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Investing in general practice

February 2003

Chapter 8 : Making it happen
8.1 The NHS Confederation, the GPC and the four Health Departments have a shared desire to realise the benefits of the new GMS contract for GPs, patients and the wider NHS at the earliest opportunity. Given that the new contract is radically different from the existing arrangements, the implementation task is considerable, but the work will nonetheless be completed as quickly as possible.

8.2 This chapter describes the three main processes:
(i) action at national level to reform legal, administrative and financial arrangements

(ii) action at local level including support and performance management of PCOs

(iii) ongoing monitoring, review and negotiation.

It also sets out a timetable of what will happen when.

Legal administrative and finance processes
8.3 Chapter 7 sets out how the statutory framework needs to be replaced with new provisions that are fit for purpose. Primary legislation will be introduced at the earliest opportunity. In England and Wales this will happen in the current session of Parliament. If the profession votes in favour of a new contract, the Government will introduce the necessary clauses into the forthcoming Health and Social Care Bill subject to Parliamentary agreement. In Scotland it is expected to follow the forthcoming election, subject to the agreement of the new administration. Primary legislation will also be introduced in Northern Ireland at the earliest opportunity and the mechanism will depend on the constitutional position.

8.4 The clauses will reflect the agreements reached in this document. The Department of Health in England, the GPC and the NHS Confederation have been discussing, and will continue to discuss, how best to achieve this. Discussions will also be held with the other three Health Departments.

8.5 The clauses will describe the parameters for a new framework of secondary legislation, such as regulations and directions, that sets out what is included in the contract and how it will operate. Subject to Parliamentary approval it is intended that the key elements of the secondary legislation will be in place by April 2004. The secondary legislation will entirely replace the existing GMS regulations and will be simpler wherever possible.

8.6 In addition to the work on primary and secondary legislative reform, the NHS Confederation working with the GPC and the Health Departments will produce:
(i) a national contract which PCOs and practices will use for their agreements. The contract will include revised terms, which will be set out in secondary legislation, and these will include the statutory requirements set out in Annex B. Read more here.

(ii) a new Statement of Financial Entitlements will set out the statutory financial entitlements of practices including the global sum and quality payments. This will also be included in the contract. The exact amounts will be calculated quarterly, and set out in a letter from the PCO to the practice

(iii) guidance for PCOs about the operation of the contract (including specifications for enhanced services) and a model contract for PCO and GMS practice employed GPs.

8.7 The GPC will be fully involved in the development of these documents through a continuing process of consultation and negotiation led by the NHS Confederation on behalf of the Health Departments. The GPC will also develop a model partnership agreement and guidance for GPs.

8.8 Primary legislation will provide for a new method of allocating GMS monies to PCOs as described in chapter 5. PCOs will take full responsibility for the first time for managing a single allocation of GMS monies alongside the unified budget allocation. To support the implementation of the Gross Investment Guarantee, expected PCO spend on enhanced services will be identified separately and this will be performance-managed by Strategic Health Authorities (or their equivalents) as described in chapter 5. Read more here

8.9 The allocation will be made by the Health Departments to PCOs covering all the funding streams outlined in this document, with the exception of premises as described in chapter 5 where the risk will be managed above PCO level. The finalised allocation will include monies for transitional protection following the submission of returns from practices of their relevant 2002/03 spend. From their allocation PCOs will allocate monies to practices in accordance with the new statutory rules. Centralised systems will be developed to support the PCO in this process but it will also require a major change in the PCO finance function which will need to be reviewed in conjunction with existing shared services arrangements.

Local level
8.10 Successful implementation of the new contract critically depends on the capacity, capability and competence of PCOs and Strategic Health Authorities (or their equivalents). Practices will also need to undertake preparation.

PCOs
8.11 PCOs have a most important set of functions in relation to implementation. These range from broad strategic to detailed operational roles. They will wish to optimise the benefits of the new contract to deliver strategic change in relation to:
(i) the general modernisation of primary care

(ii) expansion of the primary care sector and the resourced shift of secondary to primary care work

(iii) the recruitment and retention of the primary care workforce

(iv) the management of demand for primary care services.

8.12 The key PCO operational function is to develop and maintain effective locally held practice-based contracts. In moving away from GMS arrangements managed by the Secretary of State, to a locally held practice-based contract, PCOs become the commissioners of primary care services. The contracts and supporting letters will be developed by the PCO in line with the national contract and will reflect:
(i)the range of essential, additional and enhanced services to be provided by the practice. This will follow discussions between the PCO and practice about:
- workload pressures
- the application of the opt-out rules described in chapter 2. Read more here
- the commissioning of effective alternative additional services that practices opt out of
- the commissioning of enhanced services in line with the guaranteed investment floor

(ii) the overall level of quality that the practice expects to achieve

(iii) the financial and other resources available to support delivery. This will reflect decisions to deploy resources for strategic investment in premises and IM&T appropriately, which will involve working collaboratively with their fellow PCOs, Strategic Health Authorities (or their equivalents) and appropriate national bodies.

8.13 The contracts and letters will be discussed and agreed with practices. PCOs will also have responsibility for the ongoing monitoring of the contract, and for ensuring agreements to vary the contract are properly documented.

8.14 PCOs will also need to:
(i) develop an appropriate level of in-house provision of primary medical services as described in chapter 2 - read more here; and

(ii) develop a strategy for commissioning or providing out-of-hours care so that the default responsibility of GPs is removed at the earliest opportunity, and by no later than December 2004 save in exceptional circumstances and subject to agreement by the Strategic Health Authority (or its equivalent).

8.15 Many PCOs already have experience in these areas. Effective mechanisms will also be put in place to support the development of PCO competencies. In the main, these will be provided in England by the Modernisation Agency. The National Primary and Care Trust Development Team (NatPaCT), the National PMS Development team (NPMSDT), the National Primary Care Development Team (NPDT) and the Out-of-Hours Development Team will work together with other colleagues from the Agency and with other stakeholders to develop, coordinate and establish a programme of effective support for PCTs and primary care to help with the implementation of the new GMS contract. Comparable arrangements will be established in the other three countries.

8.16 The programme will draw on the skills and knowledge of the individual teams to support PCOs, general practices and the interface between them, and deliver a programme that builds on lessons learned so far about the most effective way to introduce change and improvement. Each team will bring to the programme expertise in how best to develop PCOs and the people who work within them, how best to commission and contract for primary care services and how best to promote continuous quality improvement in service delivery within primary care. The programme will be targeted to match support to priorities as they arise, as the new contract is introduced.

8.17 PCOs will wish to consider the considerable capacity they will require to discharge their new GMS functions, bearing in mind their existing expenditure on supporting primary care and their ability to supplement this from within their unified budget resources.

Strategic Health Authorities (or their equivalents)
8.18 Strategic Health Authorities (or their equivalents) have two distinct roles within the new contract. These are:
(i) ensuring the effective performance of PCOs in respect of their requirements to implement the new contract, including providing developmental support and routine performance management. In particular, Strategic Health Authorities (or their equivalents) will need to ensure that PCOs are working with practices to deliver the key strategic objectives outlined in paragraph 8.11; that the guaranteed investment floor on enhanced services is delivered in each PCO; and that PCOs rapidly develop effective strategies for commissioning out-of-hours care

(ii) discharging a limited range of technical functions as directly required of them under the new contract. These include appeals on opt-outs and forced assignments of patients, ensuring appropriate PCO arrangements are in place for the deployment of IM&T and premises funds, and a general role in performance management.

8.19 Strategic Health Authorities (or their equivalents) will require support to understand and discharge these new roles. A programme of support is being developed under the aegis of the NHS Confederation to help them with this. It is envisaged that lead Strategic Health Authorities (or their equivalents) will coordinate with lead PCOs in each Strategic Health Authority (or its equivalent) area to create an ongoing platform for local implementation, dissemination of best practice and specification of learning needs.

8.20 Strategic Health Authorities (or their equivalents) will also coordinate their performance management roles with that of external inspectorates such as the Commission for Healthcare Audit and Inspection (CHAI), which will be charged with assessing PCO performance, and in some countries, developing star ratings systems. This will minimise bureaucracy and burdens on PCOs.

8.21 Other stakeholder bodies including the Royal College of General Practitioners, NHS Alliance, National Association of Primary Care, the National Association of GP Co-operatives, the Royal College of Nursing, and the Commission for Patient and Public Involvement, will also be involved through an implementation reference group designed to support the process of implementation.

Ongoing monitoring, review and negotiation
8.22 The GPC, NHS Confederation and the four Health Departments are committed to ensuring that the implementation of the contract is consistent with the original intentions of this document and that effective mechanisms are put in place to ensure effective subsequent adaptation in the light of changing circumstances.

8.23 New arrangements are needed for the monitoring of workload, expenditure, resource allocation and the quality framework. Under the current contract the Technical Steering Committee considers the data required to enable the current pay system for GPs to function effectively. Given the very different nature of the new contract, this group will no longer need to undertake its work in the same way, but will be required to provide new support systems in order to ensure that the practice-based system operates effectively. In future, the new GMS Technical Committee, reconstituted to include NHS Confederation and Northern Ireland membership, will ensure the provision of accurate data on workload and expenditure to inform consideration of future uplifts in gross expenditure. The monitoring of workload may be achieved by developing a system of spotter practices, that are tracked throughout the year by recording their workload.

8.24 A UK-wide expert group will review the effectiveness of the new primary care resource allocation formula and make recommendations on any future changes.

8.25 A UK-wide expert group will be established to monitor, review and update the standards set within the quality framework. Its role will include:
(i) ensuring that the standards continue to be consistent with the best available evidence and data

(ii) making recommendations on the operation of the framework and possible corrective action in the event of standards being misinterpreted, corrupted or difficult to manage

(iii) making recommendations on the introduction of new standards.

8.26 The membership and terms of reference for this group will be considered by the negotiating parties. The group will not be a decision-making body, but will make recommendations to the GPC and to Ministers, which will form the mandate for the NHS Confederation, as the negotiating body on their behalf. These recommendations will be considered as a part of the continuing negotiation process.

8.27 The NHS Confederation will continue to lead the ongoing process of negotiation of the contract. Whilst this role will diminish in volume, once the contract has been agreed and the further national work identified in paragraph 8.6 completed, there will be a requirement for both sides to continue to oversee its implementation in practice and to negotiate any appropriate variations or adjustments to the contract that are required.

Timetable
8.28 Subject to acceptance of the contract by the profession, substantial implementation will occur in 2003/04:
(i) primary and secondary legislation will be put in place, subject to Parliamentary agreement
(ii) model contracts and guidance will be prepared and published

(iii) national programmes for local support will be established

(iv) PCOs will review the capacity and competence they require to implement the contract and Strategic Health Authorities (or their equivalents) will performance-manage this process

(v) PCOs will prepare locally held contracts and letters in accordance with fixed UK requirements and will discuss and agree these with practices, which will also want to review their partnership arrangements in the light of new GPC guidance

(vi) PCOs will develop strategies for out-of-hours commissioning and encourage transfer of responsibility to accredited providers

(vii) PCOs will discuss workload issues with practices and practices will indicate which additional services they may wish to opt out of or the additional or enhanced services they may wish to provide

(viii) PCOs will commission enhanced services and Strategic Health Authorities (or their equivalents) will performance-manage this spend

(ix) PCOs will submit returns in a national template on transitional protection

(x) the Health Departments will allocate resources to PCOs

(xi) centralised systems will be developed to support PCOs in allocating resources to practices

(xii) revised payments for seniority payments will be introduced

(xiii) the definition of pensionable earnings will be changed and locum pay will be pensionable retrospectively from 1 April 2002

(xiv) practices will prepare for the quality framework and be allocated preparation payments based on the Carr-Hill formula

(xv) practices supported by PCOs will take advantage of the practice management competency framework

(xvi) the baseline assessment of premises spend will be carried out and future spend agreed

(xvii) IM&T modernisation will begin, with transitional arrangements agreed nationally and discussed locally

(xviii) the new monitoring arrangements will be established

(xix) the DDRB will be asked to set salary ranges for PCO and practice employed GPs.

8.29 In 2004/05:
(i) all GMS practices will transfer to the new practice-based contract in April 2004

(ii) the global sum, recalculated quarterly, and quality aspiration payments will be paid monthly. Transitional protection will also be paid

(iii) it will be possible for opt-outs from additional services to occur from April 2004. Opt-outs from out-of-hours will occur, usually on a PCO-wide basis, from April 2004.
The expectation is that all PCOs will have taken on responsibility for commissioning out-of-hours by December 2004 and Strategic Health Authorities (or their equivalents) will performance-manage this process

(iv) from April 2004 PCOs will be given the ability to develop direct provision of primary medical care, and to commission additional and enhanced services from alternative providers

(v) the new rules concerning patient assignments will be introduced

(vi) the new performer list for England and Wales and appeals procedures will be established.

The forthcoming guidance on implementation will provide further detail. Tailored arrangements will reflect the specific circumstances of Scotland