GMS Contract changes - May 2023

Access requirement

The GMS and PMS contract was updated in May 2023 to reflect changes to the regulations affecting access to GP practices.

Contact with the practice

The regulations will now say:

1. The contractor must take steps to ensure that a patient who contacts the a patient who contacts the contractor:

• (a) by attendance at the contractor’s practice premises
• (b) by telephone
• (c) through the practice’s online consultation tool or
• (d) through a relevant electronic communication method.

2. The appropriate response is that the contractor must:

• (a) invite the patient for an appointment, either to attend the contractor’s practice premises or to participate in a telephone or video consultation, at a time which is appropriate and reasonable having regard to all the circumstances, and the patient’s health would not thereby be jeopardised;
• (b) provide appropriate advice or care to the patient by another method
• (c) invite the patient to make use of, or direct the patient towards, appropriate services which are available to the patient, including services which the patient may access themselves, or
• (d) communicate with the patient:
  • to request further information
  • to convey when and how the patient will receive further information on the services that may be provided to them, having regard to the urgency of their clinical needs and other relevant circumstances.

3. The appropriate response must be provided:

• (a) if the contact under sub-paragraph (1) is made outside core hours during the following core hours.
• (b) in any other case, during the day on which the core hours fall.

4. The appropriate response must take into account:

• (a) the needs of the patient; and
• (b) where appropriate, the preferences of the patient

Though we may agree with the aspiration of this amended regulation, GPC England (GPCE) believes that this requirement is not achievable for many practices with current resource and workforce. With GPs numbers decreasing, consultation numbers higher than ever, and general practice being under-resourced, we think this government-imposed contract will push GPs and practices to the brink of their existence, within the NHS. For this and other reasons GPCE rejected the contract changes. The government has made it clear that this contract, rejected by the profession, will come into force.

Practices where care navigation is used to allocate patients to appropriate services have various possible dispositions for patients who contact the practice, as set out in paragraph 2:

• offer on-the-day assessment by another clinician for cases perceived to be urgent
• offer assessment at another time by a clinician for cases relating to longer-term and non-urgent conditions
• signpost to another service where another service is appropriate e.g. mental health support, community services, community pharmacy
• signpost to 111, UTC, overflow hub when capacity in the practice is reached
• Request further information – for example via digital tools available to surgeries.

Paragraph 2 does not stipulate the time frame in which a further assessment or appointment is to be offered, it says “at a time which is appropriate and reasonable having regard to all the circumstances”. However, QOF and IIF targets aim to have patients seen within 14 days of contacting the practice. Some practices will be able to achieve this, but if practices cannot, this is not a breach of the contract.

Paragraph 3a places the requirement that practices respond to contacts “outside core hours” in core hours following the contact. However, practices can choose to turn off online consulting methods outside core hours which will enable more capacity to respond to in-hours (8am-6.30pm Mon to Fri) contacts.

GPCE sees the use of care navigation as a potential solution to this imposed contract stipulation, but practices may have other innovative ways of managing this issue such as total triage. We do not advocate a move back to duty doctor or other systems which place an unnecessary and unsafe burden on GPs.

How do these changes to regulations affect safe working guidance?

Practices who attempt to achieve the requirements may do so at the expense of clinician wellbeing and patient safety. GPCE safe working guidance recommends that clinicians have no more than 25 clinical contacts per day. Making more decisions than this can lead to decision fatigue, clinical errors and patient harm, and clinician burn out.

GPCE thus advises practices to protect patients and clinical staff from these risks by limiting clinical contacts to no more than 25 per day for each GP, and any excess demand beyond this being signposted to other settings such as 111, overflow hubs, or urgent treatment centres. This is permitted within the contract which says that patients should be offered assessment of need or be signposted to an appropriate service.

The new requirements do not enable practices to ask patients to call back another time, therefore, when safe clinical capacity is reached patients should be signposted to other settings as described above.

ICBs should ensure that there is a formal escalation route for practices that have reached safe capacity. Operational Pressures Escalation Level (OPEL) measurement should be used, and escalation plans should be agreed by practices, LMCs, and ICBs to enable safe onward signposting of patients. Until formal escalation plans are agreed in localities, practices should signpost patients to where they feel clinically appropriate.

Investment is required to recruit care navigators, develop care navigation systems, and provide premises and infrastructure to enable all practices to make the mandated assessment. We recommend that practices write to their ICB requesting this investment to enable them to achieve these requirements safely.

Please feedback your concerns, questions, and insights to:  [email protected]

In November 2017, NHS England issued guidance to commissioners on how practices meet the ‘reasonable needs of patients’ in providing or arranging access to essential and additional services delivered under the GMS contract.

The guidance goes beyond the requirements on practices set out in the GMS contract, the PMS agreement and regulations. Some practices have been approached by their ICB to question their arrangements.

The BMA GPs committee has been clear with NHS England that it does not agree with the guidance. We have also confirmed it is non-binding for commissioners.

Find out more about your obligations below.

Core hours and service delivery

GMS regulations define:

• core hours as 8am to 6.30pm, Monday to Friday (excluding bank holidays)
• the essential and additional services which practices are required to deliver.

GMS regulations do not require practices to:

• be open at all times during core hours
• deliver all services at all times when they are open.

They do require practices (either themselves or through subcontracting arrangements) to:

• provide services at times that are appropriate to meet the needs of patients
• ensure arrangements are in place for patients to access services throughout core hours in case of emergency (this allows practices to close, for example, to undertake training or staff reviews).

In summary:

• the GMS regulations allow individual practices to decide which services to provide when, to meet the needs of their patients
• practices should be able to show they have engaged with their PPG (patient participation group) to check the arrangements are meeting their reasonable needs, and are addressing any areas of concern (within the regulations regarding PPGs).

Subcontracting arrangements during core hours

GMS regulations allow a practice to subcontract services, provided that:

• it has taken steps to satisfy itself that it is reasonable to do so
• the sub-contracted provider is qualified
• notice is provided to the commissioner.

There are no requirements that subcontractors must provide specific services for patients beyond meeting the obligations of the GMS contractor.

The practice must be satisfied that subcontracting arrangements are appropriate and can meet the subcontractor's obligations. 

Practices must notify the commissioner, who can only object on the grounds that it would put patient safety at serious risk or put the commissioner at risk of material financial loss. The commissioner cannot object based on failure to meet the criteria in the NHS England guidance.

Checklist

• Review your practice website, practice leaflet, waiting room posters/door signs/digital posters to ensure the information regarding opening hours is correct and consistent across all platforms
• Ensure your e-DEC is submitted correctly, it is not recommend declaring the practice is closed if there are alternative physical and/or telephone access arrangements in place at certain times during core hours
• If the practice does operate a different access system during core hours, inform patients through clearly visible signage on the doors, telephone messages, and information on the practice website, including the times when the alternative access system is in place and how patients can obtain urgent assistance during these times
• During the times that the practice is providing an alternative process for patient access, an intercom or doorbell can be used to allow patients physical access into the practice to address urgent issues, as appropriate, but ensure staff are aware of this and respond to the intercom/ doorbell at all times during core hours
• Ensure telephone messages are correct – if telephone lines are switched over for a period but patients can request assistance in an emergency (by pressing 1 etc), make sure this is clear and this option is offered on the same phone call so that patients do not have to ring back on a different number or at a different time

If you operate this kind of system, please test it regularly to make sure it works at all times and that calls are answered in a timely way without fail. If an emergency number is not staffed at the time a patient calls, it may result in a complaint being upheld.

• Check practice bypass phone lines are working and are sufficiently staffed throughout the day
• Ensure staff are aware of the practice’s operating pattern and are conveying the correct and same consistent message to patients
• Engage with your PPG and seek their feedback on your alternative access arrangements

If you are challenged

If the commissioner believes your hours are not meeting the reasonable needs of your patients, they will likely approach the practice to discuss this.

1. You should provide information to the commissioner, showing:
   
   -  the times of delivering services meet the reasonable needs of patients
   -  that outside of these hours, there are arrangements so that patients can access services in an emergency
   -  engagement with your patients (usually via the PPG) around hours.
2. If the commissioner serves a breach notice as it believes you are not meeting the reasonable needs of your patients, the onus under the regulations is on the commissioner to evidence that claim as part of the breach notice.
3. If your commissioner approaches you regarding the reasonable needs of your patients and produces NHS England guidance as evidence, we advise that you inform the commissioner this guidance is not a contractual requirement.
4. We also advise that you contact the BMA general practitioners committee and your LMC.