Primary Care Contracting Contract management

1
Primary Care Contracting Contract management

• Mark Wilson
• Specialist Advisor Finance and legislation,
  Medical

2
Summary

• Legislation
• Contractor changes
• Suspension
• Termination and sanctions
• Right to a GMS contract
• Best value

3
Legislation

• NHS Act 1977 (amended)
• Allows PCTs to contract with any person for
  primary medical services
• Identifies range of contract types (GMS, PMS,
  APMS)
• Determines who can hold each type of contract
• Contract Regulations
• set out minimum requirements for each type of
  contract (APMS requirements set out in Directions)

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Regulations

• NHS (GMS Contracts) Regulations 2004 - 1 April
  2004
• NHS (PMS Agreements) Regulations 2004 1 April
  2004
• NHS (Primary Medical Services) (Miscellaneous
  Amendments) Regulations 2004 15 November 2004
• NHS (Primary Medical Services) (Miscellaneous
  Amendments) Regulations 2005 14 April 2005
• NHS (Primary Medical Services) (Miscellaneous
  Amendments) (No. 2) Regulations 2005 6 January
  2006
• National Health Service (Primary Medical Services
  and Pharmaceutical Services) (Miscellaneous
  Amendments) Regulations 2006 24 July 2006

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Contractor changes

• Partner joins
• Partner leaves
• Practice mergers
• Retirement
• Death
• Partnership splits
• Change to limited company

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Partner joins

• If GMS SH, then variation (Sch 6 para 105)
• Contractor gives PCT 28 days notice in writing
• If satisfied with accuracy, PCT confirms that
  contract shall continue and
• varies the contract
• If GMS partnership, contract is with the
  partnership as it is from time to time
  constituted (Reg 13)
• When new partner joins, the contractor must give
  PCT notice forthwith (Sch 6 para 86)
• If PMS, no specific regulation - variation at
  discretion of PCT wording of local contract

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Partner leaves

• If GMS SH left, then 28 days notice to PCT (Sch 6
  para 106)
• All persons in current partnership must agree
• If still GMS pnership, then Reg 13 and Sch 6
  para 86 applies inform PCT of change
• If GMS pnership reduced by 1 or more, then PCT
  may terminate if considers serious adverse impact
  on ability to perform obligations (Sch 6 para
  116)
• If PMS, no specific regulation - variation at
  discretion of PCT wording of local contract

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Practice mergers

• Two options
• Retain existing contracts
• Vary each contract to reflect new provider
  structure
• Other terms remain the same
• Create single contract
• Choose which contract continues and which is
  terminated
• Consider financial implications
• Vary contract to reflect new provider structure

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Partnership splits

• No definitive guidance/regulation very messy
• Implies termination of existing contract
• PCT cannot take action until practice position is
  clear
• PCT must be neutral at all times
• On termination, PCT has discretion
• Could lead to allocation of patients to open
  lists or
• Procurement process for new provider (PCT must
  put in place interim arrangements)
• Ownership of (or access to) suitable premises is
  usually a key issue.

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Retirement

• Retirement prevents GP retaining provider role
• For SH GPs this means contract terminates
• If the GP continues to work, PCT needs evidence
  that GP reduces commitment to less than
  16hrs/week for first month

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Death in GMS

• If GMS SH, contract terminates 7 days after the
  date of his death unless
• (a) the PCT agrees with the contractor's
  personal representatives that the contract should
  continue for a further period, not exceeding 28
  days after the end of the period of seven days
  and(b) the contractor's personal representatives
  agree to the PCT employing or supplying one or
  more GPs to assist in the provision of clinical
  services.
• If GMS partnership now SH as a result of death,
  then contract continues with SH (Sch 6 para 104).
• Otherwise, Reg 13 applies

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Death in PMS

• If PMS SH, contract terminates 7 days after the
  date of his death unless
• (a) the PCT agrees with the contractor's
  personal representatives that the contract should
  continue for a further period, not exceeding 28
  days after the end of the period of seven days.
• If PMS partnership, no specific regulation -
  variation at discretion of PCT wording of local
  contract

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Change to limited company

• Technically, existing contract terminates
• PCT discretion to agree new contract with
  suitable terms
• In GMS, no MPIG entitlement for contracts
  commencing after 01.04.04.
• PCTs have discretion to make payments to support
  primary care as they see fit i.e. could make
  discretionary payments equivalent to MPIG.

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Suspension

• Suspension from Performers List (removes ability
  to perform services but can still provide)
• ie. if SH, suspension does not terminate contract
  
• Intended to be a neutral act
• PCT must make every effort to ensure that
  suspended GP does not suffer financial loss
• SFE sets out payments to suspended doctors
• If and when removed from Performers List, then GP
  cannot provide

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Suspension of SH GPs

• Key point is that contract is not terminated - so
  who is the provider?
• The SH GP retains provider role or
• The SH GP delegates (sub-contracts) provider role
  to another party (usually the PCT)
• The delegation of the provider role should be
  subject to an explicit agreement setting out
  remuneration mechanism and contractual
  responsibilities eg. list closure, QOF payments,
  staff management.

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Contract sanctions

• PCT can only apply sanctions if entitled to
  terminate contract ie alternative to termination
• Sanctions must be appropriate and proportionate
• Sanctions can be
• Termination of reciprocal obligations
• Suspension of reciprocal obligations
• Withholding or deducting monies
• PCT must give 28 days notice
• PCT may also charge reasonable costs of
  administration incurred in imposing any sanction.

17
Termination in GMS

• Termination by PCT only in the following
  circumstances
• By agreement
• Breach of Regs 4 or 5 (legal/fitness grounds)
• If a breach puts patient safety at serious risk
  if contract not terminated
• If PCT is at risk of material financial loss
• If following a remedial notice, the contractor
  fails to remedy the breach by the end of the
  notice period
• If following breach or remedial notice, there is
  a further breach where PCT is satisfied that
  cumulative effect is just cause for termination
• If company carries on any business detrimental to
  performance
• If 1 or more partners leaving has serious adverse
  impact on ability to perform obligations (NB. not
  in PMS)

18
Termination in PMS

• Termination by PCT only in the following
  circumstances
• By agreement
• Breach of Reg 5 (fitness grounds)
• If a breach puts patient safety at serious risk
  if contract not terminated
• If PCT is at risk of material financial loss
• If following a remedial notice, the contractor
  fails to remedy the breach by the end of the
  notice period
• If following breach or remedial notice, there is
  a further breach where PCT is satisfied that
  cumulative effect is just cause for termination
• If company carries on any business detrimental to
  performance
• By notice (NB. Not in GMS)

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Right to a GMS contract

• Reg 19 of the PMS Regulations entitles ALL
  contractors (not just pre-April 04 contractors)
  that are providing essential services under PMS
  arrangements to enter a GMS contract.
• Contractor must give at least 3 months notice in
  writing.
• NB. MPIG does not apply to GMS contracts that
  take effect after 1 April 2004

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Best value

• PCTs have a statutory duty to secure best value
  in their use of public funds i.e. combination of
  cost and quality
• Is the PCT achieving best value across all its
  primary medical care contracts?
• Robust contracts that comply with Regulations
• Performance monitoring processes that support
  high quality delivery of care
• Financial arrangements that secure value for
  money
• As a nationally negotiated contract, GMS sets the
  benchmark for best value

21
PMS Agreements

• Robust PMS Agreements
• Comply with Regs
• Detailed financial arrangements (use SFE as
  checklist)
• Compliance with all contract deliverables
• Performance maintained (eg if funded for higher
  targets cytology/imms vacs)
• Use of growth funding
• Assess return on investment
• Compliance with existing contract does not
  necessarily deliver best value