How the GP contract will change in 2012/13

By Nick Bostock on the 10 November 2011

Pay for GP practices across the UK will be frozen again in 2012/13, negotiators revealed last week. Below, GP sets out in detail how the change will work.

The osteoporosis DES has been dropped to reflect new indicators added to the QOF for the condition

A 0.5% uplift in overall general practice funding will be delivered through an increase of around £3 to the value of each QOF point.

Practices will have to work harder to maintain their current levels of QOF achievement because thresholds have been raised for many indicators.

Changes to enhanced services have also been agreed.

The majority of changes apply UK-wide, but practices in England face additional, and significant, reforms that will extend practice boundaries in a bid to boost patient choice. Practices in England are also likely to be contractually required to join commissioning groups if the Health Bill is passed.

The only increase to core pay will come from cash recycled from the scrapped directed enhanced service for osteoporosis. But the rise is so small that BMA experts believe just 15 practices will be lifted off reliance on the minimum practice income guarantee in 2012/13.

A statement from GPC negotiators from all four UK countries as the deal was announced said: 'We believe that the changes represent the best possible agreement that your negotiators could reach in these unprecedented and challenging economic times and are confident that GPs in England, Scotland, Wales and Northern Ireland will continue to work within their contract to provide the best possible service to their patients.'

FUNDING
The pay freeze on general practice will continue in 2012/13. An overall funding uplift of 0.5% has been agreed, to enable practices to give staff earning less than £21,000 a year a pay rise of £250. The uplift will be delivered as a 2.49% increase in the value of a QOF point, with the value of each point rising from £130.51 to £133.76. This means a practice with an average list size and average prevalence could earn an extra £3,250 for achieving the 1,000 QOF points available. Payments per weighted patient through the global sum will rise by 8p, from £64.59 to £64.67, because around £1 million will be redirected from an osteoporosis directed enhanced service that has been scrapped. Negotiators will discuss possible changes from 2013/14 to the Carr-Hill formula used to calculate practices' global sum payments, to give greater weight to deprivation. Verdict The funding increase will not match rising practice expenses, which have already led to a decline in practice profits. Very few practices will be lifted off the minimum practice income guarantee in 2012/13 because of the tiny addition to core pay.

FUNDING

The pay freeze on general practice will continue in 2012/13.
An overall funding uplift of 0.5% has been agreed, to enable practices to give staff earning less than £21,000 a year a pay rise of £250.
The uplift will be delivered as a 2.49% increase in the value of a QOF point, with the value of each point rising from £130.51 to £133.76. This means a practice with an average list size and average prevalence could earn an extra £3,250 for achieving the 1,000 QOF points available.
Payments per weighted patient through the global sum will rise by 8p, from £64.59 to £64.67, because around £1 million will be redirected from an osteoporosis directed enhanced service that has been scrapped.
Negotiators will discuss possible changes from 2013/14 to the Carr-Hill formula used to calculate practices' global sum payments, to give greater weight to deprivation.

Verdict

The funding increase will not match rising practice expenses, which have already led to a decline in practice profits. Very few practices will be lifted off the minimum practice income guarantee in 2012/13 because of the tiny addition to core pay.

PMS AND OTHER IMPLICATIONS
The DoH has recommended that PMS practices should receive no uplift to baseline funding, in line with GMS. PMS practices will benefit from QOF uplifts along with other practices. The BMA has agreed in principle that if the Health Bill successfully passes through parliament, GP practices in England will be contractually required to join a clinical commissioning group. Verdict In a cash-poor NHS, locally negotiated contracts are vulnerable to local cuts in addition to the national pay freeze.

PMS AND OTHER IMPLICATIONS

The DoH has recommended that PMS practices should receive no uplift to baseline funding, in line with GMS. PMS practices will benefit from QOF uplifts along with other practices.
The BMA has agreed in principle that if the Health Bill successfully passes through parliament, GP practices in England will be contractually required to join a clinical commissioning group.

Verdict

In a cash-poor NHS, locally negotiated contracts are vulnerable to local cuts in addition to the national pay freeze.

ENHANCED SERVICES
Directed enhanced services (DESs) for alcohol-related risk reduction and the learning disabilities health check will continue for a further year, until 31 March 2013. Payment for the two DESs remains unchanged from 2011/12, with each health check worth £102.16, and a £2.38 payment for each newly registered patient aged over 16 screened with an alcohol risk assessment tool. The extended hours access DES will also continue unchanged. The osteoporosis DES has been dropped to reflect new indicators added to the QOF for the condition. Verdict No major changes to DESs for 2012/13 - the DoH appears to prefer quality and productivity indicators in QOF as a vehicle for imposing new targets. Could practice boundary pilots be converted into a DES for 2013/14?

ENHANCED SERVICES

Directed enhanced services (DESs) for alcohol-related risk reduction and the learning disabilities health check will continue for a further year, until 31 March 2013.
Payment for the two DESs remains unchanged from 2011/12, with each health check worth £102.16, and a £2.38 payment for each newly registered patient aged over 16 screened with an alcohol risk assessment tool.
The extended hours access DES will also continue unchanged.
The osteoporosis DES has been dropped to reflect new indicators added to the QOF for the condition.

Verdict

No major changes to DESs for 2012/13 - the DoH appears to prefer quality and productivity indicators in QOF as a vehicle for imposing new targets. Could practice boundary pilots be converted into a DES for 2013/14?

PRACTICE BOUNDARIES
Changes to practice boundary rules will apply only to practices in England. All GP practices in England will agree with their PCT an 'outer boundary' within which they will continue to look after patients - where clinically appropriate - who have moved out of their normal practice catchment area. 'Two or three cities' will take part in a one-year pilot offering wider choice of practices. Patients will be able to visit participating practices as a 'non-registered out-of-area patient' or as a 'registered out-of-area patient'. The pilot will enable patients to register at a practice near where they work instead of where they live, either as a registered patient or effectively as a temporary resident. Further details will be published soon. List closure procedures could be 'simplified' in parallel with the boundary changes, the DoH has said. Verdict For each practice in England to negotiate an 'outer boundary' sounds like a lot of work. This may prove complicated as PCTs shift into clusters and because of different approaches in rural and urban areas. The pilots suggest the DoH could yet push for more radical changes in future.

PRACTICE BOUNDARIES

Changes to practice boundary rules will apply only to practices in England.
All GP practices in England will agree with their PCT an 'outer boundary' within which they will continue to look after patients - where clinically appropriate - who have moved out of their normal practice catchment area.
'Two or three cities' will take part in a one-year pilot offering wider choice of practices. Patients will be able to visit participating practices as a 'non-registered out-of-area patient' or as a 'registered out-of-area patient'.
The pilot will enable patients to register at a practice near where they work instead of where they live, either as a registered patient or effectively as a temporary resident. Further details will be published soon.
List closure procedures could be 'simplified' in parallel with the boundary changes, the DoH has said.

Verdict

For each practice in England to negotiate an 'outer boundary' sounds like a lot of work. This may prove complicated as PCTs shift into clusters and because of different approaches in rural and urban areas. The pilots suggest the DoH could yet push for more radical changes in future.

QOF
Two indicators for CHD and AF will be retired, along with prescribing indicators included in the 'quality and productivity' (QP) targets added to QOF in 2011/12. The indicators being dropped are: CHD13, AF4, QP1, QP2, QP3, QP4 and QP5. The retired QP prescribing indicators will be replaced with targets for reducing A&E attendances, worth 31 points. New clinical indicators will come in for AF, smoking, peripheral arterial disease and osteoporosis. The value of indicators for BP, smoking, CKD and diabetes will be cut by 26 points. Affected indicators are BP4, BP5, CKD2, DM2, DM22, smoking 3 and smoking 4. All indicators with lower thresholds currently 40-90% have been raised to 50-90% and lower thresholds raised to 45% for indicators currently with an upper threshold between 70-85%. Upper thresholds have changed for indicators CHD6, CHD10, PP1, PP2, HF4, STROKE6, STROKE8, DM17, DM31, COPD10 and CKD5, and lower and upper threshold changes for BP5, MH10 and DEM2. Verdict Practice workload will rise as 'retired' indicators must still be delivered, points are stripped from indicators that remain, and thresholds for achieving QOF points are pushed up.

QOF

Two indicators for CHD and AF will be retired, along with prescribing indicators included in the 'quality and productivity' (QP) targets added to QOF in 2011/12. The indicators being dropped are: CHD13, AF4, QP1, QP2, QP3, QP4 and QP5.
The retired QP prescribing indicators will be replaced with targets for reducing A&E attendances, worth 31 points.
New clinical indicators will come in for AF, smoking, peripheral arterial disease and osteoporosis.
The value of indicators for BP, smoking, CKD and diabetes will be cut by 26 points. Affected indicators are BP4, BP5, CKD2, DM2, DM22, smoking 3 and smoking 4.
All indicators with lower thresholds currently 40-90% have been raised to 50-90% and lower thresholds raised to 45% for indicators currently with an upper threshold between 70-85%.
Upper thresholds have changed for indicators CHD6, CHD10, PP1, PP2, HF4, STROKE6, STROKE8, DM17, DM31, COPD10 and CKD5, and lower and upper threshold changes for BP5, MH10 and DEM2.

Verdict

Practice workload will rise as 'retired' indicators must still be delivered, points are stripped from indicators that remain, and thresholds for achieving QOF points are pushed up.