GMS2 update


24 April 2004
This is the latest in our regular series of updates on the implementation of the new GMS contract.

Implementation
We have been informed that the number of practices signing the new Standard GMS Contract is extremely high, with only a handful of practices relying on the Default Contract. The following information has been passed to us regarding the figures in the four UK countries.

England
4905 standard GMS contracts signed
8 default contracts signed

Wales
495 standard GMS contracts between Local Health Boards and practices
13 LHB Medically Managed Services (LHBMMS) arrangements in situ
0 default contracts

Scotland
All GMS practices in Glasgow, Dumfries and Galloway and in the Scottish Borders have signed the Standard GMS Contract. Informal reports from the rest of the country are that all GMS practices have signed the Standard Contract.

Northern Ireland
All practices in Eastern, Northern and Southern Boards have signed Standard Contracts. Western Board practices, in agreement with the LMC, are signing Standard Contracts this week. There are no reports of any practice signing a Default Contract.

Documentation
Since the last GPC meeting, the following documents have been published:

· - The GMS and PMS Transitional and Consequential Provisions Order 2004 (SI 2004/0865)
www.legislation.hmso.gov.uk/si/si2004/20040433.htm

· The Primary Medical Services (Sale of Goodwill and Restrictions on Sub-contracting) Regulations 2004 (SI 2004/0906).
www.legislation.hmso.gov.uk/si/si2004/20040906.htm

· NHS (GMS - Premises Costs) (England) Directions 2004
Chapter 4 of the DoH Guidance for GMS GPs included the principles to recognise Contractors' costs incurred to provide premises suitable for the delivery of new GMS services. Specific details of the arrangements to be used to calculate and make payments accordingly are set out in the Premises costs directions, which can be found at the following website address:
www.dh.gov.uk/assetRoot/04/07/68/20/04076820.pdf

Statement of Financial Entitlements
The latest version of the 2004/05 Statement of Financial Entitlements for England has been published.

A PDF version is available on the Department of Health website.

A number of detailed changes have been made since the draft version that was made available at the end of December 2003. We would advise that the document be read in full in order to understand the nature of the changes that have been made, most of which are of a minor nature.

The following, more significant, changes have been made:
i) In paragraph 2.3 the amount by which a contractor’s Contractor Weighted Population for the Quarter should be multiplied has been adjusted to £54. This figure now includes the additional 7% pensions indexation monies transferred from HM Treasury in respect of the existing level of employer superannuation contributions for GPs and staff.

ii) As outlined in paragraph 2.4, the Global Sum Payment will include a Superannuation Premium and an Appraisal Premium (to incorporate the monies for employer superannuation contributions on new income and for appraisal respectively). The figures for these have yet to be agreed between the GPC and the Department of Health; however, we anticipate that there will be agreement shortly on both the amount and – in the case of employer contributions – and the funding streams through which payment will be made. In England, until 1 July 2004 appraisal monies will be held at PCT level; thereafter they will be paid to practices via the Appraisal Premium. Practices and GPs who require funding for appraisal before 1 July 2004 should contact their PCT. Difference arrangements apply in the devolved nations.

Substantive changes have also been made to the sections on seniority (chapter 13) and administrative provisions (chapter 21).

Employer superannuation contributions
In paragraph 2.4(b) of the SFE for England, a value of £0 has been given for the superannuation premium. The purpose of this specific premium – to be paid in addition to the global sum as an off-formula adjustment – is to provide the extra funding to practices for the employer superannuation contributions on new income arising from the new GMS contract and from old income that has now become superannuable under the new GMS contract. The value of this to be added to the global sum, and indeed for other funding streams, is still being finalised.

The increase in employer superannuation contributions from seven per cent to fourteen per cent arising from the indexation transfer from the Treasury to the NHS has been factored into the global sum, which explains the increase in the global sum price per patient from £50 to £54. Increases in these contributions for GPs (see Annex D of the SFE) and practice staff (see paragraph 3.3(c) of the SFE) have also been added to the global sum equivalent so that the comparison between the GSE and global sum allocations is not affected by this increase in the global sum price.

Partnerships
We understand that there is concern that the promised guidance on partnership agreements is not yet available. There have been some erroneous reports that we have decided not to produce detailed guidance. This is not true. The guidance is currently being prepared and will be available shortly on the BMA website and sent to Local Medical Committees.

We have been asked to produce a model partnership agreement. However, our lawyers have informed us that this would be inappropriate and could be misleading. We have been advised that, instead, we should be indicating those areas of their partnership agreements that practices will need to amend to fit in with the new GMS contract. ON that basis, guidance will not take the form of a model agreement, but will be a detailed guide on how to amend existing partnership agreements. At the end of the document there will be a checklist of practices and their lawyers to use.

The guidance will help GPs to identify matters they may wish to cover under a partnership agreement under the new GMS contract, including income and expenses, accounting, superannuation, partners' obligations to each other, and the effects of retirement.
The guidance is, of course, dependent on the final form of the regulations, including the contract regulations, the Performers List Regulations and the Transitional and Consequential Provisions Orders. It is also dependent on the final form of the Statement of Financial Entitlements, which has only recently been determined in England, and will be finalised shortly in Scotland, Northern Ireland and Wales. This is why it has not been possible to produce anything definitive before now.

This is a complex piece of work that requires detailed legal input. The BMA's legal department has considered the draft guidance and has confirmed that it accords with current partnership law. The GPC's lawyer is also currently working on the guidance with the GPC secretariat and the negotiators to ensure that it reflects the new contract and the issues that the profession needs to see covered.

Some of the issues that require detailed legal consideration include the effects of the recent Premises Directions on the guidance, the position regarding profit shares and pensions, the new flexibility for practices to include non-medical partners, and goodwill.

We will circulate the guidance as soon as it is available.

Goodwill
The negotiators have taken comprehensive legal advice on all the possible legal avenues for challenging the Government’s partial lifting of the ban on the sale of goodwill. Following this advice the negotiators have decided not to challenge the ban at this time.

The negotiators believe that efforts should now be focused on producing guidance to the profession to provide an analysis of the Regulations and how they affect practices.

Following this, a careful watch will need to be kept on what transpires in the primary care market in order to inform the Government’s review in two years time and to provide any relevant evidence for a possible challenge under competition legislation.

Premises
A number of concerns have been expressed about premises funding under the new contract.

Under the new arrangements, PCOs are guaranteed existing recurrent expenditure on cost and notional rents, uprated to 2004/2005 levels, as a premises baseline. There are also guarantees of funding for new projects agreed in writing before the end of September 2003.

Other elements of premises funding – for example new projects not agreed by the end of September 2003, premises flexibilities, improvement grants - have to be met from premises growth funds, which were recently allocated. There have been reports that there are extremely low levels of premises growth funds in many Strategic Health Authority areas.

As this is a discretionary element of the new contract monies, expenditure on non-discretionary cost elements, such as the MPIG and Quality and Outcomes Framework, will inevitably put pressure on the funds available for premises.

We have asked the Department of Health for details of these allocations, so that we can ascertain the extent of the situation, and the funds available.

Appraisal costs
As above, the value in paragraph 2.4(c) of the SFE for England regarding the appraisal premium – to be paid in addition to the global sum as an off-formula adjustment – has been set at £0 pending an agreement as to the precise amount.

The Department of Health in England has announced that, for England, £17million has already been allocated to PCTs for 2004-05 for GMS appraisal costs and a further £13million is available for PMS appraisal costs. Fifty-five per cent of the money will be retained by the PCT to pay for appraiser costs, and locums and PCT-employed GPs’ appraisal costs, and the remaining forty-five per cent will be paid to practices on a monthly basis. For the first three months this will be at the PCT’s discretion and from July 2004 this will be in the form of the off-formula adjustment to the global sum payment. These arrangements were neither discussed nor agreed with the negotiators. We are continuing to make strong representations to the Department of Health and the NHS Confederation that this was implemented without our involvement and we are refuting that the allocation of £30million in total for GMS and PMS practices’ appraisee costs, and for locums, PCT-employed GPs and appraiser costs is sufficient or that the intended method of distribution is entirely appropriate.

www.dh.gov.uk/assetRoot/04/07/80/34/04078034.PDF

Patient registrations
A number of LMCs have contacted us about PCTs who have refused to accept that GPs can choose not to register new patients without formally closing their lists under the new contract. Our Focus on guidance (see above) makes clear that a GMS contractor retains its freedom under the new contract not to register new patients, provided it has reasonable and non-discriminatory grounds for doing so.

GPs working in community hospitals
The negotiators have been continuing to make every effort to establish UK-wide negotiations for GPs working in community hospitals, including further correspondence with the Department of Health in England and representations to MPs, peers and ministers. Whilst we know that officials in Wales and Scotland in particular are extremely keen to undertake these negotiations on behalf of their devolved administrations, the same cannot be said of the key officials in the English Department of Health. We are using other pressures, for example briefing MPs, to help our case, but as yet we have no positive news on establishing such UK-level negotiations.

However, as a result of the Welsh LMCs’ conference, GPC Wales has now written to Jane Hutt, Minister for Health, inviting the start of negotiations for a national solution for Wales. The negotiators are supporting this on the basis that one country’s action might spur others. It is hoped that once the DH in England accepts the urgency of this issue, we might then bring the progress started in Wales into a UK negotiating forum.

Patient Satisfaction Surveys
We understand that some erroneous advice is circulating regarding the Improving Practice Questionnaire (IPQ) issued by Client-Focused Evaluations Program (CFEP). The advice states that in order to obtain their 'incentive' payment legally, practices using the Improving Practice Questionnaire must not undertake their own analysis of the patient questionnaire.

This is incorrect; QOF points are earned if an analysis is done, regardless of who has undertaken the analysis, provided the other indicator requirements are met.

Clarification has been issued by the NHS Confederation (see below) but the incorrect advice still appears to be circulating in some areas. Please draw your local practices’ attention to the correct advice.

To meet the patient survey indicators of the Quality & Outcomes Framework (i.e. indicators PE2, PE3 and PE4), practices must use one of two accredited surveys:

· either Improving Practice Questionnaire

· or General Practice Assessment Questionnaire (GPAQ)

Both these questionnaires were reproduced in New GMS Contract 2003: Supplementary Documents. However, the IPQ questionnaire is copyrighted and PCTs/practices must not photocopy this questionnaire for their own use. If they wish to use it, practices should contact CFEP through Carolyn Black at cfep@dialstart.net.

Practices wishing to use the GPAQ questionnaire will also want to check the conditions for use of that survey on the GPAQ website (www.gpaq.info).

To meet the requirements of indicators PE3 and PE4, some analysis will need to have been undertaken on the results. There are no criteria on who has to do this - QOF points are earned if an analysis is done (no matter who by) and the other indicator requirements are met.

Any further queries should be sent to the GMS and PMS helpline (0845 900 0008 or gmspms.queries@npdt.nhs.uk).”

Restriction on private charging
A number of GPs have contacted the GPC secretariat with concerns about clause 487 of the standard contract. They have interpreted it as restricting a GP from ever being able to charge privately even after the contract expires because it states that part 18 (relating to fees and charges) 'survives the expiry of the contract'. This is an incorrect interpretation.

This clause exists to prevent the contractor from retrospectively charging a patient that it treats, or prescribes for, whilst under the contract i.e. the doctor cannot go back to the patient after the contract expires and ask for private payment for treatment given under the contract. The relevant wording is at clause 487.1 & 487.2. This clause does not prevent a GP being able to charge patients for services delivered privately after expiry of the contract.

"Part 18 [relating to fees and charges] shall survive the expiry or termination of the contract to the extent that it prohibits the Contractor from, either itself or through any other person, demanding or accepting from any patient of its a fee or other remuneration for its own or another's benefit:
487.1 for the provision of any treatment, whether under the Contract or otherwise that was provided during the existence of the Contract; or

487.2 for any prescription or repeat prescription for any drug, medicine or appliance, that was provided during the existence of the contract."

Mistakes in the standard contract
There are a number of typing/reference mistakes in the standard contract. A number of LMCs have enquired with these affect the validity of the contract.

Our legal advice is that they do not. There are a few typographical errors in the final document, paragraph 441 for example, which states: "subject to clause 441" when it should refer to clause 442. The mistakes are minor and would not adversely affect the legality of the contract. On that basis the contract can be signed without amending these. Some practices may want to mark the amendments, and this is acceptable so long as they are happy that they are making only minor typographical amendments.

Focus on…Guidance Notes
New Focus on… guidance notes are now available on the following issues:

- Vaccinations & Immunisations

- Patient Registration

- Funding IM&T 3rd Update

- Premises Costs

Devolved nations
Reports from the devolved nations can be found in appendix I.
Appendix I - Devolved nations reports
Northern Ireland
Contracts
We have no reports of any practice signing the default contract and all practices have now signed their contracts. Northern, Southern and Eastern Board GPs had signed by 1st April. Western LMC and the Western Board did not sign contracts until a week later.

Global sums
The Northern Ireland Department of Health, Social Services & Public Safety has modified the Carr Hill Formula. The Northern Ireland Capitation Review (GPC Northern Ireland were represented on the Review Team) produced a formula intended to be more appropriate to NI. Using 1 January 2004 caselists, the application of this revised formula, which was quality assured by the BMA’s Health Policy & Economic Research Unit has produced Global sums ranging from £31.43 per patient to £71.15 per patient. Although the range of figures bears comparison to the ranges produced using the Carr-Hill formula without the NI refinements, it is difficult to believe the cost of providing essential and additional services can vary so much. GPC Northern Ireland has asked for a review of the formula to start immediately. NIGPC and the BMA’s Health Policy & Economic Research Unit are content with the factors considered for weighting. We did not however have any advance information on how these weightings would affect practices and we have asked DHSSPS to begin an immediate review.

Superannuation
NI GPs and their staff are members of the HPSS superannuation scheme. Contributions will remain at 7%. However, calculations of Global Sum and MPIG were carried out in the baseline year where employer’s contributions were 5% for three quarters and 7% for one quarter. We have requested the alterations to GS and MPIG are made.

Staff appointed after the baseline year
With the changes to Appendix D13 of the SFE, Boards now have the discretion to fund these staff. It remains to be seen whether they will, however. This is a big issue in Northern Ireland and a huge amount of GP support depends on it. Co-operation with future out-of-hours providers may suffer if GPs feel they have not been treated fairly.

Out of hours
The Department is concerned about the cost of providing out of hours. NIGPC and the LMCs have organised a meeting to discuss the issue in more detail.

Wales
Contracts
All practices have signed standard contract except those run by LHBs. There has been no use of the default contract. A number of disputes now being dealt with.

Budgets
GPC Wales has been informed that the overall budget seems to be fine, despite obvious strains. The outcome of the review of global sums and Carr-Hill formula is awaited. There are indications that the correct processes have been followed.

Regulations
The Welsh regulations and SFE have now been agreed.

Enhanced services
GPC Wales agreed second tranche of enhanced services before April 1st and has agreed a minimum funding for practices. Payments for contraceptive implants has been agreed at £42 for insertion and £84 for removal. Discussing regarding payments for Zoladex are ongoing and a payment of £42 has been agreed for “Provera”

Out-of-hours
All but one LHB are on course to achieve the opt out for September. The overall cost will be approximately £20-22 million.

Scotland
Finance
Discussions with SEHD are ongoing in relation to how the MPIG shortfall can be met without affecting contractor funding streams. It appears likely that agreement on solutions for 04/05 will shortly be reached. However, as some of these solutions are short term to address funding issues only in the current year, SGPC is reserving its position in relation to funding for 05/06. Discussion on how shortfalls during 04/05 will impact on 05/06 funding will be discussed more fully with SEHD in the forthcoming weeks. In agreeing reconfiguration of the envelope for 04/05, SGPC has also reserved its position in relation to any conclusions on the Scottish envelope which the Technical Steering Committee might independently reach.

Contracts
SGPC is awaiting further information on whether all contractors have signed contracts and about whether any contractors have signed a default contract. As far as we are aware,standard contracts have been signed by all practices in Scotland.

SFE
SGPC is currently considering the final draft of the Scottish SFE which incorporates changes in the final English version. Further discussion is required on whether the proposed mechanism for appraisal payments is appropriate to Scottish circumstances. It is hoped that the final SFE will be published very shortly.

Inducement Practitioners (IPs)
Following a recent meeting of IPs which was organised by SEHD, a number of IPs have raised concerns about potential loss of GSE income because of structural changes (e.g. a move to larger premises) which have arisen since the baseline year. The baseline year for IPs is generally earlier than the baseline year for other GMS contractors as it is based on the each individual practice's most recent full year accounts as approved by SMPC at December 2003. The IPs are also questioning the basis SEHD have used to uplift baseline year accounts to 04/05 prices. These issues will be further discussed.

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