Cynulliad National Cenedlaethol Assembly for Cymru Wales Audit Committee Review of the New General Medical Services Contract in Wales Committee Report (3) 01-08 January 2008 THE NATIONAL ASSEMBLY FOR WALES AUDIT COMMITTEE Report presented to the National Assembly for Wales on 16 January 2008 in accordance with section 143(1) of the Government of Wales Act 2006 Review of the New General Medical Services Contract in Wales Contents Paragraphs Summary and recommendations 1 – 12 Review of the new General Medical Services contract in Wales There are potential benefits to the new contract for the NHS, patients and General Practice although improvements are needed in access, estates 13 – 35 and outcomes There needs to be a focus on delivering the full potential of the contract to ensure value for money 36 – 56 Annexes Annex A Relevant proceedings of the Committee (Thursday, 18 October 2007) Summary 1. Across the United Kingdom, General Practitioners (GPs) provide primary medical care services to patients and act as gatekeepers to other NHS services. Over 90 per cent of patient contacts with the NHS take place in a primary care setting. The new General Medical Services contract (new contract) was introduced from April 2004, and covers all primary care services provided by practices. Across Wales the contract cost £424 million in 2005/2006 compared to £293 million under the old contract in 2002/2003. Under the new contract Local Health Boards (LHBs) contract with practices to provide services, and the Welsh Assembly Government manages the LHBs through its performance management framework. 2. The new contract replaced the previous contract and changed the basis on which GPs’ income is calculated. The new contract was negotiated across the whole UK, on behalf of the four UK health departments by NHS Employers, and the old contract had run its course. However, concerns arose over the escalating costs, and whether sufficient improvements had been achieved, alongside concerns with the management of the contract by both LHBs and the Welsh Assembly Government. 3. On 17 October 2007, we took evidence on the basis of a report by the Auditor General for Wales1 from Mrs Ann Lloyd (Head of the Welsh Assembly Government’s Department for Health and Social Services and Chief Executive of the NHS in Wales), and Mr John Sweeney (Director of Community, Primary Care and Health Service Policy Directorate). In particular, we examined the steps that the NHS in Wales needs to take in order to optimise the benefits of the new contract. 4. We concluded that although the new contract has delivered some benefits, there needs to be a focus on delivering the full potential of the contract, particularly to improve access, outcomes and performance management. There are potential benefits to the new contract for the NHS, Patients and General Practice although improvements are needed in access, estates and outcomes 5. The NHS in Wales has benefited from the new contract, with a number of important changes increasing its influence over primary care services. Wales has some influence over how the contract is developing and changing, but has had to manage this within a framework covering all four UK countries. Some changes are already 1 Auditor General for Wales report, Review of the new General Medical Services Contract in Wales, August 2007 happening in how services are delivered. LHBs are developing the management of the new contract and are able to influence services, enhanced services are starting to bring more specialised services closer to patients’ homes and investment in premises is starting to increase in a focused way. 6. Patients have benefited from the new contract in a number of ways but we remain concerned that improved access to GPs has not been consistently delivered or monitored. Although the contract provides funding for improved access, the outcome is not being consistently delivered in all parts of Wales. 7. Patients’ views are being considered and influencing commissioning decisions, and they are benefiting from improved management of many chronic conditions through the Quality and Outcomes Framework (QOF). The Welsh Assembly Government (Assembly Government) and the wider NHS in Wales expect that the improved care driven by QOF will result in better patient outcomes over the next few years. Nevertheless, measurable improvements are not yet apparent. 8. General practice has benefited from increased pay and a reduction in working hours, with an average pay increase of around 25 per cent in the first two years of the new contract. These are not the only benefits as GPs can now control their workload, choose which services they provide and have greater flexibility about how they provide the service. All of these benefits combine to make general practice a more attractive place to work, which is reflected by the fact that GP training in Wales is now over-subscribed and there are few recruitment and retention problems. There needs to be a focus on delivering the full potential of the contract to ensure value for money 9. Expenditure on the new contact has been significant with £131 million more spent in 2005/2006 than under the old contract in 2002/2003, an increase of 44 per cent. If the expected benefits are not fully realised, particularly through improved patient outcomes, this spending is unlikely to represent good value for money. To ensure the benefits are achieved several changes are required, both by improving the broader UK framework for General Medical Services and through more effective contract management in Wales. 10. The Minimum Practice Income Guarantee (MPIG) was put in place to protect practice income during the transition to the new contract, and to ensure that the new contract was accepted by GPs. However, MPIG is now acting as a barrier to the redistribution of funds based on health needs, which was an intention of the new contract. MPIG is inequitable as some practices have gained while others have lost out. Deprived areas are likely to struggle to recruit GPs who wish to follow the traditional independent practitioner route, as practices on MPIG continue to have consistently higher baseline incomes. 11. There is inconsistency in contract management across Wales, with some important checks not happening. This is unacceptable and although the department has issued some guidance, more guidance and support is required to ensure the realisation of the potential benefits of the new contract. QOF provides the basis of a performance management framework for primary care, which some LHBs are using as a lever to improve services, but the QOF framework requires further development. Payments linked to delivery, without proper checks, represents an inherent risk which could compromise the expected improvements in patient outcomes. 12. The Assembly Government experienced difficulty forecasting how the new contract would develop and how much it would cost. In retrospect there were indications that QOF would be taken up by Welsh GPs. Out-of-hours services also cost more than the opt-out agreed across the whole of the UK, by approximately £10,000 per GP. It is not acceptable that department officials only considered advice which supported the UK wide view, and failed to identify and manage the full range of risks appropriately. The risks in Wales were different and could have been predicted. Recommendations (i) There are high expectations that QOF will improve patient care and public health. The additional investment in the GMS contract will only represent value for money if QOF delivers these improvements. The Assembly Government should monitor changes in patient outcomes over time, and in due course commission an independent evaluation of the effectiveness of QOF on patient outcomes and its impact on demand in secondary care. (ii) Improved access to primary care is a key priority for patients. Under the present Directed Enhanced Service, nearly all Welsh practices are claiming payments for meeting the 24 hour emergency target, and the pre-booking targets. However, the rigour and quality of LHB checks on practices to ensure that they are meeting the targets is variable. Drawing upon good practice across Wales, the Assembly Government should issue guidance on appropriate access checks and strategies to improve patient access early in 2008. LHBs must ensure that practices evidence achievement of the access targets under this new regime before the start of 2008/2009 (iii) Enhanced services are one obvious route to support and drive changes in health services but LHBs have developed them inconsistently across Wales. Enhanced services allow both the Welsh Assembly Government and LHBs to develop services at a local level, for example to manage chronic disease, reduce demand on secondary care, and address gaps in services. However, many LHBs are struggling to release savings from secondary care to fund these changes, and have had limited budgetary scope to fund additional local enhanced services. The Assembly Government should develop a framework that enables LHBs more easily to transfer resources from secondary care to improve primary and community services. One such measure might be the allocation of ring-fenced funding to enable LHBs to introduce more targeted local enhanced services to meet local needs. (iv) Local enhanced services should be developed in line with a medium-term strategic direction which takes account of developments at a regional level. Short-term funding on an annual basis can be a barrier to strategic development of services. The Assembly Government should develop a funding framework that supports LHBs in developing services over more than one financial year, allowing time to train and recruit appropriate practices and GPs or Practice Nurses to develop the necessary skills. LHBs should take all opportunities to commission jointly Local Enhanced Services to give a more strategic focus to the planning of services. (v) The Assembly Government has sought to move the balance of primary care estate away from practice-based developments towards a more strategic approach that encourages primary care development in those areas where services are needed, and ensures that new facilities are fit for purpose.