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Is it the end of the road for PMS?

PMS was a contract of its time, but now looks outdated and is set to be a victim of the economic crisis, says Dr Jane Lothian. But Dr Peter Smith is robust in his response, insisting PMS will survive and thrive provided GPs withstand bullying against them.

The PMS contract from its inception was intended to provide flexibility in an era where the old GMS contract imposed a rigidity that never was intended.

For those of you who were around then, think back to the good old days of the Red Book – that tome that used to take pride of place on one's consulting room shelf.

As a younger GP it was all a bit bewildering, but eventually we learned that this was the bible and instruction manual for filling out myriads of bits of paper, and the excuse for shoving a form under the nose of every poor unsuspecting patient who came for a pill check.

The structure was reassuring, but as the face of general practice began to change in the late 80s and 90s, practices started to be hamstrung by regulations such as the basic practice allowance; in areas such as the one in which I practice, development was impossible because of the loss of funds when there were no new GPs wishing to take partnerships.

Then along came PMS. It appeared to be the answer to all our prayers; freedom from forms, freedom from restrictions and freedom to develop primary care to fit local needs.

It was a bit scary leaving the safety of the Red Book but those were the days when GPs were still viewed as trustworthy professionals who could be tasked with developing primary care, not pursued as public enemy No 1. PMS was about trust, with co-operative working between primary care and the health authorities.

PMS was a contract for its time and in many areas it engaged and inspired clinicians . However, life and politics move on. Nearly 15 years have passed and for anything to have survived that long in the NHS is nothing short of a miracle.

Why won't it survive? Well, along came nGMS and the QOF; spookily much looked remarkably like the best bits of PMS experiments, rewarding quality and allowing some flexibility – that was good. Alongside these, PMS continued. Growth monies remained but now often relating to services wholly or partially covered in enhanced services.

All seemed well during times of NHS investment, but with hard times around the corner PCOs needed to take out every bit of ‘fat' possible to balance the books. What better soft target than those trusting middle-aged GPs beavering away under cover of their dusty old PMS contracts that no-one had chosen to scrutinise too closely?

Soon various battle cries were hear from our PCO masters:

‘What are you doing to justify growth monies?'

‘There's an element of double payment here'

and ‘You must show value for money.'

Contracts designed to produce a quality outcome for which no quantitative parameter had ever been required were vulnerable – to an extent which (cynically) may be directly proportional to the size of the PCO deficit.

And the rest as they say is history.

PMS requires variability, not in quality but in the elements of service delivered to local populations. This is not a weakness but an intended consequence.

How can PMS survive in a policy climate where variation is a dirty word and a synonym for poor practice? Justifiable variation – meaning patients A and B may not have exactly the same service available – is now used by the media and politicians to criticise and make claims of failure.

It's not possible to terminate nGMS contracts without due cause. The chance of bringing PMS contractors onto the same footing seems to have been lost.

With PCOs seemingly being encouraged to terminate contracts for minor transgressions, can any PMS contractor afford not to question the wisdom of staying PMS when the financial future is so uncertain?

PMS was a contract for its time. In the current financial climate it is highly unlikely to survive. However I have this funny feeling that the following scenario may arise:

May 2020; one of our younger GP partners now in the role of senior executive partner, struggling to provide services to a high demand population, will say: ‘You know, what we need is a mechanism in our service contract to allow some flexibility. I remember when I first joined this practice they had a really good arrangement. I think it was called PMS.'

Dr Jane Lothian is a GP in Ashington and secretary of Nothumberland LMC

PMS contracts can not only survive NHS cutbacks but should be seen as part of the solution to achieving sustainable savings. However, its success will depend on support for sustainable change by PCTs and GP organisations.

At a time when most unions have shown wholesale support for their members, we have witnessed a staggering abdication of our union's responsibilities towards 40% of the GP workforce.

In many cases this has progressed to almost gleeful attempts to hasten the demise of PMS contracts; witness the statement from a London GP leader that ‘the writing is on the wall for PMS'.

This disenfranchisement of a very significant proportion of its members by a union is shameful; more so because of the spurious basis on which it has been made - the recent minor changes in PMS regulations.

The process of refusing to defend PMS practices has been self-destructive and has exposed GPs to further threats. PCTs are increasingly using the private sector in APMS contracts, which appear to allow these flexibilities because GMS cannot deliver individual practice variations.

In one area a high quality practice is threatened with removal of its contract unless it signs a contract variation. Neither its LMC nor the GPC has challenged this increasingly unreasonable behaviour.

In this vacuum of support, many practices have turned to the National Association of Primary Care with its reputation for encouraging innovation through PMS.

Within the next few days the NAPC will be advising member practices on their rights and how to challenge PCTs. In the absence of union support for PMS it will consider backing a test case challenge where a PCT is behaving unreasonably.

Since the inception of the new GMS contract, GP leaders have peddled the myth, that ‘there is nothing that PMS can do that can't be done in GMS'.

Evidence is all to the contrary. The collusion of many LMCs with PCTs against PMS during recent years has certainly led to a stranglehold on individual practice innovation.

The ‘tyranny of equitable mediocrity' has held sway, with innovation held in check, rather than seeing GMS as a baseline on which individual PMS practices may demonstrate innovation and improvement. Despite this, there are many examples of developments at individual PMS practice level.

Services have been delivered to hard to reach populations through PMS, including to the homeless in the hostels of East London, to street sex workers in the Midlands and to travellers in unique local contracts.

These did not require national negotiation or the long winded levelling down process so often seen in LES negotiations.

Other PMS practices pioneered extended opening hours to meet the needs of patients; one continues to deliver a joint antenatal class with the National Childbirth Trust (NCT) using PMS to encourage breastfeeding in a deprived population, runs a late opening children's clinic and opens on Sundays to meet its patient's needs.

Practices that were not prevented by PCTs from using PMS+ and SPMS continue to demonstrate wider developments.

One practice of only 5500 patients repatriated outpatient contacts saving £100,000 a year. Another took on 60 per cent of outpatient referrals, physio and day surgery, saving £500,000 a year.

Others have introduced GPSI-run dermatology outreach, cardiology outreach and have employed ENT consultants, removing the need for expensive secondary care follow ups.

At a time when secondary care to primary care shifts are required to release savings, SHAs and PCTs should see that PMS offers a painless route to this process.

In the words of John Hutton ‘PMS is here to stay' if PCTs make the most of its flexibilities and practices stand up to PCT bullying.

It is hoped that the administration returned by the election will ensure that PMS is more closely aligned with APMS, not GMS and unlike our union leaders, will see the worth of this local empowerment of practices to deliver real change in primary care.

It will then not only survive but prosper. Until that time, practices can turn to the haven of the NAPC for support.

Dr Peter Smith is vice president of the National Association of Primary Care and a PMS GP in Kingston-upon-Thames, Surrey

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