Personal Medical Services

source:  Department of Health web site February 2004

Commonly Asked Questions & Answers

What is PMS?

Is it the same as fundholding?

No. PMS Primary Care Act pilots (PMS pilots) are an opportunity for GPs, nurses and Community Trusts to test different ideas for delivering existing GMS, focusing on local service problems and bringing out improvements. A pilot is implemented through a local agreement.

How many pilots are there in each wave?

Estimated figures from the last count:
Wave 1: 83
Wave 2: 186
Wave 3a: 755 (est)
Wave 3b: 414 (est)

Why is the government so keen to get 30% of GPs in PMS by April 2002?

The development of primary care services is key to the modernisation of the NHS. The current GP contract the ‘red book’ has often worked well, but it gives greater emphasis to the number of patients on a GP’s list and the quantity of services provided rather than the quality of them. A

PMS contract pays GPs on the basis of meeting set quality standards and the particular needs of their local population. This approach has brought a wide range of benefits, being used to develop new services for specific populations, to attract doctors and nurses and to improve services for patients.

Why is my PCT so keen to get us into PMS?

The flexible approach of the Personal Medical Services has brought a wide range of benefits. We are keen that PCTs see the benefits of PMS as a tool to help them in ensuring patients receive high quality care tailored to their needs.

But my PCT is forcing me to enter PMS. I don’t want to

PMS is entirely voluntary, so no GP can be forced to take this option.

If GMS and PMS are merging, why rush into PMS?

There is no rush PMS is voluntary, but as the number of pilots has grown, so has the understanding of the benefits that PMS can bring. Very many doctors and practices have decided to take the PMS option. The Minister of State for Health, John Hutton, has announced that PMS is here to stay.

How does it work?

What does the term ‘provider’ actually mean?

A provider means a person, other than a health authority, who enters into an agreement, which constitutes or is one of the agreements, which constitutes a pilot scheme. This can be any of the following organisational ‘types’: a suitably experienced Medical Practitioner, an NHS Trust (including PCT), an NHS employee or pilot scheme employee, an individual who is providing PMS under that or another pilot scheme.

Providers of PMS are those who make and hold contracts to provide piloted services.

Who are the ‘performers’?

The performers of PMS are those who carry out the services. Only a suitably qualified GP can directly provide PMS to patients.

What is the difference between a provider and a performer?

Providers of PMS are those who make and hold contracts to provide piloted services.

The performers of PMS are those who carry out the services. Only a suitably qualified GP can directly provide PMS to patients.

Sometimes, of course, the providers are also the performers.

How does PMS reduce bureaucracy?

PMS, through the simplification of contractual requirements, allows a practice to move away from the restrictive and complex arrangements set out in the ‘Red Book’.

PMS funding as an annual sum, can improve a practice’s cash flow, removing the requirement for quarterly returns.

What is a greenfield site?

PMS pilots that will provide services for a ‘new’ population e.g. a new service to a homeless population, or a new housing development. Note: PMS must always be for a defined and registered population. It is not possible to have dual registration for patients. It is not possible, either to offer "drop-in" services, except in the case of services to transient patients.

What are the benefits of PMS?

The pilot scheme will make improvements for the NHS in general through:

provision of value for money not only in financial terms but in improved quality of care creation of more flexibility in organisational and employment arrangements within general practice, which leads to more satisfying careers and improves recruitment and retention piloting strategic plans which take into account all the other local stakeholders in primary care leading to greater co-operation in planning and developing local health service provision.

How does my practice benefit?

With a PMS contract it is easier to work as a team and the results of the national research into PMS backs this up. You need spend less time on claims chasing and processing as the PMS contract price is often paid monthly. Many pilots have found that they can use the time saved to do some useful clinical audit.

What are the clinical benefits?

The pilot scheme will make improvements for professionals working in the health service through:

provision of opportunities for greater co-operation between GPs, nurses and other clinical providers enhancement of team working and provision of closer professional integration in service delivery extension of opportunities for the provision of improved services by extending roles and development of clinicians within primary care the offer of greater opportunity for more flexible working between primary care professionals and wider caring organisations.

Will patients benefit?

The Personal Medical Services scheme approach has brought a wide range of benefits. It has been used to develop new services for specific populations, such as ethnic minority communities, to attract doctors and nurses into deprived areas and to improve services for patients.

The PMS Contract

How will the change in contract affect me?

It means the payments you get for supplying services to your patients will be much more closely tied to what you do, and the outcomes, rather than national averages as under the current GMS contract. Under PMS, you will also be paid an annual sum, which can come into the practice monthly, removing the need for claims and allowing clinicians to concentrate on clinical outcomes.

I still want to be an independent contractor

Ministers have said repeatedly that independent contractor status is not at risk under or because of PMS. There is no need to change to a salaried option, unless you wish to do so.

Will my tax status change?

No, as long as your employment status does not change.

Will I have to be employed by the HA or PCT?

Not if you don’t want to be.

What happens if I am sick?

Through the funding arrangements, HA’s can get money from the centre for actual costs of things like sickness or maternity

How does it affect my status as a trainer?

The JCPTGP advise that the changes to practice organisation involved in moving from a GMS to a PMS practice-based pilot mean that trainers in such practices should in all cases have their approval as a trainer reviewed. The intention is that the quality of training provided in practice-based pilot sites will at least equal that currently available in GMS practices. It will be important to ensure that the range, quality and depth of experience available to GP Registrars is maintained, especially in cases where a practice becomes or ceases to be a pilot site part-way through the GP Registrar’s employment. During transitional arrangements trainees should not be adversely affected.

Trainers in practices which are under consideration for practice-based pilot site status should, in the first instance, approach their Director of Postgraduate General Practice Education (DPGPE) for advice. Trainers currently employing GP Registrars should establish whether the GP Registrar’s employment will continue after the point the practice moves across as a pilot site. If so, the employment of the GP Registrar in that Practice. If both the trainers and DPGPE agree that the training environment will remain stable and the full training curriculum can be adequately covered, the trainers should apply to the JCPTGP for re-approval as a trainer.

Will it prevent me from becoming a specialist GP?

Not at all. Many GPs with specialist interests are using the flexibility of PMS agreements to develop their skills. A number are offering out patient treatment to patients in a primary care setting, for their own patients as well as the patients of other GPs.

How often is the contract reviewed?

As often as you agree with your commissioner. The DoH suggest an annual cycle.

How will the contract affect my pay/pension rights?

How do we get paid?

Independent contractors come to an agreement with the commissioner how much of the PMS contract price represents their share of the profits. It is advisable to do this in any case so that your superannuable income can be calculated.

GMS GPs get a higher increase to fees and allowances that PMS GPs don’t they?

No. Remember that in PMS there is no such thing as fees and allowances in any case the Red Book does not apply. However, when GMS GPs get the level of their fees and allowances increased following the DDRB’s recommendations, then the equivalent uplift is made to the allocations to HA’s which represents the GMS share of their pilots.

How are our pensions calculated?

You need to agree this with the commissioner if you are an independent contractor. There are two ways of doing this. The first way is based on what historical superannuable income was in GMS. The second way is to look at the price of the contract as a whole, to calculate how much of that price represents profit, and it is your share of this profit element which represents your superannuable income.

How will I know my pension will not suffer?

It’s highly unlikely if you are an independent contractor now, and you are going into PMS. Some GPs have found an increase in their superannuable income because the profit element of the whole contract price represent superannuable income in GMS, not all the NHS income that GPs receive is superannuable. If you are unsure, it’s best to ask the advice of your accountant or another PMS GP.

Is it worth joining PMS when I retire soon?

This is up to you. It’s a voluntary scheme, and so it depends on whether PMS can offer benefits to your patients that cannot be realised in GMS. Take advice from your accountants on your pension .

Can I take a short time retirement option?

The rules on retirement are the same in PMS as in GMS basically, they relate to drawing your pension and returning to work . Under the rules of the NHS Pension Scheme you can take up further employment and draw your pension as long as the break between retiring and returning to work is at least one month, and your return to work is in a reduced capacity. The NHS Pensions Agency is the best place to go to for advice.

Contract worries

How does the contract get monitored?

In whatever way you have agreed with the commissioner.

What is involved in contract negotiation?

The contract will embody the agreement between the health authority and the pilots. You will agree the outcomes and how these will be measured and monitored. You will agree any incentives. You will agree the overall price of the contract, and how much of that is likely to represent profit, and hence superannuable income.

What if I am not happy with my contract after I have signed it?

Ask for a variation. PMS is a highly flexible tool, and it is difficult to set a once and for all contract. All parties are encouraged to continue to discuss the agreement in a spirit of cooperation.

We’ve had a lot of discussions and we can’t agree the contract. I’m not happy. What should I do?

You may find it helpful to contact a third party to see if that will help. We suggest your local PMS facilitator or HA. At the end of the day, remember that PMS is voluntary. If you don’t like the contract and feel unhappy, you can remain in or return to GMS

Why should I sign my contract when the HA/PCT have had the final baseline amount confirmed from the centre?

Most providers wish to wait until the HA/PCT is clear about the funds available. However, if you wish to do so before this, you can. What the HA/PCT receives from the centre is an amount equivalent to your GMS historical spend, plus PA and dispensing, uplifted.

Why should we sign a PCT/G wide contract?

You needn’t PMS is voluntary but there are a number of benefits to such contracts, where practices are able to work in close co-operation with the PCT, which is able to ensure a fair approach to agreeing services to the benefit of patients.

How will the contract affect my resignation or leaving rights?

The revised PMS Agreement only asks for a suitable period of notice if a provider wishes to move from PMS. If you wish to sign or leave the profession, this happens in the same way as in GMS.

What if I want to split with my practice once the pilot has commenced?

The HA/PCT will oversee this. Very broadly, if the two parties wish to continue with a broadly similar PMS contract, this should be possible, subject to agree the contract price.

What if I want to leave and I have no list?

Pilots will need to consider what would happen to a patient lists should the pilot come to an end or a doctor wishes to leave the scheme. Agreements should be made between the GPs in a similar way to the agreements currently made under GMS. If a practice list is in operation, doctors will want to consider what will happen to these patients should the pilot end. Any arrangements made should take into account the patients’ right to choose and the need for patients to be kept informed to enable them to exercise this right. Pilots may therefore be required to notify patients should their doctor move from PMS back to GMS.

What if we change our minds?

In the revised PMS agreement framework, you are asked to give a suitable period of notice before terminating the contract. This allows time for future arrangements to be made. If you have a right of return, you can go back into GMS. During the last three months of the pilot, you can begin to count claims based on the Red Book again, so that the GMS payments can begin.

When will the ‘opt’ out from PMS back to GMS no longer be an option?

There are no current plans to remove the right of return. PMS remains a voluntary option.

How will it affect the practice and the staff?

We have a retained GP, can we keep her?

Yes, of course. Remember to include the costs when agreeing the contract.

Will the service be fragmented?

There is no evidence of fragmentation in the service as a result of PMS. All the indications are that it has, in fact, expanded the service to meet the needs of patients who did not have full access to GMS

How will it affect my patient list?

Do I keep my personal patient list?

As set out in the 'NHS (Choice of Medical Practitioner) Regulations 1998’ (SI 1998/668) as amended, under PMS, patients retain the right to choose the medical practitioner from whom they are to receive primary medical services (subject to consent and capacity). There is a provision for another person to apply on behalf of the patient. In addition, as set out in Regulation 3, there is a retained right to change doctor either to one who provides general medical services or to one who performs personal medical services.

Can we have a pooled patient list?

It will subsequently be possible in a PMS pilot for the pilot to decide to offer to patients the choice of not remaining on, or going onto, an individual doctor’s list but to become simply a pooled practice patient. In this case the clinical responsibility for the patient will not be delegated to a particular doctor within the practice but to the pilot’s medical practitioners as a whole. The health authority or PCT will need to be informed of any patient moving from an individual to a pooled list or indeed from a pooled list to an individual list.

 If a pilot decides to end the pooled patient option, patients who wish to remain in the pilot will need to be given choice over which pilot doctor’s list they join. Health authorities or PCTs will need to be informed over such changes.

If I leave PMS, what happens to my patient-list?

Where a pilot practice reverts back to GMS those patients on a personal list will remain with their named doctor. Patients on a pooled list will need to be informed that the current registration arrangements no longer obtain and they will have to join the personal list of a doctor. How this process will be handled may be prescribed in the contract or, alternatively, it will need to be agreed between the PMS pilot and the health authority at the time. Any process must enshrine the patients’ right to exercise choice in obtaining their doctor.

Salaried GP’s?

Who is a salaried GP accountable to?

The salaried GP is accountable to his employer. If employed by a PMS provider, the salaried GP is accountable to that provider within the terms of his contract of employment. The provider retains overall responsibility for ensuring that services are available to its patients for every 24 hours the pilot is in existence. A GP is always accountable to the GMC.

How does a salaried GPs get paid?

By his/her employer. PMS providers who employ salaried doctors need to ensure that the costs are included in the price of the PMS agreement.

Who pays the salaried GP pension contributions?

Normally, his/her employer. There are occasions when the HA/PCT takes responsibility for the payment of employer’s contributions. This needs to be discussed and agreed as part of pricing the PMS contract.

What if GPs do not wish to be salaried?

Most PMS GPs are independent contractors. While PMS makes salaried options easier, there is no obligation on independent contractors to become salaried.

Who is responsible for delivering the services specified in the contract?

The provider is the one accountable for this. Where a provider employs performers, the terms of their contract of employment may specify their particular responsibilities, but the provider has overall responsibility. For example, if an employed doctor is ill and unable to work, and patients are not seen, the provider will be held to account as the one responsible for ensuring the services are available.

Who is the pilot accountable to?

The pilot is accountable to the HA/PCT.

Who assesses/audits performance?

Evaluation is a requirement for pilots. If a pilot scheme is not properly evaluated, then the time and resources spent on setting up and running it will have been wasted and the opportunity to extend its benefits to other parts of the NHS missed. It is clearly very important that providers make preparations as early as possible for their role in the evaluation process.

What does PMS mean for nurses?

An opportunity to deliver primary care services in a responsive, proactive way. Also it enables nurses to influence change and provide alternative ways of working.

Do you refer to secondary care?

Yes. The commissioning group needs to agree this principle. PMS should have the flexiability to make it happen.

How do you do it?

By local negotiation. It is helpful if you have a well respected PMS champion who is willing to advocate for you at a senior level.

Does clinical grading apply?

Yes, unless your GP employs you on different terms and conditions which you have accepted.

Will I receive clinical supervision?

Yes. It is part of PREP, clinical governance and risk management and should be in place.

How do I overcome traditional mindsets with colleagues if my role changes?

It is important to recognize that many people find change unsettling. It is important to have open dialogue, communicate effectively as circumstances allow, to raise awareness. It is also helpful to acknowledge that we all make a contribution to health care, no matter what model we use.

Will I be able to prescribe in my own right?

Independent nurse prescribing is now underway as the extension of nurse prescribing. From April 2002, nurses will be able to prescribe from this extended formulary having successfully completed the training course.

Will I be autonomous in my clinical practice?

As all nurses, you will have clinical freedom providing you are working within your Scope of Professional Practice and Code of Conduct.

How will I access education and training?

All members of PMS teams have PDP’s and therefore educational needs will be identified and planned time scales devised to enable staff to develop their skills and expertise.

PMS Finances

How is the baseline budget determined?

The term "baseline" is often used to refer to GMS historical spend, plus PA and dispensing. It is this sum which is centrally allocated to the HA/PCT, and may include centrally agreed growth. The HA/PCT then decides how much to supplement this from its unified budget.

How does the contract price get uplifted each year?

By whatever means you agree locally. The GMS transfer (the "baseline" of historical GMS spend plus PA and dispensing plus any centrally-agreed growth) is uplifted each year as a result of DDRB recommendations.

Potential growth under PMS

Is there an incentive to take on new patients under PMS?

There is always an incentive to increase the benefits for patients. As part of the local negotiations over the cost, an element should be decided to meet growth in list sizes, there is not recommended sum or percentage.

What happens about predicted increases in list size eg: new developments

During the negotiations around the cost of the pilot, there will need to be sums identified for predicted growth. The HA/PCT may come back to the centre to receive an increase to the GMS baseline as a result of increased patient numbers.

Growth money

What is growth money?

Growth money is centrally determined to help meet the costs of an additional GP or Nurse Practitioner.

How do we apply for growth money?

You ask your HA/PCT as part of your proposals. Very broadly, growth is considered in areas which are under doctored i.e. higher than average list size, and/or deprived.

How often would there be a review of finances for potential new growth?

As often as you agree locally. At the moment, it is considered every six months centrally, with each wave. If you are already a pilot and become in need of growth, it is possible to apply.

 Putting together a proposal

How do we write a proposal?

There is an electronic form available on the website. This is designed to help you to supply
enough information to satisfy the legal requirements. The information requested in the proforma is the
minimum necessary. If you wish to add more, that is fine and may help later.

What is the workload for the practice in preparing a proposal?

It depends but you should be supported by your PCT/HA, and there is some central funding for the costs of preparation.