Investing in general practice
February 2003
Chapter 2 : More flexible provision of services
2.1 Many problems result from the existing contract because the range of services is poorly defined and because of the obligation to ensure the provision of out-of-hours care. The existing contract:
(i) does not allow practices to control their workload
(ii) does not provide sufficient additional resourcing or reward for additional workload
(iii) inhibits the development of new services and special interests that would benefit practices, the wider NHS and patients
(iv) makes general practice less attractive for many current and future doctors.
2.2 Practices also find it hard to obtain PCO funding to enable them to deliver a wider range of services, and PCOs do not have adequate powers to develop additional primary care capacity by providing services themselves or commissioning services from other providers.
2.3 This chapter sets out how these deficiencies will be addressed through:
(i) the new system of categorising work into essential, additional and enhanced services, and new arrangements for out-of-hours care
(ii) fixed UK rules around opting out of additional services
(iii) removing out-of-hours responsibility and 24-hour availability from general practitioners
(iv) the ability for PCOs to provide and commission care to ensure that patients receive a wide range of high quality services.
Service categorisation
2.4 Following primary legislation, PCOs will be placed under a new legal duty to ensure that patients receive access to the full range of primary medical services. This will underpin a new Patient Service Guarantee described further in chapter 6. Read more here
2.5 Under the new contract:
(i) practices will be required to provide essential services
(ii) practices will have a preferential right to provide additional services, and will normally do so. They will also have an ability to opt out in accordance with fixed UK-wide rules
(iii) enhanced services will be commissioned by the PCO. There are three types:
- under national direction with national specifications and benchmark pricing which all PCOs must commission to cover their relevant population
- with national minimum specifications and benchmark pricing, but not directed
- developed locally.
2.6 There will be new arrangements for out-of-hours and services for non-registered patients. These, together with home visits, are considered in paragraphs 2.17 - 2.28.
2.7 All practices will receive funding through the global sum for essential services and those additional services they provide to their registered patients. This is described in chapter 5. Read more here
Essential services
2.8 These cover the:
(i) management of patients who are ill or believe themselves to be ill, with conditions from which recovery is generally expected, for the duration of that condition, including relevant health promotion advice and referral as appropriate, reflecting patient choice wherever practicable
(ii) general management of patients who are terminally ill
(iii) management of chronic disease in the manner determined by the practice, in discussion with the patient.
Additional services
2.9 These cover:
(i) cervical screening
(ii) contraceptive services
(iii) vaccinations and immunisations
(iv) child health surveillance
(v) maternity services - excluding intra partum care [3] (which will be an enhanced service)
(vi) the minor surgery procedures of curettage, cautery, cryocautery of warts and verrucae, and other skin lesions.
2.10 To maintain the professional ethos of general practice, practices will be funded through essential and additional services to continue to provide continuous holistic treatment and care for all registered patients, including opportunistic health promotion and management of patients’ appropriate continuing care after acute referrals. Breadth of care will also be rewarded through holistic care payments within the quality framework and these are described in chapter 3. Read more here
Childhood vaccinations and immunisations
2.11 Childhood vaccination and immunisation schemes are additional services, and the infrastructure costs of delivering these have been built into the global sum. At the same time, systems of financial incentives will remain to encourage high population coverage through a directed enhanced service. This specification will be based on the existing lower (70 per cent) and higher (90 per cent) target payments but will be subject to a review, in discussion with the GPC, to consider the scope for using target payments more effectively to achieve higher population coverage within the same overall cash envelope. Exception reporting including for informed dissent will not apply.
Influenza immunisations
2.12 A further directed enhanced service will incorporate an influenza immunisation incentive scheme for both over 65s and under 65s at risk. Informed dissent will apply.
Enhanced services
2.13 Enhanced services are:
(i) essential or additional services delivered to a higher specified standard, for example, extended minor surgery
(ii) services not provided through essential or additional services. These might include more specialised services undertaken by GPs or nurses with special interests and allied health professionals and other services at the primary-secondary care interface. They may also include services addressing specific local health needs or requirements, and innovative services that are being piloted and evaluated.
2.14 The Carr-Hill allocation formula, which determines global sum payments, recognises through the morbidity factor the varying workload involved for practices in delivering care to very different groups of patients. The PCO can choose to supplement this by funding enhanced services for particular groups of patients. For some services, eg support services to staff and the public in respect of the care and treatment of certain patients who are difficult to manage, all PCOs will be required to provide practices with the help they need to deliver care in a safe environment.
2.15 Key features of enhanced services commissioning are:
(i) PCOs will be free and able to commission whatever enhanced services they consider appropriate to meet local health need above a guaranteed minimum level of investment. HSC 2002/012 set this at £315/£394/£460m for 2003-2006 in England. The figures have since been revised upwards to £315/£518/£586m, reflecting changes in service categorisation. Comparable funding will be made available in the other three countries. These figures are set out in chapter 5. Read more here.
(ii) this freedom will subsume existing Local Development Schemes, the Improving Primary Care incentive scheme, services currently delivered under HSG(96)31, GPs with Special Interests (GPwSIs) and schemes to improve patient access. Existing contracts for such services will be rationalised into a single arrangement for enhanced services under the contract between the PCO and practice from 2004/05 and will continue for at least the duration agreed previously between the PCO and the practice
(iii) specifications for those enhanced services that are nationally directed will be published shortly. PCOs will use these for commissioning those services. They cover: support services to staff and the public in respect of the care and treatment of patients who are violent, improved access, childhood vaccinations and immunisations, flu immunisation, minor surgery and, for 2003/04 and 2004/05, quality information preparation. Other enhanced services have national minimum specifications and benchmark pricing and includes services outwith current GMS arrangements that will contribute to the resourced shift of work from the secondary to the primary care sector. Where PCOs commission these services from general practice, they will use the specifications as the basis. They include, intrapartum care, anti-coagulant monitoring, providing near-patient testing, intra-uterine contraceptive device fitting, more specialised drug and alcohol misuse services, more specialised sexual health services, more specialised depression services, more specialised services for patients with multiple sclerosis, enhanced care of the terminally ill, enhanced care of the homeless, enhanced services for people with learning disabilities, immediate care and first response care (as described in chapter 4 - read more here), and minor injury services. Enhanced schemes may also be developed in response to local need for which the terms and conditions will be discussed locally between the PCO and the practice, and either party could ask the LMC (or its equivalent) to support it in this process
(iv) most contracts for enhanced services are likely to be placed with GMS or PMS providers, but some may be placed with alternative providers including NHS trusts (or their equivalents). The PCO will also be able to provide the services itself subject to rules around audit and fair competition described in paragraph 2.44.
2.16 Service categorisation will be subject to future review and adaptation following consultation and negotiation with the GPC in response to changing technologies, patient needs and service requirements. Changes in primary care workload will be taken into account through a process of continuous workload monitoring which will inform future consideration of gross investment. This is described further in chapter 5 - read more here. There will be no obligation on practices to provide any enhanced service (notwithstanding that they have previously provided it) unless they enter into a new contract for its provision.
Out-of-hours care
2.17 The existing default responsibility for all GPs to provide 24-hour care for their patients makes general practice unattractive for many prospective and current general practitioners and works against the achievement of an appropriate work/life balance.
2.18 To overcome these problems, if the contract is accepted by the profession the obligation on practices to ensure the provision of out-of-hours care for their patients will transfer to PCOs which will become responsible for commissioning and where necessary providing the out-of-hours service. The out-of-hours period will be defined as from 6.30pm to 8am on weekdays, and also the whole of weekends, Bank Holidays and public holidays.
2.19 Existing practices will retain the option to provide out-of-hours services on a practice-wide basis provided they meet mandatory accreditation standards taking account of quality and governance arrangements. After 31 December 2004, proposals from new practices to provide out-of-hours services will be considered by PCOs alongside proposals from other potential providers and will be subject to the same standards.
2.20 Practices will also be able to provide surgeries for routine consultations in the evening or at weekends where they choose to do so in response to patient need. Where practices decide to open in the evenings or at weekends, unless the PCO agrees to fund this as an enhanced service, it will be funded from the practice’s global sum. Where the PCO requests a practice to open in the evenings or at weekends and where the practice agrees, this will be funded as an enhanced service.
2.21 PCOs will be able to consider a range of alternative provision for out-of-hours, for example NHS Direct/24, NHS walk-in centres where available, GP co-operatives, partnerships between practices, paramedics, GPs and primary care nurses in A&E departments, community nursing teams and commercial deputising services. This will facilitate service integration and better use of triage and skill mix. Examples of local innovative schemes are published in supporting documentation. National teams of experts will help PCOs to develop new out-of-hours arrangements locally.
2.22 PCOs will be required to have a contingency plan in place which can be put into immediate operation should an out-of-hours provider fail. The default option will lie with PCOs, not practices as is currently the case. All out-of-hours providers, including practices, are required to meet the mandatory accreditation standards.
2.23 These arrangements may take time to put in place in certain areas. They will be implemented on a phased basis to allow PCOs, practices and new providers sufficient time to manage the change effectively without detriment to patient care:
(i) until April 2004 out-of-hours will remain the responsibility of the individual GP. The existing ability to transfer responsibility to an accredited provider will remain and PCOs will be encouraged to facilitate this
(ii) between April 2004 and December 2004, out-of-hours will be a unique type of additional service. Individual practice opt-out will be considered and implemented in the context of a PCO-wide strategy
(iii) by 31 December 2004, all PCOs should have put in place effective alternative provision and, as a result, should have taken full responsibility for out-of-hours. Strategic Health Authorities (or their equivalents) will performance-manage this process. In certain exceptional circumstances, eg remote and isolated areas, there may be no alternative option to the practice provision.
2.24 The global sum payment described in chapter 5 - read more here - includes payment for delivery of out-of-hours care. Where a practice opts out of such services, a fixed UK-wide tariff, adjusted by the practice weighted population under the new Carr-Hill formula, will apply and the global sum payment will be reduced accordingly. The global sum of those practices that wish to continue providing out-of-hours care to their own patients after the default position changes will not alter. The existing Out-of-Hours Development Fund will continue to be allocated to PCOs to support the funding of alternative out-of-hours provision and will be increased.
2.25 The 2001 GPC National Survey of GP Opinion showed that whilst many GPs want to lose their 24-hour responsibility, others want to continue to provide out-of-hours care. In setting the tariff, a careful balance has been struck. Those practices delivering high quality care in hours will have access to additional earnings opportunities under the contract and in this way the opt out will be real and help recruitment and retention to the profession. As importantly, those practices which continue to provide out-of-hours will receive a fair reward. An average UK-wide rate in 2004/05 of £6,000 per GP with an average practice weighted population [4] (6 per cent of the global sum) achieves this balance. For practices which are unable to opt out of out-of-hours due to specific geographical circumstances, additional support will be available through the PCO as described in chapter 4. Read more here.
In-hours home visiting services
2.26 Under the new contract, patients will be made aware of the UK criteria for determining when home visits are necessary and these will be set out in the practice leaflet. These criteria state that a practice will provide at the home of a registered or a non-registered patient in its practice area such services as the practice is contracted to provide during hours which do not fall in the out-of-hours period when, in light of the patient’s medical condition, the doctor considers that such services are needed and would most appropriately be delivered by means of a home visit.
2.27 Appropriate in-hours home visiting will normally be part of the practice’s responsibility. However, the PCO can, in agreement with local practices, invest in an area-wide home visiting service through enhanced services to deliver better services to patients with less disruption to daytime surgeries. When this happens, practices will be able to delegate responsibility to the PCO in a manner similar to current out-of-hours deputising arrangements, normally following a locally agreed transfer of resources. PCOs can also provide patient transport services to improve access to primary care, where this is considered feasible and desirable.
Non-registered patients
2.28 The obligation to provide immediate/necessary/emergency treatment and treatment to temporary residents will remain. The current Statement of Fees and Allowances (SFA) fees for emergency treatment, immediately necessary treatment and the care of temporary residents will be simplified into a single allocation included within the global sum. This will be calculated on the basis of the average number of claims in the practice over the previous five years. Where it is felt that the number of temporary residents being treated by the practice is insufficiently accounted for within the global sum (eg because of a new holiday park) this can either be resourced through a variation in the global sum for non-registered patients or as a local enhanced service.
Non-NHS work
2.29 The proper role of the GP is the care of patients who are or believe themselves to be ill. Increasingly, GPs find clinical time diverted to responding to demands from outside organisations to provide medical reports. The existing Terms of Service deny practices any effective mechanism to regulate this additional, non-clinical workload or to secure appropriate reward for their efforts. Given the Government’s commitment not to introduce new NHS charges for patients, and the desire that it shares with the profession to avoid diverting scarce primary care staff and assets away from NHS patients, the existing arrangements in the Terms of Service (paragraph 38) will remain. However, under the new GMS contract the rules will be clarified so that it is clear that practices will be able to accept fees for:
(i) examining (but not otherwise treating) a patient for the purpose of creating a report arising from a Road Traffic Accident or a criminal assault
(ii) providing drugs and/or medical supplies, including travel kits, which a patient requires while he or she is abroad (this is in addition to existing provisions in respect of travel vaccines)
(iii) attending and examining (but not otherwise treating) a patient at the request of a commercial, educational or not-for-profit organisation for the purpose of creating a medical report or certificate
(iv) attending and examining (but not otherwise treating) for the purpose of creating a medical report required in connection with an actual or potential claim for compensation against any public or private body that the patient and his or her legal advisers believe may have been responsible for some harm that the patient has suffered (the issue of whether it is permissible in law for practices to be able to levy this charge in addition to any charge that the practice is entitled to make under the Access to Medical Records Act will be examined)
(v) examining (but not otherwise treating) a patient for the purpose of creating a report that offers an opinion as to whether a patient is fit to travel by air.
The ability to accept charges from a dentist in respect of the provision at his or her request of an anaesthetic for a person for whom the dentist is providing general dental services will be ended.
Opting out of additional services
2.30 Practices may not be able or wish to provide some additional services for the following reasons:
(i) workload pressures or workforce shortages which mean the practice is in danger of not being able to provide, or can no longer provide, a satisfactory level of services to its patients and opting out would secure the quality of remaining services. This would be the basis for temporary opt-outs described below
(ii) the practice has historically not provided the service under the existing GMS contract and does not wish to provide it in future
(iii) there is a lack of available skills within the practice
(iv) the practice feels unable to provide a service on conscientious grounds
(v) there is an unacceptable pattern of temporary opt-outs (more than twice in three years) without a long-term solution having been identified. The PCO and practice should cooperate in finding a solution
(vi) the practice is not fulfilling its obligations for that additional service under the new contract and there is a lack of practice commitment to solving the problem.
2.31 When a practice wants to opt out it will give notice to the PCO, with reasons. If a practice is providing any enhanced service(s), or any additional services to patients of another practice, the PCO may refuse to accept such notice.
2.32 The first step is dialogue between the practice and the PCO to identify how to solve the problems causing the practice to seek to opt out. If that is not possible, the practice would confirm to the PCO its intention to withdraw from the provision of a service. At this stage the practice will be required to notify the PCO as to whether this will be:
(i) temporary withdrawal, ie less than a year
(ii) permanent withdrawal.
2.33 Preparations for opting out can commence from April 2003 and the first withdrawals can occur from April 2004 subject to changes to legislation. Meanwhile, practices facing workload or workforce pressures may nonetheless discuss with their PCO how to solve the problems, including what support the PCO can provide. As part of the process of drawing up their contract during 2003/04, practices and PCOs will discuss any potential withdrawals or intention to provide additional or enhanced services not currently delivered. Where appropriate, consultation with affected patients should be carried out as quickly as possible and should not delay implementation of the opt-out.
Temporary opt-out
2.34 The following UK-wide rules will apply for temporary opt-outs from additional services:
(i) the PCO will seek to agree the opt-out as quickly as possible given the immediate nature of the problem, rather than follow the more time-consuming rules for permanent opt-out
(ii) duration will be a minimum period of six months and a maximum of 12 months from the start of the opt-out. More than 12 months will normally constitute a permanent opt-out, but the PCO can agree an extension taking account of exceptional circumstances
(iii) practices and PCOs will be required to agree how best to inform patients of the temporary transfer of the service, for example, through placing a poster in the practice waiting room or through the practice leaflet. In addition, information will need to be provided at the same time informing patients of the arrangements for alternative provision
(iv) the PCO will, where appropriate, agree with the original provider a programme of development, training or support in readiness for re-provision, where these were factors in the original decision to opt out
(v) the PCO will recoup a UK-wide fixed cost for the service (weighted according to the Carr-Hill formula) and the practice budget will be reduced by this amount
(vi) progress towards re-provision will be reviewed. If the PCO:
- agrees that the practice is able to re-provide the service, the service will revert back to the original provider at the agreed date
- does not consider the practice is able to provide the service within the agreed timescale, it can inform the practice of its intention to seek an alternative provider and follow the normal procedures for permanent opt-out. In some circumstances this may be due to factors outside the practice’s control, in which case the PCO has discretion to extend the length of temporary withdrawal, whilst bearing in mind the position of the temporary alternative provider
(vii) should the original provider wish to opt out permanently it will inform the PCO as soon as possible and not later than three months before the agreed re-provision date. At this stage the PCO will be responsible for securing the alternative provision of services. If the temporary provider has delivered high quality care it will be in a good position to bid to provide the service on a permanent basis
(viii) where a practice gives notice to opt out of any additional service more than twice within three years, on the third occasion any opt-out request will be considered permanent.
Permanent opt-out
2.35 The rules for permanent opt-out from additional services are:
(i) the practice gives notice of its wish to opt out permanently. The PCO will seek to secure an alternative effective provider within a three or six month notification period. Where necessary, the PCO will notify the practice at two months that the practice is required to continue provision for six months in total
(ii) where alternative provision has not been secured after six months there will be a further and final three month transitional period. At this stage the PCO and practice will discuss and agree effective local mechanisms for providing the service until such a time as alternative provision is in place, but for not longer than three months
(iii) the practice and PCO will be required to agree how best to inform affected patients of the permanent opt-out, for example through placing a poster in the practice waiting room or through the practice leaflet. In addition, information will need to be provided at the same time informing patients of the arrangements for alternative provision
(iv) the PCO will become responsible for providing the service after nine months, unless it successfully appeals to the Strategic Health Authority (or its equivalent). Before it does so there is a clear expectation that it will have used all reasonable endeavours to secure an effective alternative provider
(v) when a practice opts out of a service on a permanent basis, it cannot seek to re-provide it until the contract with the alternative provider ends. Open competition would then apply.
2.36 Opting out of an additional service will lead to an adjustment to the global sum. UK-wide tariffs have been calculated to ensure equity. To calculate these, the workload involved in delivering each service has been estimated, bearing in mind population coverage, consultations required to perform each service, length of consultation, and the primary care worker involved. Uplifted baseline spend for 2001/02 has been used. The tariff approach will be introduced from 2004/05 and will be uplifted for future years.
2.37 Figure 1 sets out the tariff for the average GP and the average practice. The amount will be adjusted by practice weighted population using the Carr-Hill formula.
Figure 1: UK tariffs for opting out of additional services
| Additional services | Opt-out price for 2004/05 indicative £s per GP [5] | Opt-out price for 2005/06 indicative £s per GP | Percentage of global sum |
| Cervical screening | 1,203 | 1,221 | 1.1 |
| Child health surveillance | 758 | 769 | 0.7 |
| Minor surgery | 654 | 663 | 0.6 |
| Maternity medical services | 2,296 | 2,330 | 2.1 |
| Contraceptive services | 2,658 | 2,698 | 2.4 |
| Childhood immunisations and pre-school booster | 1,059 | 1,075 | 1.0 |
| Vaccinations and immunisations | 2,220 | 2,253 | 2.0 |
New ability for PCOs to provide or commission care
2.38 To deliver the Patient Services Guarantee described in chapter 6 - read more here, PCOs will have a new ability to provide services themselves, or to commission them from alternative providers. Following primary legislation these will replace or amended where appropriate the existing section 56 of the National Health Service Act 1977 and the relevant part of section 33 of the National Health Service (Scotland) Act 1978 and Article 51 of the Health and Personal Social Services (NI) Order 1972.
2.39 When a practice wants to withdraw from an additional service, the PCO will be responsible for ensuring the effective alternative provision of services from:
(i) another practice that is normally providing the full range of additional services to its own registered patients and has an open list, or
(ii) an alternative provider, or
(iii) it could provide the service itself.
The extent of PCO provision will be further clarified in the implementation guidance.
2.40 The commissioning decision will normally be on the basis of quality and accessibility to the affected patients, which will be built into the terms of the contract and subsequently monitored. PCOs will consult, as appropriate, the affected patients, Patient Forums and LMCs (or their equivalents).
2.41 The PCO can also enter into further contracts for parallel additional services alongside those provided by practices. These would be funded by the PCO at no detriment to the practices. Normally, it would be considered good practice to discuss these issues with local practices and the LMC (or its equivalent). The extra care that patients receive would help the practice on whose list they are registered through reducing workload and delivering better quality.
2.42 Practices can also delegate services to other providers. Progress achieved against the quality framework would accrue to the practice except when the practice is inappropriately using secondary providers on a non-contractual basis to treat its patients. In that circumstance, quality and outcome payments will be questioned and could potentially be abated. Any proposed abatement will be subject to appeal.
2.43 The same income will not be pensionable more than once. Where practices delegate work, that part of the income due to the secondary provider will be pensionable in the hands of the secondary provider.
PCOs as providers
2.44 A PCO will be able to provide services itself but where it does so this will be on the basis that it can meet the same requirements as other feasible alternative providers. Where it provides services it will do so subject to audit and routine standing orders/financial instructions and the constraints regarding the letting of contracts. This will ensure a level playing field and Strategic Health Authorities (or their equivalents) will have an important role in managing this and will ensure that the extent of PCO provision of services does not exceed an appropriate volume. Anti-competitive or fraudulent behaviour by PCOs and practices would be addressed by the relevant statutory authorities.
2.45 Within this context, PCOs will be able to:
(i) provide additional or enhanced services if they are able to offer the same or better value for money, or the same or higher standards of care for patients than other interested parties
(ii) offer support to practices to enable them to maintain their provision of additional services rather than have to withdraw as a first option.
2.46 PCOs will be able to provide or secure the provision of primary medical services in a range of ways including by:
(i) maintaining a range of full-time or part-time salaried staff (clinical and non-clinical)
(ii) buying contracted sessions, as and when required, from existing practice-based staff on an ad hoc basis, in agreement with their employers
(iii) commissioning services from an alternative provider
(iv) making an agreement with doctors as a means of creating a bank of local support. This would enable the PCO to provide support to practices, as is currently the case in some areas.
3. Maternity services exclude the examination of the newborn baby within the first 24 hours of life.
4. An average practice, with a list of around 5,500 patients, with around three whole time equivalent GP principals and average population needs and service delivery costs.
5. An average GP would have a list of around 1,800 patients with average population needs and service delivery costs.