Published: 10/03/2005, Volume II5, No. 5946 Page 26 27 28

Alternative provider medical services have yet to make a breakthrough, but they could be poised to plug vital gaps in primary care provision. Alexis Nolan reports

It has been possible for a GP-run private company to run a general practice since mid2003 when Chilvers McCrea was given the goahead by the Department of Health to do just that under the terms of the personal medical services contract.

But now alternative provider medical services have created another way in which primary care trusts can deliver services. While general medical services, PMS and PCT-managed services are the other tools at PCTs' disposal, it is APMS that provides the possibility of introducing private sector companies, voluntary bodies and, indeed, any other non-NHS organisation into primary care service provision.

But at the moment it remains largely just that - a possibility. Ask PCTs, associations, independent providers and even the DoH if any APMS contract has been signed, and there is a pause and then an answer along the lines of 'well, I do not know of any'.

Last November, DoH head of primary medical care contracting Richard Armstrong told a meeting of the NHS Confederation's APMS forum that although 55 per cent of out-of-hours contracts were expected to be provided through APMS by the end of 2004, there were no such contracts for other services.

The DoH confirms that 'around half' of out-ofhours contracts run under APMS, but it is unable to say whether any other APMS contracts had been signed since its introduction last April.

'We do not collate a central database of APMS contracts, nor have we set any targets on the level of take-up, ' said a DoH spokesperson. 'It is for PCTs to decide whether it can help meet local needs.' Elaine Cohen, primary care contractors project manager at the NHS Confederation, says that APMS is not the only means of delivering government policy for plurality in service provision and more capacity in primary care.

'APMS is just one tool, which goes some of the way to explaining why It is not being used that much, ' she argues.

It may not be widespread at the moment, but PCTs' use of the more open tenders that can accommodate APMS is increasingly common.

Which contract is appropriate?

'What I see PCTs doing is going out with more open adverts to all service providers and not specifying the contracting route, ' says Ms Cohen.

'When bids come in they go for the best provider and use whatever contract is appropriate.' One example is a contract awarded last year by Vale of Aylesbury PCT. The region is part of a greenfield area in the South East targeted by the government for population growth. In the area covered by the PCT there will be 31,000 new homes by the end of 2031. In the first phase of this development 94,000 extra residents are due by 2016, with new residential developments to accommodate people beginning at the end of this year.

For the PCT this means having to work with developers and local authorities to make sure there will be sufficient integrated primary care services to support this new population from a single building.

In the past, the PCT could have used type-2 funding under the previous GP contract, which gave GPs guaranteed income for five years while they built up their practice. With the new GMS contract that option no longer exists, but in any case may not have suited newer ways of working.

'So we developed a procurement process, a commissioning framework and guidance on how to evaluate applications to build this service for a population that didn't yet exist, ' says PCT director of primary care and development Clare Blakeway-Phillips.

'When we sent the detailed service specification we said we were looking at flexible use of contractors, so anybody could apply under GMS, PMS or APMS. We wanted to support innovation so we were willing to use a flexible approach to contracts. And we were very keen to develop more integrated primary care services and used this as an opportunity to do that.'

Personalised innovation

The flexibility of the tender meant the PCT could get the sort of innovation it wanted. 'When I shared the [successful] application with our professional executive committee, one of the GPs said it blew his mind away because it was such a different way of providing primary care services, ' says Ms Blakeway-Phillips.

The new centre involves dentistry and pharmacy, telephone triage and nurse-led care and will employ healthcare assistants instead of reception staff to carry out tasks before patients they see GPs or nurses. It will also be used as a training centre.

The new centre will also develop its services based much more on the needs of the community, working with the local population to shape enhanced services.

The winning bidder was BK Healthcare, a GP-led private company that has built on its base of two PMS practices in Oxford to provide primary care services from three other practices across the country.

But when it came down to whether the contract was PMS or APMS, the former was chosen.

This is only possible because the company was run by a GP.

'I asked them and they couldn't see any reason to go APMS, ' says Ms Blakeway-Phillips.

APMS allowed the PCT to open up the work to non-NHS organisations, but it seems that there is little interest from private companies not run by GPs in bidding for and running services.

'To my mind as long as you have got the process right for procurement and commissioning then it doesn't matter who you contract with, ' says Ms Blakeway-Phillips. 'We do not mind whether It is an NHS body or a private company, we would have gone through the same process. We applied the process to everybody. We just didn't get the commercial companies responding.' But the PCT will be using the openness of APMS in the future, and is using it for commissioning primary care for prisons.

One company that has already been successful in winning an APMS contract for prison primary care services is Chilvers McCrea, run by managing director and nurse Sarah Chilvers and chair and GP Dr Rory McCrea. The company is well known because it was the first to win contracts to provide GP services when PMS was first introduced and now has some 14 contracts.

Because of its structure, says Dr McCrea, the company can work under GMS, PMS or APMS contracts, but finds PMS the most popular. 'APMS is new and PCTs are less familiar with it. If PMS is on the shelf and the contract can be PMS, why go to the effort of APMS?' But his company talks to PCTs about the possibilities of APMS, and Dr McCrea anticipates that as the market opens up there will be more APMS contracts signed than PMS.

One of its biggest customers is Brighton and Hove City PCT, which awarded the company a contract to run three general practices in September last year and a further two in November. Again, while the contracts themselves are PMS, the tendering framework was open to accommodate the possibility of APMS.

For Anne Foster, the PCT's primary care development manager, the important thing is not the contract itself but the services being delivered. 'It makes no difference to us whether It is GMS, PMS, or APMS, ' she says. The PCT simply wanted a solution to difficulties it faced in recruiting GPs.

'We are a trust with quite a few single-handed practices. What we found was as they left or retired it was almost impossible for us to find GPs on their own who wanted to take on that responsibility, ' she says.

'It was impossible for us to do what had always been done in the past. GPs wanted to work, but they do not want the hassle of owning a surgery and employing staff. The attraction for them was a salaried GP post.' What Ms Foster and Ms Blakeway-Phillips both emphasise is the importance of working closely with local GPs to help them understand what the PCT is doing and why. A common misunderstanding, for example, is that a private provider would mean private healthcare.

Ms Foster worked with the local medical committee to try to overcome negative sentiments from GPs. 'It is important to get them on board because we need the private provider to work with other practices, ' she says. 'If the LMC doesn't give you support it would be quite difficult.' In Aylesbury, Ms Blakeway-Phillips made sure the new provider was included immediately on mailing lists and invitations for PCT groups and workshops.

'And we asked them to arrange visits with neighbouring practices, even though they were not going to be set up for a while to make sure they were integrated into the local health economy.

There is animosity from the likes of the British Medical Association to private company involvement in primary care services, and experience to date is predominantly with private companies run by GPs who, while strictly independent, are considered part of the NHS family.

The hostility to non-NHS providers would, arguably, be worse. But this is not stopping those providers from taking advantage of new openness in primary care services.

Mercury Health has not bid for any APMS contracts yet, but is interested in the potential it provides. At the end of last year it won contracts to build five independent treatment centres in the South East, covering services such as diagnostics, treatment and inpatient orthopaedics.

While ITCs are a way of introducing the private sector into secondary care, one of the centres Mercury will build is specifically primary carefacing, providing diagnostics to GPs.

'We have a contracted volume to undertake that work, but we would seek to roll that out to other PCTs in our area, ' says business development manager David Boyd. 'APMS might be a route to do that.' Pfizer Health Solutions is involved in a pilot project in north London's Haringey teaching PCT around enhanced chronic-disease management services, which is funded through PMS but, theoretically, could be rolled out through APMS.

Pfizer says APMS has the potential to improve significantly the way primary care services are provided and delivered, particularly through enhanced services.

And Care UK has bid for a couple of contracts which, according to group marketing director Geoff Benn, 'would fit very nicely under APMS, but has to date been unsuccessful'.

'Are we pleased?' he asks. 'No. We have put in place an infrastructure to bid for and win APMS contracts, and the fact we haven't won one is unfortunate. Clearly we want to win because we do not enter into any bid to lose.' He says Care UK is looking hard at why it has been 'falling short' and has no criticism for the tenders or the motives of the commissioners.

'If you go into a competitive tender environment you want to ensure that you as a commissioner are getting the best possible result otherwise there is absolutely no point in going through the whole process, ' says Mr Benn.

Clearly, the first contract is hard to win, because of a lack of track record and the sense that it is 'unproven', even if the company does have a partnership with Essex Ambulance Service trust to provide out-of-hours services. But Mr Benn says the company is 'still confident, still hopeful and still working hard at it'.

While PCTs have opened themselves up to the possibilities of APMS, one phrase repeated time and time again by those with any experience in the area is 'It is early days'.

The experience of some PCTs in using open tenders will help others wanting to follow the same route. Through the APMS forum and in conjunction with the DoH and the NHS Purchasing and Supply Agency, solicitor Bevan Brittan has produced a guide to contracting that was due to be published this week as well as a model contract for APMS. The agency is also working on a complementary toolkit.

In some localities there is a desire to make the most of APMS. But Professor Chris Ham of Birmingham University's Health Services Management Centre, and former DoH director of strategy, says its development will not just be down to natural evolution of use by PCTs.

'I think it depends on the signal the government sends out, ' he says. 'Is it wanting to push APMS or is this just a permissive power it is going to leave with PCTs?' There will be no movement pre-election; postelection, It is a matter of wait and see.



PCTs can contract for APMS with the following organisations:


voluntary/charitable sector;

mutual provider;

public bodies;

GMS and PMS practices through a separate APMS contract.

It can be used to provide:

Out-of-hours services;

enhanced services;

replacement additional services;

essential services;

a combination of any of the above.

Key points

APMS allows PCTs the freedom to use the private and voluntary sectors to provide primary care services.

It can be used to prov ide out-of-hou rs serv ices , enhanced services, replacement additional services, essential services or a combination of any of the above.

Find out more NHS Confederation APMS Forum

www. nhsconfed. org/apms National Primary and Care Trust Development Programme

www. natpact. nhs. uk/primarycarecontracting Department of Health, APMS guidance

www. dh. gov. uk/policyandguidance