The GP Contract Made Easy

Getting Paid

Rodger Charlton

• Publisher: CRC Press
• Year: 2018
• ISBN:
  9781315345413
• Edition: 1
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

The concepts and terminology of the new General Medical Services Contract can be confusing and daunting. The GP Contract Made Easy – Getting Paid summarises and simplifies a complex contract with many practical points to maximise a practice's income and make the lives of doctors and managers easier. This book shows how the new Contract differs from the 1990 GP Contract, resulting in a change in the services that GPs provide and a change in their remuneration. This book provides advice on how GPs can maximise their income under the new regulations for the Global Sum, Enhanced Services and the quality indicators of the Quality and Outcomes Framework. General practitioners, primary care managers, and their professional advisers will find this book essential and invaluable reading.

CHAPTER 1

Getting paid under the 1990 contract

Before a doctor enters general practice, they will be accustomed to receiving a salary and a pay slip detailing deductions for tax and national insurance. This is referred to as the PAYE (Pay-As-You-Earn) method of income tax collection. However, most GPs are self-employed, although salaried GP posts are becoming more common. So, if you start as a GP principal it takes quite an adjustment to receiving a cheque of differing amounts each month according to the profits of the practice which is a small ‘business’. The cheque is a gross payment and it is advisable to save 40% in a high interest savings account for a tax bill which is in arrears and also for national insurance payments. The local PCO or Health Board deducts a proportion of your payments as superannuation and so a monthly contribution towards your eventual pension.

What it means to be self-employed

GPs have always been self-employed practitioners, who mix their subcontracted work from the NHS with a small amount of private practice. When the NHS was set up in 1948 GPs kept their independence but agreed to register all patients and provide 24-hour care for them in return for contracted payments. In keeping with the ethos of the NHS, this established universal access to GPs for the first time in the UK. This chapter describes how GPs were paid on the basis, e.g., of the number of patients registered in their name and other payments for defined services until the advent of the ‘new contract’ of 1 April 2004. It is important to be conversant with the latest version of this, the ‘1990 contract’, in order to understand the financial workings, the origins of payments and implications for the new contract. Many of the principles of being self-employed also apply to this new contract. This chapter is therefore devoted to the derivation of payments under the previous 1990 GP contract.

Gross payments

When a GP receives their first payment it seems a large amount when there have been no deductions and it is tempting to feel rich and spend a lot. However, it is important to start saving for the tax bill, which may be 12 months in coming, as late payment or taking out a loan results in high interest payments. In order to try and reduce the tax bill, GPs are diligent about keeping receipts as some of their business expenses can be put against the tax bill, e.g., car, telephone and equipment bills. The end of each tax year is usually the beginning of April. This is when a GP starts to complete their tax return form and calculate their tax bill (tax liability). It is also important to employ the services of an accountant (whose fees are tax deductible) to make these calculations. One’s first impression might be that this is a lot of hassle, but financially there are benefits to being an independent contractor or self-employed. It also means that you are an employer as opposed to being employed and wholly and exclusive business expenses can legitimately reduce the tax bill.

How did GPs get paid under the 1990 contract?

In essence there were and still are two sources; General Medical Services (GMS) and Personal Medical Services (PMS) in addition to private fees. GMS and PMS payments are for providing NHS services to patients registered with individual GPs of the practice partnership. Private fees can be for seeing patients who wish to be seen privately, although this is relatively rare these days. Private fees are more commonly received for completing reports for insurance companies or solicitors and are not part of a GP’s NHS service. In addition, GPs may charge for private sick notes, completing a holiday cancellation form, conducting a pre-employment medical or completing a cremation certificate. Also, some GPs act as occupational health physicians for local firms or as school medical officers to private schools. All these activities are sources of private income and could contribute up to 10% or more of a GP’s income before they could affect cost or notional rent reimbursement on GP premises.

General Medical Services (GMS)

These were divided into three main areas:

• basic practice allowance and patient registration fees
• target payments
• item of service payments.

Full-time GPs received a basic practice allowance (BPA) for 1200 or more patients registered with them. If they had less than 1200 patients then the BP A was proportionately less. However, in addition to the BPA, the more patients that were registered with a GP, the greater the income through capitation fees. This was a set annual payment for providing care for patients 24 hours a day, 365 days a year. This payment was greater for patients over the ages of 65 and 75. However, with more patients came a greater workload and there was a ceiling number of registered patients after which there were no additional payments.

Target payments were for providing cervical cytology services to women between the ages of 25 and 64. Similarly, there were target payments for providing defined childhood vaccinations to infants and boosters to preschool children. For both groups there were lower and higher targets to achieve a lower and higher payment. In the case of cervical cytology 80% of women within the above age group had to have had a cervical smear in the preceding five years to achieve a higher payment and the only people exempt were those who had had a hysterectomy (lower target = 50%). In the case of vaccinations the target was 90% to achieve a higher payment (lower target = 70%). In both groups patients who chose not to have a smear or have their child vaccinated would still count towards the target payment. Ways of exempting patients in the new contract will be discussed in a later chapter.

Item of service fees could be claimed for providing the following services:

• contraception advice
• inserting an intra-uterine device (IUD)
• administering certain vaccines, e.g., tetanus
• new patient registration health checks
• minor surgery and child health surveillance
• seeing temporary residents
• performing a night visit (for calls received and completed between the hours of 10pm and 8 am)
• maternity care
• arresting a dental haemorrhage
• other areas to be listed in the next chapter where they form part of the Global Sum of the new contract.

Doctors who dispense vaccines and injectables or medication in rural areas could and still can attract certain fees through the Prescription Pricing Authority (PPA).

It can be seen from this information that a lot of data needed to be stored either manually or (more usually) on computer so that the necessary individual claims could be made. The new GP contract should reduce this clerical activity through the payment of a ‘Global Sum’, which is discussed in the next chapter. This reduction in clerical activity has already been achieved for PMS practices where income is based on the last GMS claims and associated uplifts with inflation and pay reviews and changes with a practice list size. Most claims were made in arrears and they could be claimed manually or through computer links with the local PCO or Health Board. A practice manager would play a vital role in the smooth running of this business side of a GP practice.

Other GMS income

For attending 30 hours per year of approved postgraduate educational activity in the three designated areas of health promotion, disease management and service management a fee of almost £3 000 could be claimed each year. This was paid quarterly upon production of certification of attendance and was called the Postgraduate Education Allowance (PGEA).

There were practice activities for which GPs received partial or full reimbursement. For example, for employed staff whose employment is approved and fell within the agreed staff budget, a reimbursement of 70% was usual. Reimbursement was available for the salary of a GP registrar as well as the payment of a small training grant and this will continue under the new contract. Payments for GPs under the ‘GP retainer’ scheme payments should also continue.

Partial reimbursement may also have been available for computer expenses, such as hardware and software and especially upgrades which will be a particular feature of the new contract. The changes regarding funding of IT will be discussed in a later chapter, but do not form part of what is called the ‘Global Sum’.

Payments were also available for health promotion, chronic disease management - e.g., in diabetes and asthma - and locally defined quality initiatives.

One further incentive for new GPs joining a practice was the ‘golden hello’ scheme of a one-off payment of usually £5000. GPs will need to enquire of local PCOs whether this scheme will continue under the new contract.

Personal Medical Services (PMS)

PMS is very similar to GMS and many practices have converted to PMS subject to agreement with the local PCT. In PMS a budget is estimated on the basis of the previous year’s GMS claim and altered according to patient list size. This avoided all the clerical work associated with making individual claims for the above. In addition, it was possible to negotiate ‘PMS with growth’ and so the creation of salaried nurse and GP posts to undertake new and locally agreed work for the practice in conjunction with the local PCO. The changes to PMS as a result of the new contract are discussed in depth in Chapter 8.

Payments relating to premises

There should initially be no change in the way that premises-related claims and reimbursements are dealt with under the new contract for:

• cost rent and notional rent payments
• hazardous waste
• rates.

General practice as a ‘business’

Being a GP involves knowledge of medicine and developing skills in running a business. Usually, each partner in a practice looks after one area of practice income in liaison with the practice manager. It need not be a burden or daunting if it is well organised and efficient and a practice manager can undertake much of the work. Great satisfaction can be gained from achieving quality patient care and in the same way maximising income to which a GP is entitled. It allows for a degree of independence which employed hospital doctors do not have unless they are involved in private practice.

Why tell you all this?

First, it is to understand how the financial origins of the new contract have come about as it is from these figures that the Global Sum of the new contract (discussed in the next chapter) originates. Second, it is to appreciate that there are elements of the 1990 GMS contract that should in the author’s interpretation continue as they are paid mainly three months in arrears for work undertaken prior to 1 April 2004. This is detailed in the Appendix. Individual practices will need to discuss and negotiate such potential claims with their local PCO. If a practice is in doubt they should seek advice from their LMC or the GPC of the BMA.

Practical point

Income from the ‘1990 contract’ should not stop on 1 April 2004. Some of it should continue as many of the payments are in arrears and practice managers should ensure that these continue to be paid or have been settled by 1 April 2004. Under the 1990 GMS contract the old regulations allowed for claims to be submitted for up to six years. However, the limit for submitting these claims may be reduced to six months at a PCO’s discretion.

CHAPTER 2

The Global Sum

The last chapter on the 1990 contract may at first glance have appeared to be superfluous to this book, but when one tries to fathom out how the ‘global sum’ has come into being, its relevance should be apparent.

Calculating the Global Sum

Each practice will have a ‘Global Sum’ (GS) calculated using a formula called the ‘Carr-Hill formula’ and its associated adjustments based on their list size on 1 April 2004 and the payments they received in the preceding 12 months under the 1990 GP contract for the following.

Fees and allowances per GP:

• basic practice allowance (BPA)
• capitation fees
• out-of-hours payments
• deprivation payments
• Postgraduate Education Allowance (PGEA) and appraisal
• staff reimbursements and employer’s superannuation
• health promotion payments (excluding ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Dedication
• About the author
• Introduction
• 1 Getting paid under the 1990 contract
• 2 The Global Sum
• 3 Enhanced services and Directed Enhanced Services
• 4 National Enhanced Services
• 5 Local Enhanced Services
• 6 Quality and Outcomes Framework: background, the clinical domain and exception reporting
• 7 Quality and Outcomes Framework: the other domains
• 8 Additional financial issues
• 9 Summary
• Appendix
• Glossary
• Index