GP Contract 19/20
PCNs Top Tips
Legal Guidance for PCNs from BMA Law
the BMA and NHS England have reached a sensible position on the pre-requisites. While most should be achievable by the 15th May deadline, the necessity to enter into a Network Agreement was causing concern as any network is going to need to consider its objectives and operating model before moulding the Network Agreement to suit. Indeed, all PCNs should consider “function before form”.
With this in mind, it has now been agreed that practices need only sign up to the core elements of the Network Agreement by the 15th May 2019. They will then have up to the 30th June 2019 to finalise the full agreement. Even then, if agreement has not been reached the commencement of the DES will be delayed until agreement is reached.
Foreword and summary
General practice is the bedrock of the NHS, and the NHS relies on it to survive and thrive. This agreement between NHS England and the BMA General Practitioners Committee (GPC) in England, and supported by Government, translates commitments in The NHS Long Term Plan1 into a five-year framework for the GP services contract. We confirm the direction for primary care for the next ten years and seek to meet the reasonable aspirations of the profession. In our discussions we shared five main goals:
• secure and guarantee the necessary extra investment;
• make practical changes to help solve the big challenges facing general practice, not least workforce and workload;
• deliver the expansion in services and improvements in care quality and outcomes set out in The NHS Long Term Plan, phased over a realistic timeframe;
• ensure and show value for money for taxpayers and the rest of the NHS, bearing in mind the scale of investment;
• get better at developing, testing and costing future potential changes before rolling them out nationwide.
Specifically, this agreement:
1. Seeks to address workload issues resulting from workforce shortfall. Through a new Additional Roles Reimbursement Scheme, Primary Care Networks (PCNs) will be guaranteed funding for an up to estimated 20,000+ additional staff by 2023/24. This funds new roles for which there is both credible supply and demand. The scheme will meet a recurrent 70% of the costs of additional clinical pharmacists, physician associates, first contact physiotherapists, and first contact community paramedics; and 100% of the costs of additional social prescribing link workers. By 2023/24, the reimbursement available to networks amounts to £891 million of new annual investment. Practices will continue to fund all other staff groups including GPs and nurses in the normal way through the core practice contract, which grows by £978 million of new annual investment by 2023/24 and will support further expansion of available nurse, GP and other staff numbers. NHS England will also create and part-fund a new primary care Fellowship Scheme2 aimed at newly qualifying nurses and GPs, as well as Training Hubs. Current NHS England recruitment and retention schemes under the General Practice Forward View3 will be extended. Rises in 4 employer superannuation contributions will be fully funded. We have asked the Government to introduce a partial pension scheme.
2. Brings a permanent solution to indemnity costs and coverage. The new and centrally-funded Clinical Negligence Scheme for General Practice will start from April 2019. All of general practice will be covered, including out-of-hours and all staff groups. Membership will be free. The scheme is funded through a one-off permanent adjustment to the global sum. Practice contract funding nonetheless rises in 2019/20 by 1.4%, as a result of the overall investments agreed. Future costs of NHS practice under the scheme will be funded centrally, not met individually by practices.
3. Improves the Quality and Outcomes Framework (QOF). We are implementing the findings of the QOF Review4. 28 indicators, worth 175 points in total, are being retired from April 2019. 74 points will be used to create a new Quality Improvement domain. The first two Quality Improvement Modules for 2019/20 are prescribing safety and end-of-life care. 101 points will be used for 15 more clinically appropriate indicators, mainly on diabetes, blood pressure control and cervical screening. The current system of exception reporting will be replaced by the more precise approach of the Personalised Care Adjustment. This will better reflect individual clinical situations and patients’ wishes. In 2019, we will review the heart failure, asthma and chronic obstructive pulmonary disease domains. In 2020, we will review the mental health domain for change in 2021/22. Long term Quality Improvement module and indicator development will benefit from the new primary care testbed programme.
4. Introduces automatic entitlement to a new Primary Care Network Contract. In The NHS Long Term Plan, Primary Care Networks are an essential building block of every Integrated Care System, and under the Network Contract Directed Enhanced Service (DES), general practice takes the leading role in every PCN. The Network Contract is a DES established in accordance with Directions given to NHS England. Eligibility depends on meeting registration requirements. The Network Contract DES supports practices of all sizes, working together within neighbourhoods. Like existing GMS, the Network Contract DES will be backed by financial entitlements. If every network takes up 100% of the national Network Entitlements we intend, including a recurrent £1.50/patient support, plus a new contribution to clinical leadership, £1.799 billion would flow nationally through the Network Contract DES by 2023/24. CCGs could also add local investment through Supplementary Network Services. We expect 100% geographical coverage of the Network Contract DES by July 2019, so that no patients or practices are disadvantaged. Each network must have a named accountable Clinical Director and a Network Agreement setting out the collaboration between its members. Together, the Clinical Directors will play a critical role in shaping and supporting their Integrated Care System and dissolving the historic divide between primary and community medical services. A new Primary Care Network development programme will be centrally funded and delivered through Integrated Care Systems.
5. Helps join-up urgent care services. The NHS Long Term Plan envisages Primary Care Networks joining up the delivery of urgent care in the community. Funding and responsibility for providing the current CCG-commissioned enhanced access services transfers to the Network Contract DES by April 2021 latest. From July 2019, the Extended Hours DES requirements are introduced across every network, until March 2021. Following an Access Review in 2019, a more coherent set of access arrangements will start being implemented in 2020 and reflected in the Network Contract DES with coverage everywhere in 2021/22. 111 direct booking into practices will be introduced nationally in 2019. As part of these access arrangements, £30 million of additional annual recurrent funding will be added to the global sum from 2019/20. Working with NHS Digital, GP activity and waiting times data will be published monthly from 2021, alongside hospital data. Publication of the data will expose variation in access between networks and practices and we will include a new measure of patient-reported experience of access.
6. Enables practices and patients to benefit from digital technologies. NHS England will continue to ensure and fund IT infrastructure support including through the new GP IT Futures programme, which replaces the current GP Systems of Choice5. Additional national funding will also give Primary Care Networks access to digital-first support from April 2021, from an agreed list of suppliers on a new separate national framework. All patients will have the right to digital-first primary care, including web and video consultations by April 2021. All patients will be able to have digital access to their full records from 2020 and be able to order repeat prescriptions electronically as a default from April 2019. A Review of Out-of-area Registration and Patient Choice will start in 2019. The rurality index payment and London adjustment will be changed from April 2019 to avoid unwarranted redistribution between different types of provider. To safeguard the model of comprehensive NHS primary medical care, from 2019 it will no longer be possible for any GP provider either directly or via proxy to advertise or host private paid-for GP services that fall within the scope of NHSfunded primary medical services. NHS England will consult in 2019 on expanding this ban on private GP services to other providers of mainly NHS services. In recognition of income loss and workload from subject access requests, £20 million of additional funding will be added to the global sum for the next three years.
7. Delivers new services to achieve NHS Long Term Plan commitments. The scale of the investment in primary medical care under this agreement was secured for phased and full delivery of all relevant NHS Long Term Plan commitments. The annual increase in funding for the Additional Roles Reimbursement Scheme is subject to agreeing seven national Network Service Specifications and their subsequent delivery. Each will include standard national processes, metrics and expected quantified benefits for patients. The specifications will be developed with GPC England as part of annual contract negotiations and agreed as part of confirming each year’s funding. Five of the seven start by April 2020: structured medication reviews, enhanced health in care homes, anticipatory care (with community services), personalised care and 6 supporting early cancer diagnosis. The other two start by 2021: cardio-vascular disease case-finding and locally agreed action to tackle inequalities. A Review of Vaccination and Immunisation arrangements and outcomes under the GP contract will take place in 2019 and also cover screening. Available by 2020, a new Network Dashboard will set out progress on network metrics, covering population health, urgent and anticipatory care, prescribing and hospital use. Metrics for the seven new services will be included. A national Network Investment and Impact Fund will start in 2020, rising to an expected £300 million in 2023/24. This is intended to help networks make faster progress against the dashboard and NHS Long Term Plan goals. Part of the Investment and Impact Fund will be dedicated to NHS utilisation, which could cover: (i) A&E attendances; (ii) emergency admissions; (iii) hospital discharge; (iv) outpatients; and (v) prescribing. The Fund will be linked to performance and its design will be agreed with GPC England and Government. We envisage that access to the Fund becomes a national network entitlement, with national rules as well as locally agreed elements. Networks will agree with their Integrated Care System how they spend any monies earned from the Fund.
8. Gives five-year funding clarity and certainty for practices. Resources for primary medical and community services increase by over £4.5 billion by 2023/24, and rise as a share of the overall NHS budget. This agreement now confirms how much of this will flow through intended national legal entitlements for general practice under the practice and network contracts. GPC England and NHS England have agreed that we do not expect additional national money for practice or network contract entitlements, taken together, until 2024/25. Funding for the practice contract is now agreed for each of the next five years, and increases by £978 million in 2023/24. As a result, DDRB will not make recommendations on GP partner net income. Under this agreement, we assume that practice staff, including salaried GPs, will receive at least a 2.0% increase in 2019/20, but the actual effect will depend on indemnity arrangements within practices. NHSE and GPC have asked the government to ask the DDRB not to make recommendations for salaried GPs for the 2019 pay round. We have further asked the Government to continue to include recommendations on the pay of salaried GPs in the DDRB remit from the 2020 pay round onwards. Recommendations will need to be informed by affordability and in particular the fixed contract resources available to practices under this deal and will inform decisions by GP practices on the pay of salaried GPs. We have asked the Government to ensure that DDRB continues, as usual, to recommend on GP trainees, educators and appraisers. As now, the Government will decide how to respond to DDRB recommendations. A new Balancing Mechanism will, if required, adjust between the global sum and the workforce reimbursement sum in the Network Contract DES, depending on real terms partner pay levels. This will be designed by NHS England and GPC England in 2019. As a corollary of major investment, and to safeguard public trust in the GP partnership model, pay transparency will increase. GPs with total NHS earnings above £150,000 per annum will be listed by name and earnings in a national publication, starting with 2019/20 income. The Government will look to introduce the same pay transparency across other independent contractors in the NHS at the same time.
9. Tests future contract changes prior to introduction. A new testbed programme will be established to provide real-world assessment. Under this, different clusters of GP practices in Primary Care Networks will each develop or test a specific draft contract change such as a service specification, QOF indicator or QI module. Some clusters will work with innovators to discover promising approaches and develop prototypes. Testing is likely to include rapid cycle evaluation, with assessment of costs and benefits. Each cluster will be commissioned nationally, topic by topic, normally through open calls for practice or network participation. Network participation in research will also be encouraged from 2020/21, given the proven link to better quality care. This document marks the expansion of a major programme of collaboration between NHS England and the BMA over the next five years. We include a schedule of planned work. We now need to get the further design work and implementation detail right. The profession and patients expect the benefits we intend to bear fruit.
DR RICHARD VAUTREY IAN DODGE GPC ENGLAND CHAIR NHS ENGLAND NEGOTIATING TEAM