The new GMS contract: key information and issues

The new General Medical Services (GMS) contract is a contract between the practice and the primary care organisation. The contract addresses issues around:

• A more flexible provision of services. 
• Rewarding practices for quality services and outcomes. 
• Developing the human resources involved in primary care.
• Modernising infrastructure.
• Investment in primary care. 
• Providing a better service for patients who access the service.

The contract
Under the old contract GPs were organised into practices where they worked as partners or salaried doctors. Each doctor within the practice had a ‘list’ of patients and the contract was between the individual GP and the primary care organisation. With the new GMS contract the contract is between the practice and the primary care organisation; patients will be registered with the practice. The salary for each doctor was calculated on an individual basis, the figure was determined by a formula that encompassed fees and allowances; this gave each doctor an average net income.

Under the new contract money will be allocated to practices by the primary care organisation. The practice can then decide how to organise their staff and resources in order to fulfil their commitment to the contract. The financial resources allocated will be decided according to three funding streams: the global sum, quality rewards and enhanced services payments.

The global sum
The global sum covers the costs of running the practice. This sum will account for approximately 50% of practice income and will cover:

• The provision of essential and additional services.
• Staff costs. 
• Locum covers. 
• Career development.
• Protected time. 

The calculation for the global sum will take account of the population covered by the practice and should reflect the workload and local need.

Quality rewards
Quality rewards will be paid according to the standards achieved. A quality and outcomes framework has been developed alongside the new contract which is evidence-based and sets out clinical and organisational standards. Each practice will be able to decide which quality standards they wish to aspire to. Payments will reward practices for their achievements. The primary care organisations will be responsible for distributing quality payments: these payments will be allocated on a points scheme.

Enhanced services payments
Enhanced services payments will be available to any practice that chooses to expand the range of services they provide. These specialised services will include areas such as extended minor surgery. This funding will again be allocated by the primary care organisations.

Other funding will be available to enable practices to modernise their premises and update and improve their IT infrastructure. It is generally believed that these funding changes will bring about a 33% increase in investment in primary care over the next 3 years.

Essential services

Within the global sum the phrase ‘essential services’ is mentioned. This is the minimum level that each practice will have to offer and includes:

• Management of patients who are ill or believe themselves to be ill.
• Health promotion and referral as appropriate.
• General management of the terminally ill.
• Chronic disease management.

Additional services include:

• Cervical screening.
• Contraceptive services.
• Immunisation and vaccination.
• Child health surveillance.
• Maternity services (excluding intrapartum care which will be an enhanced service).
• Minor surgery (which is classified as curettage, cautery and cryocautery).

There is also an opt-out clause for provision of the out of hours service, and this has been accepted by the majority of practices. This is the greatest change that patients will notice because it will mean that there is no service provided by their own practice after 1830 h or on a Saturday morning. The new GMS contract places the onus with the primary care organisation to ensure that 24 h cover is available.

This major change in the provision of the out of hours services has made healthcare professionals consider innovative ways of working, and they will continue to do so. Many patients will be triaged by nurse practitioners or paramedics. Walk in centres, already heavily used, may become far more popular. Community hospitals will in some areas be used by the out of hours service providers, with nurse practitioners, paramedics and doctors providing care to the required standard, but possibly in very different ways to those the public are accustomed to.

Quality and outcomes framework
The new quality and outcomes framework sets out a range of national standards which are based on robust evidence. The standards fall into four domains: clinical (see Figure 1), organisational, additional services and the patient experience. This framework will be used to reward practices who achieve their aspirational standards. In order to achieve the quality payments, practices will have to demonstrate that they have attained the target set. For this to happen they will need to record patient contacts, pathology results and any interventions given. Standard software for this has been or is in the process of being developed, which will enable the calculation of the points and so allow the payments to be made by the primary care organisation.

There will be assessment by the primary care organisation after self-evaluation, including a quality review visit and will involve clinicians and the practice manager. It is expected that this review will be annual.

Organisational standards
Organisational standards relate to information, communication with patients, education and training, medicine management services, clinical and practice management.

Patient experience
The patient experience is of interest to healthcare professionals and does echo the government philosophy for greater public and patient involvement, and accredited questionnaires have been developed by the Department of Health. These will allow patients of the practice to comment on aspects of care, the physical environment, the accessibility of the services on offer and also the relationship between the practice and the patient. These questionnaires will also enable the practice to gauge their strengths and weaknesses and make improvements in line with local need.

The quality framework will increase the demand for staff working within primary care and there will need to be new ways of working, new skill mixes and development of efficient ways of managing chronic disease. Primary care organisations will have to organise effective education and training strategies for all staff involved in patient care, and will need to support staff undertaking new roles.

Diabetes and the new GMS
Many of the indicators that attract points in the quality framework relating to diabetes are areas that are covered in good practice. Each must be recorded at least ‘within the past 15 months’ to attract payment. Six points can obtained by having a register. This can only be viewed as a positive, because being able to readily identify the population of people with diabetes in a practice or over an entire primary care organisation population will be of great benefit when planning future services and identifying areas of increasing prevalence. Smoking status and recording smoking cessation advice also accrues points.

Clinical markers are also acknowledged and it is these which will hopefully drive towards better care for all people with diabetes. If 90% of patients have an HbA_1c value recorded in the past 15 months, three points will be earned: if 50% of these patients have an HbA_1c < 7.4% an extra 16 points will be attained. Blood pressure recording can also accrue points; three points will be earned if 90% are recorded and a further 17 points if 55% of those recordings are less than 145/85 mmHg.

Cholesterol recording is also a points winner – the target is 5 mmols, with 60% of the practice population having to achieve this to win the six points. A further 20 points relate to measurements around the annual review such as screening for retinopathy, foot pulses and neuropathy. There are a total of 99 points that relate to diabetes within the framework, some of which will be very hard to achieve.

Conclusion
It would be easy to pour scorn on the targets agreed within the quality and standards framework, but if the wider picture is viewed these changes highlight diabetes as a distinct area. There will be concerns that diabetes (and other chronic disease areas) will be driven by targets and all healthcare professionals involved in direct clinical care must be aware of this and continue to practice holistic care. The new GMS contract fits with the NSF for Diabetes (DoH, 2002) and in tandem the changes that come with the new way of working should bring about improvements for both people with diabetes and healthcare professionals. Clinical leaders will evolve from this process which represents a major opportunity for nurses. Nurses have proven themselves to be efficient, effective and capable at managing chronic disease such as diabetes. Most diabetes clinics in primary care are nurse led, and the development of supplementary nurse prescribing can only enhance the role for the benefit of both the clinicians involved and the patient.