With the 2020-21 financial year about to get underway, practices must be fully aware of contract changes and the impact these could have on funding and workload. Deborah Wood* gives an expert round up and commentary
Following a draft consultation relating to the next phase of the PCN DES specifications issued just before Christmas, which was not well received, NHSE/I and the BMA’s GPC worked together to publish the 2020-21 agreed contract arrangements in a joint document dated 6 February 2020.
This updates the existing five-year GP contract, Investment and Evolution, through to 2023-24, but note that following its rejection by the March LMC conference, at the time of writing it may be subject to change.
The agreement reached covers the following main areas:
1 Enhancing the Additional Roles Reimbursement Scheme (ARRS)
2 Increasing the number of doctors in general practice
3 Improving access for patients
4 Reform of vaccination and immunisation payments
5 Updating the Quality and Outcomes Framework (QOF)
6 Pay transparency
7 Primary Care Network delivery specifications
8 The Investment and Impact Fund (IIF).
Here are the main financial aspects of the agreement with specific reference to changes implemented for 2020-21.
Enhancing the Additional Roles Reimbursement Scheme (ARRS)
Workforce expansion is a top priority to reduce workload pressure and maintain sustainable primary care, while improving patient access to appointments and moving towards greater integration of care.
Two new national workforce targets have been set: 26,000 extra staff from the ARRS and 6,000 more doctors in general practice. The aim is to secure 50m more appointments.
The scope of the ARRS has been extended to give PCNs more flexibility and there will now be 10 roles available in 2020-21 instead of the original four proposed last year (see Table 1).
The Additional Roles Reimbursement Scheme (ARRS)
|The roles are:||Agenda for Change band||Maximum annual reimbursable (with on costs) £|
|Social prescribing link workers||up to 5||35,389|
|First contact physiotherapists||7-8A||55,670|
|Health and wellbeing coaches||up to 5||35,389|
Reimbursement is only for roles added since 31 March 2019 as agreed between PCNs and CCGs.
If the PCN obtains the services of its social prescribing link workers from a third party, such as the voluntary sector, a £2,400 contribution can be claimed for additional costs beyond the salary and on costs, but within the overall maximum reimbursable amount per one whole- time equivalent.
From 1 April 2020 PCNs can substitute between clinical pharmacists, first contact physios and physician associates.
Additional funding has been identified to increase the budget for the ARRS from 2020-21 up to 2023-24, with the aim of funding 26,000 staff instead of 20,000 as originally planned.
All roles will be 100% reimbursed at actual salary plus on costs up to the maximum reimbursable amounts. This releases the £1.50 per head PCN payments for management, development and transformation and can be used to enhance payments for the clinical director role.
The overall guaranteed investment in the scheme is shown in Table 2.
|2019/20 £||2020/21 £||2021/22 £||2022/23 £||2023/24 £|
|Additional role original funding||110m||257m||415m||634m||891m|
Each PCN is allocated a single combined maximum sum based on the weighted patient list.
Funding is built in for the five years of the contract so there is still concern about employer liability beyond that date. Latest contract documents indicate that staff employed through this funding will be treated as part of the core general practice base costs beyond 2023-24 when negotiating future global sum contract payments.
If all practices comprising a PCN decide to hand back the PCN DES, then the CCG must find an alternative provider and staff will follow the service under existing TUPE arrangements.
CCGs are encouraged to offer direct support from their own staff to help with recruitment for the ARRS.
Where a CCG identifies underspent ARRS resources then the funding should be made available across the relevant PCNs for the benefit of general practice. The figures involved will be determined in conjunction with LMCs, including estimates, by the end of July 2020. They can be made available across other PCNs who bid for the funding for additional recruitment under certain specified criteria.
There is a workforce planning timetable for 2020-21.
Concern has been expressed regarding how space will be created in general practice to house these additional numbers of staff. Short term solutions may be available via community provider partners.
There will be a requirement to develop a vision of fit-for-purpose estate between general practice and other providers so that capital funding can be allocated to support the PCN model.
Increasing doctor numbers in general practice
Practices will be able to make more generous offers of enhanced shared parental leave to employed GPs in 2020-21.
Funding will go to HEE to increase GP trainee places to 4,000, and NHSE/I is increasing the budget available for recruitment and retention schemes.
All international medical students entering general practice training will be offered a fixed five-year NHS contract covering three years training plus two years on a fellowship programme.
The RCGP has proposed changes to the training programme from 2022 so that GP trainees spend two years in practices during training.
The Targeted Enhanced Recruitment Scheme (TERS) is used to attract doctors into under-doctored areas. This provides a one-off incentive of £20,000 to the individual and it is intended that 500 such places will be offered in 2020-21.
For newly qualified doctors and nurses entering general practice there is a new two-year fellowship programme which guarantees funded mentorship, CPD, and rotational placements.
From 1 April 2020 there is also a New To Partnership scheme, enabling new partners to get a £3,000 training allowance and £20,000 per full time equivalent GP.
This will be in loan form and will convert to a permanent payment after a fixed period as a partner. On costs can also be claimed by the practice with the funding going to the individual. It is available to GPs, nurses and pharmacists who have never been a partner.
There will be a Locum Support Scheme to enable CPD funding for sessional GPs if they commit to providing a minimum number of sessions per week to a group of PCNs. It is intended to support at least 500 such doctors in 2020-21.
The National GP Retention Scheme continues and may be updated.
The Induction and Refresher Scheme continues and is likely to be expanded and enhanced. From April 2020, GPs on this scheme with children under 11 will be able to make a claim for up to £2,000 per child towards childcare costs. There is £1,000 available for those on the Portfolio Route.
Experienced GPs working at least three sessions will be offered the chance to mentor newly qualified GPs via the Fellowship Programme for one session, with reimbursement funding paid to their practices to release the time. This aims to support 450 GPs.
Various initiatives will commence to consider how unnecessary bureaucracy can be reduced to leave clinicians with more time for their care role. This will cover things like training, revalidation, appraisal, systems, performers list, NHS standard contract and coding requirements
There is also work underway to digitise paper records and free up space within practices.
The NHS Community Pharmacist Consultation Service is expected to relieve pressure on GPs.
The Time for Care programme is continuing to support productivity and resilience.
An improved appointments dataset will be introduced.
A new measure of patient experience will be designed and tested with incentivising performance improvement funding amounting to £30m a year.
A major new GP Access Improvement Programme will be established working with PCNs.
Vaccinations and immunisations
There will be an investment in these services of at least £30m by 2021-22.
Vaccinations and immunisations, currently an additional service, will become an essential service offering all routine, pre and post exposure vaccinations and NHS travel vaccinations.
New contractual core standards have been agreed covering five core components.
For 2020-21 there is a continuation of MMR catch up in 10-11-year olds with an item of service (IOS) fee for delivery, not for recall. The IOS fee is standardised at £10.06 fixed for the remaining period of the five-year contract.
PCNs will be funded to take the lead on flu vaccination coverage with £8m being made available for over 65s with an aligned incentive in the Pharmacy Quality Scheme.
Quality and Outcomes Framework (QOF)
A QOF review was published in July 2018 and further improvements relating to that have been agreed for 2020-21.
97 of the existing 559 points are being recycled into 11 more clinically appropriate areas.
An additional £10m is being added to QOF to cover eight more points.
For 2020-21 the new Quality Improvement modules cover:
*Improving care of people with a learning disability, and
*Supporting early cancer diagnosis.
Points and payment thresholds for unchanged indicators remain the same as 2019-20.
The value of a QOF point will be adjusted in 2020-21 to reflect population growth and relative changes in practice list size using data at 1 January 2020.
Based on the data at January 2020 compared to January 2019, there has been an increase in average list size from 8,479 to 8,799. This means the QOF point value will rise from £187.74 to £194.83.
Effective from October 2020, contractors and sub-contractors will be required to submit self-declarations annually if their NHS superannuable earnings exceed £150,000 a year, starting with 2019-20.
The earnings threshold will increase in line with CPI. The declarations will be aligned with the pension certificate process to be provided by February 2021.
This will also apply to salaried GPs and locums.
Company directors, employees and others engaged through companies that are contracted or sub-contracted to provide primary medical services, however they are remunerated, will also be expected to self-declare based on the definition of NHS earnings as GP pensionable income.
It is also intended to develop a way of reporting anonymous data on NHS earnings for all GPs and their whole-time equivalent status.
Delivering PCN specifications
Three specifications are agreed for 2020-21:
*Structured Medication Review and Medicines Optimisation
*Enhanced Health in Care Homes; a new £120 per bed per year is introduced when this service starts from 1 October 2020
*Supporting Early Cancer Diagnosis.
Every PCN will have a social prescribing service in place in 2020-21.
All funding for services previously funded by local CCG schemes which are now dealt with in the PCN DES, must be reinvested into primary care.
PCNs do not carry any contractual responsibility for failure by community service providers to deliver their part of the service specifications and vice versa.
The Investment and Impact Fund (IIF)
This is a reward for PCNs meeting the NHS Long Term Plan objectives and GP contract requirements worth £40.5m in 2020-21. The original fund was for £75m and the balance has been put into the wider GP contract to support the new elements of post-natal checks, care home premium and new QOF points.
It is set up like QOF with eight indicators for 2020-21 relating to seasonal flu vaccination, health checks for those with learning disabilities, social prescribing referrals and prescribing.
A detailed table of targets and thresholds and payments attaching has been published within the contract update documentation.
Money derived from the IIF must be used for workforce expansion and primary care services.
No further changes regarding seniority have been announced so it is assumed that as previously agreed, seniority payments ceased on 31 March 2020. The money from the seniority pot is recycled into the global sum.
Other 2020-21 changes
The new global sum per weighted patient is set to rise by £3.48 from the 2019-20 figure of £89.98 to the current year’s figure of £93.46.
The out-of-hours deduction has changed from 4.82% to 4.77%.
From 2020-21 a non-contractual requirement is introduced for GPs to offer referrals to weight management services for obese patients.
Several improvements have been applied for maternity services, including moving additional services to essential services, and £12m is provided via the global sum to support the changes, including a six to eight-week post-natal check for new mothers.
The network participation payment continues at £1.761.
Confirmation of planned funding allocations (excluding ARRS)
|2019/20 £||2020/21 £||2021/22 £||2022/23 £||2023/24 £|
|Contract baseline as at 17 July 2019||8,116m||8,392m||8,771m||9,194m||9,675m|
|Care homes premium||27m||55m||55m||55m|
|Practice funding including QOF, post-natal checks||20m||20m||20m||20m|
Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS)
Any changes announced to the core GMS contract are expected to be mirrored via PMS and APMS.
Please note: all the above information relates to contracts in England only.
Information can be obtained from your local AISMA accountant.
As ever practices must be fully aware of these many changes and their impact on practice funding and workload.
It follows that practices need to take a careful look at future strategy and work on finding the best and most profitable way of using time and resources.
Collaboration across networks will continue to be fundamental and advice should be taken at an early stage regarding how best to make the network arrangements work for your practice
For further information about the content of this blog, please contact a member of our specialist healthcare team on 01253 404404 or 0115 972 1050.