Source: http://gplaw.co.uk/chapter2-nhs-bodies-roles-and-functions/itemlist/user/804-davidlockqc
Timestamp: 2017-06-23 22:29:04
Document Index: 185197434

Matched Legal Cases: ['art 8', 'art 8', 'art 8', 'art 5', 'art 8', 'art 8', 'art 8', 'art 2', 'art 2', 'art 3', 'art 4']

Home	Chapters	Terms of Use	David Lock QC
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Chapter 11: A Guide to the law on Patient Choice	A Guide to the law on patient choice[1]
1.1 The principle that NHS patients should be entitled to choose where they are treated has become a key part of government policy in recent years. The underlying concept is that patients should be able to choose the clinician who they want to provide them with healthcare and that the money should follow the patient. Turning this political aspiration into reality is far from straightforward but this chapter attempts to explain how the systems are supposed to operate to deliver patient choice. Whether the choices made by patients are respected in practice is, of course, an entirely different matter. 1.2 The importance of patient choice was reflected in the key 5 year Forward View document published by NHS England which said at pages 12/13:
1.3 The importance of patient choice was also set out in the Mandate[2] issued by the Secretary of State for 2016/17 which said: "We want people to be empowered to shape and manage their own health and care and make meaningful choices, particularly for maternity services, people with long term conditions and end-of-life care"
1.7 There areprovisions of the NHS Constitution relating to patient choice in both primary care and secondary care. They are referred to below. 2. Patient choice of GP.
2.4 In accordance with these Regulations, once a patient is accepted onto the list of an NHS GP practice, the contractor must inform the patient of the right to "express a preference to receive services from a particular performer or class of performer either generally or in relation to any particular condition" and that, if a patient expresses a preference, the practice "must endeavour to comply with any reasonable preference". 2.5 Thus if a patient expresses a preference to see Dr Ahmad, the practice must operate a system which endeavours to comply with this preference. Patients can also request to be treated by a "class of performer". This may raise some difficult issues about discrimination. This provision could be used to permit a female patient to express a preference to see a woman doctor, particularly if she needs to be treated for gynaecological or family planning matters. Equally, a male patient may express a preference for being treated by a male doctor if he has erectile dysfunction problems. Patients for whom English is a second language may properly ask to be seen by "class" of doctors who can speak their language. However, it is almost certainly not permissible to use this part of the contract for a patient to express a preference only to be seen by a "white doctor". 2.6 There are different ways that the practice can comply with this requirement in practice, including ensuring that the practice computer system informs the receptionist where a patient has expressed a preference and prompts the receptionist to offer an appointment with the patient's preferred GP.
3.6 Regulation 38 defines the meaning of an "elective referral" as follows: ""elective referral" means referral by a general medical practitioner, general dental practitioner or optometrist to a health service provider for treatment that is not identified as being immediately required at the time of referral"
3.7 Hence, a patient cannot "self-refer" for secondary NHS care and claim to exercise patient choice rights in respect of that referral. The person making the referral must be a GP, community dentist or optometrist. Further the rules about choice for elective referrals do not apply to emergency procedures and so a referral by a GP for treatment that is "immediately required" does not give rise to patient choice rights. 3.8 The elective referral must be made to a "health service provider" This term is widely defined in Regulation 2 of the 2012 Regulations to mean:
3.13 The decision making process in the policy which constitutes the "arrangements" must provide that if the answer to all 4 questions is "yes", the CCG or NHS England must make a decision to fund the initial consultation with the preferred secondary care clinician which is the subject of the referral. That appointment must be funded because the patient's "legal right" to have NHS funded treatment have been established and so the CCG or NHS England ceases to have a discretion to decide whether to fund the treatment or not as part of NHS funded care. It follows that any set of legal "arrangements" must set up a decision making process that guide a decision maker to ask whether the answer to all 4 questions set out above are answered in the affirmative. 3.14 Regulation 39(6) provides that the assessment as to whether the referral is clinically appropriate is exclusively a matter for the person making the referral, not for the CCG or NHS England. Hence, the decision making processes cannot allow the commissioner to reach their own view as to whether the referral is appropriate treatment to be funded as part of NHS care.
4.3 It follows the purpose of limiting the legal right of a patient to choose their provider for a first out-patient appointment appears to be designed to enable the provider of the patient's choice to have a first meeting with the patient, funded by the NHS, to discuss treatment options. Following this first appointment the patient can then request the NHS commissioner for funding to support a full course of treatment with the patient's favoured provider (either as part of an existing CCG or NHS England policy or as an individual funding request outside the policy). 4.4 The purpose of limiting the legal right to a first out-patient appointment appears to allow the patient to be seen by the secondary care provider of the patient's choice and for the CCG (or NHS England) to be informed by the secondary care provider what treatment that provider recommends for the patient. The CCG (or NHS England) is then in a better position to make a decision whether to commission further treatment for the patient. It is also relevant to note:
5.1 NHS England has no policy on its website which informs patients how decision makers within NHS England are required to give effect to patient choice rights when services are commissioned by NHS England. It is therefore unclear what arrangements, if any, have been put in place by NHS England to ensure that patients can exercise their choice rights when referred for care commissioned by NHS England. 5.2 The department of NHS England which regulates CCGs appears to be focused on making sure CCGs respect the patient choice rights of patients. The NHS England website[6] says:
6.1 There are some CCGs with well developed Òpatient choice policesÓ. A good example is Blackpool CCG (see http://blackpoolccg.nhs.uk/patient-choice/). However, there are many other CCGs that have no specific policy which explains patient choice to patients and, crucially, to decision makers within the CCG. As with NHS England, CCGs will be acting unlawfully if they do not have a policy which guides decision makers to identify and respect appropriate choices made by patients. 6.2 The legal rights given by Part 8 of the 2012 Regulations need to be seen within the overall legal structures operating in the NHS. These structures provide that that decisions about which NHS funded medical treatment should be provided to an NHS patient are primarily a matter to be decided between the patient and their treating NHS GP or other primary care clinician. This balance between the decision making power of GPs and the powers of the CCG is seen in 3 areas in particular, namely:
6.8 Thus, a CCG may not lawfully adopt a policy not to reimburse a secondary care provider for providing drugs or treatments to patients with medical conditions which come within a cohort defined by a NICE TAG. 7 The requirements that must be fulfilled before a patient can establish "patient choice" rights under Part 8 of the 2012 Regulations.
a. Cancer services (where a 2 week wait right arises Ð as to which see below); b. Maternity services; and
9.1 NHS England takes a substantially different approach to the conditions which must be satisfied before patient choice rights arise. Despite the many statements made by NHS England in support of the concept of patient choice and the existence of a team within NHS England which promotes patient choice, Guidance issued by NHS England following the inclusion of mental health patients within the patient choice rights framework seeks to place additional restrictions on the ability of all NHS patients to exercise patient choice rights. 9.2 NHS England published interim Guidance on patient choice in mental health services in May 2014[11] and then published final guidance in December 2014. The December 2014 NHS England Guidance suggests that, in addition to the qualifying criteria set out in the 2012 Regulations, there are 2 further restrictions on patient choice rights, namely:
The suggestion in NHS England Guidance that the referral must be for treatment which is of a type which the patient's own CCG routinely commissions 9.5 The NHS England Interim Guidance provided at pages 4/5:
9.10 However the NHS England Guidance departs from the terms of the Regulations in suggesting that a patient's legal right to choose a provider was limited as follows: "As is the case in physical health, the legal rights to choose in mental health do not give a legal right to choose their treatment. It is for commissioners to decide which services to secure in order to meet the needs of their local population. Where commissioners routinely commissioned particular mental health services, eligible patients may choose any provider team, in line with the description above, to access those services. Where patients, with the support of their GP, wish to access services that are not routinely commissioned by their responsible commission, they may apply through the Commissioner's Individual Funding Request (ÒIFRÓ) process or if in receipt of a personal health budget through the care planning process"
9.16 The ambit of the right is also important. It is a right for a first consultation and the strict legal right does not extend beyond the first consultation. Hence, a right to a first consultation with a secondary care clinician in an area of treatment that the CCG would not routinely fund does not necessarily lead to the CCG having any further extended liability for treatment. It follows that this part of the NHS England Guidance appears to be legally incorrect mainly because a limitation to a referral for treatment that the CCG routinely commissions is not a limitation which is set out in the 2012 Regulations. 9.17 The author thus expresses the view that, as a matter of law, a patient who is referred by his or her GP for a first appointment with a secondary care clinician who has a contract with another CCG or NHS England but seeks a type of care which the patients CCG does not routinely commission can establish a legal right to an NHS funded first appointment under Part 8 of the 2012 Regulations.
9.23 The second difficulty in suggesting that a "commissioning contract" should mean "a commissioning contract in the form of an NHS Standard Contract and not in any other form" is that a CCG that entered into a commissioning contract in any form other than the NHS Standard Contract would be acting in breach of NHS England's own rules. Hence a CCG would not be acting lawfully in entering into a "spot contract" with a provider for the delivery of NHS services to a patient in any form other than the NHS Standard Contract. 9.24 The requirement on CCGs to use the NHS Standard Contract when commissioning all NHS services is set out in Part 5 of the 2012 Regulations which is headed "Standing rules: commissioning contract terms". Regulation 16 provides :
9.28 Three points appear to emerge from the 2015/16 rules concerning the extent of the legal obligations on CCGs to use the NHS Standard Contract which are relevant to the issue of patient choice, namely: i) There is no exemption from the legal duty where the proposed contract is of low value. The legal duty to use the NHS Standard Contract arises regardless of the value of the contract;
9.29 It follows that every CCG is under a public law legal obligation to use an NHS Standard Contract when placing a contract with a chosen provider following an IFR decision for an individual patient. It is therefore difficult to see that this part of the NHS England Guidance can possibly be correct because it fails to give effect to NHS England's own rules on the type of contracts that must be used by CCGs. The view is therefore put forward that the attempt by the NHS England Guidance to limit the type of contracts that count as "commissioning contracts" for establishing patient rights under Part 8 of the 2012 Regulations is wrong as a matter of law. 10 The general duties on CCGs and NHS England to commission services in accordance with preferences expressed by patients.
10.3 This general duty is clearly not relevant where a patient seeks to establish a right to exercise patient choice under Part 8 of the 2012 Regulations. However, this duty is relevant to categories of patients who are outside the patient choice rights under Part 8 of the 2012 Regulations and to any request for funding for treatment that goes beyond an initial consultation. 10.4 Sections 13I and 14V impose procedural duties which require NHS England and each CCG to act at all times "with a view" to enabling patients to make their own choices about inter alia their selected healthcare provider. It is thus a general duty which applies to all commissioning decision-making processes by NHS England and every CCG. It therefore applies to CCGs when formulating general policies as well as when they are considering Individual Funding Requests.
10.8 However, sections 13I and 14V only impose procedural duties. It follows that there can be countervailing factors on which a CCG or NHS England could rely upon to reach a final decision which does not enable a patient to make choices with respect to aspects of health services provided to them. That raises the interesting question as to how a CCG or NHS England should approach a request for a provider to fund treatment which the CCG or NHS England has made a specific decision not to commission. The factors would have to be balanced in the decision making but it is probably lawful to override the patientÕs preference and to apply the general policy. It is not, however probably permissible to adopt a general policy not to fund any medical treatments where no specific decision has been taken to fund the form of treatment. 11 These legal structures probably mean that NHS England and CCGs can only discharge the duty by adopting a starting point that it should enable a patient to make choices with respect to aspects of health services provided to them, and then depart from that position if driven to do so by other factors. Some helpful guidance on the meaning of the section 14V duty can be drawn from the observations of Aitkens LJ in R (Brown) v Secretary of State for Work and Pensions [2008] EWHC 3158 (Admin) which was concerned with the similarly worded "due regard" duty under section 149 of the Equality Act 2010. It follows that, in order to act lawfully:
vi) It is good practice for those exercising public functions in public authorities to keep an adequate record showing that they had actually considered this duty and pondered relevant questions. 12 In summary therefore patient choice rights are powerful rights but are not generally well understood and are rarely exercised in practice. However, these legal rights are likely to become more important as NHS resources become tighter and patients are therefore increasingly denied treatment that they seek in order to balance the books.
[1] The law stated in this chapter is with effect from 1 October 2016. [2] See https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/494485/NHSE_mandate_16-17_22_Jan.pdf [3] See https://www.england.nhs.uk/about/gov/patientchoice/ [4] There is a list of NHS bodies which have a legal duty to have regard to the NHS Constitution. It includes NHS England, CCGs, NHS trusts, NHS Foundation Trusts and local authorities exercising NHS functions. It does not include the Secretary of State but a like duty is imposed on the Secretary of State by section 1B of the NHS Act 2006.
[6] See https://www.england.nhs.uk/about/gov/patientchoice/ [7] This is the Regulation which requires a CCG and NHS England to have an Individual Funding Arrangement policy and to operate IFR panels. Where an IFR request is turned down the CCG or NHS England must give reasons: see Regulation 35.
[8] See https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england [9] Or another person who can make a referral under Regulation 38.
[10] See https://www.gov.uk/government/publications/the-nhs-choice-framework/the-nhs-choice-framework-what-choices-are-available-to-me-in-the-nhs [11] See https://www.england.nhs.uk/wp-content/uploads/2014/05/guid-choice-prov-health.pdf [12] See https://www.england.nhs.uk/wp-content/uploads/2014/12/choice-mhc-14.pdf [13] See https://www.england.nhs.uk/wp-content/uploads/2014/12/choice-mhc-14.pdf [14] See https://www.england.nhs.uk/nhs-standard-contract/ [15] See https://www.england.nhs.uk/wp-content/uploads/2015/03/7-nhs-contrct-tech-guid-fin.pdf Read more...	Chapter 10: Payment to GP Practices	This chapter has been updated in June 2014
Payment to GPs under Practice Contracts with NHS England. This chapter[1] contains:
3 Payment due to GP Practices under PMS contracts. 3.1 The power to set up different types of commercial arrangements with GP practices was first set out in the NHS (Primary Care) Act 1997. That power is now included in the NHS Act 2006 (as amended by the Health and Social Care Act 2012). These new forms of agreement were originally temporary but were made into permanent agreements in 2004. Section 94 of the NHS Act provides that the Secretary of State can make Regulations about the terms to be included in PMS agreements[4]. Section 94(4) then provides:
3.3 This statutory scheme appeared to envisage that the Secretary of State would make directions to set out the payments due to PMS practices in the same way as directions were made for GMS practices. However the Secretary of State has not made any Directions which fix the sums that PMS contractors are required to be paid for the provision of essential services[6] because these remain a matter for local negotiation. The Secretary of State retains a power to issue directions which would define the sums that would be paid to PMS practices but, at this point, there is no evidence that the Secretary of State has contemplated using that power. The sums payable thus continue to remain a matter for negotiation between NHS England and PMS practices. 3.4 The Secretary of State issued directions in 2013 to PMS practices which cover payments due to doctors working on the Flexible Careers Scheme, the Returners Scheme and the Doctors’ Retainer Scheme, all of which were designed to keep as many GPs as possible working within the NHS. These Directions are accessible here.
f) Minor Surgery Scheme; g) Patient Participation Scheme;
3.6 In each case the PMS Directions set out the type of conditions that must be considered when NHS England is entering into a PMS contract for each of the above schemes with a PMS practice. However, unlike the GMS Directions, when it comes to payment the Directions do not fix the sums that a PMS practice are to be paid if the practice agrees to participate in any of the above schemes. The Directions say that in determining the amount to be paid by NHS England to the practice, NHS England must “have regard to” the sums paid under the relevant part of the GMS Directions. The phrase “have regard to” means that the payments under the GMS Directions must be a starting point for any negotiations between the PMS practice and NHS England for the provision of an Enhanced Service but allows NHE England and the PMS practice to agree a higher or lower sum to be paid for the provision of the service. 3.7 If the practice and NHS England were unable to agree the amount to be paid to a PMS practice for an additional service then theoretically NHS England would be able to define the sum that was to be paid and, if the PMS practice wished to continue to provide the service, it would have to accept the sum that was stipulated by NHS England. However, in that case, NHS England would need to have considered the sum payable under the SFE for the provision of the services and to have justifiable reason for departing from that sum in the PMS agreement with the practice. 3.8 The absence of directions to cover essential services and terms such as premises costs means that PMS contracts need to be read carefully to determine the payments due without necessarily any reference to the equivalent GMS terms. A large number of PMS agreements define that the sums paid to the practice will be fixed by reference to the SFE. If this is the case then, as the terms of the SFE are varied each year, so the terms of the PMS contract are varied. However in the absence of an express term incorporating the SFE as a term of the PMS agreement, in principle, terms agreed for GMS contracts will only apply to PMS agreements if there is a written agreement between the parties that varies the contractual terms to incorporate the new term.
3.10 An example of the way this works is shown in the FHSAU decision 15512. In this case a PMS contractor sought to change the basis of its premises payment from a Cost Rent basis to a Notional Rent basis, in accordance with the National Health Service (General Medical Services - Premises Costs) (England) Directions 2004. However these 2004 Directions only apply to GMS contracts and not PMS agreements. The PCT refused to change the basis of the premises payment and referred to an “entire agreement” clause in the contract. The PCT thus disputed that the PMS practice was entitled to rely on the 2004 Directions. The FHSAU sided with the PCT saying “I am not satisfied that the PCT agreed to move to a Notional Rent reimbursement under the Directions with effect from August 2008 or that this should be applied to August 2005 for the same reasons. I am satisfied that the PCT have agreed to accept the effective rent review dated 1st August 2008 and that the parties have varied the PMS Agreement to reflect this agreement”
4 Payment due to GP Practices under APMS contracts. 4.1 APMS contracts are awarded by NHS England exercising its general powers under section 83(2) of the NHS Act. There is no provision for the Secretary of State to make Directions to govern payments under such contracts. It follows that the payment terms must be governed by the terms of any such contract (as varied by agreement between NHS England and the contractor from time to time).
5.1 The standard GMS contract commits NHS England to making payments to a contractor “promptly and in accordance with both the terms of the Contract”: see clause 18.1.1. If payments are not made by NHS England to a GP practice then the GP practice can either register a dispute with the FHSAU or, if it is a legally binding contract, sue NHS England for the monies owing in the county court. 5.2 If the practice obtains a determination from the FHSAU that monies are owing by NHS England to the practice (or NHS England obtains a determination that monies are owing by the practice to NHS England) then NHS England comes under a statutory duty to pay the monies determined to be owing. The legal route by which NHS England comes under that statutory duty is not wholly clear. When NHS Contracts were first defined in legislation by section 4 of the National Health Service and Community Care Act 1990, section 4(7) provided:
[6] Please see chapter 7 of this website for a description of the services that all standard general practice contracts are required to provide. [7] For more details on the effect of an entire agreement clause in a GP practice contract please see paragraph 11 of chapter 3 of this website.
Read more...	Chapter 9: Breaches and the termination of a GP practice contract	Breaches of GP practice contracts, Remedial and Breach Notices and termination of GP Practice Contracts.
1.4 There are a large number of obligations that GP practices take on within a practice contract. NHS England is thus entitled to require GP practices to perform all of the obligations. Thus, for example, the practice is obliged to be open for core hours as defined in the GMS Regulations. Christmas day is excluded from core hours but the practice must be open on Christmas Eve. A practice that fails to provide services to NHS patients on either Christmas Eve would be acting in breach of contract and NHS England would therefore be entitled to take enforcement action against the practice for that breach. 1.5 However NHS England is rarely able to terminate a GP practice for a single breach of contract of that type. The contract sets out a scheme under which NHS England is entitled to respond to breaches of contract in a measured and proportionate way. This scheme requires the contractor to respond appropriately to an alleged breach. The scheme seeks to avoid unnecessary confrontation and to manage the relationship between the contractor and NHS England in a sensible way. However a contractor which does not co-operate with NHS England by responding appropriately to action by NHS England under the contract can find that his, her or its contract is lawfully terminated.
Read more...	Chapter 8: When can fees be charged to a patient by a GP Practice?	When can fees be charged to
a patient by a GP Practice? (Extract)
2. The general prohibition on an NHS GP
Practice charging fees to patients.
3. Medical certificates that a GP practice must provide free of
4. Charges where the GP practice has reasonable doubts as to
whether a patient is on the practice list. 5. Charges permitted by Schedule 5 of the GMS Regulations and Schedule 3 of the PMS
for meeting the requirements of other statutory bodies.
for conducting routine medical examinations.
provided by a specialist GP for private patients in hospitals or a care home.
for emergency treatment of traffic casualties.
for attending a police station.
for preparing medical reports and issuing medical certificates.
for preparing medico-legal reports.
for preparing reports for seat belt purposes, following a traffic accident, a
criminal assault or for fitness to travel.
examinations by GPs.
15. Dispensing
doctors and scheduled drugs.
1.1 NHS services are generally free at the
point of use for patients. However the NHS has always imposed charges for some
healthcare services and there are other functions undertaken by NHS doctors
which are outside their NHS duties and hence attract a fee. It follows that full
legal position is somewhat more nuanced. The general requirement that
services should generally be provided free of charge is set out in section 1(4)
of the National Health Service Act 2006 (“the NHS Act”) which provides:
“The services provided
as part of the health service in England must be free of charge except in so
far as the making and recovery of charges is expressly provided for by or under
any enactment, whenever passed”
1.2 There are a number of areas where Regulations
provide that charges may be imposed for NHS services including:
e) Hospital services for persons who are
not usually ordinarily resident in the UK.
1.3 Primary care services provided under a
GMS[1] or PMS[2]
contract to patients on the practice list or temporary residents are required
to be provided free of charge. The GMS and PMS contracts also provide that GP
practices have a contractual obligation to provide a range of other services to
patients[3]. However GP practices are (almost all) private sectors businesses that have
contracted with NHS England to provide defined primary care services to a
defined group of patients and to provide defined level of emergency medical services
in limited circumstances. If a registered patient or temporary resident[4] seeks primary care services from an
NHS GP practice outside the terms of the contract held by that practice, the
NHS GP practice has no obligation to provide services to that person. However
the GP practice cannot charge for treatment provided outside the GP Practice
contract unless the service falls within a limited categories of specific services.
[1] GMS
stands for “General Medical Services”. It is the default form of agreement for
GP practices. For details of the different types of contracts that a GP
practice can hold please see chapter 3.
[2] PMS
stands for “Personal Medical Services”, a form of GP Practice contract
originally brought in by the National Health Service (Primary Care) Act 1997. For details please see chapter 3.
Please see chapter 7 for details of the range of services that a GMS or PMS
practice is obliged to provide.
Please see chapter 6 for details about how GP practice lists work and the
persons to whom a GP is obliged to provide services.
Read more...	Chapter 7: The services an NHS GP Practice is obliged to provide to patients	The services an NHS GP
Practice is obliged to provide to patients (Extract)
Essential Services within primary care?
3. Who is owed a
duty of “management” by a GP practice? 4. Core hours.
5. Home visits and other
treatment outside the surgery.
7. The duty on GPs to
9. Enhanced
10. Other services that a
GP practice is obliged to provide.
1.1 This chapter seeks
to identify which medical services GP Practices are obliged to provide as part
of NHS funded treatment and where a GP is entitled to refer a patient to
another NHS provider. Section 83 of the National Health Service Act 2006[1] (“the NHS Act”) provides:
Board[2] must,
to the extent that it considers necessary to meet all reasonable requirements,
exercise its powers so as to secure the provision of primary medical services
throughout England”
1.2 “The Board” in the
above section is a reference to the National Health Service Commissioning
Board, known as NHS England. The Board is referred to within this chapter as
NHS England but citation from statutes refer to it as “the Board”. Section
83(1) means that NHS England is under a statutory duty to secure the provision
of primary medical services throughout England. Sections 83(5) and (6)
“(5) Regulations may provide
that services of a prescribed description must, or must not, be regarded as
primary medical services for the purposes of this Act.
(6) Regulations under this section
may in particular describe services by reference to the manner or circumstances
in which they are provided”
1.3 The relevant regulations
under section 83 are the National
Health Service (Primary Medical Services) (Miscellaneous Amendments and
Transitional Provisions) Regulations 2013 (“the 2013 Regulations”). However
several sets of Regulations were made under the statutory predecessors of
section 83[3] which
remain in force to the extent that they have not been amended by the 2013
Regulations. 1.4 The 2013 Regulations make extensive
changes to the National Health Service (General Medical Services Contracts)
Regulations 2004[4] (“the
GMS Regulations) and the National Health Service (Personal Medical Services
Agreements) Regulations 2004 (the “PMS Regulations”). These Regulations define
the contents of GMS and PMS contracts (and have been updated on numerous
occasions since they were first published). There are no Regulations for APMS
contracts but the form of these contracts usually follows the GMS/PMS model,
with amendments made to the model as required.
1.5 The current
definitions of what are and are not “primary medical services” for the purposes
of section 83 are contained within the GMS Regulations. These Regulations define
the services that those delivering primary care within the NHS are obliged to
provide. These definitions take effect as terms of practice contracts with NHS
England held by GP practices. The definitions of primary medical services include:
c) enhanced services; and d) emergency services.
electronic version of the National Health Service Act 2006 on the www.legislation.gov.uk website has not
yet been updated to show all the changes to the 2006 Act made by the Health and
Social Care Act 2012. Hence the present publicly accessible version of section
83 at http://www.legislation.gov.uk/ukpga/2006/41/section/83
still refers to the duty to provide primary care services being a duty resting
on primary care trusts.
the NHS Act 2006 as originally passed this duty rested on primary care trusts. It was transferred to NHS England in April 2013 as a result of amendments made
in the Health and Social Care Act 2012.
Transitional provisions mean that Regulations made under the equivalent of
section 83 in the National Health Service Act 2006 continue to have effect./
electronic version of the National Health Service (General Medical Services)
Regulations 2004 on the www.legislation.gov.uk
website has not yet been updated to show all the changes made by the numerous
amending regulations made since the Regulations were introduced in 2004. The
original Regulations are at http://www.legislation.gov.uk/ssi/2004/115/contents/made
but the wording quoted in this chapter is the version which is current at 1
January 2014 when this chapter has been written. Read more...	Chapter 6: Management of the practice list of patients	Management of the Practice list of patients (Extract)
3. To whom is a GP practice obliged to provide primary care
8. Appeals by patients against decisions to refuse them entry
to a practice list.
9. Introduction to removal of patients from as GMS practice
1.1 GP services are the
building block of NHS services because, other than attendance at an Accident
and Emergency Department of an NHS hospital, the GP is the gateway by which the
vast majority of NHS services are accessed by patients[1]. However the provision of all
medical services to patients only usually occur where the patient seeks those
services from a GP practice where the patient is registered (although GP
practice must provide services to other persons as set out below). There is no
obligation on anyone living in England to register with an NHS GP practice. This is a matter of free choice for each individual. But the patient can only
generally access services by first getting themselves registered with a local
1.2 The legal duty for
the NHS to commission GP services rests on the National Health Service
Commissioning Board, known as “NHS England”. Section 84 of the National Health
Service Act 2006 (“the NHS Act”) provides that NHS England is required to set
up “arrangements” so as to provide primary medical services throughout
England “to the extent that it considers necessary to meet all reasonable
requirements”. 1.3 The
wording of the statutory duty means that there is no absolute legal requirement
on NHS England to ensure that every individual is able to register with a GP
practice which is local to their home. The duty is to set a network of GP services
to meet the reasonable requirements of patients, and what is reasonable
will depend in part on the resources available to NHS England. 1.4 There
are occasions when a person cannot find a GP who is prepared to admit that
person to their list (either as a registered patient or as a temporary
patient). There can be many reasons why an individual patient may find it
difficult to find a place on a GP list of a local practice. There are very
occasional circumstances where all local GP practices are full and have closed
their lists. In such circumstances NHS England will probably have a duty to
secure additional GP services in the area to meet its duty under section 84. However
the more common reason why a person finds difficulty in registering with a GP
practice is because that person has previously been removed from lists of other
GP practices in the area for being violent, offensive or for another
permissible reason. Most NHS areas have a reserve facility to provide GP
services to patients who have been excluded from the lists of other practices. The details of removal and its consequences are explored below.
fact that a patient is having difficulty finding a GP will not usually, of
itself, be sufficient to demonstrate a breach by NHS England of their duty
under section 84. A breach of the section 84 duty would only be established if
NHS England had failed to make a proper assessment of the level of local need
for GP services in an area or had not produced a plan to deliver services to
meet the identified needs. NHS England cannot form a judgment as to whether it
is delivering on its duty to provide services to meet the reasonable
requirements of the local population for GP services unless it has knowledge of
the needs of the population for those services. That knowledge could be based
on a needs assessment or could be judged by the number of practices who are
open to new patients in an area (and the number of registered patients per GP).
1.6 NHS England’s role
is to commission a GP practice to deliver services to NHS patients. Once the
commissioning contract is in place the onus shifts to the relationship between
the GP and the individual patient because a doctor/patient relationship will
only work if there is a measure of trust on both sides. The patient has to
have confidence in the medical practice and, if the patient does not have that
confidence, the statutory scheme allows the patient to leave the practice and
register with another medical practice. However a measure of trust is also
required the other way – namely from the doctor to the patient. This can be a
very delicate area in practice because there are conflicting interests. On the
one hand the NHS ought not to foist a patient on a GP with whom the practice
cannot build any form of therapeutic relationship. On the other hand GPs are
delivering public services and so should have a duty to work with any member of
the public who wishes to access their services. Teachers and social workers
cannot, for example, pick and choose the members of the public to whom they are
obliged to provide public services as part of their occupation (paid for by
taxpayers money). GPs should certainly not be able to react to complaints by
removing a patient from their practice list. 1.7 This chapter
explores the legal rules which apply to doctors admitting patients to their
lists, removing patients from their lists and the powers of NHS England to
force an NHS GP practice to take a patient onto the practice list.
are limited exceptions to this approach, particularly for services for those
suffering from Sexually Transmitted Diseases. STI clinics can be accessed by
patients without a referral from their GP.
Read more...	Chapter 5: GPs and the law on commissioning NHS services	GPs and the law
on commissioning NHS services (Extract).
is NHS commissioning?
legal duties on CCGs in the commissioning process.
legal duties on CCGs relevant to the commissioning process.
outputs from the commissioning process.
that a CCG are legally required to commission.
CCG Healthcare Needs Assessment and joint strategic needs assessments.
CCG Annual Commissioning Plan.
development of CCG Commissioning Policies.
Policies and pick-up funding for clinical trials.
Individual Funding Request process.
year service developments.
and patient involvement in the commissioning process.
1.1 There are many definitions of
the word “commissioning”. The NHS Improvements Website describes commissioning the achievement of high
quality and value-for-money services for the NHS. It states:
“Commissioning is a cycle of activities that includes
assessing the needs of a population; analysing 'gaps'; setting priorities and
developing commissioning strategies; influencing the market to best secure
services and monitoring and evaluating outcomes. In other words, it involves
buying in services from a range of health service providers (including GPs, dentists,
community pharmacists, NHS and private hospitals, and voluntary sector
organisations) to meet the health needs of local people, and monitoring how
well they are being delivered. Commissioning is an on-going process that
applies to all services, whether they are provided by the local authority, NHS,
other public agencies, or by the independent sector”
1.2 The placing of contracts with a
provider is thus the final act of the procurement stage of the commissioning
process. The contract is the last step in a long sequence of events that ought
to take place before the decision is made by the CCG that the NHS ought to
contract for any specific service. However commissioning is a continuing
process because, after the contract has been placed, the commissioner is then
responsible for monitoring the performance of the contractor.
1.3 Hence commissioning process is
thus complex. This chapter describes some of the legal challenges which arise
in the commissioning process. It also contains an outline as to how NHS bodies
are able to make lawful commissioning decisions. The model will not be
followed by every CCG in every case, but the steps which are set out below are
the essential building blocks of a lawful commissioning process.
1.4 Commissioning is challenging
for GPs who want to do the best for their patients because the demand for
clinically effective healthcare treatment for individual patients (suffering
from both common and rare medical conditions) vastly exceeds the ability of the
NHS to fund such treatment. NHS bodies have a finite budgets and this
means that difficult choices have to be made about how services are organised
and structured and, in the end, which drugs and other treatments can and cannot
be provided to patients suffering from both common and rare conditions. Once
it is recognised that choices have to be made as to which treatments the NHS
can afford to provide to patients, it is a legal necessity that the process of
making those policy choices should be transparent and rational.
1.5 Section 1 of the National
Health Service Act 2006 imposes a duty on the Secretary of State to continue
the promotion of “a comprehensive health service”. Some patients
and clinicians rely on this section to argue that the NHS is obliged to provide
them with a comprehensive service and so argue that rationing NHS services is
inherently unlawful. However inevitably it is not that straightforward. Section
1(1) of the NHS Act provides:
“The Secretary of State must continue the promotion in
England of a comprehensive health service designed to secure improvement—
the physical and mental health of the people of England, and
the prevention, diagnosis and treatment of physical and mental illness”
1.6 The Court of Appeal decided in Coughlan
v North and East Devon Health Authority that the “duty of promotion” on the Secretary of
State was not a duty to provide a comprehensive health service. The Court
accepted that budget considerations may mean that the Secretary of State could
never in fact provide a service that was truly comprehensive, in that it
provided services to meet all healthcare needs. The court decided that the
section meant the Secretary of State was required to use his or her powers to
focus on providing as comprehensive a service as the NHS budget would permit,
recognising that the NHS may never get to that state of healthcare nirvana.
1.7 In Coughlan the Court of
Appeal was considering the wording of section 1(1) in the NHS Act 1977. The
only change since that time is that is the Health and Social Care Act 2012 changed
the words in sub-section (b) from “illness” to “physical and mental
illness”. “Illness” already had a wide definition in section
275 of the NHS Act which states that “includes mental disorder within the
meaning of the Mental Health Act 1983 and any injury or disability requiring
medical or dental treatment or nursing”. This change accordingly
appears to make no difference at all, save that it emphasises that the NHS has
a duty to provide mental health services as well as services to meet physical
1.8 So what is the legal effect, if
any, of the duty on the Secretary of State to “continue the promotion in
England of a comprehensive health service”? The practical answer is
that this section has little if any legal effect because it is difficult to
imagine any set of circumstances in which the decision is required to be
different because the Secretary of State has the section 1 duty. There
has been no court case concerning reorganisation of NHS services or access to
NHS funded medical a treatment which (and there have been many) which, as far
as I am aware, has criticised the Secretary of State for failing to discharge
the section 1 duty.
1.9 The Court of Appeal in R (on
the application of YA) v Secretary of State for Health noted that the Secretary of State has a duty to
continue the promotion in England of a comprehensive health service. The court
“His duty under section 3 is subject to the qualification
that his obligation is limited to providing the services identified to the
extent that he considers that they are necessary to meet all reasonable
requirements. He does not automatically have to meet all the requirements and
in certain circumstances he can exercise his judgment and legitimately decline
to provide them. In exercising that judgment he is entitled to take into
account the resources available to him and the demands on those resources”
1.10 It is therefore clear that the
Secretary of State does not have a statutory duty to deliver a
comprehensive health service. NHS commissioners are required to remain
focused on the fact that the Secretary of State has a duty to promote the delivering
of a comprehensive health service remains the ultimate aim of the NHS even if
that is unachievable in practice. 1.11 The real world of restricted
budgets (which is fully recognised by the courts) means that lawful
commissioning needs to focus on how decisions are made. Commissioning
is concerned with the process by which decisions are made in the NHS because,
whenever a decision is made, there will be winners and losers. There will be
patients and clinicians who secure the funds for the services they have been
seeking and there will be those that are disappointed (and often angry) and
feel that the wrong decision has been taken. The focus of this chapter will
therefore be on the process of taking decisions and the challenges of ensuring
that the decision making process is legally robust.
1.12 The NHS has a Constitution to
which all NHS bodies, including Clinical commissioning Groups (“CCGs”) are
required to “have regard to the NHS Constitution”: see section 2 of the Health Act 2009. The duty to “have regard” to the NHS
Constitution during a decision making process means that the CCG is obliged to
understand the terms of the NHS Constitution and act in accordance with the
principles set out in that document unless it has a very good reason to depart
from those principles. The relevant part of the NHS Constitution on commissioning provides:
“The NHS commits to make decisions in a clear and
transparent way, so that patients and the public can understand how services
are planned and delivered.”
1.13 Hence, throughout the
commissioning process, there is a need for CCGs to act in a clear and
transparent way, and to ensure that they can defend their reasoning at all
times within the commissioning decision making process. It also ties in to the
central importance of public participation in the commissioning process which
is considered at chapter 11 below.
Read more...	Chapter 4 - Managing conflicts of interest for GPs	Managing
conflicts of interest for GPs (Extract).
introduction to the issues raised by conflicts of interest.
Nolan Principles.
is an “interest”?
of Interests by a CCG.
duty on CCGs to make arrangements to manage conflicts of interest.
arrangements for managing conflicts of interest are suggested by the CCG Model
rules are necessary to ensure that an interest does not affect and is not seen to
affect the integrity of the decision making process?
legal consequences where decisions are made in breach of the rules about
to the issues raised by conflicts of interest.
1.1 Managing actual or potential
conflicts of interest is essential for every professional. General
Practitioners are in no different position to lawyers, accountants or many
other professionals who ply their professional trade for the benefit of clients
but, to a greater or lesser extent, are not paid by clients but by a third
party (and often the government). No professional can avoid conflicts of
interest, every professional must be acutely aware of them, understand how
differing interests are seen by others and act in a professional manner to
manage these interests properly. This is far from easy for all professionals
but the present NHS structures have created particularly difficult issues
around conflict of interests for GPs.
1.2 NHS England has published Guidance
concerning the management of conflicts of interest. It explains their understanding
of a conflict of interest as follows:
“A conflict of interest occurs where an individual’s ability to exercise
judgement or act in one role is or could be impaired or otherwise influenced by
his or her involvement in another role or relationship. The individual does not
need to exploit his or her position or obtain an actual benefit, financial or
otherwise. A potential for competing interests and/or a perception of impaired
judgement or undue influence can also be a conflict of interest”
1.3 Helpful guidance on identifying
what is meant by a conflict of interest is also set out in a Paper
prepared by the NHS Confederation and the Royal College of General
Practitioners dated September 2011. This defined a conflict of interest as
“A conflict of interest can be defined as: “a set of conditions in which
professional judgement concerning a primary interest (such as patients’ welfare
or the validity of research) tends to be unduly influenced by a secondary
interest (such as financial gain)” or a situation in which “one’s ability to exercise judgement in one
role is impaired by one’s obligation in another”.
For a GP or other clinical commissioner, therefore, a conflict of interest
may arise when their own judgment as an NHS commissioner could be, or be
perceived to be, influenced and impaired by their own concerns and obligations
as a healthcare provider or as a member of a particular peer, professional or
special interest group, or those of a close family member”
1.4 It is impossible to describe
and provide guidance about every single all factual situation which might give
rise to a conflict of interest for GPs in practice. The arrangements which
have been set up the government which involve GPs in commissioning will inevitably
involve GPs in many situations where they potentially have more than one
interest in a proposed decision. However it is important to remember that
conflicts of interest can never be eliminated. They existed for GPs before the
creation of CCGs (in particular under the old fundholding system) are an
inevitable feature of all professional practice. 1.5 Hence the key requirements for
GPs are to identify where conflicts arise and to make sure that these are
properly disclosed and registered, and then managed in accordance the
arrangements that CCGs have put in place are the proper disclosure and
management of actual and potential conflicts. 1.6 Every GP Practice which holds
an NHS practice contract is required to be a member of the local Clinical
Commissioning Group (“CCG”) : See section 14A(1) of the NHS Act. The
constitution of the CCG will define how members of a practice can become
involved in the workings of the CCG, stand for election to its committees and
otherwise become involved in its work. There is an obvious potential for
conflicts of interest where a GP practice, which is a member of a CCG, bids for
a contract where the NHS commissioner is the local CCG.
1.7 However there are many other
circumstances where a GP, acting perfectly properly, may become involved in a
situation where a conflict of interest or potential conflict of interest
arises. Many GPs are also shareholders, directors, employees or partners in medical
or social care businesses that provide medical services to NHS patients or
provide primary medical services to such businesses. These businesses may have
contracts with NHS commissioners. There is a potential conflict of interest if
any of these businesses tender for a contract with the CCG of which the GP is a
1.8 There can be both legal and
professional consequences for a GP who fails to recognise and properly manage a
conflict of interest. However managing conflicts of interest is part of the
professional duties of a GP as the Royal College of GPs and NHS Confederation
observed in their Paper
“.. seeking to eliminate conflicts of interest
completely is unlikely to be possible or desirable”
1.9 Issues around conflicts of
interest do not usually arise with general practice contracts (i.e. GMS, PMS
and APMS contracts) because those contracts are awarded and managed by NHS
England and not by the local CCG. However local GP practices, either
individually or through consortia, are in a prime position to contract for the
delivery of a large number of services in addition to those governed by GMS,
PMS and APMS contracts. These are very often contracts which are let by the
local CCG, whose members are the local GP practices. The transfer of
NHS services out of hospital settings and into the community over the coming
years means that the volume of such contracts is certain to increase and hence
managing the actual and potential conflicts of interest inherent in such
arrangements will become a problem that GPs, CCGs and those who advise them
will need to focus on with particular care.
1.10 The legal obligations on
practising doctors concerning
conflicts of interest arise in a number of different ways. There are
provisions of the GMC Code about managing conflicts of interest (which are set
out below). There are also provisions
in both the NHS Act (as amended by the Health and Social Care 2012) and the in National Health Service
(Procurement, Patient Choice and Competition) (No. 2)
(“the 2013 Regulations”) around managing conflicts of interest. Rules for
managing conflicts exist within CCG constitutions and standing orders and guidance on this subject has also been given by both
NHS England and Monitor. Much of this Guidance from different bodies covers
the same grounds. 1.11 It follows that all GPs who are
working the NHS must have a working understanding of the concepts that lie
behind managing conflicts of interest and have a legal and professional duty to
ensure that they know and abide by the national and local rules to manage
potential conflicts. Obligations of openness and proper management of
conflicts of interest have been imposed on elected councillors and local
government officers for many years. These rules are, to a large extent, an inevitable
consequence of their roles within a tax payer funded public service. The rules
referred in this chapter impose similar obligations on those working in the NHS. Whilst GPs may resent the level of openness that properly managing conflicts
inherently entails, doctors (and CCG staff) have to take difficult decisions
about how tax-payers monies are spent and what services are received by NHS
patients. Patients pay the taxes that fund the service. The openness about
decision making required by the present arrangements is part of the system
under which those who make public service decisions are accountable to their
paymasters for the decisions that are made.
Read more...	Chapter 3 - GPs and Practice Contracts with NHS England	GPs and Practice Contracts with NHS England (Extract). This chapter
1. Background to GP
NHS Act 2006 provides for the different types of GP practice contract.
4. Details of the different
types of GP commissioning contracts including:
· The present status of former 1997 pilot
scheme contracts (as varied in 2004)
5. The Legal relationship between the
parties to a GP contract and the NHS commissioner.
6. The legal relationships
between a GP and a primary care practice.
7. The distinctions between
NHS Contracts and legally binding contracts.
8. Resolving disputes before
a primary care contract is signed.
9. The NHS Disputes
Resolution Procedure. 10. Variation and updating of GMS and PMS Contracts.
11. Entire Agreement clauses and exclusion of prior
representations clauses.
1 Background 1.1 Unlike doctors working in
hospitals, General Practitioners have never been required to be employees of
the NHS. General practices operated as private sector businesses prior to
World War II, with many patients covered by insurance schemes. As a result the
British Medical Association rejected the government’s original proposal that
GPs should become local authority employees and argued that they should remain
as self-employed individuals, contracting into the new NHS as required. This
reality was accepted by the Minister for Health, Rt. Hon Aneurin Bevan, MP, and thus when the NHS was set up in 1949 (as a result of the
National Health Service Act 1946) general practices continued without the
doctors being required to become NHS employees. GPs remained as self-employed
professionals and were originally paid a fee by the NHS for every patient on
their practice list.
1.2 Although there have been
various experiments with directly employed GPs working for the NHS in general
practice operated by NHS Trusts, the vast majority of GP practices are not
staffed by doctors who are employees of the NHS. Increasingly however there can
be a distinction between the GPs who provide professional services to NHS
patients and the individuals who own the medical practices within which those
services are delivered. 2 GP
contracting – a brief history
2.1 Section 29 of the National Health
Service Act 1977 provided that Health Authorities were required to “arrange as
respects their area with medical practitioners to provide personal medical
services for all persons in the area who wish to take advantage of the
arrangements”. Thus, under the NHS 1977 Act (and the NHS Act 1946 which
preceded it), GP practises were licensed by the NHS and were paid for treating
NHS patients under a statutory scheme. The terms of service for GPs were set
out in Regulations and the payment scheme was governed by Directions made by
the Secretary of State. This scheme was known as “General Medical Services”
and, at the time, was the only mechanism under which GPs could provide primary
care services for NHS patients.
2.2 In 1991 the Conservative
government created the division between “purchasers” and “providers” in the
NHS. The legislation which brought this about was the National Health Service and Community Care Act 1990. It created two models of commissioning – one
based on health authorities, and the other based on general practice. General
practices were encouraged to become commissioners through a route known as
“fundholding”. This meant that the GP practice held the budget that was used
to commission secondary care for the patients of the practice.
2.3 Under GP fundholding GPs held
real budgets with which they purchased primarily non-urgent elective and
community care for patients; they had the right to keep any savings and had the
freedom to deliver new services. The aim was to give GPs a financial incentive
to manage costs and to apply some competitive pressure to hospital providers. Some
GP practices came together in consortia, creating larger organisations to pool
financial risk and share resources. From 1994 the total purchasing pilot
scheme (TPP) allowed general practices – either individually or in groups – to
commission all services for their patients, though most were highly selective
in what they chose to purchase. TPPs acted as sub-committees of health
authorities and used an indicative, rather than a real, budget. However the
payment to the GPs for their own work continued to be under the general
statutory scheme. Section 29(4) provided somewhat cryptically that payment to a
“… shall not, except in special circumstances, consist
wholly or mainly of a fixed salary which has no reference to the number of
patients for whom he has undertaken to provide such services”
2.4 The details of the payment to
GPs was set out in the annual “Statement of Fees and Allowances” (“SFE”). This
is a Direction made by the Secretary of State every year which sets out the
sums that GP practices are entitled to be paid for every aspect of their work. The 2013 SFE can be accessed here.
2.5 The Labour government abolished
GP fundholding in 1997 but retained the purchaser/provider split. However just before the 1997 general election Parliament
passed the National Health Service (Primary Care) Act 1997. This introduced a
new form of “arrangement” for primary care contracting called a “personal
medical services” (“PMS”) contract. The original PMS agreements were pilot
agreements which were only designed to last for a limited period. There was
no standard PMS contract because the idea was to allow local health authorities
to be flexible in agreeing new ways of working with innovative GPs. A doctor
who provided GP services to NHS patients under a PMS agreement was not
permitted to deliver General Medical Services.
2.6 The 1997 Act brought in powers
to amend the NHS Act 1977 to allow Health Authorities to enter into permanent
PMS contracts. However that power was not implemented until March 2004. 2.7 The transition from pilot
agreements to PDS agreements was not a straightforward process, the details of
which are the subject of a present case before the Court of Appeal (Pitalia
v NHS England which is due to be heard in early 2014). However by 2004 the
government had decided that all GP practices should have contracts with their
local NHS commissioners (who were Primary Care Trusts at that stage). This
signalled an end to GPs being paid under a statutory scheme. It follows that
the primary legal relationship between the NHS commissioner and the GP ceased
to be based on statutory duties and became a contractual relationship. Read more...	Chapter 2 - NHS bodies roles and functions	A brief description of the role of the different
public bodies within the NHS.
1. The NHS is
composed of a large number of public bodies, all of which have different
functions and on occasions overlapping responsibilities. It is necessary to
have some understanding of the roles and responsibilities of the different
bodies in order to understand where general practice fits into structures of
2. NHS bodies can
broadly be divided into 3 types, namely:
of NHS services;
b. Providers of
NHS services; and
c. Regulators,
namely public bodies which supervise the performance of those individuals and
public bodies who commission or provide NHS services and body that oversee the
performance of NHS bodies.
3. Some NHS
bodies perform more than one function. Hence, for example, NHS England is both
a commissioner and a regulator. The Secretary of State sits at the apex of the
NHS. The Secretary of State is a cabinet minister and a member of parliament,
usually an elected MP. The present occupant of the office is Rt. Hon Jeremy
Hunt MP. The Secretary of State has overall political responsibility for the
NHS and plays a key strategic role, particularly by setting the Annual Mandate
for NHS England. However his operational legal role has been substantially
diminished by the Health and Social Care Act 2012.
commissioners in the NHS are: a) NHS England: NHS England is the “trading
name” of the National Health Service Commissioning Board. This body was
created by the Health and Social Care Act 2012. It licences and, to an extent,
manages, Clinical Commissioning Groups. However NHS England is also a
commissioner of a wide range of specialist NHS services, including prison
health services, medical services for the armed forces and a wide range of
specialised and tertiary acute services. NHS England commissions services for
patients with rare conditions and also commissions primary care medical and
dental services. This means that all GP practice contracts are between NHS
England and the local GP provider. Detailed arrangements for NHS England are
set out in Schedule 1 to the Health and Social Care Act
Commissioning Groups: These are local corporate public bodies created by the Health and Social Care Act 2012. The members of a CCG are the
local general practices in the CCG area who hold NHS commissioning contracts
with NHS England. CCGs substantially replaced primary care trusts by taking on
the commissioning of a range of acute and community NHS services (other than
primary care, dental care and specialist services) for the patients for which
the CCG has responsibility. The CCG has a constitution and a Board, which is
partly elected by the local GPs, and partly consists of other stakeholders in
the local NHS. Detailed arrangements for CCGs are set out in Schedule 2 to the Health and Social Care Act
Social Services Authorities: The Health and Social Care Act 2012 transferred responsibility for
public health commissioning from primary care trusts to the local authorities. In practice this means that commissioning public health services is the
responsibility of unitary local authorities or, in a case where there are 2
tiers of local authority, the county council.
of NHS services.
providers of NHS services are:
practices: Almost all GP practices are private sector businesses which are owned by GPs
which contract with NHS England to provide primary care services to NHS
patients across one or more practice areas. A GP practice can be owned by a
single GP, a partnership of GPs, a partnership consisting of GPs and other
approved persons or by a medical company. More details of the types of
organisations that can hold GP contracts can be found here;
practices: Almost all NHS Dental practices are private sector businesses which are owned
by dentists which contract with NHS England to provide primary care services to
NHS patients across one or more practice areas. Largely same restrictions on ownership
apply to dentists as apply to GP practices;
c. NHS Trusts: These are NHS bodies created
under Chapter 3 of Part 2 of the NHS Act 2006. NHS Trusts enter into acute
services contracts with CCGs to provide a wide range of community, mental
health and hospital services to patients. The present plan of the government
is that all NHS Trusts should become NHS Foundation Trusts or be taken over by
an NHS Foundation Trust by 2016. The Secretary of State has the power to issue
Directions to an NHS Trust under section 8 of the NHS Act which, if lawfully
made, imposes specific legal obligations on NHS Trusts to do things or provide
services, or to cease to do something or cease to provide a service as
specified in the Direction;
d) NHS
Foundation Trusts: These are public benefit corporations under Chapter 5 of Part 2 of the NHS Act 2006. NHS Foundation Trusts have Members and Governors, as well as a Board of
Directors. NHS Foundation Trusts are accountable to a regulator, known as
Monitor and are accountable to their members. The Secretary of State has no
power to issue Directions to an NHS Foundation Trust;
e) Special
These are NHS bodies that perform particular specialist functions within the
NHS such as NHS Blood and Transplant which co-ordinates the supply of
blood and organ transplantation services for the NHS;
6. The main
bodies that regulate the performance of services by NHS bodies and have an
interest in the way that NHS bodies are managed are as follows:
Care Quality Commission: The CQC is the statutory body with responsibility for ensuring
that hospitals,
care homes, dental and GP surgeries, and all other care services in England
provide people with safe, effective, compassionate and high-quality care, and
to encourage them to make improvements. The CQC inspects and reports on all
providers of social and health care in England, covering both the state and
b) Monitor: Monitor was
previously known as the Independent Regulator for NHS Foundation Trusts. However its role was changed by Part 3 of the Health
and Social Care Act 2012. Its new role is to “protect and promote the interests
of patients” by attempting to ensure that the whole health sector works for
their benefit. It is, in effect, the competition regulator for the health
market and so now has interests which extend far beyond NHS Foundation Trusts. It exercises a range of powers granted by Parliament which include setting and
enforcing a framework of rules for providers and commissioners, implemented in
part through licences issued to NHS-funded providers;
England: NHS England has a regulatory function in respect of
CCGs. It licences CCGs and can step in if a CCG is not performing properly;
d) Healthwatch: Healthwatch is the latest in a
long line of public bodies which are designed to feed the voice of the patient
into the NHS. Previous bodies include Community Health Councils and PALS. Healthwatch England is a new public body set up by the 2012 Act to act as a
national champion of patients’ interests. There are now 152 local healthwatch
groups who are supposed to champion the interests of patients in their local
NHS. It is too early to tell whether local healthwatch groups are likely to
have any real impact on local service delivery.
e) Health Overview
and Scrutiny Committees: These are committees made up of members of the local social
services authority. Their role is to “review and scrutinise any matter
relating to the planning, provision and operation of the health service(5) in
its area: see Part 4 of the Local Authority (Public
Health, Health and Wellbeing Boards and Health Scrutiny) Regulations 2013. The
committee must be consulted about any “substantial development of the health
service in the area of a local authority” and, if they consider that the
development is not “in the interests of the health service in its area”, it can
refer the decision to the Secretary of State who then becomes the final
f) Health and
Wellbeing Boards: The Health and Social Care Act 2012 establishes health and wellbeing boards as
committee of the local authority. It should be a forum where key leaders from
the health and care system work together to improve the health and wellbeing of
their local population and reduce health inequalities, in particular by
facilitating better working between health and social care services. Health
and wellbeing board members ought to collaborate to understand their local
community's needs, agree priorities and encourage commissioners to work in a
more joined-up way. As a result, patients and the public should experience more
joined-up services from the NHS and local councils in the future.
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