Maximising the Market Newcastle

1
Maximising the Market - Newcastle
10.00 10.10 Introduction 10.10
10.55 Primary Care over the next 5 years 10.55
11.15 Coffee 11.15 12.00 The Public Health
perspective 12.00 12.30 Workshop - Identifying
key issues for PCTs 12.30 13.30 Lunch 13.30
14.15 The 4 Primary Care contracting
routes 14.15 14.30 Coffee 14.30 15.30 The
4 Primary Care contracting routes 15.30 Close

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Simon GilbyChief Executive

• Sheffield West Primary Care Trust
• 6 October 2005
• PRIMARY CARE OVER THE NEXT
• 5 YEARS

3
Scope

• Overview of the agenda facing primary care
• policy context
• demographics and the public health agenda
• market capacity and capability
• (some challenges and some opportunities?)

4
The policy context

• A patient-led NHS
• Policy drivers
• Strong commissioning

5
A patient-led NHS (March 2005)

• Choice for patients when and 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

6
Primary Care

• Care as close as possible to patients home
• Choice and diversity in primary care
• New types of professional
• New types of services
• (from A patient led NHS)

7
Policy drivers

• Choice
• Payment by results
• Contestability
• (contestability drives innovation)

8
Commissioning a Patient-Led NHS (July 2005)

• Primary Care Trusts Fit for Purpose
• (not fit for the choice, PBR PBC, contestability
  era?)
• Secure high quality and safe services
• Improve health and reduce inequalities
• Improve the engagement of GPs
• (universal rollout of Practice Based
  Commissioning)
• Improve public involvement
• Improve commissioning/effective use of resources
• Manage financial balance and risk

9
Commissioning a Patient-led NHS

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

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Demographics and public health

• Health is improving
• Inequalities remain
• Increase in chronic conditions

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Morbidity
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The rising tide of chronic conditions

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

15
Market capacity and capability(challenges and
opportunities?)

• Improving health
• Long term conditions
• Primary care led

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Choosing Health

• Tackling health inequalities
• Reducing the number of people who smoke
• Tackling obesity
• Improving sexual health
• Improving mental health and well-being
• Reducing harm and encouraging sensible drinking
• (Choosing Health Making Healthier Choices
  Easier (2004))

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Self Care

• GP visits ?40
• O-P visits ?17
• AE Use ?50
• Hospital admissions halved
• Hospital lengths of stay halved
• Medicines intake regulated or reduced
• Days off work ?50
• (Self care a real choice DH 2005)
• (cf also Kings Fund report July 2005)

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Self Care Support and Self Care
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Self-Care Requires

• Appropriate and accessible advice and information
• Health education
• Self-care skills training
• Self diagnostic tools
• Individualised care plans
• Support networks
• Education and training of practitioners

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Primary Care Commissioning

• Hard nosed procurement
• (driving up quality and pushing down costs)
• Strategic planning (with authority)
• System management
• Allocative efficiency
• (right mix of outputs to achieve maximum health
  gain)
• Supporting GPs to secure a good range of services
  from which patients can choose

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Payment by Results

• Where are the incentives?
• Coding Creep
• Unbundling stays of care
• Data and coding expertise
• No cross subsidies
• Pre-hospital Tugs of War
• How do we get outcome focussed rather than
  provider driven?

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Choosing Health

• Local Delivery Planning
• e.g. Management of blood pressure and cholesterol
  by GPs
• NICE guidance re cancer treatments
• Smoking rates
• Increased uptake in breast feeding
• Tackling childhood obesity
• Local Area Agreements
• Children and Young People
• Safer and stronger communities
• Healthier communities and older people

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Practice-Based Commissioning

• to assist in the management of care pathways,
  influence change and performance manage
• Will resource and incentivise practices to
  invest in maintaining the health of their
  patients
• Ethical fundholding
• Choice tempered with responsibility
• But
• about managing demand counterweight to PBR?
• success measured by
• ?Access and?Emergency bed days
• Implementing Choose Book
• Enough time? What will work? Accurate data?

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Contracting flexibilities

• nGMS and PMS
• PCT PMS and PCTMS
• SPMS
• APMS
• New Pharmacy contract
• Range of providers
• Focus on innovation
• But Attention to contract
• Specification
• Price
• Performance monitoring
• Etc..

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Providers and Contestability

• Independent sector
• Voluntary sector
• Patient-led charitable organisations
• Not for profit
• NHS Trusts/NHS Foundation Trusts
• Primary and community Foundation Trusts
• GMS/PMS practices
• Collaboratives/Mutuals
• Social entreprise/Community Interest company

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Primary Care - future
PCT Contractor
Consolidation of sites by GPs or others
Contracting out to Commercial Cos., NFP, Vol.
Sector, et al
PMS/GMS Provider Commissioner
Integration into Managed Care Organisations
Interpractice Consortia Collaboration
P
NP
P
NP
P
P
NP
NP
PA
Ph
N
N
SW
Ph
C
N
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Provider models?

• Innovative alternative provider of community
  services, primary care, health improvement
• Social entreprise employee owned
• Local people engaged in its design
• Community driven health and well-being forums
• Innovative work with private sector in developing
  new community improvement centres
• Innovative approaches to health and well being
  (co-creation)

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Choice

• A process not a task - involves sharing of
  risk
• Is not just about when and where but about what
• Do we have the information (Dr Foster?)
• What about choice within primary care, choice of
  commissioner
• Choice beyond Choose Book
• Mutual endeavour between clinicians and
  patients . and between communities and
  commissioners
• (practices or PCTs?)

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Public Health Trusts?(or Health Improvement
Trusts)

• Commissioning health improvement services
• Dedicated management and expertise
• Joint governance between PCT and local government
• Can we introduce contestability into the public
  health agenda?

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The Health Promoting Pharmacy in 2015

• Information and advice
• Service provision particularly vulnerable
  groups
• Identified and support to people with risk
  factors
• Partnerships re. wider determinants
• Trusted health advocate
• Support to people with long term conditions
• Extended Pharmacy Teams
• Electronic health information
• (Choosing Health Through Pharmacy
• A programme of pharmaceutical public health
  2005-2015)

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Key challenges?

• Matching PBC to ex-PCT targets without sub
  optimisation
• Delivering on the Public Health agenda
• Becoming Market managers rather than secondary
  care commissioners
• Developing and expanding self care
• Embracing patient choice without financial
  meltdown

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And the white paper..?

• Engaging people
• Consumer v citizen
• Public health in primary care
• Urgent care
• Integrated health and social care
• Support to vulnerable people to live
  independently
• New models of care
• Choice and access to register or not?
• GPs (and other independent contractors) as
  providers
• New forms of community ownership
• What possibilities exist that we havent thought
  of yet?

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What does right look like?

• People who have more choice and control over
  their lives tend to be healthier and live
  longer.
• a virtuous circle of healthier people in safer
  communities supported by responsive public
  services.
• Patricia Hewitt, Secretary of State for Health,
  2005

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Simon Gilby6 October 2005

• The agenda facing primary care
• policy context
• demographics and the public health agenda
• market capacity and capability
• (some challenges and some opportunities)

36
Maximising the Market - Newcastle
10.00 10.10 Introduction 10.10
10.55 Primary Care over the next 5 years 10.55
11.15 Coffee 11.15 12.00 The Public Health
perspective 12.00 12.30 Workshop - Identifying
key issues for PCTs 12.30 13.30 Lunch 13.30
14.15 The 4 Primary Care contracting
routes 14.15 14.30 Coffee 14.30 15.30 The
4 Primary Care contracting routes 15.30 Close

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Public HealthDr. Phil YatesPrimary Care
ContractingNewcastle6th October 05
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Structure of Presentation

• Background Policy Change in Society
• Some facts and figures and Choosing Healths
  main priorities
• Key Questions for Maximising the Market and
  Possible Scenarios

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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.

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NHS Ethos .

• The equitable and efficient provision of high
  quality care to patients regardless of ability to
  pay.

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The Policy Context (i)Reducing DH Control

• Creating local purchasing power
• StBoP PCTs hold 85 NHS budgets 2003
• PBC 2006
• PbR 90 hospital care 2008
• Decreased DH SHA staff 2007
• Choice 5 providers 2005

• Encouraging a mixed economy of autonomous
  providers
• NHS Foundation Trusts
• Increased private providers ISTCs, surgery
  diagnostics
• 10 care competition
• PCTs not providers 2008
• HC commission 2004

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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
• Choosing Health 2004
• Creating / Commissioning a Patient Led NHS 2005
• Out of Hospital White Paper 2006

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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

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

• 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

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Implications for Public Health

• Dictats from on high wont wash
• We want to make our own lifestyle choices
  resent a nanny state
• But we want information expect it to be
  provided in an easily digestible form
• We do want the Govt to act where someone elses
  choices affect our health
• We still think we need to make special
  arrangements for children

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Life Expectancy
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Demographic Change by 2020
SG Council 2003
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Different causes of death now
ONS 2003
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General causes of Premature Death Disability

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

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Walking or Driving?
Choosing Health 2004
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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!

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Obesity Levels in Childhood
Health Survey for England 2002
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Obesity Levels in Adults
Orchard Med Centre 2005
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Reducing obesity, improving diet and nutrition
because

• There are rapid increases in child and adult
  obesity over last decade
• Effective action on diet and exercise needed now
• Left, we face a new epidemic of obesity-related
  health problems

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Change in disease prevalence due to Growth in
Obesity by 2023
Choosing Health 2004
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Current Predicted National Prevalence of Disease
QOF 2005
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Change in numbers of diabetics due to increase in
age Now by 2010.
S Glos PCT 2003
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Achievement in South Glos against these
indicators (DM)
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Renal Impairment with significant Co-morbidities
Orchard Med Centre 2005
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Existence of Co-morbidities
Orchard Medical 2005
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Prevalence of Cigarette Smoking in 11-15 yr olds
Health Survey for England 2002
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Prevalence of Smoking by Age now
Health Survey for England 2002
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CHD risks after stopping smoking
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Reducing the number of smokers because -

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

65
Alcohol Consumption
Men
Women
66
Alcohol drunk in the last week
Health Survey for England 2002
67
Been drunk in last week?
Health Survey for England 2002
68
Encouraging and supporting sensible drinking
because -

• It is related to
• absenteeism
• domestic violence
• violent crime
• physical ill health
• psychological disease suicide
• altered sexual behaviour / teenage pregnancy /
  STIs

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Chlamydia diagnoses in GUM clinics in England
Choosing Health 2004
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Improving Sexual Health because -

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

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Young People using Drugs
Health Survey for England 2002
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Improving Mental Health because -

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

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Life Expectancy is an Inequalities Issue
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Six Priorities for Action

• Reduce numbers smoking
• Reduce obesity focus on children
• Support sensible drinking
• Improve sexual health
• Improve mental health well being
• Tackle health inequalities make Healthy
  Choices easier

75
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
• Fully Engaged levels of public engagement in
  relation to their health are high

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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

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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
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Primary Care - now
P Principals N Nurses NP Non-principals
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
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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
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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
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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
82
The current NHS .

• Public monopoly insurer and provider of
  health care governed by Whitehall.

83
DH
Future PCTCommissioners of the Market
Fewer SHAs
SpPMS
SSD
Amalgamated Commissioning PCTs
APMS
D/O/Ps
nGMS nPMS
DNs/HVs?
Mental Health
Foundation Trusts
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. to the future NHS

• Insurer with devolved commissioners buying
  services from a mixed market of providers.

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Questions (i) Hospital or Community

• PbR causes supplier induced demand
• Reduced wait times increase referrals
• PbR incentivises admission
• but .
• For emergency LTCs avoidance of admission is
  probably better for patient
• Effective regulation of the market?

86
PH Damage from PBC / PBR?
Pre-primary
Primary Intermediate
Secondary Tertiary
Nurse / Pharmacist / SSD
G.P. led
Consultant led
Expert patient Phone Triage Education HVs
Assess Risks Home care DNs Protocol
driven Nursing / ESP Dietetics
Comorbidities / Hard Chronic disease management
decisions 10 diagnosis care organisation /
GPSIs
High tech. interventions. Community support
teams close links DSNs / GPSIs True
consultancy function but handing back care.
Pre-primary
Practice Based
Foundation Trusts
Nurse / Pharmacist / SSD
G.P. led
Consultant led
Expert patient Phone Triage Education HVs
Assess Risks Home care DNs Protocol
driven Nursing / ESP Dietetics
All routine care 10 diagnosis
diagnostics GPSIs to keep work in house
High tech. interventions . Development of high
earning clinical areas Consultants function is
to bring in business.
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Questions (ii) Incentives

• PbR Incentivises
• Elective surgery acts as a stand alone IOS but
• Chronic / emergency / cancer care needs
  incentivisation of collaborative care
  professionals in different institutions / sectors
• Interpractice competition / new providers but
• Patient registration increases Dr/Patient
  relationship which reduce costs / increase
  quality
• Financial incentives skew decisions

88
Scenario 1 - Market based Health Care in
provision and commissioning

• Autonomous providers vie for contracts from
  commissioners who compete for enrolled patients
• Patients choose their practices and their health
  plan
• Lightly regulated

89
Scenario 1
Patients enrol
PCT
PCT
nGMS Provider
APMS OOH
Nursing Provider
ISTC Surgery
Foundation Trust
PMS Provider
Local Authority
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Scenario 2 Tightly regulated for NHS care
provision

• Tempered by requirement for collaboration between
  networks and institutions
• Additional fees for targets met in chronic care
  / - health improvement
• Competition between commissioners limited to
  patient choice of General Practice
• Regulators more hands on

91
Scenario 2
PCT
Foundation Trust
ISTC Surgery
Nursing Provider
PMS Provider
APMS OOH
nGMS Provider
Local Authority
Patients enrol
92
Scenario 3 Selective Market for NHS care
provision

• Patient choice, NHS or IS provider, PbR applied
  selectively for elective and primary care only
• Planning approach with PBC, PCTs and providers to
  design sustainable care pathways

93
Scenario 3
PCT
Choice
PMS Provider
ISTC Surgery
Foundation Trust
nGMS Provider
Nursing Provider
Cancer Network
Renal Unit
Patients enrol
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Questions (iii) Segmentation of the NHS

• Can the NHS be diced and sliced with different
  approaches in different sectors?
• What are the trade offs for the NHS aims?
• Can we prevent distortion, perverse incentives
  and maladapted systems?
• What are the implications opportunities for
  improving Public Health?

95
Thank you
96
Maximising the Market - Newcastle
10.00 10.10 Introduction 10.10
10.55 Primary Care over the next 5 years 10.55
11.15 Coffee 11.15 12.00 The Public Health
perspective 12.00 12.30 Workshop - Identifying
key issues for PCTs 12.30 13.30 Lunch 13.30
15.00 The 4 Primary Care contracting
routes 15.00 Close

97
Maximising the Market - Newcastle

• 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?

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Commissioning flexibilities (and barriers to
implementation)
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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

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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

101
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

102
Contracting Routes - Summary
103
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

104
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.

105
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

106
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)

107
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.

108
PCTs as commissioner

• Three routes for essential services

109
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. For
  example
• Disease-specific or locality services
• Secondary-care type services
• Community services

110
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!

111
Commissioning flexibilities

• Structures
• Commissioning structures are not prescribed fit
  for purpose
• Open market for providers of primary care
• Processes
• Commissioning do what works!
• Procurement open competition to deliver best
  value
• Contracting range of options

112
Barriers to implementation

• (Lack of) development of integrated commissioning
  
• Understanding the role of PCTs
• Relationship between PCTs and PBC commissioners
• Resolving conflicts of interest
• Who commissions primary care?
• Procurement expertise
• Contracting expertise
• Development of the market

113
Process
Identify needs
Monitor outcomes
Practice-based / locality commissioners
Develop PCT commissioning strategy
PCT?
Undertake procurement process
Negotiate contracts
114
Maximising the Market - Newcastle

• Forthcoming NHS Confederation local APMS events
• Nov 8th Birmingham                          
• Nov 9th London
• Nov 22nd Exeter
• Dec 2nd Manchester
• Dec 6th Peterborough
• Dec 14th Newcastle
• Jan 11th Leeds
• Jan 12th Warrington

115
Contracting routes scenarios

• 6th October 2005

116
Contracting routes scenarios

• 6th October 2005

117
Scenario 1

• 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.

118
Scenario 2

• Dec 04, You suspend a single handed Doctor.
• His patients are high ethnicity, 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.

119
Scenario 3

• 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
  centre.
• 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 )

120
Scenario 4

• 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?

121
Scenario 5

• 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

122
Scenario 6

• 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

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Scenario 7

• 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.