The Business Side of General Practice Sarah Cousins Practice Manager, Maryport Health Services 18th June 2014 Contextual Factors  National  NHS Re-organisation:    Financial pressures – doing more for less           Pre 1/4/13 dealt with 1 organisation Post 1/4/13 deal with:  CCG plus payments agency  NHS England plus payments agency, both of which based in North East  Local Authority MPIG/PMS Reviews Contract changes Complexity of illness/increasing age Increased patient expectation Adult Social Care Fragmentation of services vs integration – care system under pressure Inspection/CQC/Mid-Staffs – Francis Report/Keogh Review GP Training/recruitment and negative publicity (eg A&E/OOH) Practices collaborating/federating/merging Local  NCUHT – financial pressures/reduction in beds Contract Types  General Medical Services (GMS)  Personal Medical Services (PMS)  Alternative Provider Medical Services (APMS)  Specialist Provider Medical Services (SPMS) Contract Summary  Global Sum/Minimum Practice Income Guarantee: basic practice income, covers: Essential Services Additional Services Out of Hours  Practices can also participate in: Enhanced Services Quality and Outcomes Framework (QOF)  All Practices can opt out of 24 hour responsibility Essential Services  All practices must provide  Management of patients who are ill or who believe themselves to be ill  General management of patients who are terminally ill  Management of chronic disease Additional Services  All practices expected to provide, but can opt out and PCO must contract with alternative provider  Cervical screening  Contraceptive services  Childhood vacc and imms  Childhood surveillance  Maternity services (except intra-partum care)  Minor surgery (curretage, cautery and cryocautery) Enhanced Services Directed National Local Competition/tendering process Enhanced Services 2004 (Cumbria)         Anti-coagulant Monitoring IUCDs Minor Injuries Drug Misuse Near Patient Testing Minor Surgery Flu Services for Violent Patients Enhanced Services 2014/15               Anti-coagulant monitoring Minor Injuries Drug Misuse Near Patient Testing Inj for Prostate Cancer Minor Surgery Flu (Adult and Children) Shingles (standard and catch up) Services for Violent Patients Extended Hours Access Pertussis MMR PPG Hep B (new born babies)               Childhood Imms Rotavirus Pneumoccocal Admission avoidance Alcohol Reduction Learning Disabilities Dementia Men C (freshers) Local Investment Scheme Health Checks STI – level 1/level 2 Opportunistic Chlamydia IUCD Hormonal Implants Contract Changes 2014/15         QOF – removal of QP and Patient Experience domains Named GP for over 75s £5 per head funding – locally aimed at O75s with complex needs to reduce admissions Electronic appointments, online repeats and access to patient’s own summary information Quality of OOH NHS number must be included in all clinical correspondence Friends and Family test Choice of GP Practice – optional Quality & Outcomes Framework  Significant changes from last year:  Points reduced from 900 to 559 (points redirected to core contract)  Fewer indicator dimensions – retired and amended  Reduction in bureaucracy  Domains:  Clinical  Public Health Clinical Domain            AF (17) CHD (45) HF (29) Hypertension (26) PAD (6) Stroke/TIA (15) Diabetes (86) Asthma (45) COPD (35) Dementia (26) Depression (10)  Mental Health (26) Cancer (11) CKD (32) Epilepsy (1) Learning Disability (4) Osteoporosis (9) RA (6) Palliative Care (6)  Total Points – 435 (610 13/14)        Public Health Domain CVD – Primary Prevention (10)  BP (15)  Obesity (8)  Smoking (64)  Cervical Screening (20)  Contraception (10)   Total points – 124 (157 13/14) Examples of retired indicators:        Thyroid Disease Gone Cholesterol gone from all except DM Hypertension – BP < 140/90, assessment of physical activity and exercise advice DM – ACR (but still need if have CKD), Retinal screening, Dietary review, ED Epilepsy – now just a register, seizure free and contraception gone RA – CVD risk and fracture risk New BP – lifestyle advice Examples of amended indicators: Depression – review needed between 2 and 8 weeks  Cancer – review back to within 6 months  BP – back to in the over 45s  Hypertension time frame now 12 months  LD register now all not just over 18  QOF Process  Up front payment based on previous year outturn  Review process  Balance of payment at the end of the financial year QOF General Principles Patient centred  Voluntary  QOF lead/disease area leads  Team approach to all domains  Positive/developmental process  Need for good organisation and information  To maximise QOF achievement:         Whole team approach Need to be well organised, responsibilities clear Robust recall systems Good, accurate data/information vital Monitoring needs to be constant Training Communication Ensure temporary staff/contractors are aware of QOF targets Other sources of Income Other Sources of Income  NHS  Dispensing  Providing extra services  Drugs  Teaching/training  CCG work  Non-NHS  Medicals/Insurances  Research  Private work (eg, local factory) Expenditure Expenditure  Staff  Salaries  Oncosts  Training  Recruitment  Administration  Printing/postage/stationary  Telephone charges Expenditure  Practice  Drugs and medical equipment  Insurance (eg locum/defence)  Telephone system and other computer equipment  Out of hours Expenditure  Premises  Rates/water  Insurance  Heat/light  Laundry/cleaning  Repairs/renewals  Refuse/waste disposal Profitability Maximise Income and minimise/control expenditure  Ensure that any work that is taken on, as a minimum, breaks even  Use Lean Management tools (Eg Productive General Practice), as incentivised via the Local Investment Scheme  Cash flow  Example: Extended Access DES Worth £1.90 per registered patient  30 mins of extended apts per 1000 patients  Must not reduce the amount of consultation time during core hours  Before 8.00am and after 6.30pm  Can be GP/Nurse/HCA  Apts can run concurrently  For Maryport: Income: £1.90 x 13,800 = £26,220  Cost per hour (including on costs):   GP Cost = £270 per session/£90 per hour  Nurse Cost = £30 per hour  HCA Cost = £16.50 per hour  Receptionist = £15 per hour  Will need to provide 7 hours of additional surgery time Option 1 – GP 2 GPs doing 1 x 3.5 hour session per week Cost per week:  7 x £90 = £630  3.5 x £15 = £52.50  Total cost per week = £682.50 Cost per year:  £35,588 Option 2 – GP and Nurse Cost per week:  3.5 x £90 = £315  3.5 x £30 = £105  3.5 x £15 = £52.50  Total cost per week = £472.50 Cost per year:  £24,638 Option 3 – GP, Nurse and HCA Cost per week:  2.5 x £90 = £225  2.5 x £30 = £75  2.5 x £16.50 = £41.25  2.5 x £15 = £37.50  Total cost per week = £378.75 Cost per year:  £19,749 Any Questions?