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GPs to face surprise visits from NHS fraud busters

By Ian Cameron

The Department of Health has finally released its crucial guidance on the new GMS contract and the future of PMS. Over the next five

pages Pulse brings you detailed coverage.

Practices whose achievement on the quality and outcomes framework is thought to be suspicious could receive an unannounced visit from NHS fraud busters.

One in 20 practices chosen at random each year will also face a thorough audit of their performance against the framework by primary care organisations to check if their claims are legitimate.

The Department of Health described the counter-fraud checks as necessary to protect the majority of GPs from a small minority who would seek to submit false claims.

But GPs said the new regime went against the notion stated in previous contract documents that monitoring would be 'light touch' and 'high trust'.

Issues that could warrant an unscheduled visit from the NHS Counter Fraud and Security Management Service

include:

·starkly different numbers of patients on disease registers, compared with PCT average prevalence

·unusually high levels of exception reporting

·inappropriate referrals to secondary care

·unexplained variation between aspiration and achievement levels.

Dr Russell Walshaw, medical secretary of East Yorkshire and Northern Lincolnshire LMC, said practice managers and GPs could not 'suddenly find the time to escort the fraud squad around the practice ­ and there are issues of patient confidentiality'.

He added: 'To put in the contract that it will be high trust and then say ''we can turn up when we like'' is totally unacceptable.'

Dr Mike Parks, joint medical secretary of Kent LMC, said: 'From an LMC point of view we would not be happy with any part of the NHS arriving on your doorstep without warning or consultation with the LMC.'

GPC chair Dr John Chis-holm said he did not believe the high trust description had been compromised, but acknowledged the process had to be carefully scrutinised to make sure it was 'fit for the purpose and not burdensome or bureaucratic'.

For most practices, confirmation of quality achievement will be gleaned from monthly reports from the Quality and Outcomes Framework Management & Analysis System, which automatically links to GPs' clinical IT systems, or via scheduled annual PCO visits.

The School of Health and Related Research at the University of Sheffield is developing protocols for visits.

Contract milestones

JANUARY 16

nDeadline for stating intentions for out-of-hours and additional services

nQuality aspiration level submitted to PCO

JANUARY 31

nEstimated global sums, global sum equivalent and MPIG details should arrive

FEBRUARY 13

nInformed PCO whether practice wants to sign private law or NHS contract

FEBRUARY 28

nAgreed whether list open or closed, set practice boundary and normal working hours

nAgreed three directed enhanced services for which practices have preferred provider status (access, quality information preparation, childhood vaccinations and immunisations)

nDecision from PCO on whether practice may opt out of additional services

nAgreed indicative budgets with PCO, reflecting provisional agreements about services to be provided

nReached provisional agreement on the contract; practices offered default contracts if provisional agreement not reached

nGiven details of recruitment and retention of staff to PCO

MARCH 31

nGMS contracts or default contracts must have been signed

nSubmit final Red Book claims to PCO

nPre-RFA 99 legacy computer systems replaced

nDisease registers set up, correct clinical codes for the quality framework in use Submitted out-of-hours opt-out notice to guarantee opt out by January 1, 2005

APRIL 1

nContract begins

nPatient leaflets reviewed

APRIL 30

nFirst monthly payments, based on indicative figures, made to practices

MAY 31

nActual budgets calculated and agreed with PCO

JUNE 31

nOver- or under-payments of actual entitlements compared with indicative entitlements made

JULY 1

nPCTs recalculate global sum with new list size data for first time (repeated every quarter thereafter)

nPractices told by PCTs when quality framework annual review visit will take place between October 1 and

January 31, 2005

2005

JANUARY 1

nPCTs take over commissioning responsibility for out-of-hours

FEBRUARY 14

nNational prevalence day, relative recorded practice disease prevalence for quality framework measured ­ occurs same day every year thereafter

MARCH 31

nQuality framework national achievement day; payment levels for 04/05 calculated, using the latest list size and with clinical payments adjusted for prevalence as at February 14

APRIL 30

nPCTs will have made 2004/5 achievement payments as a lump sum on the basis of QMAS calculations.

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