Author: Judith Chamberlain-Webbe
The Government has committed itself to modernising general practice and tackling some of the key problems in primary care.
One problem is that GPs used to be paid according to the number of patients on their list and the quantity, rather than quality, of the services provided. Practices received money for the number of doctors, which affected poor areas with few doctors.
The first step towards achieving its goals, first outlined in The NHS Plan, was to introduce personal medical services (PMS) pilots. The second was to bring in the general medical services (GMS) contract.
The very first PMS pilot schemes were set up on 1 April 1998, following the 1997 NHS Primary Care Act. The schemes are voluntary and are intended to give primary care trusts (PCTs) and providers - particularly GPs and nurses - the flexibility and opportunity to test different options for addressing primary care needs. Doctors, nurses and PCTs working under PMS arrangements are able to negotiate directly with their commissioner to provide the services patients want, for example, varying surgery times to meet the needs of the local population.
The scheme holds its new contract with the strategic health authority or PCT. It receives a set sum of money from the local NHS, based on the services it is contracted to provide. This is calculated on the basis of local people’s health needs, what the practice aims to deliver, and targets to be achieved. The team decides how to spend that money on staff and service delivery.
PMS pilots are continuing as voluntary permanent local options, regardless of the recent changes to the GMS Contract.
Implications for nurses
PMSs offer nurses real opportunities to develop and use their skills. Most schemes aim to make better use of nurse practitioners, practice nurses and other staff, freeing GPs to take on new responsibilities and offer more services to patients. Some schemes have been nurse-led, enabling them to develop special interests, or become prescribers. Nurses can refer to secondary care if the commissioning group agrees.
In June 2003, 79.4% of UK GPs voted to accept a new contract for the delivery of general medical services (GMS). It is an NHS contract between the PCT and the practice, not the individual GP, and came into force on 1 April this year. Services are split into three groups: essential, additional and enhanced.
Practices must provide essential services for people who are sick or perceive themselves to be sick with conditions from which recovery is expected, chronic disease management and general management of terminally ill patients.
Practices are expected to provide additional services, but can opt out. These cover cervical screening, contraceptive services, vaccination and immunisation, child health surveillance, maternity services (including intra partum care) and some minor surgery procedures.
Enhanced services are essential or additional services that are delivered to a higher standard, or extra, specialised services such as drug misuse clinics. They are voluntary and divided into three levels (see Enhanced services box, p16).
An extra £1.9 billion is being pumped into primary care over the next three years to support the changes. This is a rise of 33%, from £6.1 billion in 2002/03 to £8 billion in 2005/06. These resources are being allocated to practices through three main ways or streams of obtaining funding:
- A global sum of money
- Enhanced services funding
- Quality payments.
Global sum of money
This is allocated to the provider to cover practice running costs. It will make up about half of the income the practice will receive. This money will pay for:
- Essential services
- Additional services
- Infrastructure (not IT or premises)
- Staff costs and career development.
This sum is worked out from a formula based on the practice population profile, taking into account factors such as age and sex of patients, costs of living for staff and list turnover of each practice, rather than the number of doctors. An average UK practice will receive about £50 per patient in 2004/05. This formula will be applied to all UK countries but with individual adjustments in Scotland and Northern Ireland.
Practices will be able to apply to PCTs for additional funding for specialised services such as extended minor surgery. In England, a minimum of £315 million was allocated to develop enhanced services during 2003/04 and this will rise to £563 million in 2004/05. Other UK countries will receive similar funding.
A key part of the new contract is the idea of paying practices for how well they care for patients rather than the number of patients treated. Thus, practices could receive between a third and a half of their income if they provide services based on a new quality and outcomes framework that are of a high enough quality.
The new Quality and Outcomes Framework (QOF) sets out a range of national standards based on the best available research evidence. These are divided into four domains (see box below):
- Clinical standards. There are 10 key areas. Many link closely with National Service Frameworks and National Institute for Clinical Excellence guidance. This work also links with care pathways and protocols
- Organisational standards
- Additional services
- Patient experience - practices will be rewarded for reaching set standards in relation to organisational factors such as better records and information about patients; education and training, and practice and medicines management. Incentives will be offered to encourage practices to use accredited questionnaires to gain patient views and make improvements.
Every domain has a set of ‘indicators’ relating to quality standards or guidelines that can be achieved within that domain.
All work towards meeting these standards will be converted to points with a monetary value. Each point’s value will be adjusted to take into account the practice weighted population. Based on an average list size and patient profile, each point will be worth £75, rising to £120 in 2005/2006, with 1000 quality points available across the four domains.
The QOF is voluntary. Practices decide how much of the QOF they wish to take on and the number of points they wish to achieve.
Primary care organisations are responsible for funding the points scheme as follows:
- Aspiration payments will be available to help practices meet these standards, according to how much of the framework they want to take on. The payments will be a third of the predicted total points for quality
- Achievement payments reward those practices that succeed, paid as a lump sum the following April. This makes up the other two-thirds of the points for quality
- Additional payments:
- Practices can earn an additional 50 ‘bonus’ points for meeting national access targets
- If they achieve standards in at least eight clinical areas they are entitled to a ‘holistic payment’ of 100 points
- If they perform across the other three domains they are entitled to a ‘quality practice payment’ of 30 points.
Many practices are already working to many framework standards: the main difference will be how they record and retrieve data. Practices need to record data as proof that they are meeting the agreed standards, using computerised Read codes where possible. The relevant Read codes are listed in the quality guidance and the query specification for the QOF.
Performance monitoring is done using a standardised electronic report. The PCT expert monitoring team will normally visit once a year to review the report with the clinicians and practice manager. A follow-up letter will be sent to practices confirming the success or otherwise of the report and payment can then be made. An appeal process is available.
GMS and Nurses
Many opportunities are opening up with the new GMS contract, supported by the proposed expansion of nursing roles in the Government’s 2002 Liberating the Talents.
Organisational standards in the quality framework will reward practices for ensuring good human resources practice. The QOF also links with the Agenda for Change and practices that meet the requirements will get more funding. The contract has built-in requirements for continuing professional development (CPD), clinical governance, professional accountability, and clinical supervision.
Frontline nurses can extend their interests from the clinical to the business aspects. They will be able to take on a more strategic role, become partners in the practice or form their own limited company, if at least one GP is a signatory on the contract and subject to legislation.
Nurses can become sub or specialist providers of services such as sexual health, minor surgery, vaccinations and immunisations, since practices can opt out of providing additional and out-of-hours services. Nurses and other health-care professionals can sign up as equal parties to the contract. They could run practices or particular services on behalf of the GP.
Practices are now free to decide their own skill mix through the global sum and other payments, with nurses involved in decisions.
As money will be available to meet the standards of the QOF, nurses will have a key role in meeting as many standards as possible, especially where there are higher levels of points attached, such as for coronary heart disease and hypertension (see examples of nurse-led schemes below). Nurses may wish to adopt a lead role in first-contact care, for which the NHS University (NHSU) has developed a work-based programme.
They would be involved in deciding which parts of the quality framework the practice already covers and which parts it might want to cover. Nurses may wish to work as quality care co-ordinators to oversee the clinical areas and organise systematic care. This could include improving disease management services for patients.
Several models of chronic disease management are being tested in the NHS. This links with the Expert Patient Programme. Nurses will have a key role in developing disease registers, collecting data and delivering services. This could include:
- Inputting information and deciding how it will be collected
- Managing systems to maintain a disease register and a recall system, as these will be required for the clinical indicators
- Recording information for the electronic standardised return and the annual quality review visit in an easily retrievable way
- Looking out for missing data.
Primary care trust
PCT lead nurses’ new roles include:
- Commissioning services, selecting alternative providers and review of primary care services
- Considering the 10 key roles of nursing outlined in Liberating the Talents
- Ensuring all frontline nurses have access to training, professional advice and CPD
- Monitoring achievement against standards
- Analysing and interpreting data submitted in the annual return
- Ensuring compliance with clinical governance frameworks
- Ensuring the principles of Agenda for Change are being met.
The Department of Health is working with out-of-hours providers and PCTs to develop a network of clinical service providers. The aim is to integrate all aspects of the out-of-hours service which could embrace NHS Direct, accident and emergency departments, walk-in centres and ambulance services. Nurses already providing out-of-hours care could be the first point of contact, especially in district nursing; rapid-response teams; palliative care and mental health services.
The changes in primary care help tailor services to local needs, with benefits to patients. Nurses will play a key part in managing improved access to services, especially in chronic disease management. Strategically, the nurse’s role has the potential to change and expand, offering the option of becoming partners with GPs or even grouping together to form a limited company and seek contracts with the PCT. Last but not least organisational standards in the quality framework for CPD and good human resources practice should result in improving nurses’ employment conditions.
- Policy in Focus is a monthly overview of a national policy area. Next month: Foundation trusts.
Julie Foxton is a Senior Nurse Adviser for the charity HEART UK in Maidenhead, Berkshire. The charity gives advice about the risks of heart disease and supports people with inherited high cholesterol
‘Most points in the clinical domain are for coronary heart disease management. I think nurses will find that much of the day-to-day running of patient care will be their responsibility, while areas such as mental health that require more skills will become the focus of the GP’s work. This could involve more recording of parameters routinely such as blood pressure and cholesterol testing and checking of results, titrating or changing drugs. Nurses will also be key in giving patients the information and encouragement to make sure they take their medicine. Practices that have been working successfully to the National Service Frameworks should find the transition quite easy.’
Rachel Booker is Chronic Obstructive Pulmonary Disease (COPD) Module Leader at the National Respiratory Training Centre in Warwick and a member of the British Thoracic Society’s COPD disease consortium
‘The contract is a good thing for patients and for practices and it represents a major step forward, especially for COPD, which has never been on the agenda or had a specific National Service Framework. Practices which have already got delivery of care for respiratory patients organised will find the standards relatively easy to meet. Some inner city and single-handed practices that have no structure in place might struggle, though. There will also be an enormous amount of work on the back-up - a lot of the workload will fall on nurses. The indicators do not say anything about the quality of the care given. For example, you can get points for checking inhaler technique, but you don’t have to make sure the technique is good. There is also conflict between some of the NICE guidelines and the contract requirements, which needs addressing.’