Generally a surgery will have an accountant, who may visit the surgery for one day or part of a day a week, as agreed with the partners, to maintain the accounts and advice staff and GPs on various financial, tax and related issues that may arise. Only in some practices, if a Practice Manager (PMgr) were suitably experienced in accounting, would be involved, by the Partners, in dealing with certain issues, playing a second fiddle to the accountant.
The general principles of payments in earlier years are given below. Lot of changes has occurred in recent years and the statement would elucidate current payment heading.
Most payments to practices are made via the Exeter Payments system, which is a national system, used by PCTs and Payments Agencies.
After the close of the Registration quarter Exeter system calculates the Global Sum payments due to the GMS practices. The amounts calculated are paid for the three months of the quarter and then run again the following quarter.
PMS Practices are paid a monthly contract value which is agreed with their PCT. GMS Practices are paid quarterly
Most practices participate in the Quality and Outcomes Framework (QOF). Essentially there are 2 types of payments made in relation to QOF: Aspiration payments, which are paid monthly, and Achievement payments, which are paid annually. These payments are made via the Exeter system from data received from QMAS.
Each month the PCTs advise the Agency of any Enhanced Service payments to be paid and these are paid with the GMS and PMS monthly payments.
From the above payments Employee, Employer and AVC superannuation is deducted on the basis of the estimated pensionable pay of the GPs, non-GP partners and Salaried GPs notified to the Agency each year. The contributions are subsequently paid over to the Pensions Agency each month.
When we receive the GPs annual certificates of pensionable profits the contributions due for the year are reconciled to the deductions made on account and the underpayments/overpayments are actioned in the next Monthly GMS/PMS payment due to be paid.
Levies are then deducted (paid to the LMC) and courier charges for the collection of medical records etc.
Seniority and Age 2 and Age 5 Target payments are paid on a quarterly basis.
Seniority payments are paid to GP Providers (not Salaried GPs) and they reward experience, based on years of Reckonable Service. The payments become payable once a GP has been in an eligible post for 2 years and has 7 years Reckonable Service and take into account the GPs Superannuable Income Fraction.
Each month on details received from the PPD via NHS Connecting for Health of the Dispensing and Prescribing drugs payments due to the practices.
The prescribing payments are paid with the monthly Global Sum payments and are paid two months in arrears i.e. March prescriptions paid in May and the dispensing payments are paid on the first working day of the month, with March prescriptions paid on the first working day of June.
Within the monthly Global Sum payments and PMS payments we include payments for locums covering Maternity, Paternity, Adoption Leave and Sickness and also Retainer Scheme payments.
Rent and Rates payments including Notional Rents, Actual Rents and Cost Rents are paid to practices on a monthly basis with the Global Sum and PMS payments.
GP premises are reviewed on a three yearly basis and when a new rent has been assessed by the District Valuer and approved by the PCT we pay the new rent to the practice and pay any rent arrears that may be due.
Direct payments for Non-Domestic Rates and water charges to Council and Water Companies on behalf of the practices.
These payments are made on the Integra payments system.
Statements giving details of these payments are sent to practices on an annual basis for inclusion in the Practice Accounts.
Reimbursements are also made to training practices in respect of their GP Registrars. The Deanery advises the Agency of the GP Registrars working in our areas and advises the practices of the salary to pay their GP Registrar. Changes are afoot regarding stopping such payments.
Medical Practitioner Fee payments including Mental Health Assessments, Adoption reports/examinations etc. are paid normally on a weekly basis via the Integra payments system.
Statements to practices where payments have been made are available on Open Exeter.
Currently, around half of all GPs work as independent contractors under contract to provide core primary health care services and additional services as negotiated within the GP contract.
As such, these GPs are self-employed, running small businesses or practices. They have management responsibilities for staff, premises and equipment. Since most of these GPs receive a profit share, the amount each GP is paid depends not only on income to the practice but also on expenditure.
Income comes from NHS work under the GP contract and private work, such as insurance examinations, private medical examinations and certificates and outside appointments (for example industrial appointments or clinical assistant posts).
Expenditure includes the running costs of the practice—staff salaries, cost of the premises (rent, taxes, repairs, maintenance and insurance), service costs (heating, water, electricity, gas, telephone, stationery and postage), training costs and other expenses—and the capital costs of medical and office equipment.
Currently, there are two forms of contract that GP practices may have with their local Primary Care Organizations (PCOs), the General Medical Services (GMS) contract or Personal Medical Services (PMS) contract.
The contract defines the services that they will provide standards to achieve and the payment that they will receive.
The GMS contract is a contract made between an individual practice and a PCO. All the partners of the practice, at least one of who must be a GP, have to sign the contract. It includes: National terms applicable to all practices (the ‘Practice Contract’)
A description of which services will be provided by that practice, i.e.: o essential services o additional services if not opted out o out-of-hours cover if not opted out o enhanced services, if opted in A level of quality of essential and additional services that the practice ‘aspires’ to Support arrangements, for example for information technology, and premises A summary of the total financial resources
Essential services are the services that all practices must undertake. These services include the day-to-day medical care of the practice population such as health promotion, management of minor and self-limiting illness and referral to secondary care services and other agencies as appropriate, the general management of patients who are terminally ill and chronic disease management.
Additional services are services that the practice will usually undertake but may ‘opt out’ of. If the practice opts out, the PCO takes responsibility for providing the service instead. The practice then receives a reduced global sum payment.
The services included are: Cervical screening—opting out results in a 1.1% decrease in global sum Contraceptive services—opting out results in a 2.4% reduction in global sum
Vaccinations and immunizations—opting out of vaccinations and immunizations results in a 2% drop in global sum; opting out of childhood immunizations leads to a 1% reduction in global sum Child health surveillance (excluding the neonatal check)—opting out leads to a 0.7% decrease in global sum
Maternity services excluding intra-partum care (which is an enhanced service)—opting out causes a 2.1% drop in global sum
Certain minor surgery procedures: curettage, cautery, cryocautery of warts/verrucae and other skin lesions—opting out results in a 0.6% reduction in global sum
Enhanced services Enhanced services are commissioned by the PCO and paid for in addition to the global sum payment.
There are three types:
Directed enhanced services: These are enhanced services under national direction with national specifications and benchmark pricing that all PCOs must commission to cover their population. These services change from year to year and include access targets, payment targets for childhood immunizations, influenza vaccinations, and more complex minor surgery, such as joint injections, and incisions or excisions
National enhanced services: These services have national minimum standards and benchmark pricing but are not directed (that is PCOs do not have to provide these services). Examples include anticoagulation monitoring, treatment of drug or alcohol abuse and minor injury services.
Local enhanced services: These services are developed locally to meet local needs. For example special services for refugees. Out-of-hours care Practices can ‘opt out’ of providing an out-of-hours service. The decision must be made for the whole practice—individual doctors within a practice cannot ‘opt out’ alone.
The cost of opting out for a practice is 7% of the global sum. There is nothing to stop practices that have opted out from offering surgeries or consultations within the time periods specified as out-of-hours. These services can be paid for through the practice global sum or may be paid for as an enhanced service.
Currently, enhanced services providing out-of-hours surgeries can be negotiated at a local level with PCOs, but in future are likely to be part of a Directed Enhanced Service for enhanced access.
Payment to practices comprises the following components.
The global sum + quality payments + enhanced services payments + payment for premises + information technology payments + dispensing payments (if applicable). Previous Section
The global sum: this is the major part of the money paid to practices. It is paid monthly and intended to cover practice-running costs. It includes provision for delivery of essential services and additional and out-of-hours services (if not opted out), staff costs, career development and locum reimbursement (for example for appraisal, career development and protected time). Previous Section
Quality payments The Quality and Outcomes Framework was developed specifically for the new GMS contract but similar arrangements are in place for those GPs working within PMS contracts. Financial incentives are used to encourage high-quality care.
The GMS quality framework is divided into four domains (Table 1): Clinical Organizational Additional services
Patient experience every domain has a set of ‘indicators’ that relate to quality standards or guidelines that can be achieved within that domain.
The indicators are developed by an expert group based on the best available evidence at the time and are updated regularly. All data should be obtainable from practice clinical systems.