The Matrix

This double special edition of the MATRIX provides a simple checklist of facts about the new GP contract. Given that this is time for New Year’s Resolutions, the new GMS Contract represents a more of a Revolution of Healthcare Agenda’s and implications for the Pharmaceutical Industry.

10 CONTRACT FACTS

1. Every practice will have 2 x signed PROSCRIBED CONTRACTS. One will be kept at the GP practice and one will be kept at the PCT. These contracts finally pin down what GPs will be doing and more importantly what they will be getting paid to do.

THINK POINT PF: Now think about this. Why has the Government brought in a Contract now ? This is as much to do with control as it is to do with care and delivery. Remember that previous to the contract, the GPs working from a red book are acting as self-employed practitioners. Hence, they can pretty much do what they want. Hence when the pressure comes on from the health Authority (or the prescribing adviser) they can to a certain extent say ‘to hell with you !!’ give or take. But now, with a contract, all sorts of declarations, promises and undertakings will be involved. Hence, it is only with the presence and signing of a contract that one can be in ‘breach’ of contract.

2. INR Monitoring will be an enhanced service. Specialist activities such as INR monitoring will be classified as a Nationally Enhanced Service (NES). Hence GPs will not get paid as part of routine work anymore. They will have to choose to ‘opt in’ or ‘opt out’ if this service.

THINK POINT PF: This is 1 example of a change that could make or break the NHS. For example, patients on warfarin (anticoagulation) need regular INR monitoring. Under the new GP contract, GPs will not be paid to do this. So many of them will be ‘opting out’ of this service. Having said that, the PCTs responsibility is to provide INR monitoring to the patient (it’s not the GPs responsibility). So who will do it ? Well at the moment, many PCTs are hoping GPs will just ‘do it’. Many GPs will now be handing in their ‘I withdraw from INR monitoring’ letter and come April 2004 the PCTs will be frantically trying to get someone to do it. 2 Further interest points : PCTs may out source (like out-of-hours) or certain GPs may take up INR monitoring as an enhanced service. Hence patients will be going to different surgeries for different types of blood tests. Interesting.

3. Minimum Investment Guarantee (MPIG). The global sum makes up about 2/3 of the practice finances. The remaining 1/3 comes from infamous ‘points’ to make prizes. To try and ensure no-one loses out, the government have promised a ‘minimum investment’. Hence if a practice is not achieving minimum points they won’t earn anything less than they earned last year.

THINK POINT PF: This minimum investment guarantee was a carrot. It was the final push which led to the ‘yes’ vote which led to where we are today. One key effect of the MPIG is that once the GP contract comes into effect, if practices are scoring poorly on the points, they wont lose all the 1/3 income. The government have promised that overall income will be similar to previous years until they start achieving ‘points’ over and above minimum targets (25%). Once this has occurred, income will vary depending upon ‘points’ scored.

4. How many points ? There are a total of 1050 points. 550 of these are clinical points across 10 disease areas. The remaining 500 points are administrative practice points related to management, audit, practice records and documentation and patient experience related measures. The 10 disease areas are not split equally as can be seen below.

Secondary Prevention of CHD        121 points
Diabetes Mellitus                                 114 points
Hypertension                                      105 points
Asthma                                               72 points
COPD                                                 45 points
Mental Health                                       45 points
Stroke /TIA                                       31 points
Epilepsy                                              16 points
Cancer                                               12 points
Hypothyroidism                                     8 points

5. And what are they worth ? Each point is worth £75 for 2004/5 which goes up to £125 the following year and then up to £300 per point the year after that.

THINK POINT PF: Much fuss has been made about these points – and rightly so. There are some important principals of care here. We know that patients with disease are often showing poor control despite prescribing and management. Hence this system will focus more on outcomes rather than just activities. 3 Specifics : firstly each of the disease points is made up of targets which need to be achieved (ie) cholesterol below 5mmol/L. But the cholesterol target reappears many times (Secondary Prevention CHD, Diabetes, Hypertension and Stroke/TIA). Hence by investing in ‘cholesterol management’ a practice can hit a target ACROSS diseases rather than THROUGH them. This is very important. It’s like writing an essay. The first marks are always the easiest. The same applies for achieving these points. Rather than trying to treat all the targets for 1 disease, GPs will be more efficient if they treat 1 target across many diseases. Secondly, there are minimum and maximum % thresholds. For example, the cholesterol <5 mmol/L target has a minimum of 25% and a maximum of 60%. This means that no payments are made until at least a quarter of the patients in the register have a cholesterol below 5mmol/L But interestingly, once 60% of patients have achieved target, the GP does not get paid for getting more patients to target ! So will it be worth while bothering ? Finally and really a point for us all to bear in mind. The ‘family doctor’ is on the way out. The idea that the GP would understand your problems, look holistically at your circumstances and view you with your illness may be gone. Because the government want targets, targets, targets. This may not be a bad thing. But 1 of the golden rules of medicine is ‘treat the patient not the blood test’. Rightly or wrongly, that’s now out of the window.

6. What if they score too many points ? If GPs get very high outcomes – then they must be paid for achieving them. That’s what the paperwork says. That’s what the government promised.

THINK POINT PF: This is a very real concern. GPs will be asked what their aspirations are (many of them will say ‘to retire’!) So of the 1050 points, how many do you think you will get ? Or how many do you think you want to work towards. It’s just a guide and they don’t get penalised for not achieving them. But they do get some monies up front (and the rest when/if they achieve the points). You will find many practices not going for 1050, but will aim for say 700-900 points. If they don’t get there – no problem. No penalties. Just payment for targets achieved.

7. What about funding for enhanced services ? GPs will be opting in and out of services as we read this paper. The point is, they are being paid for extra services that they may want to do (say minor surgery). Some GPs don’t want to do minor surgery. So they don’t need to. But what happens in none of them want to do minor surgery ?

THINK POINT PF: There is a worry about enhanced services – will there be enough money to pay for this ? There must be otherwise the PCT will have to pay hospitals to do it !! The GPs will really have to stick to their guns when they ‘refuse’ to do work. What is interesting is the fact that the PCT has responsibility for finding and commissioning the delivery of care – not the GP. Hence we are going to see some real fragmentation (and arguably specialisation) of care delivery from primary care levels.

8. What was all the fuss about pensions ? Much of the disgruntled arguing has been over issues such as pensions and premises rather than clinical quality indicators. One thing we will now see is GPs putting all incomes through their practice accounts to prevent monies and funds from being sucked out of their pensions.

9. A Note on the Sick Note ! Demand Management points out the bulk of sick certification should move out of the GP’s remit and to that of occupational health. So you wont be seeing your GP anymore for a sicky!

THINK POINT PF: The problem with this appointment is that the patient would never have come to the GP for their illness unless they wanted the sick note !! Hence we are wasting doctors time for a piece of paper (that we often have to pay for anyway). I think we will still have to pay for it though . . .

10. What about dispensing doctors ? No changes and no funds have been taken away from dispensing doctors. They have kept interference to a minimum. The points and prizes of the quality framework still apply.

THINK POINT PF: The next time you catch up with a GP ask them about premises and work being done to the premises. It’s a sticky point now. If a practice/GP had an improvement grant/work planned which was approved before September it may go through – but some won’t. In fact from now on, GPs will not get rent to pay for this. Money has become very tight for premises. Why ? The government needed to raid premises budget for the MPIG (see above). So they will need my prescribing incentives to help to pay for this now (and also their staff see next)

11. Staffing and the new GP contract ? Arguably one of the most significant changes to the daily finances will be the way in which staffing is budgeted within practices. Until recently the government has reimbursed 75% on staff that practices employ. Well under the new GP contract – this has gone – completely! So now the GP will have to pay for each and every staff member from his own pocket.

THINK POINT PF: Why is this ? Money follows the patient not the staff. So funding is based on patient outcomes whether you have 1 nurse or 10 nurses. What’s more, for every £1 the GP spends on staff they need to add +11p for NI contributions and +14p pension contribution. So they really do need hence to look at what staff are doing. Under a current system, employing 2 x G-grade nurses and 2 X Hgrade nurses just to do BP and urine will be a complete waste of money!! Expect to see receptionists trained to NVQ doing BP,urine, health checks etc and also the employing of medical students (cheap if not free and no NI and pensions to think about). The world is changing . . .