GMS CONTRACT: GUIDANCE TO LHBs ON ENHANCED SERVICES FOR 2004/5

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1 GMS CONTRACT: GUIDANCE TO LHBs ON ENHANCED SERVICES FOR 2004/5 Purpose 1. This provides guidance to LHBs on the funding and implementation of GMS enhanced services for 2004/5. It should be read in conjunction with the Assembly guidance Introduction to Enhanced Services issued on 15 October 2003, comprehensive guidance on the GMS contract Delivering Investment in the GMS Contract and the UK specifications for enhanced services, all of which are available at Background 2. On 15 October 2003 the Minister for Health and Social Services announced a package of 7 Enhanced services that would be the priority for Wales in the first year of the GMS contract. The funding for this was an additional 7.1m, which was allocated to LHBs in December using the GMS weighted capitation formula. This package should now be in place. If not, LHBs should ensure that they work closely with LMCs to implement as soon as possible. In 2003/4 a further 6 services were funded through the Statement of Fees and Allowances (SFA), these were: influenza and pneumococcal vaccinations; IUCD fitting; minor surgery; intra partum care and vaccination and immunization target payments. Investment in these services accounted for a further 9.3m. These 2 components make up the Welsh expenditure floor for local enhanced services floor of 16.4m, which is the minimum that the Assembly is required to spend on enhanced services in 2003/4. Package for 2004/5 3. For 2004/5 the Assembly is committed to a total investment of at least 21.9 m, this represents an increase of 5.5m over the current year. This will form the new enhanced services expenditure floor. The Assembly has agreed with GPC Wales a package of measures that can be funded by this investment. This package is designed to deliver NHS Wales priorities, whilst at the same time meeting the aspirations of GPs on behalf of their patients. It will comprise 2 components: Continuation of the 7.1m package announced on 15 October Transferring 4 important services that will be delivered by the majority of practices from the SFA into the new enhanced services. 4. The 2004/5 package comprises 10 services. Six of these are Directed Enhanced Services (DESs) which LHBs are required by the contract to commission: Extended minor surgery Influenza and Pneumococcal vaccination Access Childhood Immunisations

2 QuIP Services to Violent Patients The remaining 4 services will be NESs which are at the discretion of the LHB. The Contract agreement states that most contracts for enhanced services will be with GPs. This will be a matter of judgement for LHBs, having regard to their financial duties. Continuity of services to patients and smooth implementation of the contract will be factors that LHBs will need to consider. The 4 NESs are: Services to Drug Misusers* INR Testing Near Patient Testing IUCD * In respect of services to drug misusers, LHBs as statutory partners of Community Safety Partnerships (CPSs) in Wales should agree with their CPSs the level and type of services to be commissioned 5. The Assembly is in discussions with GPC Wales about the inclusion, within the enhanced services, of parenteral gonadorelin analogue treatments for patients with prostate cancer. Specifications and Guidance 6. Specifications for all 10 services are available on the Assembly s GMS website. Advice on Access, QuIP, Services to Violent Patient, INR Testing, Near Patient Testing and Services to Drug Misusers was provided in the guidance issued on 15 October. These services will now be in place or in the advanced stages of negotiation. For new schemes announced in October, the agreement with GPC Wales was based on the expectation that payment would be made back to 1 October 2003, provided practices can provide evidence that the service was being delivered. The funding package for 2004/5 will provide for the continuation of these services. 7. Priority for the coming year should be directed towards ensuring that 4 important services funded under the SFA are continued. The key points for LHBs to consider in making commission decisions are: a. Extended Minor Surgery DES - Cryotherapy, curettage and cauterisation are classified under the new contract as additional services and funding is already included in the global sum to cover this. Practices wishing to opt out from these services will be obliged to do so in the prescribed manner. The pricing will depend on the complexity of the procedure and the involvement of other staff. The benchmark price for injections is and for cutting surgery it is LHBs will agree with GP providers the basis on which the DES will be funded in the light of the procedures to be carried out, including the need for an upper cap on procedures. The overall investment in enhanced services is higher than

3 under the old regime. This will fund the same number of extended minor surgeries claimed by GP practices last year, but at a higher rate. The planning assumption in the Contract is that 1/3 of current minor surgery will be funded through additional service and 2/3 will become extended minor surgery under enhanced services. Assuming an equal split between cutting and injection, this agreement provides funding for 40 procedures per annum for each whole time equivalent (WTE) GP. This number of procedures should be used to guide discussions between practices and their local health boards. LHBs may also wish to consider using their unified budgets to create additional capacity to expand primary care and relieve pressures in secondary care. This may form an element in local Wanless Action Plans. Practices that apply to provide Minor Surgery should be encouraged to undertake a minimum of 10 minor surgical procedures per year. This is good practice and should assist in maintaining skills and efficiency. Continuation of the current arrangements whereby many of the existing minor procedures are delivered on a sessional basis is considered to be preferable for both clinical and cost effectiveness. Contractors should consider providing the surgical procedures, agreed within the Minor Surgery Enhanced Service, on the basis of minor surgery sessions. Payment, though, will be based on the number of individual procedures, not per session. It is recommended that each session should contain a minimum of three procedures. b. Influenza and Pneumococcal Immunisation DES Agreement has been reached with GPC Wales that the pneumococcal immunisation campaign should be integrated with the Influenza DES. The purpose of this enhanced service is to offer the provision of immunization against influenza or pneumococcal infection. It is a requirement that a register is maintained ( Influenza and Pneumococcal Scheme Register ) of all the at-risk patients to whom the contractor is to offer immunisation. For influenza that will be those aged 65 and over and other at risk groups. For Pneumococcal it will be those patients who are aged 75 or over at the end of the financial year. The rate for administering the vaccines will be 7.28 per patient subject to the requirements that are set out in the DES Directions. Funding equivalent to the amount spent under the SFA has been allocated to this DES. c. Intra-uterine contraceptive device (IUCD) fitting NES this covers the fitting, monitoring, checking and removal of IUCDs in primary care. The benchmark price represents a substantial increase from the old regime. Unlike its Red Book equivalent this service now includes devices fitted for decreasing menstrual loss as part of the management of menorrhagia. Funding equivalent to the amount spent under the SFA has been allocated to this DES and this has been up-rated to take account of the changes under the new Contract. Intra-uterine contraceptive devices (IUCD) - a fee is payable for the fitting, monitoring, checking and removal of IUCDs in primary care. The benchmark

4 price will be per patient for insertion and annual review fee. This represents a substantial increase from the old item of service fee. Intra-uterine non-contraceptive devices - a new fee is introduced for fitting, monitoring, checking and removal of an intra-uterine device fitted for the purpose of controlling menorrhagia, in the situation where the patient has been appropriately investigated, diagnosed and the fitting of the IUD is consistent with accepted, evidenced based clinical practice. The fee payable will be the same as that of the IUCD, as set out above. Where a patient requires an intra-uterine device for both contraception and the control of menorrhagia, only one fee will be payable. Parenteral contraception Injections - a fee is payable for the administration of a long acting intramuscular contraception injection. This fee includes both pre-injection counselling, provision of an information leaflet and the injection, in line with the guidance set out in BNF This fee is set at the lower level for a minor operation 41.29, but does not form part of the Minor Operation NES Parenteral contraception subdermal devices - a fee is payable for the insertion and removal of any subdermal contraceptive device listed in the relevant section of the BNF, currently The fee includes pre insertion counselling, provision of a patient leaflet and follow up advice where necessary. Both insertion and removal should only be undertaken by a fully trained doctor or nurse. A fee of is payable for insertion and a further fee of is payable for the removal of such a device. d. Childhood Immunisations DES - The purpose of this DES is to continue to ensure that a high percentage of children aged five years and under receive the appropriate immunisations. The scheme remains one of the most effective public health tools in that, it not only protects children individually, but collectively in the wider community. This DES funds the achievement of vaccination and immunisationation targets. Infrastructure costs are included under additional services. For immunising children aged two years and under, the benchmark price for practices meeting the lower target of 70% will be 2,740 per practice annually. For achieving the higher target of 90% it will be 8,221 per practice annually. For pre-school boosters the benchmark price will be 849 annually for practices meeting the lower target of 70% and 2,544 for achieving the higher target of 90%. Funding equivalent to the amount spent under the SFA has been allocated to this DES. Funding and Payments 8. The calculation of the funding package at all-wales level is set out below. This sets the Assembly s commitment to the Enhanced Services Spending Floor for 2004/5, which will be monitored at UK level by TSC [joint health department/bma committee].

5 Expenditure at LHB level will be monitored in FIS returns. Each LHB is expected, as a minimum, to spend up to its local expenditure floor, which will be notified by the Assembly shortly. At individual LHB level the balance of expenditure is likely to vary from the table below as a result of local priorities and patient need. In many areas services like INR monitoring, near patient testing and violent patient schemes were already in place prior to 2003/4. This will free money from this allocation to further expand these services or to invest in local enhanced services (LESs) to meet local priorities. It should also mean that the local expenditure floor at local and national level will be exceeded. Service m Access 2.6 QuIP 1.3 Violent Patients 0.5 INR Monitoring 3.0 Near Patient Testing 0.9 Drug Misuse 1.3 Influenza & pneumococcal 2.9 Minor Surgery 3.8 Childhood Immunisations 4.7 IUCD 0.9 Total Further guidance will be issued on the Directed Enhanced Services when the Direction itself is given. The Direction will include full details on the commissioning of DESs and the conditions for making payments. Guidance on payments will follow as soon as the role of the Business Services Centre has been agreed with LHBs. Welsh Assembly Government Primary Care Division March 2004

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