Funding in General Practice Dr Andy Withers Grange Practice Allerton

Aims & Objectives Aims Increase understanding of how General Practice is financed Objectives Know how :- Practice income is calculated and received Budgets are set The difference between NHS & Private income

Questions How do GPRs get paid in practice? How do salaried GPs get paid? How do GP Partners get paid? What is the difference between a GMS & PMS practice? Are all my earnings pensionable? What is PBC? How can I earn more?

What do we get paid for? Core General Practice (= Essential Services) Additional Services Enhanced Services QOF

NHS Income

GP Funding Budget BAtPCT Essential Services Additional Services QOF LoQOF Enhanced Services Other

Premises Budget Brought forward Premises

Essential Services (63.6%) MANDATORY - common to all practices 1) The management of patients who are ill or believe themselves to be ill, with conditions from which recovery is generally expected, for the duration of that condition, including relevant health promotion advice and referral as appropriate, reflecting patient choice wherever practicable 2) The general management of patients who are terminally ill 3) Management of chronic disease in the manner determined by the practice, in discussion with the patient

Essential Services (63.6%) Either paid as Global Sum or MPIG in GMS practices (MPIG = GS +correction factor) Government want to get rid of MPIG Basic Contract in PMS practices

Additional Services (2.8%) Normally expected of all practices but OPT- OUT possible Cervical cytology Child health surveillance Maternity services (not intrapartum care) Contraceptive services

Enhanced Services (11.3%) 3 types Direct National Local

DES (2.8%) Obligatory for each PCO National specifications No one practice has to do: Services to violent patients Childhood vaccinations and immunisations financial incentives Minor surgery Flu immunisations Improved access IMT Choice & Booking (PBC) New clinical DESs Heart Failure, Osteoporosis, LD, Ethnicity, Alcohol

NES (1.7%) OPT-IN - national terms and conditions Anticoagulant monitoringIUCD Sexual healthMS Drug and alcohol misuse Terminally ill DepressionLearning disabilities Intra partum careMinor injuries Near-patient testingHomeless Immediate/first response care

LES (6.8%) OPT-IN Response to specific local requirements Local terms, conditions and standards Possibly, innovative services for piloting and evaluation

LES (6.8%) Choice & Booking (to 31/3/09) IM&T Sexual Health Minor Primary Services ECG Minor Surgery (various levels) Spirometry

GMS v PMS Little difference now PMS probably slightly higher earning practices due to historic funding. Both practice based contracts GMS nationally negotiated Either global sum via Formula Or Minimum practice income guarantee (MPIG) PMS (potentially) locally negotiated

Range of Practice Funding in BAtPCT

Seniority Begins from start of NHS service Annual increments

QOF THE FOUR DOMAINS OF QUALITY Clinical Organisational Patient experience Additional services

Total Points 1000 Clinical650 Organisational167.5 Additional Services 36 Patient Experience146.5

CLINICAL AREAS Asthma45 AF30 Cancer11 CKD27 COPD28 CHD89 Dementia20 Depression33 Diabetes93 Epilepsy15 Heart Failure 20 Hypertension83 Hypothyroidism 7 Learning Disabilities 4 Mental health39 Obesity 8 Palliative Care 6 Smoking68 Stroke & TIA24

ORGANISATIONAL AREAS Records and information Patient communication Education and training Practice management Medicines management

PATIENT EXPERIENCE Standardised approved patient questionnaires General Practice Assessment Questionnaire (Manchester) Improving Practice Questionnaire (Exeter) Length of consultation - 10 mins appts

QOF Changes 2009/10 End of Square rooting Move to true prevalence

QOF Changes 2009/10 Heart Failure (9 new points) One new indicator (which moves the current HF DES for England into QOF): HF 4: The percentage of patients with a current diagnosis of heart failure due to LVD who are currently treated with an ACE inhibitor or Angiotensin Receptor Blocker, who are additionally treated with a beta-blocker licensed for heart failure, or recorded as intolerant to or having a contraindication to beta-blockers. (9 points; thresholds 40 – 60%) Chronic Kidney Disease CKD (11 new points) Five additional points will be allocated to existing indicator CKD 5: CKD 5: The percentage of patients on the CKD register with hypertension and proteinuria who are treated with an angiotensin converting enzyme inhibitor (ACE-1) or angiosten receptor blocker (ARB) (unless a contraindication or side effects are recorded). (5 additional points (so the indicator will be worth 9 points in total); thresholds 40 – 80%) While this indicator will not change, the guidance will be changed. One new indicator: CKD 6: The percentage of patients on the CKD register whose notes have a record of an albumin: creatinine ratio (or protein: creatinine ratio) value in the previous 15 months. (6 points; thresholds 40 – 80%)

QOF Changes 2009/10 Sexual Health - contraception (8 new points plus 2 points from current CON indicators, CON 1 and 2 which will be removed) Three new indicators, as recommended in the 2008 expert panel report: SH 1: The practice can produce a register of women who have been prescribed any method of contraception at least once in the last year. (4 points) SH 3: The percentage of women prescribed an oral or patch contraceptive method in the last year who have received information from the practice about long acting reversible methods of contraception in the previous 15 months. (3 points; thresholds 40 – 90%) SH 4: The percentage of women prescribed emergency hormonal contraception at least once in the year by the practice who have received information from the practice about long acting reversible methods of contraception at the time of, or within one month of, the prescription. (3 points; thresholds 40 – 90%) Anxiety and Depression (20 new points) One new indicator: DEP 3: In those patients with a new diagnosis of depression and assessment of severity recorded between the preceding 1 April to 31 March, the percentage of patients who have had a further assessment of severity 5 – 12 weeks (inclusive) after the initial recording of the assessment of severity. Both assessments should be completed using an assessment tool validated for use in primary care. (20 points; thresholds 40 – 90%)

QOF Changes 2009/10 Cardio Vascular Disease CVD – Primary Prevention (13 points) Two new indicators: PP 1: In those patients with a new diagnosis of hypertension (excluding those with pre-existing CHD, diabetes, stroke and/or TIA) recorded between the preceding 1 April to 31 March: the percentage of patients who have had a face to face cardiovascular risk assessment at the outset of diagnosis using an agreed risk assessment treatment tool. (8 points; thresholds 40 – 70%) For the purposes of QOF measurement, at the outset of diagnosis is defined as within three months of the initial diagnosis. PP 2: The percentage of people diagnosed with hypertension diagnosed after 1 April 2009 who are given lifestyle advice in the last 15 months for: increasing physical activity, smoking cessation, safe alcohol consumption and healthy diet. (5 points; thresholds 40 – 70%) Diabetes (7 new points plus 28 current points) There are currently two indicators with HbA1c targets (DM7 and DM 20) which have been subject to changes. We will also introduce a new indicator. The three indicators are as follows: DM 23: Replaces DM 20 (which has a HbA1C target of 7.5 or less and is worth 17 points) The percentage of patients with diabetes in whom the last HbA1c is 7 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months. (17 points; thresholds 40 – 50%) DM 24: New The percentage of patients with diabetes in whom the last HbA1c is 8 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months. (8 points; thresholds 40 – 70%) DM 25: Replaces DM 7 (which has a HbA1C target of 10 or less and is worth 11 points) The percentage of patients with diabetes in whom the last HbA1c is 9 or less (or equivalent test/reference range depending on local laboratory) in the previous 15 months. (10 points: thresholds 40 – 90%)

QOF Changes 2009/10 COPD (2 new points) One revised indicator: COPD 13: Replaces COPD 11: The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the MRC dyspnoea score in the preceding 15 months. (2 additional points so the indicator would be worth 9 points; thresholds 50 – 90%) Reallocation of Points The following points will be removed: Indicator Current valueNew value Points removed PE PE SMOKING SMOKING BP CHD AF CON CON Total72

Pensions All NHS income pensionable delivering GMS / PMS delivering services under delegation including locum work board, advisory and other work for NHS bodies collaborative arrangements work education statutory certification work for GP cooperatives that are NHS bodies All locum pay pensionable from

PBC Practice Based Commissioning Voluntary Devolved budgets to all practices Virtual Money – you cant take it home For: Prescribing Secondary care, acute & elective Community Staff Can spend (up to) 70% of Freed up resources (FURs note not savings) on patient care. Pct takes rest. Only get FURs you predict (no serendipitous FUR) Idea is to provide innovations in services to produce FUR Usually done through commissioning alliances

Other Income Teaching & Training AmountNHS Pension? GPR £7.5k Y FY2 £10k Y Medical Students £15-20k N NHS related work GPwSI c £10k/session Y PCTY LMCN DHY Private N Reports Medicals etc

Getting Paid

Getting Paid 2 (This is real money) Typical Middle sized practice (approx 5500 patients) Total amount£875k Less running expenses (36%) £315k Less Staff costs (including salaried GPs & GPRs)£260k Profit (34%) £300k Divided between partners = income £100k Need to pay 20% superannuation£80k Need to pay Income tax

Premesis Lift PFI variants DIY Guaranteed income stream from PCT About 11% return for developer