1. nGMS-MH New Jargon for a New Contract

2. A review of the old contract GPs are self employed Majority of income derived from a weighted capitation formula Only 70% of staff costs reimbursed Incentives to change behaviour (targets and item of service payments) no more than about 10% of total income Inbuilt perverse incentives

3. Which contract? GMS –General Medical Services - default position –The contract is with an individual GP –Nationally negotiated PMS –Personal Medical Services – started as pilots, now becoming permanent –Contract sits with a practice and not an individual –Locally negotiated, therefore in theory a contract that meets local need

4. Basics of the new contract Essential level of care MUST be provided by all practices Practices will chose if they wish to “opt out” of certain additional services. Enhanced services will be commissioned by the PCT –National direction with national specs – must be commissioned –National minimum spec, but optional –Developed locally

5. Basics of the new contract Resources Allocated using the Carr-Hill formula Guaranteed minimum –Opt outs associated with nationally agreed reduction in resources Further financial incentives associated with Quality and Outcome Framework

6. Quality and Outcome Framework Point scoring system –Points mean ££££ 1050 points in total –550 are clinical points –184 are organisational –36 are additional services (CHS, cx screening etc) –100 are patient experience –30 are quality payments –100 Holistic Care –Access bonus 50

7. Quality and Outcome Framework Coronary Heart Disease121 Hypertension105 Diabetes99 Asthma72 COPD45 Mental health41 Stroke/TIA31 Epilepsy16 Cancer12 Hypothyroidism8

8. Quality and Outcome Framework MH 1. The practice can produce a register of people with severe long-term mental health problems who require and have agreed to regular follow-up MH 2. The percentage of patients with severe long-term mental health problems with a review recorded in the preceding 15 months. This review includes a check on the accuracy of prescribed medication, a review of physical health and a review of co-ordination arrangements with secondary care

9. Quality and Outcome Framework MH 3. The percentage of patients on lithium therapy with a record of lithium levels checked within the previous 6 months MH 4. The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months MH 5. The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months

10. MH 1: A Register Who to include on the register? –People with schizophrenia –People with bi-polar depression Why? –Evidence base How?

11. What is the Evidence Base? SMR for schizophrenia and bi-polar disorder is about 200 Cardiovascular and respiratory disease SMR is 400 Diabetes is 5 times as common 90% of people who have schizophrenia smoke (30% of people with bipolar disorder) Drug and alcohol misuse HIV is 8 times as common HCV is (perhaps) 15 times as common

12. Developing a register Search by diagnosis Search by therapeutic category Ask the Primary Health Care Team Ask the Community Mental Health Team

13. Primary Care Computing 3 major software houses Coding system that is –Hierarchical –Includes diagnoses, symptoms, signs, and virtually everything else –Up to version 5 (version 3, does not map to v.4 and v.5) –Different software houses use different versions

14. Read Codes Schizophrenia Eu20.0 Persistent delusional disorderEu22.0 Acute and transient psychosisEu23.0 Schizoaffective disorderEu25.0 Bi-polar disorderEu31.0 Only “Eu” Codes will map to ICD 10/DSM IV and hence to SNOMED

15. Therapeutic Categories BNF 4 – CNS Drugs BNF 4.2 – Drugs used in severe mental illness BNF 4.2.1 – Oral anti-psychotic drugs BNF 4.2.2 – Depot anti-psychotic drugs BNF 4.2.3 – Anti-manic drugs

16. And then? Call and recall system as for other “at risk” groups Meet regularly with the CMHT attached to the practice Regular review/audit of care that is being provided

17. MH 2 – What to do Physical health check Cardiovascular disease –BP? Diabetes and obesity –Urine analysis or blood glucose? Respiratory disease –Peak flow Smoking Substance/alcohol misuse Influenza? HIV/HCV?

18. MH 3 – 5 Mgmt. of Lithium Who is on Lithium? What level? How often should the renal and thyroid function be measured?

19. Patient experience Length of consultation, at least 10 minutes 30 Points Patient survey undertaken at least annually – and has to be approved 40 points Survey undertaken, and proposed changes 15 points Survey undertaken, changes discussed with patients, and/or NED, and implemented 15 points

20. Depression - NES Definition: Diagnosed by clinical judgement and screening tools Service Outline: Produce and maintain up to date register Multi-disciplinary approach CBT Screening procedures Undertake appropriate training Personal health plans Referrals as appropriate Audit and review

21. GMS or PMS? The NES applies to GMS practices PMS practices can continue to experiment/develop services by creating new Quality and Outcome Framework Domains…. –So what about a Q &O framework for depression?

22. What about a Q & O Framework? Undertake screening of at risk patients Produce a register of people with depression Produce register of patients with chronic depression, as a subset of the overall register Proportion of patients who are reviewed every six months who have chronic depression; review to include medication review, social needs, and contact with secondary services including key worker where appropriate

23. What about a Q & O Framework? The percentage of patients for whom a risk assessment has been carried out Percentage of patients for whom the severity of the depression is specified –The percentage of patients with mild depression who are managed with watchful waiting or talking therapy –The percentage of patients with moderate depression who are managed with medication or CBT –The percentage of patients with severe depression who are referred to the CMHT The percentage of patients who have been referred to the CMHT for depression, and already have had two, three month courses of antidepressants.

24. Some Clarification needed? The contract is NOT negotiable –There are mechanisms to review the contract that are slow (ish) Who should go on the register? What happens if they refuse? When do they come off the register?

25. More importantly Primary Care services will be commissioned by PCTs to meet local need Mental Health is a significant work load in primary care It may not be at the top of the agenda NOW, but over the next few years it will become more important

26. Thank You