Helping doctors hit moving targets

pharmafile | April 26, 2006 | Feature | |   

Introduced in April 2004, the new General Medical Services contract (nGMS) was hailed as a revolutionary new way of paying doctors, directly incentivising them to diagnose and treat priority conditions. The cornerstone of the contract is the Quality Outcomes Framework  (QOF), which awards payment for points earned in clinical practice.

Two years down the line, the contract has been widely recognised as a success, but has also added to the NHSs financial problems.

The reality has been that many practices exceeded their original targets, meaning that PCTs were obliged to pay out more than had been budgeted for in the original government forecasts, thus putting extra financial pressure on them.

It is rumoured that a high-ranking civil servant involved in the first round of the negotiations for the new General Medical Services contract (nGMS) had a memorable response to criticisms that the Quality Outcomes Framework (QOF) points were too easy for GPs. The civil servant said: We have got the pigs in the pen, now watch us change the shape of the pen.

Now, as promised, the performance pig pen is about to be changed, but what is its new shape? The overall GMS contract has been undergoing a two-stage review to help further improve the services for patients, and new contractual arrangements agreed came into effect from 1 April 2006.

The recently announced White Paper on Primary Care, Better Services and More Choice on Your Doorstep, has made proposals to radically change primary care in order to drive health improvement, particularly in localities of greatest need. These proposals will include greater choice and more diversity of provision – with private providers looking to offer primary care services where historically there have been recruitment difficulties. Such providers could include United Healthcare and the new Virgin Health group.

The White Paper will trigger negotiations for Stage 2 of the GMS contract revisions for implementation in 2007, and make the market even more competitive.

Stage 1 of the GMS contract focuses on building on the achievements already made, and introduces some new health and services priorities designed to benefit patient care. While we know some of the details, more will follow from the Department of Health (DH) in the coming weeks.

The main elements are:

1.  No inflation uplift for the contract for 2006/7,

2.  Changes to the Quality and Outcomes Framework (QOF),

3.  New investment in enhanced services to support national priorities, and

4.  New system for paying dispensing doctors

Additionally more money will be available for premises and IT, and there are some changes to MMR payment weightings.

No inflation uplift for the contract for 2006/7

As it says on the tin – no uplift to any element of the contract for inflation or cost pressures. According to Sir Nigel Crisp, 2006/7 is a critical year. The NHS must deliver improved services for patients; it must press forward with reform to deliver substantial and lasting improvements for the future; and it must return to robust financial health.

Changes to the Quality and Outcomes Framework (QOF)

The QOF is the cornerstone of the new GMS contract whereby practices are paid for achievement against quality criteria. The framework doesnt include all of the activities a general practice team undertakes, but has been devised around those areas where there is evidence of effectiveness.

The table below shows the differences between the current QOF and the 2006 QOF, with more detailed guidance on the areas and indicators covered expected in early 2006.

In 2004/5, 75 was the sum available for every point earned. In 2004/5, the average GP practice, with just under 6000 patients, was given an achievement payment of 70,875. This was 11,250 (150 points worth) more than was budgeted for.

In 2005/6 the payment per point rose to 120, and a practice achieving the same level as in 2004/5 will receive 113,400. The new QOF payments will remain at 120 per point, but 50 fewer points will be available.

The planning presumption for 2006/7 is that NHS organisations should achieve in-year balance and also recover deficits accrued in 2005/6. To support this aim and to deliver the overall financial position, PCTs will be expected to lodge reserves with their SHAs. In 2006/7 PCT allocations will grow by 9.2%, or 5.4 billion. Without any efficiency saving, underlying pay, price and other cost pressures will account for up to 3.8 billion of this.

This puts significant pressure on the already squeezed PCT unified budget. So in order to achieve financial balance, savings must be sought from elsewhere, and the most obvious targets are service re-design, prescribing, or disinvestment from services in lower priority disease areas.

New investment in enhanced services

There are three new Direct Enhanced Services (DESs) and a revised access scheme being introduced in England. These are available to any practice that wants to expand the services offered, and are in line with national priorities. Each DES of course attracts payment.

Choice and booking

A payment of 95p per registered patient will be made, based on feedback from the new patient survey. Patients should recall a conversation about the choices on offer when they are referred for a first consultant out-patient appointment, and the percentage of consultant referrals made using the new booking arrangements should also be recorded.

In order for a secondary care trust to be on the list made available to patients, they must fulfil certain criteria. If they are not on the list, they cannot attract patients, and hence revenue.

Towards Practice Based Commissioning

This is designed to encourage practices to take part in practice based commissioning (PbC), which has had a somewhat slow uptake in certain parts of the country. PbC is meant to give practices the freedom, support and incentives they need to improve care and services for patients, within a governance framework that ensures value for money and fairness.

This will see an increased number of services, historically the domain of secondary care, being delivered in primary care. Some of the efficiency savings will of course be retained by the practices involved.

For one year only, practices will be awarded 95p per registered patient to draft plans with specific PbC based objectives, and an additional 95p per registered patient if the practice delivers against these plans (this second payment is an alternative, and is not in addition to retaining savings made).

Information management and technology adoption

This is a one-off payment for practices supporting the Connecting for Health Programme (CfH  used to be called NPFIT), and includes the electronic prescription service. There is a significant budget for this DES, 70m, demonstrating the Department of Healths commitment to make this work.

Access

This brings together the 50 QOF access points and the previous payments for improving GP waiting times to 48hrs or less, with a total of 108m available for this area. Awards will be based on a firm commitment by practices to deliver on three access areas (48hrs, advance booking and telephone access), and results from the new patient experience survey.

A new system for paying dispensing doctors

This is particularly important for those companies offering Dispensing Doctor schemes (and for those companies that dont!). From 1 April, Dispensing Doctors in England and Wales will be paid on a fee per item basis. This removes the link between pay and cost of drugs. The on-cost allowance will be incorporated into a unified dispensing fee. There will be a greatly enhanced dispensing fee which will deliver the same overall sum to dispensing practices as the old system. On-cost may have gone, but the income it produced has not.

Guidance will be published for Dispensing Doctors on the need to avoid excessive or inappropriate prescribing. The changes are cost-neutral to Dispensing Doctors overall, but as with any major change of this type there will be winners and losers. While the revenue may not be overly impacted, what and how they prescribe may very well be.

The new GMS contract is of course intended to be an enabler for NHS reform, and will work in conjunction with Payments by Results with significant financial implications. In conclusion, the changing QOF is just one element of a rapidly changing NHS environment (see table) with which the industry must keep up to date if it is to understand the needs of the NHS and healthcare professionals.

New clinical areas in Quality & Outcomes Framework

Dementia20 points

Depression33 points

Chronic kidney disease27 points

Atrial fibrillation30 points

Palliative care6 points

Mental health (new)9 points

New disease registers in

Obesity8 points

Learning disability4 points

Fewer points are being allocated to disease registers set up in the 2004/5 QOF, recognising the shift to ongoing maintenance following initial work to set up the lists.

Implications for the pharmaceutical industry

The industry can no longer simply detail target doctors about the attributes of our medicines and expect it to be as effective. Customers in both primary and secondary care have changed to include non-doctor prescribers, prescribing influencers, commissioners, business managers and finance managers to name but a few.

Which antihypertensive to use doesnt keep them awake at night, but making sure they dont overspend, maximising practice or department profits, and minimising the threat of private sector competition does. Those companies that can market and sell their brands in the context of the broader customer environment will be those that gain and retain competitive advantage.

HealthGain Solutions have developed the following questions in relation to changes to the GMS Contract and Primary Care, which sales, marketing, medical and NHS Operations might consider when developing tactical and strategic plans:

Have you identified how your brand can help NHS customers achieve what they need to within the new GMS Contract?

Customers are doing things differently as a result of Contract changes; do you know what they are / when / how?

Do you know how to present your brand to different customers to ensure a win: win?

Are your customer facing teams fully conversant with the new Contract and what it means to their customers and brands?

Are your customer facing teams fully conversant with what the new Contract enables e.g. Practice Based Commissioning, and what this means to their customers and brands?

Do you understand the short, medium and long-term implications of the changing NHS on the way you do business?

As you develop new brands and line extensions, are you considering the outcomes you need from clinical trials and outcomes models to help you sell in the changing NHS environment?

Are you assisting PbC clusters in the re-design of services to ensure patients benefit from earlier access to treatment?

Who else in your organisation needs to know about the changes to the GMS Contract so they can support your plans and ensure appropriate funding?

Caroline Roberts is associate director of business development at HealthGain Solutions – specialist outsourced teams.