All change for general practice

1. All change for general practice Dr Chaand Nagpaul Chairman, BMA GPs committee Member BMA Council

2. Where we are today : under-resourced

3. Where we are today - understaffed

4. Where we are today - understaffed

5. Where we are today – overworked and demoralised • DH commissioned 7th worklife survey GPs (Aug 2013) • lowest levels of job satisfaction since 2004 contract • highest levels of stress since start of the survey series • substantial increase in GPs intending retiring next 5 yrs • BMA GPC GP contract survey (Sep 2013) • 9 out of 10 increased workload past year • Nearly 100% increased bureaucracy, 9 out of 10 say reducing appts and time for patients • Nearly 9 out of 10 reduced morale • 1 in 2 GPs less engaged with CCG due to workload

6. GP contract changes 2014/15: objectives • reverse adverse impact 2013-14 imposed changes • reduce bureaucracy, box ticking and chasing of targets • increased resources in core GP budgets, provide stability, enabling clinical judgment and flexibility in providing care.

7. QOF • 341 points released – 238 to core funding, 103 to ES • Almost all unacceptable imposition indicators removed e.g BP 140/90, GPAQ, biosocial assessment • Removal of many indicators creating most bureaucracy • Threshold increases for 2014-15 retracted • New NICE indicators for 2014-15 removed

8. Last year’s DESs • 3 of last year’s imposed DES ended • Remote care monitoring - > GS • Patient online DES- > GS • Risk profiling DES -> combined with QP points-> “reducing avoidable admissions ES” • Patient participation DES £40m -> GS and patient survey ends, Friends and Family test in contract • Dementia DES-continues

9. Reducing unplanned admissions ES (1) • New enhanced service -funded by transfer of 100 QP points & retired risk profiling DES (£162m). • Emphasis on practice availability to patients at risk of hospital admission & proactive personalised care • Risk profiling - 2% of practice adult population (aged 18 and older) “case management register”. • Contains many elements practices already carrying out as part of risk profiling DES • Focus on treating patients rather than CCG directed QP requirements.

10. Unplanned admissions ES (2) • Named accountable GP -responsibility for creation of patient care plans. Can specify a different care coordinator as main point of contact for patient • Practices to provide vulnerable patients with urgent queries with same-day telephone consultations . • Practices to provide timely access via ex-directory or bypass number to A&E clinicians, ambulance staff and care and nursing homes to support decisions on hospital admissions & transfer to hospital 

11. Unplanned admissions ES (3) • “Case register” patients discharged from hospital discharge to be contacted by practice to ensure coordination and delivery of care. • Practices to undertake regular reviews of unplanned admissions & readmissions for case register patients to identify factors which could have avoided the admission • Practices to review emergency admissions & A&E attendances of patients from care and nursing homes. • Practices to undertake monthly reviews of case management register to consider actions to be taken to prevent unplanned admissions

12. Named GP for 75s & Over • Newly registered patients to be notified of name of GP within 21 days of registration. Existing patients to be notified by 30 June 2014. • Named accountable GPs to take lead responsibility for ensuring appropriate services required under contract delivered to patients aged 75 &older. • Where required, named GP to work with relevant health &social care professionals to deliver multidisciplinary care package. Based on clinical judgement.

13. OOH Quality Monitoring • Practices to monitor quality of OOH services (opted out) to include patient feedback, complaints • Review the clinical details of OOH consultations received from OOH providers the same working day • Respond to any information requests by out of hours providers in respect of these consultations on same working day (exceptionally following working day). • Take reasonable steps to comply with systems out of hours providers put in place for rapid and effective transmission of out of hours patient data, including those with special needs

14. I.T. Changes • Additions to the GP contract • Online appointment booking • Online prescription request • inclusion of NHS Number as primary identifier in clinical correspondence • Uploads of SCR by April 2015 • Patient online access to SCR • Government commitments to wider online patient access, communication with practice 2015

15. Seniority • Government commitment to end age-related pay progression across public sector • Seniority to be phased out over six year period; those in receipt protected over this time • closed to new entrants from 1 April 2014 • no change for two years • 15% each year to be transferred to core funding, based on expected retirement rate • redistribution of all released funds to core general practice funding- to all practices • money in GS will be subject to annual inflationary rises (no uplift to seniority since 2004)

16. Friends & Family Test • Contractual requirement • Test question: 'How likely are you to recommend our practice to friends and family if they needed similar care or treatment?‘ • Requirement to ask one follow up question of their own choosing and provide monthly feedback to NHS England. • Less onerous than local practice survey as part of patient participation DES

17. Publication of earnings • Proposal for practices to publish GP earnings implemented for 2015-2016 • Working group negotiated – like-for-like basis with other healthcare professionals • GP NHS net earnings relating to contract only • No detail • Current published HSIC GP pay figures inflated with non-contractual and non-NHS income

18. Choice of GP Practice • Choice of GP practice pilot scheme to be extended across whole of England • Government committed to rolling this out despite concerns • Patient take-up in pilots low • Remains voluntary for practices

19. Movement to core funding • Value of 238 QOF points • £40m from patient participation DES • £12m from remote care monitoring DES • £24m from patient online DES • Circa £80m from seniority funding pot by 2020

20. This is the beginning….. • Demand exceeds capacity • Changing demographics; out of hospital care • Need more GPs • Need more practice staff • Need bigger and more premises • Need greater wrap around services

21. Wider issues • Keogh report: Urgent care: NHS 111, OOH care, A&E attendances • Reducing emergency admissions • Role of CCGs • Francis • 7 day opening • IT- Use of newer technologies, data sharing

22. "Developing General Practice today - Providing healthcare solutions for the future" • GPC discussion paper • 340m consultations/yr cf 21m in A&E • £130 patient/yr unlimited care vs £200 single OPD appt • GP practice as hub of coordinated integrated care • Networks of practices • Patients as partners • “Greater collaboration between community pharmacists and practices with a practice aligned pharmacist undertaking medicines management and other elements of chronic disease management”. • General practice as a solution