Since April 2013, the contracting bodies for Local Enhanced Services have been CCGs or Local Authority Public Health departments since.
In the past most LESs were ‘rolled over’ from year to year but from April 2014 there will be a requirement that no new LESs are commissioned, current LESs will be terminated and future services will be delivered through community-based service agreements (CBSAs).
As the statutorily constituted sole representatives of GPs as providers, LMCs must be consulted and to negotiate with commissioners who intend to provide services using general practices, including local authorities.
In negotiating new service agreements with local authorities, these are six points which Londonwide LMCs and London Borough LMCs have found useful to consider.
1. Build a relationship with the local authority and public health departments
Commissioning LESes will be new territory for local authorities and public health staff. Many of them are not yet aware of the nature of general practice and GP contracting and do not understand the nature and function of LMCs. There is little uniformity in terms of approach and process between different local authorities (LAs).
Establish a relationship with the local authority and especially the director of public health and their team. Ensure they understand what an LMC is, but also ensure that they recognise that working with an LMC can add value and deliver solutions.
It is helpful to understand the different constraints they work under and we have found that working with them a useful exercise. For example, we have been encouraging and supporting their application for delegated authority to contract, rather than having to wait for all decisions to be ratified at high level. So far, the public health departments in London seem to be reasonable, pragmatic and easy to work with.
Londonwide LMCs always look to agree a solution to disgareements over future commissioning which:
- Ensures continuing delivery of agreed or required services to patients.
- Allows practices or practice networks to deliver these services where appropriate.
- Avoids unnecessary bureaucracy.
- Produces a contract that balances the requirements for quality and value for money with the need for fair remuneration to providers.
- Produces a contract that the LMC would be able to commend to practices.
2. Find out which services LAs will commission
Services previously delivered through a LES, now the remit of Local Authorities to commission, include:
- sexual health services (chlamydia screening and treatment, STDs, LARC)
- substance abuse
- smoking cessation
- NHS Health Checks (e.g. CVD prevention).
3. Show you understand competition law
Be prepared to offer advice on competition law, how to avoid the need to go to full procurement and the benefits of using practices, and their registered lists to deliver services.1
The Competition and Procurement regulations recently issued by the Government make it clear that when commissioners are procuring for health services, they must ensure that the awards are fair, equitable and subject to competition where the lifetime value of the contract exceeds the procurement threshold of £113,000.
The way this can be done is threefold :
- By going through a full procurement process – that is, issuing an invitation to tender and short-listing candidates that are suitable to provide the service and then making an award based on the fulfilment of certain criteria.
- By not going through procurement, where there is only one possible provider of the services in the locality (e.g. a hospital). This is an exception rather than a rule and the commissioner will have to justify the decision.
- By tendering via AQP. This means that the commissioner has decided that the service can be fulfilled by having a list of providers that can deliver the service. This will require potential providers making an application proving that they satisfy various set criteria and, if they do, then they automatically qualify to be on the ‘provider list’ for those services. The only way in which they are refused to go onto the list if they satisfy the criteria, is if the list is full and there are too many applicants (GPC Law).
4. Set up an interim arrangement
A working knowledge of the requirements in law for a legal contract (consent, consideration, formality, legality and the intention to create legal rights) is often useful. Ensuring that true consultation takes place is important (a requirement to achieve the legal definition of ‘consent’).
Sometimes it is necessary to have an interim arrangement (e.g. by simply attaching the previous LES to the generic public health contract by way of an appendix) to deal with the conflicting pressures resulting from the determination that all current LESes must end and local authorities’ late realisation that they have to agree and disseminate new contracts by the end of March.
Ensuring that proper timescales are agreed for future negotiations is necessary and sometimes the requirements necessary for consultation to have taken place and the requirement for it to take place need to be emphasised (see David Wolfe, referenced in ‘Further reading’).
In the absence of new guidance, it is reasonable to assume that the original LES guidance still stands, although this now applies to the local authority rather than the PCT:
“Enhanced services schemes may be developed in response to local need and either of the contracting parties could ask the LMC to support it in this process.
PCTs must seek to obtain LMC agreement that the enhanced services they propose to commission count within the definition of enhanced services for financial monitoring purposes.
PCTs will be required to consult local practices, LMCs and patients’ forums about the level of investment they propose to make in enhanced services.
Where there is a dispute, the LMC and PCT should try and resolve it locally.
Planned spending against the local enhanced services spending floor must be signed off by the PEC and discussed with the LMC.” (Wolfe)
5. Clarify how practices will apply to provide a LES
Try to negotiate approval criteria which fit with what practices already do (e.g. what they already do for CQC registration, contractual requirements and the Performers’ List for example) and set up a self-declaration mechanism.
Many London local authorities use an online portal for LES accreditation, invoicing and claims. Local authorities often store incomplete information on practices and their contact details and LMCs can help them improve this information.
6. Persuade LAs to use a simple contract
Most local authorities are wedded to the national public health generic contract – a lengthy and arcane document. It may be possible to encourage the use of a simpler contract by reassuring them that this generic one is not mandatory.
We have tried (with some success), to ensure that the original service specifications in the previous LES (activity, reporting, quality standards and payment) stay the same. Public health teams seem willing to simply ensure that the new contracting process is agreed without wishing to enter prolonged negotiations about the actual services.
Dr Tony Grewal is the medical director of Londonwide LMCs.