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Investing in general practice

February 2003

Chapter 4 : Developing human resources and modernising infrastructure

4.1 Delivering high quality care across a wide range of services requires high quality support and infrastructure. The new GMS contract will facilitate this through:

(i) helping implement good human resource management practice to improve the working lives of GPs and practice staff, and encourage recruitment and retention

(ii) supporting practices in rural and remote areas

(iii) investment in information management and technology

(iv) better mechanisms to modernise premises.

Human resource management and improving working lives
4.2 The new GMS contract will:

(i) facilitate the introduction of a new career structure

(ii) support the introduction of protected time for skills development

(iii) enable the widespread employment of salaried GPs in GMS where this best suits practice and practitioner preferences

(iv) deliver family-friendly improvements

(v) encourage recruitment and retention through national schemes such as golden hello schemes, sabbatical schemes, flexible career schemes and returners schemes

(vi) support the development of practice staff including nurses and managers.

Career structure
4.3 GPs have suffered from the lack of a recognised career pathway. Enabling GPs to pursue a fulfilling career will boost the recruitment of new entrants into general practice and the retention of both new entrants and established GPs. The role and status of a GP as a generalist will be developed and valued. The new contract will also enable GPs to develop a portfolio approach to career development and provide options that are equally available to all GPs. The contract will underpin a modular approach to planning GP careers:

(i) skills development. This phase of a GP career typically, but not exclusively, recognises the needs of newly qualified or returning GPs to broaden their clinical experience and possibly work in different settings so as to tackle the wide range of clinical problems they will face in their careers as GPs. This phase may be facilitated, but not prescribed, as a phase of salaried work, taking in a variety of practices

(ii) special interest development. Currently special interest work is done as an add-on, but it could be made more integral to the GP contractual options (dependent on numbers and capacity to meet basic requirements within the practice). The types of interests here would include both clinical and non-clinical commitments (eg more specialised minor surgery, more specialised chronic disease management, management roles in PCOs, education, academic general practice, research, occupational health etc). GPwSI services will be developed in a variety of clinical areas

(iii) clinical leadership. This phase will recognise a reduced clinical commitment while undertaking roles such as those in education, mentorship, clinical leadership in PCOs and Strategic Health Authorities (or their equivalents), clinical governance, appraisal, membership of national bodies, Boards and LMCs (or their equivalents).

4.4 Although GPs may tend to opt for different phases at different points in their career (eg clinical leadership phase later than skills development phase), the career phases will not be linear. Some new GPs will wish to carry out special interest or leadership work immediately after qualifying. Some older GPs may wish to refresh their skills development (especially if this was tied in to returning following a career break or as a result of a need identified through the appraisal process). Further work will be undertaken on the details of this approach.

4.5 The examples above are not comprehensive, but give a flavour of the wide variety of roles that GPs may undertake in the NHS. They will be supported by flexible approaches in all four countries to temporary retirement and pre-retirement work such as career breaks, sabbaticals, returners schemes, flexible career schemes and a reduced clinical commitment in return for PCO or professional work.

4.6 The current career opportunities for GPs are extensive and can provide for a satisfying and fulfilling working life. However, they are not uniformly available throughout the UK and the funding for them, in terms of rewards and practice cover arrangements, is variable and rarely protected. To maximise opportunities for GPs to develop their careers, funding has been built into the global sum to enable practices to replace a general practitioner absent from work for whatever reason. This can be achieved in part by using other healthcare professionals.

4.7 The contract will also bring new career opportunities for practice staff, including nurses, by extending their roles and responsibilities and by facilitating skill mix.

Protected development time arrangements
4.8 Under the new contract learning and personal development will be supported through protected time. An element for protected development time has been built into the global sum. All GPs and their practice staff will have opportunities for protected development time but a single model is not appropriate. Learning and development should be focused on the individual’s needs although some core subjects, for example child protection or cardiopulmonary resuscitation training, will be universally applicable. Activities covered by protected time could include, for example continuing professional development, appraisal preparation, revalidation, clinical governance, audit, and practice management and development.

4.9 Practices will develop their own methodologies for supporting professional development. PCOs will also have an important role to play in supporting protected time through, for example, sponsoring protected development time events; and in considering what support is needed for isolated GPs, including those in rural and remote areas, particularly where a GP’s personal education plan can only be satisfied by travelling to a distant course. The costs of such PCO-sponsored or PCO-approved training, including travel and subsistence for GPs, will be met by the PCO.

Appraisal
4.10 The new protected time arrangements will support appraisal. The contract will carry forward the recent agreements on appraisals between the GPC and the Health Departments and will ensure proper funding of appraisal in every PCO. Work is continuing to develop appraisal arrangements for all general practitioners.

4.11 To ensure adequate supply and continuing development of appraisers, the number of appraisers per PCO will be reviewed and appraisers will take part in a review process. PCOs should make arrangements to share appraisers where appropriate and where local arrangements permit. All GPs could act as appraisers if they are sufficiently experienced and have been properly trained and rewarded. UK-wide agreements are required for the training, support, pay and cover arrangements for GP appraisers.

4.12 Where, following assessment by the National Clinical Assessment Authority in England and Wales (or corresponding support mechanisms in Scotland and Northern Ireland), the GMC or agreed local procedures, it is determined that a doctor requires remediation, some or all of the costs of GP remediation including education and training requirements will be provided by the Workforce Development Confederations (or their equivalents). The exact proportion of these costs will depend on the particular circumstances and will be discussed with the LMC (or its equivalent).

4.13 The fixed retirement age of 70 will be abolished as all GPs will be subject to appraisal and revalidation.

Salaried GPs
4.14 An increasing number of GPs have expressed a preference for salaried contracts. The global sum will give practices new flexibility to appoint salaried staff, and PCO direct provision will offer a new PCO salaried option. PCO and practice salaried GPs will work under national terms and conditions set out in model national contracts which PCOs and practices will use as the basis for their employment of GPs. These are published in the supporting documentation. As stated in the framework document, the NHS Confederation, the GPC and the four Health Departments will shortly be putting forward joint evidence to the DDRB to support the determination of a salary range for salaried GPs. In assessing the appropriate point in the range, the principle of local job evaluation will apply and personal experience will be taken into account. Both PCO and practice employers will have the flexibility to offer enhanced terms and conditions and pay rates in order to aid recruitment, but it will not be possible to offer diminished terms, conditions or rates.

Improving working lives
4.15 In support of recruitment and retention, GPs and their staff will have the same access to NHS childcare in each of the four countries as other NHS employees. This access will also be available to all GPs and GP registrars. PCOs will consider the specific needs of GPs and their staff when developing local provision, including childcare options that are appropriate to GPs and their staff who are working parents, such as time and place of provision, opening and closing times and access in times of practice crisis and domestic emergencies.

4.16 Maternity, paternity, adoptive and special leave will follow national legislative requirements. NHS conditions, where they are more generous, will be available to GPs and practice staff who wish to take advantage of them. Funding will be held at PCO level. Sick leave arrangements will be reviewed in the light of the introduction of the global sum.

Seniority payments
4.17 The existing seniority payment scheme will be improved to reward experience. The new scheme will deliver a 30 per cent increase in total resources over current spend by 2005/06. The scheme will be based on years of NHS reckonable service. As with the current scheme, the new scheme will recognise the working commitment of general practitioners with superannuable income being used as a measure of that working commitment. Under these arrangements, GPs who are receiving at least two-thirds of average superannuable income will be entitled to full seniority payments. GPs receiving between one-third and two-thirds of average superannuable income will be entitled to 60 per cent of full seniority payments. GPs in receipt of less than one-third of average superannuable income will not be eligible for the payment. The existing payment steps will be subject to some smoothing. The revised arrangements will be published in supporting documentation. GPs salaried by the PCO or by the practice will not receive separate seniority payments but these will be reflected in their overall salary scales.

Recruitment schemes
4.18 Recruitment schemes, such as golden hellos, will be developed in all four countries to meet their particular needs and be introduced, where appropriate, by no later than April 2004.

Supporting practice staff
4.19 Organisational standards in the quality framework will reward practices for ensuring employment standards comply with good human resources practice in line with Agenda for Change principles that are expected to apply to non-medical staff and to prevent exploitation.

4.20 Nurses will be given the freedom and support to work with GPs in new ways and to take on more advanced and specialised roles: [7]

(i) all practice-employed nurses should be supported to participate in clinical supervision and appraisal and to have access to professional advice and continuing professional development and to IM&T

(ii) these new roles taking on, where appropriate, more advanced and specialist roles in first contact care, chronic disease management and preventive services will need to be supported by the necessary skills and knowledge provided by training and education and an understanding by the nurse and GP of the Nursing and Midwifery Council Code of Conduct

(iii) in line with a practice-based approach it is envisaged that the new GP performer list arrangements described in chapter 7 - read more here - will, over time, be extended to other professions as appropriate

(iv) the global sum payment arrangement will enable practices to develop greater skill mix with more registered nurses, pharmacists (subject to rules governing conflict of interest) and allied health professionals providing opportunities for a range of professionals to work at all levels as part of the practice team. The skills and expertise of nurses in general practice working at a more specialised level will be developed. Nurses and others should be fully involved in practice decision-making that impacts on their work

(v) the quality framework will apply to the practice team rather than separate professionals.

Supporting practice managers
4.21 The new contract will encourage an expanded role for practice management in primary care, supported by the development of practice management competencies. Following consultation with a number of representative organisations a competency framework for practice management has been developed and is attached at Annex C - read more here. This competency framework covers strategic issues, the development and delivery of services to patients and practice infrastructure. It is not envisaged that every practice manager will have all these competencies but that the framework should be used as a resource for helping individuals’ competencies and ensuring that the practice has access to the skills it needs.

4.22 Under the new contract, practices will receive funding for practice management through the global sum. In some cases it will not be cost-effective for every practice to have its own full-time practice manager. In such cases a practice may pool resources with other practices and share a practice manager or request access to practice management expertise through the PCO. The latter approach will be supported through new primary legislation.

Supporting practices in rural and remote areas
4.23 GPs in rural and remote areas of the UK form a small but essential part of the NHS. The new contract will recognise their specific needs and help ensure they receive proper support:

(i) through the Carr-Hill allocation formula, which includes a specific adjustment for rurality. This takes account of population sparsity and dispersion, and means that rural and remote GPs will benefit in their global sum and the practice weighted population adjustment to quality payments

(ii) through the powers described in chapter 2 - read more here - for PCOs to employ staff to provide GMS and support practices. The new flexibility for PCO and practice-based salaried options may also be particularly useful in rural and remote areas

(iii) through funding arrangements that will ensure support for practices in recognition of the extra burdens of being a remote and rural GP, for example extra travel costs to attend PCO-sponsored or PCO-approved training and the continued need to provide out-of-hours care which will be supported by the Out-of-Hours Development Fund. There will be a range of independent contractor and employed options, which will improve upon and replace the current inducement scheme, which will cease on 31 March 2004

(iv) for immediate care and first responder services. Rural and remote GPs are often more involved in the provision of emergency care outside the setting of their surgery or a local community hospital. This work requires extra training (eg BASICS), equipment, resource, commitment and reward. Under the new contract, these services will be commissioned and funded as an enhanced service. PCOs will normally wish to commission such services where land ambulance response times are relatively long or the practice is remote from the nearest appropriate hospital. Practices providing these services will need to ensure relevant practitioners have the necessary skills, for example through attending a BASICS course at least once every five years

(v) for GPs working for community hospitals and minor injury clinics. Staffing of community hospitals and minor injury services is an integral part of many GP practices, particularly in rural or remote areas. Under the new contract these services will be commissioned and funded from the unified budget or its equivalent in Northern Ireland. A specification for the minor injuries enhanced service provided within a practice will be published shortly in supporting documentation.

(vi) through twinning arrangements. Under the new contract, PCOs will support arrangements to minimise the impact of geographical isolation on all professions in rural and remote areas. The Remote And Rural Areas Resource Initiative (RARARI) in Scotland will examine how twinning arrangements could best support GPs in remote and isolated areas. Lessons learned from this will be implemented throughout the UK. Where twinning is feasible, and supported by the LMC (or its equivalent), the PCO will do its utmost to support implementation.

Supporting practices in deprived areas
4.24 The new contract will recognise the additional workload involved in providing care in deprived inner city areas through the morbidity factor in the Carr-Hill formula. Under-doctored areas will also gain from the allocation of money on the basis of patient need rather than the number of doctors. Practices will be able to seek to provide a range of enhanced services for the specific needs of their population.

Modernising information management and technology in general practice
4.25 Future information systems in primary care will be based on integration at a community level and on the concept of GPs receiving an information technology service rather than simply being provided with hardware and software. The national IM&T programmes will be responsible for developing these arrangements and ensuring that all key stakeholders, especially clinicians, are fully involved in determining appropriate standards and methods of provision. The objective will be to provide clinicians and others with access to information wherever and whenever it is needed to support patient care. This will be subject to nationally agreed security and confidentiality conditions which take into account the requirement that information must be available for other medical practitioners looking after patients, subject normally to the patient’s informed consent.

4.26 New arrangements will be established to provide these integrated services and applications. Inevitably this will involve a period of transition from the current situation during which systems will be upgraded or replaced and new systems will be developed and implemented. Suppliers will need to upgrade their products to meet new national standards in line with agreed national arrangements.

4.27 GPs and other healthcare professionals will have access to all the information they need to support delivery of patient care regardless of their location on a real-time basis. The support arrangements for data hosted by GPs will need to reflect this requirement.

4.28 The stated strategic direction for information systems to support primary care, including branch surgeries, is that systems must enable:

(i) clinicians to access appropriate information about individual patients held on other systems for the clinical care and treatment of the patient

(ii) users to interrogate and maintain individual patients’ electronic health records with appropriate confidentiality safeguards

(iii) inter-communication between clinical and administrative systems

(iv) remote access to research papers, reviews, guidelines and protocols via the Internet and NHSnet

(v) health professionals to access the knowledge base of healthcare at the point of contact with patients

(vi) dispensing practices to have synchronous links

(vii) the development of a framework for electronic prescribing.

Ownership and liability issues
4.29 To facilitate the use of IM&T within primary care, PCOs, rather than practices, will be responsible for funding the purchase, maintenance, future upgrades and running costs of integrated IT systems as well as telecommunications links to branch surgeries and other NHS infrastructure and services.

4.30 This will mean that as new money is spent on providing new systems and upgrading existing systems, PCO ownership of the asset and the responsibility of the PCO to provide the full supporting service, including maintenance, future upgrades, paying for running costs of the new integrated systems and training, will be established at the same time. Under the new contract, IM&T services will be delivered to the practice based on a Service Level Agreement setting out in detail the responsibilities of the system suppliers. Costs of maintaining existing systems up to the point of migration to PCO ownership will be met in full by the PCO.

4.31 The GPC will provide an effective stakeholder and specification group for new systems, allowing GPs to be confident that these are fit for purpose and offering GPs the vital guarantees on security and confidentiality referred to in paragraph 4.25.

4.32 Future nationally specified IM&T initiatives will be delivered to practices with 100 per cent funding for initial and continuing costs.

4.33 PCO ownership of practice IM&T systems (hardware and software) will deliver the following benefits to practices:

(i) funding for IM&T systems. Provision of funding, maintenance, support and future upgrades of practice IM&T systems will be clearly specified

(ii) service level agreements. These will be based on a national template, allow local enhancements and additions to support future developments, and ensure that practices will receive higher quality IM&T services whilst preserving choice

(iii) supplier management mechanisms. These will be put in place to manage supplier failure to deliver systems in line with the SLA

(iv) nationally accredited systems. There will be PCO and practice involvement in defining national agreements, standards and systems requirements for national IT programmes which will support integrated healthcare. This will be achieved by the delivery of managed services that support whole communities, not just individual organisations

(v) data confidentiality and security. The PCO will be responsible for ensuring data confidentiality and security are in accordance with agreed protocols

(vi) liability. Liability issues will be fully managed by the PCO in line with local agreements with practices and via UK national service level agreements with suppliers removing the responsibility from the GP.

Choice of nationally accredited systems
4.34 Systems will be accredited against national standards. Each practice will have guaranteed choice from a number of accredited systems that deliver the required functionality. Such choices will be consistent with local development plans (or their equivalents) and in line with local business cases and service level agreements. From 1 April 2003 every practice in the UK will have the choice of RFA-accredited systems. Practices will not subsequently be expected to exercise this right more frequently than every three years.

4.35 As patient care is increasingly delivered across multiple organisations, professions and sectors, the ability to implement nationally specified systems to support these arrangements is regarded as essential.

4.36 The GPC, NHS Confederation and Health Departments across the four countries appreciate and value the information held in current practice systems. Future strategies will ensure this information is protected.

Development, implementation and support for primary care IM&T systems
4.37 UK standards that accommodate the specific requirements of the four countries will cover the development, implementation and support of IT systems in primary care. These will include standards and protocols relating to the access and management of electronic patient records, including the transition from existing arrangements.

4.38 Taking into account the different models of purchasing systems across the four countries, a national template SLA will be developed to support the development of future primary care IT systems providing practices with assurances on training, maintenance and support. The national template will allow local enhancements and additions in line with national programmes.

4.39 Practices will receive hardware and software upgrades from their supplier in a rolling programme as specified in their SLA. Mechanisms will be put in place to manage supplier failure to deliver systems in line with the SLA, which may also be subject to periodic reviews of implemented systems against the approved practice business case.

4.40 Professional bodies, including the GPC, will be fully involved in the definition of national agreements, standards and systems requirements and service level agreements that underpin them.

Minimum functionality specification
4.41 Work is continuing to develop a minimum functionality specification for practice systems that defines the information requirements to deliver integrated care and meets the requirements of the new GMS contract.

Education and training in use of IM&T
4.42 The initial and continuing education, training and support in the use of IM&T will be managed and properly funded by the PCO as part of a continuing practice development programme. Further information will be provided as part of the overall guidance on implementation of the contract.

4.43 In order to fulfil their new contractual obligations, practices will have to enter and retrieve high quality information from their practice clinical systems. Mechanisms will be put in place to ensure practice staff are fully supported with continuing training and education to ensure they are able to:

(i) use and manage their particular clinical and administrative information systems including data entry and retrieval

(ii) understand clinical nomenclatures and classifications

(iii) ensure data quality

(iv) implement change management and strategies to enable the move from paper to electronic records

(v) manage the risks associated with an IT-dependent working environment including disaster recovery and ensuring operational continuity

(vi) develop and implement workforce strategies to cope with the summarisation tasks associated with all clinical data flows into the practice.

4.44 Practices will ensure that practice IT systems which have been funded in whole or in part under previous NHS funding arrangements will continue to be available to support the new GMS contract on the basis of the new funding arrangements outlined in this chapter.

Innovation in IM&T
4.45 Funding for innovation in the use of IM&T to support and enhance the delivery of patient care in general practice will come from a variety of funding streams including national sources.

4.46 It will be important for PCOs to ensure that any funding used to develop IM&T over and above the minimum requirements is in line with each country’s IM&T strategy and an evaluation programme is developed.

GP-to-GP patient record transfer
4.47 The new GMS contract requires greater use of the clinical system to record patient information. Key to the successful delivery of efficient and accurate data recording will be ease of transfer of data between practices. The ‘GP-to-GP record transfer’ project will enable clinical information to be transferred from one clinical system to another without the need for re-keying and therefore will save time and resources.

Implementation
4.48 Arrangements for implementation of the above process will be developed for Scotland, Wales, Northern Ireland and England in line with developing policy. As part of continuing discussions on the implementation of the new contract, the NHS Confederation will consult and negotiate with the GPC about how to address the transitional arrangements and timescales to meet the requirements of the new GMS contract.

Premises
4.49 The contract will support the development of premises through new UK-wide flexibilities accompanied by new UK-wide standards. Funding flows will also change and these are described in chapter 5.

4.50 The provision of modern practice premises requires that GPs incur significant cost liabilities that require specific funding scheme arrangements to support their availability. The private sector is increasingly playing the role of provider of capital to build the premises and acting as landlord to its GP tenants through binding legal agreements. Explicit funding scheme arrangements will be available to provide robust, UK-wide arrangements to support GPs on a similarly favourable basis as those for third party developers, in terms of revenue stream, overall return on projects and risk. This will provide stability for GPs as well as giving assurances to funders and landlords that premises costs will attract consistency of support under the new GMS contract.

Flexibilities
4.51 Areas with poor returns on capital have historically attracted low levels of investment in primary care infrastructure. To overcome barriers to investment, a first tranche of premises flexibilities has already been introduced. A second tranche was set out in the April 2002 framework. This was designed to overcome hurdles to capital investment in primary care and to enable GPs to move from old to modern premises. These changes have been introduced to maintain GP choice in investment routes and to provide parity in access to funding. It will be implemented from April 2003 and contains the following flexibilities:

(i) the payment of a grant to meet mortgage deficit costs, to enable GPs to sell their existing premises and move to appropriate alternative premises

(ii) the payment of a grant to meet mortgage redemption costs

(iii) allowing PCOs to take an option on land

(iv) allowing PCOs to continue cost rent payments to GPs who buy premises from a single-handed/two partner practice

(v) allowing PCOs to review cost rent payments when GPs re-mortgage to lower interest rates

(vi) reimbursement of legal and other professional fees for GPs in new premises developed by public-private partnership

(vii) revised arrangements to pay notional rent in addition to cost rent when premises are modernised or extended

(viii) abatement of notional rent to pay full notional rent on GP capital invested in premises and abated notional rent for NHS capital equivalent to additional costs for heating, lighting, maintenance etc

(ix) payment of notional rent to leaseholder GPs who improve their premises

(x) extension of the timescale to repay improvement grants and PMS equivalents to 10 years for owner-occupiers and for renting GPs to re-negotiate the terms of their lease to 15 years

(xi) allowing PCOs to directly reimburse insurance and utility costs, maintenance and service charges etc

(xii) introducing periodic (potentially quarterly) reviews of building cost location factors

(xiii) introducing index-linked leases (eg RPI-based) to support capital invested in primary care premises better

(xiv) a revised premises schedule and a revised commentary

(xv) issuing a letter on safeguards and security for GPs signing leases with third party developers with the intention that PCOs will be able to have a lease assigned to them temporarily if the departing GP is unable to assign it.

Quality standards
4.52 The new contract introduces a new set of quality standards. Subject to appropriate funding agreed between the PCO and the practice, premises will not be accepted unless the accommodation provided is deemed by the PCO, following a visit, as satisfying the minimum standards. The visiting team will include representatives of the PCO and the LMC (or its equivalent). The standards which should apply to both main and branch/split-site surgeries to include the following:

(i) practices should take reasonable steps to comply with the Disability Discrimination Act 1995. This includes providing for all users of the building ease of access to premises and movement within them, adequate sound and visual systems for the hearing and visually impaired, and the removal of barriers to the employment of disabled people. Adequate facilities should also be provided for the elderly and young children, including nappy-changing and feeding facilities

(ii) a properly equipped treatment room, where provided, and a properly equipped consulting room for use by the practitioners with adequate arrangements to ensure the privacy of consultations and the right of patients to personal privacy when dressing or undressing, either in a separate examination room or in a screened-off area around an examination couch within the treatment room or the consulting room. An additional treatment room may be required where enhanced minor injury services are provided
(iii) practitioners, staff and patients having convenient access, including wheelchair access where reasonably possible, to adequate lavatory and hand washing facilities which meet current infection control standards. There should be washbasins connected to running hot and cold water in consulting rooms and treatment areas or, if this is not possible, then in an immediately adjacent room

(iv) adequate internal waiting areas with enough seating to meet all normal requirements and provision, either in the reception area or elsewhere, for patients to communicate confidentially with reception staff including by telephone

(v) the premises, fittings and furniture to be kept clean and in good repair, with adequate standards of lighting, heating and ventilation

(vi) adequate arrangements for the storage and disposal of clinical waste

(vii) adequate fire precautions, including provision for safe exit from the premises, designed in accordance with the Building Regulations agreed with the local fire authority

(viii) adequate security for drugs, records, prescription pads and pads of doctors' statements

(ix) where the premises are used for minor surgery or the treatment of minor injuries, a room suitably equipped for the procedures to be carried out.

Branch/split-site surgeries
4.53 Unavoidable costs of branch surgeries cannot be adequately picked up through the allocation formula which is unlikely to reflect the increased infrastructure costs of split-site/branch surgeries. Branch surgeries and outlying facilities can vary in size and quality and existing or proposed new facilities can improve patient access to services where convenient access to main surgery facilities is difficult.

4.54 For a branch surgery to qualify as a second main/split-site it should meet the following criteria:

(i) be open for at least 20 hours a week for provision of medical services automatically entitling it to proper IT support

(ii) meet the minimum standards set out in paragraph 4.52 above

(iii) deliver essential and additional services.

4.55 Branch surgeries that do not meet the above criteria will not automatically be considered eligible for the funding as a second main/split-site surgery. In addition, where it is deemed that proper services cannot be supplied on such sub-standard premises action should be taken as set out in paragraph 4.58. Where the shortcomings cannot be remedied or the cost of doing so is disproportionate to improvements in service delivery, and following public consultation, the premises can be closed.

4.56 A branch surgery can be can be closed subject to agreement between the PCO and providing practice. In the event that there is no agreement the practice can give notice that it wishes to close a branch surgery. There will be a given period in which the PCO can issue a counter-notice, to allow for any required consultation, requiring the surgery to remain open until the issue is resolved. Normal appeal procedures will apply. If the branch surgery is unable to close, because a counter-notice was successful, or where both the practice and the PCO agree that the surgery should remain open, then the PCO is required to continue supporting it with the necessary funding.

4.57 Branch surgery standards need not be fully met where a practice provides outlying consultation facilities using premises usually used for other purposes.

4.58 Following a visit, PCOs will determine whether premises accepted for the delivery of services are continuing to meet the relevant standards. If there are shortcomings:

(i) the LMCs (or GP subcommittee of the Area Medical Committee) will be consulted

(ii) where the shortcomings can be rectified, the practice will agree with the PCO within a month how the shortcomings can be rectified within a reasonable period of time, ensuring that patient safety is not at risk

(iii) if the shortcomings have not been put right within six months (or such longer period as may be agreed between the practice and the PCO) premises payments will cease or be abated, until the shortcomings have been put right

(iv) a practice may appeal against the PCO decisions in line with the arrangements described in chapter 7.

4.59 Specific arrangements for implementation of the premises flexibilities and standards will be developed for Scotland, Wales and Northern Ireland. In Wales, separate allocation arrangements will apply to premises funding. From April 2004, subject to primary legislation, there will be a Welsh GMS Premises Fund that will be held by the National Assembly for Wales. Local Health Boards will be guaranteed baseline funding to support existing projects and projects that have already been agreed. Baselines will be uprated annually for property cost inflation. Decisions on growth money will be taken by the Assembly, taking account of the needs of Local Health Boards as set out in their Estate Strategies and on specialist advice provided by Welsh Health Estates.

7. In England, the development of practice nursing is supported through the document “PCTs Liberating the Talents: helping PCTs and nurses to deliver the NHS Plan”.