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Investing in general practice

February 2003

Chapter 6 : Better services for patients

6.1 The new GMS contract offers many benefits for family doctors and other members of the primary health care team. But its ultimate purpose is to improve patient care. This chapter sets out how key changes within the new contract will help deliver this through new responsibilities and rights including:
(i) the allocation of resources to practices according to patients’ needs

(ii) choice of practice supported by better information

(iii) choice of practitioner

(iv) a Patient Services Guarantee, and access to a wider range of services

(v) higher quality services

(vi) the collection of patients’ experience through practice surveys and involvement in service development

(vii) a programme of initiatives involving patients to manage demand for services.

Allocation of resources to meet patients’ needs
6.2 Under the new contract, resources for the basic practice infrastructure will be allocated to practices on the basis of the weighted needs of their patient population. The allocation formula is described in chapter 5 - read more here. This new arrangement replaces the old contractual model where resources were made available on the basis of the number of doctors in a particular area. This meant that if an area was under-doctored, or lost doctors through retirement or career changes, the remaining doctors were left with greatly reduced resource available to them in order to meet the continuing needs of their patients.

6.3 Under the old contract little or no account was taken of the differing needs of patients in allocating resources to different practices. This will now change. With the exception of premises and IM&T, resources for the infrastructure costs of staffing and basic operating costs will be allocated to practices on the weighted needs of the population they serve. This will be independent of the number of doctors in the practice. If a doctor, nurse or staff member leaves the practice, the resources will remain. This will allow the practice to reorganise the service or increase their remuneration in order to recognise the increased workload experienced as a consequence.

6.4 Typically, as the new formula is introduced, patients will benefit from the increased resources available, particularly in areas with older populations, with high mortality and morbidity levels, with higher staff costs, or serving rural and remote areas.

6.5 The global sum funding arrangements will also mean that practices have greater flexibility to organise their services in whatever way best enables them to deliver high quality services for their patients.

Practice assignment and choice of practice
6.6 Patients will continue to be free to register with any local practice that is open and practices will continue to have discretion over new patient registrations. However, it is expected that in exercising this discretion, practices will have reasonable and fair grounds for doing so.

6.7 Even if all the local practices have closed lists, patients will still be able to register and obtain services through arrangements made by PCOs.

6.8 Patient choice will be supported by better local information. Patients will receive this through:
(i) information provided by the PCO about different practices, for example, the PCT prospectus in England

(ii) the practice leaflet which will set out information on opening times and the services offered by the practice.
The requirement to produce such information will be supported by legislation.

6.9 Practices that have not gone through the procedures set out in paragraphs 6.12 to 6.18 below will be required to accept assigned patients. This is important given that the new processes are intended to facilitate the dialogue between practices and the PCO at ‘stage one’ about how the practice could be assisted to handle its workload and what support the PCO can provide. These procedures should focus the attention of both the practice and the PCO on the workload pressures and will ensure that the need for forced patient assignments is progressively reduced to zero.

6.10 The new arrangements will:
(i) introduce a formal transparent process to establish list closure

(ii) include a right to have a proposed closure reviewed by an assessment panel and a specific right of appeal against an adverse assessment to the Strategic Health Authority (or its equivalent)
(iii) require PCOs to take all reasonable measures to minimise the need for forced assignment of patients.

6.11 Where a practice is closed to assignments following the procedure set out below it is then closed to all patients with the exception of the immediate family of existing patients.

6.12 Where a practice has concerns about workload it can seek to apply to close its list following the process set out below. It is expected, that in the large majority of cases, there will be no need to progress further than stage one.

Stage one
6.13 Discussions will take place between the practice and the PCO focusing on what additional support the practice could receive to keep its list open, the options for alternative provision including the feasibility of the PCO or other practices registering patients for the provision of GMS and the appointment by the practice of a salaried doctor or a nurse practitioner or other support staff. These discussions will normally take place within seven days of a notification by a practice that it may wish to close it list. The practice will be obliged to cooperate with the PCO in undertaking this review and, where appropriate, putting in place agreed changes.

Stage two
6.14 Following the procedures in stage one, which should be completed within 28 days, if the practice and PCO agree that list closure is inevitable, the practice will formally confirm that it wishes to close its list by submission of a closure notice. When such a notice has been served, it cannot be withdrawn within a period of three months unless the PCO agrees. This is to discourage ill-considered or inappropriate requests for list closure.

6.15 Within 14 days of receiving the notice, the PCO must either:
(i)approve the closure notice, in which case the practice list closes either for a period of 12 months, or until the number of patients recorded on the practice list has reduced by a percentage of the practice list size agreed by the PCO and the practice, or until the list size has fallen to the lower limit of an agreed specified range, which will apply for a twelve-month period, or by agreement otherwise between the practice and the PCO or

(ii) reject the closure notice, in which case the notice will be remitted immediately for determination by an assessment panel under the dispute resolution procedures set out in chapter 7. Read more here.

6.16 Where the range mechanism is used the list closure will be suspended when the lower figure of the range is reached. The practice list will then reopen for applicant or assigned patients, until the higher figure in the range is reached when the lists would close again until the lower figure is reached.

Stage three
6.17 Where necessary, each PCO will establish an assessment panel, both to consider practice closure notices which have been rejected by the PCO and to determine how requests for new patient registrations should be dealt with where there is mass closure. The assessment panel will comprise: a PCO Chief Executive, a patient representative, an LMC representative (or its equivalent) and a Director from the Strategic Health Authority (or its equivalent).

6.18 The procedure will be investigative and not adversarial. The panel will consider the individual circumstances affecting the applicant practice.

6.19 If a situation arises where most or all of the practices in a particular area are likely to have closed their lists to forced assignments, the assessment panel will determine how requests for new patient registrations should be dealt with. In such cases the Strategic Health Authority (or its equivalent) can insist that a separate review will be held to determine what arrangements should be put in place by the PCO to prevent the need for forced assignments.

6.20 Each rejected closure notice will be considered on its merits to prevent different standards being applied to the first or last practice to apply for list closure in a particular area. Both the PCO and the applicant practice will be required to demonstrate that they have satisfied the respective steps required of them in stage one. To help inform its decisions, the practice should be visited by at least one of the panel members.

6.21 The determination must be made within 28 days of the reference made in accordance with paragraph 6.15(ii). The panel can either:
(i) agree that the list may close within seven days

(ii) disagree, in which case the list will remain open. However, it will then be incumbent on the PCO to have further discussions with the practice concerning what assistance can be given to the practice to allow it to discharge its responsibilities to its patients in a safe and effective manner. The practice will not normally be able to reapply for list closure within three months from the date of the determination of the Panel unless there is a significant change in circumstances.

6.22 Practices with closed lists will have a fast-track right of appeal to the Strategic Health Authority (or its equivalent) against an adverse decision made by the assessment panel in respect of forced allocations. The Strategic Health Authority (or its equivalent) will consider whether the PCO has taken all practicable steps to secure accessible alternative provision.

6.23 The fast-track appeal process will be initiated within seven days from the date of determination of the assessment panel and will be completed within 21 days after the notice of appeal.

6.24 Where all processes have been followed and there is no option other than to force an assignment, the PCO will discuss with the practice what additional support is required until such time as the practice list is open.

6.25 A copy of each panel decision will be sent to the relevant Strategic Health Authority (or its equivalent). The PCO and Strategic Health Authority (or its equivalent) will include details of decisions made by the panel, or on appeal the Strategic Health Authority (or its equivalent), in their annual reports. In addition, the PCO’s management of list closure issues will be taken into account when decisions are made in respect of the PCO’s star ratings or equivalent rankings and levels of forced assignments will be published.

6.26 During the period of the process set out above, it is important that patients continue to have access to primary medical services and they will continue to have access to services under the immediate/necessary/emergency rules.

6.27 Practices that seek formally to close their lists do so in order to manage excessive workload. For this reason, whilst formal list closure will not prevent a practice from applying to provide opted-out additional services to the patients of other practices or to provide enhanced services, it is likely to prejudice its application.

6.28 These new arrangements will help make assignment of patients to closed lists a thing of the past. PCOs will no longer have an unfettered right to force patients onto a closed list irrespective of the practice’s workload. The continuing need for the reserve power to assign patients will be reviewed in 2005/06.

Removal of patients
6.29 The relationship between a practice and a patient can sometimes suffer an irreconcilable breakdown. In these circumstances the right of the practice to remove a patient from the practice list remains. Patients too will be able to apply for registration with a different practice if that is their preference. Removal from a list will follow a transparent process that normally would include a warning to the patient before removal. When a patient is removed, practices will be required to give specific reasons to the patient as to why the removal has occurred, though it is accepted that, in certain specific circumstances, a statement to the effect that the relationship between the patient and the practice has irrevocably broken down will suffice.

6.30 The right of a practice to remove a violent patient will be extended to safeguard all those who might have reasonable fears for their safety. These will now include members of the practice’s staff, other patients and any other bystanders present where the act of violence is committed or the behaviour took place. Violence includes actual or threatened physical violence or verbal abuse leading to a fear for a person’s safety. It is the responsibility of the PCO to ensure that there is a service available for patients who are difficult to manage, and this will be commissioned separately as an enhanced service as set out in chapter 2. Read more here.

Choice of practitioner
6.31 Patients will now register with practices rather than individual GPs. However, patients will retain the flexibility that they currently enjoy to request to be seen by the practitioner of their choice. This is particularly important for patients who value seeing a practitioner of their choice for the purposes of continuing care, care of particular conditions, gender or ethnicity. Primary legislation will provide for choice of practitioner to be set out as a legal right within regulations governing the contract between the PCO and the practice.

6.32 Where a patient wishes to exercise this right:
(i) the patient may have to wait longer to see their preferred practitioner and, where this was accepted, it would not count against achievement by the practice of any rewards for improved access

(ii) the practitioner would still be allowed the rights of reasonable refusal (eg in respect of a violent patient)

(iii) the patient may be asked to accept an alternative if for example the service required was now being delivered by another professional member of the practice (eg if a service had been designated by the practice as a nurse or therapist led service rather than a doctor led service).

6.33 These rights will not undermine a practice’s flexibility to organise its services in order to best meet patient needs.

6.34 This means that a practice cannot force a patient to see a doctor that the patient does not wish to see. The practice will still have an obligation to offer immediately necessary treatment to non-registered patients.

The Patient Services Guarantee
6.35 The new GMS contract is a UK-wide contract. The aim is to ensure that patients receive a consistent range of high quality services throughout the UK. The contract does, however, recognise that certain services are provided in different areas in response to local need.

6.36 The new contract will ensure that patients have access to a wide range of services delivered in primary care settings. In addition, the quality and outcome rewards in the new contract will incentivise good chronic disease management and holistic personal care within general practices. Patients who need continuity of care will be able to receive it.

6.37 The mechanisms set out in chapter 2 enable more flexible configuration of services across PCOs. These are designed to recognise that many practices are facing considerable challenges in managing increasing workload. Combined with the introduction of better human resource management policies described in chapter 4, including measures to improve the recruitment and retention of GPs, they will help ensure that primary care capacity is expanded. This will enable better services to be delivered to patients.

6.38 It is expected that most practices will deliver the full range of additional services. However, where practices have no other option, they may opt out of the provision of one or more defined additional services. In these circumstances, the PCO is responsible for ensuring that the Patient Services Guarantee is delivered. This guarantee states that ‘patients will continue to be offered at least the range of services that they currently enjoy under the existing contract.’ In some cases, however, this service may be made available to the patient from somewhere other than their own local practice. Whilst local circumstances may differ, it is expected that the PCO will use the opportunity of seeking to ensure an alternative service is provided to increase the range of choice available to the patient and minimise any travel times. The guarantee will be backed up in primary legislation by a new legal duty on PCOs.

6.39 Practices and PCOs will be required to agree how best to inform patients of service changes in accordance with the provisions of section 11 of the Health and Social Care Act 2001. Similar provisions exist in Scotland and Northern Ireland.

6.40 The arrangements set out in chapter 2 - read more here - also offer new opportunities for extending patient choice:
(i) where possible and practicable, patients who require it will be given choice, in particular, for single or short duration healthcare episodes and problems. This will be achieved through enabling patients to use alternatives such as NHS walk-in centres, NHS Direct, NHS24 or community pharmacists as complementary alternatives to attending the surgery

(ii) where a practice has opted out of provision of an additional service and there are a number of alternative providers identified by the PCO, patients will have the choice as to which provider they wish to attend for that service

(iii) PCOs will be given new powers to commission parallel additional services, which would not affect the income of existing GMS practices, but would offer patients an extra choice and may help to ease the workload of some practices
(iv) where a PCO has entered into contracts for the provision of an enhanced service, patients will have the choice as to which provider of the service they choose to attend.

Higher quality services
6.41 Chapter 3 - read more here - outlines the substantial additional investment that will support the implementation of a wide-ranging quality framework based on latest research evidence. This will help ensure excellent management of a wide range of chronic diseases. It will have a very significant impact in improving clinical outcomes for patients. It will also help avoid unnecessary referrals to hospitals. The organisational standards will also provide assurance to patients that practices are well run. The investment in premises and the quality standards attached to the new premises flexibilities described in chapter 4 will help ensure that patients receive care in a high quality physical environment.

6.42 It is considered good practice to book consultations at 10 minute intervals. The quality framework will provide a direct financial incentive for practices to achieve this.

6.43 GPs will be rewarded directly for their success in achieving improved access through an enhanced service, and maintaining it through bonus access maintenance points (see chapter 3).

Assessing and rewarding patient experience
6.44 The quality framework will also provide a strong financial incentive for practices to consider the patient’s experience by asking patients to complete an accredited questionnaire, to consider and discuss the results of the analysis, and to implement appropriate improvements. This development will allow the patients of the practice to comment on numerous aspects of their care including the physical environment, the convenience and accessibility of the services offered, the practice/patient relationship, the helpfulness of support staff and the appropriateness and timeliness of the whole episode of care.

6.45 The two accredited questionnaires have been tested and approved through a process of peer review. They have been shown to have real benefits not just in creating an opportunity to assess patients’ views, but also in alerting the practice to both strengths and weaknesses.

Working in partnership
6.46 The new GMS contract recognises that if the primary care sector is to be expanded and practices are to be allowed to manage their workload and earnings to suit their aspirations, a clear strategy to use clinicians’ time effectively whilst improving availability of services for patients is essential. This strategy will identify those situations in which patients could be enabled to manage their own conditions, use services effectively, or where the services could be offered by other health professionals, especially where these services could be accessed more easily and more cost-effectively than through traditional general practice. There are many examples of progress being made, but in some instances this work is on a small scale and implementation of proven initiatives patchy.

6.47 Under the new GMS contract there will be national arrangements to coordinate and facilitate the development of schemes to maximise the effective use of health services and provide evidence based alternatives to general practice. In Scotland, Wales and Northern Ireland existing arrangements will take forward this agenda. In England, there will be an integrated multi-disciplinary group under the aegis of the Modernisation Agency working with relevant external bodies. It will also have significant public and patient involvement as a part of its membership and hold a programme budget of £10m over three years to sponsor, evaluate and encourage spread of good practice. It will also champion these issues in discussions across Government.

6.48 Its work programme will cover a number of important areas for development, including:
(i) development of minor illness management and self-care education programmes by professionals such as nurses, therapists, pharmacists and paramedics

(ii) development and support for Expert Patient initiatives to make better use of primary care and general practice, building on the evaluation and roll out of the current national scheme, but extending its principles to more local practice-driven schemes

(iii) supporting non-GP based chronic disease management schemes aimed at helping to manage ongoing, and develop, new secondary prevention initiatives

(iv) promoting effective use of health services, better patient communication, and better self care through initiatives such as those developed by, for example, the Doctor Patient Partnership and other national health charities

(v) furthering attempts to reduce certification work within general practice. National initiatives such as those established through the Cabinet Office will be implemented. Major local pilots in large companies and the NHS will be sought to evaluate the effectiveness of in-house occupational health services as an alternative to using general practice for certification. Should the pilots be successful the aim would be to allow the system to be refined so certification responsibility can be moved to occupational physicians and occupational health nurses, making significant progress towards national coverage by April 2006

(vi) promoting the education of young people via the National Curriculum about management of health, maintaining their health status and how to use health services responsibly through initiatives such as the proposed Making Sense of Health [9]

(vii) evaluating how patients use services and understanding how best to communicate with them about effective use of, and changes in, services. This work will build on that started by the Department of Health, the Doctor Patient Partnership and the University of Southampton and will be used to inform all the demand management programmes.

9. Making Sense of Health is an initiative from the Doctor Patient Partnership. Its aims include encouraging a culture shift in public involvement in their own health care management, improving people’s ability to use the NHS appropriately and increasing the number of those in future generations who choose careers in the NHS. The initiative will provide imaginative and impartial health education and training to teachers, parents and pupils via the National Curriculum.