A PCT has won agreement from most of its 94 PMS and GMS GP practices to accept an expanded set of “core” and “extended” services in their contracts, and reduce variation in their funding. Dr Paul Cook and colleagues, who led the project, explain how they achieved it.
There is an inequitably wide range of funding and service provision between GP practices which has arisen as a result of various bid based initiatives, including the Primary Medical Services contract, over many years. NHS Derbyshire County had already begun to address this when the Department of Health asked PCTs to narrow variations in anticipation of transfer of contracts to the NHS Commissioning Board, and a possible new contract based on weighted capitation at some point in the future.
Review of this variation in Derbyshire showed poor correlation between levels of funding, outcomes and range of services provided to patients. In particular, there was no correlation between money paid to practices and effective resource usage in prescribing and secondary care.
In other PCT areas, funding inequity has been addressed using a financial cap with money withdrawn from primary care budgets. But the PCT recognised the quality of general practice in the County and the valuable contribution practices make to patient care so a commitment was given by the chief executive of NHS Derbyshire County to maintain overall funding levels to primary care in return for a process of equalisation which led, in 2008, to the Fairer Funding project. This commitment to actively invest in many practices and standardise and enhance the GP “offer” to patients has been key in engaging local GPs as a group, the LMC and patient representative bodies.
A set of core principles was agreed at the outset and applied throughout.
- Fairness - i.e. same funding for same work for GMS and PMS
- Equity of services for patients regardless of practice
- Cost neutral within existing budgets
- Process that was transparent, consultative and fully inclusive
- Seeking to agree rather than impose
The primary care commissioning team established two groups. These were
- A clinical reference team to ensure clinical engagement was at the heart of all work completed, including clinicians and practice managers from a range of practice types including potential winners and losers across the county and GMS and PMS contract holders.
- A project team including staff from finance, primary care commissioning, clinical quality, LMC and patient representation.
The proposal developed in conjunction with the clinical reference group set out an approach that would pay practices a set rate based on weighted population to provide:
- ‘Core’ primary care services (£64.59/head or the current national GMS Global Sum)
- Access for their registered patients to a ‘basket’ of services in primary care (£11.56/head)
- Access to additional funding from the PCT through the commissioning separately from the basket other services to meet local needs and more specialised services that not all practices will deliver.
The Fairer Funding process included the following steps:
- Develop and cost the above model with clinical reference group and pilot sites. Potential inclusions for services that should be provided by all practices were ranked in order of importance by the clinical reference group and subsequently included based on affordability.
- Consult all GPs on the Basket of Services. This included establishment of a discussion forum for GPs and practice managers using NHS Networks where all documentation relating to the project was posted
- Formal offer to all practices in November 2010 showing a variable pace of change over three years depending on the size of their practice gain or loss. This was accompanied by practice visits and road shows and discussion at every monthly Local Medical Committee meeting.
- Following feedback from GPs the basket of services was adjusted and the financial formula which was used to calculate all practices financial offers was amended and for some now included a branch surgery weighting (February 2011) to take account of the rurality of some parts of the county.
- Over the following months broad practice sign up was achieved
- The project group then developed a two-stage local mediation process, including both internal and independent review stages. This process enabled facilitated negotiations with most outstanding practices. For those practices that were over the new value the practices were offered a pace of change variation and some variation was offered if the practice were offering services ‘over and above’ those of others which would therefore continue to be commissioned separately.
- Final negotiations with practices declining to sign up to either fairer funding or other reduction in income – this ended 20 October 2011.
- Presentation to Derbyshire PCT Cluster board, November 2011.
It is important to consider the factors that have contributed to the success of the project, its limitations and lessons learnt along the way. We have moved from practices threatening legal action - which was actually helpful as it ensured we paid great attention to due process at every turn - to sign up by all PMS and most GMS practices in Derbyshire with just four GMS practices declining to agree to Fairer Funding at all and three agreeing a lower level of income reduction.
Factors contributing to success
- PCT committing to maintain overall funding to primary care and the Fairer Funding process. A bold decision in the prevailing financial climate.
- LMC support. LMC officers have been invaluable throughout, often in the face of anger from individual practices and lost LMC levies.
- Patient involvement. A PCT wide strategy of engaging with patient groups using communications staff on the positive aspects meant individual practices were not able to misrepresent their situation and vilify the PCT.
- A consistent and committed project team to see this through over nearly a three year process. People have move to different roles within CCGs but have still kept their role within this team.
Levers for change
The intention was always that the process would be fair with no “deals” for awkward individuals. Indeed, several practices stipulated that their sign up to Fairer Funding with reduced funds was conditional on this being the case. During the mediation process, where practices claimed special circumstances, modelling of impact on potentially similar situations often led to amended offers to those other practices.
Secondly, we were clear that practices not agreeing to Fairer Funding would be lower priority for premises developments and certain discretionary funding. We also agreed not to commission certain other services from these practices such as CVD screening and minor injuries although we would ensure their patients could still access these. Finally, there was the potential to terminate PMS contracts although we were always clear that this was a last resort. Whilst our hand was strengthened by legal cases earlier in 2011, in practical terms this would have been problematic in this transitional phase of staff moving from PCT to clinical commissioning groups, and the additional workload this would create if it had come to the need to terminate. But importantly the PCT Cluster board was prepared to support this option if it had been required.
- Pace of change: It was impractical to expect practices to accept large shifts in funding immediately. The transition will occur over four years. This shortfall is balanced by a similar pace of change for gaining practices who would also not be expected to provide all of the basket from day one. This timescale means the commissioning detail in future years will fall to CCGs or the NHS Commissioning Board. The basket will be managed similarly to any other local enhanced service and a detailed briefing will be passed to CCGs to facilitate a smooth handover.
- Negotiations: There were a hard-core of practices who were vehemently opposed to any shift and took considerable time and effort from our team to arrive at a settlement. The hardest part was ensuring that those who shouted loudest did not get a better deal and we have maintained the transparency throughout so people can see all of the special circumstances that have been agreed. We were absolutely clear that we would not compromise on our core principles and this gets tough when trying to get the last few practices signed up.
- PMS/GMS-whilst we had financial and other levers for PMS practices, the fact that GMS is a national contract left our hands tied when GMS practices declined to engage.
- GMS – we worked really closely with our legal advisers, the LMC and a senior adviser from NHS Primary Care Commissioning to find a way to allow practices to voluntarily “give up” their correction factor payment without compromising their national GMS contract. Whilst the funding has been adjusted each practice with a CF or minimum practice income guarantee (MPIG) still retains a contractual entitlement to that payment and any national changes will be reflected in future years.
In summary, this project has been a major step forward for Derbyshire and leaves CCGs in a good place regarding equity from which to build. It is a credit to the GP community who have often put fairness and patients ahead of personal interest and to the PCT staff who have worked so tirelessly to deliver it.
Appendix 1: Basket of Services
|Service Name||Description of Service|
|Care plans for long term conditions||Advance care planning paperwork, case management, rightcare and EMAS DNAR|
|Spirometry||Investigation of possible COPD/Asthma which can be carried out in Primary Care.|
|Glucose tolerance testing||As required to investigate patients in Primary Care with possible Diabetes/Impaired Glucose Tolerance. This specification is not intended to relieve Secondary Care clinicians of their responsibility to undertake Glucose Tolerance Testing where appropriate as part of an episode of Secondary Care.|
|End of life care||The existing EOL LES will be incorporated into this Basket of Services|
|Ring pessary replacement and management||NHS Derbyshire County will continue to commission discussion of treatment options and initial fitting of Ring Pessaries, where chosen, from Secondary Care.|
|Phlebotomy||Not all phlebotomy is core. Agreement has been gained that phlebotomy payments are covered broadly from the following 3 sources of income : a 1/3 is core, a 1/3 is QOF and a 1/3 funded by the basket.|
|Non emergency non chest pain ECGs||Practices will ensure that patients can access non emergency, non chest pain ECGs locally, conveniently and in an appropriate time frame. NHS Derbyshire County/Commissioning Groups/Commissioning Consortia will commission services for interpretation of ECGs in cases of diagnostic uncertainty.|
|Joint Injections||As per definition in LES|
|Suture removal||Practices will ensure that patients can have sutures and staples removed, as appropriate, locally and conveniently, no matter which NHS organisation has inserted them.|
|Sharps Boxes||Practices will ensure that patients for whom they prescribe sharps for use at home are also prescribed appropriate sharps boxes and are instructed in their correct use. Practices will accept filled sharps boxes from such patients (where the Local Authority does not provide a collection service) and ensure their safe disposal.|
|HPV||The HPV LES will be incorporated into the Basket of Services. This does not include the catch up campaign which is due to complete in 2010.|
|CVD screening||The CVD LES will be incorporated into the Basket of Services.|
|Public health vaccinations|
Practices will co-operate with local Public Health physicians in delivering local emergency immunisation programs, as and when appropriate, in response to national or local health emergencies. This specification does not absolve NHS Derbyshire County from any obligation to make additional payments if the Department of Health or other NHS national body directs or recommends such payments in pursuit of national policy.
Any concerns about the inclusion or otherwise of any specific campaign within this specification will be resolved following discussion between NHS Derbyshire County and Derbyshire LMC.
|Near patient testing||Practices will monitor patients who require it according to Shared Care guidelines agreed by JAPC. As and when new Shared Care guidelines are introduced, the resource implications will be discussed between NHS Derbyshire County and Derbyshire LMC.|
|Minor injuries||Practices will see and treat or refer patients with minor injuries as appropriate to their circumstances.|
|CPD time||Practices will develop and implement structured CPD programs for their teams. The plans should be agreed during Practice Review Meetings.|
|Minor surgery||As per Minor Surgery LES which has been amended as per the EMSCAG plastics policy and PLCV.|
|Prostate Cancer LES||As per LES|
|Non Urgent Ambulance booking||As per protocol|
|Choose and Booking|
Practices will use their best endeavours to enable patients to access other providers via C&B. Practices must be in a position to justify the use of non C&B appointment requests at Performance Review meetings. Acceptable exceptions include (but are not limited to) failure of the system to work first time, slot non-availability and non-logical Directory of Services.
Disputes about best endeavours will be referred to a joint committee of NHS Derbyshire County and Derbyshire LMC.
|Auto Divert to OOH Service||Practices will ensure that patients who contact them by telephone out of hours are automatically diverted to the out of hours service without having to make a further call.|