5 Improving Infrastructure And Reducing Risk
- The risks associated with certain aspects of independent contracting will be significantly reduced.
- GP Owned Premises: new interest-free sustainability loans will be made available, supported by additional £30 million investment over the next three years.
- GP Leased Premises: there will be a planned transition to NHS Boards leasing premises from private landlords
- New information sharing agreement, reducing risk to GP contractors.
As independent contractors, many GP practices carry the responsibility for providing staff and infrastructure to support GPs and services to patients. With this responsibility can come risk which can include the risk of changes in funding. As outlined in chapter three, one of the overarching aims of reforming practice funding is to increase practice stability and reduce risk. As outlined in chapter four, proposals for the NHS Boards to largely employ the expanding primary care multi-disciplinary team are specifically intended to avoid increasing the clinical and administrative risks of being an employer.
This chapter describes new measures to improve infrastructure and reduce risk in areas such as ownership of premises, IT and information sharing.
Practice premises are increasingly perceived as an unwanted liability by potential GP partners; and this has become a barrier to recruitment, retention and retirement.
The Scottish Government and SGPC recognise and support a long-term shift that gradually moves towards a model which does not presume GPs own their practice premises.
To this end the Scottish Government and the SGPC have agreed a National Code of Practice for GP Premises (“the Code”) which sets out how the Scottish Government will support a shift, over 25 years, to a new model in which GPs will no longer be expected to provide their own premises. The contract offer proposes that from 1 April 2018, the Code will be introduced and revised Premises Directions will take effect. The Code sets out how the Scottish Government will achieve a significant transfer away from GPs of the risks of providing premises.
To enable this transfer of risk, the Scottish Government will make available assistance of up to £30 million by 2021 (£10 million per year from 2018) to GPs with premises related liabilities. This will be through the establishment of a GP Premises Sustainability Fund. This represents a 24% increase in funding for supporting GPs with premises (compared to 2015/16, the latest available figures).
GP Owned Premises
The Code sets out the measures the Scottish Government will provide to assist GPs who own their premises. These measures include interest-free secured loans, known as GP Sustainability Loans, to be resourced through the new GP Premises Sustainability Fund.
These GP Sustainability Loans will be made available to every GP contractor who owns their premises by 31 March 2023. The loans will help stabilise general practice as a whole. They will allow partners to release capital without destabilising their practice, reduce the up-front cost of becoming a GP partner, and make general practice more financially rewarding. The loans will encourage GPs to become partners in practices which own their premises.
GP Sustainability Loans
All GP contractors who own their premises will be eligible for an interest-free loan, including those in negative equity.
The loans will be for an amount of up to 20% of the Existing-Use Value of the premises and they will be secured against the premises.
Loans will be funded from the GP Premises Sustainability Fund.
NHS Boards will have the power to top-up the amount of the loans where they decide that there are exceptional circumstances.
The loans will be repayable if the premises are sold or are no longer used by the GP contractor for the provision of general medical services under a contract with an NHS Board.
The loan will have no effect on Notional Rent or borrowing cost payments. There will be no abatements due to a loan.
A system for prioritising applications will be put in place to ensure that assistance is given first to those who need it most. However, all GP contractors who own their premises will be eligible to receive a GP Sustainability Loan by 31 March 2023.
The Scottish Government envisages that once the first cycle of GP Sustainability Loans is complete (2023) a further five yearl cycle will begin to further reduce the risk to GP practices which own their premises. The Scottish Government intends that these five year cycles of investment will continue until the transition to the new model where GPs no longer own their premises is complete (by 2043).
More information on GP Sustainability Loans can be found in the National Code of Practice for GP Premises.
GP Leased Premises
The Scottish Government’s long term strategy is that no GP contractor will need to enter a lease with a private landlord for GP practice premises. NHS Boards will gradually take on the responsibility from GP contractors for negotiating and entering into leases with private landlords and the subsequent obligations for maintaining the premises. NHS Boards will ensure that GP contractors are provided with fit-for-purpose accommodation which complies with the standards set by the Premises Directions.
GP contractors who wish to continue to provide their own accommodation will be free to do so. They will continue to be eligible to receive rent re-imbursements under premises directions.
NHS Boards will support GP contractors who currently lease premises from private landlords. The Code sets out what GP contractors who lease their premises need to do to ensure that their NHS Board takes over the responsibility of providing their premises.
There are three ways in which NHS Boards can take on the responsibility of providing a GP contractor with practice premises. These are:
- negotiating a new lease for the GP contractor’s current premises, with the NHS Board as the tenant
- accepting assignation of the GP contractor’s current lease
- providing alternative accommodation for the GP contractor when its current lease expires
If a lease expires before 1 April 2023, the most likely course of action is for the NHS Board to negotiate a new lease or provide alternative accommodation.
If the lease expires after 1 April 2023, NHS Boards will take on the existing lease from GPs where:
- The practice has ensured that its premises are suitable for the delivery of primary care services and are sufficient to meet the reasonable needs of its patients
- The practice has met its statutory obligations regarding the premises
- The practice has provided all relevant information to its NHS Board
- The practice has given sufficient notice to its NHS Board of its need for assistance
- The practice has registered the lease with the NHS Board
- The practice has the agreement of the landlord to the assignation of the lease (and the other necessary conditions)
- The practice has complied with its obligations under its existing lease
- The rent represents value for money
All premises used to provide GMS will be surveyed in 2018/19. This will provide the data which NHS Boards will require for their premises plans. Contractors will be contacted by the surveyor appointed by the Scottish Government to arrange a survey of their premises at a convenient time. This is essential if NHS Boards are to effectively support practices with premises issues in the future.
Risk of being an employer
Under the new contract GPs will be not be exposed to increased risks from being an employer as the joint intention of the negotiating parties is for the increased primary care team to be employed by NHS Boards and deployed in practices – details are outlined in chapter four.
Under Phase 2 of the funding changes it is proposed that practice expenses will be directly
re-imbursed. This will include staff costs and those associated with staff sickness, maternity, paternity and adoption leave, including staff cover for long-term sickness and maternity leave.
GP Clinical It Systems
NHS Boards have commissioned a procurement competition to provide the next generation of GP clinical IT systems for GPs in Scotland. This is being undertaken by NHS National Services Scotland.
The new systems will be more intuitive and user friendly. They will be quicker and more efficient, with increased functionality. They will be underpinned by strong service levels and performance management, with clear lines of responsibility and accountability, providing, overall, a more professional GP IT Service.
All GP practices will transition to the new systems by 2020. GPs will continue to have the right to choose a clinical IT system from those which have been approved by the Scottish Government.
The following groups will provide governance for Primary and Community Care eHealth:
Primary and community care e-health governance
GP IT Committee
Under the new contract, NHS Boards will remain responsible for providing integrated Information Management and Technology ( IM&T) systems and telecommunications links within the NHS. However the Scottish Government will set national standards which will be developed with the assistance of a new GP IT Committee. The SGPC and RCGP will form this committee along with GPs and managers expert in information technology. These standards will be agreed between the Scottish Government and the SGPC.
The eHealth Strategic Assurance Board
The eHealth Strategic Assurance Board will provide strategic direction to the development of digital technology in NHSScotland and act as the senior governance group for the escalation of issues.
The Community Care Portfolio Management Group
The Community Care Portfolio Management Group will provide direction to the development of digital technology within the community and primary care sectors in line with the overall strategy set by the eHealth Strategic Assurance Board. It will also deal first with issues escalated to it by the governance boards of individual projects. It will escalate issues to the eHealth Strategic Assurance Board where appropriate.
Primary Care Contracts and Service Management Board
The Primary Care Contracts and Service Management Board will review the performance, financial status, and key issues and risks of the GP clinical IT system. This group will play the same role for the Community IT clinical system which is in an early stage of procurement.
The proposed contract will set out the roles and responsibilities of GP contractors and NHS Boards in relation to information held in GP patient records. The contract will support adherence to the Data Protection Act 1998 and help prepare GP contractors and NHS Boards for the new General Data Protection Regulations (due to come into force in May 2018).
The new contractual provisions will reduce the risk to GP contractors of being data controllers. The contract will recognise that contractors are not the sole data controllers of the GP patient record but are joint data controllers along with their contracting NHS Board. The contract will clarify the limits of GP contractors’ responsibilities. GP contractors will not be exposed to liabilities beyond their effective control.
The work of identifying the roles and responsibilities of GP contractors and NHS Boards has been carried out with the assistance of the Information Commissioner’s Office in Scotland, and in collaboration with stakeholders who have provided expert guidance as well as practical experience of managing patient data. This includes the Caldicott Guardians Forum, SGPC, RCGP, Central Legal Office, NHS National Service Scotland, and relevant teams within the Scottish Government including the E-health Division and the Chief Medical Officer. The proposed new provisions are also consistent with the General Medical Council ( GMC) Confidentiality guidance.