GPs hold a unique position within the NHS; in most cases, they aren’t directly employed by the NHS but are contracted to deliver healthcare and are the first point of contact for roughly 90% of patients – impressive. The contracts that GPs work under outline GP obligations and provide details of funding. We revisit this year’s updates following July’s pay award announcement
General practitioners have never been required to be employees of the NHS; they are, most often, contracted to deliver medical services to NHS patients. In the past, the majority of GP practices operated as single-handed or medical partnerships – the GP was, to all intents and purposes, a ‘business owner’.
However, the general practice landscape is changing due to increasingly complex demands on the sector, the need for investment to deliver an effective service and the transfer of medical work from hospitals into the community as providers struggle with capacity. As the structures of the care delivery required change, a distinction between the GP who provides professional services to NHS patients and the individuals who own the medical businesses those services are delivered under has developed. We have seen super-practices, federations and medical companies emerge – all of which compete for NHS general practice contracts.
The contracts that govern general practice are also influenced by changes in NHS England and the healthcare landscape. We take a look at the contracts available and the 2018/19 updates.
GP contract routes
NHS England has three main contract options which it uses to commission primary medical services:
General medical services (GMS) contracts: These deliver core medical services and are agreed nationally. The funding for these types of contract is calculated based on the practice’s registered list size with a fixed, nationally agreed, price per patient, and the actual amount paid is calculated practice-by-practice.
Personal medical services (PMS) contracts: PMS contracts provide similar core medical services to GMS contracts but can also include extra health services that are considered to be ‘over and above’ the usual core services – for example, special clinics for homeless people in areas of high need, etc. PMS contracts make it possible to address specific local health needs. The funding for PMS contracts is worked out locally.
Alternative provider medical services (APMS) contracts: APMS contracts enable primary care organisations (PCO) to commission/provide primary medical services within their area to the extent that they are necessary. First Practice Management notes that they provide the opportunity for locally negotiated contracts and allow PCOs to contract non-NHS bodies, such as voluntary or commercial sector providers, or GMS/PMS practices, to provide enhanced and additional primary medical services.
However, an article published on GP Online cautions that the awarding of GMS and PMS contracts is becoming increasingly rare, as the short-term APMS contracts are favoured.
2018/19 updates to GMS contracts
Key changes to the 2018/19 GMS – and PMS – contract have been released, agreed between NHS Employers – on behalf of NHS England and the General Practitioners Committee (GPC) of the British Medical Association (BMA). The contract for 2018/19 will see an investment of £256m of funding to address practice pressures – including practice expenses and a long-overdue pay increase.
The following information has been developed Dr Nigel Watson, chief executive of Wessex LMCs, and featured on the Somerset LMC website – where you can find further details and resources.
GP pay and expenses
In March the GPC did not accept a further pay uplift of one per cent this year; instead they agreed that, from April 1, 2018, an interim payment for GP pay and expenses will be made whilst they await the outcome of the DDRB process.
Therefore, pay was initially uplifted by one per cent and expenses’ funding uplifted in line with the Consumers Prices Index (CPI). This means that, together with the annual recycling of correction factor and seniority payments, the global sum initially rose from £85.35 to £87.92.
The BMA’s submission to the DDRB called for a significant uplift to GP pay and expenses, of Retail Prices Index (RPI) plus two per cent. Any increased uplift secured through the DDRB process will be back-dated to April 1, 2018.
Following the government’s response to recommendations by the Review Body on Doctors’ and Dentists’ remuneration (DDRB), it was announced in July that GPs will see an increase of two per cent, with pay backdated to April this year.
Indemnity increase cover
The GPC agreed a sum of £60m to cover the average uplift in indemnity for the last two years. This to be paid to practices in 2018/19 on a per-patient (unweighted) basis. Practices should ensure that an appropriate equivalent amount is passed on to any salaried GP and/or partner who pays for some or all of their indemnity cover.
As with last year, locum GPs should ensure their charges reflect their costs (including indemnity costs).
Statement of Financial Entitlement (SFE) amendments
In order to ensure all real expenses are covered, the GPC agreed that vaccinations and immunisations that are reimbursed through the SFE will be uplifted by CPI. The item of service fee for these immunisations will be uplifted from £9.80 to £10.06. It is the GPC’s intention to secure a similar inflationary increase for other immunisations as soon as possible.
Amendments to vaccinations and immunisation schedule
In addition, there are some amendments to the clinical aspects of vaccinations and immunisations through the SFE. These are summarised below:
- the three-month dose of pneumococcal has been removed from the targeted childhood immunisations scheme, based on the recommendation from the JCVI. The funding for this element of the childhood immunisation will be unaffected.
- Meningococcal ACWY (MenACWY) completing dose – the date of eligibility has changed from 1/4/15 to 1/4/12 therefore all patients within the age range are now eligible. Practices are not required to proactively offer or encourage patients to be vaccinated. Vaccination of 14-16 years is only where the patient has missed their school’s provision.
- Meningococcal B – there are no changes to the vaccinations programme; however the requirements are now defined in the SFE rather than in a service specification.
Amendments to reimbursements for locum cover for parental and sickness leave
The GPC agreed that these payments should both be increased to avoid their value eroding with inflation.
Parental leave payments will increase from £1,131.74 to £1,143.06 for the first week and £1,734.18 to £1,751.52 for subsequent weeks, and the upper amount for sickness payments will increase from £1734.18 to £1751.52.
In addition to this, the GPC has clarified the rules for locum cover reimbursement such that, from April 1, 2018, if a contractor chooses to employ a salaried GP on a fixed-term contract to provide cover, NHS England will reimburse the cost of that cover to the same level as provided for locum cover, or a performer or partner already employed or engaged by the contractor.
Electronic referral service
From October 2018 hospitals will only receive payment for standard referrals if they are made through e-RS. It is expected that CCGs will work with LMCs and practices to resolve local system issues.
While it will be a contractual requirement to use e-RS for all GP practice referrals to first, consultant-led, outpatient appointments, agreement has been reached with NHS England that they will take a supportive, not punitive, approach where circumstance dictates that practices are unable to realise this.
Guidance will be clear that this does not mean that individual GPs must use the e-RS system themselves. There are a variety of models that practices could adopt and it is for practices to determine how much of the e-RS process is done by administrative staff.
The GPC has secured £10m of investment into the contract this year to ensure practices are financially supported to implement the system. NHS England and GPC England have also agreed guidance for practices.
There are many issues that need to be resolved to ensure practices have a better referral system in the future than they currently do now including:
- IT infrastructure;
- inadequate bandwidth;
- local contingency processes;
- appropriate referral pathways;
- delays in hospitals dealing with referrals and;
- inappropriately declining referrals.
These are just some of the many issues the GPC and LMC will be working to resolve.
There will be no changes to QOF indicators for the coming year. The contractor population index (CPI) will be adjusted to reflect the changes in list size and population growth, with the value of a QOF point being adjusted to take account of this; this will mean the value of a QOF point increasing from £171.20 to £179.26.
Violent patient removal provisions
There has been agreement to clarify the regulations that already allow for patients to be refused registration where there are ‘reasonable grounds’ for doing so – having a violent patient flag on the patient’s record is considered to be a reasonable ground for refusing to register.
Premises cost directions (PCD)
There are many positive changes to the PCDs; these will be expanded upon in a specific ‘Focus on changes to the PCDs’ to be published shortly.
Changes to PCDs are further clarified by the BMA.
The GPC secured agreement on two areas which frequently arise as problems; these are for Hepatitis B immunisations for renal patients and for medical students.
- NHS England has committed to work with specialised commissioning and secondary care colleagues to ensure that it is clear that the responsibility to deliver hepatitis B vaccination to renal patients lies with the renal service and not with general practice.
- GPC, NHS England and HEE will work together to ensure all medical schools provide services for the provision of hepatitis B vaccines for medical students, to ensure that this burden does not fall to practices without appropriate funding arrangements being in place.
Finally, the GPC have agreed to work with NHS England on:
- a replacement for NHS Digital’s General Practice Extraction Service (GPES);
- use of GP appointment data which is already being extracted;
- support for practices wishing to work at scale;
- the potential of a basic practice allowance;
- the implications of the EU falsified medicines directive;
- reducing the administrative burden on practices;
- research into locum usage (working with GPC’s Sessional GPs subcommittee);
- appropriate and agreed systems for ‘freedom to speak up’ whistleblowing arrangements.
NHS Employers has published a useful guide to the changes to GMS contracts
A summary of the increases, and how they are to be applied, can be found here.