The Practice Nurse survival guide to the General Practice Contract 2014-15
The General Practice contract may not seem like the most riveting of topics but what follows will affect every aspect of your professional life as a practice nurse
If you read our recent article on the Quality and Outcomes Framework (QOF) changes for this year, you could be excused for breathing a big sigh of relief: for the first time since their inception in 2004 the QOF burden on practice nurses straining to fill in the ubiquitous templates has actually reduced. All the imposed changes for 2013-14 have been reversed. A total of 341 ‘points’ has been removed from the QOF: 103 points have been transferred to Directed Enhanced Services; the rest have been ‘retired’ and the money transferred to general practice core funding (though the success of this money transfer has yet to be confirmed).
So far so good. But this does not mean that this year there are no new things to get to grips with. Even the ‘retired’ points will mean that templates have to be changed and got used to. Some of the ‘retired’ points relate to quality standards that may well be worth keeping, so there will need to be some careful scrutiny of templates to decide whether parts, even though no longer required for QOF purposes, are nevertheless worth retaining. For example DM011 has been retired this year (5 points): this is the one encouraging an annual retinal check for people with diabetes. This does not mean that the checks are suddenly irrelevant (diabetes is still a leading cause of blindness) so many practices will conclude that retaining the relevant tick-box represents good clinical care.
In addition there are contract changes and new Directed Enhanced Services which practice nurses must be aware of and able to assist with.
The timing game has again been played this year. A decision on this year’s changes was made last autumn. The document officially detailing these changes is dated March 2014, but was received in my practice on 9 April.1 The contract year starts on 1 April. If a doctor or nurse behaved in such a slack and untimely way he or she would be struck off, but if you are a politician or manager presumably different rules apply.
CONTRACT CHANGES
1. A named GP for all patients 75 and over
Do you remember the olden days when every patient, not just the elderly, was registered with a named GP? Well, it seems we are returning to those days. The named GP will:1
- Work with relevant associated health and social care professionals to deliver a multi-disciplinary care package that meets the needs of the patient
- Ensure that the physical and psychological needs of the patient are recognised and responded to by the relevant clinician in the practice
- Ensure the patient aged 75 years and over has access to a health check as set out in section 7.9 of the GMS Contract Regulations.
It is a new contractual requirement, but it is also something that general practice has been trying to do for many years, under the headings of ‘holistic care’ and ‘continuity of care’. The contract makes it clear that ‘taking responsibility for’ is not the same as ‘doing it all’: a named GP may have overall responsibility for a particular patient, but this does not mean that other team members (including practice nurses) will be any less involved than they were before. One change, however, is that patients must be notified of who their named GP is. Some patients may object to their allocation. Other patients may feel that as they have a named doctor then that doctor should be available for their care 24/7. There does not seem to be provision in the contract to deal with these eventualities.
Will having a named GP for all patients over 75 improve their care? The case for holistic care does not have to be repeated. A diagnosis should always be made in physical, psychological and social terms in order to be a complete explanation of the problem your patient presents.2
In 2010 the King’s Fund produced a report on continuity of care that reviewed the evidence.3 ‘Management continuity’ is one person having a grasp of the clinical and other management of a patient. This is plausibly a good thing because otherwise individual patient care gets fragmented (different doctors in the practice, out of hours care, outpatient visits – all likely to get more complex as a patient gets sicker) so that it makes sense for someone to get a grip on the total situation. The King’s Fund report cited research showing that fragmentation often occurs, but no evidence showing that having a nominated responsible person will benefit patients. There is much more evidence cited for ‘relationship continuity’ (patients always or usually seeing the same doctor) including increased patient satisfaction (which is also known to increase compliance with treatment), improved problem recognition (the known clinician more often gets the right diagnosis), and reduced costs (prescriptions, A&E attendances, hospital admissions).
The provisions of the contract appear to focus more on management continuity than on relationship continuity. So whether this part of the contract will actually deliver patient benefit is yet to be seen. From a practice point of view it will probably mean little in the way of change. What about patients under 75 who have complex needs and also require a steady hand on the management rudder? Might this contract requirement shift the emphasis towards age and away from patient need?
2. Quality of out-of-hours services
Nearly all general practices use a provider for out-of-hours patient care, irrespective of whether the GPs do work for that provider. There are good reasons for this. An out-of-hours provider has to follow a whole raft of rules and regulations which an individual general practice would struggle to comply with. Now the contract requires general practices to monitor the quality of their provider, a job previously done by NHS England.
Anyway, most practices are looking in a timely way at correspondence from their provider and following up any management plans, and also collecting and collating any complaints received. In addition, quality has to be reconciled with the ‘National quality requirements in the delivery of Out-of-Hours services: 2006’.4 Ever heard of them? No, neither had I.
3. Choice of GP practice
From October 2014 practices can, if they want, register patients who do not live in the practice area. This might make sense for patients who spend all their daytimes in one area (e.g. near to their place of work) but live somewhere else, or for patients who move house but want to stay on their old GP practice list. There will be no requirement on the practice to offer home visits to those patients, which raises an immediate question: who then will provide home visits? A working party has been set up to finalise the details of this one to see how it might work, but has yet to report.
4. Friends and family test
Last year, supported by a Directed Enhanced Service (DES), practices were encouraged to survey their patients and respond more to patient suggestions. This DES continues but has dropped the surveying bit. Instead from October 2014 practices are contractually required to ask patients one question:
‘How likely are you to recommend our practice to friends and family if they need similar care or treatment?’
The details of this (what exactly is the wording?, who should be asked?, what happens to the results?) will not be finalised until later. As always, the devil will be in the detail. What are the penalties? How good are our patients at judging the technical quality of the services they receive? It’s hardly surprising that the details have not been worked out yet. I bet any reader 50p that when the details are published that they will cause controversy.
5. CQC results
When the Care Quality Commission process is amended (yet again), then any practice visited must post their inspection outcome in the waiting room and on the practice website. This is, of course, consistent with the choice agenda so beloved by politicians of all hues, and presumably encourages patients to jump ship from a practice that gets a bad report. A survey of patients who changed their GP in Avon, albeit in 1993, suggested that distance from the surgery was the most important factor, followed closely by falling out with the GP and perceived organisational inadequacies.5 It remains to be seen whether in future CQC results will be added to this list.
6. IT changes
For next year’s contract, apparently notes on the back of envelopes and carrier pigeons are no longer adequate. Changes for now include: use of patient’s NHS number on all correspondence; offer the facility to book, view, cancel and amend appointments on-line; and offer the facility to order repeat prescriptions on-line. Changes for later (plans in place before October 2014 for implementation before April 2015) include offering patients on-line access to some parts of their medical records – at a minimum medications, allergies and adverse reactions.
DIRECTED ENHANCED SERVICES (DES)
Many of you will be familiar with these little gems. They are nationally supported initiatives to promote specific areas of patient care. Sometimes the support comes in the form of extra funding. More recently it has been usual for a new DES to be funded by monies pinched from elsewhere, invariably from the QOF. So it is requiring extra work for the same money. There may also be local support for local care initiatives, called Locally Enhanced Services (LES), and these will vary depending what part of the country you live in.
The existing DES for Dementia, Learning Disabilities, Alcohol, Extended Hours, and Patient Participation are carrying on for another year. There will be some minor adjustments for this year, but no relief from the gruesome sight of your doctors bleary-eyed after another late night or early morning surgery during which both they and their patients wish they were tucked up in bed. Because patient opinion is so highly valued by the government, the funding for the Patient Participation DES is being cut by two thirds. The DES on remote access for patients is being dropped, and the Risk Profiling DES is being taken over by the new kid on the block, the Unplanned Admissions DES.
Unplanned Admissions DES
You can understand why this is an issue. Hospital admission is an expensive business, and hospitals are inefficient. Despite seeing 90% of the patients, general practice only gets 9% of the funding.6 My practice was recently offered £40 to do a procedure which in hospital costs £140. Most patients would rather avoid hospitals.
This new DES is causing a lot of head scratching within GP practices. The scratching is partly because details only became available in April,7 after they were due to be implemented. The funding available is significant, and most practices will probably sign up to do it. This is not new money – it consists of savings from QOF points ‘retired’, and from cancellation of last year’s Risk Profiling DES. Can you spot a pattern here?
The main points are:
- Identify 2% of your patients 18 years and over who are at risk from unplanned hospital admission. A number of ways of doing this are already available, and a particular tool is not specified. The identified group are to be actively case managed.
- The practice must provide same-day telephone access for this vulnerable group.
- Practice ex-directory or bypass telephone numbers to be made available for A&E departments, hospital clinicians, ambulance services, nursing homes.
- A named accountable GP, a care co-ordinator and a care plan for every at-risk patient.
- Timely contact with at-risk patients after any hospital discharge.
- Regular review of unplanned admissions from nursing homes, and (separately) regular reviews of admissions from the at-risk group to see if they could have been avoided.
It is potentially a lot of work. My practice has 16,000 patients, very few of whom are under 18, and looks after four nursing homes, so we are looking at about 300 care plans.
The other head scratching among GPs is because nobody seems to be sure that this DES will make any difference. No evidence is offered in the available documents that this approach will either reduce unplanned admissions or improve patient care. It is plausible that it might do so, but to spend £160 million a year on an untested hypothesis seems a bit wasteful. If you Google ‘benefits of care planning’ you get 73 million hits, but most of these miss out the ‘benefits’ bit. The best stab at justification I found was a review from the Nursing Times8 but even then most of the discussion focussed on patient satisfaction, there was only one research reference to clinical benefits, and the emphasis was not on unplanned admissions.
CONCLUSION
Once again this year the GP contract has been altered, and the changes have made a lot of work, focussed a lot of attention, and generated a lot of hot air. This is now an annual ritual, and even when the box-ticking is potentially reduced ‘contract season’ is still a time when there are considerations other than seeing the patients. Most practice nurses will resent this interference in their work, and most GPs would heartily agree with them.
When the QOF first emerged, there was little effort to justify the quality indicators used. Then things got a whole lot better, and each annual QOF document actually gave a useful list of references justifying what was happening. So it is saddening to have taken a step backwards on the evidence front. If a DES is likely to work, if there is research evidence of benefit, then let us have it. Otherwise as well as being overworked, practice nurses and their GPs will suffer added cognitive dissonance*.9 *The state of mind where two conflicting views are held simultaneously, for example, knowing that smoking is harmful to your health but continuing to smoke
REFERENCES
1. GPC, NHS England, NHS Employers. General Medical Services Contract 2014-15. March 2014. http://www.nhsemployers.org/SiteCollectionDocuments/GMS-contract-guidance-audit-requirements-2014-15.pdf
2. The Future General Practitioner: Learning & Teaching. London:RCGP,1972.
3. Freeman G, Hughes J. Continuity of care and the patient experience. Kings Fund 2010 http://www.kingsfund.org.uk/sites/files/kf/field/field_document/continuity-care-patient-experience-gp-inquiry-research-paper-mar11.pdf
4. National quality requirements in the delivery of Out-of-Hours services: 2006 http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_073808.pdf
5. Billinghurst B, Whitfield M. Why do patients change their general practitioner. Br J Gen Pract 1993;43:336-8. http://www.ncbi.nlm.nih.gov/pubmed/8251218
6. Put Patients First. RCGP Campaign Brief. 2013 http://www.rcgp.org.uk/policy/~/media/Files/Policy/PPF/Put-patients-first-campaign-brief.ashx
7. Avoiding unplanned admissions enhanced service. http://www.nhsemployers.org/SiteCollectionDocuments/Avoiding%20unplanned%20admissions%20guidance%202014-15.pdf
8. Morton T & Morgan M. Examining how personalised care planning can help patients with long term conditions. Nursing Times 17 September 2009. http://www.nursingtimes.net/nursing-practice/clinical-zones/long-term-conditions/examining-how-personalised-care-planning-can-help-patients-with-long-term-conditions/5006427.article
9. McLeod S. Cognitive dissonance. http://www.simplypsychology.org/cognitive-dissonance.html