Thinking local

The new Personal Medical Services contract promised great things for GP practices when it first launched. Joanne Curran looks at its impact.

A FEW decades ago the Edinburgh Access Practice might not have existed. This primary care service for the homeless is based in two clinics in the city and is run by a management team with all staff employed by NHS Lothian. Here patients have ‘drop-in’ access to GPs, nurses, midwifery services, mental health nursing, dental and podiatry clinics, drug and alcohol support as well as shower facilities and a repeat prescription service.

The practice operates under the Personal Medical Services contract which was first piloted in 1997 and made permanent in 2004. PMS has been hailed by supporters as an efficient means of boosting career satisfaction, slashing bureaucracy and improving patient care in one fell swoop. It also brings greater job security, a guaranteed income for GPs and other healthcare professionals and a flexible approach to the types of services provided for patients.

Over 40 per cent of GP practices in England – more than 16,000 practitioners – held purely PMS contracts last year while around 10 per cent of Scottish practices are PMS. There are no PMS practices in Wales and Northern Ireland.

FLEXIBLE APPROACH

The contract is seen by the Department of Health as a flexible approach to delivering primary care services in a departure from the traditional General Medical Services agreement. It has been used to develop new services for specific populations such as the homeless and ethnic minority communities, to attract doctors and nurses into deprived areas and to improve services for patients. The DoH and the Scottish Government have been keen for greater numbers of practices to sign up to the contract as part of their plans to modernise the NHS.

Kirsty Hogg has been with the Edinburgh Access Practice since 1999. She says: "Flexibility is a positive feature of PMS as our clinicians can spend significantly more time with patients – an average 14 minutes - than might be possible in a non-PMS practice. And due to the drop-in nature of our surgeries, patients are usually seen by a GP or nurse on the day they attend."

Unlike GMS, PMS contracts are negotiated locally between the PCO and the practice, and are not subject to direct national negotiations between the DoH and the General Practitioners Committee of the BMA. A PMS contract pays GPs on the basis of meeting set quality standards and the particular needs of their local population. It offers the security of salaried positions for all healthcare staff in practices that have chosen to be directly employed by their PCO. Salaries are not reliant on hitting targets, allowing practice staff to concentrate on treating patients, rather than worrying about other demands such as QOF. As PCO employees, staff are entitled to the pay, terms and conditions dictated by 2004’s Agenda for Change, including generous annual leave, educational leave, maternity and paternity leave. They must also be treated in line with the PCO’s HR policy.

But PMS does not always mean a switch to salaried status. Practices can retain their independent contractor status and negotiate a PMS contract tailored to their patients’ specific needs and there are also a number of other options open to PMS practices.

DOUBLE DUTY

Aileen Wilson, 42, a practice manager for 14 years, has a unique perspective on the ins and outs of PMS and GMS. For eight years she has managed a PMS practice in rural Portsoy, Aberdeenshire, as well as a GMS practice in neighbouring Aberchirder – a challenging role as each practice has a list of around 2600.

Aileen says: "The Portsoy practice went PMS about nine years ago because it wasn’t financially viable to have as many GPs as patient demand required. Recruitment and retention was the main issue for us so we had little choice but to go down the PMS route. But I think it has worked out well. We are able to tailor the services to our patients in a way we feel is best through negotiating with our PCO and CHP."

Aileen spends around 21 hours a week at the Portsoy practice, where the medical team are all directly employed by NHS Grampian. She also spends around nine hours in Aberchirder, where the practice is run by independent partner GPs.

She explains: "Everyone has a guaranteed salary under the directly-salaried form of PMS. GPs get paid the same no matter what QOF targets they hit, so they don’t have to get as deeply involved in the financial side unless they want to. But in Aberchirder there is a direct link with how well the practice does medically for our patients with the potential to earn additional income.

"Under PMS, a practice can, for example, make use of a GP with a special interest in a particular clinical area by negotiating with the PCO to fund a specialist service for patients of that practice and neighbouring practices."

But while the benefits seem clear for patients, GPs and other practice staff, what does PMS mean for practice managers? Aileen has found she has greater autonomy but initially found the change quite challenging, especially in terms of the financial management and HR.

She says: "There is virtually no difference for a patient walking into a PMS rather than a GMS practice. The fundamental difference is for the practice manager. In GMS you are part of a tight-knit operational unit, where you know exactly what you can expect at the end of the year. But with the directly-salaried form of PMS, you have to understand and integrate into a larger-organisation approach to finance. The financial reporting structure of PMS schemes like ours in Portsoy is completely different from my experience of GMS and the financial responsibility lies largely with the practice manager. The practice is allocated a budget which may take up to three months to be fixed. While there is no direct financial incentive for GPs to achieve QOF, the practice needs to do well in QOF for this to be reflected in our annual budget as this means more money to spend on other services for patients. Since moving to PMS, I feel that the role of practice management is the linch-pin between the practice team and the wider PCO.

"HR can also be more challenging because we must adhere to our PCO’s stringent disciplinary and grievance policies and pay scales are dictated. To discipline a member of staff using the current policy available to me, it could take up to two years to reach the dismissal process. So this would be a longer process than under GMS. GMS practices, as private businesses, don’t have that issue and don’t have to implement Agenda for Change the way we have to as employees of our NHS organisation."

HERE TO STAY

The RCGP published its National Evaluation of First Wave Personal Medical Services Pilots in July 2002 in which it found PMS "can encourage innovation and act as a catalyst for change". It can "generate service change and benefit patients as a result of increased flexibility". It also found PMS had potential for "improving services for disadvantaged groups" and had a positive effect on recruitment and retention. Some drawbacks, as highlighted in The Complete MRCGP Study Guide 2006, include no agreement on pensions, funding growth is reduced for each new wave and the local contract is not aligned with national pay reviews. Whatever practice managers make of PMS, former health minister John Hutton made it clear years ago that "PMS is here to stay".

Joanne Curran is an associate editor of Practice Manager