Earlier this year, NHS England began a country-wide review of PMS contracts, which is due to continue until March 2016. Its aim is to ensure any extra funding for PMS practices, above and beyond what an equivalent GMS practice would get, is linked to providing extra services. It comes after a national review found £260 million of PMS cash was not linked explicitly to extra patient services.
Local area teams now plan to renegotiate aspects of existing PMS contracts, and set new targets and expectations.
Accountants who work with PMS practices have predicted it could lead to losses of £50,000 to £150,000 per practice, with some losing up to £400,000.
Every PMS practice that expects to be reviewed should be prepared even if they have not yet been informed when a review will take place. This article sets out 10 ways in which GPs can achieve the best outcome.
1. Assess the size of your PMS premium
The PMS ‘premium’ is the amount of funding a practice receives per registered patient above the GMS equivalent, although the latter will change as MPIG is gradually phased out. There is now a reluctance to use the term ‘premium’ as, while it correctly describes how the money is used, it perhaps does not fit with current policy to secure best value from this investment in the future. But I will use it to describe the value of the growth monies received with the PMS budget that are above GMS.
Before starting negotiation, find out the value of your PMS premium from your area team. Find your actual contract and familiarise yourself with it. The area team will tell you how much per capita your premium is and you will need to evaluate what you spend this on to justify it. This will include staff and non-core services.
When practices first moved to PMS, there was relatively little guidance attached to qualifying for the money; what guidance there was focused on bidding for money rather than justifying spending. PCTs often blindly approved bids for funding in order to meet their PMS uptake targets, so it may be difficult for practices to justify how the money is spent.
Despite PCTs’ lack of scrutiny of bids, practices were still required to submit plans and uses for growth money in their PMS applications so you should find these agreements for use in the negotiations.
The original growth money was primarily to fund doctors or nurse practitioners specifically. However, in April 2004, growth monies were made permanent in the baselines and had new flexibilities over how they could be used.
This was confirmed in John Hutton’s letter to all PMS practices on 15 Oct 2003, in which he wrote ‘The Government’s commitment to “no unpicking” means that you will be able to retain the baseline funding you receive now, together with any growth monies you have been awarded during the piloting process, as part of your PMS contract price after 1 April 2004. The growth money that has already been agreed will be for you to use flexibly as part of your local agreement. It will no longer be restricted to its current use for GPs and nurse practitioners.’1 This should work in your practice’s favour.
2. Find out when your review will be and how it will work
You should receive notice about the review in a letter from your area team. Notice will be different dependent on the region, but the date should be agreed between the area team and the practice.
Any documentation you receive about the review should include who will be present at the meeting and allow for your own accounting or LMC representative to support you. It should also include the terms of negotiation and set out details of how to proceed if you wish to appeal on process and outcome.
In Manchester, we have had no reviews from area teams as yet and we’re awaiting national guidance. But as an LMC representative, I sat through many of the reviews with PCT managers and during the process, members of the PCT went to the practice and met with whoever was there to represent it. This usually included one to two partners and an LMC representative.
The area team will not formally request any documentation, but it is in your best interest to have some to justify your premium payment.
The review generally lasts two to three hours, but this is dependent on the issues being raised.
3. Contact your LMC or someone who has already been through the process
Once you know when your review will take place, you should have an opportunity to submit supporting evidence for your practice and to also seek help from your LMC.
In Manchester, we went through a PMS contract review in 2010, which was robust and inclusive. Your local LMC can give you helpful advice and support before the review, for example by providing basic information about what services are non-core and what you can expect from the meeting with the area team. An LMC representative should also be there to support you during the meeting.
The rules on switching to GMS
• The contractor must notify the local area team that it wants to enter into a GMS contract three months before the date on which it wants the contract to take effect. It must specify the date for termination of the PMS agreement, the names of the persons entering into a GMS contract and confirmation that those persons meet the relevant conditions.
• There is no agreed formal mechanism for determining the financial position of PMS practices who wish to enter into a GMS contract. While these practices have no statutory right to MPIG, John Hutton’s October 2003 letter to PMS GPs stated: ‘A PMS pilot practice could make a strong and robust case for an MPIG from 1 April in discussion with the PCT’.
• There is no automatic entitlement to retain growth monies on movement to GMS. However, the Hutton letter stressed that this should be allowed ‘where a practice provides evidence that some growth should form part of the global sum equivalent’.
Source: Reviewing PMS contractual arrangements: Guidance for PMS practices, BMA, March 2010 and updated August 2014.
4. Prepare evidence for the review
You need to have some good detailed evidence and statistics to hand during the review, as well as documents setting out patients’ views. For example, you could provide your patients with questionnaires asking them to rate the non-core services you provide and including questions about how they would feel if you stopped providing certain services at the practice. This may cover services such a contraceptive or travel clinic or same-day triage and advanced access. You can then use this information during your review.
You will need a comprehensive list of the staff and services that are funded specifically by your PMS premium. It is therefore a good idea to review all the non-core services you provide through your PMS contract, looking at, for example, the access you provide above any local or national regulations incorporating specialist triage, phlebotomy, immunisation and vaccination, child surveillance, specialist diabetes and other chronic healthcare programmes, travel health provision, and other specialist services. It is advisable to align these services with current CCG/area team proposals and thinking.
You will also need evidence that you provide the maximum quality core services and a list of all DES/LES provision, including specialist minor surgery, contraception or other LESs.
You may also want to identify members of staff, including nurse practitioners and data clerks, who were employed at the onset of your PMS contract to provide your non-core services. It is important to have details of their contracts. There is an associated cost for any redundancies of staff in your practices resulting from this review and you need to bear in mind the current workforce problem and the effect this review may have on that.
5 Consult your patients
Remember, where there are serious threats to patient services, it is important to keep your patients up to date. You could write to patients about the possible threats or use your patient participation groups or forums to inform them. It could also be a good idea to put up posters in the surgery or attach information to repeat prescriptions.
The support of your patients can be invaluable when negotiating. If there are going to be significant changes to patient services, then the area team will need to consult with your list under the Health and Social Care Act 2001.
6. Make your case
Usually there is just one meeting arranged, but if negotiations are not straightforward further meetings could be required. Prepare your submission regarding your practice in advance of the meeting.
Carefully look at your contract. What clauses does it incorporate about changes to it or reviews of it? Have any conditions already been breached by the PCT in the past or by the area team? Has your list size changed at all?
Area teams are asked to verify that all PMS premium funding is tangibly linked to providing a wider range of services or a better quality standard or for providing care for a population with a specific need. Concentrate your efforts on services that address health inequalities, for example by doing services like homelessness projects, mental health triage or assistance with registration, alcohol and drugs team work or work related to long-term conditions. Bear in mind that any funds that become available as a result of PMS reviews are to be equitably shared nationally, so there may be grounds to increase local services using the money that are agreeable to the area team and the practice.
More on PMS
7. Discuss the final deal with your area team
If reductions in your budget are agreed on, make sure they take place in stages over a period of time. For example, in the first year your premium figure could be reduced by £1 per patient and the next year by a little more. Make sure any verbal agreements are also set out in a written agreement sent to you after the meeting. And if additional services are requested by the area team, make sure that they have a sufficient evidence base before agreeing to them.
The final decision will be sent to the practice in writing. Make sure you understand any implications for your practice and your staff and seek help from your accountant and LMC if required. You may reduce your earnings as a GP partner or you may choose to review your staffing or think carefully about the extra work you can do to try to make up for any lost income.
Mark carefully any agreed timescales and keep signed copies of any agreement you enter into. The last PMS reviews in Manchester went well. Some practices reduced their income in a managed way over two to three years so as not to destabilise the practice, and this did affect some staff as their hours were reduced. A number of practices reverted to GMS amicably and one PMS practice actually found it earned less than under the GMS contract, so gladly switched back.
8. Challenge the decision
If you wish to challenge the decision you should already know how to exercise your right of appeal as this should have been set out at the start by the area team. Seek help if required to establish the basis of your challenge. If the right of appeal is not noted on the process documentation, ask your area team for it. Obviously each practice is different; some may wish to appeal any suggestion of a reduction in funding. An appeal should be the route if you have been unable to agree a way forward by mutual negotiation.
It should be noted that an area team’s ability to terminate a contract without proper cause has been weakened substantially due to the outcome of the judicial review of the personal dental services contract (Crouch v South Birmingham PCT).2 Therefore an attempt by the area team to do this could be challenged.
9. Decide your next steps
Once you have reached the final agreement with your area team, you have the following options:
• If there are no changes, you could keep the same PMS contract at the same level of remuneration.
• Revise your contract to include more additional services at the same level of remuneration.
• Revise your PMS contract with a different level of remuneration.
• Change to GMS.
• Change to APMS.
The option you choose will depend on the negotiations with the area team, which is why an LMC representative should accompany you to the meeting. Each practice has an individual figure and each area team has a different viewpoint in its negotiation.
10. Act now
Whichever option you choose, it is of paramount importance that you act now. Dig out your contracts, prepare written information on the quality services you provide and prepare yourself so this does not destabilise your practice and the local health economy. Many practices are already financially compromised and under pressure and many need to retain workforce if they are to take on more work from secondary care. If threatened with termination, contact the GPC via your regional liaison officer or LMC. The LMCs will have guidance and should be able to advise, especially if they were present at the meeting. All LMCs can ask their GPC colleagues for advice if they need to.
Dr Tracey Vell is Manchester LMC honorary secretary