Maximising the Market

1
Maximising the Market
1000 1010 Introduction Aims of The
Day 1010 1100 Primary Care over the next 5
years 1100 1115 Coffee 1115 1200 The
Public Health perspective 1200 1215 Table
Top Discussions 1215 1315 Lunch 1315
1400 The PASA APMS Procurement Toolkit 1400
1415 Coffee 1415 1600 The 4 Primary Care
contracting routes 1600 Closing Remarks

2
Maximising the Market

• Objectives for the day
• Supporting understanding of how assessment of
  need underpins the commissioning of primary care
  services
• Making first steps towards scoping potential
  service gaps
• Raising awareness of the potential services and
  contractual approaches which could fill gaps
  identified
• Supporting overall understanding for
  commissioning services using varied contractual
  approaches.

3
The Future of PrimaryCare / NHSDr. Phil
YatesNewbury14th September 05
4
Structure of Presentation

• Current Challenges
• Potted history and a changing organisation to
  primary care
• Patients as customers
• Creating a Patient Led NHS and Commissioning a
  Patient Led NHS

5
Current Challenges
6
Life Expectancy
ONS 2004
7
Demographic Change by 2020
SG Council 2003
8
Causes of death
ONS 2003
9
Walking or Driving?
Choosing Health 2004
10
Obesity Levels in Childhood
Health Survey for England 2002
11
Estimated Impact on disease of the Growth in
Obesity by 2023
Choosing Health 2004
12
Expected numbers of diabetics Now by 2010.
S Glos PCT 2003
13
Current National Prevalence of Disease
QOF 2005
14
Diabetes in the QOF
15
The rising tide of chronic disease

• As premature deaths from CHD and cancer fall,
  more people will live with chronic disease
• Population aging and dependency ratio rising
• Obesity rising, smoking levels stable in recent
  years

16
Demand on the system
North Bristol Trust 2004
17
Prevalence of Cigarette Smoking in 11-15 yr olds
Health Survey for England 2002
18
Prevalence of Smoking by Age now
Health Survey for England 2002
19
Alcohol drunk in the last week
Health Survey for England 2002
20
Whether drunk in last week
Health Survey for England 2002
21
Chlamydia diagnoses in GUM clinics in England
Choosing Health 2004
22
Young People using Drugs
Health Survey for England 2002
23
Potted History a Changing Organisation to
Primary Care
24
The Policy Context (i)

• 1997. World Bank Development report, The State
  in a changing world.
• 2000. WHO report,
  Health Systems, Improving Performance.
• 2002. Milburn Health secretary of state.
  Unleash the spirit of public sector enterprise
• Patient Choice
• Foundation Hospitals
• Franchising

25
The Policy Context (ii)

• Securing our Future Health Taking a long-term
  View. Derek Wanless 2002
• Securing Good Health for the Whole Population.
  Derek Wanless 2004
• The new GMS Contract
• Choosing Health 2004
• Creating a Patient Led NHS 2005

26
Direction of travel
1965 ?
2005 ?
1998 ?
1990 ?
Organisational Unit
Individual GPs
PCTs /- ?Integrated Trusts (NB Kaiser)
10 Health Services nGMS / CHS
Larger GP Units
Mechanism of Delivery
The Red Book
Various NHS and Private Providers
Practice Contracts (PMS)
GP Commissg GP Fundholdg TPP/Multifund
Service Focus
Populations Communities of Interest Choice
Practice Populations
Specific Target Groups gt75 years etc
Individual Patients
27
Primary Care?- historically
Only Principals each holding a contract
HA Commissioner
GMS
GMS
GMS
P
P
P
P
P
P
P
N
N
N
N
28
Primary Care - now
Performers -fewer Principals holding the contract
plus Non-principals Nurses.
PCT Commissioner
nGMS Provider
PMS Provider
PCTMS Provider
P
P
P
P
N
P
NP
NP
NP
N
NP
N
NP
NP
N
N
N
N
29
Features of current PMS

• Practices have the contract - therefore they need
  to work as teams.
• Performance management relates to contract
  outcome quality.

• Multi-professional steering groups are evolving
  to skill-mix teams appropriately and develop a
  range of staff.

30
Multi-professional Practice Team leadership
Partners meetings
PHCT meetings
Steering Group Practice manager Partner
Salaried doctor Senior PN, DN HV Senior
reception Admin
Business Development Meetings
Doctors, Nurses, Receptionists meetings
Clinical meetings
31
Primary Care- imminent!
Performers become separate to Providers
Specific service provision eg OOH by
APMS Contracts with NFP, Vol sector Private
Sector
PCT Commissioner
Integration into Managed Care Organisations
Link with FTs
PMS/GMS Provider
Interpractice Consortia Collaboration
Consolidation of sites by GPs or others
P
NP
P
NP
P
P
NP
NP
N
N
N
N
SW
N
C
N
32
Features of future Primary Care Contracts

• Providers have the contract - they may be NHS or
  commercial enterprises.
• GPs will become a much smaller, more selectively
  used part of the workforce. They may be mainly
  employed by providers.
• Practices are unlikely to continue to have so
  much development input. They will need to be more
  commercially savvy.
• Performance management by the new PCTs relates to
  all contract outcomes.
• All available contracts will include patient
  satisfaction and VFM components.

33
Shifting boundaries between 10 20 care
Influence ofPbR and PBC
PCT Commissioner
Hospital Services
PMS or nGMS
P
NP
NP
C
Ph
GPSI
N
N
N
SN
SW
ESP
34
The new environment

• Contract monitoring will be stronger - there is
  increased focus on use of public funds.
• There will be greater contestability diversity
  of provider - 15 minimum.
• Competition will force consolidation. Primary
  care will want to take on additional community
  staff to prevent referral to the hospital sector.
• Increasingly, parts of the care pathway will be
  contracted out.

35
Patients as Customers
36
Changes in generational Characteristics

• Silent Generation
• 1925-1942
• Hard-working
• Economically conscientious
• Trust of government
• Optimistic about future
• Strong moral obligations

• Baby Boomers
• 1943 - 1960
• Strong ideals traditions
• Family-oriented
• Fearful of future
• Politically conservative
• Socially liberal
• Trend setting

37

• Generation X
• 1961 - 1980
• Live for the present
• Like to experiment
• Expect immediacy
• Cynical survivors
• Question authority
• Connected to peers
• Independent hot on work / life balance
• Internet/cable/video

• Generation Y
• 1981 - 1994
• Very materialistic
• Challenging
• Individualistic
• Technologically highly literate
• No good role models
• Brand image conscious

38
Implications for Improving and Delivering Health

• Dictats from on high wont wash
• We want to make our own choices resent a nanny
  state
• But we want information expect it to be
  provided in an easily digestible form
• We want convenience and choice
• We dont like a one-size-fits-all approach any
  more.

39
Why is CDM a priority for us?

• The scale of the current need
• The rising tide of chronic disease
• Chronic disease as a source of inequality
• Pressure on NHS resources
• We can do better than episodic care

40
Equity of resource allocation life-expectancy
variation S. Glos.
41

• 450,000 people in AGW SHA with limiting long-term
  illness (15of pop., c. 40 of households)
• Nearly half of people with a chronic disease have
  more than one problem, a quarter have three or
  more problems.
• Not just about the elderly

42
Existence of Co-morbidities
Orchard Med Centre 2005
43
Chronic disease as a source of inequality

• Chronic disease is a health inequalities issue
• Actions to improve care must target these groups
• Beware of just providing excellent services for
  the better-off who opt in

44
Pressure on NHS resources

• About 20 of admissions and bed-days are for
  patients with 3 unplanned admissions in a year
• This group represents only 1 in 300 i.e. 7 per
  practice
• Early intervention may have an impact on hospital
  usage

45
Intensive Input
Case Selection Skill mix / Experts
Risk Analysis
Medicines Management Informatics
Setting Standards
Expert Patient QOF
46
Creating a Patient-led NHSCommissioning a
Patient-led NHS
47
A joined up service?
Pre-primary
Primary Intermediate
Secondary Tertiary
Nurse / Pharmacist / SSD
GP led
Consultant led
NHS Direct Phone Triage Health education
expert patients Pharmacist led repeat
Rx Walk-in centres Expert Patients other
Self-Help
CDM / Risks Elderly surveillance Minor
injury Minor illness Specialist nurses Links
with Social Services
Diagnostic uncertainty 10 diagnosis with good
diagnostic support Hard CDM referrals Ongoing
care GPSIs / Consultants in Primary
Care (Specialists in triage)
Surgical and other high technological
interventions. Community support teams True
consultancy function but handing back
care. Management of rare conditions Specialist
teams in the community
48
Creating a Patient-led NHS

• Policy goal to increase diversity to give -
• Choice for patients - when where treated
• Tailored support to local communities
• Support to individuals to maintain health
• Locally driven but national standards
• Better quality and more capacity (stimulated by
  financial incentives)
• Joined up services and integrated care.

49
Commissioning a Patient-led NHS

• PCTs fit for purpose -
• Securing high quality safe services
• Improve health reduce inequalities
• Improve engagement of GPs (roll out of PBC)
• Improve public involvement
• Improve commissioning and effective use of
  resources
• Manage financial balance and risk

50
Commissioning a Patient-led NHS

• The NHS
• Move from being . provider to commissioner
  driven
• PCTs functions can be provided by external
  agencies, partners and consortia working on their
  behalf

51
Current PCTsManagers Providers in the System
DH
SHA
SSD
Developing Providing PCTs
DNs/HVs
nGMS/nPMS
PCTMS
Therapies
D/O/Ps
Mental Health
Acute Trusts
52
DH
Future PCTCommissioner of the System
Fewer SHAs
SSD
SpPMS
Amalgamated Commissioning PCTs
D/O/Ps
APMS ?DNs/HVs
nGMS/nPMS ?DNs/HVs
Mental Health
Acute Trusts
53
Payment by results

• Where are the incentives?
• Coding creep
• Unbundling stays of care
• Data and coding expertise
• No cross-subsidies
• Shortened lengths of stay
• Pre-hospital tugs of war?
• Outcome focused / provider driven?

54
Practice based commissioning

• Will resource and incentivise practices to
  invest in maintaining the health of their
  patients
• Referral management systems activity analysis
• Admission avoidance - Community nurses?

55
Practice based commissioning

• Measure success by
• Improved access
• Decreased emergency bed days
• PSA targets met
• What will happen when Foundation Trusts arrive?

56
Systems Changes

• PBR suck money into secondary care
• PBC Counterweight
• Secondary to primary care shift
• Care closer to patient
• Demand management
• Referral control
• Quality commissioning
• ?vertical integration
• ? Pathway development Medic to Medic

57
Alternative Providers of Medical Services

• Range of providers. 15 at start.
• Focus on innovation
• But
• Attention to the contract
• Specifications
• Price
• Performance monitoring

58
Making the Market shifting the balance of care

• Contestability use of private sector - 15
• Deliver 18/40 maximum wait by 2008
• Expand capacity
• Secondary primary care (difficulty recruiting,
  quality of services)
• Diagnostics (available to and in primary care)
• New and existing private sector

59
Organisational Model
20 30 interventions / High tech.
investigations Consultancy function Management
of rare conditions Clinical / research /
community support networks
Hospital
Many investigations (X-rays, Scans, ECGs,
etc.) Minor Surgery, Minor injury, Re-modeled
OPs, Mental health, Elderly, Diabetes, Comm.
Paeds. Other links - IT / Community Leisure
Locality
All normal PC - strong full PHCTs. attached
social care teams, pharmacists, dentists.
Extended services (Physio, OT, mental health).
Practice
60
Estates Implications
Thornbury
Yate
NBT UBHT 20 30
Kingswood
Practice Units gt15,000 patients
or consortia gt50,000
ISTCs 20
61
Challenges (i)

• Matching PBC to ex-PCT PSA targets
• Delivering on Choosing Health
• Becoming market managers not just secondary care
  commissioners
• Embracing patient involvement choice without
  financial meltdown (inc 15 savings) or
  fragmentation of care.
• Tension of PBC integrate work with LAs

62
Challenges (ii)

• Transitional role for PCTs very different to
  subsequent ongoing role
• New PCTs will need to manage multi-layered sets
  of relationships, strategic operational
• Commissioning will be complex
• Range of relationships including PPI
• At procurement level in view of breadth of
  providers

63
Thank you
64

• A Public Health Perspective of Primary Care
• Primary Care Contracting Newbury 14.09.05
• Philip Leech
• Consultant adviser to DH and Primary Care
  Contracting
• philip_at_primarycareleads.com

65
Public Health Primary Care

• A very short history of public health
• What are we trying to achieve?
• PH makes economic sense!
• Choosing Health
• Fit for the Future programme
• Practice based commissioning

66
A very short history of public health

• 1830s Dr Duncan Liverpool
• Health problems - medicine no help
• PH measure the only successful ones
• Birth of NHS post war optimism
• 1980s CHD, Legionella, HIV / AIDS
• New public health

67
PUBLIC HEALTH

• The science and art of preventing disease,
  prolonging life and promoting health through the
  organised efforts and choices of society,
  organisations, public and private, communities
  and individuals

68
General causes of premature death and disability

• 10 due to inadequate access to medical care
• 20 genetic
• 20 due to environmental factors
• 50 due to life style factors

69
SCENARIOS IN THE WANLESS REPORT

• SLOW UPTAKE no change in the level of public
  engagement in PH agenda
• SOLID PROGRESS people become more engaged in
  relation to their health
• FULL ENGAGED levels of public engagement in
  relation to their health are high

70
HEALTH IMPROVEMENT

• By 2010 increase life expectancy at birth in
  England to 78.6 years for men and to 82.5 years
  for women.
• Reduce death rates for circulatory disease by at
  least 40 for under 75s, 40 reduction in health
  inequalities
• Reduce death rates for cancer by at least 20 for
  under 75s, 6 reduction in health inequalities.
• Tackle the underlying determinants of health and
  health inequalities by 2010
• Reducing adult smoking rates to 21 or less with
  a reduction in prevalence among routine and
  manual to 26 or less
• Halt the year on year rise in childhood obesity
• Reduce under age teenage conception rate to 50

71
HEALTH IMPROVEMENT 2

• Reduce infant mortality by 20 by 2010
• A 50 reduction in admissions to hospital caused
  by falls amongst the elderly by March 2007
• 70 uptake of pneumococcal vaccination amongst
  over 65s by March 2008.
• 48 hour access to GU services by March 2008.
• No increase in the rates of chlamydia
• Reduce rates of suicide

72
Background to Choosing Health

• Biggest Public Consultation Exercise.
• Public interest in improving health.
• Priorities and reasons for identifying these.
• More down to earth more practical approach to
  public health.
• A Peoples Manifesto for Improving Peoples Health
  through new action and fresh thinking.

73
6 Priorities for action

• Reduce numbers smoking building on current
  progress
• Reduce Obesity with focus on children
• Support sensible drinking - new programmes
• Improve sexual health new programmes
• Improve mental health and well being
• Tackle health inequalities - targets

74
Reducing numbers of smokers because

• It leads to heart disease, strokes, cancer and
  many other fatal diseases
• Many people felt was area which they needed more
  personalised support
• Many people concerned about effects of
  second-hand smoke
• Many parents concerned about their children
  taking up smoking

75
Reducing obesity, improving diet and nutrition
because

• Rapid increase in child and adult obesity over
  last decade
• Effective action on diet and exercise needed now

76
Encouraging and supporting sensible drinking
because

• It is related to
• absenteeism
• domestic violence
• violent crime
• physical and psychological disease

77
Increasing exercise because

• It reduces risk of major chronic diseases and
  premature death.
• People are not active enough to benefit their
  health.
• People feel better!

78
Improving sexual health because

• Risk-taking sexual behaviour is increasing across
  the population
• Teenage pregnancy important issue
• STDs can lead to cancer, infertility
• HIV still a potential serious threat in UK

79
Improving mental health because

• Mental well-being crucial to good physical health
  and making healthy choices
• Mental ill-health can lead to suicide

80
Health inequalities

• Support to vulnerable people
• Social exclusion
• Social justice issue
• Social cohesion

81
Life Expectancy

• A boy born in the most disadvantaged ward in
  Barnsley can expect to live 12 years less than a
  boy born in an affluent ward in England.

82
Key Messages

• A new approach to the health of the public
• Respect Individuals - informed choice
• Support and advice - from next door rather than
  advice from on high
• Close the Gap - too many left behind or ignored

83
Practice-based commissioning

• Opening public sector to the market place
• Purchasing by results
• Foundation Trusts (acute and community)
• ISTCs

84
Fund holding revisited

• Primary care will become more concerned about the
  cost of treatment
• Preventing inappropriate admissions
• Short term - frail elderly
• Longer term smoking, diet, exercise
• Cost per case / out of area treatment

85
Health inequalities

• Support to vulnerable people
• Social exclusion
• Social justice issue
• Social cohesion

86
Fit for the Future Structure
Local Strategic Partnership One Barnsley
Use current strategic and operational and
participation structures
Champions and leaders are at all levels in
organisations
Fit for the Future Steering Group
Programme Areas
SNAP
Families, Children and Young People
Strengthening Communities
Wider Determinants of Health
Improving Primary Care
Role of the NHS in the Local Economy
87
Fit for the Future

• Winning hearts and minds
• Securing funding
• maximise special funding
• bending the mainstream
• Social marketing
• Evidence base
• Scale of intervention

88
Statutory PH functions primary care

• Emergency planning especially flu pandemic
  plans
• Infectious diseases including STDs
• Screening cervix, breast, colon
• Vaccination and immunisation

89
The new PH workforce

• Lay health workers, health trainers
• GPs, practice nurses, health visitors, school
  nurses , midwives
• Health promoting hospitals
• Pharmacists
• Public health specialists
• Others drug advisors, counsellors, dieticians,
  teenage pregnancy advisers, physiotherapists
• PCT Staff

90
Summary

• Strong economic case for PH
• Primary care commissioning - opportunities to
  improve health have never better!
• Primary care must engage with statutory PH
  programmes

91

• A Public Health Perspective of Primary Care
• Primary Care Contracting Newbury 14.09.05
• Philip Leech
• Consultant adviser to DH and Primary Care
  Contracting
• philip_at_primarycareleads.com

92
Maximising the Market

• Session 3 - Table top discussion
• Identify the key challenges over the next 5 years
• What will drive these challenges?
• How can PCTs overcome any obstacles?

93

• The APMS procurement guide
• Faye Robinson, Category Manager
• Maximising the market event
• Newbury Racecourse
• 14 September 2005

94
Agenda

• the role and remit of the NHS Purchasing and
  Supply Agency
• the APMS procurement guide
• other category activities 2005/6

95
NHS Purchasing and Supply Agency

• Established 1 April 2000
• works on behalf of the NHS
• executive agency of the Department of Health
• centrally funded
• 326 staff
• NHS Logistics Authority

96
Role of the Agency
NHS PASA
97
Role

• purchasing and supply strategy across the NHS and
  UK Department of Health
• national contracting which has delivered around
  1.5 billion savings since 2000
• once-only services
• E.g. national terms and conditions, supplier
  information database, purchasing procedures etc
• training and development to support procurement
  professionals within the NHS.

98
NHS non-pay spend 17bn
99
National purchasing categories

• pharmaceuticals
• stationery
• utilities
• IT
• professional services (e.g. Agency Staffing)
• medical and surgical
• food
• cleaning products
• medical equipment

100
Criteria national purchasing

• clear benefit in aggregating demand
• best value for NHS as a whole
• cannot be bettered at hospital/confederation
  level
• commitment and support by hospitals
• procurement guides to support NHS Trusts
  confederations where work not contracted
  nationally

101
National contracts programme

• initial phase
• - 11 categories
• - 113 million savings (additional)
• next phase
• - scoping 12 categories
• outcome by 2007/08
• - 240 million savings on 4 billion spend
• lessons learnt
• PASA restructuring and operation

102
 
Procurement guide
Alternative Provider Medical Services (APMS)
August 2005    
103
APMS toolkit

• purpose of the procurement guide
• to provide a comprehensive step by step guide to
  enable a PCT to establish an APMS contract
• has been compiled in conjunction with colleagues
  at the DoH
• contains a policy section but is not a policy
  document
• scope of the guide
• not mandatory but provides best practice
  procurement guidance and legal compliance
  information
• using the guide

104
Contents of APMS toolkit

• introduction
• background policy content
• the procurement process flowchart
• service requirements
• risk overview
• EU issues
• evaluation criteria overview
• sourcing potential service providers
• invitation to submit a preliminary offer
• offer evaluations, evaluation of preliminary
  offers
• award of contract
• post award notification
• monitoring performance
• other resources

105
APMS toolkit

• comments, feedback and updates
• this is a live document and may be subject to
  amendments following wave 1 pilot programme
• all comments and feedback welcomed please email
  as per contact in the document
• where to find the guide
• Agency website via NHS net nww.pasa.nhs.uk/nhsfor
  um/shared/pct/

106
Other Category activities 2005/6

• production of a purchasing guide for Palliative
  care
• early stage investigation into forensic mental
  health services
• support to NHS supply confederations work on
  whole area of purchase of non acute healthcare

Long-Term Care
Intermediate Care
Continuing care
Palliative Care
Mental Health
Short term rehab
ALD
Young Physically Disabled
Temporary Nursing Care
Older People
107

• For further details or information please
  contact
• Faye.Robinson_at_pasa.nhs.uk or telephone 01626
  864698
• also see
• http//nww.pasa.nhs.uk/nhsforum/shared/pct/

108
The 4 Primary Care Contracting Routes

• Mark Wilson
• Specialist Advisor
• NHS Primary Care Contracting

109
Legal responsibility

• Each Primary Care Trust must, to the extent
  that it considers necessary to meet all
  reasonable requirements, exercise its powers so
  as to provide primary medical services within its
  area, or secure their provision within its
  area.     
• Section 16CC(1) of the National Health Service
  Act 1977

110
PCT powers

•     A Primary Care Trust may (in addition to
  any other power conferred on it) -
• (a) provide primary medical services itself
  (whether within or outside its area)
• (b) make such arrangements for their provision
  (whether within or outside its area) as it thinks
  fit, and may in particular make contractual
  arrangements with any person.
• Section 16CC(2) of the National Health Service
  Act 1977

111
PCT Provision

• PCTs are encouraged to develop a minimum level
  of (provision of essential) services....
• If PCTs propose to become large-scale providers
  of primary medical services, they are expected to
  discuss this first with their SHA. They are also
  expected to consult with LMCs.
• para 2.6 Delivering Investment in General
  Practice

112
Why provide?

• Provision is not an easy option
• No transfer of clinical risk (capacity?)
• No transfer of financial risk (equity?)
• Performance (measuring quality?)
• but
• Control
• Inject competition/capacity?
• Innovation?

113
PCT Provision

• Two routes
• PMS
• PCTMS
• NB. If PCT is providing dispensing services in
  addition to primary medical services, these can
  only be delivered through a PMS arrangement.

114
Whats the difference?

• PMS
• Requires contract between SHA and PCT that
  conforms to Regulations
• Where the contractor is a PCT, the agreement
  must specify that its list of patients is open.
• Para 11(4) NHS (PMS Agreements) Regulations
  2004
• PCTMS
• No contract required
• No requirement to maintain open list

115
PCTs as PMS provider

• Under PMS, the PCT can be the contractor but
  this involves the SHA acting as the commissioner.
  The SHA commissioner role is increasingly
  anomalous given StBoP and PCTs may ... wish to
  transfer such PMS contracts to PCTMS arrangements
  where the PCT is the direct provider.
• para 2.6 Delivering Investment in General
  Practice

116
Why commission?

• Benefits
• Transfer of clinical risk
• Transfer of financial risk (to varying degrees)
• Expansion of capacity/competition?
• Innovation?
• but
• Effective procurement process
• Effective performance monitoring

117
Procurement Process

• Securing essential services
• Can choose PCTMS, or commission-
• For greenfield sites, two stage process
• First, competition between GMS and PMS practices
  (which would have preferred provider status)
• Then, open competition.
• For brownfield sites, could go straight to tender
  
• para 7.20 Investing in General Practice

118
Contracting Routes - Summary
119
Contractor types

• Contracting routes are options not requirements
• The key determinant of the options available is
  how the ownership of the business is structured
• Contractors may therefore hold a variety of
  contract types with a variety of commissioners
• Eg. a GMS contractor might also hold an APMS
  contract with a second PCT.
• For new arrangements, contract type is determined
  by the commissioner

120
Pensions

• If a contractor qualifies as a GMS or a PMS
  provider then they may become an NHS Pension
  Scheme Employing Authority ie can offer NHS
  Pensions to their staff.
• If a contractor only qualifies for APMS contracts
  then they cannot be an NHS Pension Scheme
  Employing Authority ie they cannot offer NHS
  Pensions to their staff
• NB. this includes staff who have transferred
  from the NHS.

121
GMS Contractors

• A general medical practitioner
• Two or more individuals practising in
  partnership
• At least one partner (who must not be a limited
  partner) must be a general medical practitioner
• Other partners must be individuals from within
  the NHS family
• Company limited by shares
• At least one share must be legally and
  beneficially owned by a general medical
  practitioner
• Other shares must be legally and beneficially
  owned by individuals from within the NHS family

122
PMS Contractors

• Agreements can be made with one or more of the
  following
• An NHS Trust
• A medical practitioner
• A healthcare professional
• An individual who is a GMS or PMS provider
• An NHS employee or a PMS employee
• A qualifying body (a company limited by shares,
  all of which are legally and beneficially owned
  by persons identified above)

123
APMS Contractors

• PCTs may make contractual arrangements with any
  person (for the provision of primary medical
  services)
• Section 16CC(2)(b)of the National Health Service
  Act 1977
• Specific provisions for
• Individuals
• Companies
• Partnerships
• Industrial and provident societies, friendly
  societies, voluntary organisations
• ie. must be fit and proper persons.

124
PCTs as commissioner

• Three routes for essential services

125
Contracting for enhanced services

• GMS Regulations require provision of essential
  services
• PMS Regulations do not require provision of
  essential services
• APMS contracts without essential services or
• PMS contracts without essential services (SPMS)
• Allows for contracts with organisations solely
  for the provision of enhanced services

126
Full range of services

• If contract does not require provision of
  essential services then
• No requirement to register patients
• No requirement for GP input
• BUT
• PCT must ensure that all patients have access to
  the full range of essential services
• SPMS or APMS (without essential services) must
  always be combined with another contract such
  that the combination of contracts secures the
  full range of essential services

127
Commissioning Strategy

• Whole systems approach
• Commissioning strategy must cover the full range
  of services
• Key area is boundary between primary and
  secondary care enhanced services
• Focus on commissioning services not contractual
  form
• Contractual form is dependent on organisational
  structure of contractor
• Whatever the service and whoever the provider,
  there is a contractual form that fits!

128
Process
Identify needs
Monitor outcomes
Practice-based / locality commissioners
Develop PCT commissioning strategy
Undertake procurement process
Negotiate contracts
129
Contracting routes scenarios
130
Scenario

• PCT wants to establish a service for drug misuse
  and a shared care program.
• This doesnt include essential services for these
  patients, these will be provided by their
  registered practice
• Option 1 direct provision by PCT employed staff
  
• What contract do we use?
• Option 2 , a group of specialist nurses want to
  do this ?
• They wish to remain employed by PCT.
• What contract?
• What if they want to have the budget and be a
  NHS body?
•  
• Option 3 A GMS practice has shown interest in
  doing this for a locality
• What Contract ?
•  
• Option 4 A local pharmacy consortium wants to
  provide the service and employ the nurses.

131
Scenario

• Dec 04, You suspend a single handed Doctor.
• His patients are high ethnicity, obviously
  quality is an issue and reflected in a poor QOF
  score at this point ( less 200 )
• Your knight in shining armour is a fairly local
  practice that has 4 GPs and offers to provide
  cover and at the same time increase the quality
  as demonstrated by the QOF.
• They are a leading practice, quality is
  excellent, the principal partner is PEC chair
• Their offer costs which equate to 200K ( just
  for GP cover )hourly rate equates to twice the
  remuneration of a PEC GP
• They also suggest that pending the result of the
  GP enquiry, they are willing to take on the
  practice population.
• You predict the enquiry will take 18months to
  complete.

132
Scenario

• 2 partner GMS practice, 4200 patients, Dr G is
  70, Dr A is a PEC member, Dr As wife is the
  practice manager. They practice from a PCT owned
  health center
• They write to PCT with a termination notice and
  add that they wish to split the partnership and
  continue as 2 single handers from the health
  center.
• A practice nurse has shown a keen interest to
  become a Provider and employing Dr G as salaried
  GP. ( he simple wants to carry on working )

133
Scenario

• Single handed GP wants to retire, take his
  pension in April 06, and return
• He asks you what he must do.
•  Do you have to terminate the contract, provide
  the service for the month while hes retired and
  give him a new contract?
• Can he continue the same contract and employ a
  full time or series of part time locums?
•  Do you have to give him a contract on his
  return?
• Do you reduce he global sum by the amount he was
  paying into the pension fund, now that he doesnt
  contribute?
• MPIG?, Patients?

134
Scenario

• 2 GMS practices 5 miles apart want to merge
• 1 practice is a training practice, 3 GPs ,( 5000
  patients ) the other is a single hander, 2200
  patients and GP is 63 years old. He has not
  stated any plans to retire
• Both Premises are privately owned.
• 1 practice is EMIS, 1 is IPS Vision

135
Scenario

• Large PMS practice, 12,000 patients 7 GPs urban
  locations.
• 2 sites, 2 distinct populations
• 6000 students, all access 1 site, remaining
  patients are a typical urban mix, access the
  other surgery
• The practice feels it is being disadvantaged by
  the national QOF because of prevalence. They
  suggest a local QOF for the Student half of the
  patients
• They do not want to break up the partnership

136
Scenario

• Locality manager has a problem of quality with a
  number of single handed practices in an urban
  area. High ethnicity, poverty , average list
  sizes gt2,500
• All of the problem practices are based in health
  centres , there is a multi-million premises
  development planned and been approved ( money
  secured)
• Locality manager wants to set up a PCTMS. LMC
  dont want to rock the boat.

137
Maximising the Market

• Closing Remarks