If you are a PMS practice and have not gone through a PMS review, you should expect to do so. PCTs and clusters have been told to look into equity between PMS and GMS contracts, and are looking for a real justification for receipts over and above the GMS average.
On the whole, PCTs have taken a considered and responsible approach, but a minority have behaved in an irresponsible and belligerent fashion.
In the best cases, PCTs have made only few alterations – or made considerable changes and still kept their PMS practices on board through appropriate and mature handling. In the worst, practices have been destabilised and PCTs have had to admit failure by ending – or in some cases, beginning – the process with a threat of termination of contract.
It is important you get in touch with your PMS colleagues and prepare for a review. Then you will be equipped to make the best of the contract review process. This article will give you some steps on how to do this.
Prepare the ground
Even if no review is currently planned in your area, get together with your local PMS colleagues and start to share figures and ideas. Look at what others are doing and how you might justify the resources you are receiving, and prepare for closer working.
Meet your PCT
Try to find out as soon as possible if a review is to be held – colleagues on the PEC or emerging clinical commissioning group may be able to give you an idea of when this could happen. Hopefully, clusters and PCTs will wish to start off by approaching PMS practices early and without threats.
If you are aware of a review in the offing, get together with your PMS colleagues locally if you have not already done so, ask to meet your primary care director and propose a meeting to introduce the members of your group and request inclusion from the earliest stages.
Agree your negotiators
Agree a team – a maximum of four or five if possible – to negotiate for your PMS group, including a practice manager if you can. The team should constantly and proactively feed back on developments and recommendations to the broader group of PMS practices, who must see that you are still representing all of them.
Make sure only one person is authorised to convey agreements to the PCT, and be careful you are not divided and then picked off one by one. Your LMC personnel may have close working relationships with your cluster or PCT and will also have to represent your GMS colleagues, so it may be inappropriate for them to negotiate on your behalf.
It is a little-known fact that your LMC can, on your behalf, request assistance from the GPC with the negotiation process in the form of an experienced outside negotiator. We did so, and it is one of the key reasons we reached agreement.
I would urge all PMS groups to do this, as it also avoids the opening of old local wounds, whether with other practices or with your PCT or cluster.
Agree basic principles
Once you are ready to go, you should agree basic principles with your PCT or cluster – what are you both hoping to achieve from this process?
You could accept that the PCT or cluster has been instructed to look at equity and that value for money must be demonstrated. Delivering greater quality for the same cost is an important QIPP principle that may be achieved through this process, and is a good place to start.
This will mean, however, that any extra resources will require justification. Even so, most areas have agreed that the PMS pot will remain within PMS as long as it is justified.
Perhaps most importantly, you will want to agree at the outset that no practice should be destabilised by the PMS review process.
This was an important early agreed principle in our review that went some way to reassure both sides, and later led to an understanding of the need for a transitional period for the practices that were to suffer the greatest losses.
Run a ‘legal blackline’ on your contract
At this stage you will be ready to negotiate, but do not leave agreeing a basic contract until last thinking it will be a formality. It is a long process, usually slowed down by legal advisers.
Your LMC should be able to have contracts looked at by lawyers. However, I would recommend that you run your own ‘legal blackline’ comparison of whatever the PCT presents against the GMS contract yourself. In our negotiations, external advice turned up one minor difference – whereas our comparison turned up around 50, often major, changes. For instance, in the version we were given, all references to allowing the LMC to help had been removed and another PCT’s monitoring mechanisms had been included. The names of two previous PCTs that had dabbled with the contract were also included.
Anyone who has taken legal advice on contracts will have been terribly impressed by the documents produced by lawyers where every difference in versions has been underlined in black – in fact, this is done automatically and takes around 10 seconds.
There are several issues that apply only to PMS contracts, but the basic format should be the same. If it is broadly similar in structure, take a Word version of the contract, and open a version of the standard GMS contract as well. Depending on which version of Word you have, go to ‘tools’, then ‘compare and merge documents’, or ‘review’ then ‘compare’. At this point, choose ‘legal blackline’. You will then have your original document with every change underlined saying who changed it and when. This will save you having to read through the whole thing.
One note on version control – make sure each new version is clearly marked so that you know you are all discussing the same one. If several people are commenting, make sure they track changes and include their initials at the end of the new title. One person should be responsible for being the keeper of the most current document. When you have agreed the final document, run the blackline again – it is remarkable what can creep in.
Agree baseline funding
Look at the variation in PMS funding across practices and consider what level practices consider achievable as a baseline. This might be £10-15 per patient over and above the local GMS baseline.
Remember this will be on the basis of weighted lists – in most areas there do not seem to be any winners from this consideration, so you are likely to appear to have fewer patients. You will therefore require a greater capitation per head to achieve the same income as from a weighted population.
Your practice manager or cluster primary care team should be able to get the Exeter access that give your official list size and the calculations within the capitation formula that give your final weighted list. (Your practice manager will understand what this means.) You should check these figures, but by and large they are beyond the control of your PCT or cluster.
Remember: if you are opted in for out-of-hours, you may still be receiving development funding that was based on unweighted patient numbers. This needs to be removed before your baseline is calculated. Your PMS baseline should also still contain around £3.30 per unweighted patient covering out-of-hours. This should also be removed before the baseline calculations are made.
If you have a prescribing agreement, it is unusual for this to have been included within the baseline and could be separated out as a service level agreement. Also, any PMS-plus payments outside primary care should be removed from the PMS baseline if equity is being explored.
Set performance indicators
At this stage you need to agree the additional key performance indicators that will bring your figure to the agreed local PMS baseline. This could include issues such as higher vaccination targets and better access. Once this figure has been calculated against weighted lists, the extra pooled PMS funding should go to, what we call in Kingston, premium key performance indicators (KPIs). These are services that are over and above PMS baseline delivery.
Find some insomniacs in your PMS group with an interest in doing this, and you can achieve it. We came up with 20 plus costed premium KPIs. These included premium KPIs developed with the public health department to address the issues of health inequalities and hard-to-reach groups. Figures were costed and agreed with the PCT.
Click here for an example spreadsheet for costing these premium KPIs and a guide to service costings, although this will only give you a ballpark figure as several of the parameters have since changed. Final figures should be rounded up to the nearest 50p per head. Practices can then choose the premium KPIs that are most appropriate for them to reach an agreed upper per-capita limit.
Include a transitional period
If there are practices losing more than 4-5% in any year, a transitional period should be agreed. Any practice losing more than this is at risk of destabilisation, which is not in the interest of either party.
For many areas this has been a period of three years at least, indicating the extent of losses in some practices. Both increases and reductions should be managed from within the total PMS pot.
Sign off on the agreement
This always takes longer than expected and don’t let managers bully you – there is nothing to be gained by a PCT at this stage threatening termination of contract when you know you are nearly there.
You will need to agree the following:
• the base contract
• a spreadsheet with the actual contract figures, including the years of transition for practices set to lose more than 4-5%
• individual budget offers
• the KPIs to reach the local baseline
• the premium KPIs to reach the local PMS maximum
• the monitoring process
• any payback agreements if premium KPIs are not met.
But if it all goes wrong…
In the rare event of a PCT or cluster being unable to reach agreement, practices should always be left with some PMS offer. However, there can be an element of spite, almost, where a PCT has said ‘agree by this date or we take the contract away’. The practice has three months to reach agreement. In the first three months of the six-month notice period, the practice has the right to request return to GMS.
If you are faced with a return to GMS, do not go it alone. Your LMC may again be able to help, but for the reasons given above, you may wish to look elsewhere. At the very least, your accountants should be able to get you a better deal (but remind them about the out-of-hours development funding). Some areas have reached agreement on variable amounts over and above baseline via a variety of routes to reach an MPIG agreement that does not destabilise the practice. It is a fact that in many cases, ‘growth monies’ were given to practices to deal with localised health inequalities and GP staffing inadequacies. If this is the case, the same arguments apply, and in some areas MPIGs have been agreed above the local GMS baseline.
This process may leave you out of pocket, but should ensure that you can make clear business decisions and rationalise your delivery of services to your patients appropriately and in a planned fashion. In future, it is hoped that responsible and mature clusters will continue to honour the agreements that have often had huge investment by PCTs and practices.
Dr Peter Smith is a GP in Kingston and vice-president of the National Association of Primary Care