Applications for Proposed Practice Mergers

NHS England (Leicestershire and Lincolnshire)

Applications for Proposed Practice Mergers

Guidance for Practices

Applications will be considered from practices to merge in accordance with the NHS England policy ‘Managing Regulatory and Contract Variations’ and the local process developed to implement the national policy.

This guidance sets out the timescales and the information required by practices at each stage of the process.

1.     Expression of Interest

The practices will need to complete the Expression of Interest form with the information identified in the table below. The intention of this is for the practices to provide a high level understanding of a viable business case to enable the proposal to move forward to the patient engagement/consultation stage. 

Area to be covered	Details should include as a minimum
High level service benefits of the proposal	- Innovative model of service delivery to improve  patient outcomes. - Range of services  to be offered that demonstrates  added benefits to patients - Opening hours – core and extended - Skill/gender mix of workforce including any  special interests - WTE clinicians
Logistical delivery plan	Where services will be run from two premises following the merger: - How will patients access services across 2 sites - How will sites be used in different ways to benefit  patients - Telephone access - IT systems
Practice Boundaries	Details of the existing boundaries of both practices plus the proposed inner and outer boundary of the merged practices
PPG comments	Initial comments on the proposed merger from both practices PPGs

2.     Service Plan

The Service Plan should provide significant detail, expanding on the Expression of Interest submission. Practices should seek advice and assurance regarding their application from the CCG and discuss the proposal with the LMC.

The areas to be covered in the Service Plan should include: 

Frequently Asked Questions 

1. Which policy sets out the process and principles of mergers?

The NHS England policy ‘Managing Regulatory and Contract Variations’. 

2. What are the main areas of consideration for merging contracts

As per the national policy these are as follows:

• In general terms contractual mergers should only be considered in cases of like-for–like contracts i.e. GMS with GMS and PMS with PMS because of the differences in terms and financial arrangements. However this does not remove the right for a PMS provider to merge its business with a GMS provider.

• What would be the benefits to patients? The AT requires a service plan which should provide details on how patients would access a single service, what would the practice boundary be, assurances that all patients will access a single service with consistency across provision i.e. home visits, booking appts, essential and additional services, opening hours. Extended hours, and so on, single IT and phone system and premises arrangements. The service plan should also set out the proposed arrangements for consulting with the patients about the proposal, communicating the change to patients and ensuring patient choice throughout.

• Costs. Merging contracts with two different values would have an average effect, possibly resulting in a higher cost per head of population. The financial arrangement would need to be reviewed before any non-financial matters are considered.

• Impact on QOF.

• Impact on Premises. 

• Additional service and OOH opt outs.

• Procurements and Competition.

• The AT must consider any application having regard to but not limited to value for money, IT requirements, patient access, GP choice and primary care strategy.  

3. We are a PMS practice proposing to merge with a GMS practice. Is this possible?

As per the national guidance PMS and GMS are not like-for-like contracts. Therefore, in order to merge, the options are:

• Under PMS the contractor could exercise their right to a GMS contract and apply to merge following completion of this process. 

• GMS and PMS providers could seek to vary each agreement to take the other as a party to their contracts, eventually seeking to terminate one or the other of those contracts. There would be a discussion between the practices and the Area Team as to which contract would be terminated. 

4. What will the decision makers be looking for to enable the merger to be approved?

• The onus must be on the practices to present a sustainable and effective service plan which illustrates the added value of the merger. The practices involved in the merger will be asked to attend a meeting at the Area Team to present their case.

• The service plan must not result in a reduction of services and must identify the quality benefits of the merger including assurance that a different model of service delivery will produce added value.  

• The service plan must address issues which reflect patient feedback, improved access and lead to optimal service delivery efficiency for the practice and patients. The service plan should not be used to dismiss known performance issues which must still be managed through due process. 

• The service plan must demonstrate satisfactory operational logistics, particularly where two or more sites are to be retained following the merger.        

• The merger will result in reduction of patient choice of practices. There must be sufficient choice of practices remaining after the merger. 

• The proposed realignment of practice boundaries for the merged practices must include an inner and outer boundary, include at least all existing geographical areas for both practices but also where necessary and practicable be expanded to increase choice for patients.     

• The merger must comply with competition and procurement rules. The resultant merged contract must not be significantly different in scale or kind to the individual contracts.

• A satisfactory outcome from patient consultation is essential. 

5. Are there any issues relevant to this Area Team to consider? 

In considering the options the following points should be noted:

• If the practices chose the option of joining each other’s contracts the PMS contract will be part of the planned PMS review and the contractual value may change.

• PMS contract holders would not be able to carry any growth monies into the GMS contract.

• The FDR review could impact on the relevant practices.   

• It is very likely that the Area Team would be seeking the retention of any PMS contract. This would necessitate negotiated and necessary amendments to the terms of the remaining PMS contract. 

• The cost of implementing any operational changes of the merger will fall to the practices and not the AT.

• The financial implications must be affordable to the AT and in line with national and local policy and guidance. It should not result in an overall increase in funding for the merged contracts when compared to the pre-merger status. This should also take account of any known future changes to contract funding.     

• The preferred resultant contract type would be PMS which is not time-limited but will allow for a renegotiation of terms whilst being mindful of competition and procurement rules. 

6. How do we undertake patient consultation?

Involving local patients, members of the public, carers and patient representative groups is important. This may take the form of engagement or consultation

• Engagement

Engagement describes the continuing and on-going process of developing relationships and partnerships so that the voice of local people and partners is heard and that plans are shared at the earliest possible stages.  Examples of this type of engagement would include patient participation groups It also describes activity that happens early on in an involvement process, including holding extensive discussions with a wide range of people to develop a robust case for change.

• Formal consultation

Formal consultation describes the statutory requirement imposed on NHS bodies to consult with overview and scrutiny committees (OSCs), patients, the public and stakeholders when considering a proposal for a substantial development of the health service, or for a substantial variation in the provision of a service. Formal consultation is carried out if a change is ‘significant’. This is determined where the proposal or plan is likely to have a substantial impact on one or more of the following:

• Access (eg. reduction or increase in service due to change of location or opening times) 

• Wider community (eg. economic impact, transport, regeneration) 

• Patients or users (either current or future) 

• Service delivery (eg. methods of delivery or relocation of services) 

The outcome of a formal consultation must be formally reported, together with the feedback received, and must show how this has been taken into account in any recommendations and decision making.

At the Expression of Interest stage of the proposed merger, the Area Team will assess the likely level of impact on patients is likely to be and then agree the level of engagement or formal consultation. The practices will be advised of the process they will need to undertake to seek the views of their patients and representatives, and will be assisted with this by the CCG. This will include discussions with the PPGs of both practices, sending letters out to patients (at a cost to the practices), holding an engagement event and undertaking an on-line survey.

7. Why will it take up to 9 months? 

• The proposal requires an application in two stages. The meeting where the applications will be considered is held monthly. Therefore the application needs to be submitted at the beginning of the relevant month to meet the deadline for submission of papers. If the deadline is missed, the application will be considered at the next available meeting.  

• Patient consultation is likely to take a minimum of two months to enable prior notice of events and sufficient time for completion of surveys and analysis of feedback.

• 3 months patient notice is required for a substantial change.