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The new GMS contract - implications for nurses

Christopher Derrett
MPhil MRCGP
General Practitioner
Barton House Health Centre
London
Head of GP Development
City and Hackney TPCT
E:chris.derrett@nhs.net

The current system for organising and paying GPs has changed little since the 1960s. Patients register with a named GP who is in contract with the local primary care trust (PCT) to provide, or subcontract, 24-hour care, 365 days a year.
In the last 40 years, general practice has become less doctor-centred and practice teams have become larger and multidisciplinary. People have become healthier, therapeutics and preventive medicine have advanced apace, and patients' expectations have increased enormously. Enhanced primary care teams, with the introduction of nurse practitioners and healthcare assistants, improved premises, more professional management and a rapid expansion in the use of information technology, have transformed general practice and greatly increased the level of financial investment needed.
The current system of payment rewards quantity, not quality; practices can earn more by providing minimal services to a large "patient list" than by offering comprehensive healthcare to fewer patients. The public and politicians want a system that combines greater accountability with less inequality in the level of care. They are seeking guaranteed minimum standards of organisation and clinical care and payments that reward quality.
Social change within the NHS also plays an important part in determining the professionalism and morale of primary care staff and in influencing recruitment and retention. Many nurses and doctors are reviewing their work-life balance and exploring ways in which they can better incorporate family life and other interests within a primary care career. The expansion of part-time working and flexible career schemes have been part of these developments.
The new contract attempts to reward quality of ­practice, while providing greater flexibility of working for healthcare teams and individual nurses and doctors. At the time of writing, many details of the new arrangements remain to be resolved, but the principles have been agreed. It is planned that most of the changes of the new contract will be ­introduced during 2004.

The future under the new GMS contract

A practice-based contract
Under the new contract, patients will register with a practice, not an individual GP; however, they will be free to see the nurse or doctor of their choice. The practice-based contract acknowledges that primary care is now a team enterprise. It also recognises the benefits of continuing care by known and trusted healthcare professionals.

Payment based on workload ­and quality standards
The payment system for the new contract is practice- based and is intended to reflect workload and the quality of services offered. The payments are divided into three main categories:

1. Global sum
The global sum payment is intended to cover the basic operation of the practice. This includes an element to cover the cost of staff, locums, training and career development. In the past, practices have enjoyed a system where approximately 70% of staff costs have been reimbursed, irrespective of staff numbers. In the new contract, the payment for staff is fixed.
The intention is that the global sum should reflect practice workload and costs; it should take into account the time required when consulting with patients of varying needs and in areas with differing costs. Initially, the plan was to use a specially developed "resource allocation formula"; however, this has been shown to significantly and unfairly disadvantage some practices, particularly those in London, and so a last-minute compromise called the "minimum practice income guarantee" (MPIG) was devised based on historical income data. The full implication of this fudge has yet to be determined, but the financial stability of some practices may remain under threat for some time.

2. Quality payments
The new contract attempts, for the first time, to ­quantify organisational and clinical quality and pay practices accordingly. The standards are measured in a range of domains, including chronic disease management, for example:

  • Coronary heart disease.
  • Stroke.
  • Raised blood pressure.
  • Diabetes.
  • Chronic obstructive pulmonary disease.
  • Epilepsy.
  • Cancer.
  • Mental health.
  • Hypothyroidism.
  • Asthma.

The practice will be required to document and audit a range of process and outcome measures for each domain. For example, coronary heart disease has 12 quality/outcome indicators (see Box 1). 3d and 3f are clinical "outcome" measures, while the others measure "process". Practice payments are scaled according to the performance reached on each of these measures, and the payment will reflect the difficulty in achieving the target. Outcome measures attract the highest payments.

[[NIP14_box1_69]]

Education and training also form part of the new- contract quality framework. Practices will be rewarded for good organisation, which will include the following areas of competency:

  • Life support skills - training and updating.
  • Significant event analyses.
  • Appraisal.
  • Induction training for new staff.
  • Review of patient complaints.
  • Personal learning plan review.

Many practice-based nurses already operate within organisations that recognise the importance of the above competencies; the new contract will help to raise standards in less well-organised practices.

3. Enhanced service payments
Under the new contract, practices or alternative providers will be able to contract to offer a range of enhanced clinical services. These include services for particular patient groups, such as the homeless, drug users, the terminally ill, people with multiple sclerosis or people with learning difficulties, and provision of particular specialist clinical procedures, such as intrauterine contraceptive device (IUCD) fitting, anticoagulant monitoring or sexual health services. Some of these "enhanced" services will be offered nationally, but others will be negotiated locally.
Some of these new services will be provided by nurses, while others may require the recruitment of new members to the team, such as phlebotomists or healthcare assistants.
The "alternative provider" option could offer a new opportunity for one or more nurses (in a consortium) to work under contract to primary care organisations. The "freelance" option might appeal to nurse practitioners with specialist skills or to clinical specialist nurses who want to manage themselves.

Out-of-hours care
The new contract allows GPs to opt out of out-of-hours (OOH) care; it is probable that many practitioners will choose to exercise this option. As fewer GPs will be available, the nature of OOH provision is bound to change. OOH cooperatives, NHS walk-in centres, accident and emergency departments and ambulance paramedics might work together in an integrated service, and opportunities could arise for nurses to take on a major role in triaging patients and in dealing with a substantial proportion of OOH primary care problems. It is not yet clear whether the financial attractions to work within these new facilities will mitigate for the unsocial hours.

Information technology
The introduction of quality indicators has important implications for the recording of clinical data. All healthcare professionals who run chronic disease clinics will need to enter data into the practice computer using a standardised set of computer (Read) codes. In order to facilitate this, all the main GP computer suppliers are currently developing software for data collection and analysis. Chronic disease management is likely to become more structured and protocol-driven. In theory this should lead to more consistent care. It remains to be seen whether this data collection process will significantly increase the consultation time or inhibit the rapport between the nurse and patient.
The new contract promises a significant amount of new money to develop IT provision within general practice. This is intended for hardware, software and training. In the long term, the government envisages an integrated electronic system of medical records for the entire NHS. A key part of this strategy is the rationalisation and standardisation of practice computer systems and much wider use of computers for recording clinical information in hospitals and in practices.

Premises
Good premises are seen as a prerequisite for good general practice. A range of flexible funding options is on offer to encourage practice teams to upgrade and extend existing surgery premises and, where appropriate, to build anew. In future, primary care premises should include access for disabled people, a properly equipped treatment room, appropriately equipped consulting rooms (including facilities for undressing and dressing in privacy) and satisfactory arrangements for cleaning, security and maintenance.

Flexible and family-friendly working arrangements
The government is committed to stimulating recruitment and retention of primary care professionals by promoting more flexible working arrangements. Many primary care nurses already work part-time; it is not clear how many would like to work more flexibly. In some practices it might be possible to accommodate term-time working, which may suit a parent with children at school. However, this would not be convenient in all practices, and it is not obvious how greater flexibility of working fits with the government's aspiration to improve access to primary care professionals.
Many practice-based nurses are involved in teaching and other professional duties within and outside their practices. It is hoped that flexible working might enable more use of available skills and provide an increase in protected time for continuing professional development.

Conclusion
The new GMS contract is likely to have a profound influence on the professional lives of all nurses working in general practice. The government has promised a major investment in general practice and is expecting visible and measurable results. The changes that nurses will observe will involve new responsibilities, particularly relating to the achievement of organisational and clinical standards.
According to the new contract, it is hoped that primary care teams will develop in ways "that enable nurses to be fully involved in practice decision-making that impacts on their work". In a few cases nurses may take on the role of practice partners: in others they may contract with their local PCT as alternative providers of enhanced services.
The contract should lead to better clinical accommodation and equipment, and it could bring new colleagues and managerial responsibilities. It is likely to offer greater opportunities to develop professionally and present the possibility of more flexible working.

Resources
The new GMS contract and supporting ­documents are available from
W:www.doh.gov.uk/gmscontract/thecontract.htm
and
W:www.doh.gov.uk/gmscontract/supportingdocs.htm
National Primary and Care Trust Development Programme
The role of nurses under the new GMS contract
Available from
W:www.doh.gov.uk/gmscontract/practicenurses.pd