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Do what you can

GPs may think, how dare the Government lay down the law on how to spend hard earned quality pay ­ but the money should not be thought of as purely a means to instant profits, says Dr David Colin-Thome

It may seem like an easy choice for GPs. Should I spend quality pay on a holiday, or should I blow it all on a

shiny new spirometer? GPs already thinking about spending this April's quality pay may want to consider the benefits of investing in their practice, whether it's a piece of kit or, more likely, an investment in extra nursing capacity.

Some of you may recoil in horror at the very suggestion. How dare the Government lay down the law on how I spend the rewards for improving the quality of care my practice offers? This is surely a case of giving with one hand and taking with the other.

Others among you may recognise that the quality and outcomes framework actually presents a real opportunity to develop and expand practices. You have to speculate to accumulate.

Just reward

The new GP contract includes enhanced service payments for practices delivering specialist services. Investing more of that money now may pay dividends in the future ­ and not just in terms of patient benefits.

The average practice can look forward to receiving £22,000 for quality aspiration and a further £45,000 should they achieve those aspirations, based on a national aspiration of 85 per cent. And that's only for the 2004/5 Q&O. In 2005/6 a similar performance would earn well over £90,000 by spring 2006. Just reward indeed.

GPs may ask, how much of this money is the Department of Health now telling me to spend on my practice? The department takes the view, agreed with the GPC, that the work involved in delivering the new contract, including Q&O, requires input not just from GPs, but the whole practice team. Therefore, the extra quality pay is intended to act as an incentive to adopt these improvements and to help cover the costs of providing them.

Traditionally, the split between profit and expenses has been 60:40. The department took this ratio into consideration when setting out the Q&O.

It is not being suggested that every individual practice must adhere to this ratio. The best practices will achieve high quality through innovation and adopting the right skills mix. Getting these two factors right will improve efficiency in financial terms.

Business case

There is a strong business case for investing some quality pay, which GPs should not ignore. Investing in capacity will enable practices to take on new patients, deliver further improvements in quality, or increase their range of services. This will lead to a further financial incentive as new patients have a weighting of 1.46 in the Carr-Hill methodology ­ an additional £25 above the standard global sum amount. This is significantly higher than the previous reward for new patient checks.

Increasing capacity also brings potential for increased enhanced services and Q&O income. Practices demonstrating high quality and continuing to register additional patients to meet local demand should find it easier to secure enhanced services from their PCT. Equally, they will be able to recruit and retain staff with a wide range of skills. The increased population base also brings opportunities for greater efficiency through economies of scale and has potential rewards in wider policy areas such as practice-based commissioning.

It simply makes more sense for GPs to look at re-investing a proportion of quality pay to increase capacity, so they are able to keep patient registration open. A new patient registration is worth £57.47 x 1.5, with further opportunity to gain extra rewards for delivering high-quality care to these new patients to the tune of around £15 per patient.

So, if the department is not forcing GPs to invest money in their practices, there must be a bigger conspiracy. It is sometimes suggested that the very livelihood of GPs is under threat, with rumours that Q&O will inevitably lead to swathes of GPs being replaced by private health care providers. This is simply not true.

Technically, PCTs could use alternative provider medical services to provide services where current capacity is poor or not coping with demand. However, to expect that PCTs will use these contracting flexibilities where Q&O achievement is low is extremely unlikely, given that participation in the Q&O incentive scheme is voluntary. PCTs, the Government and patients are looking to increase capacity in primary care and, therefore, want PCTs to support under-performing practices, not simply replace them.

But if individual Q&O scores are worryingly bad and other evidence supports this, it would be negligent for PCTs not to investigate further. Ultimately, it is up to PCTs to decide whether to terminate contracts with GPs, but only in line with the contracts that both parties have signed. Poor or unexpected Q&O results should merely prompt PCTs to investigate the reasons behind these results.

Arbitration processes

Checks are available to prevent abuses of the system. Most, if not all, PCTs will have local arbitration processes to attempt to resolve disputes. Strategic health authorities will play a key role in ensuring PCTs act within the law.

LMCs will support practices in disputes. Ultimately, practices have the right to appeal to the Family Health Services Appeals Authority. If they have chosen not to have an NHS contract they can go to court over contractual disputes.

The aim of Q&O is to reward performance and lead to continuing improvements in care. Long-term planning and action is required by all parties. PCTs need to consider how they can help practices. And GPs should not view Q&O purely as a means to instant profits.

David Colin-Thome is National Director for Primary Care and a GP in Runcorn, Cheshire

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