PMS Review raises concerns

At a recent meeting with practices affected by PMS Reviews, the following concerns were raised.

• I’m concerned about the paragraph in the letter around option 3 stating that the PMS Premium is the difference between the baseline and £78.33 – which is rather misleading and some Practices have used that figure.
• I think it would have been better for NHS England to have told each Practice their premium as they know what it is, rather than Practices have to do the calculations themselves.
• Timescale in the letter is far too short. Any movement on this
• How long is Option 3 on the table for?
• Some clarity is needed around the process for those Practices who wish to remain in PMS i.e.
•  What is Core GMS Services?
• Involvement of the CCG and LMC in designing the process.
• If they remain and then cannot agree – will NHS England withdraw all the premium over the 4 years and then Practices need to fight for some of it back?
• The reinvestment of the money released – as stated in the seminar the enclosures that came with it seem to suggest that Practices could do a net impact analysis, and also not have to give up funding with knowing and receiving some reinvestment.
• If Practice remains in PMS and after review cannot demonstrate any amount for services over and above core, can they then take option 3? (My view would be no.)
• If a Practice is a gainer by going to Option 3 – for example we have one who has a PMS Premium of £2.76 so will lose 0.46p per weighted patient per year, but gain 0.55p. The Practice receives some Fairness in Funding money. The letter says that FDR will remain in 2015/2016 and then reviewed. We would need  to check that the AT will not seek to claw back the gain from Option 3 from their FDR money.
• Cash flow – PMS Practices are paid on 10th of the month, GMS on last working day. This will have an impact on PMS Practices, particularly if they pay staff before last working day of the month.

Our PMS Review Survey also identified common concerns among members.

Q.1 Job title

GP Partner	62.96% 34
Salaried GP	0.00% 0
Practice Manager	38.89% 21
Total Respondents: 54

Q.2 Do you have a clear understanding of the  communication sent by NHS England on 30th December and the implications for your practice?

Yes	5.66% 3
No	94.34% 50
Total	53

Comments:

• Much better since Rowleys
• This only became clear when I attended a seminar that our accountants put on this week
• Information is very superficial & general, not specific for our Practice
• Not yet I’m attending an accountant led seminar on 16 jan to go through
• Inaccuracies and assumptions
• I am unclear from documents sent so far
• Lacking in sufficient detail but I assume this was intentional
• The letter is reasonably clear, the implications need to be worked on and the spreadsheet is silly 

Q.3 Has the deadline for expressions of interest (30th January) given your practice sufficient time to make an informed decision about the proposed options for the future?

Yes	0.00% 0
No	100.00% 54
Total	54

Comments:

• There has been little time for Practice discussion or to seek LMC guidance or fully understand financial implications 
• A bit tight to fully consider and get all the info 
• Need lots of clarifications with NHSE and then partner meetings 
• We have insufficient time 
• Because of lack of information on what constitutes a core contract, what could be classed as over and above GMS, what criteria the appeal process involves

Q.4 Has a member of your practice attended one of the events hosted by Glyn Rawlings?

Yes	60.47% 26
No	39.53% 17
Total	43

Q.5 In your opinion, what action should your practice take?

Option 1	0.00% 0
Option 2	5.56% 3
Option 3	18.52% 10
Undecided	74.07% 40
None of the above	3.70% 2

Comments:

• Of the 3 options, 3 is my best option but still leaves the practice in a position it will become unviable financially to continue within probably 2 years 
• Not able to make informed decision at the moment 
• Not yet confirmed 
• Wavering between Option 2/3 until further information, clarification and reassurances are provided by NHSE 
• Discussing this at the partners meeting next Monday 
• Depends on if we keep some non-core funding 
• But there is only one left 3- but we gave monies back under Fairshare so what happens to that? 

Q.6 Would you like the LMC to arrange a meeting for PMS Practices to share ideas and concerns?

Yes	100.00% 53
No	0.00% 0
Total	53

Q.7 Would you like an opportunity for your practice to send representatives to a 'financial clinic' meeting with representatives of NHS England and your CCG to consider and review possible financial implications and viability of your practice?

Yes	93.88% 46
No	6.12% 3
Total	49

Comments:

• I would like to meet with Leslie Harrison, Matt James and Diane Pegg to discuss how and why there figures are misleading, how and why this will affect patient care and destabilise the practice and ultimately lead to its closure. I would like to meet as an individual practice how we can agree a sensible way forward in order to continue to ensure patient care is maintained, the practice remains and staff are not made redundant. 
• Needs to be specific & tailored to individual Practices 
• Not known yet 
• Not sure 
• Absolute minimum requirement 
• Unsure 
• I will need to discuss with the partners 

Q.8 You would like the PMS Review proposals -

Implementing as soon as possible	11.11% 5
Renegotiating with new proposals to consider at some stage before March 2016	88.89% 40
Total	45

Comments:

• We think for fairness and consistency we should be treated equitably, and have a negotiated review with any adjustments occurring over a 7 year period. 
• We think for fairness and consistency we should be treated equitably, and have a negotiated review with any adjustments occurring over a 7 year period. 
• Would like equitable treatment: a negotiated review with adjustments occurring over a 7 yr period 
• I think for fairness and consistency, we should be treated equitably, have a negotiated review with any adjustments occurring over a 7 year period 
• We think for fairness and consistency we should be treated equitably, and have a negotiated review with any adjustments occurring over a 7 year period 
• I would like more time, with a clearer framework for the review, with fairness and taking into account some of the historical precedents such as staff funding at the time we embarked on PMS. Also more information about the strategic requirements so that existing services can be tailored to fit in order to ensure continuity. 
• For fairness and consistency we feel that a negotiated review with adjustments being made over a 7 year period would be more appropriate 
• For fairness and consistency, we should be treated equitably and have a negotiated review with any potential adjustments made over a 7 year+ period. 
• We need to understand the proposals better & in particular specific for our Practice 
• Not sure 
• Only after we are completely aware of the implications 
• This important proposal was rushed and sneaked in between Xmas and New Year - not professional! Need more time to meet and discuss. 
• Provided that all the above are taken into consideration, and any errors corrected before they are implemented. 
• Particularly as NHS England is most probably devolving responsibility for GP contracts to the CCG from April this year 
• The move of the payment date from 10th of the month to the last day of the month has serious cash flow implications that would cause immediate problems if implemented quickly (i.e. April) 
• With A/L and late notification we feel we are being rushed into a decision that could have significant consequences for the future planning of workforce etc 

Q.9 Do you have any questions around the recent communications on the PMS Review?

Comments:

1. I will detail these through the LMC after the meeting we are attending on 20th January 2015. 
2. I will detail these thru the LMC after the meeting we are attending on the 20th of January 
3. I am not clear about the timescale for option three, when does the timing start for the 6/7 years? 
4. I will have further questions after the meeting planned for 20/1/15 
5. What is the big rush? Why does it need to be done prior to the Government's agenda of 2016? I will direct further questions through LMC. 
6. Bearing in mind the length of time since we became a PMS practice I do not confidently know what services we deliver over and above GMS practices that would be taken into consideration if we requested part of our PMS funding to be retained. 
7. 1. Figures not clear what is included in PMS Premium compared with what is included in GMS core. 2. What exactly is included in core work? 3. Figures for options supplied by NHS England are unclear, incorrect, misleading and make unreasonable assumptions that put it in a better light than the reality. For my Practice the figures indicate I will lose £60,000 over 6 years (option 3 £10k per year) while when I calculate the figures I will in fact lose over £250,000 over the 6 year time period - this will destabilise the practice and affect patients care., make people redundant and almost certainly mean the practice will close within the 6 year time period. 4. We had local PMS agreement in place signed by then acting chief exec Toby Saunders in 2010 in which my practice gave up 17.5% of growth money, in return the remaining growth money would not be 'touched' in future. This agreement is being reneged on. 
8. 1. How can we be expected to choose between options 2 & 3 if no guidance on the PMS review timing/operation/backdating etc has been issued. If we choose option 2, can we later switch to option 3 if the PMS review is unfavorable (given that we have no mechanism to assess this). 2. If we take option 3, can GMS payments be moved to earlier than the last day of the month, in order to avoid cash flow implications in 3 months’ time. 3. Need further information on GMS payment of childhood vaccinations in order to consider their implications 
9. Struggled with the excel worksheet! 
10. Whether it is absolutely necessary to revert to GMS and how not to lose funding as it would have a detrimental effect on staff and patients. 
11. Are they trying to pull the wool over our eyes - the amount of money lost is calculated as if the income reverts to the original amount each year - it does not show the cumulative loss? Why are reviews being arranged now when they don't have to be implemented until next year? Has the area team not thought about the impact of this on GP viability - especially in a part of the country where GP recruitment and retention is at crisis point already -? Can individual practices make a case on their own circumstances as different practices may be affected differently in terms of the financial impact and therefore the ability to continue as a practice? 
12. 1. Do Option 2 practices have same entitlement to annual uplift of around 55p/pt as Option 3 practices? 2. Do Option 2 practices have any safeguards against further such reviews for say at least another 5yrs? 3. If Option 2 discussions falter, can such practices then revert to Option 3? 
13. The document says that PMS practices should be told how the money removed from contracts will be reinvested locally so that they can work out how they might benefit from this if they agree to its removal, but no details have been given. NHS England assumes lost PMS income will be offset by list size increasing, but takes no account of the extra expenses incurred if list size does increase. 
14. Under the FDR PMS city practices agreed to give up a % of Growth in return for having Growth funding become part of core baseline PMS funding on the understanding that this would not be touched in future. The current PMS review seems to be a breach of that agreement with PCT in that PMS premium is merely PMS Growth by another name. Should Leic City PMS practices party to that agreement be facing ANY reduction in PMS baseline as they effectively have already had a PMS review? 
15. Clarity on the £78.33 move toward GMS funding being used as a baseline being wrong. Clarity of getting the MPIG reallocation as definitive. The logic of this proposal in a deprived practice when there is no current strategy to offset the proposed loss with resultant concerns re practice viability 
16. Why do we need to respond within days of getting the information , when we need to do our own research and get advice from our accountant ? 
17. We need time to understand the full financial implications to the practice to make arrangements for possible redundancies of staff etc- without knowing these it is impossible to make a decision 
18. We need more information about what constitutes GMS core services and what criteria will be used to determine how much of the PMS money can be kept by a practice if we choose that option. All too rushed and many questions unanswered. 
19. Can you help us access a core contract can NHS England provide guidance on what is now classed as over and above core services 
20. Our GPs will forward these 
21. Re option 2 - what are core services and how do we put a case in for retaining some funds and will we know the answer to this before the deadline and a decision has to be made? 
22. It's often difficult as a PMS practice to sign up for an enhanced service in a month when they want all partners' signatures. This review has major implications that still can't be properly modelled and yet a decision is asked for within weeks. What happens if we can't make a decision by the end of January? 
23. Would have appreciated better timing and not just sent to Practice Managers 
24. I thought there would be no review until there was a national agreement. This was agreed with the PCTs following the FDR review.

We are organising a 'town hall' meeting for all interested PMS practices on Friday 13th February 1-3pm at Glen Parva Memorial Hall. There is room to accommodate 2 representatives from each practice, and we are hoping that each practice will send a Practice Manager and a GP partner.

In addition to Shanee Baker, the leading lawyer and expert adviser from LMC Law, we have invited Glyn Rawlings, the local accountant with specific expertise on GP practice finances, to inform the discussion and to help practices to consider all options.

To reserve a space and confirm who is attending, please email charlotte.woods@llrlmc.co.uk