The second wave of personal medical services pilots brings a greater degree of flexibility to primary care, but presents challenges for HAs as well, write Richard Lewis and Rigo Pizarro

The number of personal medical services pilots - which allow for a salaried GP service - is set to triple with the advent of the second wave last month. From being very much a minority interest, PMS pilots are beginning to feel increasingly mainstream. The first wave was unevenly spread across the country, but approval of the latest tranche of schemes means 80 per cent of health authorities will now have at least one pilot in their area.

London, in particular, has seen a dramatic increase in numbers.

1 Some commentators have tentatively concluded that the future of the national GP contract may be in doubt. In Lambeth, Southwark and Lewisham this conclusion does not seem far-fetched - with the second wave, almost onethird of the local population will be served by PMS pilots (see table, below). In all, 27 per cent of GPs will have chosen a local contract and the budget for primary medical care will be in excess of£16m.

Clustering under an umbrella

While the largest number of practices involved in the pilots (14) are partnerships of more than three GPs, there is a significant contingent of single-handed practices, too (13). Many practices regard PMS as a way of increasing the medical workforce and diversifying available employment options.

No fewer than 14 pilots have introduced a mix of independent contractor and salaried GPs. Salaried practice is particularly useful where partnerships have historically proven unstable or where it has been difficult to attract high-calibre partners - for example, in deprived inner city areas where negative equity in buildings may act as a deterrent to recruitment.

And a number of small practices are exploring creative ways to cluster together under the same pilot umbrella.

This creates a new primary care organisation where the constituent practices share common objectives, skills and resources and maintain a sharper focus on the needs of the locality rather than just on registered patients.

A variant of this model involves a joint venture between one large practice and two single-handed practices in which they share services, management and infrastructure. There are currently four pilots of this nature involving 11 practices.

Tailoring services to local need

PMS provides an opportunity to tailor services to meet the needs of local people. Pilots in Lambeth, Southwark and Lewisham have identified, with their PCGs, a range of specific service priorities including: sexual health (10 pilots), mental health (nine pilots), drugs and alcohol (nine), refugees and ethnic minorities (nine), elderly people (six), children and young people (five), and homeless people (four).

PMS pilots are attempting to use the local contract and the PMS flexibilities to move away from the 'broad brush' approach to incentives characteristic of the 'Red Book' of GPs' terms and conditions. This is of particular relevance to Lambeth, Southwark and Lewisham, where widespread deprivation is combined with a locally specific pattern of need not easily addressed using the national contract.

For example, the refugee hostels in the HA's area mean that local practices may have to cope with large and unplanned arrivals of patients with high levels of need.

PMS offers the opportunity for an effective response through a comprehensive package of care supported by a contract that combines block payments, targeted incentives and PMS 'plus' services. The contract is flexible and can be adjusted if necessary. This is a far cry from some GMS practices, which are compelled to close their lists in the face of unexpected demand.

Management challenge

The sheer volume of pilots has presented a major local management challenge. In the first wave of PMS, a close relationship developed between the pilots and the HA during implementation. This allowed a continuous process of negotiation and project development.

With 28 pilots in the second wave, this type of relationship has proved impractical and the HA has had to develop a more off-the-peg approach. While this may at first appear a disadvantage, it has resulted in a process that has relied on the early development of systematic guidelines and policies.

To ensure that the 39 initial applicants had considered the full implications of entering into a pilot and would be able to complete the preparatory process, a comprehensive application pro forma was developed. This prompted applicants to consider not only their own service objectives but also the strategic 'fit' with wider local and national strategies such as the plans of the local primary care group.

External project managers were appointed to act as a bridge between the pilots and the HA, providing independent advice and support.

The 28 pilots that were approved by the health secretary were then set the task of developing a business case. This had to set out the full justification for pilot status and demonstrate that the provider had the capacity to deliver the service developments highlighted in the formal application (see box, right).

Each pilot has to meet core standards for the range and quality of services set out in a generic contract, along with clauses tailored to individual pilots. A performance management framework has been agreed that sets down agreed processes and indicators for monitoring.

The active engagement of the pilots has been a key factor in development. This was achieved through a series of workshops and seminars and through the development of a local group of pilot representatives. This group has begun to develop a collective negotiating role (not dissimilar to that of the general practice committee) and has received advice and support from the British Medical Association.

Importantly, it understands the local context and the strategic aims of the health authority and PCGs. It also leaves discretion for each pilot to negotiate specific contract details for itself.

Policy implications

The importance of PMS in commissioning and developing primary care has increased significantly and may soon rival general medical services. This has raised a number of important policy issues.

The implementation process has underlined the unusual triangular relationship that binds together the HA, PCG and PMS pilots. HAs have formal responsibility to commission PMS, yet they do so using, in part, PCG resources. This has led to some difficulties in delineating formal responsibilities.

Just as HAs are passing responsibilities for primary care development to PCGs, PMS presents a powerful new opportunity to effect change.

As PCGs develop their primary care investment plans, it is particularly important that there should be a dynamic relationship in which PCG priorities influence and, in turn, are influenced by the PMS pilot objectives. It is also anticipated that PCGs will have a growing role in monitoring and performance managing PMS pilots in association with the HA.

Concerns have been raised that PMS will have an impact on the equity of provision between practices. PCGs, in particular, were anxious that, as with fundholding, a two tier system might result if PMS pilots benefit from fast-track development and preferential access to resources. But many of these fears have been allayed by the integration at PCG level of bidding processes for new funding. PMS and GMS practices are judged against the same criteria.

PMS practices will still demonstrate a degree of inequity in service provision. But, because funding is based on historical resource use, these inequities will be the same as those under GMS. PMS, however, brings greater transparency. PMS contracts and the funding that goes with them will be in the public domain. For the first time, everyone will be able to see the resources that are channelled into different practices. This may pose uncomfortable questions about why resource levels (and GP earnings) do not obviously equate with local perceptions about the range and quality of services offered to patients.

As local budgets for primary care grow, PMS will also allow better comparison of how resources are distributed.

GMS is flawed in its ability to match funding to patient needs, particularly in deprived areas. PMS will not rectify this.

But it seems only a matter of time before the historical funding basis used for PMS must give way to needs weighted allocation, as with all other NHS services. This has profound implications for the national GP contract.

Meanwhile, PMS pilots are an important organisational development tool for primary care, making it ready for the transition to primary care trust status. The drive, flexibility and creativity found in general practice can be harnessed through PMS.

Business case criteria Pilot objectives Pilot benefits Strategic fit Funding sources Value for money Risk analysis Legal, contracting and management arrangements Phasing of developments Organisational development Performance management indicators Public involvement Key points From this month, 80 per cent of health authorities will have at least one personal medical services pilot scheme in their area.

The extension of the schemes raises concerns about equity and management issues for HAs.

An HA where schemes will cover almost a third of the population has had to adopt an off-the-peg approach to development.

References

1 Lewis R, Gillam S (ed ). Transforming Primary Care - personal medical services in the new NHS . King's Fund Publishing, 1999.

Richard Lewis is visiting fellow, King's Fund.

Rigo Pizarro is PMS pilot project manager, Lambeth, Southwark and Lewisham health authority.