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In full bloom

The seeds for the new GMS contract were planted a year ago and was meant to create radical changes in primary care. Has it met with early expectations, or is it yet to blossom?

FlowersThis month marks the first birthday of a new contract for GPs, which was meant to create radical changes in primary care. Government and the industry alike promised that it would improve clinical quality, and make the NHS more responsive and accessible to patients.

Even as the NHS is taking stock of the first year, parts of the contract are already being updated. All in all, it is a good time to look back and see whether the contract has been fulfilling its promise - and to look ahead at what it will look like in another year's time.

"Points win prizes" - The QOF
The Quality and Outcomes Framework (QOF - pronounced like the word quaff) has been the part of the contract with the most immediate impact on the pharmaceutical industry.

It is also of vital importance to practices, because it attracts two- thirds of the funding available under the new contract. Practices earn points according to how well they are meeting QOF targets, known as quality indicators. There are rewards for establishing disease registers, and treating patients as stipulated.

In some cases, the QOF calls on practices to produce defined clinical outcomes, such as lowering blood pressure to 150/99 mmHg for hypertensive patients.

The QOF focuses on 10 clinical areas (see figure 2, overleaf). It is meant to map to national priorities and in some cases - for example, where there are National Service Frameworks - this link is clear. In other instances, it is less obvious why these topics were selected for the QOF. Some of the categories attract a huge proportion of the points (CHD, stroke and hypertension), while others collect just a few (cancer and mental health are just two examples).

Industry impact
What has the contract meant for the pharmaceutical industry? One obvious result will be higher prescribing in some clinical areas, and this likelihood has already been acknowledged by the NHS Prescription Pricing Authority (PPA). Drugs falling into the clinical domains within the QOF account for 42 per cent of NHS prescribing costs, according to a PPA report released in March.

Even though most of the areas of prescribing covered by the QOF are already areas of high growth, the contract could be an additional stimulus, the PPA notes. Yet, there are also more subtle trends to be aware of. For example, companies are thinking about new customer groups within primary care, in addition to the GP.

It is important to look at the changes that the new GMS contract is making on practices as organisations - the increasingly important role of the practice manager in driving delivery of the QOF, and the expanding role of nurses and pharmacists as practices address skill mix opportunities and free up GP time to focus in patients who need their attention, says Judy Willits, PCO customer leader for AstraZeneca.

The new contract for community pharmacy, which comes into effect this month (April 2005), has also been designed to complement the GMS contract.

Bright outlook
A recent survey by the NHS Alliance, a group that represents Primary Care Organisations, provides an optimistic view of the contract's impact on the health service. Most people in PCTs think it's been a great success and most people in primary care also think that, says Dr David Jenner, a GP in Devon and GMS lead for the NHS Alliance. [Only] a minority feel it's reduced medicine to tick boxes, and it has brought in more work and bureaucracy in the short term.

Chris Town, chief executive of Greater Peterborough Primary Care Partnership and a GMS contract negotiator for NHS Employers, shares this bright outlook. So far everybody is delighted that it is working very well, particularly the QOF. There has been a significant change in the way that people are treating long term conditions. Practices have exceeded all expectations in delivering on the contract, he adds. That's good news for patients and, as far as I'm concerned, for the service.

The new contract has certainly been good for the GP's pocket. Dr Jenner cites reports that profits have increased by 15 per cent for practices in the first year of the GMS contract.


However, government funding for the contract has fallen short and this has created financial burdens for PCOs, Town says.

The contract was meant to attract more doctors into general practice and it has succeeded in doing so, but with an unforeseen effect on hospital services. The financial package in general practice is now so attractive that staff grade doctors are leaving the NHS to become GPs. The BMA noticed the exodus soon after the contract came into force, and says that A&E units are hardest hit.

Ironically, the contract may be undermining a key government priority, the reduction of social inequalities in healthcare. The problem is that it is more difficult for practices in deprived areas to deliver the QOF targets, explains Dr Jenner at the NHS Alliance.

The leafy suburban practices tend to do better than the inner cities. There are real concerns about the future of general practice in the inner cities and in London.

Problems with out-of-hours services have also been prominent in the media and the Commons Health Select Committee flagged up potential problems last summer, soon after the contract was launched. Failed out-of-hours provision has been a hot topic of debate in the Welsh Assembly as well.

The contract allowed GPs to opt out of providing night and weekend cover, and passed this responsibility on to PCOs. While many localities have managed the transition, some PCOs were caught unawares on this issue, notes Town. The Department of Health has issued guidance and is currently reviewing out-of-hours arrangements.

One aspect of the contract that has been particularly disappointing is a failure to develop enhanced services at a PCO level, according to the British Mediical Association (BMA). The contract leaves scope for PCOs to commission services from specialist GPs, instead of hospitals, according to local needs. Yet, in some cases, the BMA claims, PCOs have not even spent the minimum amount of money earmarked for these services.

Despite these issues, doctors seem to think the contract is improving patient care. There have been some teething problems but then you would expect that, says Dr Laurence Buckman, a GP in north London and deputy chairman of the BMA's General Practitioner's Committee. However, it's going to improve care for patients. The quality and outcomes framework has been one of the most innovative benefits to the NHS in a very long time.

What patients think
Consumer advocates say it is too early to gauge how well the contract is working for patients. However, all the evidence is that there is quite high satisfaction with GP services among the public, says Frances Blunden, principal policy adviser at Which? (formerly the Consumers Association).

The most common complaint is that it is hard to schedule appointments at convenient times, she says. When it comes to new out-of-hours provision, Which? sees continuity of care as a potential concern. Patient choice, in a patient-centred service, is one of the central planks of government healthcare policy. It is ironic, then, that patients had no involvement in the contract negotiations.

There is a need to recognise the consumer as a key stakeholder and their voice needs to be represented, Blunden adds.

Contract updates now underway
The contract was originally designed to allow for periodic reviews and updates, and this process is already starting. Two key parts of the contract are under review at the moment: the QOF and the global sum allocation formula, which determines the baseline payment received by practices.

The new QOF update is scheduled to come into effect in April 2006 and while this is a year away, the timetable is actually very tight because of the number of parties involved and complexities of the review process. Companies and interest groups are already lining up to have new clinical indicators included in the QOF, says Town.

The BMA insists that any additions or changes added to the contract must be firmly based on the evidence. To that end, an expert review group will be appointed to sift through the many possibilities and the supporting evidence.

The update of the funding formula will be of at least equal, if not greater, interest to GPs. When the GMS contract was launched, there was confusion about how the global sum would affect different practices and grassroots fears that some would actually lose money.

A lot of GPs are sort of scared of it now, says Dr Buckman of the BMA. That will have to be looked at very carefully.

The bigger picture
While the GMS contract and the upcoming changes are certainly important for the industry, these trends are only part of the broader programme of NHS reform.

The new GMS contract is just one of the factors in the whole focus on longer term conditions and decreasing health inequalities, says AstraZeneca's Willits.

It's all interwoven, and the contract is one of the levers. There is also practice-based commissioning, payment by results, patient choice... we need to look at where the new GMS contract fits into the bigger picture.

Fig 1: about the gms contract

  • The new General Medical Services (GMS) contract for GP practices was launched in April 2004
  • It was negotiated between the British Medical Association's (BMA) General Practitioner's Committee (GPC) and the NHS Confederation (the contract is now handled by a recent Confederation offshoot, NHS Employers)
  • The contract applies across the four nations of England, Wales, Northern Ireland and Scotland
  • The contract moved GP remuneration away from the size of the patient list, and towards demonstrable achievement of clinical and organisational quality

Within the contract are three levels of service:

  • Essential services, which all practices must provide
  • Additional services, which some practices may elect to provide
  • Enhanced services, which Primary Care Organisations can commission according to local needs
  • The Quality and Outcomes Framework (QOF) is an important part of the contract and has the most direct relationship to prescribing.

More information on the contract, along with latest updates, can be found here.

Fig 2: targets in the QOF

The clinical topics in the QOF are meant to map to national priorities - for example, as spelt out in National Service Frameworks. The current QOF includes:

  • Coronary heart disease (CHD)
  • Stroke
  • Hypertension
  • Diabetes
  • Chronic obstructive pulmonary disease (COPD)
  • Epilepsy
  • Hypothyroidism
  • Cancer
  • Mental health
  • Asthma.

In addition to the clinical domain, there are three other domains:

  • Organisation (records, communications, training, medicines management, administration)
  • Additional services (cervical screening, child health surveillance, maternity services, contraception)
  • Patient experience (surveys and consultation length).

The Author
Colleen Shannon is a freelance healthcare journalist.

2nd September 2008


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