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Practices are going to need to work hard to achieve full payment for access DES, and the trick will be to achieve what is genuinely within reach, says Dr John Couch

There are no two ways about it ­ achieving full payment for the new access DES will be very difficult. Payment will be based on quantitative evidence from a national patient experience survey (NPES).

You might as well accept that you will not be able to please all your patients all of the time. Therefore it is much more realistic for individual practices to aim to achieve what is doable, and not try for the impossible.

For the last two years GPs have been receiving access payments from two sources. Some payments been made ad hoc from PCTs either six monthly or annually. Few of us were ever sure if and when they would arrive, but when they did appear they were welcome. There were also 50 QOF points for achieving 48-hour access. Most practices received 100 per cent payment.

Both of these payments have now stopped and their combined value amalgamated into a DES. Therefore this is most decidedly not new money, and assuming most practices do not achieve a maximum payment, a drop in income will result. The maximum available for 2006/7 is £2.06 per patient. This means that for an average list of £1,800 the scheme will be worth just over £3,700 per GP.

Points reshuffle

It is also worth pointing out at this stage that the value of the 'patient experience' domain of QOF has actually been increased from 100 points to 108 points by reshuffling points from other areas.

These revolve around a patient survey of which access makes up some of the questions. So there is natural overlap between both areas. Eventually the survey will cover both this and the DES. For 2006/7 there will be two separate surveys.

The value of the QOF points for patient experience is around £5,000 per GP, so the two areas combined total around £8,700 or 7.5 per cent of the average GP's income.

Payments will be broken down into two components:

Component one will account for a third (£0.69 per patient). Of this half will be paid on PCT agreement of a written plan showing how the practice will work towards the first three 'dimensions' of access.

The other half will be paid if a practice signs up, in writing, to the monthly primary care access survey (PCAS). Most practices have been doing this for the last two years anyway, but a fresh mandate is required. PCAS has been amended to include a randomised survey date and third available appointment. The payment is refundable to the PCT if the practice subsequently defaults.

A key point: draw up written plan, as above, and get this agreed by your PCT as soon as possible. Sign up to PCAS as soon as possible. Payment for both of these should follow, presumably within a month or two, although we all know about PCT delays!

Component two accounts for two-thirds of the payment, £1.37 per patient. It will be based on four dimensions. Payment weighting is shown in brackets:

1 Opportunity to consult a GP within 48 hours (30 per cent)

2 Opportunity to book appointments more than 48 hours in advance (30 per cent)

3 Ease of telephone access to the

practice (30 per cent)

4 Opportunity to be seen by practitioner of preference (10 per cent)

It is worth noting that the fourth item, which may be more difficult for larger practices to achieve, carries a lower value.Payment will be made based on the results of the NPES survey.

This is supposed to occur in quarter four of 2006/7 with payment in quarter one of 2007/8. Once again there are no prizes for anticipating payment delays as there are several links in this chain.

Payments are also subject to thresholds and tiers.

As you can see from the table on the left, any dimension where the minimum threshold (20-50 per cent) is not achieved will receive zero payment and maximum payment is only made once the higher threshold (80-90 per cent) is reached.

The table showing tiers of payment can be found in annexe four of the 'Revisions to GMS contract 2006/7' PDF via the BMA website. The main points to note are:

·There is no payment for any dimension below minimum threshold

· The scoring system for the survey is such that if you average 'good' responses (the range is poor/fair/good/very good/excellent) your score will be only 33 per cent, ie below at least two of the minimum payment thresholds

· The maximum payment levels are set very high

· There are tiers of payments between

min-max threshold

· The more difficult-to-achieve dimensions have lower minimum thresholds, which may offer hope of at least some payment.

Maximising payments

You must first make a policy decision. Do you have a realistic chance of maximum payment? For many practices the answer is likely to be No. Most are likely to decide how much they are able to achieve within their resources. Some strategies could include:

·Develop more flexibility to cope with

unpredictable demand

·Develop the ability to extend surgeries at short notice

·Arrange to have off-duty GPs willing to be called in at short notice

·Assess current triage efficiency and amend if needed

·Reassess skill mix ­ are all clinical staff

doing the right jobs?

·Have more walk-in-and-wait surgeries

·Improve patient education

·Recheck current demand and

appointments offered

·Tailor appointments to average demand, allowing for predicted daily and seasonal variations

·Increase appointments if needed

·Have more internet booking

·Institute careful management of GP

holidays to avoid 'tight' weeks

·Review your telephone system and

manning levels, especially at busier times

·Increase the number of lines and/or staffing levels if needed

·Review staff telephone skills and training regularly

·Make more use of 'scripts' for regular

patient requests to ensure uniform and

polite response to patients

·Ensure it is the staff with the best

telephone skills that man the lines.

·Review individual GP availability,

especially if you have few regular sessions and too many GPSI, PCT or other sessions ­ consider amending 'balance' if needed

·If a patient sees a different GP for each new episode, encourage continuity until episode ended or stabilised

·Ensure GPs book follow-up appointments before patient leaves consultation

·Ensure 'list sizes' are proportionate to GP availability, ie larger list for full-time and smaller for part-time

John Couch is a GP in Ashford, Middlesex

Minimum threshold % payment at Threshold for

for any payment minimum threshold maximum payment

48-hour GP access 50% 50% 90%

Advance booking 40% 40% 90%

Telephone access 30% 50% 80%

Practitioner of choice 20% 40% 80%

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