Chapter 1 - Introducing the changes to the GMS contract for 2006/07 – summary of UK agreement

Introduction
1.1 This chapter represents a summary of the agreement reached between NHS Employers and the British Medical Association's (BMA’s) General Practitioners Committee (GPC) on the changes to be made to the General Medical Services (GMS) contract for 2006/07.

1.2 NHS Employers and the GPC agreed that they are committed to ensuring a contract that:
  • is better for patients
  • is fair to the profession
  • represents good value for public money.
Extra investment and new initiatives
1.3 NHS Employers and the GPC agreed that it was more appropriate for the current 50 access points in Quality and Outcomes Framework (QOF) to be moved and the finance associated with them to be utilised on access awards outside QOF as appropriate for each country. It was also agreed that the new funding for each country (equivalent to the value of 100 QOF points) would be used to establish additional directed enhanced services (DESs) which may be specific to each country.

1.4 Subject to take up and delivery of new DESs, Scotland has identified a total of £12.6m new investment, Wales £6.7m and Northern Ireland £4m. England is making significant additional investments over and above the value of 100 QOF points.

1.5 It had already been agreed that England would invest a further £132m in premises and IT in 2006/07.

1.6 It was agreed that future uplifts to the global sum should seek to reduce the reliance upon correction factor payments and therefore release an element of the correction factor envelope.

Inflationary cost pressures
1.7 The negotiating parties agreed that there would be no uplift to any existing element of the contract for inflation or cost pressures in 2006/07, and that all new investment would be via the new DESs.

Efficiency savings
1.8 It was agreed that, in addition to the efficiency savings that could be presented through the absence of inflation or cost pressure increase, the agreement included the release of 138 points worth of QOF funding to be reinvested in new QOF indicators and a redistribution of a further 28 points within the existing QOF.

1.9 The negotiating parties agreed, with the full support of the four Departments of Health, that the 2006/07 GMS review contract package addresses the perceived value for money issues associated with the original nGMS contract. These will not be revisited in future negotiations.

1.10 All parties recognised the responsibility of the four Departments of Health and NHS Employers to achieve and demonstrate ongoing improvements in efficiency and value for money as part of normal ongoing negotiations or commissioning processes within the NHS. This normal process of refinement, revision and improving value for money and efficiency will apply to future GMS negotiations as it applies to other NHS services.

Normalisation (England and Wales only)
1.11 Normalisation of weighted practice populations will now take place quarterly on a national basis, rather than at PCO level. Quarterly normalisation already applies in Northern Ireland and Scotland.

Contractor Population Index (England only)
1.12 The Contractor Population Index (CPI) reflects the national average practice list size. It is used primarily to allocate QOF payments to practices relative to their list size. With the following proviso, th e SFE will be amended so that from 1 April 2007, the CPI mechanism becomes an in-year resource neutral redistributive tool based on an average list size updated in January each financial year. Such a change in the SFE would be dependent upon a separate mechanism being agreed and funded as appropriate as an integral elemetn of future GMS negotiations to recognise changes to the QOF workload as a result of an increase or decrease in population numbers.

Gross Investment Guarantee
1.13 NHS Employers and the GPC acknowledged that the current Gross Investment Guarantee (GIG) expires on 31 March 2006. It was agreed that the GIG would not be renewed for 2006/07 and beyond.

Enhanced services floor
1.14 Enhanced services floors will be frozen at 2005/06 levels. Expenditure on the new 2006/07 DESs will be monitored over and above the 2005/06 floor but as practices may elect not to provide services under these DESs or they may fail to achieve target payment levels, the 2006/07 enhanced services are only an indicative figure.

1.15 Expenditure on the new access DES should be apportioned so that the 2005/06 enhanced service floor still includes the full value of the previous access DES and that expenditure on the 2006/07 access DES above this level (ie utilising the funding transferred from the 50 QOF access points) should be recorded against the new 2006/07 indicative DES levels.

1.16 Any local disputes regarding investment in GMS should, if all local routes have been exhausted, be referred by strategic health authorities (SHAs) (or equivalent) and local medical committees (LMCs) to the NHS Employers/GPC Implementation Co-ordination Group (ICG), or equivalent.

Maternity Cover
1.17 It was agreed to lift the maximum amount payable for maternity, paternity and adoptive leave to £1500 per week from week three of the potential entitlement. All such payments remain discretionary. It was also agreed to review the extent to which PCOs are exercising discretion. The PCO’s protocol in respect of locum cover payments (as detailed in the Statement of Financial Entitlements (SFE)) should be updated.

Employers Superannuation Contributions
1.18 The negotiating parties agreed that 14% (7% in Northern Ireland) employer’s superannuation contributions were included in all funding envelopes for 2006/07 unless specifically stated otherwise.

Quality and Outcomes Framework
1.19 NHS Employers and the GPC agreed to release 138 QOF points for new indicators mainly in clinical areas. A further 28 points have been reallocated to existing indicators where data suggested the potential for further improvement.

1.20 The following new clinical areas were agreed: heart failure, palliative care, dementia, depression, chronic kidney disease, atrial fibrillation, obesity and learning disabilities.

1.21 The following clinical indicator sets were amended: mental health, asthma, stroke and transient ischaemic attack, diabetes, chronic obstructive pulmonary disease, epilepsy, cancer and smoking.

1.22 The negotiators agreed, in the light of 2005 achievement data, that all lower thresholds for existing indicators should be raised to 40%. The upper threshold will remain at 90% for the majority of indicators. For those indicators which had an upper threshold of less than 90%, the upper threshold will be raised in line with average UK 2005 achievement.

1.23 There will be no changes to the exception reporting criteria for 2006. However, the negotiating parties agreed to issue further guidance to PCOs as to what constitutes good practice in exception reporting (see Chapter 2 ).

1.24 Details of the new QOF indicators for 2006/07 including technical supporting guidance can be found at Annex 1 . Details about current QOF indicators that will change or be removed can be found at Annex 2 .

1.25 The negotiating parties agreed and recognised that the QOF is a “living thing” which will be subject to a process of change and improvement over time as part of the negotiation process. It is expected that changes will be negotiated with references to those elements of the QOF where science and evidence has moved on, or which are no longer necessary, or where the workload has been shown to have changed, and in the context of the value for money agreement described above. Equally the negotiating parties agreed that for the ongoing success of the QOF, it should have a reasonable degree of stability, be evidence based, be able to be supported by information management and technology software and be governed by an agreed process of evidence review and refinement.

Directed Enhanced Services (DESs)
Access to general practice services – England only
1.26 There will be four main components to the new access DES: the opportunity to consult a GP within two working days, the opportunity to book appointments in advance, ease of telephone access to the surgery, and the opportunity for the patient to consult their practitioner of preference.

1.27 The awards to practices for delivering access will be split into two parts:
  • one third of this investment will be provided on an aspirational basis up front to assure practices’ commitment to deliver the first three of the above four components and to continue to participate in the Primary Care Access Survey (PCAS). Primary Care Trusts (PCTs) will make an award on agreement of a written practice plan
  • the remaining two thirds will be earned according to the results of a new independent patient experience survey. The survey will include a yes/no question covering each of the four components. The results of this survey will determine the level of award made.
1.28 There will be a total investment of up to £108m in England, assuming full uptake and achievement. This comprises £55m from QOF Access payments and £53m from the former access DES. The specification for this DES is at Annex 4 .

Choice and Booking – England only
1.29 This one year DES, outlined in Annex 5 , is designed to provide an incentive to practices both to offer choices to patients who are referred for a consultant outpatient appointment by a GP and to utilise the Choose and Book system.

1.30 In 2006/07 PCTs will have a duty to make payments to practices at the end of the year in respect of this DES, providing that the results of a new patient experience survey and/or electronic booking validation are sufficient to trigger an award. An award of component 1 is not dependent on an award of component 2 and vice versa. Aspiration payments will be made in year and final payment for delivering booking arrangements will be made by PCTs upon receipt of national data.

1.31 This DES is valued at 96p per registered patient which is split equally between the following two components:
  • component one is an award for offering choice to patients through a discussion between the GP and patient about the range of a clinically appropriate choice of providers which should include some clinical information to help patients make an informed decision. Patients and GPs should also have access to meaningful information in the practice to support their choice decision eg patient information booklets and posters. Payment for offering choice will be based on feedback from a new patient experience survey on whether patients recall a conversation about choice
  • component two is an award made in response to the practice’s utilisation of the Choose and Book systems. This will include bookings made in the GP surgery, by the appointments line, on the internet, through a local booking service or via Indirectly Bookable Services (IBS). Payment for utilising the Choose and Book systems will be based on the percentage of referrals to first consultant outpatient appointments (ie converted UBRNs) that are made using these systems.
Towards Practice Based Commissioning (PBC) – England only
1.32 This one year DES provides encouragement to practices to engage in PBC. It directs PCTs to offer this enhanced service to all of their general practices from April 2006. The specification can be found at Annex 6 .

1.33 Practices will be entitled to an award for component one (95p per registered patient) of this DES when a plan to deliver the DES has been agreed with the PCT. This payment reflects the practice’s time involved in developing and implementing the practice plan. Practices must receive the award for component 1 to be eligible for component two.

1.34 Practices who successfully deliver the agreed plan and its objectives will be able to reallocate either the resources associated with component two of the DES or any freed up resource made against the agreed PBC budget. Component two resources will not be available in addition to any resources freed up from the PBC budget where they already equal or exceed the equivalent value of component two.

Information Management and Technology – England only
1.35 This DES, outlined in Annex 7 , is designed to facilitate Information Management and Technology (IM&T) adoption to support the delivery of the National Programme for IT. It requires PCTs to award practices specified, non-recurring payments following successful preparation for and adoption of IT systems and processes. There will be variations in the timing of roll out of these systems across the country. Therefore timing of payments in respect of this DES will also vary across the country. In some cases, the implementation of an area of work might not take place until 2007 or later and PCTs will need to ensure, for budgetary purposes, that they plan for the likely local timescales of implementation.

1.36 This DES will support practices to become properly equipped for the innovative new IT approaches to patient service delivery. Practices will be required to:
  • actively implement the key national initiatives
  • ensure that all appropriate practice staff, clinical and non-clinical, receive adequate training to equip them to adopt new methods and systems
  • provide adequate support to ensure smooth service delivery during installation of new systems and their adaptation to new ways of working
  • acquire accreditation of the quality of electronic record keeping.
1.37 The value of this DES is £1.33 per registered patient. This has been split into four components:
  • component two: in order to receive an upfront, first component payment practices will need to agree a written practice plan with the PCT. This payment acknowledges the commitment and planning the practice will need to invest ahead of programme deployments
  • component two: practices will receive a further payment following data accreditation, as set out in the standards identified in Annex 7
  • component three: practices will receive a further payment for successful completion of the requirements set out in paragraphs 13 and 14 of Annex 7
  • component four: practices will receive a further payment following migration to a Connecting for Health accredited hosted system.
Directed Enhanced Services – Wales
1.38 Subject to agreement, in Wales PCOs will be required to commission four new directed enhanced services: access, information technology, learning disabilities and severe mental health. Further information about each of these will be made available shortly.

Directed Enhanced Services – Scotland
1.39 In Scotland, the investment described in paragraph 1.4 above will be used to commission four new directed enhanced services. Subject to final agreement, these focus on:
  • cardiovascular risk registers for patients aged 45-64
  • services for adults with learning disabilities
  • services for carers
  • cancer referrals.
1.40 A fifth DES will be introduced for access, re-badging the 50 QOF points for access, as described in paragraph 1.3 above. Further information about each of these will be made available shortly.

Directed Enhanced Services – Northern Ireland
1.41 Subject to agreement, in Northern Ireland PCOs will be required to commission a new directed enhanced service to improve the management of prescribed long-term chronic diseases as well as directed enhanced service for access to general practice services. Further information about each of these will be made available shortly.

National Patient Experience Survey – England only
1.42 A new national, patient experience survey will be introduced. This is expected to be in quarter four of 2006/07. It will help the Government understand, from the patient's perspective, how well national priorities are being implemented. In its first year, the focus of the survey will be on primary care and the delivery of access and choice through general practice. Patients' responses to the survey will trigger practice awards on:
  • opportunity to consult a GP within two working days
  • opportunity to make advance bookings
  • ease of telephone access to the surgery
  • opportunity to book with a practitioner of preference
  • where relevant, recalling a conversation with a GP about choice of secondary care provider.
Managing practice lists
1.43 The negotiating parties recognised that in certain circumstances there are difficulties in managing practice lists and have prepared advice for practices and PCOs to follow. Through open and transparent list management both practices and PCOs will find it easier to meet patients’ access requirements to register with a primary medical care provider of choice. This advice can be found at Annex 9 .

Arrangements for dispensing doctors (England and Wales only)
1.44 NHS Employers and the GPC agreed a new resource-neutral fee scale for dispensed items which includes an additional £1.4m towards the costs of compliance with the Disability Discrimination Act. This removes the direct link between drug costs and remuneration for dispensing doctors.

1.45 It was agreed that the Department of Health in England and the Welsh Assembly Government would not pay a VAT allowance on dispensed items from 1 April 2006 and that to continue to receive VAT reimbursement from this date dispensing practices should register for VAT purposes with HM Revenue and Customs.

1.46 From 1 April 2006 the Department of Health in England and the Welsh Assembly Government will pay a VAT allowance on personally administered items for all practices, as these are an exempt supply for VAT purposes.

1.47 There will be a budget of up to £8m in England for extending the range and quality of dispensary services under a new dispensing quality payments scheme. An equivalent scheme will be developed in Wales.

1.48 Guidance which outlines what might be considered excessive or inappropriate prescribing has been developed for PCOs and health professionals. This should help ensure that prescribing decisions are based on clinical appropriateness. It is available at Annex 9 .

Vaccinations and Immunisations
1.49 From April 2006 the weighting for childhood vaccinations and immunisations targets for all four countries will be:
  • 50% for the Pentavalent Vaccine
  • 25% for Measles, Mumps and Rubella (MMR)
  • 25% for Meningitis C.
Stage two negotiations
1.50 Negotiations for stage two will follow publication of “Our health, our care our say: A new direction for community services” in England and similar documents in the other three countries, for implementation in 2007, when the negotiating teams know more about the implications for primary care and general practice.

1.51 Discussions between NHS Employers and the GPC on the future of the GMS allocation formula have been underway since the start of 2005. As part of the two-stage process the Formula Review Group will report the outcome of the review and any recommendations during 2006.

1.52 Scotland has its own formula, the Scottish Allocation Formula (SAF). A review process has also been underway in Scotland since the start of 2005 and will report and make recommendations during 2006.

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