To All GPs in Wales
7 January 2013
IMPORTANT: Final changes to Welsh GP contract 2013/14
Just before Christmas I received notification of the details of the contractual changes which Welsh Government wish to impose on the GP contract in Wales for 2013/14. I have had a number of discussions with government since last writing to Welsh GPs and following representations to both senior officials and the Heath minister Lesley Griffiths a number of changes have been made to the original proposals. The proposals and accompanying letter to GPC Wales are attached.
WG still wish if possible to reach a negotiated settlement on the basis of these proposals but following consultation with the full GPC I have written to say that I do not believe a negotiated settlement is possible on this basis, particularly when it includes the intention to move away from correction factor to a position where the money currently paid via Global sum and the correction factor is redistributed using the allocation formula to move to an equitable level of funding.
Clearly this would mean that about half of Welsh practices – including all those on Global sum only – would receive slightly higher funding whereas the rest would have their funding reduced. The concern is that these practices (and some would lose over 30% of their MPIG funding) could be fatally destabilised.
I think it is worth expanding the thinking about this decision by GPCW. Whilst superficially the idea of even allocation of funding via a workload based funding formula seems fair there were two changes made to the Carr-Hill formula before the 2004 contract was agreed (both insisted on by the then government against the wishes of GPC). They had the effect of removing weighting for unavoidable smallness and the weighting for multiple sites. The effect of the multiple site weighting seems obvious and of course disproportionately affects more rural practices and the unavoidable smallness weighting reflects that in an allocation formula based entirely on weighted patient numbers there is an irreducible minimum amount of admin support needed regardless of practice size.
Both these factors tend to affect smaller more rural practices more and unsurprisingly almost all the largest correction factor practices in Wales are in rural counties with half of the worst affected being in North Wales. The worst affected urban practices tend to be those with disproportionately young practices with lower patient weightings – many with high student populations who also tend to have a problem with an inadequate allowance for unavoidable business costs.
It is for these reasons that GPCW could not agree to a negotiated settlement that included erosion of the correction factor even though we accept that this would not reduce overall GMS funding. In this event Welsh Government will begin a consultation on imposition from early January.
That said I must acknowledge that, in common with the Scottish government, the Welsh government has listened to concerns about the damaging effect on workload and patient access that slavishly following the draconian English imposition would have led to. I have summarised below the changes to the contract that WG wish to bring in and where they differ from England.
GP Pay uplift
As you will see from the attached letter from WG they propose to uplift the GMS contract in Wales by 1.5% intended to provide a net pay rise of 1% to GPs. This will of course take no account of the increased expenses from new work or the cost to practices of the threshold rise and the loss of a net 60 QOF points which have to be “earned” back.
GPC has always insisted that we will present evidence to the Doctor and Dentists Review Body (DDRB) this year which is the independent body set up jointly between the profession and the government to advise on pay rates. We have submitted evidence to DDRB as we always intended, as we do not wish to see the independent process bypassed. That said we think that a 1.5% gross rise would indeed produce about 1% net if no other changes were made to the contract.
Of course if 1% is recycled through global sum only to erode correction factor only those practices which are “global sum only” (or very close to it) will get any uplift beyond the 0.5% earmarked for Global sum equivalent to meet expenses.
Contract changes in Wales
All suggested changes to the QOF from NICE over the last two years will be introduced including those rejected by the UK QOF negotiators last year and those rejected this year in the ultimately unsuccessful contract negotiations with NHS Employers. Details are in the attached letter.
There will however be a number of variations from the English imposition:
· Two new indicators relating to annual exercise questionnaires for all hypertensive patients (HYP4, HYP5) will not be introduced and exercise advice will remain in the lifestyle advice indicator. These indicators were rejected in negotiation as we thought they were patronising to patients and represented a huge workload as they included both the questionnaire and a brief intervention for all those patients who “failed”. The average practice has at least 800 patients and the proposed reward in England is 6 points.
· The new indicators relating to secondary care services (DM14, COPD6, HF3) will have in guidance that an offer of referral is sufficient if the service is not available and exception reporting need not be used (exception reporting would remove the denominator and thus the payment if used for all patients) It is the intention of WG – which we fully support – that these services will be universally available in Wales.
· Guidance in Wales on dietary advice for diabetics (DM13) will stipulate that NO extra professional training is required for GPs and practice nurses to deliver this indicator.
· The move from a 15-month to a 12-month window for delivering most indicators will not take place in Wales. QOF negotiators believe that this change will be massively disruptive to practices in the other countries with little if any tangible patient benefit and potential negative impact on access. This is because to allow for the change practices will not be able to afford the luxury of an annual recall date after about mid February each year as any default for holidays, lack of appointments or DNAs will not be correctable before the end of the QOF payment year (March 31st) which would result in the QOF funding for those patients being lost. This would lead to obvious disruption of work patterns and appointment availability. Negotiators in the other three countries are also trying to persuade their governments of the inadvisability of introducing this change.
· The raising of thresholds for most indicators over the next two years will still go ahead but using median average Welsh achievement rather than upper quartile (as in England). While this will still make targets harder to achieve it will result in upper thresholds on average over 4 percentage points lower than an upper quartile target. The ridiculous proposal of a constantly moving (thus never achievable) upper quartile rolling target in England will also not happen in Wales. The rise in thresholds will take place in two steps over the next two years as laid out in the accompanying letter.
· Lastly in recognition of the much more challenging target in the new hypertension indicator (HYP3) where the target goes from 150/90 to 140/90, the thresholds for this indicator will not be changed. Given the high points value of the indicator this will certainly reduce pressure on QOF funding as practices try and achieve these more challenging targets.
· A number of QOF changes were provisionally agreed in the failed negotiations – including a new Rheumatoid arthritis domain and changes to depression indicators and cancer follow ups. These will all be introduced as part of the imposition. A number of modifications to other indicators including erectile dysfunction and risk assessment in hypertension and RA were also agreed as we felt they were more patient friendly and we are attempting at UK level to ensure that these changes are included in the indicators for all four countries. The depression indicators will, I suspect, be widely welcomed as a more professional assessment of what we do than the widely disliked depression questionnaires.
A number of other significant changes are being made to the contract and again there are significant differences to the changes to the English contract where the entire organisational domain (137.5 points) has been discontinued. The principle one relates to the way that the organisational points and the QP domain will be handled.
In Wales 59 of the Organisational points will be retained as set out in the attached imposition letter. Some of these do represent work (in particular pharmacy advisor visits), which would be dropped in England, but overall this will represent a significant retention of funding within the contract. As in England 17 points related to BP screening are transferred into the public health domain and are effectively unchanged although the target population has been very significantly enlarged without extra points. The other points will be used to “fund” the new QOF indicators and a new risk profiling QP domain. The organisational work that they previously helped resource however will largely still need to be done by practices, although the penalty for falling below 80% notes summarisation will go.
The new QOF clinical indicators are as described above and in the attached list but concurrently with the addition of the QP risk profiling domain (a DES in England) the A&E QP domain will be removed and the points value re-invested in Global Sum Equivalent. This in effect means that the number of organisational points removed to fund new work effectively drops to 47.5 compared to about 138 in England as other new DESs will not be introduced in Wales. The risk profiling domain in Wales will also require lower numbers of patients to be assessed which will hopefully increase the actual value of the work by enabling those patients looked at to be properly assessed without an unsustainable pressure of numbers. The Welsh work will by and large be designed to enable a real difference to be made to patients rather than a merely introduce a punitive increase in workload for practices. The first referral and emergency admission elements of QP will continue unchanged.
The other significant changes include:
Transferring the responsibility for locum doctor’s employer’s superannuation contributions to individual practices.
This money (£782,000 across Wales last year) will be transferred into the GMS contract – probably through global sum to every practice. Pensions are England and Wales so this decision is taken by UK government and again will not reduce total funding in General Practice however again it is likely to disadvantage smaller practices with higher need for short-term locums because of less ability to cross cover.
Changing CPI – Contractor Population Index
This is the figure used to calculate prevalence and multiply QOF points to the actual practice size. It has artificially remained stable since 2004 but will rise according to actual average practice size from 2013. The value of a QOF point will rise by the same proportion as the average population and will continue to be uprated in future years. This change will be neutral going forward but corrects an anomaly that faster growing practices were previously disadvantaged by faster growth in terms of their QOF payments.
In conclusion the proposed changes to the contract in Wales represent a very significant increase in workload for, for the majority of practices with a correction factor, no increase in pay. In addition the protection of correction factor which the Minister of Health in 2004 said would be “in perpetuity” will be lost by 2021 for the over 60% of Welsh practices who still receive it.
Whilst it would be unfair not to recognise that these changes will be far less damaging to practices than those in England, they, along with increased pension contributions, are likely to lead to the largest drop in income for Welsh GPs since the dawn of the new contract.
Dr. David Bailey
General Practitioners Committee (Wales)