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Twelve ways to prepare for the 2014 contract

Twelve GPs offer advice on how practices in England can prepare now for the contract changes due to come in April

Allocate named GPs, and inform patients

Dr Andrew Green online

 

Dr Andrew Green, chair of the GPC clinical and prescribing subcommittee and a GP in Hedon, East Yorkshire

The 2014/15 contract stipulates that GPs must accept a ‘named GP’ responsibility for older patients from April onwards. The details are not yet out but in summary, NHS England has said ‘all patients aged 75 and over will have a named, accountable GP with overall responsibility for their care’. Although clearly of more political than medical importance, the introduction of a named GP for the over-75s will require preparation before April.

The key words in this obligation are ‘allocate’ and ‘inform’. Practices without a personal list will need to link patients to GPs, but to do so randomly will inevitably result in some toxic combinations, so allocate patients to the last GP they saw. Allocating this way will also automatically adjust workload for part-time GPs.

Rural practices might like to allocate geographically, with GPs taking on individual villages.

Informing patients at the time of prescription collection will reduce the need to send individual letters, but you must be clear to patients that the named GP co-ordinates care, rather than personally delivering it.


Cost of undertaking this work

We estimate that allocating patients a named GP will cost about £40 (or four hours) per 1,000 in staff time (based on 80 patients per 1,000 being over the age of 75, and 20 allocations being made per hour).

Informing patients who their named GP will be should cost about £10 per 1,000 for postage, stationery and staff time (assuming 90% of patients are informed through repeat prescription collection or attendance at the surgery, and 10% informed by letter).

Potential annual income

None – this will be a contractual requirement.

Make a list of patients at risk of emergency admission

ken Aswani online

 

Dr Ken Aswani, member of the executive committee of the NHS Alliance and a GP in Waltham Forest, north-east London

The unplanned admissions DES will require GPs to undertake two main tasks – identifying patients at risk of emergency admission, and planning care. It’s a big change of mindset for GPs and practice staff, and will require change on a greater scale than previous DESs.

To identify patients, use your local risk analysis tool, which profiles patients based on data from primary and secondary care based on the number of admissions a patient has had. Our local tool (Health Analytics, which is also used in Barking, Havering and Redbridge CCGs) identifies the high-risk patients by putting together a range of risk factors. If you don’t have a standard local tool, you could use the open-source score, QAdmissions, available online.

But GPs should also use practice data – not just the formal risk-scoring systems. For example, GPs can find out which patients:

• Take a significant number of different repeat medications (four or more).

• Have two or more long-term conditions.

• Require frequent home visits.

• Attend the surgery regularly.

• Suffer from a mental health problem in addition to their long-term condition.

Often practices making their own lists of patients can pick up at-risk patients at an earlier stage.

Ask your practice manager to create
a list of patients (around 2% of the practice list size, or 5% if you have the resources to pursue this work more fully) based on both the local risk score and GPs’ own data and experience of these patients’ patterns of admissions. Allocate these patients priority of care. This might mean giving them a named GP – this is not the same as the named-GP scheme for over-75s (although it may overlap with this work). Patients should be informed at an appropriate stage and will be much more likely to engage in a more proactive approach.

Although standard templates for care plans are likely to become available, the key information in a review should include:

• The patient’s perspective.

• Medication and clinical updates.

• Social and psychological review.

• Functional ability.

GPs should record on the patients’ notes their higher risk status.

Cost of undertaking this work

It will take at least one hour-long partners’ meeting to discuss the list of high-risk patients. It should take the practice manager four to eight hours to compile the list.

Potential annual income

Full details of the new unplanned admissions DES have yet to be confirmed, but it will be worth up to £162m in total to GPs in England.

Promote online access

Dr Osman Bhatti online

 

Dr Osman Bhatti, LMC representative and GP in Tower Hamlets, east London 

GP practices will be contractually required from April to offer patients the chance to book appointments, order repeat prescriptions and access their Summary Care Record online (the current online services DES is due to expire at the end of March). Most practices are on systems that have the functionality to do all this. Start to get processes in place for staff members to promote the use of online access for patients. Get all staff involved, from receptionists to clinicians.

• Place posters by reception to tell patients they can book appointments online.

• Hand out login codes to new patients at their new patient check.

• Offer online booking for patients needing a follow-up appointment.

• Get your local pharmacist involved with electronic prescriptions.



Cost of undertaking this work

Staff must be trained to handle prescription workflows and issue codes to patients. Clinicians must be trained in using electronic prescriptions. The cost of promoting the initiative to patients also needs to be considered.

Potential annual income

None. GP practices will be contractually required from April to offer patients the opportunity to book appointments, order repeat prescriptions and access their Summary Care Record online – or have
a published plan in place to offer this by March 2015.

Adjust for the loss of seniority payments

Dr John Grenville, secretary of Derbyshire LMC

Dr John Grenville

 

Seniority payments will be reduced by 15% a year until they are completely abolished in 2020. There will be no new entrants to the scheme after April.

Practices have the option of introducing a mechanism into the partnership deed to reinvest global sum income into an internal seniority scheme, which could encompass partners and salaried GPs if appropriate.

Many older GPs will feel they have become used to automatic pay progression, and some will have made long-term plans based on seniority payments. This group in particular may find it difficult to cope if that is taken away.

Younger GPs may or may not feel they’d like automatic pay progression so it’s up to individual practices to discuss whether to set up an internal seniority scheme. Assess your practice’s needs. At the one end you might have older partners who will walk if they lose seniority. On the other hand you want new partners coming in to get more from the beginning. Will having a seniority scheme help you attract young partners, or put them off?


Cost of undertaking this work

One partners’ meeting, plus the cost of rewriting the partnership deed.

Potential annual income

This depends on your course of action.

Join with other practices to pitch for contracts

Dr John Ashcroft - online

 

Dr John Ashcroft, deputy chair of Derbyshire LMC and a GP in Erewash, Derbyshire

Many CCGs are looking to put contracts out to tender from April. Some of these will represent new opportunities for GPs; in other cases it is about protecting existing funding. GPs working at the 12 member practices of our local CCG (Erewash) have wanted to set up a provider arm of the practices for some time, and it looks like we’re beginning to make progress. The group of practices is in the CCG, but we are working separately from it on this task.

If, for example, our local enhanced services go out to tender, practices could miss out on a large tranche of income.

We’ve seen lawyers and accountants, and worked out the cost of a professional pitch for services. We hope to split the cost between the 12 practices.

We haven’t got all the details sorted yet and might also consult southern Derbyshire practices on whether some of the contracts will be too big for north and south networks to pitch for separately, but the more preparation we do now, the more likely we’ll be to prepare quality pitches for the work we want to do.

The cost and complexity of making bids makes working as a larger group more attractive (for instance, with the southern Derbyshire provider group, or via the LMC), especially on bids put out to tender by the councils, as they often cover greater areas than CCGs. Also, the different commissioners of services (councils and CCGs) are not co-terminous, which makes setting up appropriate providers harder.

Cost of undertaking this work

Paying a professional to prepare to pitch for services will cost around £60,000, with the cost shared between practices.

Potential annual income

You have to think in terms of income protection. Your practice could lose out on thousands of pounds if another provider takes over a contract for enhanced services.

Prepare for a drop in QOF income 

Dr Gavin Jamie - online

Dr Gavin Jamie, QOF Database website manager and a GP in Swindon

From 1 April, the new GP contract will cut 341 QOF points  – around £54,000 in funding for the average practice. Many of the new QOF indicators introduced last year will be reversed, although the planned hike in all thresholds (to match the upper quartile of achievement among practices) is only delayed by a year.

This change is not so much a cut in workload as an increase in flexibility. Income that is dependent on QOF will be much lower as the points have been cut and the money has been transferred to the global sum. There are no new indicators – the changes are mainly about recording less. A couple of specific changes:

• Several diabetes indicators have been retired, including erectile dysfunction, dietary review and retinal screening – so these can be taken off computer templates.

• GPs will no longer be specifically rewarded for offering biopsychosocial assessments to patients with depression, but the review remains at between two and eight weeks. Practices need to make sure they have a system to review anyone with a new depression code during that time.

Cost of undertaking this work

Meetings and preparing guidance for staff should take roughly two hours of a GP or practice manager’s time.

Potential annual income

Most of the cash from clinical indicators has moved to the global sum. The workload should be similar, but as exact codes are not needed several hours of admin time a month can be saved.

Join with other practices to pitch for contracts

Dr John Ashcroft - online

 

Dr John Ashcroft, deputy chair of Derbyshire LMC and a GP in Erewash, Derbyshire

Many CCGs are looking to put contracts out to tender from April. Some of these will represent new opportunities for GPs – in other cases it is about protecting existing funding. GPs working at the 12 member practices of our local CCG (Erewash) have wanted to set up a provider arm of the practices for some time, and it looks like we’re beginning to make progress. The group of practices is in the CCG, but we are working separately from it on this task.

If, for example, our local enhanced services are put out to tender, then practices could miss out on a large tranche of income.

We’ve seen lawyers and accountants, and worked out the cost of a professional pitch for services. This takes the work off our shoulders and ensures a quality pitch. Therefore we hope to split the cost for joint work between the 12 practices.

We haven’t got all the details sorted yet and might also consult southern Derbyshire practices on whether some of the contracts will be too big for north and south networks to pitch for separately, but the more preparation we do now, the more likely we’ll be to prepare quality pitches for the work we want to do.

One of the issues that has emerged is the cost and complexity of making bids, which makes working as a larger group more attractive (for instance with the southern Derbyshire provider group, or via the LMC), especially on bids put out to tender by the councils (as they cover greater areas than CCGs, generally). Another issue is that the different commissioners of services (councils and CCGs) are not co-terminous, so it makes the setting up of appropriate providers more difficult.

Cost of undertaking this work

Paying a professional to prepare to pitch for services will cost around £60,000, with the cost shared between the GP practices.

Potential annual income

You have to think in terms of income protection. Your practice could lose out on thousands of pounds if another provider takes over a contract for enhanced services.

Become an early adopter of the Friends and Family Test

Dr Brian Fisher

 

Dr Brian Fisher, patient and public involvement lead with the NHS Alliance and a GP in New Cross, south London

The current Friends and Family Test used in hospitals doesn’t do what it’s meant to. It comes from the corporate world as a measure of brand loyalty, which we don’t think is useful for the NHS as it doesn’t tell us much about quality of care. Hospitals currently using it might have thousands of replies, but the test doesn’t advise how to improve the system based on this feedback. GP surgeries will be expected to start using the Friends and Family Test by December, given the fact the patient participation scheme will no longer require GPs to do a local survey. As elsewhere in the NHS, practices must publicise results online.

We wouldn’t want it to be used as is in a GP setting so the NHS Alliance is working with iWantGreatCare (IWGC) to develop a supplement of questions to provide meaningful feedback when this test is introduced in GP practices in April:

• Is it easy to get an appointment?

• Are receptionists helpful?

• Were you involved in decisions made about you?

• Was the surgery clean?

• Would you recommend this surgery?

• Do you trust your doctor?

• Does your doctor listen to you?

• Would you recommend this doctor?

• Would you recommend the nurses?

Practices could adopt these questions early if they like – the questions GPs should ask are already available and GPs can post them on the practice website or ask for patients to submit responses using paper questionnaires anonymously. Patient responses are logged and published anonymously on a website that covers all local GP practices.

If you are concerned that you wouldn’t fare well on the questions at the moment, raise concerns with the partners to see if you can improve problem areas before April.

Cost of undertaking this work

Negligible – it will cost very little (around £5) to offer the questionnaire on the practice website or to prepare print-out versions of the original test and the supplementary questions (above).

Potential annual income

This is hard to quantify, but ultimately rolling out the test part of contractual requirements.

Prepare to start using a new template for care plans

Dr Richard Vautrey - LMCs conference 2013 - online

 

Dr Richard Vautrey, deputy chair of GPC and a GP in Leeds

At the moment the BMA is developing a template for care plans with NHS Employers that GPs across England will be able to use. The new care plan will be simple and practical, making a difference to patient care as well as to GPs, community health providers and out-of-hours doctors’ workloads. We expect it to include will be name and address (and that of the patient’s carer if they have one), details of current key diagnoses, medications and some free text areas for notes on, say, the next annual diabetes review or the use of emergency steroids for COPD patients. It will be designed for use as a tool to achieve the new DES on reducing unplanned admissions.

This won’t be the same as the Summary Care Record, so we’ll need the support of GP IT system providers to help us ensure the data is easy to share and extract – such as giving the patient a printout or making it available to mobile devices on GP home visits.

It will also vary from existing care plan templates because all the advice will be useful to the people reading it. At the moment, care plans can be dangerous if they run on too long or fail to get updated regularly.

The new care plan is due out by the end of February; NHS Employers and the GPC will advise GPs of the publication of the care plan template through the NHS Employers’ and BMA websites, and the trade press.

In the meantime GPs should refrain from setting up anything other than simple care plans for their patients. The simpler, the safer – as before I’d advise you include name, address, and the same for a carer if applicable; details of current diagnoses medication, and a free text area for upcoming reminders about, say, annual reviews or advice for treating the patient during a crisis.

Cost of undertaking this work

If the IT system can be configured to support this, the cost should be limited. However, the main potential cost is that of any additional appointments required to create and discuss the care plans with patients. The cost for that is significant but it is central to the enhanced service.

Potential annual income

The main reason to use care plans is clinical benefit, but undertaking this work will contribute to achievement in the new reducing unplanned admissions DES.

Make sure your system can offer online services

Dr John Hughes - LMCs conference 2013 - online

 

Dr John Hughes, chair of the Association of LMCs in Manchester, GPC member and a GP in north Manchester

There are a number of GP systems that aren’t compliant with the new contract which if they are not updated, may break leave the GP in breach of the new contract. The services outlined by the Improving Online Access section of the contract: offering online booking, offering online scripts and offering patients online access to the Summary Care Record. Note that all three versions of EMIS are compliant.

Wording for this part of the contract hasn’t been confirmed but unless it states online services should be offered ‘subject to system compliance’, you will breach your terms if you fail to update your system by April.

If your system can’t offer those three things, talk to your local area team (LAT) or commissioning support unit (CSU) via the CCG to ask for an update. GPs won’t be charged for upgrades but because they’re financed by the CCG or LAT it can be hard to get fast service in the way a GP could as a customer– and it may take more than six months to update the system and train staff to use it. The CSU or LMC might be able to offer training in time for 1 April if the system provider is snowed under.

Practices also need to make sure that when they offer online access they keep back at least a fifth of appointments for the average number of patients who lack the means to book online to ensure fair access for all patients.

Cost of undertaking this work

No software costs, but it will take several hours training for each staff member to learn competence on a new system. The upgrade itself will be paid for under the GP Systems of Choice scheme.

Potential annual income

None, but you won’t be compliant if your system isn’t.

Grow your list through word of mouth

Dr Paul O’Reilly, chair of Kensington, Chelsea & Westminster LMC and a GP in central London

The fundamental basis of nearly all GP income is the practice list, so make sure it’s as big as it reasonably can be, particularly in areas like London where there is a high prevalence of both unregistered patients and ghost busting-obsessed managers.

GPs underestimate the importance of word of mouth in their marketing. Our practice asked all new registrants who had recommended us and was a little shocked to discover that 88% of them came through the personal recommendations of friends and relatives and few through more professional routes. Cheap and cheerful ways of increasing list size through word of mouth are:

• asking all new patients at registration if they know of anyone else who needs to register with a GP

• posters in the waiting room asking patients to ensure their family and friends are registered

• if you have a patient participation group, ask all of its members to promote registration through their own networks

• campaign with your LMC to have your CCG run a publicity campaign to promote universal GP registration.

Cost of undertaking this work

Negligible – a few minutes in each new registration; a few posters in the waiting room; a few emails to the LMC chair.

Potential annual income

Since doing this, our new registrations have increased by around 40%.

Write guidelines for staff working on key income-generators

Dr Dean Eggitt

Dr Dean Eggitt, medical secretary of Doncaster LMC

Given QOF is shrinking, it’s more important than ever to use staff time effectively so you achieve as many points as you can without spending hours doing so. I write our own EMIS templates as the national templates are too bulky and comprehensive, rather than getting to the point. My nurses love this and find that it makes their life much easier. Modifying our practice templates from EMIS to bespoke versions takes me a few hours, but saves the team hours of reading and revising the new QOF areas.

I write a quick ‘idiot’s’ guide to QOF too, so everyone can see what needs to be done for each disease area.

You can programme the computer to prompt the user to use a template when a new code for, say, hypertension is entered.  Essentially it is a script: staff fill it in as they go through the appointment and ensure you have all the info you need to hit the QOF indicators you’ve chosen to pursue

Cost of undertaking this work

Three hours of my time.

Potential annual income

Improves QOF income.

Readers' comments (1)

  • I agree with Dr Ashcroft that working together is the only practical way for the vast majority of practices to be able to respond to this but why is CCG scale the right size? If you are competing against Virgin 20 or 30 practices will not have the scale to afford the support systems that can help achieve a competitive price.

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