Welcome to The new GMS & PMS Learning Exchange

1. The National Primary and Care Trust Development Programme Welcome to The new GMS & PMS Learning Exchange

2. The Future is NowNew GMS and PMS Rob Webster Director, contract implementation

3. Principles of Public Sector Reform • National Standards • Empower frontline staff to design and deliver services • Flexibility of service provision to meet patient need • Giving people choice

4. Primary Care Quality (What Patients’ Value) • Availability and Accessibility • Technical Competence • Communication Skills • Interpersonal Attributes of Care • Continuity of Care • Range of On-Site Services

5. Vision • Universal, fast and convenient access • by informed patients • to an extended choice and range of high quality services • delivered in modern primary care settings • by suitably trained and qualified professionals

6. Context • GP most respected public figure • Primary Care highest satisfaction rate • Primary care internationally admired • Quality is improving • PCTs as inclusive organisations • and new contracts mean we are in the verge of a renaissance in Primary Care

7. Scope [England] • c300 Million Consultations • c1m Specialist Attendance • 6 Million on-line hits • 6 millon NHS Direct calls • Over 7 Million OOHs calls • c1 Million WiC attendances • 600 Million items dispensed

8. Strategic Test 1 • Did you replace your out of hours service or reform your emergency care system?

9. Strategic Test 2 • Did you support the effective use of the quality frameworks to manage chronic diseases?

10. Strategic Test 3 • Did you use enhanced services, and the “floor”, to reconfigure services or treat them as a cross to bear?

11. Strategic Test 4 • Did you use patient feedback and flexibility in the new contracts to advance the notions of patient choice and improve the patient experience?

12. Strategic Test 5 • Did you use the practice based contracts and new roles of the PCT to develop opportunities around skill-mix?

13. Strategic Test 6 • Did you use the contract as a lever for recruitment and retention and for improving morale?

14. Strategic Test 7 • Did you use the additional flexibilities in PMS and PCTMS to tackle specific local issues?

15. Strategic Test 8 • Did you develop the entrepreneurial culture in primary care?

16. Strategic Test 9 • Did you use contracts as a lever for modernising services or as a payment mechanism for GPs?

17. Summary • Alignment: principles, values, vision • Positive context, huge scale • Operations and Strategy • Contracts can deliver Strategy for NHS • Use this event to get you there

18. The National Primary and Care Trust Development Programme The new GMS & PMS Learning Exchange

19. The Provision of General Medical ServicesIan Dodge, Head of GMS, Department of Health

20. Objectives for the session • Key points from chapter 2 of Delivering Investment in General Practice (except OOHs) • What PCTs need to do, why, and when • Q&A Not a substitute for reading chapter 2

21. Five Themes • Using the four contracting routes • Understanding essential services and related statutory requirements • How patient registration, list-closure and forced assignments will work • Understanding additional services • Using enhanced services to deliver whole system change

22. The Four Contracting Routes (1) • New Primary Medical Services duty • PCT must from 1st April “commission or provide primary medical services to the extent that it considers necessary to meet all reasonable requirements” • PCTs must ensure sufficient alternative provision in place at the time additional service/OOHs opt-outs take effect

23. The Four Contracting Routes (2)

24. The Four Contracting Routes (3) • Obligations & rights with GMS contract: • essential services: must provide • additional services: right & expectation to provide for own population • enhanced: right to provide 3 DES: access, QUIP, CVI • “GMS and PMS contractors do not have preferred provider status for other enhanced services” (para 2.13, page 22) • Greenfield sites (“significant population expansion”): expectation PCT “could advertise and seek applications through a two stage process” • Brownfield sites: no preferred provider status

25. Essential Services (1) • Understanding is pre-requisite to effective commissioning of enhanced services • Management of all patients suffering from disease as defined in the ISCD- eg disabilities, long-term conditions, infertility, depression etc • Contractors must provide “appropriate ongoing treatment and care for all registered patients and temporary patients”, including advice about health promotion

26. Essential Services (2) • Enhanced services specifications: “no part of the specification by commission, omission or implication defines or redefines essential or additional services” • Para 2.19: “GMS contractors are funded through the global sum and MPIG to provide the equivalent services for which they were previously funded under existing GMS” • Exceptions are flu; CVI; cervical cytology and minor surgery (part); intra-partum care; intrauterine contraceptive devices and implants

27. Essential Services (3) • Core hours: contractor responsible for ensuring provision 8am-6.30pm, Monday to Friday except public and bank holidays • Normal surgery hours: must be “to the extent necessary to meet reasonable needs” • Replaces 26 hour a week face to face commitment on an individual GP

28. Essential Services (4) • Temporary patients obligations remain • Home-visiting “if the patient’s medical condition is such that, in the reasonable opinion of the contractor, it is necessary to do so” • Newly registered patients • Three-year rule and over 75 checks at patient request

29. Patient registration (1) • Obligation to ensure lists are accurate • Choice of practitioner subject to availability, appropriateness, reasonableness • New PCT Guide to Primary Care Services • Contractors to review patient leaflets before April • PCTs and contractors agree practice areas before April

30. Patient registration (2) • Open/closed status: discuss with practices before end of February • Open list: • “must accept any application … unless it has fair and reasonable grounds for not doing so” • must not discriminate & give reasons for refusal in writing and keep a record (same applies for all removals) • PCT can assign patients

31. Patient registration (3) • Closed list: • must not accept new patients save immediate family • new patient assignment procedure applies • Formal closure and assignment procedures from 1st April: • rejecting closure notice/application to assign patients to contractors with closed lists leads to Assessment Panel determination • appeal is to the SHA (not the FHSAA(SHA)) • PCTs cannot assign to closed lists from 1st April other than through this procedure; may need to develop applications, and put panel arrangements in place • Open list: • “must accept any application … unless it has fair and reasonable grounds for not doing so” • must not discriminate • must give reasons for refusal in writing and keep a record • PCT can assign patients

32. Additional services (1) • PCTs must ensure sufficient in place from 1st April • Contractors do not have to provide if not already doing so • PCT discretion to agree opt-outs before April 2004 when opt-out procedure applies; ascertain intentions in January, decide in February • Tariff for opt-out (% of global sum, not GS+MPIG) • No fixed price for recommissioning additional services

33. Additional services (2) • Purpose of opt-outs is to manage contractor workload • PCT can reject opt-outs if the contractor is providing any enhanced services • If it approves the opt out, but then cannot find alternative provision despite best endeavours, PCTs can seek SHA approval that there are exceptional circumstances

34. Using enhanced services (1) • Expanding range, improving choice, convenience, VFM, & reducing pressures on hospitals • Local floor from 2004/05 monitored nationally • Initial plans during February - to include the 6 DES • PEC sign off proposals and must seek LMC agreement that spend counts to floor

35. Using enhanced services (2) • Tighter definition of spend • Includes: • DES, NES, LES from any provider • PWSI • Plus in PMS Plus, Specialist in PMS specialist • Local incentive schemes from GMS & PMS providers • Recommissioned services ONLY if contestable for GMS & PMS contractors & could reasonably be provided by them • Excludes any baseline spend on trusts/other providers simply rolled forward, or anything funded through other primary care routes

36. Using enhanced services (3) • PCT must commission 6 DES from 1st April, and offer 3 of the DES to GMS contractors • PCT commissions as primary medical services, decides when, from whom & how it commissions other enhanced services • Bear in mind definition of essential services • PCTs may wish to be guided by NES but “commissioning decisions are entirely a matter of local negotiation” (para 2.84)

37. Summary • New duty & four commissioning routes • Understand essential services • New patient registration, list closure & assignment arrangements • Additional services commissioning & opt outs • Understand enhanced services commissioning rules, spend, and use to deliver strategic change

38. PCT actions • Strategy for commissioning primary care • 1st Jan: offer 2003/04 access & QUiP DES • End Jan: reviewed additional services commissioning & contractor intentions • 1st Feb: commission violent patients DES • End Feb: agreed practice areas, open/closed status, discussed normal hours, offered 3 DES, agreed early additional service opt-outs • End Feb: drawn up initial plans for commissioning enhanced services • Apr: set up assessment panels & proposals for assignments if need be

39. Questions

40. The National Primary and Care Trust Development Programme The new GMS & PMS Learning Exchange

41. nGMS and PMS EVENTSFINANCE Michael Munt

42. nGMS and PMS IMPLEMENTATIONFINANCE Overview • Financial Arrangements • Contractors - Statement of Financial Entitlements • Allocations to PCT’s • Contractor Budgets • Financial Management and Monitoring • Key Milestones

43. nGMS and PMS IMPLEMENTATIONFINANCE Financial Arrangements - Headlines • Spending on Primary Medical Services in the UK to increase from £6.1bn in 2002/03 to £8bn in 2005/06 • Arrangements underpinned by Gross Investment Guarantee for the years 2003/04 to 2005/06 • All allocations are now cash limited with some minor elements of dispensing remaining as non cash limited • Link to Local Development Plan

44. nGMS and PMS IMPLEMENTATIONFINANCE Gross Investment Guarantee (GIG) • Mechanism to monitor overall spend on Primary Medical Services. • Technical Sub Committee established comprising representatives of DH/NHSC/BMA to monitor arrangements. • Component Parts • GMS Non Cash Limited • PCT Unified Allocation, GMS Cash Limited, Dispensing Drug costs • Centrally Funded Initiatives • New Monies Primarily For Quality

45. nGMS and PMS IMPLEMENTATIONFINANCE EXPENDITURE TYPE England 2002/03 2003/04 2004/05 2005/06 GMS fees and allowances 2,990 3,100 - - GMS cash-limited payments 988 1,086 - - Global sum payments 0 2,651 2,690 Quality payments 0 80 682 1,102 Enhanced primary care services 254315 518 586 Premises 0 60 600 756 IT 0 60 108 108 Other PCT administered funds 0 332 354 Transitional protection 0 297 197 Other (R&R & OOH DF) 74 74 90 90 Demand Management 5 5 Dispensing 726 784 847 917 TOTAL SPEND 5,032 5,559 6,131 6,806

46. nGMS and PMS IMPLEMENTATIONFINANCE Gross Investment Guarantee GIG is currently being revised to take account of : • Outturn on 2002/03 fees and allowances • Growth assumptions in GMS Cash Limited monies • Increases in dispensing and drugs costs • Changes in superannuation employers costs • Projected over/underspend in 2003/04

47. nGMS and PMS IMPLEMENTATIONFINANCE Contractor Entitlements SFE

48. nGMS and PMS IMPLEMENTATIONFINANCE Contractor Entitlements • Red Book replaced by the Statement of Financial Entitlement (SFE) • Concept of Entitlement continues but not on the basis of individual Practitioner but on the basis of a Contractor Practice • All payments under the old arrangements cease 31 March 2004 • PCT’s must make adequate provision for the accrual of outstanding amounts in their 2003/04 accounts

49. nGMS and PMS IMPLEMENTATIONFINANCE • Additional cash financing requirement will, if necessary be made available • Any additional costs to be met by PCT • The SFE gives Contractors certainty over the minimum level of entitlement • Discretionary funds will be available to Contractors • The SFE sets out 17 different types of entitlement

50. nGMS and PMS IMPLEMENTATIONFINANCE Key Entitlements Global Sum • Based on Formula - Carr Hill to establish allocation fair shares • Formula is weighted at Contractor level to be updated every quarter for changes in Contractor characteristics and weighted population • Indicative price is currently £50 per weighted patient