GUIDANCE FOR DEVELOPING PMS CONTRACTS

ANNEX D GUIDANCE FOR DEVELOPING PMS CONTRACTS (MAY 2001) www.show.scot.nhs.uk/lhcc (PMS Button) AMI040P20 1

GUIDANCE FOR DEVELOPING PMS CONTRACTS The enclosed outline PMS contract aims to help Primary Care Trusts, LHCCs, Practices and Primary care professionals with the development of local PMS contracts. The outline PMS contract covers: a core set of contractual requirements, which Trusts and Practices/Primary Care professionals would need to include in every PMS contract. a series of headings highlighting the areas which Trusts and Practices/GPs will want to consider for inclusion in a contract, although the detail and content will vary to suit local requirements. The Scottish Executive has also updated its Comprehensive Guide on the development of PMS. This provides considerable detail on each facet of a PMS contract and the outline contract crossrefers to the appropriate section of the manual, wherever more detail might be required. This guidance and the PMS guide is available on SHOW, www.show.scot.nhs.uk/lhcc PMS button. If you wish to discuss any of the above or clarify any further information on PMS, please do not hesitate to email the Health Department PMS Team as shown below: Susan Malcolm Helen Doyle Jackie Brock susan.malcolm@scotland.gsi.gov.uk helen.doyle@scotland.gsi.gov.uk jackie.brock@scotland.gsi.gov.uk AMI040P20 2

CONTENTS Page CONTRACTUAL FRAMEWORK Introduction 5 PMS CONTRACTS Summary 6 DIFFERENT TYPES OF PILOT 8 OUTLINE PMS CONTRACT 9 A. CORE REQUIREMENTS 9-16 Parties to the Agreement Background Scope of Agreement Contract Agreement Patient Information Patient Registration Responsibility for care and quality of care Temporary residents/immediate necessary and emergency treatment Acts and omissions Complaints and breach of contract procedures Services and treatment for which a charge may be made Child health surveillance, contraceptive, maternity medical and minor surgery services Health promotion and chronic disease management Vaccination/ immunisation Cervical cytology Social security requirement Indemnity Medical records Competence of doctors Competence of GP Assistants Health and safety Employment issues Preferential rights of transferring to medical lists B. LOCAL REQUIREMENTS 17 Para 5- Patient issues Administrative issues Staff issues OUTLINE OF PILOT PROPOSAL 18-21 CESSATION OF PILOT 21 EVALUATION 21 AMI040P20 3

FINANCE Annexes 1. NHS Circulars 26 2. Applying to become a PMS Site 27-29 3. Proforma for Expression of Interest 30-33 4. Funding arrangements for PMS Contracts 34-37 AMI040P20 4

CONTRACTUAL FRAMEWORK Introduction This guidance sets out an accountability framework and outline contract for personal medical services (PMS) and PMS+ pilots (see page 8) under the NHS (Primary Care) Act 1997. PMS is defined as services of a kind provided by general medical practitioners under Part II of the NHS (Scotland) Act 1978. The purpose of a PMS pilot is to test different ways of contracting for general medical services (GMS) so as to address local service issues and bring about improvement in the provision of Primary Care Services. The NHS (Primary Care) Act 1997 defines a personal medical services pilot scheme as one or more agreements made by a Primary Care Trust (PCT) or Island Health Board for the provision of personal medical services. PMS provides the opportunity to develop a more flexible and clinically based contract for the provision of primary care services, focussed on the needs of the practice population. It also offers the opportunity for practices to develop new local contractual arrangements with HBs/PCTs, either via a practice-based contract (PBC), or a trust based contract (TBC) where all the staff in a practice, including GPs, becomes salaried to the PCT under Part I of the NHS (Scotland) Act 1978. As part of the process, the doctors within the practice are required to resign from the HB/PCT Medical List. A PMS site can apply for NHS Body Status, which allows the practice to enter into NHS contracts for services under the NHS. This can be a useful tool to develop additional services for the practice population. These issues are discussed in more detail in Annex two. The legal framework of the NHS (Primary Care) 1997 Act requires PMS practices to deliver, at least the full range of primary care services provided under GMS including arrangements for registration of patients, de-registration, assignments, immediately necessary treatment, Out of Hours arrangements, certification and medical reporting, return of information and records. This framework document should be read in conjunction with the Comprehensive Guide to PMS. The outline PMS contract provides a framework document, with core areas that must be included in your contract. The highlighted areas require to be filled in with details related to the local PMS contractual arrangements. AMI040P20 5

PMS CONTRACTS Summary The PMS contract should detail clearly the objectives of the pilot. The PMS contract replaces the current national GMS contract with a simpler, clearer, local contract tailored to the needs of the practice population, based on the clinical needs of that population within a flexible working framework. The PMS contract abolishes the need for participation in the GMS payment arrangements which includes capitation fees, Item of Service (IOS) claims, allowances etc. IOS claims are claims for GMS activity related payments ie item of service fees, target payments and fees for other services. The PMS contract provides the practice with a contractual framework that offers greater flexibility, allowing practitioners to work to agreed practice protocols and focus the care on the patients in a more pro-active and quality-measured basis. The development of the PMS contract will take time, given that it is practice specific, but once it is in place, it will facilitate more time for practitioners to devote to clinical issues. GMS payment arrangements are replaced with a negotiated contract value, as part of the Practice Based Contract (PBC) or Trust Based Contract (TBC). Practice based contract The PMS contract value is based on historical GMS income, which can be averaged out over past years where the last year is not representative, plus any additional investment that the Trust agrees to meet. Where the previous net value of a GPs income was historically low, consideration should be given as to whether this is representative of the workload, and whether this needs to be reviewed. A PMS practice will not be required to participate in the GMS payment arrangements. However, the Trust and practice will wish this information to be maintained at the practice during any pilot phase, at least. This will allow the Trust to monitor actual GMS activity against the projected activity as the basis of the contract value and also allow audit/accountability reviews to be undertaken. It will also provide a reasonable basis for the Trust to make any necessary adjustments required and the practice to seek to renegotiate the contract value where there has been significant change in activity e.g. significant increases in the practice list size. GPs who negotiate a PBC with the Trust remain independent contractors and will continue to receive their income based on the practice agreement/profit shares basis. AMI040P20 6

Trust based contract Where a PMS practice is transferring to a TBC, the PMS contract value will be set, using historic GMS as the base, together with costing for additional services to be provided as part of the contract. The PCT may be establishing a new service. Here the contract value plus salary levels need to be set, taking into account the previous GMS activity and any new/enhanced services to be provided (the +element). The Trust, in conjunction with the LHCC, and the Practice will negotiate the terms of the contract i.e., appropriate salary scale for the doctors, and whether any of the GMS personal allowances will still apply e.g. seniority, PGEA. Premises and practice staffing issues will be addressed as part of the negotiations. Where new or additional services are proposed, this will require contract negotiation. Both Contracts The PMS contract should reflect the priorities of the Trust and LHCC, and should link to its local Health Plan. It would be expected that a practice wishing to go PMS would be a member of their local LHCC. The PMS site will need to demonstrate value for money and the contract should build in how this will be measured. The objective of PMS is to allow the NHS to respond better to the primary care needs of patients. By introducing flexibility into the way practices are resourced and incentivised, and by enabling a more appropriate range of service provision, PMS contracts can improve both access to, and the quality of, primary care services. AMI040P20 7

DIFFERENT TYPES OF PMS CONTRACTS PMS only contracts Provision of at least the full range of services patients would normally expect to receive from a GP under GMS. PMS plus contracts Provision of a wider range of services over and beyond that normally provided as GMS e.g. elements of Hospital and Community Health Services (HCHS). Salaried GPs GPs can be salaried within practices or by PCTs, and should continue to provide the full range of PMS services to the practice population; If a practice wishes to use a PMS contract to employ a salaried doctor, the practice must enter into a local practice-based contract to achieve this; If a Trust wishes to use a PMS contract to employ doctors as salaried GPs, they will require a trust-based contract to achieve this. Practice based contracts A practice can negotiate a practice-based PMS contract, which takes the practice out of the GMS National Contract, but where GPs remain independent contractors; The practice-based contract can include the employment, by the practice, of a salaried doctor. Nurse-led pilots Nurses can hold the contract and take responsibility for the development, implementation and achievement of a PMS contract, they would have to employ a salaried GP to provide the full range of PMS services. GP/Nurse This option allows GPs and nurses to jointly hold the contract for the delivery of PMS and hold equal employment status. LHCC/Locality Pilots An LHCC or a Locality within an LHCC, could combine under PMS, either through all the practice GPs becoming salaried to the Trust or through a multi-practice-based PMS site. Here, the current GPs would apply to become a health service body and this body would contract with the PCT; Other potential LHCC/locality models are currently being explored. AMI040P20 8

OUTLINE PMS CONTRACT A. CORE ELEMENTS 1 PARTIES TO THE AGREEMENT 1.1 This contract is between (The Trust) on the one part and the partners in the medical practice of and all future partners thereof from time to time. (The Practice) on the second part, is recognised as an NHS body for the purposes of the pilot (optional). NB: For salaried contracts with the Trust, each doctor will have an individual contract covering the main elements of this outline contract. 1.2 The contract is effective from and will run for a period of [insert Pilot PMS sites may run for a period of three years] 2 BACKGROUND 2.1 The contract covers the provision of personal medical services under the NHS (Primary Care) Act 1997. 2.2 The contract is made under the Comprehensive Guidance issued from the Scottish Executive Health Department. A list is provided at Annex 1, page 27. 2.3 The contract covers all services currently provided via GMS under the National Health Service (General Medical Services) (Scotland) Regulations 1995 as amended, known as the GMS Regulations for the purposes of the contract. 3 SCOPE OF AGREEMENT The aim of the pilot is: The aims and objectives of the pilot should be listed here. This should be lifted from the detailed business case approved by Scottish Ministers. For example: The aim of the pilot is to test a practice-based contract involving two elements: Personal Medical Services (PMS) will be extended with the introduction of a structured management plan to address chronic health and social needs. Patient healthcare will be improved by the application of protocols and guidelines to chronic disease categories within a multi-disciplinary approach. Evaluation will assess the degree to which this improves patient outcomes and reduces workload within the secondary sector. Current General Medical Services (GMS) income will be replaced by a PMS budget, based on agreed qualitative indicators. AMI040P20 9

4 CONTRACT AGREEMENT 4.1 Patient information The Practice shall:- 4.1.1 produce a leaflet setting out specific information about services (along the lines of pilot Directions and PMS Regulations) and display this at each PMS site; 4.1.2 make the practice leaflet available to the Trust, to each patient on the list of the Practice and to any other person who the Trust and the practice jointly agree might need a copy; 4.1.3 review the practice leaflet annually; 4.1.4 Among other issues, the leaflet should detail the practice s access arrangements for meeting their 24 hour duty of care. In particular, the arrangements or plans for guaranteed access to a primary care professional within 48 hours and for out of hours services. Access within 48 hours is a core requirement within Our National Health: a plan for action, a plan for change. 4.2 Patient registration (This shall be in line with current arrangements under GMS). The Practice shall: - 4.2.1 confer the right of any person to choose a GP from whom he or she is to receive personal medical services, subject to:- - the practitioner s consent, and - any limits imposed by Regulations on the number of patients a practitioner may accept; 4.2.2 Set out the procedure for choosing a GP (including on a patient s behalf), applying for transfer to another and applying for removal from the Practice list; 4.2.3 provide for both the acceptance of patients and for assignment by the Trust of patients refused by a practice or practitioner of their choice or who have made no choice; 4.2.4 remove, in line with PMS Directions, from the Practice list:- - service personnel on enlistment; - any patient leaving UK with intention of being away at least three months or any patient whose absence from UK has exceeded three months; - patients in hospital (learning difficulties or mental health) for two years or more; - patients serving a prison sentence of more than two years or a sentence totalling more than that period; - any patients who die. AMI040P20 10

4.2.5 have a policy and set out arrangements for the removal of patients from the Practice list, including for a person who has committed an act of violence against a doctor or any practice staff, or has behaved in such a way that the doctor or any practice staff have fear for their safety, in line with GMS regulations. 4.3 Responsibility of care and quality of care The Practice shall:- 4.3.1 provide to its patients, all necessary and appropriate personal medical services; 4.3.2 ensure that the doctor complies wit h his obligation, that where treatment is not personally provided by the doctor, reasonable steps are taken to ensure continuity of the patient s treatment whether:- - by another doctor or - by some other health care professional to whom any such treatment is delegated and who the doctor is satisfied is competent to carry out, or - by an organisation (e.g. Out of Hours Coops) with whom the Practice has entered into an agreement to provide such services.; 4.4 Temporary residents/immediate necessary and emergency treatment The Practice shall:- 4.4.1 provide to anyone not on the Practice list of patients, including overseas visitors or travelling people, emergency and immediate necessary treatment, including maternity medical services/ obstetric emergencies; 4.4.2 provide treatment to patients staying in the locality of the Practice for not more than three months; 4.4.3 provide immediate necessary treatment where the patient has been: - 4.5 Acts and omissions - refused acceptance for inclusion on a practice list; - refused treatment as a temporary resident; or - removed from a practice list for a period of not exceeding 14 days from the date of the previous doctor s decision or until the patient has been accepted by or assigned to another doctor, whichever is the shorter. Text for this para to vary according to whether Salaried GP PMS contracts or practicebased: AMI040P20 11

4.5.1 As with GMS doctors, any salaried doctor employed by the Practice for the purpose of this contract, when acting as a deputy to a doctor currently within the Practice, will be responsible for his or her acts or omissions as if he or she were a doctor on the Trust s medical list or PMS /Supplementary Medical List. 4.5.2 Where an act or omission on the part of a salaried doctor employed by a practice in carrying out services covered by the contract, is both a breach of the contract and would have been a breach of his or her terms of service were he or she providing GMS, that act or omission would be treated as though it were a breach of his or her terms of service. 4.5.3 PMS doctors employed by a PCT will be subject to the Trust's disciplinary procedures. 4.6 Complaints and breach of contract procedures 4.6.1 The Practice shall establish a written complaints procedures, in line with current regulations. 4.6.2 Where appropriate, the Trust will establish a system of independent review to deal with complaints in the Practice, in line with current regulations. 4.6.3 Where any dispute relating to contractual rights and liabilities arises, the matter will be referred to an independent arbitrator appointed by Scottish Ministers, but agreed by parties concerned, who will determine the matter. 4.6.4 The Practice shall have in place appropriate internal disciplinary procedures. 4.7 Services and treatment for which a charge may be made The Practice may choose to provide any or all non-nhs services, and if so provided, is entitled to charge the patient for that service, in line with current regulations. Whether this income would be retained by the practice would need to be determined in the contract agreement. 4.8 Child health surveillance, contraceptive, maternity medical and minor surgery services The current provision of child health surveillance, contraceptive, maternity and minor surgery services provided under GMS Regulations will continue under personal medical services, and current GMS criteria for eligibility will continue to be a requirement. 4.8.1 In regard to child health surveillance services the Practice shall ensure that any doctor providing the service has the required medical experience and training necessary to enable them to perform the services properly. 4.8.2 In regard to contraceptive services, the Practice shall ensure that any doctor providing the service will have regard to, and be guided by, modern authoritative medical opinion. AMI040P20 12

4.8.3 In regard to obstetric/maternity medical services the Practice shall ensure that any doctor providing the service has the required medical experience and training necessary to enable them properly to perform such services, as determined by the GP Sub Committee. 4.8.4 In regard to minor surgery services the Practice shall ensure that any doctor providing the service has acquired the appropriate medical experience and training necessary, and that the Practice has access to the appropriate facilities necessary to enable them properly to undertake the procedures offered. 4.9 Health promotion and chronic disease management programmes The Practice shall:- 4.9.1 offer opportunistic advice, where appropriate, to a patient in connection with their general health; 4.9.2 offer health promotion and chronic disease management programmes. If one of the contract s objectives is to consider different models of HP/CDM, enter objectives, standards and targets here. 4.9.3 offer new patient registration examinations and also, if requested checks to patients not seen in the previous three years and patients over 75 years of age. If local variations to these standards are planned under PMS enter here. 4.10 Vaccination/immunisation The Practice shall:- 4.10.1 participate in vaccination/immunisation programmes equivalent to GMS arrangements and provide to patients, where appropriate, vaccinations or immunisations in line with current public health policy, including against measles, mumps, rubella, pertussis, poliomyelitis, diphtheria, tetanus, meningitis C, influenza and haemophilus influenza B, at no cost to patients; 4.10.2 provide to persons not travelling abroad, all appropriate immunisations in line with current nationally agreed arrangements, at no cost to patients; The practice will wish to ensure that any costs related to this are covered within the contract value. 4.10.3 provide to persons travelling abroad immunisations against typhoid, poliomyelitis and hepatitis A in the same circumstances given under GMS arrangements; 4.10.4 maintain the current target levels; AMI040P20 13

The practice may wish to consider reviewing the target levels and develop, as part of the PMS proposal, more appropriate quality measures for these services. 4.10.5 maintain the statutory requirements for recording and notifying immunisations. 4.11 Cervical cytology The Practice shall:- 4.11.1 arrange access to an adequate cervical smear test of all eligible women, through arrangements at least equivalent to the current GMS target scheme; 4.11.2 maintain the current target levels; The practice may wish to consider reviewing the target levels and develop, as part of the PMS proposal, more appropriate quality measures for this service. 4.11.3 maintain the statutory requirements for recording and notifying smears. 4.12 Social security requirement The Practice shall:- 4.12.1 issue free of charges to a patient or personal representative(s) a medical certificate in circumstances analogous to those described in GMS Regulations/Directions; 4.12.2 provide, in response to a request from an authorised medical officer, relevant clinical information about patients of the Practice to whom a medical certificate has been issued or refused. 4.13 Indemnity For doctors within a Practice Based Contract it is an essential condition of this contract that the Practice/Trust shall ensure that appropriate arrangements through a recognised defence union or insurance based scheme, for indemnity against claims by patients for negligence by partners and salaried staff are in place throughout the period of this contract, and this would be the responsibility of the Practice. On request, the Practice shall exhibit evidence of such indemnity provision to the Trust from time to time. For a Trust Based Contract, indemnity will be the responsibility of the Trust. 4.14 Medical records The Practice shall:- 4.14.1 make and keep clinical records on forms supplied by the Trust in respect of all patient consultations and treatment, or in an electronic form as agreed with the Trust; AMI040P20 14

4.14.2 forward records to Practitioner Services Division of the Common Services Agency, in the normal manner, in response to a patient transfer, without charge; 4.14.3 make and forward via the Trust clinical record to the home practice in respect of patients treated under temporary residents/immediate necessary/emergency treatment provisions without charge; 4.14.4 forward records to Practitioner Services Division of the Common Services Agency, on request and in the event of patient s death; 4.14.5 comply with all requests from patients for personal information under the terms of the Access to Health Records Act. 4.15 Competence of doctors The Practice shall:- 4.15.1 ensure that all doctors in the Practice are suitably experienced (in line with those guidelines applicable under the PMS Regulation/Directions), 4.15.2 or, by virtue of sub-section 2 of section 11 of the NHS (Primary Care) Act 1997, exempt from the need to have acquired that experience, eg GP Registrars preregistration house officers. 4.15.3 ensure that all GPs declare any convictions or professional proceedings against them. It should be noted that where any GP is convicted of murder or receives a jail sentence of six months or more, the Trust is required to remove the doctors name from its medical or PMS/supplementary medical list. 4.16 Competence of GP Assistants/ salaried doctors, for Practice-based contracts The Practice shall:- 4.16.1 ensure that any person employed or deputy engaged to assist with the provision of the services is suitably qualified and competent to discharge the duties for which he or she is to be employed or engaged, and is not the subject of a declaration of unfitness to be engaged in any capacity in the provision of general medical services and suspended by direction of the NHS Tribunal. 4.17 Health and safety The Practice [or Trust for Trust-based contracts] shall:- 4.17.1 ensure adherence to the Health and Safety at Work Act 1974 and the Health and Safety Regulations 1992 and the Trust s policies and procedures as they are introduced (a written Health and Safety policy and risk assessment are mandatory requirements). 4.18 Employment issues AMI040P20 15

The Practice [or Trust for Trust-based contracts]shall:- 4.18.1 have in place, appropriate procedures, including disciplinary and grievance procedures, recruitment, equal opportunities, maternity leave, training and redundancy policies. 4.18.2 ensure that the practice adheres to good practice in regard to the recruitment and retention of staff, in line with the Trusts policies and procedures. 4.19 Rights on transferring to medical lists 4.19.1 shall resign from the Trust s medical list and will have their name included in a PMS/Supplementary medical list of the Trust for the duration of the contract. 4.19.2 Where leaves the medical list to join a pilot PMS contract, s/he will have the preferential right to be re-admitted to the list of the Trust at a conclusion or the cessation of, or withdrawal from, the contract. 4.19.3 Any doctor, who replaces during the operational period of the PMS pilot contract, who had previously been on a medical list in the Trust s area, will also have the preferential right to be re-admitted on to the Trust s medical list. 4.19.4 Any doctor in the practice who does not fall into either of the above categories and was not on the Trusts medical list prior to the contract, will have no automatic preferential right to be admitted to the medical list. 4.19.5 Where leaves the medical list to enter a permanent PMS contract, they will have no automatic preferential right to be re-admitted to the Trust s medical list if the contract ends. 4.20 Training/Teaching Practices 4.20.1 Where the practice is designated a training/teaching practice, it will be entitled to the same fees and remuneration applicable to GMS practices, which will be included in the contract value. 4.21 Arrangements for absences 4.21.1 Where a doctor is absent from the practice on account of sickness, she will be entitled to any locum reimbursement that would have been applicable under GMS, which will be included in the contract value. 4.21.2 Where a doctor goes on maternity leave, she will be entitled to any locum reimbursement that would have been applicable under GMS, which will be included in the contract value. AMI040P20 16

B LOCAL CONTRACTUAL REQUIREMENTS 5.1 Patient issues Include here information about the surgery arrangements, detailing the opening hours, consulting hours and OOH arrangements. The contract should detail the number of working hours of each of the doctors, other primary care professionals and support staff. A change in the partnership structure or organisation needs to be detailed. 5.2 Administrative issues The practice will no longer be required to participate in the GMS payment arrangements. Practice based contract The practice and Trust will need to agree the mechanism for monitoring the PMS activity against the historical GMS, which was used as the budget, but will wish to ensure a reduction in the bureaucracy associated with the GMS payment arrangements. Agree quality outcomes and measures for monitoring the contract. Trust based contract Agree quality outcomes and measures for monitoring the contract. 5.3 Personal/Career development for Primary care team PBC & TBC Post Graduate Education Allowance (PGEA). The practice/gps/trust will need to review whether they will continue to maintain the appropriate levels for continued eligibility for PGEA. The practice/gps/trust may wish to explore alternative methods for continuing personal and professional development. For the TBC, the Trust and the practice will need to agree whether the doctors will continue to receive PGEA, and whether they wish to maintain the GMS arrangements. Appropriate arrangements for continuing personal and professional development should be developed for all practice staff, in conjunction with the Trust. Salaried practices should participate in the Trust s appraisal and career/personal development systems. This should be extended to the whole of the primary care team. AMI040P20 17

6 SUMMARY OF OUTCOMES 6.1 General There should be measurable benefits in the PMS contract in terms of quality and standards of care provided. The benefits should be measured against the objectives set for the pilot. For example: The anticipated outcomes could be tested using measurable objectives set by the following parameters: - Is there more effective management of the practice workload? Are areas of greatest need being targeted? - Is there implementation of recognised best practice in the management of care? - Has equity of access to services been improved? - Is there improved integration and continuity of care - both within primary care and with providers of secondary care? - Are there improved relationships between the primary care team and the users of their services. 6.2 Outcomes for patients The outcomes targeted for patients should be detailed and measured against the contract s objectives e.g. improved access, health care and health outcomes, and reduction in secondary care referrals. For example The anticipated outcomes could be tested using measurable objectives set by the following parameters: Is there an improved delivery of health care? Are there long-term implications for patients health and health care needs as a result of improved service delivery? Has the CDM programme reduced the acute or relapse workload within the practice and reduced secondary sector referrals; and Are services being delivered closer to patient s home at a time and place which suits them? AMI040P20 18

7 OUTLINE OF PMS PROPOSAL 7.1 Aims of PMS Contract The aim(s) of the PMS contract should be clearly stated. 7.2 Objectives How the aims of the contract will be achieved. The processes/systems to be introduced to achieve this and measurable objectives. 7.3 Methodology Detailed outline of the methodology to be used. For example a PMS contract focussing on chronic disease management would state: The targeted increase in the number of appointments/sessions /clinics for each disease and the increase in length of appointment, eg from 7 to 20 minutes. Selection criteria for patients. Procedure at the consultation. Process for the development of the care management plan. Audit process to measure outcomes 7.4 Monitoring Insert processes for monitoring and reporting performance against the contract standards and proposed outcomes The contract value should be reviewed annually or earlier, particularly if there is a significant change in previous historical information e.g. increase/decrease in practice list. 7.5 Employment issues for Trust-Based Contracts (GPs salaried to the PCT) The TBC (total salaried option) allows the doctors to become employees of the Trust. Staff and premises, if agreed would transfer to the Trust; Transfer of Undertakings (Protection of Employment) Regulations (TUPE) will apply where a practice opts to become salaried to a PCT. GPs employed by a Trust or a practice, negotiate their local terms and conditions of employment (see paras 7.7 and 10.1.5 below). Employers are required to provide new employees with a written statement of the terms of employment, within 2 months of commencement (Trade Union Reform and Employment Rights Act 1993). GPs employed by a Trust will have the right to trade union representation applicable to Trust employees. AMI040P20 19

Premises may be an issue for GPs transferring from GMS to salaried status, with cost-rent premises, particularly where there is negative equity. This would need to be negotiated with the PCT. Developer-led premises should be more straightforward with the practice transferring the lease to the PCT as part of the contract; The line management arrangements between PCT and GP will need to be outlined. Salaried GPs should report to the Medical Director and the PCT will provide personnel, management and clinical support to the PMS primary care team. PCTs will need to consider their employment policies and ensure that PMS practice-based consultation processes are in place. The policies and employment regulations which should be considered include: The Management of Health and Safety at Work Act 1974; The Health and Safety Regulations 1992; The Sex Discrimination Acts 1975 and 1986; The Race Relations Act 1976; The Disability Discrimination Act 1995. The Working Time Directive ECHR The statutory rights to: Maternity Leave and Maternity Benefits (DSS Leaflets N1257 and N117A Employers Guide to Statutory Maternity Pay); NHS Pension Scheme and pension arrangements. 7.6 The contract of employment should include Continuity of employment; Period of employment; Period of notice; Details of salary and allowances; Contract of employment should set out broadly the responsibilities and duties, and whether there are any pre-requisites e.g. inclusion on the Minor Surgery List; Hours of work should be clearly stated, and in particular whether there will be any out of hours commitment/requirement; Annual leave public holiday entitlement; Notification of absence; Compassionate leave; Maternity leave; Study leave; Local Sick pay scheme; Statutory Sick Pay entitlement must be claimed by practice, which can then be supplemented so that, during sickness, payment is made in accordance with the sick pay scheme within the contract. When time limits are exhausted, paid during the remaining period of entitlement of SSP; Arrangements for locum cover during absence; Appraisal; Pension arrangements will need to be agreed locally; AMI040P20 20

Register of interests; Continuous Professional Development; Governance Arrangements. 7.7 Whether salaried or practice based contract: Convictions/offences declaration required; Outside activities; Transport e.g. is there a requirement for a car; Disciplinary and grievance procedures; Retirement Confidentiality; Access to medical records; Policy on prescribing prescribing budgets may be included in the contract valuation, but arrangements relating to over/under spends should be in accordance with local Trust arrangements; Dispensing Practices arrangements as per GMS Health and safety; Complaints; Accidents or injury at work. 7.8 Contract Management The contract should run for 3 years, with annual reviews and re-negotiation of the contract value; Insert details of the monitoring arrangements. This should include operational arrangements, eg there should be regular meetings with the practice by an appropriate officer of the PCT, together with finance representative, to deal with operational, including financial issues; For strategic/developmental issues, the PCT/PMS site could consider setting up a Project Board whose membership could be wide-ranging and include PCT/LHCC representatives, Practice representatives, Public Health, Acute Trust, and social work. PMS Doctors will be subject to the annual appraisal system to be introduced for GMS doctors. PMS practices will participate in the Trusts Clinical Governance initiatives 7.9 Financial monitoring/accountability Financial reporting mechanisms, agreed internal and external audit arrangements and agreed procedures for the management of financial transactions systems must be in place. Reporting and resolving variances on expenditure must also be detailed here. 8 CESSATION OF CONTRACT 8.1 Participation of the partners in a pilot PMS contract is conditional on their being given preferential treatment (assuming no change to individual partner eligibility in the period of the contract) to return to the Medical List in the event of the cessation of the contract for any reason. The terms and conditions of service on return will be the same as prior to the commencement of the contract, but making due allowance in payments for seniority, etc, as if the doctor had continued in GMS. 8.2 Where a practice opts for permanency, the preferential right of return to the Medical List will no longer apply, but the contract should outline the mechanism for return to the Medical AMI040P20 21

List. This is likely to require each doctor to re-apply for the inclusion of their name in the Trust/Health Boards Medical List. 8.2 A six month period of notice (or such period agreed between the Trust and the Practice) from the contract will be required for voluntary withdrawal from the contract by both the Board/Trust and the Practice, and where this occurs, the practice will be obliged to provide continuity of service throughout any handover or transitional period. 8.3 Where there is a change in legislation, which directly affects the continued viability or appropriateness of the contract, the Board/Trust and the Practice will review the position, and if applicable apply 8.2 above. 8.4 In the event of cessation of the PMS contract, the enhanced service as proposed under Personal Medical Services will cease, other than services which could be accommodated under the working arrangements in place prior to commencement of the contract. 8.5 Contracts of employment for additional staffing to support the implementation of the project will be on a temporary or fixed term basis and will be terminated in the event of cessation of the contract consideration should be given to incorporating a redundancy waiver clause. (Employing bodies should seek their own legal advice when drawing up temporary or fixed term contracts.) 9 EVALUATION A local evaluation is a requirement of PMS pilots and the Primary Care Act 1997 requires a review of each pilot by Scottish Ministers within 3 years of its commencement. The design of the evaluation should fit the pilots aims in terms of its purpose and scale. Clear objectives and a robust system for generating information for monitoring against objectives is vital. The local evaluation should also take account of the local context, and how the pilot has fitted into the local purpose. A review by Scottish Ministers will not be required for permanent PMS contracts. 10 FINANCE 10.1 Contract value The contract value will be established using the historical GMS income that the practice received as the base value and any additional resources that the PCT agrees to fund service developments. See Annex 4 Funding Arrangements for PMS Contracts. Since a PMS site no longer participates in the GMS payment arrangements, payments to the practice will be made on a regular monthly basis either via the PBC or TBC. 10.1.1 Historical GMS The historical GMS income is the income that the practice achieved in the last financial year including capitation fees, IOS, personal allowances such seniority, PGEA. This can be averaged out over several financial years if the last year is not representative. AMI040P20 22

For seniority, it would be anticipated that the years of service in a PMS practice would count towards seniority levels. In addition cash-limited GMS for staffing, premises and prescribing must be included. Arrangements for any prescribing savings must be in line with local LHCC/Trust agreements. Where the practice is a dispensing practice consideration will need to be given to how this will be developed within the PMS framework. Any adjustments applicable to GMS practices will be applied to PMS practices by an adjustment in the contract value e.g. DDRB awards or any new payments available to GMS doctors. Whilst a pilot, current arrangements for pensionable share income continue to apply for practice-based contracts. GPs becoming salaried may wish to retain the practitioner benefits they currently accrue as independent contractors. Salaried GPs retaining practitioner benefits will not be eligible for officer benefits such as redundancy pay and early retirement. Income implications will require to be considered. Where a PMS practice opts for permanency, for PBC, subject to amendment pension regulations, current arrangements for pensionable share income will continue to apply. For salaried doctors in a TBC, doctors will no longer be able to participate in the pensionable share income system, but will require to Trust-officer based arrangements, which may result in a reduction in their final pension. In these cases consideration will need to be given to the Additional Voluntary Contribution (AVC) scheme. 10.1.2 Additional resources If the PMS contract has received additional investment from the PCT from the PMS development allocation; the amount should be inserted. Arrangements for pensions and income will apply as for GMS resources. 10.1.3 Incentives PMS providers will be able to negotiate incentives linked to the achievement of specific clinical targets, expressed as process or outcome indicators. 10.1.3 Allowances Personal allowances such as PGEA and Seniority can continue to be paid, if agreed as part of the contract. The continued payment of personal allowances such as seniority will need to be agreed, and where it is not paid, the years of service in a PMS practice would continue to count towards seniority, were any doctors to return to a GMS practice.. AMI040P20 23

10.1.4 Tax/Pension Doctors in a PBC (whether pilot or permanent) should not have to move from schedule D payments to PAYE: this should be discussed/clarified with accountants/inland revenue. Pensions should not be affected for PBC, although this should be confirmed with SPPA. Allowances that are superannuable should be detailed in the contract. As a pilot, doctors in a TBC may need to consider moving into schedule E payments for tax purposes, but the system for their pensions will not be affected. Where they opt for permanency, the above arrangements for tax will continue to apply, but new arrangements for pensions will be applicable. 10.1.5 Determining salary levels If GPs are transferring from GMS to PMS, the current income should provide the starting-point for salary level negotiations. Determining income under GMS should include the value of pension arrangements, transport allowances and payments for premises. A value can also be placed on entitlements to annual leave, maternity pay, study leave etc, which may be more advantageous under a salaried contract than under GMS. Negotiations should also take into account that the PCT will be taking on responsibility for the management of the practice and maintenance of premises, any additional responsibilities would require to be taken into consideration. Where the salaried post is new or it is the salaried practitioner first post, the skills and experience of the post-holder and the duties required must be taken into account. It would be expected that a GP who goes salaried should not be disadvantaged because of their salaried status. In negotiating salary levels Trusts will wish to have access to as much information as possible, including Practices audited accounts. The formula for assessing the Intended Average Net Income (IANI) for DDRB purposes, might be useful background for PMS providers and PCTs in their negotiations: Sum all practice payments Minus rent and rates (these are 100% directly reimbursed Minus practice staff and IT (these are partially directly reimbursed as per local arrangements) Minus remaining 30% practice staff and IT (indirectly reimbursed through Fees and Allowances) Minus fees and allowances classed as transfer Payments (Associate/Assistant/Trainee allowance) AMI040P20 24

Minus further indirectly reimbursed expenses: admin and premises costs (fuel, lighting etc Minus 2/3 of Higher target payments (not included in IANI). The final figure provides basis for setting IANI. Previous GMS payments income come to the Trust, but allowances such as PGEA and Seniority, subject to agreement, can still be paid to the GP, on the basis of GMS requirements; There are implications for GMS practitioners transferring to salaried PMS on a permanent basis where GPs will cease to be treated as Schedule D for income tax purposes and will move to a PAYE/Schedule E system. Independent advice from Accountants/Inland Revenue should be sought. Doctors in a total salaried practice, if allowable under the contract agreement, may continue to undertake locum work or other practice /NHS/private work, which may attract schedule 4 payments. So there may need to be a mixed declaration to the Inland Revenue. This would need to be clarified with Accountants/Inland Revenue; For permanency, pension entitlements may also be affected. Salaried GPs, as employees of the PCT, will be eligible for officer levels in regard to pension, certainly for the years of service related to the PMS arrangements; Clarification in regard to pre-pms arrangements will be required from SOPA, and whether the years of service for that period can be dynamised as per current GMS arrangements; Where a PMS salaried GP would appear to be losing out in their pension calculation, consideration of AVC payments may be required when negotiating the contract; These issues should form the starting point for assessing a level of salary. The final determination will have to be based on local factors. 10.1.6 Retention of Non-GMS income The PCT and PMS site will need to agree a position on the retention of non-gms income. Where this is agreed, arrangements to enable the GPs to retain a proportion of the non-gms income should be incorporated into both the salaried GP and practice-based PMS contracts. AMI040P20 25

The Board/Trust and the Practice agree to the terms of this contract. For and on behalf of: For and on behalf of: Trust/Board Practice Signature: Signature: Signature: Signature: Signature: Signature: Signature: Signature: Address: Address: Date: Date: AMI040P20 26

ANNEX ONE NHS CIRCULARS AND PMS PILOT AND PERMANENT REGULATIONS The National Health Service (Personal Medical Services) (Scotland) Regulations 2001 The NHS (Scotland) Act 1978 Directions to Health Boards concerning the Delegation of Functions to Primary Care NHS Trusts * * * * * National Health Service (Primary Care) Act 1997: "Directions to Health Authorities and Health Boards Concerning the Preparation of Proposals for Pilot Schemes (Personal Medical Services)"; National Health Service (Primary Care) Act 1997: "Directions to Health Boards Concerning the Implementation of Pilot Schemes (Personal Medical Services)"; National Health Service (Primary Care) Act 1997: "Directions to Health Boards Concerning Patients Lists (Personal Medical Services)"; National Health Service (Primary Care) Act 1997: "Directions to Health Authorities and Health Boards Concerning Variation of Proposals for Pilot Schemes (Personal Medical Services)"; Statutory Instrument 1997, No.1821 National Health Service, Scotland: "The National Health Service (Pilot Schemes: Financial Assistance for Preparatory Work) Regulations 1997"; Statutory Instrument 1997, No.1827 National Health Service, Scotland: "The National Health Service (Pilot Schemes: Financial Assistance for Preparatory Work) Regulations 1997"; Statutory Instrument 1997, No.2289 National Health Service, Scotland: "The National Health Service (Proposals for Pilot Schemes) and (Miscellaneous Amendments) Regulations 1997". Statutory Instrument 1997, No.2929 National Health Service, Scotland: "The National Health Service (Pilot Schemes - Health Services Bodies) Regulations 1997"; Statutory Instrument 1998, No.646 National Health Service, Scotland: "The National Health Service (Pilot Schemes: Miscellaneous Provisions and Consequential Amendments) Regulations 1998"; Statutory Instrument 1998, No.657 (S.27) National Health Service, Scotland: "The National Health Service (Service Committees and Tribunal)(Scotland) Amendment Regulations 1998"; Statutory Instrument 1998, No.659 (S.29) National Health Service, Scotland: "The National Health Service (Choice of Medical Practitioner)(Scotland) Regulations 1998"; Statutory Instrument 1998, No.660 (S.30) National Health Service, Scotland: "The National Health Service (General Medical Services)(Scotland) Amendment (No.2) Regulations 1998"; Statutory Instrument 1998, No.665 National Health Service, Scotland: "The National Health Service (Pilot Schemes: Part II Practitioners) Regulations 1998. AMI040P20 27

Applying to become a PMS site Annex Two A practice who is interested in exploring the PMS option should approach the PMS contact at their Trust, who will provide advice and support, to work up the expression of interest (stage1); The Scottish Executive (SE) will receive expressions of interest to pilot PMS (stage 1) at any time, but any pilots approved following the formal application submission (stage 2) need to commence on either 1 April or 1 October; Stage 1 is an Expression of interest of interest to pilot PMS and a copy of the expression of interest proforma is attached as Annex 3. The Expression of interest sets out what the practice would like to do and how the contractual arrangements will change. It is not a costed-business case, but is merely a summary of the main themes and issues. SE aim to turn around applications within 3 weeks; If the Expression of interest is approved for Stage 2 Formal Application Submission, then a more detailed and costed proposal is required. Given that practices undertake this in conjunction with the Primary Care Trust/LHCC, and GPs require protected time to develop this, additional resources may be available to facilitate this; The Formal Application Submission is a detailed business case which should set out the process of change proposed, how this will be taken forward, and whether this will be a Practice Based Contract (PBC) or a Trust Based Contract (TBC), where the whole practice becomes salaried to the Trust; The Business Case requires the agreement/approval of the LHCC and PCT, and the PCT is required to seek the views of the LHCC, Local Health Council and Local Medical/GP Sub Committee; The views of these bodies must be submitted, together with the decision of the PCT to the SE. If the SE approves the application, it can make available additional resources for Start-up, costs which should be outlined in the business case application; When Stage 2 approved the practice and the PCT begin the process of contract negotiation based on the business case, with start dates of 1 April or 1 October. Practice Based Contract: The PBC proposal allows the doctors within the practice to remain independent contractors, but they enter into new contractual arrangements with the PCT, which no longer requires them to participate in the GMS payment arrangements as their means of remuneration; The practice negotiates a PBC, with an agreed contract value based on historical GMS, uprated for DDRB increases, and any additional resources to fund new services/developments; Doctors must resign from the Medical List (Part II of NHS Act), but will be included in the PMS/Supplementary medical list as a PMS practice; Practice can apply for NHS Body status, which allows the practice to enter into NHS contracts with others in the NHS; A salaried GP can be employed by the practice, as part of the PBC; All PMS doctors will be subject to the same assessment process applicable to GMS doctors. 28