Local enhanced services (LESs) are a part of GP income that date back to the 2004 GP contract and were intended to reward practices for innovative services that were either being piloted or that responded to local needs.
Yet like other aspects of GP income the future of LES funding is uncertain. Its loss would undoubtedly have a significant impact on practices with £270m spent on LESs in England in 2011/12, equivalent to an average of £34,000 per practice.
The uncertainty has been created because money for LESs, previously under the control of PCTs, has now been devolved to CCGs and local authorities. This money is not ringfenced, so could be spent on any services provided by the CCG or authority - or with any provider.
In March an investigation by GP magazine found that almost a third of CCGs had yet to finalise their LES plans and Dr Nigel Watson, GPC member and chief executive of Wessex LMC, warned that some practices could ‘implode’ without it.
Three months later the good news is that most practices have not had LES schemes withdrawn so far.
Dr Richard Vautrey, deputy chairman of GPC, says: ‘Most CCGs do seem to have rolled forward existing local enhanced services to give everyone a bit of breathing space.’
NHS England guidance
This is in line with guidance issued by NHS England at the end of April, which suggested that while CCGs were free to decide how to spend resources for LESs that expired on or before 31 March 2013 those which had not expired could continue.
However, the guidance adds: ‘No transitional local enhanced services should last longer than one year.’ It points out that previous guidance recommended that LESs continuing into 2013/14 should contain a review clause to enable CCGs to use funding in different ways after this point, if they wish.
Crucially it goes on to say that from April 2014 CCGs will need to commission services using the NHS standard contract ‘so they are not technically local enhanced services but they are in other senses analogous to local enhanced services’.
The NHS England guidance says CCGs will need to take account of competition law and decide whether to undertake a competitive procurement or to allow patients to choose from a range of providers by using the ‘any qualified provider’ (AQP) route. However, it also says that this may not be necessary in all cases.
Will LESs become AQP services?
Chris Locke chief executive of Nottinghamshire LMC says: ‘There is quite a lot of debate going on about requirements to go to AQP and there seems to be a dichotomy of views about the demands of competition law and whether you would be open to a legal challenge if you did not do it.’
Draft guidance from the competition watchdog Monitor issued late last month said competition rules should not force commissioners to go out to tender for every service.
Avoiding AQP would be welcome news for most GPs. Mr Locke says practices ‘find AQP very difficult to understand and are frightened by the process’.
To counteract this Nottinghamshire has already held an information event for its Nottingham City practices outlining what AQP involves.
Nottingham City CCG has been among the most proactive on enhanced services, with its proposed list of AQP-suitable services including h-pylori breath testing, invasive minor surgery procedures and injections of muscles, tendons and joints, treatment room services and phlebotomy services.
All other local enhanced services, which will be called ‘primary care enhanced contracts’, will be procured under a ‘single action tender’ (see box below).
Dr Vautrey says: ‘For the enhanced services currently provided with relatively low value resources and for example where a registered list is used a CCG probably has no reason to use AQP.’
Public health LESs
Responsibility for commissioning public health services in England, including relevant LESs, moved to local authorities in April.
NHS England guidance says services that local authorities will be responsible for will probably include contraceptive implants, emergency hormonal contraception, fitting and removal of intrauterine contraceptive devices and health promotion services such as smoking cessation.
In the coming 12 months local authorities must review all such services and decide whether they need to be tendered to fulfil local strategic objectives and the public health outcomes framework.
Dr Vautrey warns that local authorities are more cash-strapped than CCGs, which might lead them to stop commissioning some of the LES services that they are now repsonsible for.
However, in some areas there are positive signs that local authorities are keen to retain GPs provision of services. Peter Higgins, chief executive of North West Lancashire LMCs says both Lancashire and Cumbria local authorities have recommissioned existing schemes that now fall within their public health budget.
Mr Locke meanwhile predicts that local authorities will be ‘more inclined to competitiveness’ than CCGs, and look at other providers such as private companies and pharmacists.
More opportunities for practices?
Dr Vautrey is keen that practices should not be put off from competing, even if it means getting together with other local practices.
‘There may be high value opportunities where practices may want to work with others and bid to be a provider,’ he adds.
Mr Higgins adds that if AQP is used there will be nothing to stop doctors in, for example, Blackpool bidding for work previously done by GPs in Burnley.
He adds: ‘It will keep some level of GP engagement in the whole process but lead to even more fragmentation of the service and be difficult for individual GP practices to compete so that would be a real challenge.’
For now practices may be well advised to spend the next few months working out the cost and benefit of providing additional services and familiarising themselves with the tendering process if there are services they want to bid for. Calculating the impact of losing LES money must also be on the agenda.
As Mr Higgins adds: ‘It is so far so good but also watch this space.’
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