Maximising the Market London

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Maximising the Market - London
9.30 9.40 Introduction 9.40 10.25 Primary
Care over the next 5 years 10.25 11.00 The
Public Health perspective 11.00
11.20 Coffee 11.20 12.00 Stragegic planning
For Primary Care 12.00 12.30 Table Top
Identifying Key Issues For PCTs 12.30 13.30
Lunch 13.30 14.45 The 4 Primary Care
Contracting Routes 14.45 15.00 Coffee 15.00
15.45 Scenario Working 15.45 16.00 Feedback and
Closing Remarks

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• Mark Wilson ? Yvonne Thomas Tony
  Snell

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Maximising the Market - Birmingham

• 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.

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Future of Primary Care / NHS

• Dr Tony Snell
• Medical Director
• Birmingham Black Country SHA

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? Future Primary Care/NHS

• Demographic challenges
• Changing primary care organisation
• Patients as customers
• Creating a Patient Led NHS
• Capacity building and fit for purpose
• PBR
• PSA targets
• LTCs
• PBC

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Demographic Change by 2019
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Expected numbers of diabetics now
by 2010
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Progress of primary care
1965 ?
2004 ?
1997 ?
1990 ?
Organisational Unit
Individual G.P.s
Integrated Trusts (NB Kaiser)
PCGs / PCTs / - Care Trusts
G.P. Units (larger practices)
Mechanism of Delivery
The Red Book
Various NHS Private Providers
Practice Contracts via PMS
GP Commissg GP Fundholdg TPP/Multifund
Service Focus
Communities of interest
Practice geographical communities
Specific Target Groups gt75 years etc
Individual Patients
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Primary Care from April 2005
PCT Commissioner
Performers -mainly the Principals holding the
contract
nGMS Provider
PMS Provider
nGMS Provider
P
P
P
P
P
P
P
P
N
N
NP
N
N
NP
P
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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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Contracting flexibilities

• nGMS and PMS
• PCT PMS and PCTMS
• SPMS
• APMS

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Patients as Customers 2010 Scenario

• Patient speaks little English and has poor
  literacy level
• Local GP identifies Type II Diabetes explains
  condition, but patient is confused.
• Patients son contacts PALS (Patient Advisory
  Liaison Service) who pass details to MHDSS
• Patient seen by outreach HCA who finds BP up
• Patients details are stored on Personal
  Electronic Health and Social Care Record (PESCHR)
• Patient put on Diabetes risk register and 5 10
  year risk assessment produced.

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Patients as Customers (2)

• Patient provided with 24 hr ambulatory BP monitor
  data uploaded to her PESCHR via systems network
  and will inform GP if BP elevated
• Ambient intelligence environment installed in
  patients home to monitor critical events and
  contact relatives/emergency services as
  appropriate
• Patient has a Diabetes Management Plan created
  for her and chooses case manager who can speak
  her language to provide feedback for her
  self-management program.
• Patient enrolled on new to diabetes course

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So 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

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Scale of the current need

• 450,000 people in BBCSHA with limiting long-term
  illness (20 of 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

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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

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Chronic disease as a source of inequality

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

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Pressure on NHS resources

• About 20 of admissions and bed-days are for
  patients with 3 or more unplanned admissions in a
  year
• This group of patients (9,845 people) represents
  only 1 in 300 of our population, or about 7 per
  practice
• Early intervention with these patients could have
  significant impact on health and hospital usage

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Delivery what BBCSHA is doing
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CREATING A PATIENT - LED NHS

• A very radical document
• 2000 NHS Plan - National targets
  - Patient Centred Care
• 2005 Creating a Patient Led NHS - Focus on the
  patient experience by choice and
  contestability

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Public Perception and NHS performance
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8 STRATEGIC CHALLENGES

• STRATEGIC DEVELOPMENT
• CAPACITY BUILDING
• HEALTH IMPROVEMENT
• SUPPORTING STRATEGIES
• Connecting for Health
• Workforce Development
• Choice
• MAKING THE MARKET
• SHIFTING THE BALANCE OF CARE
• SYSTEMS CHANGES
• NETWORKS REVIEW

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Strategic Development and
Capacity Building

• PCT mergers to align with LA boundaries
• NHS Trusts developed to be able to be FTs by 2008
• PCTs Fit for purpose
• Not designed for era of CHOICE, PBR, PBC,
  contestability, etc.
• Need to change, especially in relation to
  providers and contractors and align with patients
• Role of PECs/ clinical engagement - ? engine
  room

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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

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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

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CONNECTING FOR HEALTHTOWARDS ONE MANAGED
ELECTRONIC RECORD SERVICE
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CHOICE

• December 2005 Choose Book 4-5 Health care
  providers
• 2006 - any provider that meets HCC standards
• Elective first then much wider range

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Making the Market
shifting the balance of care

• Contestability use of private sector upto 15
  !!!!!!
• Deliver 18/40 max wait by 2008
• Expand capacity
• sec. and primary care (diff. recruiting, poor
  quality services and ?)
• Diagnostics (available to and in primary care)
• New and existing private sector
• Voluntary and Charitable Sector, eg MH,
  inequalities, lifestyle targeted, BME.
• To provide CHOICE
• International driver- no way back outside
  National Government control

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Systems Changes -


Networks Reviews

• PBR suck 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
• DOCS R 4 US
• Clinical Networks
• Disinvestment strategies

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CREATING A PATIENT - LED NHS

• What?
• - National Picture
• - A Wider View
• How?
• - Choice
• - Contestability
• - System Reform

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Choosing HealthMaking healthy choices easier
Dr Tony Snell Medical Director Yvonne
Thomas Public Health Lead
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Structure of presentation

• Part one
• Background to the Public Health White Paper
• Main priorities
• Key messages
• Impact on Clinicians
• Part two
• Clinicians Response to the White Paper

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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.

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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 crucialto
  good physical health
• Tackle health inequalities- targets

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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

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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

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Encouraging and supporting sensible drinking
because

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

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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.

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Improving sexual health because

• Risk-taking sexual behaviour is increasing across
  the population
• STDs can lead to cancer, infertility and death

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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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Health inequalities

• Vulnerable people
• Social justice issue

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Key Messages

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

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Local Hero
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GP View

• ? My responsibility not in my contract
• ?Individual v population focus
• Practice v PCT population
• Dont have enough time who does it?
• Who pays where is ?
• What about PCT PH and health promotion?
• What about PBC?
• Why should I be responsible/accountable for
  delivery of national targets?

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Fundholding experience in early 1990s

• No waiting for any service!
• Large private sector usage consultant led
• Large planned savings
• Reinvested into health promotion e.g.s
• Close collaboration with community and HP staff
• Very positive feedback from patients
• ? Similar opportunities now PBC BUT LDP
  requirements, eg PSA targets

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Challenges for Clinicians

• How demonstrate Clinicians responding to publics
  expectations
• Where get the money for prevention
• Identifying workforce to deliver lifestyles
  advice and support
• How to increase understanding to champion the
  prevention agenda locally

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PSA Targets

• 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 heart disease stroke 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
• 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

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Money

• Historical reliance on funny money to deliver
  prevention projects.
• DH ring fenced budgets to protect prevention
  activity in NHS
• Incentives e.g. Expert Patients
• PBC planned savings
• Shift from secondary to primary care?

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Emerging Lifestyles Services Menu

• Stop Smoking Services
• Weight Management Service
• Physical Activity Services
• Sexual Health Services
• Expert Patients Service
• Health Trainers Service

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Personalised Stop Smoking Service

• Choice consists of
• One to One Advice or Group Support
• One to One Advice can be offered as a face to
  face contact or telephone contact
• One to One Advice from Practice Nurse, Pharmacist
  or Lay Health Advisor
• Group Support can be offered as planned or drop
  in sessions
• Choice of gum, patches, sprays

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Emerging Personalised Stop Smoking Service
Providers

• GP Practices
• Pharmacists
• Dentists
• PCT Stop Smoking Teams
• Acute Hospitals pre op and OPD
• Voluntary and Community Sector
• Pharmaceutical Industry
• Community Business
• Sports Leisure Sector

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A new public health workforce?

• Health Trainers and EPP
• Existing established workforce
• New service providers. Voluntary Community, NHS
  Direct.
• Independent Sector - Leisure Industry

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Continuing Professional Development

• Mosaic, QOF- how use data to target discrete
  populations?
• Commissioning and then managing local health
  information and advice campaigns and lifestyles
  services
• GPs, Pharmacists, Dentists, AHP etc with a
  special interest in health improvement.

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Practical Actions for Local Heros

• PSA Targets - fair share
• Choice and Prevention - produce your own list of
  local lifestyles service providers and menu
• Put the Public into Public Health - ensure that
  you employ or commission others to employ only
  local people as health trainers
• Identify health improvement as part of your
  Continuing Professional Development.
• Catch up. Use new data to target services and
  improve access for those in greatest need.

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How will we get there ?

• Commission whole system approach driven by a
  clear and ambitious vision for quality of patient
  care
• A clear and agreed framework of clinical and
  organisational standards negotiated with key
  players.
• Acknowledge unique fingerprint of any
  organisation by setting standards but allowing it
  to determine the how
• Getting the logistic back-up in place first i.e.
  EBP, Education, CPD Support, Clinical Support -
  takes time but ensures proper support and enables
  system wide roll-out.

Leadership
Ownership
Logistics
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Local Hero
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Strategic planning in primary care

• Rigo Pizarro
• Assistant Director-primary care
• North East London SHA

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North East London

• Deprivation
• Diversity
• Problems with access
• High morbidity-Chronic diseases
• Large number of small practices
• Owner-occupier premises
• Retirements
• Capacity problems

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Challenges to primary care

• Patient choice
• Access
• preventing ill health
• Management of long-term illness
• service integration
• Unscheduled care
• Capacity and capability
• Practice-based commissioning
• Payments by Result

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New contractual environment in primary care

• As nGMS contract is practice-based the focus for
  contracting shifts to the capacity and
  capabilities of organisations to deliver
• Emphasis on quality and outcomes
• New arrangements offer a range of contracting
  options and
• opens up competition-It is a more commercial
  environment

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What it might look like?

• Smaller number of larger units
• OSPCCs as hub for a network of services and
  community facilities
• Vertical and horizontal integration including
  diagnostics close to patient
• Focus on CDM and interception
• Not only case management but prevention and
  expert patients
• Specialisation

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What it might look like (2)

• More WIC type facilities and services
• Standardisation of services and systems so that
  patients can be seen at different outlets
• More services commissioned in PC on a locality
  basis
• Partnership with acute trusts
• Plurality of providers

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How do we get there?

• Strategic commissioning
• Effective contract management
• Use procurement process to raise standards
• Improve productivity and efficiency in primary
  care

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Strategic commissioning

• Starting point needs assessment
• Identify outcomes
• Demand and capacity planning
• Configuration of services and redesign
• Workforce development
• Infrastructure e.g. LIFT and SSDPs
• Financial strategy and cost minimisation through
  efficiency and redesign
• Practice based commissioning-next stage

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Managing the contract in new environment

• Minimum standards
• Addressing poor performance
• Focus on outputs
• QoF
• Decommissioning where required
• Support clinical leadership

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Procurement

• previous position- recruitment of GPs to
  vacancies
• new position-procurement of services from
  organisations A tendering process
• New approach requires a new type of
  specifications that draw up the capabilities of
  these organisations
• GMS, PMS, APMS or PCTMS contractual routes
• Broader framework of requirements to meet new
  challenges to primary care
• Appropriate scale for procurement?

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What needs to go into a APMS process?

• Business case consistent with strategic
  commissioning approach
• Clear statement of outputs or outcomes
• Definition of standards over and above GMS and
  QoF if necessary
• Clear Pre-qualification criteria
• Evaluation criteria and decision making process
  standardised
• Can this be reflected in GMS/PMS contractual
  framework?

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Examples of issues to consider(1)

• GMS type financial envelop or a tariff system?
• What kind of staffing and skill mixes can be
  used?
• What kind of efficiencies can be obtained from
  working in a different way?
• Must maximise quality (e.g. QoF)
• Opening hours and unscheduled care-extended
  hours, better use of assets

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Examples of issues to consider (2)

• Management of long-term illness and provision of
  services close to patients (e.g. diagnostics and
  outpatients in the community)?
• How will premises be provided?- via LIFT or own
  alternatives?
• What will be offered to improve access and
  unscheduled care?
• What are the clinical governance arrangements?
• Will services be delivered in a standardised way
  across many sites?

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Conclusion

• New Challenges and demands
• New models of primary care
• PCTs commissioning primary care
• Contract management and monitoring are key
• Procurement process must be rigorous
• APMS is one vehicle to unlock new thinking

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Maximising the Market - Birmingham

• 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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Contracting for Primary Care
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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

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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

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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?

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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.

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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

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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

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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

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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

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Contracting Routes - Summary
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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

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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.

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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

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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)

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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.

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PCTs as commissioner

• Three routes for essential services

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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

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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

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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!

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

• 18th July 2005

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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.

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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.

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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 )

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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?

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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

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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

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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.