nGMS-MH

New Jargon for a New Contract

A review of the old contract

• GPs are self employed

• Majority of income derived from a weighted capitation formula

• Only 70% of staff costs reimbursed

• Incentives to change behaviour (targets and item of service payments) no more than about 10% of total income

• Inbuilt perverse incentives

Which contract?

• GMS – General Medical

Services - default position

– The contract is with an individual GP

– Nationally negotiated

• PMS– Personal Medical

Services – started as pilots, now becoming permanent

– Contract sits with a practice and not an individual

– Locally negotiated, therefore in theory a contract that meets local need

Basics of the new contract

• Essential level of care MUST be provided by all practices

• Practices will chose if they wish to “opt out” of certain additional services.

• Enhanced services will be commissioned by the PCT– National direction with national specs – must be

commissioned– National minimum spec, but optional– Developed locally

Basics of the new contract

Resources

• Allocated using the Carr-Hill formula

• Guaranteed minimum– Opt outs associated with nationally agreed

reduction in resources

• Further financial incentives associated with Quality and Outcome Framework

Quality and Outcome Framework

• Point scoring system– Points mean ££££

• 1050 points in total– 550 are clinical points– 184 are organisational– 36 are additional services (CHS, cx screening etc)– 100 are patient experience– 30 are quality payments– 100 Holistic Care– Access bonus 50

Quality and Outcome Framework

Coronary Heart Disease 121

Hypertension 105

Diabetes 99

Asthma 72

COPD 45

Mental health 41

Stroke/TIA 31

Epilepsy 16

Cancer 12

Hypothyroidism 8

Quality and Outcome Framework

• MH 1. The practice can produce a register of people with severe long-term mental health problems who require and have agreed to regular follow-up

• MH 2. The percentage of patients with severe long-term mental health problems with a review recorded in the preceding 15 months. This review includes a check on the accuracy of prescribed medication, a review of physical health and a review of co-ordination arrangements with secondary care

Quality and Outcome Framework

• MH 3. The percentage of patients on lithium therapy with a record of lithium levels checked within the previous 6 months

• MH 4. The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months

• MH 5. The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months

MH 1: A Register

• Who to include on the register?– People with schizophrenia– People with bi-polar depression

• Why?– Evidence base

• How?

What is the Evidence Base?

• SMR for schizophrenia and bi-polar disorder is about 200

• Cardiovascular and respiratory disease SMR is 400

• Diabetes is 5 times as common• 90% of people who have schizophrenia smoke

(30% of people with bipolar disorder)• Drug and alcohol misuse• HIV is 8 times as common• HCV is (perhaps) 15 times as common

Developing a register

• Search by diagnosis

• Search by therapeutic category

• Ask the Primary Health Care Team

• Ask the Community Mental Health Team

Primary Care Computing

• 3 major software houses

• Coding system that is– Hierarchical– Includes diagnoses, symptoms, signs, and

virtually everything else– Up to version 5 (version 3, does not map to

v.4 and v.5)– Different software houses use different

versions

Read Codes

• Schizophrenia Eu20.0• Persistent delusional disorder Eu22.0• Acute and transient psychosis Eu23.0• Schizoaffective disorder Eu25.0• Bi-polar disorder Eu31.0

Only “Eu” Codes will map to ICD 10/DSM IV and hence to SNOMED

Therapeutic Categories

• BNF 4 – CNS Drugs

• BNF 4.2 – Drugs used in severe mental illness

• BNF 4.2.1 – Oral anti-psychotic drugs

• BNF 4.2.2 – Depot anti-psychotic drugs

• BNF 4.2.3 – Anti-manic drugs

And then?

• Call and recall system as for other “at risk” groups

• Meet regularly with the CMHT attached to the practice

• Regular review/audit of care that is being provided

MH 2 – What to do

Physical health check• Cardiovascular disease

– BP?

• Diabetes and obesity– Urine analysis or blood glucose?

• Respiratory disease– Peak flow

• Smoking• Substance/alcohol misuse• Influenza?• HIV/HCV?

MH 3 – 5 Mgmt. of Lithium

• Who is on Lithium?

• What level?

• How often should the renal and thyroid function be measured?

Patient experience

Length of consultation, at least 10 minutes

30

Points

Patient survey undertaken at least annually – and has to be approved

40 points

Survey undertaken, and proposed changes

15 points

Survey undertaken, changes discussed with patients, and/or NED, and implemented

15 points

Depression - NES

Definition: Diagnosed by clinical judgement and screening tools

Service Outline:Produce and maintain up to date registerMulti-disciplinary approachCBTScreening proceduresUndertake appropriate trainingPersonal health plansReferrals as appropriateAudit and review

GMS or PMS?

• The NES applies to GMS practices

• PMS practices can continue to experiment/develop services by creating new Quality and Outcome Framework Domains….– So what about a Q &O framework for

depression?

What about a Q & O Framework?

• Undertake screening of at risk patients• Produce a register of people with depression• Produce register of patients with chronic

depression, as a subset of the overall register• Proportion of patients who are reviewed every

six months who have chronic depression; review to include medication review, social needs, and contact with secondary services including key worker where appropriate

What about a Q & O Framework?

• The percentage of patients for whom a risk assessment has been carried out

• Percentage of patients for whom the severity of the depression is specified– The percentage of patients with mild depression who are

managed with watchful waiting or talking therapy– The percentage of patients with moderate depression who are

managed with medication or CBT– The percentage of patients with severe depression who are

referred to the CMHT

• The percentage of patients who have been referred to the CMHT for depression, and already have had two, three month courses of antidepressants.

Some Clarification needed?

• The contract is NOT negotiable– There are mechanisms to review the contract

that are slow (ish)

• Who should go on the register?

• What happens if they refuse?

• When do they come off the register?

More importantly

• Primary Care services will be commissioned by PCTs to meet local need

• Mental Health is a significant work load in primary care

• It may not be at the top of the agenda NOW, but over the next few years it will become more important

Thank You