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At the heart of general practice since 1960

Why are QOF points league tables being 'endorsed'?

With quality framework money now rolling in at most practices, 2005/6 will be the year of enhanced services, says Dr Peter Stott

Like most other practices, mine has had a good year financially. Income is up by about £100,000. Costs have been maintained within inflation. So our end-of-year account shows profit has increased by about 15 per cent.

Meanwhile, the taxman is still trying to get his share from the 2002/3 year when profit was not so great. So on the face of it, we have done quite well and the partners have shared a quite hefty interim bonus.

We have heeded the warnings about saving for extra superannuation and extra tax; and we need to think more about investing in our staff salaries. But overall, everyone is pleased. I suspect many other practices will be in the same position.

New money

Most of the new money has come from the QOF. As a PMS practice with 10,000 patients and scoring 1,020 points with a high prevalence of many key conditions, we have been delighted to earn this £100,000 or thereabouts of new money. It is difficult to estimate the new costs of achieving this; but if we cost staff time at £20/hour, then it must be in the order of £20,000-£25,000. We started the year with several definite advantages:

·with our existing PMS contract we were already used to working to targets

·we were fully computerised and paperless

·we had a full range of nursing skills and clinic staff used to running recall services

·we had key clinics already in place

·we have an excellent practice manager

A tribute to primary care

Many other PMS and GMS practices also started with these advantages and it has been gratifying to learn that so many of us earned many more points than the Government expected.

This is a tribute to the quality of care practices provide and something that is still going unrecognised by the Department of Health. At the beginning of the year, the Government expected the average score would be 777 points and costed allocations to PCOs accordingly.

In fact, surveys at the time of writing show two-thirds of GMS GPs expect to score more than 950 points and almost half of PMS GPs expect to score about 1,000. Given that most of us consider the last 50 to be a bureaucratic nonsense not worth the effort, this is a fantastic result.

It will result in average GMS income being about £80,000-£90,000 per whole time equivalent with PMS GPs earning about £10,000 more. A fortunate few (less than 10 per cent) expect income to be over £125,000.

Bankrupting the PCO

This may be good for GPs but it could bankrupt many PCOs. Technically most will be overspent this year because when we hit the unforeseen QOF standards it left them a funding shortfall.

Collectively this come to about £100 million. Fortunately, the Government has allowed them a safety outlet.

Normally PCOs have to balance their debts every year. From this year, they can roll their debts forward by extending the financial planning cycle from one to three years.

Nevertheless, many will still have less to spend in 2005/6 and in 2006/7 than they would ideally wish.

More next year

QOF income is likely to rise further in 2005/6 when payment per point increases from £75 to £112; but watch this space for 2006/7 when more targets are introduced and the existing ones are made more difficult.

Astute practices will already have started work on the following evidence-based areas of clinical practice:

·tighter lipid targets (watch for the new British Hypertension Society guidelines later this year)

·mental health ­ depression

·osteoporosis (working to the new NICE guidance)

·obesity (prevalence data in the first instance)

·long-term neurological diseases (Parkinson's, MS, etc following guidance in the long-term conditions NSF)

·rheumatology (particularly rheumatoid arthritis)

Enhanced services

PCOs knew they would be overspent very early in the financial year so very few commissioned more enhanced services than they had to. The six nationally directed enhanced services (table right) are mandatory and have to be provided by every PCO.

Most GPs have continued to supply everything expect two of them ­ minor surgery and services for violent patients. Minor surgery is a lottery and poorly organised.

PCOs will need to get to grips with this soon because it is swamping outpatient dermatology departments and different PCOs have different definitions of what is covered by essential services or by their PMS contracts.

As regards services for violent patients, only around half of PCOs have commissioned anything at all.

Very few PCOs have done very much with the national enhanced services either (table right). Anticoagulation monitoring is probably the most common because the evidence base shows the work can be done very well in primary care, it is cost-effective to delegate it to primary care (around £80 per patients can be saved by shifting the work from secondary into primary care), and the payment levels seem acceptable to practices.

Surveys have shown around three-quarters of PCOs have commissioned anticoagulation monitoring from practices. But from 2005 there will be competition for this work.

Under the new pharmacy contract, retail pharmacies can also tender and if they offer it at less than level four rates, will undercut that which is economically feasible for smaller GP practices.

PCOs' only hope

PCOs must get to grips with enhanced services, for it is only be managing these effectively that they can reduce unnecessary referrals to hospital.

Getting GPs to take on national and locally enhanced services offers an effective way of balancing the books. PCOs have been given a raft of new ways they can commission this work and they must get on and do it.

For GPs, with the 2005/6 QOF payments 'in the bag' and another 50 per cent increase in QOF payments expected next year, 2005/6 will be the year of the enhanced services.

It is to this work that the high-earning practices will next turn.

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

·Access to GMS*

·Childhood immunisations

·Influenza immunisation for those in

the 65 and over and other at-risk

groups*

·Minor surgery

·Quality information preparation*

·Services to support staff dealing with violent patients

* PCOs are bound to use GPs as 'preferred providers' for

these services

National enhanced services1,2

·Anticoagulation monitoring

·Enhanced care of the homeless

·Intrapartum care

·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 response care

·Specialised care of patients with depression

References

1 Department of Health (2004). Investing in General Practice: The New General Medical Services Contract. Available at: www.dh.gov.uk/assetRoot/04/

07/19/67/04071967.pdf

2 Contract Documentation - The NHS Confederation. Available at: www.nhsconfed.org/gms/gms_contract_documentation.asp

Peter Stott is a GP in Tadworth, Surrey

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