Fiona Jenkins
Primary Care IT Training
Solutions Director

Fiona specialises in training and consultancy specific to primary care. Her expertise lies not only in clinical IT systems but also in the GMS contract. Fiona's firm provides consultancy services to PCOs, practices and other NHS-related organisations

Agreement has now been reached between the British Medical Association (BMA) and NHS employers to develop further the GMS national contract. These agreements contain the Quality and Outcomes Framework (QOF), which lists quality standards across primary care, and a system for rewarding practices where these qualities are met. They aim to produce better outcomes and improve mortality and morbidity for patients. These changes are the first part of a two-stage review; the second stage is due for implementation in 2007.

Initially, QOF was implemented in April 2004. This signified a massive change to general practice, allowing a better understanding and control of practice environments and the ability to provide more appropriate local services for patients.

The changes coming into force in April will build on the existing QOF, including the management of 10 chronic disease areas (CHD, stroke, asthma, COPD, hypertension, hypothyroidism, epilepsy, cancer, mental health and diabetes). However, it also introduces nine new areas to build and continue the benefits of patient care (heart failure, atrial fibrillation, depression, dementia, chronic kidney disease, obesity, learning disabilities and smoking).

These changes will ultimately result in a greater focus on clinical areas. This will have a profound impact on patients suffering from any of these conditions. It will also provide statistics to help tackle recognised health problems, such as obesity, smoking and depression.

Summary of changes

• No inflationary uplift across the contract for 2006/07.
• In total, 166 points have been redistributed: 138 recycled points have been allocated to new clinical areas; 28 points will strengthen existing indicators. Higher qualifying thresholds for practices will demonstrate value for money in quality patient care. All qualifying thresholds, with the exception of one or two indicators, have risen from 25% to 40%.
• New investment in directed enhanced services (DES) to support national priorities and initiatives. In England, this includes practice-based commissioning, Choose and Book and adopting Connecting for Health's (CfH) Information, Management and Technology programme. Details on country-specific DES for Scotland, Wales and N Ireland are still being finalised.
• In England, a new Access DES extends its scope, and a new independent patient experience survey will be developed. This survey will trigger payments to general practice, with specific emphasis on access and choice for patients.
• In England, £132m will be available for premises and IT.
• In England and Wales, a new system for paying dispensing doctors.

Clinical domains
With the exception of diabetes, all existing areas have lost points for having a register, due to practices now only having to maintain the register. Practices will be required to record diabetics over the age of 17 years as either type 1 or type 2 diabetics, in line with the diabetic National Service Framework (NSF). Also, the age range for epilepsy has risen from 16 to 18 years. Many of the upper thresholds for clinical standards have risen by 5–10% (eg, blood pressure and flu immunisations). The mental health register has been further defined to include patients with schizophrenia, bipolar affective disorder and other psychoses, resulting in a more standard register across primary care.

With the exception of depression and smoking, new disease registers will need to be created. It is anticipated that most, if not all, of these will be created from a diagnosis Read code previously entered into patients' records. As many practices have achieved their summarising targets, this should not present too many problems. However, that does depend on whether practices have summarised entire records or just the information previously required for GMS. A register for obesity will be required, based on patients over 16 years with a BMI ≥30 recorded in the previous 15 months.

Organisational domains
Many of the record indicators required a written protocol around areas where practices were already working. As the written protocols are now in place, most of these indicators have been removed. Previously, smoking status for patients over 15 years had to be recorded, but there was no limit on how long ago this status was recorded. This must now be recorded within the last 27 months.

A new-patient survey is being introduced in England, focusing more specifically on patients' experiences, concentrating on access and choice. Although points have always been available under QOF for summarising patient records for 60% and 80% completed, a further indicator has been added at 70%. This will help practices struggling to get from 60–80%, giving them a further reward for achieving 70% (12 points).

It will be a requirement to obtain ethnic origin for all new registrations from 1 April 2006. Read codes to record this information are already available on clinical systems. However, practices will need to ensure that they have a protocol in place to ensure this information is requested when new patients register.

Directed enhanced services (DES)
Three new DES, plus a revised Access scheme DES, are being introduced in England. DES must be made available to all practices via their PCT. They enable practices to offer an enhanced range of services to their patients and be rewarded for doing so. These include:

• Choose and Book – when patients are referred to secondary care, practices will have the ability to discuss choices on offer to their patients. As well as a choice of secondary care providers, this may also involve the practice "booking" an appointment for them. The payment, 95p per registered patient, will be measured from the feedback of the survey and will be based on the total percentage referred and booked in this way.
• Practice-based commissioning (PbC) – this two-part payment will encourage practices to engage in PbC. Initial payment will be based around practice plans, detailing objectives agreed between practices and PCTs. The second payment enables PCTs to award practices that deliver against their plan. Each payment stage will be 95p per registered patient.
• Information management and technology (IM&T) – this is a one-off DES, worth approximately £70m across primary care, supporting practices that adopt CfH initiatives, such as electronic transfer of prescriptions (ETP), GP-to-GP records, Choose and Book, and the NHS Care Records Service. Payments will depend on implementation, which will vary according to national rollout and probably clinical systems used.
• Access DES (England) – focuses on four key areas for patients: being able to consult with a GP within 48 hours; being able to book in advance; ease of telephone access; option of waiting for a GP of preference with no time limits. Initial payment will be based on practices committing to deliver, as well as their participation in the national survey. Retrospective payment will be based on the results of the survey.

The future
Guidelines for this new way of working have only recently been issued to practices, and supporting guidance is still sketchy. Not only will practices have priorities for this financial year, but they will also need to start planning and preparing for the next GMS year.

New disease registers will need to be created. Data quality searches on existing data will need to be run. Data entry templates will need editing, not only for new areas but also to reflect the changes within the existing clinical areas. In some cases, new Read codes may have been requested, but these will not be available until later in the year. In these instances, practices will have to develop a protocol to manage this, using temporary or existing codes not currently used, with a view to performing Read code swaps when the codes do become available.

Although the changes will not affect practices as much as when the contract was first introduced, it is still a time of further big change. Due to some Read codes, GMS software for clinical systems and QMAS not being available from 1 April 2006, practices will need to ensure they have robust systems in place for capturing data, which they may well need to adapt as the year progresses. Time is of the essence, and for the busy practice manager, time is something that there is just not enough of. Though there are still more details to come, the sooner practices can adapt, the higher the achievement should be for 2006 and beyond.