Contracting for Primary Care

PCT Strategic Functions

• The general modernisation of primary care

• The expansion of the primary care sector and the resourced shift of secondary to primary care work

• The recruitment and retention of the primary care workforce

• The management of demand for primary care services

Patient Services Guarantee

PCTs will have a legal responsibility to ensure that:

‘patients will continue to be offered at least the range of services that they currently enjoy under the existing contract’

Process

Develop commissioning strategy

Undertake procurement process

Monitor outcomes

Contracting Routes - Summary

CONTRACTING ROUTE

PROVIDERS

General Medical Services (GMS) Practices with at least one GP provider (single-handers, partnerships, or a certain type of limited company)

Personal Medical Services (PMS) Practices (single-handers, partnerships, or a certain type of limited company) Nurses and other clinicians PCTs

Alternative Providers Medical Services (APMS) Commercial providers Voluntary sector Not-for-profit organisations NHS trusts and foundation trusts Other PCTs

PCT Medical Services (PCTMS) PCTs

GMS Contractors

• A general medical practitioner• Two or more individuals practising in partnership;

– At least one partner (who must not be a limited partner) must be a general medical practitioner

– Other partners must be individuals from within the NHS family

• Company limited by shares– At least one share must be legally and beneficially owned by

a general medical practitioner– Other shares must be legally and beneficially owned by

individuals from within the NHS family

PMS Contractors

Agreements can be made with one or more of the following:

• An NHS Trust

• A medical practitioner

• A healthcare professional

• An individual who is a GMS or PMS provider

• An NHS employee or a PMS employee

• A qualifying body (a company limited by shares, all of which are legally and beneficially owned by persons identified above)

APMS Contractors

PCTs may make contractual arrangements with any person (for the provision of primary medical services)

[Section 16CC(2)(b)of the National Health Service Act 1977]

Specific provisions for:• Individuals• Companies• Partnerships• Industrial and provident societies, friendly societies, voluntary

organisations

ie. must be fit and proper persons.

PCTMS

A PCT may provide primary medical services itself (whether within or outside its area)

[Section 16CC(2)(a) of the National Health Service Act 1977]

PCTs as commissioner

Three routes:

GMS PMS APMS Negotiation

National Local Local

Contractor type

Prescribed, at least one GP provider

Prescribed, but no requirement for GP provider

Completely flexible

Contract terms

Min. requirements set out in GMS Regs

Min. requirements set out in PMS Regs

Min. requirements set out in Directions (based on PMS Regs)

Payment Prescribed, as per SFE

Flexible, but likely to be linked to SFE eg seniority, QOF

Flexible, may be linked to SFE if desired

Why commission?

Benefits• Transfer of clinical risk• Transfer of financial risk (to varying degrees)• Expansion of capacity/competition?

but• Effective procurement process• Effective performance monitoring

PCT Provision

“ PCTs are encouraged to develop a minimum level of (provision of essential) services....

If PCTs propose to become large-scale providers of primary medical services, they are expected to discuss this first with their SHA. They are also expected to consult with LMCs.”

[para 2.6 Delivering Investment in General Practice]

PCTs as provider

Two routes:– PMS– PCTMS

“ Under PMS, the PCT can be the contractor but this involves the SHA acting as the commissioner. The SHA commissioner role is increasingly anomalous given StBoP and PCTs may ... wish to transfer such PMS contracts to PCTMS arrangements where the PCT is the direct provider.”

[para 2.6 Delivering Investment in General Practice]

What’s the difference?

PMS• Requires contract between SHA and PCT that

conforms to Regulations

“Where the contractor is a PCT, the agreement must specify that its list of patients is open.”

Para 11(4) NHS (PMS Agreements) Regulations 2004

PCTMS• No contract required• No requirement to maintain open list

Why provide?

Provision is not an easy option:• No transfer of clinical risk (capacity?)• No transfer of financial risk (equity?)• Performance (measuring quality?)

but• Control• Inject competition/capacity?

Procurement Process

• For greenfield sites, two stage process:– First, competition between GMS and PMS

practices (which would have preferred provider status);

– Then, open competition.[para 7.20 Investing in General Practice]

• For brownfield sites, could go straight to tender or choose PCTMS