'Scrapping the unplanned admissions DES is a significant achievement'
Pulse news editor Sofia Lind speaks to GPC chair Dr Chaand Nagpaul in the wake of the contract deal announcement.
How are you feeling about the contract deal?
I’m glad the contract is finally announced. Up until today it was subject to approval by the Prime Minister’s office.
What I will say is that the contract plays an important part of the much wider environment in which general practice operates in, and the scope of the contract cannot address all of the overwhelming pressures that affect GPs and staff.
In fact, one of the biggest pressures GPs have is work not inside of their contract but work that is outside their contract – work that is often unfunded and which they are being overloaded with.
For example, the contract can’t solve problems with recruitment of GPs and support staff. So we knew that we are working within a bigger agenda.
But within the scope of the contract we set out to achieve certain improvements.
One of them was of course getting rid of the avoiding unplanned admissions DES, which is a significant achievement because this was an area that was very important to the Government. And having removed the whole bureaucracy of it. It was a priority area for the Government but I think it has been a case of common sense.
But there’s still requirements linked to it which are now contractual instead?
All you now have to do is a medication review and to ask frail patients about falls. These are the patients that are the most vulnerable in society and all of these patients will have been seen by a GP. The requirement is not asking for a care plan, it is not specifying the detail of what you do. You are able to be a GP providing clinical care. Most of these people are on multiple medications and medication review is part of our normal practise. So there is nothing actually extra to do. This is just allowing GPs to be GPs, looking after their older patients.
So how much extra will practices receive in the global sum?
The global sum calculations includes several factors. There are several strands. All of that has to be put in the pot and a calculation made. I am told that will be very soon, but it won’t be today. We will try our best for tomorrow.
But there will be a figure and that figure will show a significant increase. A proper increase, which is core funding, that is not amenable to being picked off.
We were expecting QOF to be reviewed ahead of this contract deal, but it is remaining unchanged?
QOF is quite a complex area and we have done some modelling. Changing QOF carries with it risks of winners and losers and we believe we need to deal with this in in a proper manner, not in haste. We don’t want any unintended consequences. We are trying to deal with it and we have had lots of different viewpoints from GPs around QOF and there is a spread of opinion. In fact we have GPs who want to retain it, GPs who want to change it, some GPs who want some of it gone. It would not have been right to have gone into a hasty decision around QOF. Especially when we don’t want to see practices destabilised.
So the review group will not necessarily look at completely scrapping it?
No, that is not true. We are looking at a replacement of QOF. I guess the question is what will come after QOF, what will be the replacement. Scotland has replaced it with new requirements. So when you look at that, I’m not sure that that in England would be welcomed by GPs. We have a different environment, with CQC and how data is used to judge GP practices. So it would not have been a simple task, to just take off the shelf from Scotland. We want to be careful with QOF not to replace it with new work, while clinically appropriate work carries on. So there’s a lot that needs to be thought through.
If it is moved into global sum for instance, it means you will have practices winning and losing. But also those practices that have different prevalence levels will then not receive the same amount of money because it has been redistributed. It is a complex area and we did not want to destabilise practices. Our modelling showed that crude transfers into global sum could have resulted in considerable destabilisation. I’m not saying that is the only factor but I am saying that there is a lot that has to be thought through and we want to do this properly.
How about the new contractual requirement to allow extraction of retired QOF and enhanced services data?
This is something that has been done since 2004, when the contract was negotiated. The extractions have been going on now for years, and the majority of practices enable the extractions. We’ve never had any issues around it and we will only be agreeing to clinically appropriate extractions. So we are not introducing something that practices are not doing. The Government wants public health data, that is what their interest is, but it is not a new phenomenon and it is already being done by a majority of practices.
It seems your colleagues on the GPC are very happy with the deal. Was it a unanimous vote of approval?
I will tell you it was an overwhelming vote in favour. I don’t want to give you figures but it was overwhelming. I think if we reflect and we look at the contract within the scope of the contract, which I come back to, it certainly has achieved some important aims that we had at the outset. There is no new clinical work for GPs, but a reduction in the biggest area of frustration for GPs, which is getting rid of the unplanned admissions enhanced service.
CQC fees were set to rocket. We have gone further than even the GP Forward View had put forward. Even then it was ‘looking at compensating practices’. We’ve gone further and now CQC fees, you could say, are a financial burden for NHS England, not for GP practices. And in fact we hope that NHS England will now be motivated and incentivised to look at the burden of CQC expenses. We hope it will want to ensure that we are not spending inordinate money on a bureaucratic process.
Can I also just tell you that I think one of the most important gains is the non-discretionary payments for sickness absence. For me, when the 2004 contract was negotiated and I was not a negotiator that was one of the biggest omissions, which placed the entire risk of GP sickness onto practices. Potentially having to pay for a salaried GP full time for six months is a major risk and many practices have not been able to offer their salaried GPs that kind of cover.
It is a huge gain that has dogged the GP contract since 2004 – something that I’ve even been pushing for since before I became a negotiator. I am pleased we have managed to put that wrong right. This is good for salaried GPs, who can have better terms, and for practices to have that security.
The other aspect is that most practices are incurring thousands of pounds on locum insurance to cover for sickness, which on the basis of this agreement will – for large number of GPs - no longer be needed, or they can significantly reduce their insurance cover.
Overall it looks like you have got a lot of good things come out of negotiations this year. Was it easier this year? Were they more inclined to listen to you?
No, I think we put forward our arguments in a coherent, cogent manner and I believe that there was a spirit of working constructively with NHS England and trying to address the very real issues that are affecting GPs and practices within the contract. So there was a cooperative approach. To some degree that cooperative approach extends to the fact that NHS England, as you know, are working with us on broader issues – the Urgent Prescription for General Practice. So it isn’t just the contract.
The negotiations for general practice, which are going on at the moment, is bigger than the contract. In this climate of trying to negotiate the wider pressures facing general practice, the negotiations were couched within this framework of working together. Last year’s LMC contract motion asked us to get NHS England to accept the Urgent Prescription. It did not ask us to go for mass resignations. It did not ask us for industrial action. It asked us to do something, and we did that.
I am just trying to explain that the agreement from NHS England to work with us on the Urgent Prescription, and to work with us on the pressures facing general practice, clearly that the contract is part of that wider dialogue. What is critical to understand is that the contract plays one part of this, and we have addressed the contract issues this year, but actually it is part of a wider dialogue in which we are actively addressing a range of other pressures on general practice with NHS England.
Finally I should mention some of the contract changes were part of our Urgent Prescription priorities e.g ending unplanned admissions DES and CQC fee reimbursement, and reimbursing expenses. The fact NHS England ‘accepted’ the Urgent Prescritpion enabled us to tackle these and other areas in the contract negotiations – hence we have got payment for individual components of expenses such as superannuation increased costs, workforce data and even Capita – we modelled actual staff time incurred in calculating these expenses. In the past the DDRB ‘formula’ had an opaque way of calculating expenses
This is maybe why it has been a more productive [contract negotiation] but we have clearly negotiated this. We have negotiated hard. We have put forward evidence, we have explained the rationale behind all of these changes. So no, it wasn’t straight forward. They were hard-fought negotiations but done with coherence and a clear reasoning as to why these changes need to happen.