PMS was introduced as an alternative to the traditional GMS
contract. The Government wants these local contracts "to encourage GPs and
nurses to work and develop new health services, particularly in deprived areas,
and to encourage enterprise and reform".
The Government’s expectation was that
30% of practices would be in PMS by April 2002. The national figures were 18% at
that time, but even lower in Bedfordshire and Hertfordshire
Most local pilots derived from GMS practices transferring to
become PMS practices, with the GPs keeping their independent contractor status.
A very small number locally have achieved growth funding to allow them to employ
a salaried GP (not all have found one).
There is one existing Community Trust led pilot for a small
number of patients in Hertfordshire with 2 salaried GPs. Two pilots involve
three practices joining together to form a pilot (the Hatfield and DASH pilot in
Hertfordshire). One pilot starting in October 2002 will be a PCT led pilot,
employing salaried GPs to perform PMS services and a ‘PMS Plus’ element
aimed at the homeless. The Bedfordshire expressions of interest for 4b mainly
derive from Heartlands PCT, and there is interest in their forming a ‘Locality
PMS’ arrangement.
All of the pilots which have gone live have used the LMCs’
PMS Contract purchased from a leading legal firm with PMS expertise. Our PCTs
are under considerable pressure to encourage PMS, especially because our uptake
is seen as ‘under target’.
Evaluation of PMS
GPs will want to know the clinical impact of changing to PMS
for themselves and their patients. PMS has been extensively evaluated and indeed
compared with GMS by a range of university departments. However, there have been
difficulties in comparisons with GMS services because GMS has also changed and
improved over the last 3 years as PMS has developed. The PMS National Evaluation
Team published "An integrated report from 4 research projects evaluating
the 1st Wave" in December 2000.
A summary follows, the findings were very general and do not
help practices which are trying to decide about the value of PMS for patient
care.
National Evaluation of First Wave NHS
Personal Medical Service Pilots
The National Primary Care Research
and Development Centre (NPCRDC) has published the interim findings of research
commissioned by the Department of Health evaluating the first wave Personal
Medical Services (PMS) pilots.
The work looks at four different aspects of PMS:
Accountability, Integration and Responsiveness; quality of Care; Salaried GPs in
PMS Pilots; Addressing Inequalities.
Accountability, Integration and Responsiveness
Twenty-seven
first wave pilots are included in the research. The study found new models of
primary care being introduced along with a more strategic approach to planning
and collaborative working.
New roles are being created for nurses through the training
of health care assistants and the modification of the way services are provided.
This has enabled GPs to take up new responsibilities and improve patient access
to a wider range of services.
Some of the pilots were critical of the quality of health
authority monitoring and are calling for greater communication in the future.
Quality of Care in PMS
Quality of care is defined as a combination of effectiveness
and access across the twenty-three PMS pilots compared with the same number of
GMS controls.
Pilots reported a number of changes aimed at improving
quality surrounding the way work is organised and the management of healthcare.
The research discovered a number of points which are important in creating
improvements – good practice management, a shared sense of ownership, and a
responsive and open practice culture. Pilots lacking these qualities found a
slower pace of change and improvement.
Salaried GPs in PMS Pilots
The research suggests salaried posts appeal more to younger
GPs who are not working as principals.
National Evaluation of PMS
Lower than average pay for salaried GPs was found to be
balanced by the advantages of good employment benefits, stability of pay levels,
job security and predictable working hours. The research found salaried GPs to
be happier with their income, hours and recognition for their work.
Levels of stress were lower for salaried GPs in respect of
workload and practice management but higher in terms of poor working conditions
and lack of support from colleagues.
Addressing Inequalities
This branch of the research concentrated on improving access
to primary health care for disadvantaged groups.
A number of pilots involved in the sample offered ‘drop in’
clinics and an increased range of clinical services on offer to homeless people,
drug and substance misusers, and the mentally ill. The emphasis was on open
access clinics coupled with improvements in referrals to secondary and
specialist services.
For many people living in ethnic communities the use of
interpreters has overcome some of the barriers preventing people from benefiting
from primary care. Pilots aimed at vulnerable groups are generally located in
deprived Local Authority Districts but not all of these areas have the benefit
of being served by a pilot scheme.
Staff involved in the pilot schemes say they are satisfied
with the contractual stability and freedom the schemes offer.
The preliminary findings of these four research projects
relate to first wave pilots only. Full report on website (www.npcrdc.man.ac.uk).
More recent research
Has been undertaken on:
 | Does PMS improve quality of care? |
| Salaried GPs in PMS pilots |
| Addressing inequalities
|
Unfortunately, these have only been presented to the National
PMS Implementation Group, and may not be published in time for GPs considering
Wave 4b to study them. In summary, the study looking at
The future of PMS and permanent arrangements
John Hutton, Health Minister, reinforced in January 2002
"PMS is here to stay". The original understanding was that a pilot
would function for 3 years and, if successfully evaluated by the Secretary of
State, then move to Permanent PMS Status.
However, the arrangements for Permanent PMS Status have not
yet been revealed and will need legislation to enact. A fifth wave is expected.
The 1st and 2nd wave pilots have
therefore been extended for a further two and one year respectively.
Who is your contract with?
Originally PMS contracts were between the PMS providers (the
practice) and the Health Authority. With Wave 3b, PCTs took over holding the
contracts. Some of the original pilots wanted to stay with a Health Authority
held contract. However, during 2002, they will need to move to a PCT contract as
the Health Authorities will disappear. PCTs will need to develop their
competencies on PCT issues.
The National Development Team is producing a competency
framework for PCTs including the knowledge and skills needed to implement and
support PMS, especially the financial regime of PMS. The LMC Chief Executive has
contributed to this.
Single handed GPs and PMS
The Government’s ‘NHS Plan’ stated that all single
handed GPs would be in PMS by 2004. This statement has not been retracted, but
there is no current mechanism to make PMS compulsory for single handed
practices. The LMC would resist any pressure put on unwilling practices to
change contractual status.
Many PCTs will wish to become ‘whole
PCT led pilots’ in time. This is the only
mechanism whereby the PCT can employ GPs on a contract (or series of short term
contracts). There is some anxiety that the permanency arrangements will
facilitate PCT led PMS with salaried GPs.
New PMS directions, guidance and national contracts
are not subject to the rigour of GPC (General Practitioners Committee) scrutiny
and negotiations. Instead, the National PMS Implementation Group is consulted on
new regulations and there are errors which need correction.
The GPC is fighting for national negotiating rights to
protect PMS GPs.
Section II Arrangements and Timetable for Wave 4b
Financial arrangements for 4b
Preparatory money is likely to
be £4,500 per practice or per locality arrangement. This is usually paid (well)
after the work is undertaken so practices must expect to make a preliminary
investment for legal and accountancy advice.
Growth monies for 4b will not
depend on proving patient deprivation alone but "underdoctoring will be an
additional criteria when considering growth." The last wave’s growth
monies were £50k per salaried GP and £30k for a nurse practitioner, paid once
posts have been filled.
PMS Plus
Where a practice wishes to take on ‘plus’ activities,
e.g. aspects of traditional secondary care, they will need to negotiate with
their PCT for the additional funding from the PCT’s unified budget. This will
be challenging locally, given the local Saff round and the shortfall between
allocations to our PCTs and their obligations and plans. The LMCs are extremely
concerned that our local financial problems may restrict the development of both
GMS and PMS. We would wish to see equity of opportunity for all practices to
develop services to patients.
The LMCs believe that there must be some principles in the
financial arrangements for PMS:
4th Edition of the Comprehensive Guidance
This is being revised by the Government as a more practical
manual on how to do PMS. It is essential reading for all prospective pilots and
your PCT should make it available to you as soon as it is completed.
Revised framework for PMS Pilot Agreements
This was launched in January 2002 to replace the previous
Core Contractual Framework (CCF) which was seen as a deterrent to PMS uptake.
However, Although the PMS Agreement contains all the aspects
of what is expected in the National PMS Agreement, in itself it is not
sufficient protection for GPs and needs to build in the most important elements,
i.e. your local arrangements with your PCT. It is for this reason that the LMC
has purchased a contract which is tailored to the Wave 4b Agreement (see Section
III)
National Support
There is a national PMS Development Team led by Dr Mo Dewj,
which will establish a website later in February.
There will be an attempt to keep an individual with PMS
expertise to offer advice at StHA level, although most PMS operational issues
will pass to PCTs. It is therefore crucial that PCTs ensure that they have a PMS
lead and develop the skills to support PMS practices. The LMC has worked closely
with the Bedfordshire and Hertfordshire Health Authorities in their PMS Steering
Groups and will work closely with PCTs on PMS.
Timetable for Wave 4B (October
2002)
|
Beds
22 February 2002 |
Practices develop their PMS proposals including growth
requirements using the PMS Wave 4 proforma document. |
|
Applications submitted to HA April 2002 |
PCTs submit their recommendations on pilots together
with the CHCs’ and LMCs’ responses. |
|
Mid April 2002 |
Regional Office/StHA will complete internal assessments
and approvals and negotiate with the DoH on growth allocation. |
|
May 2002 |
Notification of Secretary of State’s approval to
pilots and individual growth allocations. |
|
June – September 2002 |
Prospective pilots negotiate PMS service agreements
with PCTs. LMC can help. Begin staff recruitment, negotiate budget with
PCT. |
|
End September 2002 |
Final allocations to pilots. |
|
1st October 2002 |
Pilots go live |
NB For PCT led pilots, the StHA will be the commissioner
and hold the contract with the PCT as provider. The GPs are then employed as
‘performers’ of PMS.
Section III What your LMC can offer
Links with National PMS Implementation Group
Dr Judy Gilley, Chief Executive of the LMCs is a member of
the National PMS Implementation Group and has been involved in PMS since the
first legislation in 1997 (when she was a GPC negotiator).
This means we are ahead of the field in our understanding
of PMS developments.
Purchase of PMS Contracts
The LMCs agreed to support PMS colleagues by purchasing a
suitable contract for them. This lengthy but crucial document was available for
Wave 3a and modified for Wave 3b. It will require further modification for 4b
– this latest version will be available to prospective pilots electronically
in February.
Contact Viv Seal at the LMC for your copy: vivseal@bedshertslmcs.org.uk
Remember, PMS contracts are NHS contracts, arbitrated by the
Secretary of State rather than through the Law Courts. They are still legal
contracts and should be robust.
The LMCs in Bedfordshire and Hertfordshire are constituted to
represent all GPs, PMS as well as GMS and non principals.
We receive regular updates on PMS from the GPC and its PMS
Subcommittee and pass these on to pilots.
The LMCs believe that all practices should have full and
objective information on PMS and will assist and support all practices who
choose to go into a PMS pilot.
LMC levies
PMS GPs in Bedfordshire and Hertfordshire have all continued
to pay the LMC an administrative levy from its levies to GPs (equivalent to the
Statutory Levy for GMS GPs) and also pay the Voluntary Levy which goes to the
GPC to support some of its functions and legal cases concerning GPs. These are
usually deducted at source by the Practitioner Services Unit (PSU).
Lord Hunt, Under Secretary of State for Health, made clear in
the House of Lords (May 2001) that "PMS is a locally contracted system. The
Government believes that representation is crucial at the local level. For GPs,
this should be through the Local Medical Committee – the LMC".
Developing PCTs role in PMS
The LMC will continue to work closely with PCTs on the
development of PMS and to act as a resource of PMS knowledge.
Section IV Further help
Other guidance documents on PMS which may help your decision
making
| Negotiating your PMS contract: how your LMC can help 2001, on LMC website:
www.bedshertslmcs.org.uk. |
| Introduction to PMS (GPC, NAPC, NHS Alliance supported by RCGP) Nov 2000,
on GPC website: |
| PMS Contracts: Establishment & Review, Guidance from BMA Regional
Offices and LMCs Nov 2001. |
| The Simple Guide to PMS, Doctor Magazine 2001. |
PMS: the legislative framework
A list of regulations is included for your future reference:
|
The National Health Service (Proposals for Pilot
Schemes) and (Miscellaneous Amendments) Regulations 1997 (SI 1997 No.2289)
The Health Authorities and Primary Care Trusts
Concerning the Preparation of Proposals for Pilot Schemes (Personal
Medical Services) Directions 2001
The National Health Service (Financial Assistance for
Preparatory Work) Regulations 1998 (SI 1998 No.1330)
The National Health Service (Choice of Medical
Practitioner) Regulations 1998 (SI 1998 No.668), as amended by The
National Health Service (Choice of Medical Practitioner) Amendment
Regulations 1999 (SI 1999 No.3179) Directions to Health Authorities
Concerning Patient Lists (Personal Medical Services)
The National Health Service (Service Committees and
Tribunal) Amendment Regulations 2001 (SI 1998 No.674)
The Family Health Services Appeal Authority (Primary
Care Act) Regulations 2001 (SI 2001 No.xxxx)
The National Health Service (Pharmaceutical Services)
Amendment Regulations 1998 (SI 1998 No.681)
The National Health Service (Pilot Schemes – Health
Service Bodies) Regulations 1997 (SI 1997 No.2929)
The Health Authorities and Primary Care Trusts
Concerning the Implementation of Pilot Schemes (Personal Medical Services)
Directions 2001 (the "implementation Directions")
The Health Authorities and Primary Care Trusts
Implementation of Pilot Schemes (Personal Medical Services) Amendment
Directions 2001
Directions to Health Authorities and Health Boards
Concerning Variation of Proposals for Pilot Schemes (Personal Medical
Services)
The National Health Service (Pilot Schemes: Part II
Practitioners) Regulations 1998 (SI 1998 No.665)
The National Health Service (Vocational Training for
General Medical Practice) Amendment Regulations 1998 (SI 1998 No.669)
The National Health Service (Pilot Schemes:
Miscellaneous Provisions and Consequential Amendments) Regulations 1998 (SI
1998 No.646)
The National Health Service (General Medical Services)
Amendment Regulations 1998 (SI 1998 No.682)
The National Health Service (General Medical Services)
Amendment (No2) Regulations 1998 (SI 1998 No.2838)
Directions to Health Authorities on Dealing with
Complaints about Family Health Services Practitioners and Providers of
Personal Medical Services
The Primary Care Trusts (Functions) (England)
Regulations (SI 2000 No.695) as amended by the Primary Care Trusts
(Functions) (England) Amendment Regulations 2001 (SI 2001 No.745)
The Health Authority and Primary Care Trust Incentive
Payment Scheme (PMS) Directions 1st November 2001 |
Advice on Superannuation from the BMA
The impact of PMS on superannuation and pensions is a grey
area, and it is likely to remain so until the permanent arrangements for PMS are
obtained in legislation.
If you enter PMS as an independent contractor your
pension is still calculated on the traditional ‘practitioner’ method for
GPs. However, you need to negotiate the best arrangement for yourself with
regard to treatment of expenses. In essence, you must decide whether to base
calculations on the actual expenses incurred in the practice or use the
current GMS ratio (see box). You will need accountancy advice.
Fortunately, our PSU has considerable expertise in superannuation.
If you enter PMS as a Salaried GP, moving from
independent contractor status, then your pension will still be calculated on the
‘practitioner’ basis for the length of the pilot. If you enter permanent
arrangements your previous pension will be increased with the Retail Prices
Index, not dynamised. Again, accountancy advice is needed.
CONTACTS
Bedfordshire & Hertfordshire LMCs:
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