Inform and let parents make choice
This year there is real motivation to make the enhanced service part of the new contract work, says Dr Peter Stott
As far as enhanced services were concerned, 2004/5 was a major disappointment for GPs. In April 2004, when the details of the new contract were announced, most PCOs had already committed the funds the Government intended should have been used for enhanced services purposes to other projects. As a result, with very few exceptions, there was little enhanced services development.
This situation should change in 2005/6. All PCTs now know the ground rules and should have ring-fenced funds for enhanced services. This is not to say they will always play according to the accepted rules.
LMC watchdogs have already identified a range of 'creative ideas' that PCOs are using to develop services that should be financed in other ways like paying for nurse facilitators and pharmacy stop-smoking schemes from GMS money. But most PCOs are well-intentioned and, far from playing offside, are in fact supplementing the ring-fenced enhanced services money with extra funds from other sources.
Priorities for PCOs
In developing enhanced services, the PCOs have three priorities:
1. To provide essential and additional services for those practices that have opted out of providing them like improved immunisation services, services for violent patients, influenza vaccination, minor surgery and near-patient testing. These are the 'directed enhanced services' (table 3) with national benchmark pricing.
(To keep the distinction between essential/additional and enhanced funding, it has been agreed that these services should not be funded from enhanced services money but rather from the PCO's GMS global sum or PMS equivalent.)
2. To develop services which it is sensible to provide in primary care like insertion of intrauterine contraceptive devices, anticoagulation monitoring, minor injuries and near patient-testing. These are the 'national enhanced services' (table 4) and again there are national minimal specifications and benchmark pricing.
3. Finally there are the 'local enhanced services' services not normally provided in primary care. If PCOs identify a specific need they will commission these from local providers. The preferred provider will be a GP practice, but hospital trusts, charities and private providers can also make bids.
The Government is keen to introduce competition for enhanced service provision and has recently indicated it will top-slice financial allocations to those PCOs that do not commission a satisfactory number from private providers. There is no benchmark pricing for this level of service and local negotiations between the commissioner (PCOs) and providers will be necessary.
For 2005/6 the Government has allocated £631 milion for enhanced services in England and £21 million for Wales (table 1). Scotland and Northern Ireland have their own legislature but the arrangements are broadly similar. So the average amount available for enhanced services comes to about £60,000 per practice.
Many practices will not be interested, but many will, because in 2005/6 enhanced services will provide the only new money on offer. Practices that are likely to succeed will be those with insight into the PCO agenda, such as those with partners who serve on PCO committees or on the LMC.
All enhanced services agreements must be agreed with the LMC and signed off by the professional executive committee of the PCO. So it will be important to have these people well-briefed as to your intentions.
What sort of local services
The NHS wishes to encourage schemes that will help to achieve national priorities:
·reducing outpatient waits
·specialist treatment closer to home
·intermediate care schemes
·enhanced care in the community
·schemes that transfer work from secondary into primary care.
There is also a need to develop the role of the GPs with special interests.
So, taking a broad view, examples of the type of enhanced bids that may succeed include:
·ENT and ophthalmology triage into secondary care
·Insulin diabetes clinics
·Contraception for areas of greatest need, eg IUDs, teenagers
·Sexually transmitted diseases
·Obesity management incentives
·Phlebotomy and INR services
·Drug and alcohol services
·Heart failure clinics
·Pre-hospital emergency care
·Services to nursing homes
·Services related to intermediate care
·Services related to long-term conditions.
Service descriptions and benchmark pricing for the directed and national enhanced services (tables 3 and 4) were published in the supporting documentation for the new contract. The 2003/4 prices will be updated by 3.225 per cent each year till 2005/6 (table 2).
Local enhanced services
There are few examples as yet of pricing for local enhanced services, though the established PMS-plus pilots are undoubtedly leading the way on this. The BMA has asked LMCs to keep a watching brief and to share information on pricing trends as soon as this becomes available. In the meantime, the professional fees committee of the BMA has published guidance on calculating the costs of providing such services and this can be found on its website.
It advises that costs should include:
1. The actual cost of providing the service:
·additional staff costs (eg pensions and NI)
·training and cover while training
·secretarial support and stationery
·additional medical defence costs
·costs of annual review activities and PCO annual verification meetings
·patient information materials
2. The profit element you wish to make for providing the service, taking into account the complexity of the work, litigation risks, training implications and financial risks.
If 2004/5 was the year of target payments, 2005/6 will be the year of enhanced services. There is a real motivation to make this part of the contract work.
It is possibly the only innovation since fundholding that offers the potential to move work out of secondary care and into primary care where it can be done more simply, more efficiently, with less resource implications and with greater benefit for the patient.
In the process, the development of enhanced services will also offer GPs more fulfilled and interesting career development.
Peter Stott is a GP in Tadworth, Surrey
1 Allocation of monies for enhanced services (England)
enhanced services (England)
England £563m £631m
Wales £16.4m £21m
Northern Ireland £5m
2 Directed enhanced services 2003/4 prices
Joint injection ·£40 per injection
Cutting surgery ·£80 per surgery
Dealing with violent patients ·Retainer £2,000 pa ·Consultation fee £40-80
National enhanced services 2003/4 prices
Care of the homeless ·Retainer £1,000 ·Plus £100 per patient pa
Intrapartum care ·£200 per patient ·Plus £50 per neonatal check
Intrauterine contraceptive device ·Insertion fee £75 ·Annual review £20
Minor injuries ·Retainer £1,000 pa ·Plus £50 per patient episode
Alcohol misuse ·Retainer £1,000 pa ·Plus £200 per patient pa
Drug misuse ·Retainer £1,000 pa ·£500 withdrawal per patient pa
·£350 maintenance per patient pa
3 Directed enhanced services1,2
The GMS contract lists six services in this category and for each one there is a description of the specific aims and targets laid down for each service and of the benchmark pricing
·Access to GMS*
·Influenza immunisation for those in the 65 and over and other at-risk groups*
·Quality information preparation*
·Services to support staff dealing with violent patients
*PCOs are bound to use GPs as 'preferred providers' for these services
4 National enhanced services1,2
There are also guidelines and benchmark pricings for each of the NESs
·Enhanced care of the homeless
·Intrauterine contraceptive device fittings
·Minor injury services
·More specialised services for patients with multiple sclerosis
·More specialised sexual health services
·Patients who are alcohol misusers
·Patients suffering from drug misuse
·Provision of near-patient testing
·Provision of immediate care and first
·Specialised care of patients with depression
1 BMA. March 2004. Focus on the financial monitoring of enhanced services. www.bma.org.uk/ap.nsf/Content/focusfinancia · ES0304
2 Department of Health (2004). Investing in General Practice: The New General Medical Services Contract.
3 Contract Documentation The NHS Confederation. www.nhsconfed.org/gms/gms_contract_documentation.asp