality standards. The assessment should cover hardware, software and training. Submit the plan to the PCO so that the requirements can be included in the Primary Care Investment Plans (PCIPs).

Recording data

Ensure that all major diagnoses, laboratory results, health promotion advice and measurements (height, weight and blood pressure) are added to the EPR and correctly coded. Each PCO or practice should agree on the Read codes to use for each area (this is known as a minimum data set).

Encourage all members of the primary health care team to enter data, especially that relating to health promotion, on the EPR, and ensure that it is correctly coded. Free text entries or those that are incorrectly coded will not be detected by the reports and are therefore of little use.

Box 2 (below) gives some examples of data that could be added to an EPR to ensure that a practice is not penalised because a patient is either unable to take a prescribed medication or refuses such treatment.

Box 2: Example of data to add to an EPR

Text

Read code

Statins

Declined

Contraindicated

Not indicated

 

8I3C

8I27

8I63

Aspirin

Over the counter aspirin

Aspirin prophylaxis IHD

Aspirin contraindicated

Aspirin prophylaxis refused

Aspirin not indicated

 

8B3T

8B63

8I24

8I38

8I66

Beta-blocker

Beta-blocker contraindicated

Beta-blocker therapy refused

Beta-blocker not indicated

 

8I26

8I36

8I62

Audit

Quality is not achieved without planning and hard work. The proposed framework for a new GMS contract focuses clinical quality on cardiovascular and cerebrovascular disease, namely hypertension,6 ischaemic heart disease,7 chronic heart failure,8 atrial fibrillation and stroke. Consider developing a practice-based management plan for each of these areas and auditing against set criteria.

Investment in IT

An initial reaction to the proposals would be to suggest that if a practice has to pay 50% of any investment now and could potentially receive 100% reimbursement in future, all investment should be delayed.

This could be a mistake, especially if investing early helps practices to achieve higher quality targets, and it would be worth investing in low cost, particularly software, requirements. Nevertheless, careful consideration is needed before making any major investment.

GP registrars, assistants, retainers and locums

Under the new contract framework, it is intended that any data should be entered onto the EPR as part of the normal consultation and should not create additional work. It is therefore essential that when doctors perform clinical tasks they record the data to the standards required by the practice - as should all other staff. It is all too easy to target training and protocol development at GPs and forget the other members of the team.

Remember, the more data - and the better quality the data - the greater the practice's potential for earning additional money.

Implications for practices

Although IM&T only warrants four short paragraphs in the new proposal document, it is probably the single most important issue for practices to address to ensure that they are winners if the contract is agreed and implemented.

 

  1. Your Contract Your Future. General Practitioners Committee, British Medical Association, April 2002. www.bma.org.uk
  2. Watson N. Using clinical coding systems to best effect in electronic records. Guidelines in Practice 2001; 4(12): 72-5.
  3. Watson N. PRIMIS will ensure effective practice computers. Guidelines in Practice 2001; 4(7): 76-8.
  4. Watson N. What EHRs and EPRs will mean for GPs. Guidelines in Practice 2002; 5(2): 74-8.
  5. Watson N. Why every practice needs a computer development plan. Guidelines in Practice 2001; 4(4): 80-4.
  6. Watson N. Hypertension audit brings practice in line with BHS guidelines. Guidelines in Practice 2001; 3: 39-46.
  7. Watson N. Practice audit points the way to improved monitoring of CHD. Guidelines in Practice 2001; 4(2): 63-7.
  8. Watson N. Chronic heart failure audit highlights the need to update practice guidelines. Guidelines in Practice 2001; 4(7): 68-71.