GP Gavin Jamie provides a run-through of how the contract update and other recent changes affect coalface GPs - from 'accountable GPs' and practice boundary pilots to IT updates.
The contract changes for both English GMS and PMS practices in 2014 has seen a move of funding from both the quality and outcomes framework (QOF) and enhanced services into the global sum, or funding baseline. This reflects the movement of work into the core contract. In the past the core has been more about the delivery of traditional general practice services. Much of the contract was about when and where these services should be delivered.
Unlike the enhanced services and the QOF, the revised contract specifications will be compulsory. Not delivering these will not result in a loss of income but could result in a breach of contract notice and potentially the termination of the practice contract. The changes are the same for practices irrespective of whether they hold a GMS or PMS contract.
Some of these services have previously been available as enhanced services in 2013 but are moved to core services in 2014.
The area that has received the greatest publicity is the requirement for each patient over the age of 75 to have a named GP - referred to in the contract as the “accountable GP”. Prior to 2004 all patients were registered with a specific partner and for many practices this is a formalisation of current practice. However, this may be a role with greater political than clinical importance…
There are specific responsibilities given to the named GP which are listed below.
Many GPs might be surprised that these functions were not already expected of them. Health checks have actually been in the contract for some time and the other roles were part of the responsibilities of the registered GP prior to 2004. The main area that could add to current work is the requirement to work with other care providers to plan care for these patients. It remains to be seen how this will be interpreted across the country.
This is a distinct and separate role to the care co-ordinator which is specified in the unplanned admissions DES although there is substantial overlap and in a great many cases it will involve the same patients and doctors.
Patients should be informed of who their accountable GP is and this is likely to require some resources to fully comply with the letter of the contract. As well as the name of the GP patients should also be given the contact details and a brief description of the role of the GP.
The way in which this is communicated to patients is left up to practices but practically this will have to be in writing. The first batch of patients should be informed by the end of June. From then on patients will need to be informed within three weeks of turning 75 or joining the list if they are already over that age.
The first batch will be quite large but there will be three months to hand out notices. It may be possible to give the notifications to many of these patients as they come through the surgery, saving on postage. For large mailings such as this my practice has secured considerable savings in the past by using a secure external mailing company.
In the future notifications would most likely be by mail as new patients join the practice or turn 75. As practices have three weeks after the patient’s birthday or registration they should be searching for new patients at least fortnightly from the first of July. Hopefully the workload in sending out these letters will fall over the year as practices systems improve and computer system suppliers respond to the needs of the contract.
If an accountable GP is no longer able to fulfill the role, for instance if they leave the practice or even go on to maternity leave, then a new accountable GP will need to be allocated and another round of letters sent. This aspect of the contract is likely to be easier for practices with a more traditional partnership model and low GP turnover.
Although it is not expected that the accountable GP will be the sole provider of clinical care, practices should decide early on how the responsibility will be allocated among the doctors. Most of the time the majority of GPs in the practice will be involved. Some practices may wish to have a geriatric lead GP who takes on the role for all patients over 75. This would depend on having someone who has a particular interest in this area of medicine but could be an efficient way of coordinating care.
The government has stated that there should be five pounds of funding for each patient on the practice list to pay for all this. This is expected to work out on average to about £50 for each patient over 75. However as the payment is per patient of any age the effective payment will be diluted where practices have a high number of elderly patients. Similarly the workload will vary greatly between practices.
A code should be entered in the practice computer system when the patient is informed of their accountable GP and this will be monitored by the GPES and CQRS systems.
There is some doubt from CCGs about whether they can afford to pay the five pound premium and it is not year clear if there will be other conditions attached to the funding. As the accountable GP is specified in the core contract practices will be expected to do this with or without additional funding.
Practice boundary pilots
Practice boundaries have had a similar political importance. While pilots of schemes to allow patients from outside a practice’s area to register for some services have had equivocal results, the contract changes allow this to be rolled out much more widely. On their own these changes do not make the scheme compulsory but enable systems to be set up. In any case these alterations to the contract do not come into force until 1 October 2014.
Practices will be able to offer less than a full service to patients who are outside their practice area. This would mean that practices would not need to provide home visits to patients at their registered address if it was not considered practical. There could also be other specialist services.
Patients who are outside the practice area should be informed of which services they can expect to receive.
There is nothing in the contract changes about how remuneration would be allocated for providing services to patients from outside of the practice area. That is likely to come later in the year and be specified separately.
Many of the other changes related to the use of information technology in one way or another.
GP Systems of Choice and IT
In all of these cases it is understood that practices may not currently have computer systems capable of delivering all of these services. In these cases practice will have to, by the end of September 2014, have a statement of intent on display at the practice of how they plan to deliver these services by the end of March 2015. Effectively this is the last warning to practices and will likely see the end of several legacy practice computer systems over the course of the year.
Two national systems are specified in the contract. Use of the GP2GP system to transfer records between practices will become compulsory although there is no abolition of the requirement to also send paper records. When a patient moves practice at the start of the year the chances that both the new and old practices being able to perform an electronic transfer are likely to be much lower than if they move in 2015.
Practices will also be required to upload to the national summary care record (SCR) at least once a day. This is the record that could be visible to other healthcare providers such as A&E departments or out of hours providers. There is no mention of the more recent care.data uploads in the contract changes.
Many practices already load data to the SCR. For those that have not the publicity and the circulation of opt out forms was several years ago and the patients registered with the practice may have altered considerably in that time. Patients under twenty years old are unlikely ever to have been asked to and further period of notification may be appropriate.
Other services will be more visible to patients. Online appointment booking and repeat prescription requesting were enhanced services in 2013 but have now been moved to the core contract along with the associated funding.
If the practice computer system is capable then practices must offer booking, amendment and cancellation of appointments online. In addition patients should be able to view their repeat prescriptions and order further prescriptions. Where practices have offered this in the past then there is not likely to be any additional work. Even for practices offering these services for the first time there are no firm targets and reasonable effort is likely to be enough to satisfy the requirements.
Practices should also be able to offer access to those parts of the medical record which have been submitted to the Summary Care Record. There is no requirement for full record access. In fact it is possible that full record access will not fulfill this requirement as it specifically refers to the summary record. Practically, practices are going to be in the hands of their computer system suppliers for this and there is little to do other than inform patients of the availability of this service.
Quality of care
Practices will also be responsible for monitoring the quality of care delivered by their local out of hours provider. The standards which practices are expected to monitor are contained in the “National Quality Standards in the Delivery of Out of Hours Services” dated 2006. These standards include maximum times to telephone assessment of non-urgent patients of one hour and a maximum time until face-to-face consultation (if needed) of six hours. These times fall to twenty minutes and two hours respectively for patients with urgent needs.
Practices should collect any feedback or complaints from their patients along with deviations from the National Standards and pass them on to NHS England, most likely through their local area team. Individual practices will not be able to get a full picture of the local performance but should pass on any significant concerns.
Aside from the national standards practices are unlikely to be permitted to view the contract which will remain with their CCG and will be commercially confidential. The Care Quality Commission will continue to inspect and licence out of hours providers. NHS England, to whom practices should report concerns, does not have a direct relationship with OOH providers.
Overall this does not seem to have received a lot of thought. The effect is to reinforce GPs professional duty to report poor practice. Currently practices should be passing on any concern from patients to their local area teams but should expect more details later in the year as this is properly fleshed out.
A rather simpler requirement is that practices should include the NHS number on all correspondence within the health service. Mostly this will apply to referral letters and it will require only a minor change in the templates used to generate the letters.
Most of these changes seem to have come directly from the government with very little modulation as they have passed through NHS England. It is perhaps inevitable that technical changes to the contract say very little about the care that is delivered and a lot more about the internal workings of practices and the wider NHS.
As usual starting early will make things much easier for practices, particularly in the allocation of accountable GPs. For the majority of changes the largest workload will be in the first few months of setting up services and the summer could be a quieter time to do this.
Requirements of accountable GP
- Take lead responsibility for ensuring that any services which the contractor is required to provide ... [are] delivered to the patient.
- Take all reasonable steps to recognise and appropriately respond to the physical and psychological needs of the patient in a timely manner.
- Ensure that the patient receives a health check if, and within a reasonable period after, one has been requested
- Work cooperatively with other health and social care professionals who may be come involved in the care and treatment of the patient to ensure the delivery of a multi-disciplinary care package designed to meet the needs of the patient.