Implementation Coordination Group


October 2006 The Implementation Coordination Group (ICG) was first established as an interim arrangement to deal with problems during the implementation phase of the new General Medical Services (GMS) contract. It was re-established in response to calls from local medical committees (LMCs) for involvement from the General Practitioners Committee (GPC) and the Department of Health in local disagreements with primary care organisations (PCOs) that could not be resolved locally and which were inappropriate for formal dispute resolution procedures. The ICG meets monthly and comprises of a negotiator from the three National negotiating parties – Richard Armstrong (Department of Health), Philip Grant (NHS Employers Organisation) and Hamish Meldrum (GPC). The ICG deals with both local and national problems arising from the interpretation of the GMS contract regulations and guidance and provides a final recommendation on matters raised.

This document shares learning from recent decisions to allow learning from these cases across the wider NHS.

This is the first of a series of communications to share information on decisions made at ICG to a wider audience. The ICG has recently received a significant number of queries relating to enhanced services therefore these cases are particularly highlighted in this briefing.

(*Cases regarding Enhanced Services Floors in bold)
1 List cleaning
2 (a) Enforced allocation of nursing home patients across primary care trust (PCT) border
(b) Level of service required in nursing home
3 Use of Enhanced Services Floor (ESF) for ‘Evercare’ model of nursing
4 Locum appraisal funding
5 Use of ESF for same day treatment centre
6 Locum reimbursement: interpretation of the Statement of Financial Entitlements (SFE)
7 Minor surgery Directed Enhanced Services (DES)
8 Seniority payments
9 Primary care incentive scheme
10 Use of ESF for care of patients in cottage hospital and in-house physiotherapy
11 Use of ESF for
(a) Emergency Saturday morning surgery;
(b) PRIMIS Facilitator
12 Salaried GP Contract of Employment
13 Use of ESF for
(a) Ex – GP fund holding services
(b) personal medical services (PMS) Greenfield sites
14 Use of ESF for
(a) Minor surgery
(b) Prescribing incentive scheme
15 Quality Information Preparation Payment
16 Rent reviews
17 Consultation on single handed vacancy
18 Enhanced services floor and contestability – counselling, anti-coagulant service and physiotherapy
19 Use of ESF for medical cover funding
20 Rebasing the Enhanced Services Floor
21 Quality and Outcomes Framework (QOF) and practice performance
22 Reimbursement of IT costs
23 Practice Based Commissioning local enhanced service (LES)
24 Interpretation of QOF – Asthma 6
25 Premises expenditure
26 Use of ESF for Prescribing Incentive Scheme (PIS)

1. List cleaning exercise
A PCT proposed to claw back from practices sums which they state had been ‘overpaid’ when patients had not been removed from practice lists. However, the PCT recognised that it had failed to remove the duplicate registrations from the registered list within the required 6 month period from the date of notification to the practice of the duplicate registration and, therefore, no action could be taken on the overpayment.

Learning point: Recovery of payments arising from list cleaning exercises
List cleaning exercises that identify erroneous duplicate registrations and subsequently apply a policy of recovery of past payments made to practices can only be actioned where the identified registration is removed from the registered list within a 6 month period from the date of notification to the practice. Under the SFE for 2005/06 (paragraph 20.1) PCTs may recover monies either by deducting the amount from any other payment under the SFE, or if no deduction can be made, the sum can be withheld from a future payment. The General Medical Services Transitional and Consequential Provisions Order 2004 (SI 2004/865) also provides that it is possible to recover incorrect SFA payments made before 1st April 2004 as a civil debt (Article 41).

2. (a) Enforced allocation of nursing home patients across PCT border (b) level of service required in nursing home
a) Patients from a nursing home with high dependency elderly patients were allocated to GPs in a different PCT area. The workload was putting pressure on practices and raising workload for nursing homes. The ICG clarified that practices had the right under the regulations to refuse to register patients from outside their practice area.

b) The level of service required in this nursing home was greater than that demanded from essential services. Due to the resignation of a GP who had been paying a retainer to do this work, the nursing home owner now expected patients to register with one GP in the area. ICG agreed that this was unacceptable as asking GPs to provide services outside their competencies would put patients at risk and set a precedent for other private nursing homes. It was agreed that the PCT should be encouraged to put pressure on the home owner locally to change its policy and to keep in mind that not providing for patients properly could lead to enquiries by the Healthcare Commission.

Learning point: Border issues and patient allocations
Section 16CC(2)(a) and (b) of the 1977 Act (as amended by the Health and Social Care (Community Health and Standards) Act 2003) states that a PCT may make arrangements for the provision of, or provide, primary medical services whether in or outside its area. Under the new GMS Regulations, a practice can accept patients on to its list who live outside the practice area, including those who live in a different PCT area. However, the regulations are clear that refusing to register a patient from outside their practice area is a practice right.

The PCT’s power to assign patients is restricted to a provider with whom it has entered into a contract (previously it was limited to a GP on its medical list). Therefore, a PCT cannot assign a patient to a provider whose contract is with a neighbouring PCT, although it can enter into a contract for the provision of primary medical services to, for example, the patients of a nursing home within its boundaries with a provider that is based outside of the PCT boundaries. That contract would, of course, need to be voluntarily entered into by the provider and be on whatever terms were negotiated, but such terms would have to be compliant with the rules surrounding that contractual type (GMS/PMS/APMS/PCTMS).

3. Use of ESF for ‘Evercare’ model of nursing
A PCT insisted a pilot of the ‘Evercare’ model of nursing was a valid Enhanced Service and had funded this out of the ESF. It was agreed that any enhanced service should be subject to contestability. Given that there had been no demonstration of the PCT undertaking a tendering process that allowed GMS or PMS contractors to bid for the contract, the Evercare model should not count towards the ESF. Although it may be a suitable enhanced service in future, subject to the services being contestable, it could not be funded from the ESF for 2004/5.

Learning point: Contestability
Enhanced service disputes have been raised over ‘rebadging’ of existing non-GMS/PMS services. Where it is shown there has been a lack of contestability (or competition) of services by GMS and PMS providers these cases have been upheld.

There are two key tests as to whether re-commissioned services can be classified as an enhanced service for monitoring floor spend. These are:
(i) could the service reasonably be provided by GMS or PMS providers - a good test here is whether the PCT is aware of the disputed service currently being provided by any practice
(ii) the award of the service was subject to some form of competitive process in which GMS or PMS providers were able to participate

Future intentions to make services contestable are not an argument for inclusion of expenditure in the floor, only when that process has been undertaken can expenditure count.

Related to contestability issues is the provision of services by Practitioners/GPs with Special Interests (P/GPwSI). Guidance is clear that expenditure on such services will generally count towards the floor. It is advised that the appointment process of such personnel should be clear and transparent, enabling GMS and PMS providers to participate where they have the necessary skills and training. Such skills and training may be available in-house through existing personnel or practices may propose and detail through the application process how they intend to make available such personnel e.g. sub-contracting.

4. Locum appraisal funding
A PCT was not offering appraisal to those GPs on their Performer List not employed in practices. The PCT for which the locum is on the list refused to fund appraisal when the locum worked in a different PCT. Information from the SHA suggested that this one PCT had taken responsibility for registering all locum GPs in the area, including those that should have been on the list for neighbouring PCTs, for ease of administration. However no further funding had been made available. The ICG asked the SHA to ensure that funding was available, from other PCTs if necessary, to fund this. The ICG agreed that PCTs for which the locum actually works should pay for the appraisal.

Learning point: Locum appraisal payments.
It is the PCT within which locums work that is responsible for making appraisal payments. Funding arrangements in place reflect and support this.

5. Use of ESF for same day treatment centre
A PCT funded a £500k same day treatment centre from the ESF. It was agreed that the GP surgery would usually have to pay for such a service. Therefore, certain elements could not be classified as enhanced services, whilst others potentially were. It was subsequently established that the PCT’s ESF for 2004/05 had been constructed to include historic funding for this service. The ICG, however, noted that the scheme was not contestable and that the service remained an integral part of the local health economy. Therefore, it was agreed that as the initial costs of this service had been included in the ESF, the PCT and LMC should agree to fund these services from the current floor or remove the funding and lower the floor. The ICG recommend that in future the LMC is consulted by the PCT to ensure that any part of the ESF is contestable.

Learning point: Historic expenditure on enhanced services
Historic expenditure concerns services that were in place and funded prior to the construction of enhanced service floors. In the main the resolution has been that where such expenditure was shown to the ICG to be counted in the floor at the time of its construction PCTs and LMC have been offered a local choice, either:
(a) continue to count such expenditure in the floor construct and towards PCT floor expenditure; or,
(b) don't count towards PCT floor expenditure and rebase the PCT floor (therefore the PCT’s floor falls by corresponding amount not just for that year but future years also).

Where the service in question is judged not to be of a service type that would normally be defined as an enhanced service, the ICG’s view is that rebasing should occur so to ensure consistency in enhanced service definitions. The Department of Health requires notification of any local rebasing decisions.

It is worth noting at this point that PCT enhanced service floors were constructed from the following three elements of funding, all of which were calculated slightly differently:
(i) floor funding from within the unified allocation, which was calculated pro rata to the unified baseline
(ii) floor funding from GMS non-cash limited, which was the equivalent of enhanced services previously funded in GMS practices and was based on historic spend reported as per the AWP exercises.
(iii) floor funding from PMS non-cash limited, which was calculated by first estimating the level of enhanced services spend within the PMS allocation then allocating this pro rata to the 2004-05 funding for PMS practices

This information should assist PCTs and LMCs in establishing whether any local historic funding issues apply to any disputed services and therefore reach agreement on its treatment without referral to ICG.

Historic expenditure arguments have been found across all funding streams such that:
  • Primary Care Incentive Scheme monies were mapped to the construct of PCT enhanced services floors as a pro-rata calculation to a unified budget. Both recurrent and non-recurrent elements of this scheme were included in this calculation.
  • Examples of funding lines reported locally under the AWP exercise that contributed to floor construct include services previously funded from Improving Primary Care Access monies and ex-GP fund holding
  • A pro-rata of PMS growth funding informed floor construct (and therefore elements of that funding used to deliver enhanced services may count or rebase against the floor).
6. Locum reimbursement: interpretation of the SFE
A PCT claimed that they did not have to pay £948.38 when full-time GP performers were on maternity, paternity, adoptive leave or sick leave and a locum from outside is contracted to cover. This came out of their interpretation of SFE paragraphs 9 and 10. Under the Red Book, this entitlement would have been enforced. Whilst it was accepted that part 4 of the SFE could be interpreted that the maximum should not automatically be paid and that PCTs do have some discretion regarding payment, the ICG agreed that it was not acceptable for the PCT to adopt a policy of paying a figure below the maximum to all requests for locum cover. Each case should be examined on its merits and the PCT can not have a blanket policy to pay less than the maximum.

Learning point: Locum reimbursements
Part 4 of the Statement of Financial Entitlements states that PCTs must provide financial assistance to a GMS contractor to employ locum cover for GP performers on maternity, paternity, adoptive or sick leave where the specified conditions are met.

To qualify for this payment, certain criteria must be met. The GP performer must normally be entitled to a leave of absence either by statute, or by the partnership agreement (see SFE 9.3 and 10.3 for actual requirements). The qualifying periods of leave are:
  • More than one week (but see SFE 10.4 for sick absences)
  • Maximum of 6 months at full rate and six months at half rate for sick absences
  • Maximum of 26 weeks for maternity and ordinary adoption leave for main carer
  • Maximum of 2 weeks for paternity leave and adoption leave when GP performer is not the main carer.
Where a GP performer is employed by the contractor, and his contract entitles him to full salary during an absence outside any statutory entitlement, locum payments should also be made (see SFE 9.3 (b) (iii) and 10.3 (b) (ii).

It is normally considered unnecessary to engage a locum in circumstances where the PCT has offered cover and this has been rejected, or where the GP performer’s right to work has expired. Similarly, it would not normally be necessary to engage a locum where a new employee has already been engaged to cover for the performer on leave unless the practice is carrying another vacancy.

The maximum figure payable for locum cover is £948.33 per week. The PCT does have powers to exercise discretion regarding payments. However, it would be unreasonable of the PCT to set a pre-determined standard of paying a figure below the maximum to all requests for locum cover. Paragraphs 21.16 and 21.17 of the SFE set out guidance for a protocol which the PCT should agree with the LMC:
  • How they are likely to exercise their discretionary powers to make payments having regard to their budgetary targets;
  • The circumstances in which they are likely to pay less that the maximum figure;
  • How they are likely to use discretion in payments for absent GPs where cover is being provided by nurses or health care professionals;
  • How they are likely to use discretion to make payments to partners, shareholders or employees who are covering for a GP who is also a partner, shareholder or employee.
Providing the PCT sets out the above in its protocol, it has the discretion to adopt a policy of paying less than the maximum figure. It should validate its actions in each individual case to ensure that a reasonable decision has been reached.

7. Minor surgery DES
A PCT commissioned a Minor Surgery DES at a lower rate then specified in the ‘Blue Book.’ They questioned whether such a price and specification had to be followed. It was agreed that when the services were in line with the guideline specifications, it is expected that the nationally agreed prices should be followed. If LMCs/practices were unhappy with the funding offered then they could refuse to provide the service. Although the PCT agreed to bring the payments for minor surgery back in line with the recommended rates over future years, GPC would seek to raise this issue as part of the contract review.

Learning point: Minor Surgery DES payments
There is a clear expectation for the Blue Book rates to be followed in the case of minor surgery and PCTs should seek to honour the national agreements with the GPC.

8. PCT – Seniority payments
A PCT was not providing full seniority payments to a doctor working in a low-earning practice. Under the nGMS contract the GP would receive less in seniority payments this year than he did previously. It was agreed that the doctor was entitled to the full annual rate of seniority payments and that these should be protected at the level he had received under the old scheme. It was noted that this situation may have been caused by a poor PCT-LMC relationship and that low-income practices should not be disadvantaged with regards to seniority payments.

Learning point: Seniority payments
GPs seniority payments should not be less than the equivalent payments received under the ‘Red Book.’ However there was always a clear intention within the national agreement to ensure GP contractors working in a low earning practice should not be disadvantaged in relation to high earning practices, particularly where practitioners are full-time. This may occur where the seniority payment has been fixed at previous ‘Red Book’ levels.

Where GP contractors believe they have been disadvantaged a case may be raised with the PCT for consideration with the LMC over the appropriateness of their seniority entitlement. Where the GP contractor is shown to be disadvantaged, PCTs should use their discretionary powers to amend the seniority award as agreed locally.

9. Failure to pay 2003/04 enhanced services expenditure for the primary care incentive scheme
Two PCTs failed to pay the non-recurring elements of the Primary Care Incentive Scheme for 2003/04. The ICG decided that the PCTs’ ESFs for 2004-05 had been constructed to include the non-recurring elements of the Primary Care Incentive Scheme for 2003-04. Therefore, provided that all the money in the ESF for 2004-05 had been spent, the PCT had paid these monies to practices.

Learning point: Primary care incentive scheme and enhanced services
Non-recurrent ‘reward’ elements of the scheme need not be paid out as reward payments providing the funding has been used to fund new enhanced services.

10. Use of ESF for care of patients in cottage hospital and in-house physiotherapy
A PCT included care of patients in a cottage hospital and in-house physiotherapy in their ESF. It was discovered that the PCT’s ESF had been constructed to include historic funding for both the disputed items. Therefore, the ICG ruled that the PCT and LMC consider whether, for 2004-05, they wished to fund these services from the ESF, or remove it and lower the floor.

[See Enhanced Services learning point 5]

11. Use of ESF for (a) Emergency Saturday morning surgery; and (b) PRIMIS Facilitator
a) It was agreed that the provision of an out-of-hours (OOH) emergency service should not be funded from the ESF. This was because the LES specification did not indicate that this OOH service was any more enhanced that the existing OOH provision. However it was agreed that if this was amended to include other services (e.g. requesting and collecting prescriptions, public health screening and new patient checks etc) then it was possible that a proportion of this activity – not the part for providing an emergency OOH service – could be funded from the ESF.

b) The PCT had stated that the PRIMIS facilitator had originally been funded from a proportion of the recurrent ‘Investing in Primary Care’. It emerged that the PCT’s ESF had mistakenly been constructed to include historic funding for a PRIMIS facilitator. Therefore, action should be taken to fund the services from the ESF or remove it and lower the floor.

Learning point: Enhanced service definitions
Ultimately many disputes have been raised because of the nature of the service in question. Example disputes raised here include:
  • Prescribing Incentive Schemes/Prescribing Advisers. Unlikely to count against the floor unless there is a clear service specification outlining the enhanced services patient will receive.
  • ‘Evercare’ model of nursing. If there was a tendering process then it is a service that practices could reasonably provide and therefore be included in the floor expenditure.
  • Intermediate Care facilities. Often disputed because of an assumption that such services should be funded from secondary care commissioning budgets. If re-commissioning tests are met – i.e. the service was contestable – then it may count to the floor.
  • Counselling services, an anticoagulant service from a local phlebotomist, a private provider of physiotherapy to practices. These services were not contestable, but because of the historic expenditure argument the PCT and LMC were given the option to count this towards the floor or rebase.
  • Funding of a PRIMIS facilitator. Does not enhance patient services but because of the historic expenditure argument the PCT and LMC were given the option to count this towards the floor or rebase.
Ultimately the enhanced service learning points outlined in this note are intended to assist in local agreements over monitoring of expenditure against the enhanced service floor. However, it is by no means conclusive and does not set a precedent on a particular service type. Ultimately inclusion of a disputed service will depend on the unique factors associated with that case, i.e. contestability, historic funding, enhancement to patients services. Invariably there will be inconsistencies between what may be included in one’s PCTs floor and that of another because of such factors and local agreements.

12. Salaried GP Contract of Employment
A PCT declined to recognise the continuity of service provision for redundancy, maternity and sick leave purposes in newly employed Salaried GP employment contracts. The ICG determined that this was not in accordance with the minimum terms and conditions for PCT employed Salaried GPs, introduced from April 2004. While employers should consider issues on a case-by-case basis, it was agreed that they should recognise all employment in primary medical services for continuity of service purposes including aggregated ad hoc locum work.

Learning point: Salaried GP contract of employment
Under the terms of the model offer letter and the model terms and conditions, service as an ad hoc locum (particularly if providing or performing primary medical services) should be taken into account for certain parts of the terms and conditions.

13. Use of ESF for (a) Ex – GP fund holding services; and (b) PMS greenfield sites (homeless, violent patients, substance misuse and Ex GPFH services)
(a) It was decided that as these services had not been contested, it was not possible for them to count towards the ESF in 2004/05. However, the ICG noted that should notice be served on the contracts for Ex-GPFH services, and contestability ensured, they would be eligible to count towards the floor expenditure in the future.

(b) It was noted that the construct of the PCTs Enhanced Services Floor (ESF) includes a pro-rata element of PMS growth funding which the PCT had used to fund the development of Greenfield sites and that the expenditure on these services constituting enhanced services had been reported as enhanced service spend. In view of the historic construct the ICG recommend that the PCT and LMC should jointly consider and agree whether, for 2004-05, they wish to fund these services from the ESF as it currently stood (i.e. expenditure to count towards monitoring of floor spend) or remove this funding from the ESF (i.e. and lower the required floor spend).

[See enhanced services learning point 11]

14. Use of ESF for (a) minor surgery; and (b) prescribing incentive scheme
(a) and (b) It was agreed that, in both cases, because the schemes were established prior to the new contract and not offered to GPs at the time, they were not contestable and could not be included within the ESF for 2004-05. If the scheme became contestable, then it could be funded from the ESF in the future.

[See enhanced services learning points 7, 9 and 11]

15. Quality Information Preparation Payment
A PCT was paying Quality Information Preparation Payments (QUIP) to practices at less than the legal minimum guaranteed sum of £1,000 per nominal practice when a plan had been agreed. They were only agreeing to pay for 2004/5 if the practice could prove a need. ICG confirmed that it was always the intention of the QUIP scheme that every practice would get the legal minimum QUIP payment.

Learning point: QUIP Payments
Practices, subject to meeting the arrangements set out in the locally agreed plan, will be entitled to at least the legal minimum payment set out in Directions.

16. Rent reviews
A PCT believed that PCTs had discretion in awarding increases to notional rents on triennial review. The ICG clarified that PCTs had no discretion in deciding whether to award increases to notional rents on triennial review.

Learning point: Rent reviews
ICG were asked to consider obligations over reimbursement for recurring premises costs for GP practices, specifically whether PCTs could treat a triennial rent review as a new application for funding and therefore exercise discretion in meeting the reviewed new notional rent.

Under notional rent payments, PCTs must review them every three years to bring payments in line with current market rent. The review may take place earlier if certain circumstances apply (paragraph 42). It is the responsibility of the PCT to undertake and implement these reviews.

For leasehold premises, the rent review is determined by the terms of the lease. The PCT must continue to reimburse rental costs where these change as a result of the rent review, subject to the provisions of paragraph 32. In such instances, it is the responsibility of the practice to take all reasonable steps to ensure that the new rent proposed by the landlord has been determined at the proper level.

Where the rent is reviewed to market value, it is expected that the practice will have been professionally advised throughout the proceedings.

It is recommended that a practice should advise their PCT of any rent review notice received from its landlord at the earliest opportunity to forewarn them of a possible increase in the level of rent reimbursement.

PCTs only have discretion in reimbursing recurring premises costs (including rent) in terms of granting or rejecting the initial application for funding. Once PCTs have agreed to reimburse recurring premises costs they must continue to do so (including any future changes to these costs).

If the PCT agrees to reimburse a practice's rental costs then the amount to be reimbursed is the lower of the current market rent (CMR) for the premises (with the calculation basis set out in schedule 2) and the actual lease for the premises plus VAT, if appropriate (paragraph 32). PCTs should seek professional advice on this matter.

17. Consultation on single handed vacancy
A single handed GP retired and the PCT failed to formally consult with the LMC when they set up a PCTMS practice for which they have employed GPs and TUPED staff. The ICG reaffirmed that PCTs are expected to undertake a consultation process when a single-handed practice becomes vacant.

Learning point: Practice vacancies
The position in respect of vacancies within the new primary medical services environment is not set out in legislation or Directions. Guidance is set out in paragraphs 2.14-2.16 of the document, Delivering Investment in General Practice. This should be read with paragraph 7.20 of the NHS Confederation/GPC Agreement, Investing in General Practice.

PCTs will be faced with two types of vacancy; brownfield sites and greenfield sites. For brownfield sites PCTs are free to commission services from what they consider to be the most appropriate source. PCTs are expected to consult LMCs before reaching a decision. In respect of greenfield sites the PCT is firstly obliged to consider any expressions of interest from existing GMS/PMS contractors - but they are not forced to accept any such expressions of interest.

If the PCT chose to provide the services via an Alternative Provider Medical Services provider or to provide the service themselves (PCT Medical Services) they will be obliged to follow the:
  • Alternative Provider Medical Services Directions 2004; and
  • Primary Care Trust Medical Services Directions 2004;
Plus the accompanying brief guidance.

18. Enhanced services floor and contestability – counselling, anti-coagulant service and physiotherapy
A PCT’s ESF for 2004-05 had been constructed to include historic funding for a counselling service, an anticoagulant service from a local phlebotomist, and a private provider of physiotherapy. The LMC believed that although these services could be contestable, they had not been offered to practices. In addition, the money had previously come from secondary care budgets and were contracts that had been rolled forward and therefore could not be counted towards baseline spend.
  • It was agreed that counselling and physiotherapy could acceptably be considered an enhanced service as could anti-coagulant monitoring as clearly there is an enhanced service specification for it.
  • Contestability - GPs have to have the opportunity to bid for the service. Even if the GPs were not to be awarded the enhanced service they should have the right to put in their offer. If the service was contestable at any point then they would be classed as an enhanced service.
19. Medical cover in an Intermediate Care Centre
An LMC believed that medical cover at an Intermediate Care Centre should not be included within the Enhanced Services Floor as funding intermediate care from the floor was not appropriate. Prior to the floor being created the service had been funded from secondary care monies. The ICG agreed that had the service been contestable, the ESF could have been raised to include the original funding for this care centre. However as the PCT had exceeded its ESF, there was no need to include the medical cover within the ESF for 2004-05 and that this should remain funded separately.

[See enhanced services learning point 5]

20. Case for rebasing the Enhanced Services Floor
A PCT submitted a case for rebasing. A figure had been identified as being included in the baseline collection data for the construction of the PCT’s ESF arising from the following services:
  • Nurse Prescribing
  • Direct Access Counselling
  • Direct Access Physiotherapy
  • Direct Access Dexa Scans
  • Direct Access Chiropody
  • Phlebotomy
However, this expenditure was subsequently not counted against the ESF for monitoring purposes. The ICG agreed the PCT’s ESF for 2004/05 had been constructed to include the historic funding of these services and the case for rebasing was agreed. These services should continue to be funded from outside the ESF.

Learning point: Rebasing the ESF
The ICG recommended that the PCT and LMC should jointly consider and agree whether to:
(i) fund these services from the ESF as it currently stood (i.e. allowing the expenditure to count towards the floor); or,
(ii) remove the funding from the ESF (i.e. and lower the required floor spend).

In coming to a decision, both the PCT and LMC will wish to be mindful of maintaining accurate definitions of enhanced services.

Where action is taken to lower the ESF the Department of Health will need confirmation of the amounts concerned so that monitoring of spend can be appropriately adjusted, i.e.
(i) Current floor (2004/05)
(ii) Less Amount to be rebased for 2004/05 (and future years)
(iii) New floor (2004/05)

21. QOF and practice performance
A PCT had drafted a paper stating that practices which scored less than 750 points in the QOF review would be referred to a Performance Panel on the basis that there was cause for concern about the level of clinical care. It was agreed that in this instance this was not appropriate as the identification of the figure of 750 points was arbitrary, and no factors other than the QOF achievement had been taken into account when determining the overall performance of the practice.

Learning Point: QOF and practice performance
QOF scores represent achievement against quality indicators. Levels of QOF achievement provide valuable information to PCTs about the quality of service provided by a practice, but should be used in conjunction with other available data e.g. prescribing.

22. Reimbursement of IT costs
A practice requested reimbursement from their PCT for costs of a printer and workstation for a newly appointed healthcare assistant. The PCT did not accept this request as it believed recent policy decisions by its Professional Executive Committee (PEC) IT Sub Committee did not allow for reimbursement in this case. However, as this policy was introduced several months after the initial request for reimbursement by the practice, the ICG have determined the practice was justified in seeking reimbursement for the purchase of equipment.

Learning point: Reimbursement of IT costs
Paragraph 4.29 of the GMS contract states that ‘to facilitate the use of IM&T within primary care, PCOs, rather than practices, will be responsible for funding the purchase, maintenance, future upgrades and running costs of IT systems as well as telecommunications links to branch surgeries and other NHS infrastructure and services’.

IT Items have been categorised. ‘Core’ items are those that must be fully funded by the PCT. This includes the requirement that ‘practice based staff should be able to access the clinical system and NHSnet via terminals or workstations from their normal working location within the practice (including branch surgeries as defined in the GMS contract).’

The PCT has an obligation to fund maintenance and minor upgrades of practice IT equipment. Moreover, the PCT is obliged to ensure that core items for practices, as detailed in Department of Health guidance, are funded. Financial allocations have been made to PCTs for this purpose. The ICG agree that the surgery’s purchase was necessary and falls in the category of core items. The ICG recommended the PCT reimburse the costs incurred by the practice but noted that, in future, the practice should seek direct funding for IT equipment in line with IT policies, prior to any purchase, rather than seek reimbursement for equipment they have purchased themselves.

23. QOF – Asthma Indicator 6
A PCT had stated that the use of telephone assessments did not satisfy the current QOF criteria for successful achievement of Asthma indicator 6*. The basis of the PCT case was that it was not possible to assess either a peak flow measurement or inhaler technique over the telephone. The LMC believed that asthma review via telephone when the patient does not attend the practice is effective in reaching the stable asthmatic. The case was considered by the QOF subgroup. They concluded that the current evidence base, two studies into trials of telephone triage of asthma patients, was insufficient to promote widespread use of telephone reviews in general practice. It was therefore decided not to include telephone reviews in the QOF for 2006/07. The ICG upheld this decision.

* “The percentage of patients with asthma who have had an asthma review in the last 15 months.”

Learning Point: Interpretation of QOF: Asthma 6
Current evidence does not support widespread use of telephone assessment for Asthma reviews. Unless practices have an agreement with the PCT to conduct reviews by telephone, these should be done face-to-face. Practices and PCTs are reminded of the four elements of an Asthma review, detailed on page 134 Revisions to the GMS Contract 2006/07.

24. Premises expenditure 2005/06
An LMC believed that monies which had been set aside by a PCT specifically for premises development had instead been used to redress the PCT’s budget deficit. However, it was determined that the funding which the LMC claimed was taken out of premises money to finance the PCT’s deficit, was not the £108m set aside specifically for premises and could be spent on whatever the PCT chose. Although there was no obligation on the part of the PCT to spend this money on premises, it was felt that it would be best for PCTs to reach agreement with LMCs on how it would be spent. It was agreed that the long term effects of using premises money for other things would not be beneficial for practices or the PCT and that PCTs should be encouraged to spend premises development monies on what they were intended for.

Learning Point: Premises expenditure
Unless money is ring-fenced, as was the case for the £108 million allocated to PCTs for 2004-06 to support premises development, that there is no obligation on the PCT to spend money on premises. However PCTs and LMCs should be aware that not investing in premises will have long-term damaging effects and PCTs should be encouraged to spend money allocated to improve premises on what it was intended.

25. Prescribing Incentive Scheme (PIS)
An LMC objected to a PCT seeking to include a PIS within it’s 2004/05 and 05/06 Enhanced Services Floor. As the Floor was originally constructed to include historic spend on PIS the ICG agreed that in such situations there is a case for rebasing and therefore recommended that the PCT and LMC should be given the choice to agree either of the following:
(a) to continue to count such expenditure in the Floor construct and towards PCT Floor expenditure; or
(b) not count towards the Floor expenditure and rebase the Floor.

[See enhanced services learning points 9 and 11]

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