Dr Gerard Panting explains the new contract’s mechanisms for ensuring that practices will be rewarded for achieving high quality patient care
The new GP contract allows practices to be far more flexible than ever before in the services that they provide. They can play to their strengths by including additional enhanced services in their portfolio and may opt out from additional services and out-of-hours care.
Under the new contract, each PCO will be required to provide primary care services and underwrite the new patient services guarantee for individuals within its catchment area.
PCOs will be responsible for filling the gaps so that a complete range of services is available to patients, which may involve commissioning care from non-NHS providers or employing some healthcare professionals direct.
The patient services guarantee, which will place a legal duty on PCOs, states:
"Patients will continue to be offered at least the range of services that they currently enjoy under the existing contract. The difference is that in future some services in the additional category may only be available to patients from providers other than their own practice.”
However, although the guarantee sets the minimum standard, the aspiration is to provide a wider range of higher quality services, including some services currently provided in secondary care centres. The intention is that patients will benefit and be able to make better use of the NHS.
If quality, and in particular quality improvement, is the main theme of the new contract, then the subtext is about rewarding practices for delivering clinical and organisational quality by tying practice remuneration closely to the outcomes of the framework.
Financial reward is determined by measuring achievements against quality standards. The four domains of the framework – clinical, organisational, additional services and patient experience each contain a range of areas with key indicators.
The clinical domain contains 10 subheadings and for each of these a points score will be given. In the first year of the contract, each point is worth £75 but in 2005/2006 this figure will rise to £120. However, in order to calculate the practice’s entitlement, an adjustment is made by reference to disease prevalence data. The General Practitioners Committee of the BMA is currently finalising arrangements for the implementation of this new weighting from 2004/2005.
Three types of payment will be made, but in the initial stages the focus will be on preparation and aspiration payments, with achievement payments coming to the fore from 2005/2006 onwards.
The idea of preparation payments is to enable practices to collate data so that their baseline position in the framework can be calculated as a prelude to determining what they hope to achieve the following year.
Aspiration payments depend on agreement between the practice and the PCO, and relate to a third of the predicted total quality points. Practices wishing to increase their performance by, say, doubling their points score in a particular area, will receive an aspiration payment to help with the additional infrastructure costs associated with delivering higher quality.
The practice’s achievement during 2004/2005 will be measured at the beginning of 2005/2006, following which the practice will receive an achievement payment which will, in effect remunerate the practice for the points it scored above the points in the aspiration payment. So if a practice aspires to 600 points and is given an aspiration payment based on 200 points, on achieving 600 points the practice will be remunerated for the remaining 400 through the achievement payment.
If the practice performs better than expected, extra payment will be made according to the points scored, while practices that under-perform will, predictably, suffer a reduction in the achievement payment; in some cases, this could be less than the aspiration payment already paid. Any over-payments will be deducted from the aspiration payment for the following year.
Calculating achievement payments involves a quality score card with a total of 1050 points, 1000 for achievement and 50 for improved access, to determine the level of quality payments a practice is entitled to. To construct a score card, each practice chooses which areas to focus on in the clinical, organisational, additional services and patient experience domains.
Taking the coronary heart disease area of the clinical domain as an example, there are 15 key indicators – 12 relating to CHD plus three in the left ventricular dysfunction subset. Indicator 8, the percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the past 15 months) is 5 mmol/l or less, attracts 16 points. To achieve all 16 points, 60% of patients must satisfy this criterion. However, if the achievement is, say, 30% only half the available points will be awarded.
Taking another example, this time from the diabetes area, indicator 9 relates to the percentage of diabetes patients with a record of presence or absence of peripheral pulses in the previous 15 months. This attracts 3 points if 90% of patients have such a record in their notes; if only 60% of patients do, the score will be 2 points.
In the organisational, additional services (except cervical screening) and patient experience domains, payment is based on a yes/no determination. So having a written procedure manual of staff employment policies, covering topics such as equal opportunities, bullying and harassment and sickness absence, to which staff have access – meeting practice management indicator 10 under the organisational domain – attracts 4 points.
Under patient experience, undertaking an approved patient survey each year will attract 40 points and a further 15 if the practice has reflected on the results and proposed changes if appropriate.
However, it doesn’t quite end there. Practices can receive an extra award for breadth of achievement across different areas by qualifying for holistic care and quality practice payments.
Practices that achieve standards in eight or more of the 10 clinical areas are entitled to a holistic care payment, worth 100 points. This payment is calculated by looking at the number of points achieved in each of the 10 clinical areas, with the proportion of points achieved in the third lowest clinical area determining the proportion of holistic care points to be awarded.
Quality practice payments, which reflect achievement in the nonclinical areas, will also be determined by looking at the third lowest points score in the relevant areas.
In both instances, the calculation of the third lowest would include any areas in which no points at all were scored.
All the clinical indicators set out in the new contract are based on current evidence derived from several quarters, including the RCGP’s quality team development programme and practice accreditation scheme.
The quality framework will evolve over time, requiring practices to review their targets annually for the following year.
The contract states: "To qualify for payment, quality framework data will be recordable, repeatable, reliable, consistent and auditable.” Inevitably, this will rely very heavily on IT systems, without which the whole process threatens to grind to a halt quite quickly. The contract documentation says:
"The practice quality review will be founded on the development of a relationship between the practice and the PCO based on the principles of high trust, evidence base, appropriate progression and development within the practice context, minimising bureaucracy, and ensuring compliance with the statutory responsibilities of the PCO. The PCO’s role will be given appropriate underpinning in legislation.”
The legislation will allow PCO representatives to visit practices annually for audit purposes, which will include a discussion with the clinicians and practice manager.
Where extra evidence is required, or there is concern about the accuracy of information or suspected fraud, PCO visits may be more frequent.
The review will also deal with the practice’s aspiration for the forthcoming year as well as achievements to date.