If anything, it was the atmosphere of mutual congratulation that was most unsettling.
When the BMA and NHS England announced last month that a deal on the 2014 contract had been reached, the contrast with the protracted wrangling over this year’s contract could not have been more marked.
Where there had been months of stalemate and bitter recriminations about the imposition of the widely resented 2013 changes, here was a swiftly agreed deal for 2014 that was welcomed from all sides.
GP leaders and ministers hailed it as, variously, an end to pointless bureaucracy, the ‘return of the family doctor’ and the best deal that GPs could hope for in such austere times.
But it quickly became clear that many grassroots GPs did not share their leaders’ enthusiasm. Almost two-thirds of some 360 GPs polled by Pulse the weekend after the announcement rated the deal as ‘poor’ or ‘very poor’.
As the dust settles, and the detail becomes apparent, what will the 2014 contract really mean for GPs?
The good
Certainly there seems plenty to be positive about in the new contract, with almost 40% of QOF targets removed – including nearly all of the unpopular clinical indicators imposed last year and the whole of the onerous Quality and Productivity domain – and much of that funding ploughed back into the global sum.
Professor Clare Gerada, RCGP chair at the time of the announcement, said this was ‘welcome news for patients and for GPs as it will help us to get back to our real job of providing care where it is most needed, rather than more box-ticking’. Her successor Dr Maureen Baker has backed this position.
Dr Peter Swinyard, chair of the Family Doctor Association, was equally positive about the deal, saying it would ‘reverse some of the complete daftness of the contract imposition from last spring’ and would give GPs ‘headroom to look after people and start planning care, rather than spending their entire lives ticking boxes or going through their colleagues’ notes to check their boxes were ticked.’
The message on box-ticking struck a chord with grassroots GPs too, with 73% of those who responded to the Pulse survey backing the reduction in the QOF and 78% welcoming the reinvestment of QOF funding back into the global sum.
Dr George Sowemimo, a GP in north-east London, said: ‘I am encouraged by the changes – it appears that GPs are being listened to… at last.’
The not-so-good
Yet not even the GPC believes it is all good news. Although chair Dr Chaand Nagpaul said the new deal would ‘help ease the pressure on GPs’, he admitted to Pulse that the potential workload associated with the new enhanced service aimed at cutting unplanned admissions was significant.
The scrapping of seniority payments was unsurprisingly opposed by 70% of respondents to Pulse’s survey, while another policy that has not gone down well is the requirement for GPs’ pay to be published. The assurance that the figures will be an average of drawings and salaries across each practice and not the pay of individual GPs has done little to appease opposition from 78% of GPs.
The uncertain
And there are a series of measures on which the jury is still out.
There is confusion over how GPs will prove they are checking the quality of out-of-hours services, and the extent to which they may be held to account when things go wrong; there are also outstanding questions over how available ‘named, accountable GPs’ will need to be. The impact of forcing practices to publish Ofsted-style CQC ratings and removing practice boundaries, albeit in a voluntary way, may also be significant.
Bob Senior, chair of the Association of Independent Specialist Medical Acccountants and head of medical services at Baker Tilly, said the overall impact of the contract changes was ‘very hard to predict’. ‘In terms of winners and losers, it’s too difficult to call at the moment,’ he said, adding that changes to the MPIG could ultimately be the single biggest factor. ‘The wording says they will release money from the correction factor back into the global sum – but again, we don’t know how much.’
The situation in the devolved nations further complicates any attempt to assess the overall picture. As Pulse went to press, GPC Northern Ireland was close to a deal that would remove around 240 QOF points and shift funding into the global sum equivalent, but retain the quality and productivity indicators. Talks in Scotland are at ‘an early stage’, while an agreement in Wales is expected before Christmas. In any event, the series of different deals seems likely to finally spell the end of the UK-wide contract.
GPC negotiator Dr Peter Holden, meanwhile, insists the deal in England was ‘the best we could do’. ‘You have to remember the environment,’ he says. ‘There is no new money and the Treasury wanted to impose something far, far worse.’
Grassroots GPs are likely to reserve judgement until the full impact of the changes becomes apparent in April.
New enhanced service on unplanned admissions
What is it?
A new DES worth a total of £160m will be funded by the removal of the QOF Quality and Productivity domain and the current risk-profiling DES.
Practices must identify a minimum of 2% of adult patients (and any children) who are at high risk of admission to hospital for the ‘case management register’.
A named, accountable GP will be responsible for developing a personalised care plan for each patient on the register, and overseeing their care. Another healthcare professional can be assigned to co-ordinate the patient’s care – this can be someone outside the practice, such as a community matron or district nurse.
Practices must also offer same-day telephone consultations for patients on their at-risk register and provide a dedicated practice telephone number to other healthcare staff such as A&E, ambulance service and care home staff, to support decisions relating to admission and transfer to hospital.
What it means for GPs
The enhanced service involves a considerable workload but appears to be relatively well funded. Practices, rather than the CCG, will have control over case-management review, with no need for ‘multidisciplinary review’ meetings.
Practices will be monitored through a national reporting template, which they will submit to the CCG and local area team.
Payments will be relative to practice list size (based on the 2% on the case management register). In areas with a higher-than-average number of vulnerable patients, CCGs will have the option of funding an additional enhanced service locally.
What we don’t know yet
Full details of payments are yet to be revealed, although we do know there will be no requirement to achieve any outcomes targets, such as reductions in emergency admissions. Additional guidance will follow for practices with large numbers of patients in nursing or care homes.
Out-of-hours monitoring
What is it?
GPs who have opted out of providing out-of-hours care will have a new contractual duty to monitor the quality of their patients’ out-of-hours services, based on national quality standards and patient feedback, and to raise any concerns with NHS England or a delegated commissioner.
Practices must also co-operate with the out-of-hours provider, agree timely sharing of patient data, review clinical details of all out-of-hours consultations the same day and respond to information requests from the provider.
What it means for GPs
This new responsibility, while heavily trailed in the national media, appears to formalise what most practices are already doing.
What we don’t know yet
The details of how practices will report on out-of-hours performance are yet to be finalised.
It is also not clear whether practices will face a breach of contract notice or other sanctions if serious problems emerge with their local out-of-hours provider. Neither is it clear what the medico-legal implications could be.
Choice of GP practice
What is it?
From October 2014, practices will be able to register patients outside their traditional boundary areas on a voluntary basis, under an extension of existing pilots.
What it means for GPs
Practices will have the option to sign up patients from outside their catchment area but will be under no obligation to do so if, for example, they are reaching capacity and wish to limit new registrations to patients within their traditional boundary.
There will be no duty to provide home visits for registrants from outside the usual boundary. NHS England local area teams will be responsible for arranging urgent care at or near home for these patients.
The criteria for registering patients will mirror those for the existing pilots, whereby practices cannot discriminate between patients but may refuse registration to patients unsuitable for remote registration – for example, those with serious mental health problems who need to remain attached to the local mental health team.
What we don’t yet know
Details are yet to be finalised but payment for registrants outside the usual catchment area is likely to be reduced, to reflect lack of need for home visits. It is also unclear exactly how local area teams will commission home visit cover.
QOF cut by almost 40%
What is it?
A total of 341 points will be removed from the QOF, including 185 from the clinical domain, 33 from the public health domain, and 33 from the patient experience domain.
The equivalent of 238 points will be transferred to the global sum; 100 points (taken from the Quality and Productivity domain) will be transferred to the new enhanced service on unplanned admissions, and three points transferred to the learning disability enhanced service.
What it means for GPs
Less box-ticking, in a nutshell. The changes remove the unpopular hypertension indicators for a stricter target blood pressure of 140/90 mmHg, physical activity screening (HYP003, HYP004 and HYP005) and diabetes indicators on erectile dysfunction (DM014 and DM015), as well as the controversial biopsychosocial screening indicator in depression (DEP001).
Also gone are process indicators on renal function and eye screens in diabetes (DM005 and DM011), cholesterol checks for patients with CHD, peripheral arterial disease or stroke/TIA (CHD003, PAD003, STIA004 and STIA005), as well as cholesterol, glucose, blood pressure and BMI checks in patients with serious mental illness (MH004, MH005
What we don’t know yet
Some of the indicators that have been removed may be considered routine practice – so the reduction in GPs’ workload may not be quite as much as advertised.
IT changes
What is it?
Practices must promote and offer online appointments, repeat prescriptions and access to the Summary Care Record (SCR) as part of the core contract from April 2014.
What it means for GPs
Patients must be able to access their SCR, which covers medications, allergies, adverse reactions and other information they consent to, by the end of 2014/2015.
From 1 April 2014 practices must also:
• Upload SCRs automatically on at least a daily basis, or have a published plan to do this by the end of 2014/2015
• Use the GP2GP facility to transfer patient records between practices, or have a published plan in place for this
by the end of 2014/2015
• Include patients’ NHS number as the primary identifier in all clinical correspondence, in particular referrals, whether made through Choose and Book or on paper.
What we don’t know yet
The IT commitments in the 2014 contract continue to push in the direction of the ‘paperless NHS’ pledged by Jeremy Hunt – but the small print reads somewhat differently to last year’s deal. In particular, it remains unclear whether the SCR commitments mean Mr Hunt is backtracking on his pledge to offer patients access to their full record, and not just their SCR, by 2015.
End to seniority payments
What is it?
Seniority payments will be removed from April 2014, with existing payments phased out over six years.
Money released from the seniority ‘pot’ will be transferred into the global sum.
What it means for GPs
GPs will no longer be able to enter the scheme from 1 April 2014. Those currently receiving the payments, worth an average of £8,000 a year, will see their payments reduced by 15% a year over six years, ending in 2020.
All practices, including those with a correction factor, share in the money released from the seniority pot and transferred to core funding.
What we don’t know yet
The impact on recruitment and retention of GPs is unclear but very much a concern.
Publishing pay
What is it?
GPs’ net NHS earnings relating to the contract will be published from April 2015.
What it means for GPs
Calculation and publication will be based on net NHS earnings, on a like-for-like basis with other healthcare professionals, so this will not include other income streams such as private income.
What we don’t know yet
The details are to be finalised by the working group but the published figure is expected to be based on the average salary across each practice, not individual GPs’ salaries.
NHS England would not comment on how this might affect recruitment and retention in areas where partners’ pay is lower than average.
Named, accountable GP for patients aged 75 and over
What is it?
A contractual requirement for every patient aged 75 years and over to have a named GP who is responsible for ensuring their care needs are met, working with associated health and social care professionals as needed.
What it means for GPs
From April 2014, practices will need to ensure there is a named, accountable GP assigned to each patient in the age group. Practices can assign GPs – partners or salaried – as they wish and then inform each patient of the name of their accountable GP. This can be done at the next routine consultation but no later than 30 June 2014.
Newly registered patients must be notified of the name of their GP within 21 days of registering.
The named GP takes the lead in ensuring all appropriate services – including a multidisciplinary care package if clinically appropriate – are delivered to the patient.
What we don’t know yet
Details of GPs’ role in co-ordinating patients’ care are still to be revealed, but the GPC insists it will not require them to deliver the care themselves or to be available around the clock.
New enhanced service on unplanned admissions
What is it?
A new DES worth a total of £160m will be funded by the removal of the QOF Quality and Productivity domain and the current risk-profiling DES.
Practices must identify a minimum of 2% of adult patients (and any children) who are at high risk of admission to hospital for the ‘case management register’.
A named, accountable GP will be responsible for developing a personalised care plan for each patient on the register, and overseeing their care. Another healthcare professional can be assigned to co-ordinate the patient’s care – this can be someone outside the practice, such as a community matron or district nurse.
Practices must also offer same-day telephone consultations for patients on their at-risk register and provide a dedicated practice telephone number to other healthcare staff such as A&E, ambulance service and care home staff, to support decisions relating to admission and transfer to hospital.
What it means for GPs
The enhanced service involves a considerable workload but appears to be relatively well funded. Practices, rather than the CCG, will have control over case-management review, with no need for ‘multidisciplinary review’ meetings.
Practices will be monitored through a national reporting template, which they will submit to the CCG and local area team. Payments will be relative to practice list size (based on the 2% on the case management register). In areas with a higher-than-average number of vulnerable patients, CCGs will have the option of funding an additional enhanced service locally.
What we don’t know yet
Full details of payments are yet to be revealed, although we do know there will be no requirement to achieve any outcomes targets, such as reductions in emergency admissions. Additional guidance will follow for practices with large numbers of patients in nursing or care homes.
