Primary Care Service Framework:
Accessible and Responsive General Practice
- Preface
- ensure that they achieve and maintain the minimum standard of 50% cent of their GP practices offering extended opening outside core hours, and also that they make ongoing progress in improving GP services (in particular that patients have guaranteed access to a GP within 48 hours and can book appointments further ahead).
- seek year-on-year improvements in patient satisfaction with GP services, as measured by the GP Patient Survey.
- contribute towards the achievement of World Class Commissioning competencies
- stimulate consideration of what “good” looks like in the context of the population being served
- create a culture of challenge, continual improvement and change in primary medical care
This PCSF is part of a suite of supporting tools that will be published over the coming months to support PCTs in commissioning services from their practices to improve access and responsiveness.
This will sit alongside PCTs’ work to develop and improve all primary and community services, including pharmacists and Transforming Community Services.
- Purpose of this Primary Care Service Framework
The purpose of this framework is to incentivise and provide practices with resources to tackle the specific access issues relating to their own practice and their patients. It is important to be clear that this PCSF is not about developing new services; it is intended to support PCTs in commissioningcontinuing improvements to existing ones. It can be used in a number of waysto develop new approaches or change existing working practices and systems through the implementation of
- incentive schemes
- capital grants
- Local Enhanced Services
- Scope and Definition of Service
Approach: it is unlikely that a single “one size fits all” approach will be appropriate to all practices in a PCT. The approach adopted will need to balance and reconcile how to improve low achievers and yet incentivise high achievers to innovate further. PCTs will therefore want to reach individual agreements with practices that are set in the context of the services and activities they currently undertake.
As a first step, it is recommended that PCTs agree locally the minimum standards they expect, taking into account current contractual requirements.
Where a practice does not meet current minimum standards, especially those required by their contract, discussion will be needed about how the practice will reach those standards. Additional investment under the PCSF is concomitant with achievement of the minimum standards. A mechanism for managing diagnostic visits to these practices coupled with additional support to enable them to improve may need to be put in place. The use of existing improvement methodologies, such as collaboratives should be considered. The Department is also developing a suite of supportive resources both for PCTs, in the form of World Class Commissioning guidance for access and responsiveness, and for practices, through a practical resource of good practice and step-by-step guides, developed and disseminated through national stakeholder organisations. These will be made available of the coming months.
Where practices are already operating with high levels of patient satisfaction both the PCT and the practice may want to look at more innovative approaches to reaching the most hard to reach people and those that do not normally access primary medical services, eg through the use of social marketing techniques.
PCTs should be clear that this additional investment should support continuous improvement.
PCT will want to consider whether it is appropriate for a practice to be eligible for this payment if they operate "open but full "arrangements.
Providers: This PCSF is open to all GP practices
This primary care service framework should not be confused with (and sits outside of) essential and additional GMS or PMS services already provided, current Quality and Outcomes Framework (QOF) indicators and any Directed Enhanced Services.
- Parties to the agreement
Names of any accountable individuals and organisation details.
- Background
- aspects of the surgery environment and helpfulness of reception staff
- getting through on the phone to book an appointment, or obtain test results
- accessing GP appointments quickly and conveniently ie being able to book ahead
- waiting time in the surgery
- seeing a preferred doctor
- satisfaction with practice opening hours
- aspects of the consultation with doctors and nurses
- overall satisfaction with care received
PCTs are expected to use this broader range of data to identify specific priorities for local improvement. From April 2009, the GP Patient Survey will be undertaken on a quarterly basis. The broad aim of developing this PCSF is to assist PCTs in commissioning local improvements in access and responsiveness from their GP practices. PCTs may also wish to use the Primary Care Commissioning Tool (developed by McKinsey & Co) to pinpoint priority areas for action.
- Summary of Local Need
It would also be valuable to map current usage of urgent and unscheduled care services, eg A&E, GP-Led Health Centres out of hours and walk in services. This could help to build a better picture of where patients are experiencing difficulties in accessing services.
The results of the national GP Patient Survey should be reviewed to establish patient satisfaction levels. Patient satisfaction should be considered by client group, eg those with a particular long-term condition – this is more likely to show variations and will be more sensitive than just using average measures.Resources to assist PCTs with this include:
- National Improvement Team Report for Access and Responsiveness
- “No patient left behind” Report
- Service Objectives and Intended Health Outcomes
The objectives have been divided under three headings, although there is some overlap between them:
Patients
- Improved patient and/or carer experience
- Improved health outcomes resulting from earlier attendance and consequent diagnosis of long-term conditions, eg cancer
- Improved response to hard to reach patient groups
- The provision of enhanced health opportunities helping to reduce the health divide
- Better signposting to lifestyle advice
- Supports the delivery of other national strategies, eg vascular checks
- Improved access to in-hours primary care leading to a reduction in unnecessary attendances for urgent or unscheduledcare, eg A&E, out of hours services, walk-in centres
- Encouraging innovation whether in terms of new service models, new skill mixes and technologies
- Value for money
- Improved patient satisfaction resulting from enhanced interface between practice and patients
- Improved staff morale from enhanced interface between practice and patients
- Increased efficiency resulting from more streamlined processes within practices
- Improved uptake of screening
- Improved QoF achievement
- Service Outline
PCTs should set out their local priorities in context of their needs assessment. Business cases should then be sought from providers that demonstrate clearly how the items they are seeking funding for as additions to existing services will result in improvements in access for patients. These business cases will need to contain:
- a clear statement of practices access issue(s)set in the context of GP Patient Survey results
- a description of how the proposal(s) will improve this
- how patients will be informed actively of any changes that will enable them access services more easily
- value for money
- details of review and evaluation mechanism and timescales
A suggested template is included in annex 2.
Annex 1 details areas where PCTs may want to consider investing these funds.
- Location of Service
- IntegratedGovernance
Any commissioned service must meet all current quality requirements. Compliance with relevant NICE guidance is also required.
Patient and Public Involvement– Improving access and responsiveness needs to be strongly founded on engagement with patients and should be a dynamic process. Providersshould be required to demonstrate active engagement with people and local communities in developing services, self care plans or in supporting people to utilise self care opportunities. Providers should demonstrate how they respond to patient feedback and this is to be used to shape and improve services. Involving family carers and supporters will help deliver the components within this service specification. Local Involvement Networks (LINks), the voluntary sector and patient advocacy organisations are all further mechanisms to seek active involvement in service planning, delivery and monitoring.
Professional competency, education and training- Healthcare staff delivering the service will be required to demonstrate their professional eligibility, competence, and continuing professional development in order to remain up-to-date and deliver an effective service which is culturally appropriate. Staff appraisal on an annual basis and at an appropriate level will also be required. Commissioners will need to be reassured that practitioners have the required competencies at an appropriate level.
Commissioners should be satisfied that providers who deliver the services described have a planned, regular programme of education, training and support for their staff.
Providers should ensure safe staffing capacity at all times and staff should be able to demonstrate that they have participated in any necessary training, for example infection control, manual handling, risk assessment as required.
Patient, public and staff safety – Providers will be required to demonstrate that evidence based clinical guidelines are being used. Providers should have in place appropriate health and safety and risk management systems and ensure that the PCT’s required premises standards are met. They should also ensure that any risk assessments and significant events are both documented and audited regularly and outcomes of these implemented. Services should comply with national requirements for recording using an agreed risk reporting, investigation and implementation of learning from incidents. Further details can be found on the National Patient Safety Agency website
The provider will ensure that staff undertaking patient assessments will have full CRB checks/clearance
Information management - The protection, use and disclosure of patient information must comply with the information governance policies and guidance set out in the NHS Information Governance Toolkit which can be found at This encompasses the NHS Codes of Practice on Confidentiality, Records Management and Information Security and supports delivery against core standard C9 of Standards for Better Health. All staff should undertake the information governance training provided on-line at
Equipment–Providers will be expected to adhere to Medicines and Healthcare Regulatory products Agency (MHRA) advice and guidance on selection of appropriate equipment, training in its use and ongoing management, troubleshooting, and quality assurance processes that ensure the accuracy and reproducibility of test results.
Clinical audit and review – Providers will be required to demonstrate their coordination of and involvement in regular inter-professional and inter-agency meetings and regular clinical audit of the service interventions and outcomes such as drug therapies or well-being and behaviour changes. This audit can be carried out by extracting data using the Read codes.
Equality and Human Rights - Delivering good quality care will require organisations to demonstrate competence in identifying and taking action on inequality and also needing to engage with communities that have not found accessing public services easy. Undertaking Equality Impact Assessments (EQIAs) is a specific legal obligation, and conducting EQIAs and using the evidence to create a meaningful dialogue with communities (especially seldom heard from groups) is central to effective commissioning and service provision. This will create an evidence-based approach. As a minimum, core standard C7e of Standards for Better Health stipulates “healthcare organisations should enable all members of the population to access services equally and offer choice in access to services and treatment equitably”. To assist this process, organisations may wish to refer to ‘Creating a Disability Equality Scheme: a Practical Guide for the NHS’ -
Managing complaints – providers should have in place a complaints system that reflects the arrangements introduced on 1 April 2009. This provides an opportunity for all organisations to review their local systems so they can both respond flexibly to complaints, concerns and complements and feed the resulting lessons into their work on learning from patients’ feedback to improve services.
The new approach which focuses on the complainant and enables organisations to tailor a flexible response that seeks to resolve the complainant’s specific concern should provide valuable feedback to ensure providers are continually enhancing their responsiveness to patients.
Continuous quality improvement – a set of indicators should be selected or developed and then agreed which defines the key quality requirements of the service. The service should also identify how it uses these measures and others to ensure that the quality of the service is continuously improved.
- Information management/requirements
Any monitoring that PCTs want to put in place should be proportionate to the activities being commissioned. It is recommended that monitoring is picked up as part of the normal performance cycle. The PCT’s monitoring will include some or all of the following:
- evidence of improvement as demonstrated by GP Patient Survey results. Practices should ensure they have a mechanism in place to ensure that the results are reviewed on a regular basis
- evidence that the agreed activity has occurred, for instance that
- patient participation groups have met with the frequency agreed, and their recommendations acted upon
- telephone responses have improved
- results of demand and capacity audits
- Service Monitoring and
- Patient Experience – Patient experience is central to the development of responsive practices. Patients’ views on their experiences and satisfaction levels will need to be measured through an on-going, systematic process to test whether the service is engaging with patients, family carers and supporters in a way that supports them. Different and innovative approaches to obtaining these views and experiences will be necessary, eg through capturing stories of community members experiences of the NHS and applying the learning from these. These processes should also be stratified where possible to show any differential impact on disadvantaged groups (e.g. Black and Minority Ethnic groups, deprived groups, males, females etc) and any resultant service changes (planned or achieved) should be highlighted.
- Service Activity – Volume of work against any agreed activity levels and distance from profile, capacity, needs and demand analyses, workforce arrangements, real time referral data to other care pathways or appropriate agencies recorded appropriate Read codes.
- Clinical Outcomes – Regular analysis and interpretation of clinical outcomes data as well as regular analysis and interpretation of PPA data for prescribing.
- Quality and Governance – Quality criteria will need to be established (in agreement with commissioners) and measured with standards needing to be met on a continual basis. Results of clinical audits will be used to inform service provision during the year. EQIA data should be used to underpin local integrated service provision.
- Value for Money – Cost effectiveness or ‘best value’ analyses of the primary service outcomes in relation to comparative costs of hospital activity or those services providing equivalent quality of care.
- Funding
- Contract Management
Name and contact point of the contract manager of both the commissioner and provider. Any specific local arrangements for contract management should also be stated.
- Review, variation and de-commissioning process
Suspension arrangements
Payments under the scheme will be suspended if at any time the practice is unable to provide services in line with the agreed service specification or fail to meet eligibility criteria.
Before any suspension the practice and PCT will meet discuss the reason for the suspension identifying any possible resolution.
If the matter is not resolved the PCT will issue a suspension notice to the practice within 7 days.
Notice period
Either party may exit the scheme by giving 3 months written notice.
Decommissioning
Arrangements for the exit of the contractor from the agreement whether it is due to termination or because the agreement has come to an end should be included. The inclusion of an exit plan that details the processes to manage the exit of the Contractor from performing the Services is recommended.
Termination
The PCT may terminate the scheme within 28 days if, following suspension of payments the contractor fails to re-establish services according to the service specification or take appropriate action to address deficiencies within eligibility criteria.
Before issuing an exit notice, the parties will meet to discuss the reason for termination.
If after this meeting the reason for terminating is not resolved then the relevant party will issue an exit notice.
The PCT right to claw-back monies as a result of underperformance or failure to deliver on agreed action plans shall survive the termination of this agreement.
Appeal procedures
Either party can appeal against a suspension or termination noticeusing the contractual dispute resolution procedures, or, where that is not appropriate, the Trust Contract Appeals process
Review
The PCT will evaluate the scheme for its success and review in the light of any changes to national requirements- Signatories