The latest regulations that underpin the General Medical Services (GMS) contract in Wales came into effect on 1 October 2023.
The National Health Service (General Medical Services Contracts) (Wales) Regulations 2023 (the “new regulations”) bring about the “Unified Contract”. This has been the subject of detailed discussion between the Welsh Government, GPC Wales and NHS Wales over many months.
The Unified Contract will simplify what services all GP practices in Wales must provide and how they evidence assurance of delivery. Key aims are:
- to make it easier for patients and healthcare professionals to understand responsibilities for the provision of services.
- to reduce administrative bureaucracy, freeing up time and resource for service delivery.
- to enable use of data and technology to help plan resources and delivery of services.
Key changes
The proposal in essence is for the structure the Unified Contract to consist of three elements.
A new Assurance Framework has been developed via a tripartite task and finish group. A key goal of the Assurance Framework is to reduce unnecessary bureaucracy via a system of robust and proportionate checks, built on systems and sources mostly already in place.
Unified Services will form most of the contract and are the key services all GP practices must provide (previously commonly referred to as ‘core’ services). These are funded via the GMS Global Sum formula.
In simplifying the contract, all services under the 2004 contract which were classed as Additional Services or Directed Enhanced services have been considered against the key question ‘what it is that every GP practice can be expected to provide?’.
As a result, all of the Enhanced Services have been reviewed on this basis to determine what is reasonable for all practices and what is a more specialised function. This key test has enabled us to consolidate and simplify the contract.
The following have been agreed and will be taken forward through the amended Contract Regulations:
- All services currently identified as Additional Services will be re-classified as Unified Services (previously known as Essential Services).
- Those services which do not need to be provided by all GP practices and continue to be considered supplementary in nature will be redefined as Supplementary services and delivered through commissioning by Health Boards. (Local Enhanced Service arrangements will remain the responsibility of Health Boards).
- A suite of Quality Improvement projects has been agreed, as part of a transition period until the cycle is realigned with the financial year. We also agreed the clinical indicators of QAIF transferred into the Core contract, with the associated funding consolidated into the Global Sum.
- The GMS contract will be monitored via strengthened and holistic contract assurance measures, performance management and monitoring through a new Assurance Framework.
Unified Services
These are the basic services all GP contractors are responsible for delivering to all registered patients of the practice. Other than the inclusion of those services previously described as ‘Additional Services’, this does not represent a significant change in real terms for the vast majority of practices in Wales.
These cover the:
(i) management of patients who are ill or believe themselves to be ill, with conditions from which recovery is generally expected, for the duration of that condition, including relevant health promotion advice and referral as appropriate, reflecting patient choice wherever practicable.
(ii) general management of patients who are terminally ill.
(iii) management of chronic disease in accordance with national guidance and accepted best practice, in discussion with the patient.
(iv) cervical screening.
(v) contraceptive services.
(vi) vaccinations and immunisations (that currently form part of Essential or Additional Services).
(vii) child health surveillance.
(viii) maternity services - excluding intra partum care.
(ix) the minor surgery procedures of curettage, cautery, cryocautery of warts and verrucae, and other skin lesions.
Management of chronic disease includes the basic patient care for chronic conditions, delivered using clinical judgement in consultation with the patient, in accordance with national guidance issued by bodies such as National Institute for Clinical Excellence and All Wales Medicines Strategy Group, using national or local care pathways where available.
Supplementary Services
These are GP services that do not need to be provided by all GP practices and are considered to be supplementary in nature. In most cases these would have been classed as Enhanced Services under the 2004 GMS contract.
As part of the Unified Contract, Health Boards will be directed to provide some services and Health Boards will retain the ability to commission Local Supplementary Services in line with the needs of local population.
The review of Enhanced Services that has been undertaken as part of the Unified Contract Task and Finish Group work has identified some service specifications that required amendment, and some that are no longer required or fit for purpose.
Work has commenced and is ongoing to update service specifications and these will be released in due course. Health Boards will be required to demonstrate in the future development of Supplementary Service specifications which fit with care pathways whether national or health board specific.
Directed Supplementary Services
- Warfarin DSS
- Minor Surgery DSS – Injections
- Minor Surgery DSS – Minor Skin Surgery
- Extended Surgery Opening DSS
- Diabetes DSS Gateway Module* (see below)
- Learning Disabilities DSS
- Care Homes DSS
- Vaccinations & Immunisations (V&I): Childhood Immunisations, Influenza & Pneumococcal Immunisations Scheme,Pertussis Immunisation for Pregnant & Post-natal Women (subject to review of V&I delivery policy), Shingles
*Please note, after further discussion, it has been agreed that the Diabetes Gateway Module will remain within the Directed Supplementary Service (DSS) at this time, and not transfer into Unified Services as has been previously outlined in communications. Practices should continue to claim for activity through the usual process. The Diabetes DSS will be kept under review and will be subject to an evaluation over the coming year.
National Supplementary Services
- Shared Care Drug Monitoring
- IUCD
Services to be delivered at scale
The following services are identified for delivery through Advanced Cluster Development in the medium term, and will continue to be delivered as supplementary services until new arrangements are developed.
- Services for Violent Patients
- Gender Identity DSS
- Homeless DSS
- Asylum Seekers & Refugees DSS
Quality improvement
As a result of wider changes within this agreement, the Unified Contract will have a specific emphasis on Quality Improvement (QI). As part of that reconfiguration a number of areas have been strengthened including:
- How QI projects are developed, valued, and included in the QI domain.
- Clarity on the scope and purpose of a QI project to ensure we maximise on learning and outcomes.
- Removing delays in project rollouts to ensure practices can fully meet the requirements of the project within the QI cycle.
Through a Heads of Terms approach, a Task and Finish Group has developed a clear framework addressing those key issues.
QI delivery will be realigned to a financial year cycle from 1 April 2024.
Transition funding arrangements were instituted for the current 18-month cycle, mitigating any negative financial impact on practices.
For the current cycle, the QI basket includes:
- Mandatory Prevention of Unhealthy Behaviours Project
- Mandatory Data Project
- Mandatory Phase 2 Green Inhaler Project
Assurance Framework
The Assurance Framework draws on the work of the Contract Assurance Task and Finish Group which has seen extensive discussions on principles of assurance, sources of data and processes that already exist.
The Framework is to be applied across NHS Wales, building upon existing systems and seeking to instil consistency of approach to assurance of the Unified Contract.
The GMS Assurance Framework is a governance process for the evaluation of services delivered through the Unified Contract, in the context of the Duty of Quality legislation. It has three components:
- A nationally agreed data set for quality, safety, governance, and contract management. This comprises of a national set of indicators, a practice assurance return, the already familiar CGPSAT and IG toolkits.
- A nationally agreed process for assessing contractors’ compliance against contractual requirements.
- A nationally agreed escalation ladder for managing concerns, including an appeals procedure.
The key purpose of the nationally agreed data set is to standardise the information that the Health Board Primary Care Management Teams consider through the Assurance Framework. This will give a fair and equitable basis for application of a consistent process in assessment of prioritisation of the level of review a contractor will receive across Wales.
Principles of Assurance
- Open and transparent in process.
- Proportionate and not bureaucratic in execution.
- Makes use of existing sources of data.
- Data analysed at a national level and provided to practices and Health Boards.
- Uses national standards and measures.
- Consistently applied across Wales.
- Processes should be formative and supportive whenever possible.
- Provides a clearly articulated stepped approach to escalation if concerns exist.
To ensure assurance processes are proportionate and also formative, Health Boards will prioritise which contractors are to receive a governance review and consider what depth of review is necessary for assurance. A standard set of measures using existing data will be consistently applied across Wales.
Data for Assurance
Current data sources, which in principle are already available to Health Boards, include:
- Audit+
- Welsh Immunisations System
- DATIX RL and other local processes for incident reporting to Health Boards
- Serious incidents
- Safeguarding
- Complaints/compliments
- Coroners reports
- Medical Examiner referrals
- Ombudsman referrals
- Post Payment Verification reports
- NHS Wales Shared Services Partnership Primary Contractor Services claims
- Enhanced Service audits/reports
- Clinical Governance Practitioner Self-Assessment Toolkit
- Information Governance Toolkit
- Prescribing data
- PHW vaccination data
- Referrals/diagnostics rates
- Admissions/ED/GP Out of Hours data
- Welsh Index of Multiple Deprivation
- European Standardised Populations
Future Data sources will be identified and agreed by the GMS Quality Committee on a national basis as part of regular tripartite discussions.
Wherever possible it is intended that existing data, automatically collected and collated centrally, will be used for assurance in order to minimise bureaucracy for all parties. Health Boards may differ in weightings of individual measures according to local problems (e.g., Antimicrobial Stewardship, National Diabetes Audit results).
Variation in performance is often related to features of the registered population, including health inequalities and vulnerable groups, or factors such as practice premises or workforce availability. These features will need to be recognised and taken into account.
Early engagement between the Health Board and contractor presents the best opportunity to support practices in making effective and sustainable changes to support service improvement should this be found to be appropriate and necessary.
Issues identified from governance review discussions should be incorporated into local population needs assessments, and ultimately into cluster, pan-cluster, and Health Board plans.
Contract variation process
To make the updating process as simple as possible, Health Boards will be using the contract variation process within the former GMS regulations (and retained within the new regulations). This features in existing practice contracts, usually at clause 516, and will look like the below:
“… the Local Health Board may vary the contract without the contractor's consent where it—
(a) is reasonably satisfied that it is necessary to vary the contract so as to comply with the Act, any regulations made pursuant to that Act, or any direction given by the Welsh Ministers pursuant to that Act, and
(b) notifies the contractor in writing of the wording of the proposed variation and the date upon which that variation is to take effect, and where it is reasonably practicable to do so, the date that the proposed variation is to take effect must not be less than 14 days after the date on which the notice under paragraph (b) is served on the contractor.”
Two standardised template documents will be shared with Health Boards to help with this variation process:
- a template variation notice containing the changes needed for an existing GMS contract to comply with the new regulations, and
- a template document from which Health Boards will prepare a “conformed copy” showing, for ease of reference, what your contract looks like after the variations.
Health Boards will need to personalise both documents for each contractor’s GMS contract (e.g., to reflect your original contract date, names, addresses, contractor status, practice premises, and any other differences already included in your GMS contract). Health Boards will then forward both documents to you, during October and November.
When you receive those documents, please follow any instructions, and then sign and return them to your Local Health Board as soon as you can. Your signature will not be required for the variations to take effect.