Negotiations on changes to the quality framework have broken down for the second year running. With the GPC and DoH at loggerheads, the direction of the quality framework appear to be hanging in the balance.
In the four years since the quality framework was introduced, indicators have been changed once, in April 2006.
Any hopes that new clinical areas would be added for 2007/8 were quashed when the GPC decreed that GPs should not increase their workload without a pay rise. Negotiations over change for 2008/9 have hit such difficulties that the GPC has walked away from negotiations and plans to ballot all UK GPs about the proposals (see box).
The story so far
Negotiations began in October, after the expert review panel had reported on what it considered were worthy clinical contenders to be added to the quality framework. GP exclusively revealed that the DoH was planning to take 60 points from the quality framework to fund extended hours (GP, 12 October 2007).
It now appears that in its original mandate to NHS Employers, the DoH, along with health departments in Scotland, Wales and Northern Ireland, called for up to 60 points to be 'freed' from the quality framework.
These points were from the holistic and organisational domains as well as those for giving flu jabs to at-risk groups because this also falls under the directed enhanced service (DES) for flu.
A DoH official told GP that under the mandate these points were to be recycled, in the quality framework or otherwise, to fund a range of access areas and some new clinical areas.
The DoH proposes an access quality domain including extended hours, improvements to 48-hour access, advanced booking, telephone access and wider access issues, such as whether the surgery was physically accessible to patients.
Extended hours would be funded from the £158 million freed up by the ending of the access and the choice and booking DESs finishing in March. This funding would go back to GPs if they agree to offer an extra 30 minutes' consultation time per 1,000 patients per week. For an average practice with 6,000 patients, this would mean three hours extra a week.
The DoH is also offering a 1.5 per cent increase in general practice investment for 2008/9.
The DoH had originally wanted changes to the patient survey element of the quality framework, with the 75 quality points allocated to individual practices' patient surveys to be axed to make way for a national survey.
The £80 million spent on this domain would then be distributed to practices according to patient survey scores. However, this does not form part of the DoH offer currently on the table.
The GPC counter proposals suggest that 38.5 of the 60 'freed up' quality points could fund new clinical areas.
Dr Richard Vautrey, deputy chairman of the GPC, said it opposed DoH plans to drop points for giving flu jabs to patients with CHD, TIA or stroke, diabetes and COPD.
The GPC also disagreed with proposals that points to ensure safe handling and storing of patient records should be axed.
The remaining 38.5 points that it agreed could be changed were from holistic care (20 points) and organisational domains. The GPC wants these to be allocated to clinical areas recommended by the framework's expert review panel.
The suggested new indicators included: prescribing beta blockers to patients with heart failure; ensuring osteoporosis patients were put on a register and given correct treatment; putting patients with peripheral vascular disease on a register and giving appropriate care and extra points to be allocated to the chronic kidney disease domain for high GP workload.
According to a Whitehall official, the DoH had originally wanted to see new, albeit different, clinical areas introduced to the quality framework, although these do not appear in its current offer and it refuses to give further details.
Dr Vautrey said that the GPC had not been told of any DoH clinical quality proposals during negotiations.
'The indicators that we agreed were part of the process of joint negotiations between NHS Employers and us,' said Dr Vautrey. 'They were indicators brought forward by the expert panel.'
The GPC has also proposed that 20 of the 75 points for patient surveys could be redistributed to reward practices according to patient responses on access.
Closer ground was found on extended hours which were, to some degree, accepted by the GPC. It said that in England, in exchange for the £158 million DES funding, GPs would offer an extra 15 minutes' consultation time and five minutes' administration time per 1,000 patients per week.
For the average practice, this would be an extra two hours of surgery time a week, which the GPC said could constitute an extra evening or a Saturday-morning surgery.
The GPC rejected the DoH offer of an extra 1.5 per cent. According to Dr Vautrey, it had 'got massive strings attached'.
The DoH said it would ensure the potential income of UK GPs increased by 1.5 per cent, whatever the Review Body's decision on increases to GMS income in 2008/9.
However, this increase could be given outside the contract, in the form of a DES, for example, ensuring GPs did extra work in return.
What is happening now?
In December, the GPC rejected the DoH proposals and lambasted it for 'imposing draconian contract terms on GPs'.
However, no compromise has been reached and the GPC is now consulting GPs on the original DoH offer.
The DoH said that if agreement is not reached on its current proposals by 21 March, it will impose a settlement which will differ from its current plan in certain areas. These include the £158 million from the access and choice DESs being given to PCTs to reinvest in extended GP services.
The 60 quality points would be dropped rather than reassigned and the money saved, over £65 million, given to PCTs for local service. It is not clear how these changes will affect practices in Scotland, Wales and Northern Ireland.
It would also take all of the 75 points for patient satisfaction out of the quality framework.
Current quality framework thresholds would also be increased, raising lower thresholds to 50 per cent and upper thresholds to average achievement of practices for 2006/7.
DoH proposals for GMS contract changes
- Change 58.5 of the current quality points
- Use these to pay for improved access
- Recycle £158 million from the choice and access DESs for extended hours
- Offer 30 minutes consultation time outside of core hours per week for every 1,000 patients
- Guaranteed 1.5 per cent extra investment in general practice.