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What does the future hold for PMS GPs?

PMS GPs have gone from flavour of the month to the target of PCT clawbacks - so what might future hold?

By Lilian Anekwe

PMS GPs have gone from flavour of the month to the target of PCT clawbacks - so what might future hold?

Ten years ago, there were lofty aims for PMS. The new contract would be a powerful tool in recruiting an army of GPs to under-served areas. For a while, PMS GPs were seen almost as an elite, the focus of Government targets – to attract them that is, not to attack them.

Yet the thousands of PMS GPs who have sprung up in England since the introduction of the concept in 1998, have gone from white knights to overpaid sponges in the eyes of ministers, as the Government has stepped up efforts to claw back cash.

The latest ammunition comes via a report by an influential team of researchers from the Centre of Health Economics who analysed 2002/3 tax returns, and found PMS GPs earned £12,500 more than GMS GPs working in a practice with identical characteristics, even after additional expenses were accounted for.

And more recent statistics illustrate how PMS GPs have increasingly moved into the firing line.

Figures from the NHS Litigation Authority show the number of disputes between PMS practices and PCTs rose six-fold between the 2005/6 and 2006/7 financial years. PMS GPs find themselves an easy target for cost-cutting PCTs and those who were initially happy to agree to the contracts 10 years ago are now furiously renegotiating them as a means of clawing back the ‘extra' £12,500 – by fair means or, as PMS GPs claim, by foul.

PMS GPs in Waltham Forest, Redbridge, Suffolk, Hounslow and Northumberland have all been involved in bitter and lengthy disputes with their PCTs over the terms of their contracts in the last six months alone. And with the Government and PCTs scanning the new report, more is set to come.

Dr David Shubhaker, a GP in Barkingside, east London and secretary of Redbridge and Waltham Forest LMC, tells how in the last round of negotiations, Redbridge PCT had initially demanded PMS GPs provide extra clinical services, extended and weekend access, and an additional 122 appointments per GP per 1,000 patients in order to receive their PMS gross payment – and threatened to withdraw the MPIG if PMS GPs refused.

The terms were so demanding that since they were agreed in January, three practices have lost their gross income after not being able to meet them.

‘PMS practices are finding it very difficult to cope with the terms and the extended hours, along with their standard QOF work. They are monitored and micro-managed so closely by the PCT and they have gone along with it to earn their gross income, but a lot of them are considering giving up and going back to GMS contracts,' says Dr Shubhaker.

It would seem times have gone full circle for PMS, which could prove a metaphor for wider NHS policy. What is flavour of the month today can soon become an unwanted fad.

PMS was also introduced to address recruitment and retention problems in areas where there had traditionally been doctor shortages. Until then, it had been difficult for a GP to move between practices, and recently trained GPs who wanted to explore a variety of options before selecting a practice had little choice apart from locum work.

The introduction of well-paid salaried posts in PMS practices removed this obstacle for both practices and individual GPs. The contract gave GPs a new flexibility to innovate: in agreement with their PCT, practices were encouraged to meet the needs of their local patient populations and address inequalities.

In many cases, this meant offering different surgery opening hours, or setting up services for minority ethnic communities, asylum seekers or the homeless.

The number of PMS GPs has risen markedly – from 401 in in 1998, to 7,524 in 2002 and, at the time of the NHS Information Centre's last count, 13,180 in 2006 - approximately a third of all GPs.

But as early as 2004, motions were tabled at the LMC conference hinting at a troubled future for PMS GPs. Negotiators had failed in their bid to secure national negotiating rights and there were doubts superannuation contributions, practice-based commissioning and access to the MPIG.

Four years later, and PMS GPs have found themselves forced to pool resources to hire lawyers to represent them in their negotiations with their PCT.

Dr Jane Lothian, Northumberland LMC secretary, says that even after a long battle, which involved seeking legal advice from the GPC on what their rights were, some practices still stood to lose 25% of their operating budget. Others have been forced to rally round to make up the shortfall in income to keep those practices that stand to lose out afloat.

Even though it was never explicitly mentioned, Northumberland PMS GPs were also negotiating under the threat of the latest Government flavour of the month - that of APMS providers. ‘It was intimated on several occasions that if we didn't meet their demands, there were APMS providers who would', says Dr Lothian.

‘PMS GPs around here don't earn more than their GMS colleagues and we certainly don't feel the criticism that we are overpaid is fair. We are concerned it will fuel the PCT in the future. The PCT is very much dictated to by the Department of Health, so the future of PMS GPs depends on what the Department of Health want for the future of PMS.'

A spokesperson for the department admitted the future of PMS GPs would be one of the subjects tackled by a group convened to review the global sum formula – following heavy criticism of the current Carr-Hill formula.

And a spokesperson for Northumberland PCT suggested PMS GPs in the area might be asked to take on yet more work to maintain their income. ‘We are working with GP representatives to look at services that can be done in primary care that will result in more services for patients closer to home, for example, pre-operative checks.'

Accountants predict more trouble ahead.

Bob Senior, vice-chair of the Association of Independent Specialist Medical Accountants (AISMA), warns as PCTs continue their squeeze on PMS practices, the gains will become even slimmer. ‘The perception is the funding for PMS has been disproportionately high compared with the services they provide over and above GMS. That's why there has been so much focus by PCTs on getting the money back, and at the moment PMS practices are under severe pressure.'

Mr Senior says that pressure may become worse depending on future pay negotiations, as the futures of GMS and PMS contracts ‘go hand in glove'.

‘If they get rid of the MPIG for GMS services it would be very hard to see why they would not do that for PMS practices as well. PMS practices are generally carrying a higher level of funding compared with GMS and if they reviewed the correction factor the majority would find their income squeezed.'

GPC negotiator Dr Chaand Nagpaul, a PMS GP in Stanmore, Middlesex, admits the coming years will be testing. ‘Many PMS GPs are living in a period of real insecurity with regards to what their PCT is going to do and not having national security. They don't have certainty of income flow and are operating under constant threat from their PCT, which makes it very difficult to forward plan because they can't take their budget for granted.'

‘Many GPs are waiting to see the eventual outcome of the GMS negotiations, to see what that holds for GMS and in turn, PMS, says Dr Shubhaker. ‘In the beginning PMS practices were providing a lot and were given more money than GMS ones, but the demands have become greater and greater and many PMS GPs are now asking: "is it worth it?".

Meanwhile many PCTs and, even more worryingly for PMS GPs, the Government, may be asking the same question about them.

Case Study: ‘The Suffolk Test Bed'

In August 2007 GP leaders called the legal wrangling between PMS GPs and Suffolk PCT a test case for future disputes across the country, which signalled a dangerous trend of unilateral renegotiation of PMS contracts. After protracted negotiations and action including a march on Downing Street and the delivery of a 10,000 signature-petition, what has become of the Suffolk testbed?
A spokesperson for Suffolk PCT painted a rosy picture, saying the new PMS agreement ‘brings significant benefits to patients'. ‘The total former level of investment has been redistributed according to a national need-based formula and so there is a fairer payments system in place for the county', she added.
But a PMS GP in Suffolk told Pulse: ‘We were forced to agree but we're stuck between a rock and a hard place. We have had to cut the number of doctor's hours because that's the only way to manage, and I think that's what has happened in all the PMS practices in the area. I don't think PCTs will stop trying to renegotiate contracts – they are going to play hard ball.'
Dr Clare Giles, chair of Suffolk LMC and a GP in Bury St Edmunds, says there have been winners and losers but overall the outcome was fair.
‘I'm one of the losers, we have lost a doctor and a part-time nurse. Every surgery has lost local enhances services but the sum of money spent has not been reduced by the PCT.
‘I do feel that it has been a test case. Thank goodness, all the PMS practices stuck together to make sure we were not railroaded – had we not managed that it would have been different for PMS disputes elsewhere.'

Dr Chaand Nagpaul Dr Chaand Nagpaul; PMS GP and GPC negotiator

'Many PMS GPs are living in a period of real insecurity over what their PCT is going to do.' Dr Chaand Nagpaul; PMS GP and GPC negotiator

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