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GP access: meeting the reasonable needs of patients

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

The guidance goes beyond the requirements on practices, as set out in the GMS contract, the PMS agreement and Regulations.

Based on the guidance for commissioners, some practices have been approached by their CCG to question their arrangements.


What the BMA are doing

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


What you can do

Read the following guidance to be clear on your contractual obligations and what you can do if you are challenged by the commissioner.


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  • Core hours and service delivery

    GMS Regulations defines:

    • core hours as 08:00 – 18:30, Monday to Friday (excluding Bank Holidays)
    • the essential and additional services which practices are required to deliver

    GMS Regulations do not require practices to:

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

    GMS Regulations do require practices to (either themselves or through sub-contracting arrangements):

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

    In summary

    The GMS Regulations allow individual practices to decide which services to provide when, to meet the needs of their patients.

    Practices should be able to show that they have engaged with their Patient Participation Group (PPG) to check the arrangements are meeting their reasonable needs and take measures to address any areas of concern (recognising the requirements within the regulations regarding PPGs).

    See the GMS Regulations tab for more details.

  • Subcontracting arrangements during core hours

    GMS Regulations do allow practices to:

    1. Subcontract services, provided that:
      • it has taken steps to satisfy itself that it is reasonable to do so,
      • that the sub-contracted provider is qualified, and
      • that notice is provided to the commissioner

    In summary

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

    The practice must satisfy itself that the subcontracting arrangements in place are appropriate and can indeed meet the contractors' obligations. If not, the practice must not agree those arrangements.

    Practices must notify the commissioner who can only object on the grounds that it would put patient safety at serious risk or put the commissioner at risk of material financial loss.

    To enforce such an objection under the terms of the Regulations, the commissioner needs to be able to demonstrate that either of these criteria apply. The commissioner cannot object based upon failure to meet the criteria in the NHS England guidance.

    See the GMS Regulations tab for more details.

  • What to do if you are challenged

    The NHS England guidance asks commissioners to review the hours of service delivery and subcontracting arrangements for all practices.

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

    You should provide reasonable information to the commissioner, upon request, showing that the times of delivering services are appropriate to meet the reasonable needs of patients, and that at other times within core hours, there are arrangements in place so that patients can access services in an emergency. You should also show engagement with your patients (usually via the PPG) around hours and service delivery.

    If the commissioner serves a breach notice as it believes your hours of service provision are not meeting the reasonable needs of your patients, the onus under the regulations is on the commissioner to evidence that claim as part of the breach notice.

    If your commissioner approaches you regarding the reasonable needs of your patients and produces NHS England guidance as evidence, we advise that you inform the commissioner this guidance is not a contractual requirement. We also advise that you contact GPC and your LMC.

    See the GMS Regulations tab for more details.

  • GMS Regulations

    See the details of the relevant GMS Regulations for the main issues highlighted in the above sections.

    Regulations - core hours and service delivery

    GMS (Part 1, General)


    3. In these Regulations— …

    "core hours" means the period beginning at 8.00am and ending at 6.30pm on any day from

    Monday to Friday except Good Friday, Christmas Day or bank holidays;

    GMS (Part 5, Contracts: required terms)

    Services: general


    1. A contract must also—
      1. state the period (if any) for which the services are to be provided except where those services are—
        1. essential services,
        2. additional services funded under the global sum, and
        3. out of hours services;
      2. contain a term which requires the contractor to provide—
        1. essential services, and
        2. additional services funded under the global sum,

          at such times, within core hours, as are appropriate to meet the reasonable needs of patients; and

      3. contain a term which requires the contractor to have in place arrangements for its patients to access essential services and additional services funded under the global sum throughout the core hours in case of emergency.


    Regulations - subcontracting arrangements during core hours

    GMS (Schedule 3, Part 5, Sub contracting)

    (1) Subject to sub-paragraph (2), the contractor must not sub-contract any of its rights or duties under the contract in relation to clinical matters to any person unless-

    (a) In all cases, including those duties relating to out of hours services to which paragraph 45 applies, it has taken reasonable steps to satisfy itself that-

    (i) It is reasonable in all the circumstances to do so, and

    (ii) The person to whom any of those rights or duties is sub-contracted is qualified and competent to provide the service; and

    (b) Except in cases to which paragraph 45 applies, the contractor has given notice in writing to the board of its intention to sub contract as soon as reasonably practicable before the date on which the proposed sub-contract is intended to come into effect

    (2) Sub-paragraph (1)(b) does not apply to a contract for services with a health care professional for the provision by that professional personally of clinical services

    (3) A notice given under sub-paragraph (1)(b) must include-

    (a) the name and address of the proposed sub-contractor;

    (b) the duration of the proposed sub-contract

    (c) the services to be covered by the proposed sub-contract; and

    (d) the address of any premises to be used for the provision of services under the proposed sub-contract

    (4) On receipt of a notice given under sub-paragraph (1)(b), the Board may request such further information relating to the proposed sub-contract as appears to it to be reasonable and the contractor must supply such information to the Board promptly.

    (5) The contractor must not proceed with a sub-contract or, if the sub-contract has already taken effect, the contractor must take steps to terminate it, where—

    (a) the Board gives notice in writing of its objection to the sub-contract on the grounds that the sub-contract would—

    (i) put the safety of the contractor's patients at serious risk, or

    (ii) put the Board at risk of material financial loss, and notice is given by the Board before the end of the period of 28 days beginning with the date on which the Board received a notice from the contractor under sub-paragraph (1)(b); or

    (b) the sub-contractor would be unable to meet the contractor’s obligations under the contract.

    (6) A notice given by the Board under sub-paragraph (5)(a) must include a statement of the reasons for the Board's objection


    Regulations - patient participation

    26.— (1) The contractor must establish and maintain a group known as a "Patient Participation Group" comprising some of its registered patients for the purposes of-

    1. obtaining the views of patients who have attended the contractor's practice about the services delivered by the contractor; and
    2. enabling the contractor to obtain feedback from its registered patients about those services.
    1. The contractor is not required to establish a Patient Participation Group if such a group has already been established by the contractor in accordance with any directions about enhanced services which were given by the Secretary of State under section 98A of the 2006 Act(1) (exercise of functions) before 1st April 2015.
    2. The contractor must make reasonable efforts during each financial year to review the membership of its Patient Participation Group in order to ensure that the Group is representative of its registered patients.
    3. The contractor must—
      1. engage with its Patient Participation Group, at such frequent intervals throughout the financial year as the contractor must agree with that Group, with a view to obtaining feedback from the contractor's registered patients, in an appropriate and accessible manner which is designed to encourage patient participation, about the services delivered by the contractor; and
      2. review any feedback received about the services delivered by the contractor, whether by virtue of sub-paragraph (a) or otherwise, with its Patient Participation Group with a view to agreeing with that Group the improvements (if any) which are to be made to those services.

    The contractor must make reasonable efforts to implement such improvements to the services delivered by the contractor as are agreed between the contractor and its Patient Participation Group.