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How to increase your




Further activity in enhanced services is probably the only way GPs can increase their NHS income for 2006/7, says Dr John Couch, who urges GP to plan ahead

The Department of Health has already said it is likely there will be no official GP principal pay rises in 2006/7. Staff budgets are now firmly embedded in core GMS/PMS income. For many practices this now includes associate GPs.

Staff will expect a pay rise. In addition to this, inflation is running at around 2.5 per cent so the real value of profits is likely to fall by at least this amount.

Effectively this means a drop in principal pay unless partnerships find other means to increase income and/or reduce expenses. The new financial year will soon arrive, so it is clearly time to plan ahead.

Enhanced services offer probably the only route where it may be possible to increase NHS income for 2006/07. Just to refresh memories, see the boxes overleaf for a list of the three main enhanced service areas.

There are three logical steps to take when you audit your own practice performance.

Review all the areas for which you are currently paid and check whether your performance is falling in any of them. Pay particular attention to childhood immunisations.

The Pulse campaign has drawn attention to the fact that rules for calculating this target have changed. The most difficult immunisation to persuade parents to allow their children to have, MMR, now accounts for 50 per cent of the childhood immunisation target rather than the previous 25 per cent figure.

Unless you can achieve an MMR rate of 85 per cent with a 95 per cent DPTHibPol rate, payment will fall by around £2,000 per partner to the lower target. While it may be impossible to improve the MMR rate by much, it would be foolish not to try.

Even if the department agrees that MenC can be included in the calculation we still need to get MMR rates above 80 per ent to ensure top targets are maintained.

Address any other areas that are falling back in a similar way. Often this is due to lack of team focus. For instance, if numbers are falling back in near patient testing services, find out why.

This service should be easier for patients. Are you offering enough phlebotomy spac-es? Are patients getting their results properly? Are you listening to any complaints?

Improve profits in services provided

Next look again at the same services and explore how much scope there is to increase patient numbers. Bear in mind that most of the payments for enhanced services are partly or completely based on a fee per patient. In other words the more of your patients receiving the service, the more you get paid.

A good example is anticoagulant monitoring. A computer search should soon provide you with total numbers of patients receiving warfarin (with perhaps one or two on phenindione). You can compare this with the numbers coming to your clinic.

The difference will be patients who are being initiated and those who are on stable treatment but not yet attending your service. You need to target the latter group, trying to get them to use your service.

Another approach is to increase the level of service in those areas with a tiered payment. Anticoagulant monitoring and near patient testing are good examples. Laying on the services of your own phlebotomist increases the payment by up to £11 per patient.

If you do the 'laboratory procedure' the fee can increase another £5-£10 per patient. This is certainly feasible if you have enough patients to justify the purchase of an INR prick test machine. This also allows a one-stop service.

Finally, do not forget influenza and pneumococcal vaccinations, attracting net profit of around £12 and £7.50 respectively per vaccination. Few practices fully maximise the potential numbers involved.

Check your success rate against the numbers eligible and it is likely that you will find several hundred non-refusers you may be able to vaccinate in 2006.

The scope for increasing enhanced services varies considerably across PCTs. At one extreme, PCTs have been keen to set up locally relevant schemes while others have frozen new commissions in order to divert cash to fund large budget deficits.

Although enhanced services have been running now for more than 18 months, uptake has varied so it is still worth exploring any remaining options, especially before they go out to tender from private companies.

You could at least find out from your PCT if any categories of enhanced schemes have not yet been taken up and also their plans for new schemes based on local need (local enhanced services or LES). If you have identified a locally relevant need you could also present this to the PCT for possible funding.

Before you proceed officially you must research the service carefully by drawing up a business plan. The BMA has a useful online resource 'GPC focus on enhanced services' at

This will allow you to list start-up costs, running costs including materials, staff/GP time and training expenses. These can be compared with potential income to arrive at an estimated profit figure. This is essential if you decide to proceed and you should aim for a minimum 45 per cent net profit.

Some schemes offer an annual retainer as well as a fee per patient. The level of the fee increases with the difficulty of the service. Services for drug/alcohol withdrawal and violent patients attract particularly high fees. A violent patient service also offers infrastructure costs, but even this has not tempted many practices!

Finally, remember that all of your enhanced services will be monitored annually. You must be able to demonstrate good performance with relevant protocols, statistics and evidence of training in your yearly written report.

So ensure efficient data entry, call and recall systems and monitoring. Enhanced services can be taken away or put up for best bids.

We are now subject to competition and autopilot mode is not an option.

John Couch is a GP in Ashford, Middlesex

NATIONAL services

· Alcohol misuse

· Anticoagulant monitoring

· IUCD fitting

· Patients with depression

· Drug misuse

· Immediate/first response care

· Care of the homeless

· Intrapartum care

· Minor injury services

(more specialised)

· Sexual health services

· Multiple sclerosis services

· Near patient testing

Directed services

· Improved access

· Childhood immunisations

· Influenza and pneumococcal vaccinations

· Violent patient services

· Minor surgery

Local services

· Dictated by local need

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