Q&A: Dealing with practice payment chaos
How not to get stung by the NHS payments system and ways of preparing for contingencies
Q. What problems do you envisage the QMAS shut down/switch to CQRS causing (or what problems have already arisen)?
The main problems are that there hasn’t been enough training or support and this situation has been compounded by the rate at which the switch took place.
The introduction of any new system needs to be underpinned by proper training and support to build users’ awareness and confidence. Unfortunately, the speed in which a change, such as this one, has been introduced is a case of too little (training and on-going support), too late.
There has already been negative feedback from practices on the quality of CQRS training, which Londonwide LMCs has fed back to CQRS.
Q. Have there been more QOF appeals than usual? If so why? And are they taking longer than usual to sort out?
Yes, definitely. For example in London there are a significant number of appeals across the three local area teams (LATs), the majority of which are associated with organisational indicators. NHS England is focussing on and becoming intransigent about whether practices submitted the required evidence by 31 March and whether they can evidence this.
There is the added challenge of streamlining the QOF appeal process - in London, for example, this will go from at least five different approaches in the PCT clusters last year, to one single approach across London under NHS England. The QOF appeal panel dates have now been set, and there will be a representative from Londonwide LMCs to provide advice on process helping panel members to ensure that correct process has been followed in coming to their determinations.
Q. Have QOF achievement payments been delayed even for those practices not in dispute?
We are not aware of delays in achievement payments where there has been no dispute in the London area, other than in cases where practices themselves had delayed signing off their declaration of achievement on QMAS.
Q. The situation with enhanced services payments is now confusing , with payments coming from a variety of sources. Are the systems that have developed national or do they vary among locality? Are there any ongoing efforts to rationalise/streamline/ simplify the payment process?
Payment systems vary from place to place. The impact of the widescale NHS restructuring, staffing changes, the loss of organisational memory and so on has resulted in payment systems becoming fragmented, disjointed and confusing, as reported in your news pages elsewhere.
In London, as possibly elsewhere, the shift to a borough based structure for three Area Teams has resulted in practice payments requiring three steps: authorisation, entry onto the Exeter system and payment transactions undertaken by an external payment processing agent or company (e.g. NHS Shared Business Services(SBS)).
In particular, enhanced services can be paid by three different bodies or authorities: DESs, as they are national, sit with NHS England; most LESs sit with CCGs; some public health LESs (Implanon services, for example) have been transferred to local authorities (to be called ‘community-based service contracts’).
This means that practices now have to deal with three different paymasters whereas before they only had one. The different parts of the system do not seem to be communicating with each other effectively yet, which has resulted in confusion and practices not always knowing what to claim, how to claim, from whom and when.
We don’t know if we can rationalise or streamline the payment process, but we’re trying to simplify it. Local medical committees (LMCs) in different parts of the country are putting effort into helping both NHS England and regional offices to make substantial improvements in their practice payment systems as a matter of urgency.
For example, Londonwide LMCs has established a joint working group, involving decision-makers in London’s area teams (who have replaced former PCTs in relation to all primary care contracting functions) to do what should have been done before the NHS restructure took place - mapping out a clear process and steps around the authorisation and processing of payments.
We have also instigated meetings with some family health services providers (such as NHS SBS) to try and understand their role in the system and how this can be co-ordinated with NHS England, CCGs and local authorities to produce a more unified, streamlined and easy to follow payment system.
Q. What should practices do to ensure payments aren’t delayed or overlooked?
Firstly, practices should try and ensure they stick to payment deadlines, as nowadays, there is little or no flexibility.
Secondly, ensure any email communication sent from your practice regarding payment queries is sent with a ‘delivery/read receipt’ in case you need to provide evidence of raising your queries. Keep a record of all attempts to sort out any payment problems.
Thirdly, if you aren’t sure which of the multiple payment bodies may be responsible for dealing with your various practice payments, for example, your area team, your CCG, or the local authority, then do contact your LMC. They will be able to navigate and represent your practice, so use them.
Q. If payments are delayed, who should practices appeal to?
It depends what they payment is. If you’re appealing to NHS England, then Londonwide LMCs has developed an easy to use template for practices to complete and we have agreement from NHS England that queries using this system will be dealt with promptly. In your area, your LMC may have negotiated a local solution for addressing the problems being experienced.
Q. If initial challenges are not successful, how can practices exert more pressure? What legal courses of action do practices have for delayed DES, LES or QOF payments?
A: Ask your Local Medical Committee (LMC) to apply pressure to the respective area team. Practices suffering severe payment problems could consider:
- Making a formal complaint under The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009.
- Issue a late payment notice to NHS England under contract regulations.
- If the practice is a recognised NHS body, as many PMS providers are (its contract will be recognised as an NHS contract), it may follow the NHS Dispute Resolution Process (detailed within contract regulations).
- Finally, if the non-payment problem is experienced by a practice which is a non-NHS body (holding a private law contract), it has the choice of pursing its dispute either through the NHS disputes route or through the courts.
Q. Local authorities are not used to paying practices for LESs. Are their systems set up correctly to enable GPs to claim?
It varies. Experience to date suggests that every local authority has a different way of dealing with payments for LESs. At present, LMCs are trying to work with local authorities, with varying degrees of success. It may be that a national framework needs to be negotiated.
Q. What contingency plans should practices take to cover delays in payment?
Firstly, review your cash flow in the practice, as a matter of urgency.
Secondly, ensure your claims have been submitted with the required supporting information and within the required timescales ensuring there are no unclaimed payments.
Finally identify sources of financial buffering but be aware that a business overdraft facility can be expensive and is really a last resort.
Q. Many factors have militated against GPs being able to achieve DESs and /or LESs, work towards QOF targets etc (such as tight deadlines, delayed QOF codes and prompts and delayed service level agreements for LES). Will these factors be taken into account when assessing achievement?
In short, no. NHS England is looking at every pound spent in general practice. Today, there is no leeway. If a practice doesn’t fulfil their contract to the letter, there are no allowances, despite the mitigating factors. Practices are faced with operating in a very different world. LMCs across the country will be actively defending and negotiating workable solutions locally; they are your best route for support, so please use them.
Dr Eleanor Scott is a medical director at Londonwide LMCs and is also a member of the BMA’s GP Committee, the GPC.