Enhanced services and floors from April 2007


(revised August 2007) 1. Enhanced services floors in 2007-08
The establishment of primary care organisation (PCO) enhanced services floors (ESFs) was agreed as part of the initial general medical services (GMS) contract negotiations and was originally set for three years – 2003-04, 2004-05 and 2005-06. During the GMS contract review negotiations last year, it was agreed that for 2006-07, ESFs would be frozen at 2005-06 levels. [Note that the Allocation Working Paper (AWP) 06-07 PCT01, which notifies primary care trusts (PCTs) of their 2006-07 and 2007-08 allocations, announced a 9.2% increase in floor allocations for 2006-07.] No formal agreements have been made between the GPC and NHS Employers regarding ESFs for 2007-08 and AWP 06-07 PCT01 refers to a figure for national minimum expected spend on GMS enhanced services in 2007-08 which represents a 9.6% increase to the 2006-07 figure.

We would therefore advise that in 2007-08, LMCs continue to encourage PCOs to spend at least up to the floor, using the 2005-06 figures as a minimum. The Technical Steering Committee (TSC) will continue to monitor PCO spend at a national level, furthermore, AWP 06-07 PCT01 says the following:

“PCTs are expected to spend at least this level of resources on primary care service providers: in particular, GMS practices, and existing and future PMS practices many of whom have developed innovative ideas for PMS Plus funding. [Paragraph 23]”

AWP 06-07 PCT01 can be found online - please visit the Department of Health website.

The General Practitioners Committee (GPC) acknowledges that enhanced services have been a source of frustration for both GPs and local medical committees (LMCs) alike and that in a number of areas, LMCs are in dispute with PCOs on their use of ESF monies. It is worth noting that, despite a stronger emphasis on them to do so in the earlier years of the agreement, there has never been a legal obligation on PCOs to spend to the enhanced services floor. Nevertheless, the GPC negotiators have and will continue to seek to ensure that central pressure is put on PCOs to do so.

If PCOs do disinvest in enhanced services, for whatever reason, we would continue to advise practices that they should refuse to provide services for which they are either not funded or inadequately funded. GPs and LMCs should remind PCOs that investment in enhanced services is key to cost containment since care provided in primary care will often be more cost effective than in secondary care. If well established enhanced services are decommissioned, GPs should stop providing the services, with the likely consequent result of increased healthcare costs to the PCO.

The established criteria according to which a LES can be funded from the ESF, for example that it directly provides patient services, is contestable by all GP practices and can be reasonably provided by practices remains unchanged.

2. Directed enhanced services (DESs)
Here is a list of all the DESs and details of their status as of April 2007.

2.1 UK
(1) Childhood immunisations
The original DES, including the agreed funding, will still apply and PCOs continue to be legally obliged to commission the service from all GMS and PMS contractors in the area.

(2) Influenza and pneumococcal immunisation
The original DES, including the agreed funding, will still apply and PCOs continue to be legally obliged to commission the service from primary medical services contractors in the area. Note that the DES has not been amended to include any other at risk groups, such as poultry workers, but this group may be covered by a local enhanced service (LES), for which the same rates as stipulated in the DES should apply.

(3) Minor surgery
The original DES, including the agreed funding, will still apply and PCOs continue to be legally obliged to commission the service from primary medical services contractors in the area.

(4) Service to support staff dealing with violent patients
The original DES, including the agreed funding, will still apply and PCOs continue to be legally obliged to commission the service from primary medical services contractors in the area.

(5) Quality information preparation
The original one-year 2004-05 DES ceased to apply from 1 April 2005.

2.2 England
(1) Access to primary care
The original UK-wide access DES (2004-06) was replaced with a new, one-year 2006-07 DES specific to England. As the original intention to review the 2006-07 access DES did not take place, it will continue, unchanged, in 2007-08.

(2) Towards practice based commissioning (TPBC)
This one-year 2006-07 DES will came to an end on 31 March 2007. There will be no national successor, however unlike the other one-year DESs, there is a definite proposal from the Department of Health to enable GP practices to continue this work in 2007-08, via locally agreed incentive schemes (see paragraphs 4.10-4.13 of the latest Department of Health guidance on PBC, 'Practical implementation').

(3) Choice and booking
The 2006-07 DES will continue, unchanged, in 2007-08.

(4) Information management and technology
This two-year DES, 2006-08, has one year remaining.

For further information on the UK and England-only DESs, please visit the following websites: 2.3 Northern Ireland
(1) Access to primary care
The original UK-wide access DES (2004-06) was replaced with a new, one-year 2006-07 DES specific to Northern Ireland, which will continue, unchanged, in 2007-08.

(2) Long-term condition management
The 2006-07 DES has been rolled over, unchanged, to 2007-08.

For further information, please visit the following website: 2.4 Scotland
(1) Access to contractor-based primary care services.
The original UK-wide access DES (2004-06) was replaced with a new, one-year 2006-07 DES specific to Scotland. This DES will continue unchanged in 2007-08.

(2) Cardio-vascular disease (CVD) risk dataset
This one-year 2006-07 DES came to an end on 31 March 2007.

(3) Cancer referral
This one-year 2006-07 DES came to an end on 31 March 2007.

(4) Adults with learning disabilities
This one-year 2006-07 DES came to an end on 31 March 2007.

(5) Carers
This one-year 2006-07 DES came to an end on 31 March 2007.

Discussion is currently taking place on a programme of services that health boards will be funded to commission through local negotiations in 2007-08.

For further information, refer to the Primary Medical Services (Directed Enhanced Services) (Scotland) Directions 2006.

2.5 Wales
At the time of publication, national negotiations in Wales regarding DESs were on hold. Welsh GPs will be kept informed of any developments.

(1) Access
The original UK-wide access DES (2004-06) was replaced with a new, one-year 2006-07 DES specific to Wales; this came to an end on 31 March 2007.

(2) Severe mental illness
This one-year 2006-07 DES came to an end on 31 March 2007.

(3) Learning disabilities
This one-year 2006-07 DES came to an end on 31 March 2007.

(4) Information management and technology
This one-year 2006-07 DES came to an end on 31 March 2007. The future of this DES is being considered at present.

For further information, refer to the Primary Medical Services (Directed Enhanced Services) (Wales) Directions 2006.

3. National enhanced services (NESs)
No changes have been made to the original NESs since their introduction in April 2004 and they will continue to apply.

For further information, refer to the NES specifications.

4. Local enhanced services (LESs)
The definition of services, ie whether they are essential or enhanced, will not change from April 2007. Where LESs have been agreed, PCOs wishing to review or bring to an end existing arrangements must do so in line with the relevant termination clauses set out in individual practices’ contracts. If the length of the notice period is not stipulated, three months is generally considered a reasonable notice period for both parties. It goes without saying that practices should not continue providing a service if they are no longer funded to do so.

5. Enhanced services and practice based commissioning (England only)
In theory, it should be the role of practice based commissioners to lead on the enhanced services agenda in the future. However given the fact that practice based commissioning (PBC) is still in the early stages in many areas of the country and there is some doubt as to whether or not PCTs will abide by commissioners’ recommendations, this will not necessary be the case. Where it is however, we would suggest that LMCs maintain an overview of the use of the enhanced services contracting route and seek to be involved in any relevant local discussions and/or negotiations as appropriate.

The latest Department of Health guidance on PBC, 'Practical implementation' (November 2006) sets out guidelines for practices who may wish to develop new services in line with their commissioning activity, by submitting a business case to the PCT (see paragraphs 2.16-2.20). It should be noted that the Department of Health guidance does not suggest that established enhanced services will be replaced with such services as a matter of course. The mechanism of funding such new services could legitimately be a LES, as specified in the Department of Health guidance ‘Health reform in England: update and commissioning framework’ (July 2006, paragraph 3.12).

However, such LESs should not come from within the ESF, they should be funded over and above the floor from the hospital commissioning budget since they will represent a secondary to primary shift in the context of service redesign. Practices' proposals will need to be priced fairly and reflect the cost of delivering the service, the assumption being that this is part of finding more cost-effective ways of treating patients, reviewing the level of patient care managed within the secondary care sector and ultimately, reducing spend against the PBC indicative budget.

Although provision of such services may be exclusive to a few practices in the PCT area, if other practices within the area also wish to provide the service, then upon approval from the PCT on a business case, they will be able to do so.

PCTs were instructed to use monies above and beyond the 2006-07 floor in order to fund the TPBC DES. The same should apply to any local incentive schemes designed to support practice’s involvement in PBC in 2007-08. Guidelines on such local incentives schemes can be found in the latest Department of Health guidance on PBC, 'Practical implementation' (November 2006, paragraphs 4.10-4.13).

As stated earlier in this guidance note, the established criteria according to which a LES can be funded from the ESF, for example, that it directly provides patient services, is contestable by all GP practices and can be reasonably provided by practices, remains unchanged. It may be helpful for LMCs, practices and PCTs to draw a distinction between this, the original concept of a LES, and the more recent, broader concepts relating to i) provider services developed through PBC and ii) incentive schemes designed to support practice’s involvement in PBC.

Visit the Department of Health website for their latest guidance ‘Practical implementation’.

The GPC has issued its own guidance on the Department of Health guidance and a summary of PBC policy in 2007-08 later in the month. These are available on the BMA website.

© British Medical Association 2008

Log in to your BMA here



Download the guidance in PDF format (79K)

  • Adobe PDF iconTo view and print PDF files, you must have Adobe® Acrobat® Reader installed.

    Download Adobe here