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List of proposed changes to the Welsh GMS Contract

Full list of proposed changes to the contract for Welsh GPs from the Welsh Government

Proposed Changes to the GMS Contract 2013/14 

1.   GP pay and expenses uplift

It is proposed GP pay and expenses is uplifted by 1.5%.  This increased investment will allow for an average pay increase of up to 1% for GPs and practice staff, in particular, to allow for pay increases for lower paid employed staff, in line with public sector pay policy for 2013/14 and a margin of 0.5% for increases in non-staff expenses. 

The proposal is to apply 1% to the Global Sum (weighted) and any savings offset against the correction factor and recycled. It is proposed to apply 0.5% to the Global Sum Equivalent (which includes the correction factor). The Welsh Government will be mindful of DDRB recommendations on GP pay and expenses should their recommendations be in excess of 1.5%.   

Although not part of the GMS Contract negotiations, it is also proposed (in line with England) to transfer the responsibility for paying locum superannuation payments to GP contractors to pay.    

2.  Quality and Outcomes Framework: new NICE recommendations

It is proposed to implement the majority of NICE recommendations for improvements to patient care.  The NICE recommendations include improved care for patients with rheumatoid arthritis, diabetes, hypertension, chronic obstructive pulmonary disease, heart failure together with improved support for cancer patients. 

Details of the proposed new and replacement indicators recommended by NICE are outlined in Annex 1.  The proposals address concerns about workload and loss of income as follows:     

(a)  It is proposed not to implement the Hypertension recommendations NM36 and NM37. The introduction of these indictors will be assessed for 2014/15. The existing requirement for physical activity under existing PP2 will remain for 2013/14.  

(b)  It is proposed the thresholds be retained at the 2012/13 level (45% - 80%) for the Hypertension recommendations NM 53 and NM 54 which replaces BP5.  

(c)  The Diabetes Mellitus recommendations NM 27, the COPD recommendation NM 47 and the Heart Failure recommendation NM 48 are predicated on a record of referral to either a structured education programme within 9 months of entry on to the diabetes register; a record of an offer of referral to a pulmonary rehabilitation programme; offer of referral for an exercised based programme.  Where these programmes of care are not available in the Health Board GP practices will not suffer a loss of income. Guidance will be issued to Health Boards asking them to make the required QOF payment if their programmes of care are not available. 

(d)  In relation to Diabetes Mellitus NM 28, it is proposed guidance is developed to define competency including the scope for a practice nurse to deliver this review.

The new and replacement indicators will be partly funded by accepting NICE recommendations for retiring indicators from the Clinical Domain and partly by retirements of indicators from the Organisational Domain. 

3.  Quality and Outcomes Framework: new lower and upper payment thresholds for 20 indicators  

Current QOF achievement (based on 2011/12 QOF data) is significantly above the current 2012/13 threshold.  In order to retain financial incentive and to encourage improvements in the quality of care, increases to the 2012/13 thresholds are proposed.

In setting a new payment threshold concerns about a disproportionate workload required to achieve the additional points in reaching a new upper  threshold have been considered.  It is recognised a disproportionate workload in treating the most hard to reach patients will also have an opportunity cost in terms of patient care. In order to alleviate the potential for a disproportionate workload, it is proposed the new upper threshold be set at the (median) 50th centile achievement based on 2011/12 QOF data with the new lower threshold being set at 40 percentage points below the new upper threshold.  However, where the new lower threshold is lower than the existing 2012/13 threshold, it is proposed the new lower threshold for 2013/14 be retained at the 2012/13 level.  Details of the proposed increase in thresholds are outlined in Annex 2.   Setting the new thresholds at the 50th centile will result in an average 10.8% increase in the upper threshold levels across the 20 indicators and an average 9.1% increase in lower threshold level across the 20 indicators.

The raising of payment thresholds for the remaining fraction indicators, including the 20 indicators affected by the 2013/14 change, will be assessed through the contract negotiations for 2014/15. 

4.  Quality and Outcomes Framework: Organisational Domain

 

The proposed changes to the QOF Organisational Domain are outlined in Annex 3

It is proposed indicators worth 78.5 points which require compliance through either recognised standards of good medical practice or good business practice are discontinued. It is proposed that the 78.5 points to be released are used to fund the new QOF NICE requirements [31 points] and a new QOF QP indicator [47.5 points] aimed at improving the care for patients who suffer from a chronic condition and who are predicted to be at significant financial risk of unscheduled admission or unscheduled care. In addition, it is proposed that indicators worth 17 points are transferred to the new Public Health Domain. 

In relation to the 78.5 points which are proposed to be discontinued, it will be assumed GP practices will continue to meet the requirements of the indicators without financial incentive.  In order Health Boards continue to have reasonable assurance on the continuation of these requirements, Welsh Government will discuss with Healthcare Inspectorate Wales (HIW) the potential for HIW to include appropriate validation work, using existing health care standards for Wales, in their programme of work for primary care from 2014/15. 

It is proposed to retain indicators worth 59 points. These indicators have a clinical and patient safety focus. 

It is proposed to retain the current Patient Experience Domain. 

5.  Quality and Outcomes Framework: Quality and Productivity Domain

The proposed changes to the QOF Quality and Productivity Domain are outlined in Annex 4

It is proposed discontinuing QP12, 13,and 14 Accident and Emergency Attendances [ worth 31 points] given the potential overlap with the proposed new indicator for patients who are suffer from a chronic condition and who predicted to be a significant risk of unscheduled hospital admission or unscheduled care.  It is proposed the 31 points are applied to Global Sum Equivalent (weighted).  

It is proposed to introduce a new QP indicator [QP 15, 16,17and 18] for patients who have a chronic condition and who predicted to be a significant risk of unscheduled hospital admission or unscheduled care.  The new indicator, worth 47.5 points, is funded from discontinued Organisational Domain indicators. Concerns about the prevalence of chronic conditions in Wales have been addressed through the proposal for a maximum of 0.5% of the practice list to be applied for QP16. The guidance for this the new indicator is currently being drafted and will provide clarity on a number of practical points including the number of meetings to be held with multi- disciplinary professionals.   

6.  Quality and Outcomes Framework: A new Public Health Domain  

It is proposed a new Public Health Domain will apply to Wales in line with national proposals.  The proposals, broadly, involve moving indicators (worth approximately 15% of current QOF points) which are related to public health into a new Public Health Domain.   The Public Health Domain would continue to operate as an integral part of QOF within the GP contract.  The priorities for the Public Health Domain would from April 2013, will be decided by PHE, in consultation with the Devolved Administrations

7. Quality and Outcomes Framework: Review dates

No changes to the QOF review dates are proposed.  The decision not to implement the proposed changes to the QOF review dates reflects GPs workload concerns and the potential impact on GP access.  Although there is no evidence of clustering of activity in the last quarter of a financial year concerns expressed about duplication of payment will be addressed through proposed post payment verification checks which will be undertaken by NHS Wales Shared Services Partnership Wales.  In addition, it is proposed Health Boards will be asked to monitor the time elapsed between the first and second review as part of their QOF validation work and to consider the impact of exception reporting using a general exception code.  Note however, the decision not to implement the QOF review dates changes will be dependent on the capacity for software suppliers to apply different business rules for Wales within required timescales and reasonable costs.   

8.  Minimum Practice Income Guarantees [MPIG]

In order to address GMS funding inequalities, it is proposed to eliminate MPIG over a 7 year period starting from 2014/15.  It is proposed the elimination will be spread equally over the 7 year period.  It is also recognised the impact of  withdrawal of MPIG on those practices who are heavily reliant on the correction factor will require careful consideration and those practices most heavily reliant on MPIG will need to identified as an outlier. An analysis of the range of price per patient has indentified approximately 95% of practices fall within the £61.00 - £79.99 price per patient range.   

Guidance will developed to identify outlying those practices most at risk of the withdrawal of MPIG - for example, multi-site practices, small practices, and practices with a population skew towards a patient type.  It is recognised the withdrawal of MPIG should not undermine the financial viability of a GP practice such that its ability to continue to provide high quality patient care to its practice population is jeopardised. 

9.  Adjustment to the Contractor Population Index (CPI) 

It is proposed to amend the anomaly in relation to the Contractor Population Index (CPI) by basing the Index on the actual practice size list at the start of the financial quarter before the financial year in question.  The intention is to undertake the index rebasing annually and to revalue QOF points. 

 

Annex 1

Proposed New Indicators  
AreaIDIndicator wordingThresholdsPoints
Diabetes MellitusNM27The percentage of patients newly diagnosed with diabetes in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months of entry on to the diabetes register40-9011
Diabetes MellitusNM28The percentage of patients with diabetes who have a record of a dietary review by a suitably competent professional in the preceding 15 months40-903
COPDNM47The percentage of patients with COPD and Medical Research Council (MRC) Dyspnoea Scale ≥3 at any time in the preceding 15 months, with a subsequent record of an offer of referral to a pulmonary rehabilitation programme40-905
Heart FailureNM48The percentage of patients with heart failure diagnosed within the preceding 15 months with a record of an offer of referral for an exercise based rehabilitation programme40-905
Diabetes MellitusNM51The percentage of male patients with diabetes with a record of being asked about erectile dysfunction in the preceding 15 months40-904
Diabetes MellitusNM52The percentage of male patients with diabetes who have a record of erectile dysfunction with a record of advice and assessment of contributory factors and treatment options in the preceding 15 months40-906
Rheumatoid ArthritisNM55The practice can produce a register of all patients aged 16 years and over with rheumatoid arthritisN/A1
Rheumatoid ArthritisNM56The percentage of patients with rheumatoid arthritis aged 30-84 years who have had a cardiovascular risk assessment using a CVD risk assessment tool adjusted for RA in the preceding 15 months40-907
Rheumatoid ArthritisNM57The percentage of patients aged 50-90 years with rheumatoid arthritis who have had an assessment of fracture risk using a risk assessment tool adjusted for RA in the preceding 27 months40-905
Rheumatoid ArthritisNM58The percentage of patients with rheumatoid arthritis who have had a face to face annual review in the preceding 15 months40-905
COPDNM63The percentage of patients with COPD and Medical Research Council (MRC) Dyspnoea Scale ≥3 at any time in the preceding 15 months, with a record of oxygen saturation value within the preceding 15 months40-905
Total points new indicators                        57 points

 

 

Proposed Replacement Indicators  
AreaIDReplacingIndicator wordingThresholdPoints
CVD Primary PreventionNM26PP1In patients with a new diagnosis of hypertension aged 30-74 years, recorded between the preceding 1 April to 31 March (excluding those with pre-existing CHD, diabetes, stroke and/or TIA), who have a recorded CVD risk assessment score (using an agreed risk assessment tool) of ≥20% in the preceding 15 months: the percentage who are currently treated with statins (unless there is a contraindication)40-9010
DepressionNM49DEP 1&6The percentage of patients with a new diagnosis of depression in the preceding 1st April to 31st March who have had a bio-psychosocial assessment by the point of diagnosis50-9021
DepressionNM50DEP 7The percentage of patients with a new diagnosis of depression (in the preceding 1 April to 31 March) who have been reviewed within 10-35 days of the date of diagnosis45-8010
HypertensionNM53BP5The percentage of patients under 80 years old with hypertension in whom the last recorded blood pressure (measured in the preceding 9 months) is 140/90 or less45-8045
HypertensionNM54BP5The percentage of patients with hypertension in whom the last recorded blood pressure (measured in the preceding 9 months) is 150/90 or less45-8010
Diabetes MellitusNM59DM13The percentage of patients with diabetes who have a record of a urine albumin:creatinine ratio test in the preceding 15 months50-903
StrokeNM60Stroke 8The percentage of patients with a stroke shown to be non- haemorrhagic, or a history of TIA whose last measured total cholesterol (measured in the preceding 15 months) is 5mmol/l or less40-655
Blood pressureNM61Records 11& 17The percentage of patients aged 40 years and over with a blood pressure measurement recorded in the preceding 5 years50-9015
CancerNM62Cancer 3The percentage of patients with cancer diagnosed within the preceding 15 months who have a review recorded as occurring within 3 months of the practice receiving confirmation of the diagnosis50-906
Diabetes MellitusNADM15The percentage of patients with diabetes with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are treated with ACE inhibitors (or A2 antagonists)57-973
CVD Primary PreventionNACVD PP2The percentage of people diagnosed with hypertension (diagnosed after 1 April 2009) who are given lifestyle advice in the preceding 15 months for: smoking cessation, safe alcohol consumption and healthy diet40-755
Mental HealthNAMH10The percentage of patients on the register who have a comprehensive care plan documented in the preceding 15 months agreed between individuals, their family and/or carers as appropriate40-906
Total Points replacement indicators139
Total number of Points required for new and replacement indicators196



Points released by retirements

Retirements due to replacement
QOF ID12/13 PointsNICE indicator wording
NM26 replaces PP18In those patients with a new diagnosis of hypertension aged 30-74 years, recorded between the preceding 1 April to 31 March (excluding those with pre-existing CHD, diabetes, stroke and/or TIA), who have a recorded CVD risk assessment score (using an agreed risk assessment tool) of ≥20% in the preceding 15 months: the percentage who are currently treated with statins (unless there is a contraindication)
NM45 replaces Cancer 36The percentage of patients with cancer diagnosed within the preceding 15 months who have a review recorded as occurring within 3 months of the practice receiving confirmation of the diagnosis
DEP 16The percentage of patients on the diabetes register and/or the CHD register for whom case finding for depression has been undertaken on 1 occasion during the preceding 15 months using two standard screening questions
NM49 replaces DEP617The percentage of patients with a new diagnosis of depression in the preceding 1 April to 31 March who have had a bio-psychosocial assessment by the point of diagnosis
NM50 replaces DEP78The percentage of patients with a new diagnosis of depression in the preceding 1 April to 31 March who have been reviewed within 10-35 days of the date of diagnosis
NM53 replaces BP555The percentage of patients under 80 years old with hypertension in whom the last recorded blood pressure (measured in the preceding 9 months) is 140/90 or less
NM54 replaces BP5The percentage of patients with hypertension in whom the last recorded blood pressure (measured in the preceding 9 months) is 150/90 or less
NM59 replaces DM133The percentage of patients with diabetes who have a record of an albumin:creatinine ratio (ACR) test in the preceding 15 months
NM60 replaces Stroke 85The percentage of patients with a stroke shown to be non- haemorrhagic, or a history of TIA whose last measured total cholesterol (measured in the preceding 15 months) is 5mmol/l or less
NM61 replaces Records 1110The percentage of patients aged 40 years and over with a blood pressure measurement recorded in the preceding 5 years
NM61 replaces Records 17     5 
DM153The percentage of patients with diabetes with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are treated with ACE inhibitors (or A2 antagonists)
CVD PP25The percentage of people diagnosed with hypertension (diagnosed after 1 April 2009) who are given lifestyle advice in the preceding 15 months for: smoking cessation, safe alcohol consumption and healthy diet
MH 106The percentage of patients on the register who have a comprehensive care plan documented in the preceding 15 months agreed between individuals, their family and/or carers as appropriate
Total                                            137

 

 

Retirements

 

QOF ID12/13 PointsIndicator Wording
CHD107The percentage of patients with coronary heart disease who are currently treated with a beta-blocker
CKD24The percentage of patients on the CKD register whose notes have a record of blood pressure in the preceding 15 months
DM103The percentage of patients with diabetes with a record of neuropathy testing in the preceding 15 months
DM21The percentage of patients with diabetes whose notes record BMI in the preceding 15 months
DM221The percentage of patients with diabetes who have a record of estimated glomerular filtration rate (eGFR) or serum creatinine testing in the preceding 15 months
EPILEPSY 64The percentage of patients aged 18 years and over on drug treatment for epilepsy who have a record of seizure frequency in the preceding 15 months
BP48The percentage of patients with hypertension in whom there is a record of the blood pressure in the preceding nine months
Total28

 

 

NICE recommendations for QOF: point calculationsPoints
Points required for new indicators57
Points required for replacement indicators139
Total points required196
Points available from retirements due to replacement137
Points available from retirements28
Total points available from clinical domain165
Points required from organisational domain31

 

Annex 2

 

Proposed Increases in Thresholds for 2013/14

 

ID in UEA researchID 2011/12ID 2012/13ID 2013/14

Existing 2012/13

thresholds

Proposed 2013/14

thresholds

    lowerupperlowerupper
CHD6CHD6CHD6CHD00240755191
CHD8CHD8CHD8CHD00345704580
CHD9CHD9CHD9CHD00550905393
CHD12CHD12CHD12CHD00450905393
CHD 10/11CHD14CHD14CHD006408060100
STROKE10STROKE10STROKE10STIA00645855090
STROKE9/12STROKE12STROKE12STIA00750905494
BP5BP5BP5HYP00245804580
DM15DM15DM15DM00645805191
DM18DM18DM18DM01045855292
DM6/7DM26DM26DM00740504072
DM6/7DM27DM27DM00845704581
DM6/7DM28DM28DM00950905191
DM12DM30DM30DM00245715191
DM12DM31DM31DM00340654072
COPD8COPD8COPD8COPD00745855494
LVD3HF3HF3HF00445805090
CKD3CKD3CKD3CKD00245704576
AF3AF3AF6AF00350905494
SMOKE2SMOKE4SMOKE6SMOK00550905393

 


Annex 3

 

Proposed changes to the QOF Organisational Domain   

 Indicators to be discontinuedPoints
R8Recording drug allergies / adverse reactions in the notes1
R9Identification of repeat medicines in records 4
R1980% of new patients have up to date clinical summaries within 8 weeks7
R20Up to date clinical summaries for 70% of records12
E8Practice employed nurses have Personal Learning Plans and subject to annual appraisals    5
E9Practice employed non clinical team members have an annual appraisal  3
PM2Arrangements in place to back up computer data1
PM3The Hep B status for doctors and relevant practice staff is recorded and immunisation recommended if required   0.5
PM7System to ensure regular inspection of equipment.  3
PM10Written procedure manual covering employment policy2
E1Record of practice staff attending life support training in the preceding 18 months4
E5Record of practice staff attending life support training in the preceding and 36 months 3
R15Up to date clinical summaries for 60% of records25
R18Up to date clinical summaries for 80% of records8
 Total points discontinued78.5
 Indicators to be transferred to the Public Health DomainPoints
R11Blood pressure of patients aged 45 years and over is recorded in the preceding 5 years  for at least 65% of patients10
R17Blood pressure of patients aged 45 years and over is recorded in the preceding 5 years  for at least 80% of patients5
I 5Practice supports smokers in stopping smoking by a strategy which includes providing literature and offering appropriate therapy. 2
 Total points transferred to the Public Health Domain17
 

Indicators to be retained

 

Points
R3System for transferring / acting on information about patients seen by other doctors OOH  1
R13System to alert OOH services / doctor to patients dying at home   2
E6Practice conducts annual review of patient complaints3
E712 significant reviews undertaken in last 3 years  4
E10Practice has undertaken at least 3 significant event reviews within the last year6
PM5Minimum appointment times3
PM9Protocol to identify carers3
PM1Health professionals have access to information on local procedures dealing with child protection 1
MM 2Practice has equipment and drugs to treat anaphylaxis 2
MM 3System for checking expiry dates of emergency drugs2
MM4Availability of prescription within 72 hours3
MM6Practice meets with PCO prescribing advisor annually and agrees 3 actions   4
MM8Collection of prescription within 48 hours   6
MM10Practice meets with PCO prescribing advisor annually and agrees 3 actions and provides evidence of change    4
MM11Medication review is recorded in notes in preceding 15 months for patients who are prescribed 4 or more repeat medicines   7
MM12Medication review is recorded in notes in preceding 15 months for all patients who are prescribed repeat medicines   8
  Total points to be retained59

 

Summary of Changes to Organisation Domain

 

Total number of points 154.5
Points discontinued : applied to fund NICE   31
Points discontinued : applied to fund new QP indicator for chronic conditions  47.5
Points transferred to Public Health Domain17
Indicators retained59


Annex 4

 

Proposed changes to the QOF Quality and Productivity Indicators

 

 Indicators to be discontinuedPoints
QP12Accident and Emergency Attendances  - review data7
QP13Accident and Emergency Attendances  - participate in external review 9
QP14Accident and Emergency Attendances  - implement improvement plan15
 Total points to be discontinued 31
 The discontinued points to be transferred to Global Sum Equivalent (weighted)  
 Existing indicators to be retainedPoints
QP6  The practice meets internally to review the data on secondary care outpatient referrals provided by the PCO               5
QP7The practice participates in an external peer review with a group of practices to compare its secondary care outpatient referral data either with practices in the group of practices or with practices in the PCO area and proposes areas for commissioning or service design improvements to the PCO5
QP8The practice engages with the development of and follows 3 agreed care pathways for improving the management of patients in the primary care setting (unless in individual cases they justify clinical reasons for not doing this) to avoid inappropriate outpatient referrals and produces a report of the action taken to the PCO no later than 31 March 201411
QP9The practice meets internally to review the data on emergency admissions provided by the PCO5
QP10The practice participates in an external peer review with a group of practices to compare its data on emergency admissions either with practices in the group of practices or practices in the PCO area and proposes areas for commissioning or service design improvements to the PCO15
QP11The practice engages with the development of and follows 3 agreed care pathways (unless in individual cases they justify clinical reasons for not doing this) in the management and treatment of patients in aiming to avoid emergency admissions and produces a report of the action taken to the PCO no later than 31 March 201327.5
 Total points68.5
 Proposed new indicators 
QP15The practice produces a list of 5% of patients in the practice who are predicted to be at significant risk of unscheduled admission or unscheduled care.10
QP16The practice identifies a minimum of 10% ( with a maximum of 0.5% of the practice list ) of those patients from the list produced in indicator QP15 who would most benefit from review and ensures there is an active management plan (see template attached) in place for each patient. The active management plan must include an appropriate review date. The frequency of each patient’s review should be determined in light of their clinical and care needs. The practice will be responsible for ensuring that an appropriate system is in place for monitoring and review of the patients identified10
QP17The practice has at least four meetings during the year to review the needs of the patients identified as a result of developing the active management plans, to identify learning needs and related changes in patient management. These meetings should be open to multi-disciplinary professionals who support the practice’s patients.22.5
QP18The practice reports annually to the CCG or PCO on system changes that may benefit patients5
 Total points47.5
 Points funded from discontinued Organisational Domain  indicators 
  New  Total  QOF QP points 116
 Retained existing indicators  ( 68.5 points ) and new risk profile indicators ( 47.5 points)  

Summary of Changes to Quality and Productivity indicators 

 

Total number of points 99.5
Points discontinued31
New indicator : funded from Organisation Domain47.5
Indicators retained116

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