In the third article in a series of five, Paul Midgley of the Healthcare Partnership looks at how the ‘Quality & Outcomes’ framework (QOF) within the new GMS contract (nGMS) will help pharma repre-sentatives work more closely with practices to their mutual benefit. Next month’s nGMS article focuses on the opportunities arising from extended roles for nurses, practice managers, GPs and pharmacists, followed in December by the implications of PCT enhanced services commissioning on local healthcare.

Introduction
The new UK-wide General Medical Services comes into force in April 2004. This contract will affect all practices – whether they are currently working under a GMS contract (about 65% of UK GPs) or a PMS contract. The implications of nGMS will be far reaching for all parties involved in chronic disease man-agement – practices, GPs, PCOs, acute trusts (in time), SHAs – and you as a representative. The biggest lever of change in nGMS is the ‘Quality and Outcomes Framework’ an incen-tive scheme devised to boost standards of care for patients, and improve the way care is delivered by encouraging a better use of skill mix, in the following areas of general practice:

• Chronic Disease Management (reducing the need for hospital involvement)
• Practice Management
• Patient Experience
• Additional services

Rewarding Quality and Outcomes
By the third year of nGMS, additional General Practice funding through the ‘Quality and Outcomes Framework’ is predicted to account for an extra £1.3billion per year out of a total of £1.9billion of new money avail-able through nGMS. This additional practice income will be paid to all practices who can prove they have achieved levels of quality pre-agreed with their PCO. The higher the points total, the better the payment, therefore practices will inevitably try to climb the Quality Ladder each year to increase their income.

How does the Quality Ladder work?
A ‘points means prizes’ scheme, with a maximum of 1050 quality points, will be available to all GMS practices (to be con-firmed for PMS practices). In the first year of nGMS (2004-5) each point is worth £72 for the ‘average practice’ (5500 patients). Practices calculate their £ per point by divid-ing their list size/5500, multiplied by £72. In year two (2005-6) each point will be worth £120 for the average practice. So, an average practice, achieving 350 points in nGMS year one will earn an additional £25k over and above their current (guaranteed) level of income. If the practice were to ‘up’ their qual-ity and achieve 500 points in year two, this would earn an additional £60k. Clearly, this kind of additional income is significant, and a real incentive for practices to completely re-think how they deliver their service to strive for these extra resources. Will we see GPs devising staff incentive schemes to ensure they hit target?

Payments schedule
Payments are made as follows. One third of the ‘aspirational’ points target agreed with the PCO (ie, where the practice hopes to be by year-end) are paid in monthly instal-ments over the year. The balance of the money is paid at the end of the year, follow-ing submission of audit evidence of points achieved, and verified by a practice visit from the PCO nGMS inspection team. Any over-achievement against the aspirational level is guaranteed to be paid in full. Gross under-achievement (ie less than one third of the aspirational points) will result in a repayment to the PCO.

Preparing for Quality
Prior to the first year of nGMS, and each year thereafter, PCOs will visit each practice to determine the current level of Quality Points achieved, and agree a target for the end of the next year. Practices will be given a ‘Preparation Payment’ before April 2004 of £9k (again, based on a multiplier of the aver-age practice size), and again in Q1 2005 (£3.25k). This payment is to help practices take time out to review their existing services, plan for the year ahead, and make any struc-tural changes to help them climb the quality ladder. Practice away days and Protected Learning Time sessions are the ideal way for practices to review their services and plan for the year ahead (see ideas to help this process at the end of the article).

How can you help practices achieve these targets?
Those of you selling the types of products listed below in the following clinical areas will be able to help practices attain quality pay-ments directly, by persuading them to work with you, use your products and the allied services your company offers to improve management to the required standards to hit the quality payments on offer in the clinical section.

• Smoking cessation (see CHD, Stroke, Hypertension, Diabetes, COPD and Asthma quality indicator section) Flu vaccines (see CHD, Stroke, Diabetes, COPD and Asthma quality indicator section)
• Ace/A2 antagonists (see CHD, LVF and Diabetes quality indicator section) Statins/cholesterol lowering (see CHD, Stroke and Diabetes quality indicator section)
• Anti-platelet/anti-coagulation therapy (see CHD and Stroke quality indicator section)
• Beta blockers (see CHD quality indicator section)
• Hypertension treatments (see hyperten-sion and diabetes quality indicator sections)
• Diabetes treatments (see diabetes quality indicator section)
• COPD treatments (see COPD quality indi-cators section)
• Epilepsy treatments (see epilepsy quality indicators section)
• Schizophrenia treatments (see mental health quality indicator section)
• Asthma treatments (see asthma quality indicator section)

So, get familiar with the QOF standards relevant to your therapy area. Help the prac-tice audit their existing quality standard. Then agree with them the areas where you and your company can help to boost them higher up the Quality Ladder in your therapy area(s). This will mean that your marketing colleagues will have to reframe your product offering into nGMS language – if they can do that, and you can help practices boost their income, you may never have been so popular!

What if your drugs are not in these therapeutic areas?
Practices still have a duty to provide essen-tial services for all comers presenting with non-life-threatening diseases, so they still need to keep up to date with information about drugs in all common disease areas. However, practices are likely to concentrate their energy on developing those more rewarding therapeutic areas mentioned above and building therapy-based partnerships with relevant representatives. So if that doesn’t include your drugs, you may find that time and interest in your drug and therapy area being squeezed.

Don’t despair!
You can instead build partnerships by pro-viding support to practices in the non-clinical quality domains. Whilst this may be unrelat-ed to your product, you will still have an opportunity to promote your product whilst spending time helping the practice with these other key quality areas.

Practices face major challenges to devel-op the organisational and patient experi-ence aspects of their service – these are the areas you should examine in more detail to look to provide an added-value service over and above information about your drug and disease area. You too can become a valuable partner to the practice and help them boost their income – and your access and scripts. Implementation Timetable

Preparations to implement the Quality and Outcomes framework will start in Q4 2003. Here is a guide to what practices will need to do so you will know where your help may be welcomed:

• Audit their existing standards against the framework to establish their baseline points score (they may need to do some work on their IT to make this possible, eg standardising their READ coding of diag-noses, to enable accurate data input and extraction) – can you provide IT support?
• Agree as a practice which Quality areas they wish to focus on and their aspira-tional points target for 2004/5 (probably a top team decision, ie GPs, nurses, Practice manager – may be best achieved at an ‘Away Day’) which you could sponsor
• Meet with the PCO and agree a realistic aspirational points target, based on their existing points and service development plans – can you provide lunch?
• Produce a detailed Practice Development Plan to ensure the required changes are brought in – detailing what, by whom, by when for each change required – again, away from the practice – another sponsorship opportunity.

A ‘Preparation Payment’ will be made to practices before April 04 as mentioned above. In April 04, the first monthly instalment of one third of the agreed ‘Aspirational Points’ will then be made, and each month thereafter till March 2005. In Q1 2005, £3.25k prepara-tion money will be paid for the year head. If all has gone well, and with your help, by April 2005 practices should be able to prove achievement of improved quality, have hit or exceeded vs target, and gain significant new money as described above.

Summary – QOF a Critical Success Factor in your 2004 Territory Business Plan
You need to know the detail of the QOF in areas relevant to your product. This frame-work will drive through changes to your key target practices very quickly due to the guar-anteed extra funding available, and because GPs largely agree with a quality-rewarded system as it is good for patients too. It is also likely that QOF performance will be included amongst a PCO’s star rating indicators from 2005 onwards.

You need to start asking key GPs, Practice Nurses and Practice Managers what you can do to help them maximise their Quality points (and come along armed with ideas of your own). Based on this, your 2004 business plan should re-allocate resources to those target practices who are first to innovate (and pre-pared to work with you to maximise their Quality points). Get a copy of the detailed quality standards document (see below). Read it thoroughly and identify areas where you and your company can help practices. Be pre-pared to look at both clinical and non-clinical areas of quality improvement. Use outside help if required to provide you with support. This is too good an opportunity to miss to be at the cutting edge with your key customers.

End of PGEA requires new thinking for meetings
You can help organise away days to enable practices to consider an overhaul of the way they deliver their service, then specific training around key elements that need changing over the following year. You can be sure that if you aren’t offering help to key customers around nGMS, there will be plenty of competitor companies prepared to fill the breach. Remember, PGEA ends with the advent of nGMS in April 2004, so plan to spend your budget in different ways from next year. Supporting practices to implement nGMS is one way to continue to offer a valuable service that will keep target customers coming to your meetings. Who needs PGEA after all?