GMS regulations have replaced terms of service under the new contract. Dr Gerard Panting explains how this affects working partnerships in primary care
With the new contract, doctors’ terms of service are a thing of the past and new general medical services regulations set out what is now required of doctors.
Many of these requirements have a familiar ring to them.The regulations define, for example, who is eligible to provide medical services, the services to be provided to patients, procedures for the removal of patients from the practice list, prescribing, dispensing, the provision of certificates, the maintenance of records and complaints procedures.
However, the new contract aims to be more than a statement of what is now required of doctors and others providing medical services. It seeks to develop human resources and modernise the infrastructure of general practice.
As far as GPs are concerned, it aims to introduce a new career structure, develop skills and encourage recruit ment through financial and other inducements.
The contract also promises development opportunities for other practice staff including practice managers and nurses, by extending their roles and facilitating a greater mix of skills within practices.
Protected time arrangements now enable doctors and other staff to develop. This time may be spent on subjects as diverse as appraisal preparation, clinical governance, audit, directed learning or practice management. It is for each practice to shape its own model for these activities – the contract acknowledges there can be no standard formula.
The contract envisages a high standard of premises for general practice. They must be suitable for the delivery of services to patients and to meet the reasonable needs of those patients.
For example, they must comply with the Disability Discrimination Act and allow ease of access to all users, provide visual and sound systems for individuals with hearing or visual impairment and facilities for the elderly and young children.
Premises should also have a properly equipped treatment room and consultation rooms designed to ensure privacy for patients throughout consultations, so that they are not embarrassed when dressing or undressing or liable to be overheard.
Staff and patients must have access to suitable lavatory and handwashing facilities to meet infection control standards.
Premises must also have adequate waiting areas with enough seating to meet normal requirements, and reception areas must be designed to allow patients to communicate confidentially with staff.
The premises must have adequate heating, lighting and ventilation, and all fixtures and fittings must be kept clean and in good repair. There must be facilities for the storage and disposal of clinical waste. Drugs, records, prescription pads and other important documentation must be kept securely.
Last, but not least, a safe exit must be provided for everyone in the building in the event of fire.
Branch surgeries may qualify as a second site but only if they are open for at least 20 hours a week and meet all the requirements set out above.
Complaints and cooperation with investigations
Just as previously, all practices must maintain a complaints procedure and publicise it to their patients.
All the regulations governing complaints are incorporated in the contract, as is a requirement to cooperate with investigations by the Health Service Ombudsman, the PCO or a local authority.
Cooperation is defined as answering reasonable questions, providing any reasonably required information relating to the complaint and attending any meeting to consider the complaint providing it is held at a reasonable place and time with proper notice.
Although the new contract requires all practices to establish and operate a complaints procedure, there is no mention of a disciplinary process.
There is, however, a section dealing with termination of the contract by the PCO where there has been a breach of the contract or to terminate specific obligations under the contract or to deduct money otherwise payable under the contract.
Before taking action, the PCO must issue a breach notice detailing how the practice has fallen short of its obligation, what must be done to put the situation right and how long the practice has to do so. Usually this period will be at least 28 days but if there is a question of patient safety, or the danger of material financial loss, shorter notice periods may apply.
Failure to comply with the remedial notice invites the severe sanctions cited above, i.e. in the worst case terminating the contract in whole or in part and withholding money that would otherwise be due.
The new contract envisages two distinct legal relationships between GMS providers and PCOs. Where GMS providers become NHS bodies NHS contracts will be in place, but where they do not, ordinary contracts of law will be in place.
Under NHS contracts, any dispute between the GMS provider and the PCO is resolved by the Secretary of State – in reality someone appointed on his behalf.
Where ordinary contracts are in place, issues that cannot be resolved by other means will be put before the courts.
The costs of GP indemnity cover will be factored into the global sum, and measures for the compulsory introduction of GP indemnity as originally set out in the 1999 Health Act will be adapted to reflect the practice-based nature of the contract and allocation of funds.
Removing patients from the list
Removing patients from practice lists is a contentious issue and one the document addresses directly.
Where there is an irreconcilable breakdown between practice and patient, practices retain the right to remove the patient from the practice list. This would normally follow an initial warning to the patient, and if a patient is ultimately removed, specific reasons must be given.
The right to remove violent patients has been extended. Anyone using actual or threatened violence or verbal abuse leading practice staff or bystanders to fear for their personal safety can be removed immediately.
The new GP contract radically restructures the relationship between GPs and their PCOs.
The previous general medical services legislation, terms of service and tribunal regulations are now redundant. The new legislation requires PCOs to underwrite a patient services guarantee and take a more active role in managing primary care services.