welcome to the new gms & pms learning exchange

Welcome to

The new GMS & PMS

Learning ExchangeThe National Primary and Care

Trust Development Programme

The Future is NowNew GMS and PMS

Rob Webster

Director, contract implementation

Principles of Public Sector Reform

• National Standards• Empower frontline staff to design and

deliver services• Flexibility of service provision to meet

patient need• Giving people choice

Primary Care

Quality (What Patients’ Value)• Availability and Accessibility• Technical Competence• Communication Skills• Interpersonal Attributes of Care• Continuity of Care• Range of On-Site Services

Vision

• Universal, fast and convenient access• by informed patients• to an extended choice and range of high

quality services• delivered in modern primary care settings• by suitably trained and qualified

professionals

Context

• GP most respected public figure• Primary Care highest satisfaction rate• Primary care internationally admired• Quality is improving• PCTs as inclusive organisations• and new contracts mean we are in the

verge of a renaissance in Primary Care

Scope [England]

• c300 Million Consultations• c1m Specialist Attendance • 6 Million on-line hits• 6 millon NHS Direct calls• Over 7 Million OOHs calls• c1 Million WiC attendances• 600 Million items dispensed

Strategic Test 1

• Did you replace your out of hours service or reform your emergency care system?

Strategic Test 2

• Did you support the effective use of the quality frameworks to manage chronic diseases?

Strategic Test 3

• Did you use enhanced services, and the “floor”, to reconfigure services or treat them as a cross to bear?

Strategic Test 4

• Did you use patient feedback and flexibility in the new contracts to advance the notions of patient choice and improve the patient experience?

• Did you use the practice based contracts and new roles of the PCT to develop opportunities around skill-mix?

Strategic Test 5

• Did you use the contract as a lever for recruitment and retention and for improving morale?

Strategic Test 6

• Did you use the additional flexibilities in PMS and PCTMS to tackle specific local issues?

Strategic Test 7

• Did you develop the entrepreneurial culture in primary care?

Strategic Test 8

• Did you use contracts as a lever for modernising services or as a payment mechanism for GPs?

Strategic Test 9

Summary

• Alignment: principles, values, vision• Positive context, huge scale• Operations and Strategy• Contracts can deliver Strategy for NHS• Use this event to get you there

The new

GMS & PMS

Learning Exchange

The National Primary and Care Trust Development Programme

The Provision of General Medical Services

Ian Dodge, Head of GMS, Department of Health

Objectives for the session

• Key points from chapter 2 of Delivering Investment in General Practice (except OOHs)

• What PCTs need to do, why, and when

• Q&A

Not a substitute for reading chapter 2

Five Themes• Using the four contracting routes

• Understanding essential services and related statutory requirements

• How patient registration, list-closure and forced assignments will work

• Understanding additional services

• Using enhanced services to deliver whole system change

The Four Contracting Routes (1)

• New Primary Medical Services duty

• PCT must from 1st April “commission or provide primary medical services to the extent that it considers necessary to meet all reasonable requirements”

• PCTs must ensure sufficient alternative provision in place at the time additional service/OOHs opt-outs take effect

The Four Contracting Routes (2)Contract Providers

General Medical Services (GMS) Practices with at least one GP provider (single-

handers, partnerships, or a certain type of limited

company described in chapter 6)

Personal Medical Services (PMS) Practices (single-handers, partnerships, or a

certain type of limited company described in

chapter 6)

Nurses and other clinicians

PCTs

Alternative Providers Medical

Services

(APMS)

Commercial providers

Voluntary sector

Not-for-profit organisations

NHS trusts and foundation trusts

Other PCTs

PCT Medical Services (PCTMS) PCTs

The Four Contracting Routes (3)• Obligations & rights with GMS contract:

– essential services: must provide– additional services: right & expectation to provide for own population– enhanced: right to provide 3 DES: access, QUIP, CVI– “GMS and PMS contractors do not have preferred provider status for

other enhanced services” (para 2.13, page 22)

• Greenfield sites (“significant population expansion”): expectation PCT “could advertise and seek applications through a two stage process”

• Brownfield sites: no preferred provider status

Essential Services (1)

• Understanding is pre-requisite to effective commissioning of enhanced services

• Management of all patients suffering from disease as defined in the ISCD- eg disabilities, long-term conditions, infertility, depression etc

• Contractors must provide “appropriate ongoing treatment and care for all registered patients and temporary patients”, including advice about health promotion

Essential Services (2)• Enhanced services specifications: “no part of the

specification by commission, omission or implication defines or redefines essential or additional services”

• Para 2.19: “GMS contractors are funded through the global sum and MPIG to provide the equivalent services for which they were previously funded under existing GMS”

• Exceptions are flu; CVI; cervical cytology and minor surgery (part); intra-partum care; intrauterine contraceptive devices and implants


• Core hours: contractor responsible for ensuring provision 8am-6.30pm, Monday to Friday except public and bank holidays

• Normal surgery hours: must be “to the extent necessary to meet reasonable needs”

• Replaces 26 hour a week face to face commitment on an individual GP


• Temporary patients obligations remain

• Home-visiting “if the patient’s medical condition is such that, in the reasonable opinion of the contractor, it is necessary to do so”

• Newly registered patients

• Three-year rule and over 75 checks at patient request

Patient registration (1)

• Obligation to ensure lists are accurate

• Choice of practitioner subject to availability, appropriateness, reasonableness

• New PCT Guide to Primary Care Services

• Contractors to review patient leaflets before April

• PCTs and contractors agree practice areas before April

Patient registration (2)

• Open/closed status: discuss with practices before end of February

• Open list:– “must accept any application … unless it has fair and

reasonable grounds for not doing so”– must not discriminate & give reasons for refusal in writing

and keep a record (same applies for all removals)– PCT can assign patients

Patient registration (3)• Closed list:

– must not accept new patients save immediate family– new patient assignment procedure applies

• Formal closure and assignment procedures from 1st April:– rejecting closure notice/application to assign patients to contractors with closed lists leads to Assessment Panel

determination– appeal is to the SHA (not the FHSAA(SHA))

• PCTs cannot assign to closed lists from 1st April other than through this procedure; may need to develop applications, and put panel arrangements in place

• Open list:– “must accept any application … unless it has fair and reasonable grounds for not doing so”– must not discriminate– must give reasons for refusal in writing and keep a record– PCT can assign patients

Additional services (1)• PCTs must ensure sufficient in place from 1st April

• Contractors do not have to provide if not already doing so

• PCT discretion to agree opt-outs before April 2004 when opt-out procedure applies; ascertain intentions in January, decide in February

• Tariff for opt-out (% of global sum, not GS+MPIG)

• No fixed price for recommissioning additional services

Additional services (2)

• Purpose of opt-outs is to manage contractor workload

• PCT can reject opt-outs if the contractor is providing any enhanced services

• If it approves the opt out, but then cannot find alternative provision despite best endeavours, PCTs can seek SHA approval that there are exceptional circumstances

Using enhanced services (1)• Expanding range, improving choice, convenience,

VFM, & reducing pressures on hospitals

• Local floor from 2004/05 monitored nationally

• Initial plans during February - to include the 6 DES

• PEC sign off proposals and must seek LMC agreement that spend counts to floor

Using enhanced services (2)• Tighter definition of spend

• Includes:– DES, NES, LES from any provider– PWSI– Plus in PMS Plus, Specialist in PMS specialist– Local incentive schemes from GMS & PMS providers– Recommissioned services ONLY if contestable for GMS & PMS contractors &

could reasonably be provided by them

• Excludes any baseline spend on trusts/other providers simply rolled forward, or anything funded through other primary care routes

Using enhanced services (3)• PCT must commission 6 DES from 1st April, and offer 3 of the

DES to GMS contractors

• PCT commissions as primary medical services, decides when, from whom & how it commissions other enhanced services

• Bear in mind definition of essential services

• PCTs may wish to be guided by NES but “commissioning decisions are entirely a matter of local negotiation” (para 2.84)

Summary

• New duty & four commissioning routes

• Understand essential services

• New patient registration, list closure & assignment arrangements

• Additional services commissioning & opt outs

• Understand enhanced services commissioning rules, spend, and use to deliver strategic change

PCT actions

• Strategy for commissioning primary care• 1st Jan: offer 2003/04 access & QUiP DES• End Jan: reviewed additional services commissioning &

contractor intentions• 1st Feb: commission violent patients DES• End Feb: agreed practice areas, open/closed status, discussed

normal hours, offered 3 DES, agreed early additional service opt-outs

• End Feb: drawn up initial plans for commissioning enhanced services

• Apr: set up assessment panels & proposals for assignments if need be

Questions

The new

GMS & PMS

Learning Exchange


Microsoft PowerPoint Presentation

nGMS and PMS EVENTSFINANCE

Michael Munt

nGMS and PMS IMPLEMENTATIONFINANCE

Overview

• Financial Arrangements• Contractors - Statement of Financial

Entitlements• Allocations to PCT’s • Contractor Budgets• Financial Management and Monitoring• Key Milestones


Financial Arrangements - Headlines

Spending on Primary Medical Services in the UK to increase from £6.1bn in 2002/03 to £8bn in 2005/06

Arrangements underpinned by Gross Investment Guarantee for the years 2003/04 to 2005/06

All allocations are now cash limited with some minor elements of dispensing remaining as non cash limited

Link to Local Development Plan


Gross Investment Guarantee (GIG) Mechanism to monitor overall spend on Primary Medical

Services. Technical Sub Committee established comprising

representatives of DH/NHSC/BMA to monitor arrangements.

Component Parts• GMS Non Cash Limited • PCT Unified Allocation, GMS Cash Limited,

Dispensing Drug costs • Centrally Funded Initiatives• New Monies Primarily For Quality


EXPENDITURE TYPE England 2002/03 2003/04 2004/05 2005/06

GMS fees and allowances 2,990 3,100 - -

GMS cash-limited payments 988 1,086 - -

Global sum payments 0 2,651 2,690

Quality payments 0 80 682 1,102

Enhanced primary care services 254 315 518 586

Premises 0 60 600 756

IT 0 60 108 108

Other PCT administered funds 0 332 354

Transitional protection 0 297 197

Other (R&R & OOH DF) 74 74 90 90

Demand Management 5 5

Dispensing 726 784 847 917

TOTAL SPEND 5,032 5,559 6,131 6,806


Gross Investment Guarantee

GIG is currently being revised to take account of :

• Outturn on 2002/03 fees and allowances• Growth assumptions in GMS Cash Limited monies• Increases in dispensing and drugs costs• Changes in superannuation employers costs• Projected over/underspend in 2003/04


Contractor Entitlements SFE


Contractor Entitlements

Red Book replaced by the Statement of Financial Entitlement (SFE)

Concept of Entitlement continues but not on the basis of individual Practitioner but on the basis of a Contractor Practice

All payments under the old arrangements cease 31 March 2004

PCT’s must make adequate provision for the accrual of outstanding amounts in their 2003/04 accounts


• Additional cash financing requirement will, if necessary be made available

• Any additional costs to be met by PCT

• The SFE gives Contractors certainty over the minimum level of entitlement

• Discretionary funds will be available to Contractors

• The SFE sets out 17 different types of entitlement


Key EntitlementsGlobal Sum

• Based on Formula - Carr Hill to establish allocation fair shares

• Formula is weighted at Contractor level to be updated every quarter for changes in Contractor characteristics and weighted population

• Indicative price is currently £50 per weighted patient


Off formula adjustments for :

• A London weighting of £2.18 per registered patient not weighted

• Temporary patients adjustment to be calculated as part of a five year rolling average

• Additional Service and Out of Hour Opt outs


Minimum Practice Income Guarantee

To provided support to global Sum formula losers

Income levels protected based on comparison of the Global Sum and Global Sum Equivalent

Global sum Equivalent based on reference period July 2002 to June 2003

GSE to be adjusted to take account of changes in list size between reference period and 1st April 2004


The initial MPIG is then amended to take account of the adjusted GSE

MPIG is a one off calculation

Uplifted only in line with Global sum

No Global Sum uplift in 2005/06


Quality payments

Three payments under the quality heading:

• Quality Preparation Payments -2004/05 is the second and final year

• Quality Aspiration based on one third of the anticipated level of achievement at average £75 per point For 2005/06

• For 2005/06 aspiration payments will be set at 60%


Quality Achievement

• Achievement Payments will be based on achievement points multiplied by £75 for a Contractor with average list size

• Payable by end of April 2005

• PCT’s will need to provided for these amounts in their 2004/05 annual accounts


Other entitlements will cover:

• Directed Enhanced Services • Locum Payments • Seniority payments • Recruitment and Retention Initiatives • Dispensing to be rolled forward but fee rates have

been uprated• Premises - Existing commitments brought forward• Information Technology - Changes reflect new

reimbursement arrangements


Implications for Personal Medical Services

Establish baseline 2003/04 allocation up to wave 5b Excludes Quality preparation and flu allocations Access to new funding streams Improved seniority pay and pensions Ability to opt out of OOH responsibility PMS to GMS movement potential MPIG equivalent based on local data or

benchmark based GMS Global Sum Equivalent based on banded list size


Conditions attaching to SFE payments:

• Provision of all necessary information not available to the PCT

• Must be Accurate to the best of the Contractors knowledge

• Provide up to date and accurate information for registration system purposes

• Breach will be subject to disputes resolution process• Obligation to co-operate with investigation undertaken by

auditors and counter fraud services


Allocations


Allocations to PCT’s

2004/05 Cash Limited Primary Medical Services

Ten separate funding streams but only one “pot”

No separate target for primary care funding will be part of the overall Unified Budget determination

Will need to be managed as part of the overall UB Will become incorporated into three year allocation process


• Not ring fenced except for Enhanced Services/OOH

• Local floor level to be set for Enhanced services

• Majority of funding to be allocated to PCT’s

• Only minimal central budgets


ALLOCATION ARRANGEMENTS

Global sumMPIG

Correction factor

Enhanced services

QOF

PCO Administered

Out of Hours Premises

Dispensing & PA

PMS allocation

IT


Allocation Arrangements

Global Sum and MPIG• Data to inform the calculations via a number of Allocation

Working papers• Practice populations from the Exeter system during April 2003• PCT’s were asked to confirm the attribution of GP’s to practices

and practices to PCT’s• Adjusted for PMS practices in waves 5a and 5b• Expenditure mapped on a cash payments basis from the

reference period July 2002 to June 2003 to establish GSE


• Global sum covers 27 categories for expenditure previously paid via the NCL route

• Changes in configuration of practices

• Included were the implication of GP vacancies but NOT practice staffing

• Additions will be made to the £ per weighted registered list size for the increase in employers superannuation cost


• Agreed that the historical cost will be on formula.

• Superannuation adjustment will effect both GMS and PMS

• Further information will be provided once agreed


Out Of Hours Funding

There are four specific sources of funding to resource out of hours services:

Existing Unified Budget for Out of Hours Development Additional recurring allocation of circa £46m A non recurrent sum of £28m over two years A transfer of 6% of a contractors Global sum excluding

MPIG. The allocation methodology for the OODF will change to a

capitation basis form 2005/06.


Enhanced Services

Most of the enhanced services has already been allocated to PCTs in their three year allocations

HSC 2002/12 identified sums of £315m/394m/460mand a national floor

2004/05 additional funding will result from the transfer in of existing non cash limited payments.

The national floor is to be replaced by a local PCT floor in 2004/05. Still to be agreed

Planned spending needs to be signed off by the PEC in consultation with the local LMC


Quality and Outcomes Framework

Three funding elements for the QOF• Quality Preparation - to be allocated in January 2004• Aspiration - allocation to be made to PCT in April 2004 • Achievement - resource only to be allocated in year• Financial provision to cover QOF indicatively sufficient to

support 74% and 85% achievement in 2004/05 and 2005/06

• NHS to manage the risk through the NHS Bank - policy still to be determined


PCT Administered funds

This will cover:• Seniority• Locum Payments• Recruitment and Retention arrangements

To be allocated mainly on an historical basis except recruitment and retention which will be held central to target

Precise detail will be included in the Allocation statement


Premises Funding

Allocations will be based on

• Existing spend• Agreed new premises developments contractually agreed by 30

September 2003• New premises developments including LiFT based on a weighted

capitation approach

The first two elements will be allocated to PCT’s in main allocation followed by the third element going to the nominated lead PCT within the SHA area


Information and Technology

Historically funding for IMT part of the Cash limited GMS allocation

Topped up by at least £20m to meet 100% costs of minor upgrades and maintenance. This will be made recurrent.

Allocations to be mapped on the basis of historical spend Balance of funding will be held centrally within National

Programme for IT PCT’s will need to establish asset registers


Contractor Budgets


Establishing Contractor BudgetsPCT’s will receive ACTUAL Allocations which will include indicative budgets for contractors

ACTION REQUIRED To establish indicative budgets one week after receipt of

allocation To negotiate and provisionally agree by the end of

February 2004 Contracts signed by 31 March 2004 Firm up Actual Contractor budgets during April/May 2004 Make first payment by the end of April 2004, agree a

deduction for superannuation purposes


Indicative Contractor Budgets

Contractor Budget Spreadsheet distributed in December 2003PCT’s will need to adjust indicative global sum and MPIG’s where appropriate for:• Any changes in practice configuration since the

reference period• Changes in registered list size • Temporary Patient adjustment to be updated for a five

year average• Any agreed staff vacancy factors• Take account of any PMS returners


Contractors Budgets post April 2004

Exeter system will automate the process

Changes that will still need to be reflected by PCT are:• Contractor movements between PMS/GMS• Confirm registered populations are accurate• Reflect any change in opt out arrangements• Take account of contract terminations, withholding of

monies, splits and mergers• Start to record Temporary Patients numbers for future

reference and allocation purposes


Financial Management and Monitoring


Monitoring Arrangements

Need to change both National and Local Reporting arrangements. This will require:

• Changes to local expenditure coding structures• Local Reporting and monitoring arrangements• National Financial Information System• Statutory Accounts

Aim to produce one set of information that can meet all requirements


Key Milestones


Key Milestones

1. Mid-January 2004 The Department will have shared 2003/04 baselines for each funding

stream

2. January 2004 PCTs started to complete the indicative contractor budget

spreadsheet

3. First week in Feb 2004 DoH will have given notice of actual PCT allocations with

estimated contractor global sums, GSEs and

MPIGs


4. End of January 2004 PCTs prepared indicative financial risk management plan as they are

finalising indicative contractor budgets; linked to their Local Delivery Plans

5. First week Feb 2004 DoH will have allocated the remaining premises money, for

new developments, to lead PCTs

6. Feb 2004 - One week

after allocation rec’d PCTs will have calculated and shared indicative budgets with all GMS

contractors


7. Early in 2004 PCTs will have reviewed their financial ledger structure and

new reporting requirements

8. End of February 2004 PCTs will have been notified of changes to the Exeter system

9. End of February 2004 PCTs and contractors will have agreed indicative budgets,

reflecting discussions and provisional agreements about what services will be provided

10. End of March 2004 PCTs will have encouraged GPs to submit claims under the Red

Book


11. End of March 2004 The Department will have allocated the additional global sum monies to reflect the increase in employer superannuation contributions

12. From April 2004 PCTs will have made monthly payments of new GMS funding to contractors

13. From April 2004 PCTs will have provided FIMS returns on the new basis

14. April 2004 PCTs will have made adequate year-end provision for old GMS sums in 2003/04 accounts

15. By the end May 2004 PCTs will have calculated and agreed actual budgets with contractors

The new

GMS & PMS

Learning Exchange



New Arrangements for GMS& PMS Premises

Jim Latta

0113 2547 164

07788 416 504


• Demise of Statement of Fees & Allowances

• Replaced by easier to administer nGMS arrangements set out in Directions

• These arrangements may be used for PMS


• Separate element for infrastructure costs comprising three elements:– existing spend– resources to meet commitments

contractually agreed by 30 September 2003– plus weighted growth element to meet costs

of developments agreed after 1 October, IGs, use of flexibilities etc


• The first and second elements will form a baseline allocation to all PCTs

• The third element will be allocated to lead PCTs on SHA-aggregate basis

• For onward cascade to PCTs in line with priorities agreed collectively


• Premises funding an element of PCT allocations and can be topped-up

• Baseline determined by recent AWP exercise

• Significant growth funding will start to be made available from 1 April 2004

Role of SHA is to….

Appoint lead PCT to put in place investment prioritisation arrangements

Endorse a framework for SSDP development (to include PPF)

Be satisfied that proposed estate investments address national and local service priorities

Role of SHA (contd.)

• Establish links between Lead PCT proposals and SHA wide capital developments

• Be satisfied that financial accounting and governance framework in place

• Be satisfied premises investment underpins Modernisation

• Broker agreements in disputes between PCTs

Role of Lead PCTs

Ensure adequate arrangements for management of the premises allocations

Work with constituent PCTs to develop an agreed policy on:

- arrangements to prioritise investment proposals

- business case arrangements

- funding use of new premises flexibilities, contingency measures etc

Role of Lead PCTs (contd)

Co-ordinate PCT SSDPs and estate strategies

Ensure parity of access to growth funding to address historic lack of estate investment

Link service developments to modernisation, e.g. Out of Hours, Walk in Centres

Facilitate collective expertise on estate management and procurement

Advise SHA of PCT-agreed investment strategy priorities

New Premises Arrangements Include…..

• Joint MS(H)-GPC Letter

• New premises flexibilities to attract capital investment and allow moves to modern premises

• Revised minimum standards & branch surgery global sum funding

Access to Support

• New Primary and Social Care Planning and Design Guidance

• Web-based with links to supporting sites and search facilities

• www.primarycare.nhsestates.gov.uk

Support Facilities

• NHS Estates Strategic Advisors

• NHS Estates PC Development Managers

• NHS Estates-NatPaCT partnership

Overall Aim Is To….

• work thro’ SHAs to monitor and support PCT delivery to….

• inform PC NHS capital allocations to….

• target investment where most needed.

The new GMS & PMS

Learning ExchangeThe National Primary and Care

Trust Development Programme


welcome to the new gms & pms learning exchange

Documents

modernising services

effective use

items dispensedstrategic

new roles

modern primary care

patient feedback

patient experience

emergency care system