PERSONAL MEDICAL SERVICES PILOTS

Introduction

This booklet aims to provide you with a brief guide to Personal Medical Services (PMS) pilots and the opportunities they offer to develop primary care services within your local community.

Whether you are a GP, member of an LHCC, or working in a Primary Care Trust (PCT), we hope that you will be interested in knowing more about PMS pilots and how a pilot could help you change the way you provide primary care services to your patients.

There are 12 PMS pilots in Scotland with several more in the pipeline. In England, there are almost 300. Experience so far shows that PMS offers an increasingly popular option to those GPs, LHCCs and their PCTs who want to explore different and more flexible ways of providing health care services.

Once you have read this guide, if you want to know more, please contact your Primary Care Trust in the first instance. Alternatively, contact Jackie Brock (telephone: 0131-244-2462, or e-mail:jackie.brock@scotland.gov.uk or Susan Malcolm (telephone, 0131-244-2680, or e-mail: susan.malcolm@scotland.gov.uk).

You could also contact:
Dr George Crooks
Associate Medical Director
Grampian Primary Care Trust
Bennachie
Royal Cornhill Hospital
ABERDEEN
AB252ZH

Ms Tina Davidson
Primary Care Development Manager
Grampian Primary Care Trust
Bennachie
Royal Cornhill Hospital
ABERDEEN
AB252ZH

Mr Duncan Millar
Primary Care Development Manager
Lothian Primary Care NHS Trust
Astley Ainslie Hospital
133 Grange Loan
EDINBURGH
EH92HL
(Tel: 0131 537 9000)

Mrs Dawn Whiteside
Practice Manager
Milton Surgery
132 Mountcastle Drive south
EDINBURGH
EH153LL

who are involved in running pilots to hear what a pilot has meant for them.

Primary Care Act Personal Medical Services Pilots What Are They?

The National Health Service (Primary Care) Act 1997 sets out a new range of contractual options for GPs and other primary health care staff. The Act allows these flexibilities to be implemented through a series of properly evaluated pilots, testing new models in practice before considering their wider application.

All pilots must seek to improve access and the quality of services provided within primary care. They can also be used to:

• help to recruit and retain GPs in areas of greatest need
• develop new arrangements for the delivery of services, giving different professionals greater scope and opportunities
• reduce the bureaucracy involved in the management of primary care provision
• improve integration of services provided by the extended Primary Health Care Team

Within two years, we went from a practice (in a deprived area) which had no applications for a vacancy to one which had 7 applications - all of them appointable"

Dr M. Knight, Salaried GP, Aberdeen

Contractual Arrangements

Pilots must include services which patients are currently entitled to receive from their GPs under GMS (General Medical Services). They also need to ensure continuity of care for all their individual patients _ as GPs do now _ including the provision of out of hours cover.

It is also necessary for pilot practices to be members of their local LHCC, where one exists.

Local contractual arrangements are made for the provisions of PMS, that is GMS plus any additional services which the pilot is designed to deliver.

The contractual arrangement can take various forms:

Salaried GPs

GPs can be salaried either within practices or by NHS Trusts or other health service bodies (but the legislation does not allow them to be salaried to Health Boards). Salaried GPs must be able to provide the full range of PMS to the whole of a registered population.

"I would never go back to independent contractor status..I can now do my job - devote my time to my patients"

Dr. Mike Duffy, Salaried GP, Dundee

Why would a GP want to choose this option

• To remove the need for capital investment and free them from the administrative responsibility of running a small business and to use that time to concentrate on meeting the clinical needs of patients.
• To bring together separate organisations allowing health care professionals to work closer together, to share resources and to offer a wider range of services to patients.
• To focus on service development in areas where primary care provision is deficient or to fill vacancies where recruitment is difficult _ perhaps in deprived or rural areas.
• To target particular patient groups not well served under existing arrangements, such as the homeless and drug misusers.

Why would a PCT choose a PMS pilot to employ a salaried GP?

• To develop services in areas where the provision of primary care medical services is inadequate.
• To take on the running of an existing practice to allow the GPs greater freedom to concentrate on the clinical care provided to patients or to provide better support to single-handed practices.
• To fill a vacant practice where there is a continuing difficulty to recruit a GP under current arrangements.
• To explore contractual arrangements that will focus on quality of care and support clinical governance.

"There were minimal services available to meet the needs of homeless people in the centre of Edinburgh . . now there is a whole team, with 3 part-time salaried GPs."

Duncan Miller Lothian PCT

Other Contractual Arrangements can include:

• An LHCC-wide practice based pilot could help to integrate primary care provision in local communities, supporting the development of additional capacity in primary care. Recruitment and retention difficulties in deprived and rural areas could also be improved.
• An LHCC-wide pilot, where the GPs in each practice are salaried to the PCT. Such a pilot may help an LHCC focus on the co-ordinated provision and quality of a wide range of clinical services and also to develop services through shared resources.
• A practice-based bid, where the practice contracts with the PCT to provide services over and above GMS such as community nursing services. This allows for services to be provided by the most appropriate mix of skilled professionals and for improvements in local team management.

"By cutting out the time spent on managing the business, I can now provide 20 minute appointments to all my patients"

Dr Gavin Brydone, Milton Surgery

Review and Permanent Arrangements

The 1997 Act specifies that at least one review of each pilot scheme must be conducted by the Secretary of State (now Scottish Ministers) within 3 years of the commencement of the scheme.

Scottish Ministers will be able to approve applications for permanent arrangements where, on review, pilots are judged to be successful.

Primary Care Act Pilots: Why Bother?

Many will argue that the current national contract has served GPs and their patients well and there is no need to change. This is true, for some. But for many professionals considering a career as a GP, the practice-based, self-employed model is no longer attractive:

• Some do not want to take on the risk of financial commitment involved in investing in premises.
• Many will not feel attracted to the stress and commitment involved in running a small business.
• Many may want to concentrate on seeing patients and developing services.
• Others want more time for continuing professional development at both personal and practice level.

In addition to the changing needs of medical professionals, a number of practices are reporting difficulties in recruiting to vacant posts. In areas where on-call commitment is high or where professionals face burn-out after only a few years, identifying new ways of working is a priority _ this is where pilots can help.

A PMS pilot would allow the PCT, the GPs and other primary care professionals to work together on a local contract to provide services which are specifically tailored to prioritise specific aspects of their work to meet local health needs.

 In an area like Argyll and Bute where there are significant recruitment difficulties and a heavy on call workload in practices and community hospitals, we need to explore the opportunities that a PMS pilot may offer in addressing these problems.

Dr Erik Jespersen Argyll and Bute LHCC

LHCCs and PCTs provide an organisational structure to support the development of primary care. Together with GPs and other professionals, PCTs and their LHCCs are working together to prioritise the needs of their local communities, often together with partners in local authorities and the voluntary sector. An LHCC-wide PMS pilot could help to develop new initiatives to meet local need.

What does negotiating a PMS Pilot contract mean for GPs?

The nature and extent of services to be provided to patients, in addition to the range of services provided under GMS, will need to be specified. This could mean that a GP will offer more targeted services to priority patient groups, such as patients at risk of cardiovascular disease or to homeless people; or, it may mean that they will increase the length of the appointment to patients with specific clinical needs. These additional services, and remuneration for them, are agreed with the Trust.

Some specific questions which GPs might have include the following:

1. Will my existing income/salary level be maintained? Will the potential for it to grow in subsequent years be available as there would be if GMS activity levels grew?

All involved in drawing up the contract need to agree and specify:

• services to be delivered under the contract;
• the 'baseline' value for PMS, normally representing the current year equivalent of the underlying level of GMS payments
• a 'baseline' value for additions to the contract

The total of these 'baseline' values will be the starting point for agreeing the contract value and the GP's income.

Incentives for PMS providers may be built into the contract.

Contracts should also state how any year-on-year salary or service increases would be dealt with.

2. How firm is the guarantee that GPs can opt out of the PMS pilot and go back to their individual contract with the Primary Care Trust?

Every GP previously in GMS who has moved into a PMS pilot in England or Scotland has been given a preferential right to return to the medical list should the pilot end.

Additional doctors taken on under PMS who seek entry to the medical list if a pilot ends are likely to have their requests considered favourably.

3. Do the existing pension arrangements for all staff continue in the pilot?

GPs entering pilots as independent contractors will continue to accrue practitioner benefits. The contract should define which income is pensionable. PCTs will continue to pay the employer's contributions of these GPs.

GPs entering pilots as employees will wish to retain the practitioner benefits they currently accrue as independent contractors. It is the intention to amend the regulations to make this possible for the duration of the pilots.

Access to the NHS Pension Scheme for GP practice staff is already allowed. Anyone employed by a NHS Trust and not already a member of the scheme will be entitled to join automatically. Staff employed by a GP who become employed by a Trust will retain their membership.

Arrangements for sickness benefit and maternity leave should be agreed within the contract.

4. Should a PMS GP wish to resign/retire, how are the premises treated? What reassurances can be given that the outgoing GP will be able to realise the value of his/her asset?

PCTs need to agree in contracts with PMS providers the nature and extent of premises from which to provide PMS. Normally, agreed contract values would include the revenue costs of providing premises (on a similar basis to notional rest). "Red Book" arrangements do not apply to, and SFA allowances are not available to, PMS providers.

We recommend seeking legal advice about the arrangements for the ownership and use of premises

5. Under an LHCC contract, will all GPs practising within the PMS Pilot become salaried practitioners paid by the LHCC or PCT. If so who sets the level of salary?

It depends on the nature of the pilot.

If it is a multi-practice-based pilot then the current GPs will be able to apply to become a health service body. The health service body will then contract with the PCT.

If it is a salaried pilot then the GPs will become salaried to the PCT. (The LHCC is not a legal entity so they could not be salaried to it). The salary levels would be for negotiation between the pilot providers and the PCT. The Terms of Service would in effect be the agreed contract.

6. Currently the individual GPs or Practices directly employ support staff. Under a PMS pilot, who are their employers? Will salaries and benefits be maintained at the present level or will they be assimilated into a common salary spine?

For practice staff whose current employing practice becomes part of a practice-based pilot, the transition should be fairly seamless. For GP practice staff transferring into a NHS Trust led pilot, TUPE (which protects the terms and conditions of their employment) is likely to apply. But where the practice is taken into a pilot run by a NHS Trust there will be employment issues to resolve if staff do not wish to make this transfer. It is important to consult staff at the earliest opportunity about the proposals.

7. What benefits are there for the practice in staff transferring to the PCT?

The practice would be able to tap into the Human Resources staff at the PCT for help and/or advice when dealing with areas like appointment of staff, discipline, contracts etc. Similarly Finance staff at the PCT will be able to offer help and advice when required.

What are the Benefits for the Trusts?

As Trusts develop their priorities and take on the challenges faced by providing primary care, they might wish to support PMS pilots in order to:

Tackle recruitment and retention problems

Address the health care needs of specific groups, such as homeless people

Tackle specific clinical priorities

Test the value of flexible arrangements for the provision of PMS

Identify economies of scale

Interested?

PMS Pilots require PCTs to work closely with GPs and other professionals to analyse the local health needs and how services could be improved. If you are a GP or a member of a primary care team and you are interested in knowing more about pilots then you should speak to your PCT in the first instance.

Support for the Bid

The Scottish Executive will support the costs of developing a pilot bid. The amount will be determined by the nature of the bid. Practical support in developing a pilot is available from your Primary Care Trust.

If you are a GP, LHCC member or work in a PCT and you want to discuss whether a PMS pilot could help you develop and improve primary care in your area, contact:

Jackie Brock (telephone: 0131-244-2462), or email: jackie.brock@scotland.gov.uk; or,

Susan Malcolm (telephone, 0131-244-2680), or email: susan.malcolm@scotland.gov.uk.

We look forward to hearing from you.

This booklet has been produced by the Primary Care Directorate, Health Department, Scottish Executive.

We would like to thank all those who have contributed to the content of this booklet.

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