3. Contracts and Finance

The GMS contract in England, Scotland, Wales and Northern Ireland

The revised GMS (nGMS) contract became live on 1 April 2004. It supersedes any previous contract and references to the ‘Red Book’ The Statement of Fees and Allowances. The Statement of Financial Entitlements (SFE) has superceded the Statement of Fees and Allowances and provides the mechanism under which PCTs pay their contractors.

The contracts in the four countries are broadly similar in principle and practice, as are PMS contracts. The contract as described in HOPM is the English version. Where possible, we draw attention to the major differences and these are noted below, but we cannot guarantee that every significant difference has been highlighted. Readers should check critical information with their own contract. If readers would like to let us know of important regional or PMS differences we have not identified, we would be pleased to incorporate them in future updates. References are to the English Schedule of the National Health Service (General Medical Services) unless otherwise stated. At the time of writing the BMA are in the process of negotiating the detail of the contractual changes for Scotland, Wales and Northern Ireland. The BMA website can provide a source of informaton with regard to amendments.

GMS and PMS

Practices with a PMS contract will find that much of the material on the GMS contract is relevant to them. However, pages 3-50 to 3-54 cover the key differences including negotiation of PMS contracts.

Advice to readers

Interpretation of the GP contract varies from primary care organisation (PCO) to PCO, and your PCO will use discretion in their management of the contract and the payments related to it.

Our overview of the main principles and procedures relating to the financial entitlements under the (nGMS) contract from April 2004 covers:

Performers

Qualified GPs are performers. Their names appear on the PCO’s performers list, and only doctors on a performers list can provide GP medical services. Where GPs have patients in several areas, their name will normally be on the list of the PCT in which most of their patients live.

Providers

Practices are provider units. They provide medical services to the patients registered with them. Every provider must include one qualified GP. The provider unit will often, but not always, be the partnership.

NHS body – to be or not to be?

All PCOs, Trusts and many PMS practices are NHS bodies, i.e. they work under NHS contracts (in Northern Ireland, Health and Social Services contracts as they provide integrated health and social care). In the past, GMS practices held private law contracts with their PCOs, but now they too can elect to become NHS bodies.

The only difference being an NHS body makes is in the avenues open to the practice in dispute over an NHS contract. NHS bodies must use the NHS disputes resolution procedures. NHS England have published a document that outlines the procedure for managing a dispute, entitled ‘Managing Disputes for Primary Medical Services The document can be found at www.England.nhs.uk. Non NHS bodies have the option of raising their dispute under the umbrella of this procedure or using the juidicial court system. Again this is outlined within the previoulsy specified document.

A practice can change its status at any time, and practices may prefer to keep their options open by remaining as they are. If a practice changes its status, the partnership agreement needs to be amended.

Open, full and closed lists

A practice that is registering new patients has an open list.

A practice may declare that its list is full. This means that the practice is refusing to accept new patients. This is an unofficial and temporary state, perhaps reflecting a staff crisis or building works. There are no other restrictions on the practice. Patients can still be assigned to a practice with a full list (see ‘Declining to register patients’ below and regulation 17 of part 2 of schedule 6). It is advisable, but not officially required, to let the PCO know if you have a full list.

A practice which is dangerously overloaded with no hope of immediate relief, perhaps because of lack of space, may apply to the PCO to have its list declared formally closed. It cannot register new patients unless they are new members of current patients’ families.

The concept of formal closure has been introduced to protect struggling practices from assignments (see below). Practices with closed lists will not normally be assigned patients.

Application to close a list initiates an informal discussion with the PCO about the maximum list size the practice can safely manage, and the size at which re-opening the list would be reasonable. Practices will also be asked what their plans for provision of additional and enhanced services are, and what steps they are taking to boost their ability to provide care. Applications are then assessed by a panel whose decision may be challenged. If permission is given to close the list, conditions for re-opening the list are determined, e.g. a fall in list size to a manageable level or 1 year, whichever is the sooner. Practices with closed list may still offer enhanced services.

Personal versus shared list systems

In the past, practices ran personal lists, i.e. except in an emergency patients would see only the GP with whom they were registered. Personal lists offer maximum continuity of care but are difficult to maintain with part-time and flexible working. Over recent years, many practices have moved to shared (‘open’) list systems, i.e. patients can see any doctor, although to foster continuity of care patients are usually encouraged to develop a relationship with one doctor and to see one problem through with one doctor if possible. Patients now register with the practice rather than with a specific doctor, but doctors can maintain an internal personal list system if they wish. For partners, being able to demonstrate a de facto personal list, especially if it is acknowledged in the partnership agreement, provides security if the practice splits.

Patients’ choice of doctor

Many patients still value having ‘their’ doctor, and for many GPs, the virtue and reward of general practice is the growth of a therapeutic relationship through the continuity of care. Practices must offer new patients the option of choosing to have a named doctor. The practice is obliged to record patients’ preferences (‘usual doctor’ can be recorded on clinical systems) and should try to meet patients’ requests. It is, however, particularly in larger practices, often difficult to offer the patients appointments with their preferred doctor, especially when their preferred doctor is part-time or has other commitments within the practice, e.g. teaching of students. It therefore may be helpful to advise patients registered with larger practices to have two or three doctors that they feel comfortable consulting with. This then covers them for emergency situations and in instances when their preferred doctor may be off sick or on annual leave.

Practice area

Practices are required to define their practice boundaries to their Local Area Team (LAT) which then sits alongside their contract. They are also required to define their outer boundaries. This allows patients who move outside of the Practice area to remain with their current GP if they wish to providing they remain within the Practices outer boundary. The Practice is obliged to register patients that live within the traditional boundary but is not obliged to take on new patients that move to live between the inner and outer boudnaries. From October 2014 Practices will be able to register patients that live outside of their tradtional boundary. They will not however be obligated to provide home visits for these patients as NHS England will assume respnsibility for the arragnement of in house urgent medical care for patients who register with practices away from their home.

Different sorts of registration

There are three categories of registration of NHS patients: they may be fully registered (registered patients), registered as temporary residents, or registered for immediately necessary treatment. An informal category of patients for whom only contraceptive care is provided also exists.

Assigned patients (allocated patients)

The GMS contract uses the term assigned, but the term allocated is commonly used in practice.

PCOs have an obligation to provide care for patients who have been unable to find a practice that will accept them as patients. The PCO may work with practices to enable them to increase their list sizes, or it might set up its own primary care service. If no other way of providing care can be found, PCOs will assign such patients to local practices. Practices are then obliged to register them. Assignments are unsatisfactory for both sides: practices feel that patients are being dumped on them, and patients do not have a choice. In some urban areas, assignments are a major source of practice dissatisfaction.

Patients can be assigned to practices with open or full lists. Occasionally, patients may be assigned to practices with closed lists, after discussion and if there is no other option. Practices with closed lists have a right of appeal against assignments.

The PCO is allowed to assign to a practice a patient who lives outside the practice area. If a patient is going to be assigned, the PCO should inform the practice by telephone, although the practice does not have responsibility until the patient’s administrative details have been received. The medical records should be transferred urgently. Practices are obliged to keep assigned patients on their list for a minimum of 3 months, unless they are violent, in which case the PCO is responsible for providing medical care. This will generally be under a special arrangement with a practice who has agreed that it will provide this level of care. The practice will be funded for the service and security arrangements will be paramount. See Section 8 of HOPM, ‘Violent patients’.

In most areas, urban and rural, there are a few patients who are such a burden on practices that by agreement they rotate from practice to practice at 3-month intervals. Cooperation with colleagues over sharing the burden is in everyone’s interest.

Private patients

In most places, the market for private general practice is small, but practices may be approached by people wanting to register with them on an entirely private basis. Practices need to explore potential patients’ expectations and to decide whether they can meet them without prejudice to the care of their NHS patients, and to negotiate the scope and cost of the service they might provide.

Out-of-area patients

Until/if practice catchment areas are abolished, practices may have some patients who live outside their practice area. This may be because:

Practices need to agree a policy about out-of-area patients and everyone must stick to it. Doctors may need to be reminded that they cannot have one rule for nice patients and another for heartsinks.

Practices may suspect that patients have moved but are using their old address or that of a friend in order to stay registered. It can be difficult to prove this. The risk is that the patient does not receive important correspondence. A request for a home visit and referral to hospital may force the patient to reveal their new address. PCOs have the powers to deal with such situations if they can prove that the patient has moved.

Eligibility for free healthcare

Eligibility to receive free primary medical care in the UK is determined by whether a person is resident in the UK, and is not related to nationality or payment of National Insurance or taxes.

Patients coming to live in the UK from abroad

Anyone coming to the UK intending to stay for less than 6 months does not fulfil the qualifying criteria for free non-emergency NHS care. For patients coming to the UK intending to stay 6 months or more, entitlement to free treatment begins on arrival in the UK – there is no qualifying period of residency before free treatment starts.

British nationals living abroad

A British resident on extended holiday or a business trip still counts as ordinarily resident and is entitled to free healthcare on return.

Someone who has emigrated and ordinarily lives abroad, but returns from time to time to take advantage of free NHS care, does not qualify. Persons leaving the UK to reside abroad for 6 months or more should not continue to be registered with a GP. The onus is on the patients to inform the relevant authorities and surrender their medical cards.

Practices should treat UK nationals who are usually resident abroad like any other overseas visitor. The exceptions to this rule are embassy staff, merchant seamen or those in the armed forces, when entitlement to NHS care is maintained.

UK residents going abroad for short periods

Doctors should not provide NHS scripts for conditions that might arise whilst the patient is away on holiday or business trips, e.g. for traveller’s diarrhoea.

Prescribing interval for any repeat NHS medication should be related to the next time that medication would normally be reviewed. Generally, this should not be more than 13 weeks. The prescribing doctor retains medicolegal responsibility for the duration of the prescription.

If the doctor does decide to prescribe for a longer interval to cover a patient’s stay abroad in excess of the usual prescribing interval (e.g. if repeat supplies cannot be obtained at the destination or the drug prescribed has a narrow therapeutic index), it is essential to inform the patient of the need to consult a doctor for any regular monitoring, as well as the need to consult a doctor in the event of any unforeseen complications or symptoms.

General rules for British patients travelling abroad

Patients travelling abroad should ensure they take out travel insurance with a reputable company in the first isntance. If patients are travelling in Europe it is also advisable to carry.

The European Health Insurance Card (EHIC)

The EHIC entitles holders to reduced-cost, sometimes free, medical treatment that becomes necessary whilst in another European Economic Area (EEA) country or Switzerland. The EHIC can be obtained online (see http://www.nhs.uk/NHSEngland/Healthcareabroad/EHIC/Pages/about-the-ehic.aspx) or at any Post Office. NHS Choices (HYPERLINK "http://www.nhs.uk" www.nhs.uk) provides a comprehensive list of countries where the EHIC is accepted. Patients should bear in mind that each country has its own rules and entitlements will vary from country to country. British citizens moving to live in another EEA country are not entitled to use an EHIC to obtain medical treatment.

Other reciprocal agreements

The UK has reciprocal agreements with certain other countries for the provision of urgently needed medical treatment at reduced cost or free. Countries and the services available are listed on the NHS Choice website as before. Only urgently needed treatment is provided on the same terms as for residents of that country. Proof of British Nationality or UK residence is required.

Patients from abroad seeking medical treatment in the UK

Entitlement to healthcare in the UK is based on residency. However, the following NHS treatment is free for everyone:

However, since the withdrawal of the Health Service Circular 1999/018 there has been a large amount of confusion and uncertainty about overseas visitors entitlement to primary medical care. In the absence of any substantive subsequent guidance, the BMA have devised the following guidelines, extracted from the BMA website HYPERLINK "http://www.bma.org" www.bma.org in order to clarify the current situation:

In addition, they offer the following guidance on referring patients onwards for secondary care medical services:-

GPs should avoid making any judgements about the likelihood of an individual patient being charged for secondary care and should refer whenever clinically appropriate.

General rules for treatment of overseas visitors to the UK from non-EEA countries

Further information:

Department of Health travel advice website: http://www.nhs.uk/Livewell/TravelHealth/Pages/Travelhealthhome.aspx.

New patients – contractual obligations and good practice

Registration is a two-way process. The patient learns about the culture of the practice, the practice has an opportunity to find out about the patient’s medical needs. The way in which they are treated when they come to register shapes new patients’ opinions of the practice and may influence their decisions about where they register. It is important to make patients feel welcome and to ensure that they have the information they want and need.

A pack for new patients saves time. Contents should include:

Receptionists should make sure they ask new patients what they want to know. A good receptionist will be able to form an idea of a patient’s state of health and to arrange for patients on regular medication or with chronic medical problems to see a doctor, or if appropriate a nurse, as soon as possible so that arrangements can be made for their ongoing care. Receptionists may be able to help patients fill in the health questionnaire and to guide patients towards the most suitable ‘own GP’.

Explaining the appointments system to new patients can save both sides a lot of frustration in the future.

Patients with poor English may be unable to fill in a health questionnaire, and if they are recent immigrants there will be no NHS record of their past medical history. If possible, arrangements should be made for them to come back at a time when an interpreter is available. This is particularly important if the patient is in poor health. Interpreter services are generally commissioned by your PCO.

Housebound patients are entitled to a consultation at home and it is clearly important that they be seen as soon after they have registered as possible.

The information on health questionnaires needs to be transferred promptly into the computer records. A data entry clerk or receptionist should be given the responsibility. When initiating such questionnaires ensure that the answers to the questions can be easily adapted to computer codes as there is no point obtaining the information if it does not update your data to reflect the requirements of the contract.

Practice leaflets

Regulations require that practice leaflets must be available for patients and include the information listed below:

Practice leaflets must be updated at least annually. It is possible to cover some or all of the costs by allowing advertising space, but it is important to ensure that advertisers do not promote products that are inappropriate. Equally, no impression should be given that the practice endorses the products of advertisers. Possible organisations that could be approached include other professionals, nursing homes and restaurants.

Declining to register patients

Even if its list is open, a practice may refuse to register a patient, but must ensure that its reasons cannot be interpreted as discriminatory.

Reasonable grounds for refusing to register a patient include living out of the practice area or a history of violence.

The practice does not need to record enquiries, i.e. telephone queries or enquiries made to reception about registration. However, if a request is made in writing, the practice is contractually obliged to provide the reasons for declining to register in writing.

Removal of patients from the list by the PCO

Patients are removed (deducted) from the list by the PCO when it is informed that they have registered with another practice. PCOs also have the power to remove patients who they know to be out of the country for more than 3 months or in prison for more than 2 years.

The PCO will request the return of the patient’s notes, and these should be checked before they are sent to ensure that they are complete and that no inappropriate documents have found their way into the notes.

See also ‘Ghost patients’ below and the Quality and Outcomes Framework (QOF) later in this section.

Removal of patients from the list by the practice

It is legitimate to remove from the list patients who live out of area, who are violent or who steal from or deliberately deceive the practice. However, GPs come in for a great deal of criticism for removing patients from their lists. Removal may be seen as discriminatory or unsympathetic to patients’ age, problems or views about their health.

‘Irretrievable breakdown of the doctor–patient relationship’ is a permissible but arguably unsatisfactory reason for removal of patients, and in cases where the practice feels that there is a risk of bad feeling and bad publicity, it may be wise to contact the LMC or defence organisations for advice.

Patients must be sent a written warning unless the reason is simply that they now live out of area, and even then it is courteous to remind patients of the need to re-register. The warning and the written statement of removal must give the reasons, and copies must be kept. In some cases where the problem is misuse of services, patients will heed a warning.

Patients remain the responsibility of the practice until 30 days after the PCO has received notification from the practice or when the patient has reregistered, whichever is the earlier.

Removal of violent patients

Patients who are violent, or whose behaviour gives rise to fears that they may be violent, towards staff or other patients may be removed immediately from the list. See Section 8 of HOPM, ‘Violent patients’.

Difficult situations

Practices may register patients under the age of 16 without parental consent as long as they are confident that the teenager is able to make a rational decision about their own healthcare. Under 16s are more likely to request contraceptive services (away from possible parental observation) than general medical services.

The collapse of a practice can create pressures on nearby practices. Normally, a PCO will discuss with affected practices how the situation can be managed. Practices may find themselves torn between providing care for needy patients and overloading themselves, and should not let themselves be pressured into taking on a large number of patients, either permanently or as temporary residents.

Patients with dental problems

Patients often come to GPs with dental problems because GPs are more available and free of charge. GPs are not trained or insured to diagnose or treat dental problems and should resist the pressure to do so. It is helpful to have available information about local emergency and community dental services. If there are serious problems inform the PCO, which has obligations to provide services, and the LMC, which can raise the issues with the Local Dental Committee.

Ghost patients and green cards

Every practice will hold the records of a number of patients who have not consulted for years. These are usually patients who have gone abroad, so the PCO has no record of their departure. Ghost patients may appear to be a free source of capitation but their presence on the list will adversely affect income potential in other ways, as the blood pressure and smoking habits of a ‘ghost’ cannot be recorded.

Practices have an obligation to clean their lists of ghosts. If a PCO believes a patient to be a ghost, it will issue an electronic notification effectively removing the patient from the practice list. The practice then has 6 months to prove that the patient is still living at the registered address. Bureaucratic delays sometimes mean that patients are deducted and then reinstated.

See also ‘Removal of patients from the list by the PCO’ above.

Consultation obligations

All practices are obliged to offer or provide the following consultations on request and must advertise them in their patient leaflet:

Doctors’ availability

Practices have to provide essential services during the core hours of 8.00 a.m. to 6.30 p.m. Monday to Friday, excluding Good Friday, Christmas Day and bank holidays. Practices will probably be open during these hours, but as long as services are available (e.g. through a deputising service), practices may shut over lunch time or for a half day, or in the case of branch surgeries for much longer.

Practices that see patients outside core hours are entitled to funding under a directed enhanced service (DES). See later in Section 3 of HOPM for details of the English ‘DES’ regarding extended opening hours.

Normal hours may be different for different practices and patients need to know what the practice’s hours are.

The regulations apply to PMS practices, unless they have negotiated a different contractual arrangement. Any amendments to advertised opening hours must be notified to your Local Area Team.

Short-term sickness

Patients should use forms SC2 to self-certify the first 7 days of any episode of sickness.

Many employers (including some within the NHS!) are not content with an SC2 and demand a doctor’s note. Employer expectation that GPs will police their staff sickness claims is responsible for many consultations, which both the doctor and the patient deem unnecessary. The practice needs to have a policy for handling these requests, and it should be one that aims to discourage them. All should follow it – it is unfair on patients to be charged by one doctor for what another provides for free.

GPs may provide a private sick note, although ethically it is the employer who should pay for it. Alternatively, or additionally, they can give patients a proforma letter for their employers explaining their legal obligations. LMCs often have model letters and it is worth checking with your local LMC.

After 7 days sickness, or from the outset if the doctor expects the patient’s inability to work to last for more than 7 days, the GP or the patient’s hospital doctor will need to issue a medical certificate. This is called a ‘fit note’.

On completing this form, the doctor has two options.

It is important to note that a Statement is not required to certify that a patient is fully fit to return to work without adjustments. If an employer requires such a statement, it should be requested as a private service.

The Statement of Fitness for Work may be issued:

Only one Statement of Fitness for Work can be issued per patient per period of sickness. If mislaid, reissue and mark ‘duplicate’.

Further information:

Department of Work and Pensions. Getting the Most of out the “fit Note” www.dwp.gov.uk

‘Notes for school’

Most of these requests are seen as unnecessary when the parent realises that a fee will be incurred. If a school is insisting on a doctor’s note, agreement should be reached on who will pay the cost.

Fitness for alternative treatment, fitness programmes, sport, etc

Practitioners may request a doctor’s approval to provide alternative or complementary therapy. GPs are rightly unwilling to take on responsibility for the patient’s health while receiving treatment under these circumstances. It is unwise to declare a patient’s fitness for an unknown therapy, however benign it may sound. Doctors have the options of declining to provide assurance (with reasons), or asking for details of the planned therapy and doing a medical (for which a charge appropriate to the work involved should be made), or finding a bland form of words.

Gyms may ask for assurance that a patient is fit for an exercise programme. A proforma along the lines of ‘A properly graduated programme of exercise is known to be beneficial to people with . . . and I know of no reason why . . . should not undertake such a programme’ might be used.

Certificates/reports for charities

Many GPs find it hard to charge charitable organisations, and charities for patients sometimes resent being charged, but the responsibility and the workload can be significant. Again, a common approach is the only fair strategy.

Private services related to travel

The government’s policy on travel prophylaxis is based on whether providing prophylaxis may prevent spread of an infectious disease when the traveller returns home, not on the traveller’s risk of contracting a disease or the cost to the NHS of treating it. Thus, immunisation against a rare disease may be free but antimalarials are not. Travel immunisations are an additional service, and remuneration for immunisations that are available on the NHS is part of the global sum.

Practices may charge for providing a certificate of immunisation, even if the immunisation is free.

Medication required for pre-existing health conditions must be provided on the NHS. This includes contraception.

Practices may charge for issuing prescriptions for medication requested ‘just in case’, e.g. antidiarrhoeals or courses of antibiotics for travellers’ diarrhoea, and, by the same logic, for travel packs. However, travel advice cannot be charged for.

Some practices have decided to make provision of travel immunisations an entirely private service. In doing so they are in breach of their terms of service, although it is possible that the regulations may change (see also Section 10, ‘Prescriptions, prescribers, prescribing’).

Age–sex adjustments

Older people and children under 5 years of age require the most GP care. The Carr-Hill formula uses an age–sex curve to adjust payments to practices based on the age and gender of their registered populations. The number of patients in each age/gender group is multiplied by the age–sex workload index (see the following examples).

Age–sex workload index (using males aged 5–4 = 1) for the UK excluding Scotland.

OPEN IN VIEWER

Age!	0–4	5–14	15–44	45–64	65–74	75–84	85+
Male	3.97	1	1.02	2.15	4.19	5.18	6.27
Female	3.64	1.04	2.19	3.36	4.9	6.56	6.72

Age–sex workload index (using males aged 5–14 = 1) for Scotland only.

OPEN IN VIEWER

Age!	0–4	5–14	15–24	25–44	45–64	65–74	75–84	85+
Male	2.51	1	1.153	1.272	1.823	2.672	3.207	3.468
Female	2.24	1.102	2.371	2.524	2.714	3.067	3.342	3.340

Nursing and residential homes

Patients living in nursing and residential homes generate more workload, mainly through increased travelling time. The workload adjustment factor applied to all patients living in permanent community residential care is 1.43.

List turnover

Areas with high list turnover often have higher workloads, as patients tend to have more consultations in their first year of registration in a practice. Therefore a factor of 1.46 is applied to all new registrations.

Additional needs

In the UK (apart from Scotland), Standardised Limited Long-Standing Illness (SLLI) and the Standardised Mortality Ratio for those under 65 years of age (SMR < 65) are best at explaining variations in workload over and above those due to age and gender of patients. They are related to workload by a complex formula used to make the payment adjustment.

In Scotland, the SMR < 65 together with unemployment rate, number of elderly people (over 65 years) on income support and number of households with two or more indicators of deprivation are used in the adjustment formula.

Staff market forces factor (MFF)

This adjustment reflects geographical variation in the staff costs practices incur. The staff MFF is based on the latest 3 years of the New Earnings Survey Panel Dataset. The adjustment does not apply to GPs or non-staff expenses. It uses data on individual earnings of full-time employees aged 16–70 in the private sector, whose pay is not affected by absence, to determine the impact of geographical area on costs, controlling for the effect of other factors such as age, sex, industry and occupation.

Northern Ireland: The MFF for Northern Ireland outside Belfast has been taken as the average between Scotland and Wales, outside of Edinburgh and Cardiff, respectively, whilst the MFF for Belfast has been taken to be the average between Edinburgh and Cardiff.

London

A sum has been set aside to recognise the potentially destabilising effects of the implementation of the Carr-Hill formula in London. This sum will be distributed amongst practices in London on the basis of practice populations after adjustment for list inflation, unweighted for age, sex or additional need.

Combining the adjustments

Each adjustment generates a separate practice index, comparing the practice score on the adjustment to the national average. The indices are then simultaneously applied to the practice list (adjusted for list inflation – see below). This produces a practice-weighted population. Payment to each practice is then based on this weighted population.

List inflation

Under the old GP contract, most fees and allowances were scaled back by 6% to take account of list inflation. This figure reflected the fact that the number of patients on GP lists totalled 6% more than the Office for National Statistics population estimate. However, this method of adjustment penalises those areas of the country where list inflation is lower or those practices that have cleaned their lists.

Under the nGMS contract, each PCO population will be scaled back to its own census population estimates. PCOs will then scale back individual practice lists based on the PCO list inflation figure.

Future changes

As more data become available through the QOF, the Carr-Hill formula will be adjusted to take into account additional factors influencing workload such as disease prevalence rates.

Minimum practice income guarantee (MPIG)

The MPIG protects those practices that lost out under the redistribution effect of the new Carr-Hill resource allocation formula. It is calculated by subtracting the global sum allocation (GSA) under the nGMS contract from the global sum equivalent (GSE) – the amount the practice would have earned for providing the same service under the old GMS contract (the Red Book).

If the GSA is less than the GSE, a correction factor (CF) will be applied as long as necessary to make up the difference; i.e.

GSA + CF = GSE

In 2006–2007, NHS employers and the BMA agreed that any future uplifts to the GSA should aim to reduce practice reliance on CF payments to ensure a fairer allocation of resources across practices. Hence year-on-year, less practices are needing CF payments.

The Department of Health recently announced that from April 2014 there would be a phasing out of the MPIG and proposals would move all practices to a common capitation price, based on current average expenditure on the global sum, correction factor payments under MPIG, and basic elements of PMS funding.

Further information:

http://www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/Pages/Contract.aspx

Essential services

All practices must undertake these services. Services must be provided within core hours (i.e. between 8.00 a.m. and 6.30 p.m., Monday to Friday, with the exception of public holidays) ‘as appropriate to meet the reasonable needs of patients’. Arrangements should be in place for access to essential services throughout the core hours in case of emergency.

Essential services include:

For patients not registered with the practice:

Additional services

These are services provided to registered patients and temporary residents within core hours that the practice would usually undertake but may ‘opt out’ of providing. The practice then receives a reduced global sum payment. If the practice opts out, the PCO takes responsibility for providing the service instead and may offer the service to other practices to provide for additional payment.

Services included:

Enhanced services

Enhanced services are essential or additional services delivered to a higher specified standard or services not provided through essential or additional services. The practice, as a contractor, does not have an automatic right to provide enhanced services, although for directed enhanced services (except influenza and pneumococcal vaccination for at-risk groups) there is a preferential right. Enhanced services have in the past been commissioned by PCOs, however from 2014/15 the responsibility for these contracts has been transferred across to NHS England. In turn NHS England have devolved funding for local enhanced services to Clinical Commissioning Groups (CCGs) Note there will be variations for Scotland, Wales and Northern Ireland.

Nationally defined enhanced services

These are enhanced services that are under national direction with national specifications and benchmark pricing which must be commissioned to cover their relevant population.

There are currently four directed enhanced services which all PCOs must provide. These are:

In addition, there are a number of directed enhanced services that operate only in England, Scotland, Wales or Northern Ireland. These vary from year to year.

In 2014/15 a new enhanced services is being introduced. It is a one year service introduced to improve services for patients with complex health and care needs who may be at risk of unplanned hospital admission.

The aims of the service as summarised by NHS employers (www.nhsemployers.org.uk) are:

undertake internal reviews of unplanned admissions/readmissions

In addition although listed above, the following will be rolled over in England, for the twelve month period ending on 31 March 2015

Childhood immunisations

This directed enhanced service continues the target payment scheme for routine childhood vaccination for pre-school children that existed for many years. It requires practices to:

Childhood Influenza and Vaccination Programme

Extended hours Access Scheme

Introduced in 2008 this scheme came into force in a bid to encourage GPs to offer appointments outside of the Practices core contraced opening hours. There is a defined criteria which has been made more flexible in 2014/15 allowing practices to work together to provide the most appropriate service to their patients. Further detail is awaited at the point of writing.

Practices will be paid £1.90 per registered patient per annum for providing this service.

Facilitating Timely diagnosis and Support for People with Dementia

Introduced in 2013/14 and designed to support GPs in providing a timely diagnosis to patients considered at risk of dementia by commiting to the provision of the service The GP practice undertakes:-

to make an opportunistic offer of assessment for dementia to ‘at-risk’ patients and, where agreed with the patient, to provide that assessment.

b) For the purposes of this enhanced service, an opportunistic offer means an offer made during a routine consultation with a patient identified as at-risk and where the attending practitioner considers it appropriate to make such an offer. Once an offer has been made there is no requirement to make a further offer during any future attendance.

c) For the purposes of this enhanced service, ’at-risk’ patients are:

Payment is made in two components:

For more information please refer to www.nhs.england.nhs.uk

OPEN IN VIEWER

Table 3.1

is a summary of the current childhood immunisation requirements (2013), sourced from http://www.patient.co.uk/doctor/immunisation-schedule-uk.

UK 2013 Immunisation Schedule
AGE Immunisation (Vaccine Given)
2 months • DTaP/IPV(polio)/Hib (diphtheria, tetanus, pertussis (whooping cough), polio, and Haemophilus influenzae type b) - all-in-one injection: Pediacel®; plus: PCV (pneumococcal conjugate vaccine) - in a separate injection: Prevenar 13®. Rotarix® (rotavirus gastroenteritis) - oral route.
3 months • DTaP/IPV(polio)/Hib (2nd dose: Pediacel®); plus: MenC (meningitis C) - in a separate injection: NeisVac-C® or Menjugate Kit®. Rotarix® (rotavirus gastroenteritis) - oral route.
4 months • DTaP/IPV(polio)/Hib (3rd dose: Pediacel®); plus: PCV (2nd dose: Prevenar 13®) - in a separate injection.
Between 12 and 13 months • Hib/MenC (combined as one injection) - 4th dose of Hib and 2nd dose of MenC: Menitorix®; plus: MMR (measles, mumps and rubella) - combined as one injection: Priorix® or MMR II®; plus: PCV (3rd dose: Prevenar 13®) - in a separate injection. 3 years and four months to 5 years • Pre-school booster of DTaP/IPV(polio): Repevax® or Infanrix-IPV®; plus: MMR (second dose: Priorix® or MMR II®) - in a separate injection.
Around 12-13 years (girls) • HPV (human papillomavirus types 16 and 18) - three injections: Gardasil®. The second injection is given 1-2 months after the first one. The third is given about six months after the first one.
Around 13-18 years • Td/IPV(polio) booster: Revaxis®. MenC (booster dose: NeisVac® or Menjugate Kit®) - in a separate injection.

Influenza and pneumococcal immunisations for at-risk groups

This enhanced service aims to provide influenza and pneumococcal vaccination for the elderly and other at-risk groups. Practices DO NOT have preferred provider status for this service.

Learning disabilities Health Check Scheme

Minor surgery

The directed enhanced minor surgery service extends the range of procedures beyond those practices are expected to carry out as an additional service (see page 3-27).

For the purpose of payment, procedures have been divided into three groups:

Treatments are priced according to the complexity of the procedure, involvement of other staff and use of specialised equipment. Terms for this must be negotiated locally. Typical figures are £40 for a joint injection or £80 for a simple excision.

Practices can provide this service if they can demonstrate they have the necessary facilities and personnel (either partner, employee or sub-contractor) with the necessary skills. This includes:

In all cases:

If the patient is not registered with the practice undertaking the minor surgery, then a complete record of the procedure must be sent to the patient’s registered practice for inclusion in the GP notes.

Clinical directed enhanced services for England only

Patient Participation Scheme

The patient participation scheme has been extended into 2014/15, its objective being to involve patients in decding upon the range and quality of services available within the Practice. There are various components to the scheme, updated in 2014/15. There is no longer the requirement to survey your patients. This requirement will be replaced by the friends and family test which simply asks patients whether they would recommend the practice to their friends and family. This is set to be introduced in December 2014.

Practices who achieve all of the components of the patient participation scheme enhanced service will at the time of writing receive a fee of £1.10 per patient.

Pertussis for Pregnant Women

This is a temporary scheme established in 2012 which targets the vaccination of women in their third trimester of pregnancy against whooping cough. The current fee for provision of the service is £7.67. The programme will continue until the chief medical officer suggests that there is no longer a sufficent risk of whooping cough to pregnant women.

Risk Profiling and Care Management Scheme

Continuing beyond introduction iin 2013/14 this enhanced service aims to rewards GPs for the identifiation and case management identified as seriously ill and potentially at risk of being admitted to hospital. The current payment for providing the service is 0.74p per patient.

Shingles Catch up Vaccination Programme

This scheme runs alongside the shingles vaccination programme which began in 2013/14. The programme began with vaccinating 79 year olds against shingles. This has been extended into 2014/15 to cover those now 78 years of age. This may be extended furthr dependent upon the availability of the vaccine. The current fee for provision of this service is £7.64.

Shingles Vaccination Programme

Offers the shingles vaccination to all patients aged 70 years. The fee for this service is currently £7.63 per vaccine administered.

Extended opening hours access DES, 2011–12

The DES was extended for one more year (2011–12), but there have been changes:

The payment per registered patient for the DES has decreased to £1.90.

Further information can be found at:

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_125940.

This DES has been extended into 2013/14.

Staffing issues

Practice managers will have to consult staff regarding extended hours, and alterations to contracts may be necessary. It should be remembered that GPs will receive an income for the DES that should enable practices to either employ additional members of staff or pay overtime. Some PCOs are paying additional sums to help facilitate this. Practices must take into consideration religious and cultural sensibilities in discussing these issues with staff. In addition, consideration needs to be given to security for both clinical and non-clinical staff working late and at weekends.

Although PCOs are encouraged to make future commissioning decisions to reflect GP opening times, there is concern that patients seeing doctors in extended hours may not get the ‘full-package’ (e.g. local hospital services such as phlebotomy and diagnostic services, which are available to patients seen in core hours). It is too early to know what impact this may have on patient satisfaction, but it is important for patients to understand the limitations.

The above summary needs to be read in the light of local circumstances as there is much variation between PCOs.

Further information is available at:

www.dh.gov.uk/en/Healthcare/PrimarycarePrimarycarecontracting.

National enhanced services

These are services with national minimum standards and benchmark pricing, but are not directed (i.e. PCOs do not have to provide these services). A practice does not have to provide these services and has no preferential right to do so. In order to provide one or more of these services, a practice must put a proposal together and submit it to the local PCO for a decision to be made about whether the PCO wishes to provide the service and then to be considered in competition with any other bids to perform a similar service.

Currently there are 12 national enhanced services:

A full list of national enhanced services with a summary of their requirements is shown in Table 3.4. Please note that this list includes details of those national enhanced services (NESs) made available up to 2012/13. There are a number of new ones available for 2013/14. Details can be found at http://www.nhsemployers.org/Aboutus/Publications/Documents/2013-14-GMS-contract-Guidance-audit-requirements.pdf and the authors will endeavour to summarise them for future updates.

Getting the facts

Before undertaking to participate in an enhanced service, it is important to find out exactly what participation will entail. In many cases, details cascaded to practices are scanty and it is important to make enquiries to establish the full details so that a complete review of the implications of service provision to the practice is possible.

Financial implications

Practices are paid for provision of enhanced services. Often payments are staged; for example, a practice may receive a payment for agreeing to participate, another for collecting data and yet another for implementing the proposal completely. Payments are usually dependant on list size and/or achievement towards a target. Questions to ask include:

Workload implications

Most enhanced services involve the practice putting in some additional work. Many of the more recent enhanced services, both at local and national level, have been time limited to a year. If capacity to do the additional work required is not already present in the practice, then employing someone on a short-term basis to cover the additional work can be expensive and also unsettling for staff. Even if additional employees are not required in order to meet the targets, putting in a great deal of effort only for a service to be decommissioned after a year can be both disruptive and demoralising. Questions to ask include:

Clinical domain

The following tables show in detail how points are earned in the various clinical domains and have been updated to include the 2014/15 revisions.

The following information has been collected from NHS Employers (www.nhsemployers.org) and the BMA (www.bma.org.uk).

There have been many changes to the 2014/15 the most significant being the reducation of the number of indicators. Both the quality and productivity indicators and patient experience indicators have been retired. There are now two domain – the clinical doman and the public health domain. Note these following areas relate to QOF in England. Readers in Scotland, Wales and Northern Ireland should consider local variations.

Atrial fibrillation (AF)

OPEN IN VIEWER

Indicator	Points	Payment stages
Records
AF001. The contractor establishes and maintains a register of patients with atrial fibrillation.	5
Ongoing management
1).	10	40–90%
AF005. In those patients with atrial fibrillation in whom there is a record of CHADS2 score of 1 (latest in the preceding 12 months), the percentage of patients who are currently treated with anti-coagulation drug therapy or anti-platelet therapy.	6	57–97%
AF004. In those patients with atrial fibrillation whose latest records of a CHADS2 score is greater than 1, the percentage of patients who are currently treated with anti-coagulation therapy.	6	40–70%

Secondary prevention of coronary heart disease (CHD)

OPEN IN VIEWER

Indicator	Points	Payment stages
CHD001. The contractor establishes and maintains a register of patients with CHD.	4	–
CHD002. The percentage of patients with coronary heart disease in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHG or less.	17	53–93%
CHD007. The percentage of patients with coronary heart disease who have a record of influenza immunisation in the preceding 1 August to 31 March.	7	56–96%
CHD005. The percentage of patients with coronary heart disease with a record in the previous 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken.	7	40–90%
CHD006. The percentage of patients with a history of myocardial infarction (from 1 April 2011) currently treated with ACE (or ARB if ACE intolerant), aspirin or an alternative anti-platelet therapy, beta blocker and statin.	10	60–100%

Heart failure (HF)

OPEN IN VIEWER

Indicator	Points	Payment stages
HF001. The contractor establishes and maintains a register of patients with heart failure.	4	–
Initial diagnosis
HF002. The percentage of patients with a diagnosis of heart failure (diagnosed after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment.	6	50–90%
HF003. In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, the percentage of patients who are currently treated with an ACE-I or ARB.	10	60–100%
HF004. In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction who are currently treated with an ACE-I or ARB, the percentage of patients who are additionally currently treated with a beta-blocker licensed for heart failure.	9	40–65%

Hypertension (HYP)

OPEN IN VIEWER

Indicator	Points	Payment stages
HYP001. The contractor establishes and maintains a register of patients with established hypertension.	6	–
HYP006. The percentage of patients with hypertension in whom the last blood pressure reading (measured in the previous 12 months) is 150/90 mmHG or less.	20	45–80%

Peripheral Arterial Disease (PAD)

OPEN IN VIEWER

Indicator	Points	Payment stages
PAD001. The contractor establishes and maintains a register of patients with peripheral arterial disease.	2
PAD002. The percentage of patients with perhipheral arterial disease in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHG or less.	2	40–90%
PAD004. The percentage of patients with peripheral arterial disease with a record in the preceding 12 months that aspirin or an alternative anti-platelet is being taken.	2	40–90%

Stroke and transient ischaemic attack (TIA)

OPEN IN VIEWER

Indicator	Points	Payment stages
STIA001. The contractor establishes and maintains a register of patients with stroke or TIA.	2	–
STIA008. The percentage of patients with a stroke or TIA (diagnosed on or after 1 April 2014) who have a record of a referral for further investigation between 3 months before or 1 month after the date of the latest recorded stroke or TIA.	2	45–80%
STIA003. The percentage of patients with a history of TIA or stroke in whom the last blood pressure reading (measured in the previous 12 months) is 150/90 mmHG or less.	5	40–75%
STIA009. The percentage of patients with TIA or stroke who have had influenza immunisation in the preceding 1 August to 31 March.	2	55–95%
STIA007. The percentage of patients with a stroke shown to be non-haemorrhagic or have a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent or an anti-coagulant is being taken.	4	57–97%

Diabetes mellitus

OPEN IN VIEWER

Indicator	Points	Payment stages
DM017. The contractor establishes and maintains a register of all patients aged 17 or over with diabetes mellitus, which specifies the type of diabetes where a diagnosis has been confirmed.	6	–
Ongoing management
DM002. The percentage of patients with diabetes on the register in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHG or less.	8	53–93%
DM003. The percentage of patients with diabetes on the register in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHG or less.	10	38–78%
DM004. The percentage of patients with diabetes on the register whose last measured total cholesterol (measured within the preceding 12 months) is 5 mmol/l or less.	6	40–75%
DM006. The percentage of patients with diabetes on the register with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are treated with ACE-I (or ARBs).	3	57–97%
DM007. The percentage of patients with diabetes on the register in whom the last IFCC-HbA1c is 59mmol/mol or less in the preceding 12 months.	17	35–75%
DM008. The percentage of patients with diabetes on the register in whom the last IFFC-HbA1c is 64mmol/mol or less in the preceding 12 months.	8	43–83%
DM009. The percentage of patients with diabetes on the register, in whom the last IFCC-HBA1c is 75mmol/mol or less in the preceding 12 months.DM018. The percentage of patients with diabetes, on the register,who have had influenza immunisation in the preceding 1 August to 31 March.	5	50–90%
DM012. The percentage of patients with diabetes on the register with a record of a foot examination and risk classification: (1) low risk (normal sensation, palpable pulses); (2) increased risk (neuropathy or absent pulses); (3) high risk (neuropathy or absent pulses plus deformity or skin changes or previous ulcer); or (4) ulcerated foot within the preceding 12 months.	4	50–90%
DM014. The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months of being entered onto the diabetes register.	11	40–90%

Asthma (AST)

OPEN IN VIEWER

Indicator	Points	Payment stages
AST001. The contractor establishes and maintains a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months.	4	–
Initial diagnosis
AST002. The percentage of patients aged 8 or over with asthma (diagnosed on or after 1 April 2006) on the register with measures of variability or reversibility recorded between 3 months before and any-time after diagnosis.	15	45–80%
AST003. The percentage of patients with asthma on the register who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using the 3 RCP questions.	20	45–70%
AST004. The percentage of patients with asthma aged 14 or over and who have not attained the age of 20 on the register in whom there is a record of smoking status in the preceding 12 months	6	45–80%

Chronic obstructive pulmonary disease (COPD)

OPEN IN VIEWER

Indicator	Points	Payment stages
COPD001. The contractor establishes and maintains a register of patients.	3	–
COPD002. The percentage of all patients with COPD diagnosed on or after 1 April 2011 in whom the diagnosis has been confirmed by post bronchodilator spirometry between 3 months before and 12 months after entering onto the register.	5	45–80%
COPD004. The percentage of patients with COPD with a record of FeV1 in the previous 12 months.	7	40–75%
COPD005. The percentage of patients with COPD and Medical Research Council dyspnoea grade >3 at any time in the preceding 12 months, with a record of oxygen saturation value within the preceding 12 months.	5	40–90%
COPD007. The percentage of patients with COPD who have had influenza immunisation in the preceding 1 August to 31 March. 5	6	57–97%

Dementia

OPEN IN VIEWER

Indicator	Points	Payment stages
DEM001. The contractor establishes and maintains a register of patients diagnosed with dementia.	5
DEM002. The percentage of patients diagnosed with dementia whose care has been reviewed with a face-to-face review in the preceding 12 months.	15	35–70%
DEM003. The percentage of patients with a new diagnosis of dementia recorded in the preceding 1 April to 31 March with a record of FBC calcium, glucose, renal and liver function, thyroid function tests, serum Vitamin B12 and folate levels recorded between 6 months before or after entering on to the register.	6	45–80%

Depression

OPEN IN VIEWER

Indicator	Points	Payment stages
DEP003. The percentage of patients aged 18 or over with a new diagnosis of depression in the preceding 1 April to 31 March who have been reviewed not earlier than 10 days after and not later than 36 days after the date of diagnosis.	10	45–80%

Mental health

OPEN IN VIEWER

Indicator	Points	Payment stages
MH001. The contractor establishes and maintains a register of patients with schizophrenia, bipolar affective disorder and other psychoses and other patients on lithium therapy.
Ongoing management
MH002. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a comprehensive care plan documented in the record, in the preceding 12 months agreed between individuals, their family and/or carers as appropriate.	6	40–90%
MH003. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 12 months.	4	50–90%
MH007. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 12 months.	4	50–90%
MH008. The percentage of patients aged 25 or over who have not attained the age of 65 with schizophrenia, bipolar affective disorder and other psychoses whose notes record that a cervical screening test has been performed in the preceding 5 years.	5	45–80%
MH009. The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 9 months.	1	50–90%
MH010. The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 4 months.	2	50–90%

Cancer (CAN)

OPEN IN VIEWER

Indicator	Points	Payment stages
CAN001. The contractor establishes and maintains a register of all cancer patients defined as a register of patients with a diagnosis of cancer, excluding non-melonotic skin cancers, diagnosed on or after 1 April 2003.	5	–
CAN002. The percentage of patients with cancer diagnosed within the preceding 15 months who have a patient review recorded as occurring within 3 months of date of diagnosis.	6	50–90%

Chronic kidney disease (CKD)

OPEN IN VIEWER

Indicator	Points	Payment stages
CKD001. The contractor establishes and maintains a register of patients aged 18 or over with CKD (US National Kidney Foundation: Stage 3 to 5 CKD).	6	–
CKD002. The percentage of patients on the CKD register in whom the last blood pressure reading, measured in the preceding 12 months, is 140/85 mmHG or less.	11	41–81%
CKD003. The percentage of patients on the CKD register with hypertension and proteinuria who are currently treated with an (ACE-I) (ARB).	9	45–80%
CKD004. The percentage of patients on the CKD register whose notes have a record of a urine albumin:creatinine ratio (or protein:creatinine ratio) test in the preceding 12 months.	6	45–80%

Epilepsy (EP)

OPEN IN VIEWER

Indicator	Points	Payment stages
The contractor establishes and maintains a register of patients aged 18 years or over receiving drug treatment for epilepsy.	1	–

Learning disabilities

OPEN IN VIEWER

Indicator	Points	Payment stages
LD003. The contractor establishes and maintains a register of patients with learning disabilities.	4	–

Osteoporosis: Secondary prevention of fragility fractures

OPEN IN VIEWER

Indicator	Points	Payment stages
OST0014. The contractor establishes and maintains a register of patients: 1) aged 50 or over who have not attained the age of 75 with a record of a fragility fracture on or after 1 April 2012 and a diagnosis of osteoporosis confirmed on DXA scan, and 2) aged 75 or over with a record of a fragility fracture after 1 April 2012.	–	–
OST002. The percentage of patients aged 50 or over who have not attained the age of 75 with a fragility fracture on or after 1 April 2012 in whom osteoporosis is confirmed on DXA scan, who are currently being treated with an appropriate bone sparing agent.	3	30–60%
OST005. The percentage of patients aged 75 or over with a record of a fragility fracture on or after 1 April 2014 and a diagnosis of osteoporosis who are currently being treated with an appropriate bone sparing agent.	3	30–60%

Rheumatoid Arthritis (RA)

OPEN IN VIEWER

Indicator	Points	Payment stages
RA001. The contractor establishes and maintains a register of all patients aged 16 and over with rheumatoid arthritis.	1	–
RA002. The percentage of patients with rheumatoid arthritis, on the register, who have had a face-to-face annual review in the preceding 12 months.	5	40–90%

Palliative care

OPEN IN VIEWER

Indicator	Points	Payment stages
PC001. The contractor establishes and maintains a register of all patients in need of palliative care/support irrespective of age.	3	–
Ongoing management
PC002. The contractor has regular (at least 3 monthly) multi-disciplinary case review meetings where all patients on the palliative care register are discussed.	3	–

Public health domain

Cardiovascular Disease – Primary Prevention (CVD-PP)

OPEN IN VIEWER

Indicator	Points	Payment stages
CVD-PP001. In those patients with a new diagnosis of hypertension aged 30 or over and who have not attained the age of 75, recorded between the preceding 1 April to 31 March (excluding those with pre-existing CHD, diabetes, stroke and/or TIA), who have a recorded CVD risk assessment score (using an assessment tool agreed with the NHS Commissioning Board (CB)) of ≥ 20% in the preceding 126 months; the percentage who are currently treated with statins.	10	40–90%

Blood Pressure (BP)

OPEN IN VIEWER

Indicator	Points	Payment stages
BP002. The percentage of patients aged 45 or over who have a record of blood pressure measurement in the preceding 5 years.	15	50–90%

Obesity (OB)

OPEN IN VIEWER

Indicator	Points	Payment stages
OB001. The contractor establishes and maintains a register of patients aged 16 or over with a BMI ≥ 30 in the preceding 12 months.	8

Smoking (SMOK)

OPEN IN VIEWER

Indicator	Points	Payment stages
SMOK002. The percentage of patients with any or any combination of the following conditions: CHD, PAD, Stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar disorder or other psychoses whose notes record smoking status in the preceding 12 months.	25	50–90%
SMOK003. The contractor supports patients who smoke in stopping smoking by a strategy which includes providing literature and offering appropriate therapy.	2
SMOK004. The percentage of patients aged 15 or over who are recorded as current smokers and have a record of an offer of support and treatment within the preceding 24 months.	12	40–90%
SMOK005. The percentage of patients with any or any combination of the following conditions: CHD, PAD, Stroke or TIA, hypertension, diabetes, COPD, CKD, asthma, schizophrenia, bipolar disorder or other psychoses who are recorded as current smokers and have a record of an offer of support and treatment within the preceding 12 months.	25	56–96%

Public health (ph) domain – additional services sub domain

Cervical screening (CS)

OPEN IN VIEWER

Indicator	Points	Payment stages
CS001. The contractor has a protocol that is in line with national guidance agreed with the NHS CB for the management of cervical screening, which includes staff training, management of patient call/recall, exception reporting and the regular monitoring of inadequate sample rates.	7
CS002. (England) The percentage of women aged 25 or over who have not attained the age of 65 whose notes record that a cervical screening test has been performed in the preceding 5 years.	11	45–80%
CS004. The contractor has a policy for auditing its cervical screening service, and performs an audit of inadequate cervical screening tests in relation to individual sample takers at least every 2 years.	2

Maternity services (MAT)

OPEN IN VIEWER

Indicator	Points	Payment stages
MAT001. Ante-natal care and screening are offered according to current local guidelines and the NHS CB.	6

Contraception (CON)

OPEN IN VIEWER

Indicator	Points	Payment stages
CON001. The contractor establishes and maintains a register of women aged 54 or under who have been prescribed any method of contraception at least once in the last year or other clinically appropriate interval, e.g. last 5 years, for an IUS.	4
CON003. The percentage of women on the register prescribed emergency hormonal contraception one or more times in the preceding 12 months by the contractor who have received information from the contractor about long acting reversible methods of contraception at the time of, or within 1 month of, the prescription.	3	50–90%

Know the rules

Despite the excellent achievements, QOF remains complex and it is therefore important to ensure that you remain abreast of the changes and plan to review your QOF management strategy each year (see over).

Plan your strategy at the start of the year

Planning is essential to maximise QOF income. It is too late to do much about unmet targets if failure to achieve the required standards is flagged too late in the year. Prior to the start of the financial year, have a meeting:

Do the sums. Whilst it is a quality framework, it is important that the practice is still working efficiently and is not investing more time in, than income it is going to receive from, the work undertaken.

Work at your QOF targets all year

Ensure regular internal interim QOF reviews. If the practice is falling behind on one standard, then have a drive to increase achievement levels. In addition to recording for clinical targets, make a record of evidence supporting organisational markers met, to facilitate future PCO visits.

Involve the whole team effectively

The income generated by the QOF affects the whole practice. All staff, including receptionists and administration staff, should be aware of this and take responsibility for achieving the maximum QOF points available. If staff are not getting involved with maximising QOF achievement, is it because they do not understand the importance, in health and financial terms? Alternatively, is it because they feel they don’t have time, it’s not their job, etc?

Make sure that everyone knows what they should be doing. Consider staff training sessions, reviewing job descriptions and changing induction procedures to ensure staff understand why maximising QOF achievement is important and what their roles in that objective are.

Use your practice computer effectively

All licensed GP software includes mechanisms to record QOF data. Since searches are done on specific Read codes, it is important to ensure that the correct Read codes are entered to enable the computer to extract all relevant information. Every system does this slightly differently so it is important to ensure that everyone entering data is aware of how to do it and which terms they should be using on your system.

Many software systems include review programmes or disease templates. The clinician (or another staff member) can work through the programme for any given QOF domain (e.g. heart failure) and the programme will automatically prompt the clinician to enter the information required and code it using the correct Read codes. Another feature on many systems is a summary of each QOF domain. This can be accessed via the patient’s notes to establish whether the patient should be included on the disease register and what other information is needed. Often this information can be entered directly through the QOF summary screen into the patient’s notes and again the correct Read codes are automatically supplied.

Most systems also enable practices to insert prompts for anyone using the system. For example, a box may flash up reminding users that the patient is on specific disease registers, has an overdue smear, needs a coil check, etc. when that patient’s notes are accessed. This can be an effective way to remind clinicians and other staff to ensure data needed for the QOF is collected or other tasks are done, but if prompt boxes appear on every screen, it is easy for staff to start to ignore them. Ensure that any prompts are correct and conform to current policy. For example, if the routine immunisation schedule changes, then it is important to ensure that new prompts are inserted at the correct time reflecting these changes. Failure to do so can result in children not being called for immunisations and vaccination targets being missed.

Make good use of other IT tools including add-on management and planning tools such as ‘Contract Manager’.

Actively target specific patient groups

Targeting specific patient groups is important to achieve maximum QOF points for several reasons.

Maximise points for patients on multiple disease registers

Many patients have multiple chronic diseases. For example, it is not uncommon for a single patient to be obese, a smoker, have coronary heart disease, chronic obstructive pulmonary disease, chronic kidney disease, diabetes mellitus and a history of stroke. That patient is very valuable to the practice as he or she can potentially contribute to a high amount of QOF points for the practice. It is important to make sure that reviews for these multiple category patients take place as missing reviews can affect multiple targets. There are many common elements in the reviews required for several of these domains, so combining routine reviews for all the conditions affecting that patient is a cost- and time-effective way of maximising QOF points for a practice. Measure and record all relevant information about a patient in one visit using templates, reminders, etc. to make sure that you don’t miss anything.

Scrutinise exception reporting

Patient exception reporting applies to those indicators in the clinical domain of the QOF where the level of achievement is determined by the percentage of patients receiving the designated level of care. There is a considerable variation in exception rates across the indicators. In general, the lowest exception rates are observed in relation to indicators that measure a process, such as recording smoking or blood pressure. The highest exception rates are observed in relation to indicators that measure outcome, such as HbA1c level.

Look at your practice exception rate compared with national and local figures. If you are excepting too many patients, check that you can justify your exceptions. If you are excepting too few patients, look at your disease registers and the exception criteria. Is there anyone else on the disease register who should be excepted?

Prevalence

Prevalence is defined as a measure of the burden of a disease or health condition in a population at a particular point in time.

QOF prevalence rate equals the total number of patients on the QOF register calculated as a proportion of the total number of patients registered with the practice. The QOF prevalence rate is based on the total number of persons registered with the practice – taken from the practice list size – at one point in time. The formula for the calculations is said to be very crude as it does not necessarily take into account variations between practices.

The Information Services Department of the Scottish NHS service provides a useful summary of QOF and prevalence and can be accessed via: www.isdscotland.org/isd/3367.html.

Post-payment verification

In addition to your PCO’s visit, practices may be chosen at random for a post-payment verification visit. PCOs use different methods for selecting the practices that will receive a post-payment verification visit, which is usually carried out during the summer each year. Some PCOs simply pull names from a hat. This process ensures that the system is randomised. It does, however, mean that some practices will never be selected and others may be selected 3 years in a row for the visit. The visit is normally carried out by a neighbouring PCO who will spend perhaps a day within the practice scrutinising systems to ensure that payments have been valid. PCOs will offer advice to practices going through the process. Practices who have been deemed to have claimed inappropriately may be required to reimburse their PCO for the area identified.

Premises

Practices have historically received funding to support the running of their premises in the form of notional rent or cost rent reimbursements. Funding for premises is now drawn from one centrally funded cash limited budget, which is managed by NHS England have discretion. Practices considering new premises and requiring income in the form of either capital investment or revenue should liaise with their Local Area Team as early as possible in the process. Under the juristiction of the GMS Premises Cost Directions (2013) the Local Area Team will need to identify funding and ensure that it is outlined within their strategic development plans. They are at liberty to refuse funding if they do not feel it is money well spent. It is worth bearing in mind that you will be competing for funding against clinical services; therefore, it is imperative that you have a robust business case for any proposed premises development and that you have the support of a project management team who are equipped to advise in these matters. There are many commercial organisations who can offer this service.

Information technology

Since nGMS, CCGs are directly responsible for funding 100% of IT costs which include:

As CCGs are responsible for funding IT hardware and software systems they are also the owners of the equioment.. Responsibility for refreshing I.T. equiment also sits with the CCG.

Practices should also be mindful of the GP Systems of Choice Commitment (GPSOC), and once they have signed up to this document should liaise with their CCGs before purchasing any software or equipment that falls outside of the remit of the PCO to ensure that it fits within the framework of the GPSOC.

Seniority

Seniority is defined as a loyalty payment. It is a process that rewards length of service within the NHS, rather than applying to just those years since registration or as a GP. The rules, however, have been revised under nGMS. The contract now rewards every year’s extra service with an increase in payment.

It has recently been agreed that seniority payments will end on 31 March 2020. If GPs are already in receipt of payments at 31^st March 2014 they will continue to receive payments and progress. There are to be no new entrants from 1^st April 2014. The itnention if to reinvest any savings into core funding.

Differences between the nGMS contract and PMS contract

The nGMS contract is a nationally agreed, locally managed contract. The PMS contract is a locally agreed, locally managed contract. It alters the way the primary care providers, not individual doctors, are paid. As decision-making is closer to the patient and more flexible, theoretically PMS contracts can be adjusted to meet local needs better and are freer to innovate to solve problems. At the time of writing, many PCOs are questioning the value of PMS contracts. Some PCOs have withdrawn them altogether as contract values were often higher in comparison to GMS contracts.

Benefits of PMS

External evaluation of the PMS pilots demonstrated that, compared with the old GMS contracting arrangements, the new PMS arrangements provided greater opportunities for reforming the delivery of primary care. Whether these differences will be maintained relative to the new GMS contract is unclear.

Current situation

More than 40% of GPs in England now work under PMS contracts. Even though the GMS contract has recently undergone radical reform, the option to become or stay a PMS practice remains. In fact, since 1 April 2004, PMS has stopped being a pilot scheme and has become a permanent alternative contracting arrangement.

Application to become a PMS practice

Until recently, to become a PMS practice, applications had to be made centrally in waves, with a deadline of application for each wave. Since PMS ceased to be a pilot scheme, the application procedure has changed. Now practices must apply through their local PCO and there are no longer any deadlines for applications.

At a time when the GMS contract has undergone such a radical shake up, the decision to become a PMS practice is perhaps more difficult than it has been for practices in the past. Earlier PMS pilot practices have been able to identify clear benefits to patient care, practice administration and even practice finances. However, as the edges of the PMS and GMS contracts blur and similarities outweigh differences, the choice may be more difficult to make.

Eligibility to become a PMS provider

PCOs can enter into PMS contracts with:

The conditions of eligibility are stated within the 2004 PMS Agreements Regulations.

Elements of the PMS contract

From 1 April 2004, all new PMS agreements will need to comply with the requirements of the 2004 PMS Agreements Regulations. A list of points that should be included in all new PMS contracts is included in Table 3.5.

OPEN IN VIEWER

Table 3.5.

Points to include in PMS agreements.

Point	Notes
Parties to the agreement	PCT and PMS provider
Type of agreement	PMS/PMS Plus
Start date and duration	Start date, review date and/or duration (if required)
Performers	Name of people providing the services. PMS providers have the right to subcontract and the PMS contract should include details of any subcontractors.
Services	Except where a provider provides ‘essential services’ there is no necessity to mimic the nGMS contract.
Address	Address where services will be provided
Population	Can be defined in several ways depending on the nature of the contract:
	• Practice list based	• Wider, e.g. drop in centre, OOH centre
	• Specific patient group, e.g. homeless	• Catchment/practice area
Registration	‘Registration’ applies only to patients being provided with essential services; however, a patient list is usually required.
Performance monitoring, reporting and incentives	Should include: • Quality and incentive arrangements • Specific incentive schemes, e.g. prescribing scheme, practice-led commissioning (where a practice is given a budget to commission secondary care services)In all cases the review period and process should be clearly stated.
Patient information	Practice leaflet
Common standards	Several elements of the nPMS contract are covered by regulations and common standards which should be included in the PMS agreement where relevant. These include:
	• Storage of vaccines • Infection control • Notifications of deaths • Certification • Prescribing/dispensing • Registration of gifts • Patient charges • OOH quality standards • Complaints procedure • Training of GP registrars • GP appraisal • Notification of changes in partnership	• Obligation to perform services with reasonable care and skill • Clinical governance • Insurance/indemnity • Compliance with relevant legislation • Confidentiality • Rights of entry • Cooperation with investigations/inquiries • Use of accredited IT systems
PCT support arrangements	E.g. supporting appraisal of staff, locum provision, partial reimbursement of locum costs, etc.
Dispute resolution	The PMS regulations contain extensive provisions for dispute resolution. The exact process depends on whether the provider is a health service body and thus has an NHS contract or whether the provider has a ‘contract at law’.
Price of the contract	See financial contract.
Termination of Contract Signatories	Period of notice required to terminate the contract (usually 6 months) .

PMS contracts do not necessarily contain all the elements of the nGMS contract and may contain others in addition. Practices do not claim for each individual service, but are paid to provide a package of services. How the practice provides those services is up to the practice. Most PMS budgets consist of:

The financial contract

The ‘contract price’ is based on the previous financial year’s income from GMS/PMS. As well as checking the figures are correct, it is also important to highlight any areas where income was particularly low due to a specific reason. For example, a partnership vacancy can result in loss of income. Negotiate to have this deficit allowed for in the final budget offer.

‘Variables’ can be negotiated out of the financial package such as rent, business rates, clinical waste, prescribing costs and business rates. In essence, this is asking the PCT to carry the risk element of the financial package.

In the past, new PMS practices were eligible to apply for growth money from a central fund to enable them to develop services. Since transfer of administration of the PMS contract to local PCOs, there has been no further central growth money funding for PMS initiatives. Any growth money, whether it be for PMS or GMS, will have to be found locally.

Therefore, a PMS practice NHS budget includes:

Health service body status

It is the choice of the PMS contractor whether or not to be a health service body. However, all providers have health service body status unless they actively choose (in writing to their PCO) to opt for a ‘contract at law’.

Practices with health service body status have NHS contracts with their PCO. An NHS contract is an arrangement between one health service body and another for the provision of goods and services. The major advantage of being a health service provider is that the dispute process is simpler and less costly. Practices without health service body status have a normal business contract with their PCO. For more information on health service body status, see page 3-04.

The QOF and the PMS contract

Mechanisms for quality delivery and the quality framework are broadly comparable for nGMS and PMS practices. PMS practices can apply for aspiration payments and achievement payments in the same way as nGMS practices. However, in order to reflect the local nature of the contracts, standards PMS practices are working to do not have to be the same as those contained in the national QOF. Nevertheless, all standards must be:

All PMS practices have the option to enter into the QOF. However, to ensure comparability with GMS practices, there will be a reduction of points from overall quality points scored to reflect payments which are already within PMS baselines. The amount of points deducted may vary from year to year and will be at the discretion of the Department of Health.

Transfer back from PMS to nGMS

PMS practices retain their right of return to GMS. There is a ‘commitment’ to fair financial arrangements on transfer to nGMS; however, maintenance of practice income is not guaranteed.

APMS

This contracting route (again through a locally negotiated contract) gives the NHS the flexibility of contracting with non-NHS bodies. These bodies can be commercial companies, voluntary providers or other practices so that enhanced or additional primary services can be offered to a cohort of patients who are registered with a practice who is not offering that particular service. Entrepreneurial practices can also run an APMS contract alongside their existing GMS or PMS contracts to provide ‘additional’ services that meet local needs or objectives. Some practices have set up limited companies as a vehicle for delivery of the contract, thus keeping their partnership business (the practice) and their provider status separate.

References and further information:

Department of Health, GMS statement of financial entitlements 2004/2005, Consultation Document, December 2003.

National Health Service (General Medical Service – Premises Costs) (England) Directions 2004, www.dh.gov.uk/assetroot/04/07/68/20/04076320.pdf.

Primary Care Contracting: www.primarycarecontracting.nhs.uk.

Statutory Instrument 2004 No. 291: The National Health Service (General Medical Services Contracts) Regulations 2004 (HMSO) – available from www.legislation.hmso.gov.uk/si/si2004/20040291.htm.

The General Medical Services (GMS) contract – available from www.dh.gov.uk (under Primary Care Contracting in the A–Z index).

The General Medical Services Contract news – http://www.nhsemployers.org/PayAndContracts/GeneralMedicalServicesContract/Pages/Contract.aspx

NHS Confederation: GMS contract supplementary documents – available from www.nhsconfed.org/gms/default.asp.

BMA: FAQs and Focus on . . . series – available from http://www.bma.org.uk/ap.nsf/Content/gms2update240404#FocusonGuidanceNotes.

Simon Cartwright. Contract 2003: A GP’s guide to earning the most. Butterworth–Heinemann, 2003.

Department of Health, Sustaining innovation through PMS development, 2003, www.dh.gov.uk.

The National Health Service (Personal Medical Services Agreements) Regulations (2004) Statutory Instrument 2004 No. 627, The Stationery Office: www.legislation.hmso.gov.uk/si/si2004/20040627.htm.

PMS Agreements Framework Version 3.1, 2004: www.napc.co.uk.

Bookkeeping

Bookkeeping is the basic recording of the business transactions. These transactions will usually be recorded in the cashbook and petty cash book.

Cashbook

The purpose of the cashbook is to record all the income and expenditure that passes through the bank account. This should be kept accurate and up to date.

An example of a manual cashbook is shown overleaf, although many practices these days will have computerised accounts packages. The cashbook is set out in a columnar format. The right hand side of the cashbook is used to record the income and the left hand side records the expenses. In both instances, there will be a total column with several columns to the right, which are used to analyse the income or expenses in categories.

The cashbook should be written up each month using the remittance advices, paying-in books and cheque stubs. For each income transaction, the details that need to be recorded are the date received, the details of the income, the source, the paying-in number (if applicable) and the amount. Each entry of income should then be analysed under the appropriate heading. The amount will therefore be entered twice, once under the total column and once under the analysis column. For each payment transaction, the details that need to be recorded are the date paid, the details of the payee, cheque number and amount. Each payment should then be analysed under the appropriate expenses heading. The entries in the cashbook are recorded for each month, and at the end of the month the columns should be totalled. The total of the analysed columns should agree to the total of the total column.

For computerised packages, you would still be required to enter the date received/paid, details of income/expenses, cheque number/paying-in number, the amount and also what category of income or expenses the transaction should be allotted to.

Transactions that are recorded in the cashbook must be supported by documentary evidence (see section on records that need to be kept). This provides a trail so that if you need to check entries in the cashbook, these can easily be traced.

Bank reconciliations

At the end of each month, the cashbook should be reconciled to the bank statement to ensure all entries in the bank have been recorded and are accurate.

The reasons why the cashbook balance (see below for explanation of this) and the balance per the bank statement may differ are because of:

The bank reconciliation should be prepared to the last day of each month. Suggested stages of preparing the bank reconciliation are as follows:

Bank reconciliation

OPEN IN VIEWER

Balance per bank statement as at 31 March 2009				5691.00
Add:	Outstanding lodgements (i.e. payments into the bank not yet showing on the bank statement)			250.00
		Chq No
Less:	Outstanding cheques (i.e. cheques which have not yet shown on the bank statement)	000123000125000126000129000131	125.003425.00 46.00257.00547.00	5941.00
				(4400.00)
Cashbook balance (this should agree to the computer bank balance)				1541.00*

Cashbook bank control (if computerised package, this is what the computer is doing)

OPEN IN VIEWER

Opening cashbook balance as at 1 March 2009	2457.00
Add: Receipts per cashbook	26489.00
Less: Payments per cashbook	(27405.00)
Closing cashbook balance as at 31st March 2009	1541.00*
(this will be the opening balance for next month)

*

If these two figures do not agree you must have made an error.

Petty cash

Most practices will have petty cash that they use to pay for low value items, e.g. milk, stamps, etc. The transactions that are in cash should be recorded in a ‘petty cash book’. Each transaction should be supported by documentary evidence, e.g. a receipt or petty cash voucher.

It is advisable that income received in cash for signing passports and for travel vaccinations be kept separately and banked. Money should then be drawn from the bank account each month for the petty cash tin. This ensures that all of the cash income is recorded and accounted for.

Alternatively, if the practice receives a lot of income in cash, they may prefer to use this cash to pay for cash expenses, instead of going to the bank to draw the cash out. However, it is extremely important that all cash coming in is recorded and accounted for, for Inland Revenue purposes.

Petty cash should be reconciled each month to the amount of money left in the petty cash tin as follows:

Money in petty cash tin at start of the month x

Add: Cash drawn from the bank and/or cash x income received in private fees into tin (if cash income has been paid into the bank this can be ignored)

Deduct: Petty cash expenses per book (x) balance of cash; this should tally with the amount of x cash in the petty cash tin.

Imprest system

Practices may wish to use the ‘imprest system’ for controlling petty cash. This is where a set amount is used as a running balance for each month. At the end of the month, a transfer from the bank would be made so that the money in the petty cash tin was the same at the start of the month, e.g.

Cash in tin at start of month £100

Cash expenses £(60)

Balance of cash in tin £40

Cash drawn from bank for next month £60

Cash in tin at start of next month £100

Therefore, whenever you counted the petty cash, the cash plus expense receipts would always equal £100.

Control of the petty cash tin should be limited to as few staff as possible and kept under lock and key. This is an area where money can be misappropriated.

Records that need to be kept

There should be documentary evidence to support all transactions for Inland Revenue purposes. It is advisable that the following records are kept for maintaining the cashbook.

Budget setting and the cashflow forecast

It is a useful management tool to prepare a budget and cashflow forecast for the forthcoming year. A budget is a predication of the profitability of the practice. This will take into account all income that is receivable in the year and all expenses that are payable, e.g. a practice with a 31 March year end should include the income for the QOF achievement in their budget, even though it will not be received until after the year end. This is included as it is income that has been earned in the practice year.

The cashflow is quite different from the budget as it looks at the actual income and outgoings and when they are physically received or paid into/from the bank account. In the example of a practice with a March year end, their budget for the year would include the QOF achievement payment, but the cashflow would only include the monthly aspiration payment. This is because the income would be paid into the bank account after the year end. Another difference is that the budget looks at profitability, whereas the cashflow looks at the liquidity of the practice.

How to prepare a cashflow forecast

The cashflow is based on the budget for the income and expenditure received and paid. You need to enter all the income in the months that it is expected to be physically received into the bank account, e.g. the income for the QOF is going to be paid as an aspiration payment and then an achievement payment at the end of the year once the actual points achieved are known. The amount of detail needed in your cashflow will vary. All the incomings for each month should be added together so you have a total income for the month.

Next, you need to record all the outgoings from the practice bank account. This will include the practice expenses per the budget, the partners’ drawings, tax, repayment on loans and also cost of purchasing any equipment. You should record the outgoings when they will happen, e.g. partners’ tax is only paid in January and July. Also include the total amount for the outgoing, e.g. paying a loan, the budget should only include the interest cost of a loan, but the cashflow will show the monthly payment.

All the outgoings for each month should be added together to give a total for the month.

To calculate the effect on the cashflow for each month, you need to add the incomings to the surplus/deficit brought forward at the start of the month. From this you need to deduct the total outgoings for the month; this will give you the expected surplus/deficit of cash at the end of the month. This amount is then carried forward as the surplus/deficit at the start of the next month.

Following is an example of a budget and a simple cashflow forecast for a practice.

OPEN IN VIEWER

Dr Ramsay and Partners – Income and Expenditure Budget – 1 April 2012-31 March 2013
INCOME	Year ended
	31 March 2013
GMS income
Global sum	198,962
Employers superannuaton for GPs	(25,200)
Cost to opt out of out-of-hours (6% of global sum)	(11,938)
MPIG correction factor	41,168
QOF aspiration 2008/2009	36,505
QOF achievement 2007/2008	24,337
Enhanced service
Age 2	3,885
Age 5	1,408
Flu	2,548
Reimbursements
Rent	0
Rates and water rates	0
Computer maintenance	0
Drugs and vaccinations – PPA reimbursement	12,000
Other fees
Private fees	8,000
TOTAL INCOME	291,675
EXPENDITURE
Staff salaries	107,000
Staff welfare	600
Staff training	500
Locum	2,000
Drugs	10,000
Medical supplies and instruments	1,500
Rent	0
Rates and water rates	0
Heat and light	2,300
Insurance	1,000
Repairs and maintenance	1,500
Computer maintenance	0
Printing, postage and stationery	2,500
Telephone	2,600
Books and journals	100
Professional subscriptions	7,000
Locum insurance	500
Cleaning and laundry	2,000
General expenses	500
NHS levies	1,200
Accountancy	2,600
Bank interest and charges	300
TOTAL EXPENDITURE	145,700
NET PROFIT	145,975
Dr Ramsay and Partners – Assumptions
INCOME	Registered list 3,356; weighted list 3,549
Global sum	No account for increase in list, although the intention is to increase to 4,000 patients
QOF aspiration 2012/13	60% achieving 890 points in 2007/2008
	Not accounted for achievement payment for 2007/2008 as assumed will be kept by PCT
QOF achievement 2011/12	Achieving 890 points
Age 2	High target for 28 children
Age 5	High target for 34 children
Flu	350 patients over 65
Other enhanced services	Ignored as no other enhanced services commissioned yet
Reimbursements
Rent	100% reimbursed and therefore ignored
Rates and water rates	100% reimbursed and therefore ignored
Computer maintenance	100% reimbursed and therefore ignored
Drugs and vaccinations –	Actual expense plus 20% profit
PPA reimbursement
Other fees
Private fees	Estimated
EXPENDITURE	All expenses estimated

Income from non-NHS sources

All practices receive some income from non-NHS sources; some practices choose to undertake a lot of private work. The following should be noted:

Private fees attracted by work related to the practice’s own patients

See pages 3-18 to 3-20 ‘Private services for NHS patients’ for information and advice about the services that patients commonly request from practices.

Insurance reports

The standard paper GP report form (GPR) for insurance reports is now available electronically (eGPR). As long as patients’ notes are fully summarised on computer, eGPR cuts down on the time taken to complete reports as it automatically extracts information from the patients’ electronic record. The tool is available from the medical software companies. Practices must register at www.egpr.co.uk to use eGPR. See the GPC’s Good practice guidelines on completion of GP reports on www.bma.org for valuable advice.

The patient’s signed consent must be viewed on paper or electronically before reports are sent.

Electronically generated reports should be checked carefully and inappropriate information removed, e.g. negative HIV tests, information about third parties.

The practice is only obliged to show reports to patients who have requested to see them before they are sent, but if a report is going to contain prejudicial information, it is good practice to discuss the report with the patient before it is sent.

Medical examinations

GPs may be asked to perform insurance medicals on their own or other GPs’ patients. It is possible to increase this latter work by making a willingness to perform medicals known to insurance companies. A cancellation fee may be claimed if the patient does not attend. Other medicals that may be requested by patients include medicals for work purposes, e.g. for professional drivers, sports and flying medicals. Medicals generally require longer appointments, though patients may not say that they are coming for a medical when they book an appointment.

Firearms and shotgun certificates

Many GPs decline to sign such certificates on principle lest they find themselves feeling, or being held, responsible for a shooting, or lest they put their relationship with the patient at risk by refusing to sign. The BMA supports this choice. A doctor who is considering signing should consult the GPC guidance, which outlines the doctor’s responsibilities and describes what can and cannot be charged for.

A doctor who believes that a patient in possession of weapons is putting others at risk can disclose the information to an appropriate authority subject to the law on confidentiality, i.e. that the risk justifies the breach of patient confidentiality (see pages 8-34diii–8-34e).

Further information:

GPC guidance, www.bma.org.uk/ap.nsf/Content/Firearms.

Other sources of private income

There are many opportunities, a few of which are listed below.

Private patients

See page 3-9 ‘Private patients’. Practices near conference hotels, embassies and other places with overseas visitors may establish an agreement with those institutions about treatment of sick visitors.

Occupational health

Companies may employ GPs to provide occupational health services. For work involving more than simple pre-employment medicals, the Diploma in Occupational Health is usually required. If company employees are also practice patients, doctor and patient may find it difficult to handle the dual relationship.

Private treatment including complementary, alternative and other therapies

Suitably trained GPs can provide conventional treatments, e.g. vasectomy or complementary therapies, and can charge anyone who is not their own patient.

Provision of medical advice and services to other organisations

Possibilities include the police, sports clubs and organisations, and the media. Some posts require special training.

Research and clinical trials

There is a need for research conducted in primary care. Academic research can be very valuable and rewarding. Medical schools may recruit practices for research projects and take a lot of the hard work out of the projects. Rates of pay vary but are generally lower than research for drug companies, which pays well. Practices considering participating in research should look at the Royal College of General Practitioners’ research web pages on www.rcgp.org.uk, and the NHS Research and Development Forum site www.rdforum.nhs.uk.

Private care homes

The practice may charge if it is providing non-NHS services to a care home, e.g. advice on hygiene or staff recruitment.

Pharmacies

More and more practices are establishing professional and business relationships with pharmacists. One source of information is Your own pharmacy: a guide for GPs by Dr David Roberts, Radcliffe Medical Press, 2004, ISBN: 1857756304.

Gifts from patients to staff

Many patients wish to show their appreciation of the care they have received, and to turn away gifts of biscuits or bottles of wine at Christmas would be churlish.

In drawing up a practice policy, considerthe following:

Practice managers should refer to the Health and Social Care Act 2001 when drawing up their policy on receipt of gifts within the practice. Under this Act, practices are required to declare gifts, and indeed under the terms of the nGMS contract practices must declare any gift received over the value of £100.00. This register is not exclusive to gifts from patients and the PCO can request to view the register if they choose. See www.dh.gov.uk and follow the relevant links.

Staff parties and gifts from partners to staff

Staff parties to which all staff are invited are tax-free if the costs are less than £150/head in each year. Gifts worth less than £25 will generally be ignored by the taxman. Gift vouchers and more costly presents will be taxed, although the practice can arrange to pay the tax by making a PAYE settlement.

Staff profit shares and bonuses

The idea of reserving a percentage of the practice profits to share with staff is an attractive one when times are good. But before setting up such a scheme the pitfalls must be considered:

Staff bonuses are treated as extra salary and are subject to tax and NI deductions. If staff receive a bonus as a matter of course, the bonus is pensionable. If bonuses have been paid regularly, not paying a bonus could be seen as a breach of contract even if the contract states that bonuses are not automatically paid.

General Practitioners Council

The GPC is a standing committee of the BMA, but represents all GPs whether BMA members or not. It is the only organisation mandated to negotiate with government on behalf of GPs. GPC members are elected by the regions or by special interest groups, e.g. the Medical Women’s Federation, freelance GPs. Policy is decided at the annual conference of LMCs and the GPC elects members to negotiate with the Secretary of State or his/her appointed representatives, currently the NHS Confederation (www.nhsconfederation.org). The GPC’s guidance on contractual and employment matters is available online via the BMA website or on LMCs’ websites (see below).

There are GPCs in each of the four countries of the UK and an overarching UK GPC. See www.bma.org.uk and follow the links to GPC.

Local Medical Committee

LMCs have provided GPs with statutory representation since 1911. LMCs are not trade unions but fulfil a somewhat similar function. Every area has an LMC, its members elected by their colleagues. The chair and secretary are usually working GPs and some LMCs have the support of a professional secretariat. LMCs are funded by a statutory levy taken annually from the practice and related to the number of patients. There is also a voluntary levy, which finances the national GMS Defence Fund.

LMCs defend the profession’s interests, and those of its patients, principally to the PCOs but also to other bodies, e.g. GMC and the Royal College of Medical Practitioners (RCGP), and with hospital colleagues and management. As well as their statutory functions, they also offer advice, support and mediation to GPs and practices. They have a significant welfare role. Practice managers may ask the LMC for advice; they do not need to go through a GP.

The LMCs’ various roles are illustrated below. The degree to which an LMC can advise and support depends on the sophistication of its secretariat.

The websites of Londonwide LMCs (www.lmc.org.uk), Wessex LMC (www.lmclive.co.uk), Glasgow LMC (www.glasgow-lmc.co.uk) and Bro Taf LMC (http://work.health-central.co.uk/brotaflocmed/door/) have a lot f information and advice which is available to all.