Primary Medical Care Policy And Guidance Manual (PGM) (v3)
Primary Medical CarePolicy and GuidanceManual (PGM) (v3)1 Page
Primary Medical Care Policy and Guidance Manual (PGM)Version number: 3.0First published: 12 January 2016 (as Policy Book for Primary Medical Services)First update: 09 November 2017Current update: February 2021Changes from version 2 have been highlighted in yellowPrepared by: Gary WilliamsClassification: OFFICIALThis information can be made available in alternative formats,such as easy read or large print, and may be available inalternative languages, upon request. Please contact the PrimaryCare Commissioning Team on england.primarycareops@nhs.net
ContentsPart A – Excellent Commissioning and Partnership Working . 151 Introduction. 161.1Introduction . 161.2Structure. 171.3Transitional arrangements. 172 Abbreviations and Acronyms . 192.1Abbreviations and Acronyms . 193 Commissioning Described . 223.1Commissioning Arrangements . 223.2Introduction . 223.3Background . 223.4Co-commissioning Models: . 233.5Greater involvement in primary care co-commissioning: . 233.6Joint commissioning arrangements: . 233.7Delegated commissioning arrangements: . 243.8Co-Commissioning and Primary Care Policies: . 253.9Primary Care Networks . 264 General Duties of NHS England (including addressing healthinequalities). 284.1Introduction . 284.2Equality and Health Inequalities Duties . 334.3The Regard Duties . 424.4The Promote Duties . 444.5The View to Duties . 454.6The Involvement Duty . 474.7Duty to Act Fairly & Reasonably . 494.8The Duty to Obtain Advice . 504.9The Duty to Exercise Functions Effectively . 514.10 The Duty Not to Prefer One Type of Provider . 515 Working Together – Commissioning and Regulating . 59
5.1Introduction . 595.2Background . 595.3Implementation . 605.4Existing Good Practice and Interim principles . 605.5Why: . 615.6The ambition being delivered: . 62Part B – General Contract Management . 631 Contracts Described . 641.1 Comparison of Contract Types (Standard Medical and as part of models i.e.MCPs / PACS) . 641.2Urgent Contracts . 691.3Public Involvement . 711.4Annex 1 Persons Eligible to Enter into a GMS Contract. 731.5Annex 2 Persons eligible to enter into a PMS Agreement . 821.6Annex 3 Persons Eligible to Enter into an APMS Contract . 901.7Annex 4 Primary Care Support Services Notifications . 952 Assurance Framework Contract Review . 962.1Introduction . 962.2Background . 972.3Contract Review . 972.4Setting and Monitoring Key Performance Indicators . 992.5Using data and information effectively. 992.6Practice Visit – Best Practice . 1053 Managing Patient Lists. 1093.1Introduction . 1093.2PART A: Managing Patient Assignments . 1093.3Part B1: General List Maintenance for Primary Medical Services . 1193.4Part B2: Targeted List Maintenance for Primary Medical Services . 1313.5PART C: MANAGING CLOSED LISTS . 1384 GP Patient Registration Standard Operating Principles forPrimary Medical Care. 143
4.1Policy statement . 1434.2Aims . 1434.3Context . 1434.4Who can register for free primary care services? . 1444.5Immediately necessary treatment. 1464.6Determining if the patient lives in the practice area . 1464.7Access to registration . 1474.8New patient health checks . 1474.9Requesting documentary information from patients . 1474.10 Refusing Registration . 1494.11 Patients who are temporarily resident in a specialist hospital away from home1504.12 Registering children. 1504.13 Registration of those previously registered with Defence Medical Services (DMS)and Priority NHS care for Veterans. 1534.14 Persons released from prisons, immigration centres or children’s secure facilities1544.15 Temporary Residents . 1544.16 Sensitive Patient Registrations . 1554.17 Appendix A; Draft Framework for a Memorandum of Understanding between GPPractice and Private provider (MH facility) . 1555 Temporary suspension to patient registration . 1585.1Formal List Closure . 1585.2‘Informal’ or ‘Temporary’ List closure. 1585.3Overview of current activity . 1595.4Facts/Principles . 1595.5Issues to be taken into consideration . 1605.6Process to be adopted . 1625.7Appendix A; GMS paragraph 21 of Part 2 of Schedule 3 . 1646 Special Allocation Scheme (SAS) . 1656.1Executive Summary and Key Messages . 1656.2Introduction . 1686.3Commissioning a robust SAS . 171
6.4 When to request a removal of this type under the Regulations (Information oneligibility for Commissioners and Providers) . 1716.5 Working with Primary Care Support England (PCSE) (delivered on behalf of NHSEngland by Capita) . 1816.6Appendices . 1827 Contract Variations (templates available) . 1877.1Introduction . 1877.2Types of Contract Variation . 1877.3Legislation / Regulatory Changes. 1877.4Changes to the Contracting Party . 1907.5Partnership Changes. 1907.6Retirement of a Contractor – Single Handed. 1987.7Retirement of a Contractor – Two or More Partners/Individuals . 2007.8Twenty-Four Hour Retirement . 2017.9 Variation Provisions Specific to a Contract with a Company Limited by Shares(GMS) or a Qualifying Body (PMS) . 2027.10 Contracts and Incorporation/Dis-incorporation . 2027.11 Practice Mergers and/or Contractual Mergers . 2157.12 Changes to Services . 2377.13 Open and Closed Lists . 2377.14 Boundary Changes. 2377.15 Premises . 2397.16 Opt Outs . 2447.17 Financial Changes – Statement of Financial Entitlements . 2497.18 Annex 4 Primary Care Support Services Notifications . 2507.19 Annexes . 2508 Managing a PMS Contractor’s Right to a GMS Contract . 2548.1Introduction . 2548.2Roles and Responsibilities . 2548.3Background . 2548.4Notification from a Contractor . 2558.5Process for PMS Agreements . 2558.6Disputes . 2579 Practice Closedown (Planned / Scheduled) . 259
9.1Introduction . 2599.2Scope . 2599.3Timetable for Managing Contracts Coming to an End . 2609.4Summary of Key Stages. 2609.5Stage 1 – 9 – 15 Months before Contract End . 2619.6Stage 2 - 12 Months before Contract End . 2639.7Stage 3 – At Contract End. 2649.8Primary Care Networks . 2659.9Links to relevant PCSS information and documentation . 26610 Discretionary Payments (made under Section 96) . 26710.1 Introduction . 26710.2 Key Principles . 26810.3 Programme and Non Programme Financial Assistance . 26810.4 Process for Financial Assistance for individual Provider . 27010.5 Process for CCG and NHS England Proposed Financial AssistanceProgrammes . 27410.6 Reporting. 27410.7 Maintaining Records. 27510.8 Addendums . 27611 NHS England Procurement Support Contract and NationalProcurement Tool . 28311.1 Background . 28311.2 The Offer . 28311.3 Contacts . 28411.4 APMS Purchasing System - national procurement tool for APMS and CaretakerGP services . 28411.5 Annexes . 28512 Premises Running Costs and Service Charges . 28612.1 Introduction . 28612.2 Principles. 28712.3 The Model . 29212.4 Process flowchart . 29712.5 Annexes . 299
12.6 NHS Resolution guidance note on Premises costs (Current Market Rent)disputes . 30112.7 PCN Workforce and Estates Guidance . 30113 Sub-contracting of Clinical Services . 30313.1 Assurance Framework: Sub-contracting of Clinical Services Under GMSContracts . 30313.2 Introduction . 30313.3 Guidance on assuring sub-contracting proposals . 30413.4 Annex A – Assurance Checklist . 31013.5 Annex B – Mandatory terms regarding sub-contracting . 31013.6 GP and NHS provider (NHS trusts or FTs) sub-contracting checklist. 311Part C – When things go wrong. 3151 Contract Breaches, Sanctions and Terminations . 3161.1Introduction . 3161.2Contract Breaches. 3161.3Remedial Notices and Breach Notices . 3171.4Contract sanctions. 3241.5Termination . 3271.6Key Considerations on Termination . 3301.7Rights of Termination . 3341.8Consequences of Termination . 3411.9Dealing with CQC issues. 3411.10 Annex 1 Remedial Notice Flowchart . 3431.11 Annex 2 Template Remedial Notice . 3431.12 Annex 3 Template Notice Receipt . 3431.13 Annex 4 Template Remedial Notice Satisfaction Letter . 3431.14 Annex 5 Breach Notice Flowchart . 3431.15 Annex 6 Template Breach Notice . 3431.16 Annex 7 Calculating a Financial Contract Sanction . 3431.17 Annex 8 Template Contract Sanction Notice. 3431
Primary Medical Care Policy and Guidance Manual (PGM) Version number: 3.0 First published: 12 January 2016 (as Policy Book for Primary Medical Services) First update: 09 November 2017 Current update: February 2021 Changes from version 2 have been highlighted in yellow Prepared by: Gary Williams Classification: OFFICIAL This information can be made available in alternative formats, such as easy .
Access the latest updates to medical policies and other documents at: Medical Policy Blue Cross Blue Shield of Massachusetts December 2020 NEW MEDICAL POLICIES New Medical Policy Title Policy Number Policy Summary Effective Date Products Affected Policy Type None N/A N/A N/A N/A N/A REVISED MEDICAL POLICIES Medical Policy Title
4 Figure 1. The Ecology of Medical Care, 2001 2.2. What Are the Benefits of Primary Care There is strong evidence of the benefits of primary care for both populations and personal health.6-17 Studies show that robust systems of primary care can improve health.6 Access to primary care can lower overall health care utilizat
2.4 Overall structure of primary care 61 2.5 Good practices and challenges for structuring primary care 63 2.6 Conclusion 65 References Chapter 3 The delivery of primary care services 67 Andrew Wilson, Adam Windak, Marek Oleszczyk, Stefan Wilm, Toralf Hasvold, Dionne Kringos 3.1 Access to primary care 67 3.2 Continuity of primary care 77
Principles of Primary Health Care Although the name of the program team reflects key service elements, it functions based on the principles of Primary Health Care. Primary health care is integrated and inter-sectoral. Primary health care emphasizes health promotion. Primary health care views the individual as a whole being.
3,070 primary care practices Multi-payer Payment model: Track 1 FFS, Care management fee, performance based payment Track 2 -Comprehensive Primary Care Payment, reduced FFS, performance based payment Care delivery requirements and milestones Comprehensive Primary Care Plus Primary Care First 5 year demonstration
Primary care spending is rising while total medical spending is falling: Total primary care spending for commercial members increased by 23% while total medical spending fell by 18% (2007-2011). In 2011, insurers spent 8.0% of medical claims dollars on primary care, up from 5.4% in 2007.
4 Current Drivers of Home-Based Medical Care Models 5 The Opportunity 6 The Spectrum of Home-Based Medical Care Models Table 1. Longitudinal Home-Based Medical Care Models Table 2. Episodic Home-Based Medical Care Models The Bottom Line 12 Case Studies 15 Looking Ahead: An Integrated Home- and Community-Based Health Care Ecosystem 16 Endnotes .
On Getting What You Want: Our Method of Manifestation This point cannot be overemphasized. You need to see that the way it is now is the way you have chosen it to be on some level.
