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Primary care for all: the "equitable access" procurement scheme

The Department of Health has announced that primary care trusts in the poorest parts of England must establish new GP-led health centres in easily accessible locations. Sally Corton examines how this will be carried out, and the effect it will have on improving outcomes.

Sally Corton
RGN
Specialist Practitioner Practice Nursing
Independent Prescriber
Nurse Manager
DMC Healthcare

Having worked in primary care for over 10 years, I have witnessed the ongoing evolution of services within the NHS firsthand. This has accelerated in England over the past 18 months with the Darzi review of healthcare, the implementation of practice-based commissioning and, most recently, the Equitable Access to Primary Medical Care (EAPMC) scheme.1–3

Despite sustained investment over the years, there continues to be variation in access to, and quality of, primary care services across the country. It is hoped that the EAPMC scheme will reduce the inequalities that still exist in the poorest communities in England and will go some way towards achieving the personalised care set out by Lord Darzi with the aim of meeting the individual needs of those communities.2

Ministers announced that £250m is being made available to support the establishment of at least 100 new general practices in the primary care trusts (PCTs) with the lowest levels of healthcare provision, based on the fewest primary care clinicians, dissatisfaction with access and poorest health outcomes. The new centres are to be open from 8am–8pm, 365 days a year. They are to be based in easily accessible locations and provide a flexible range of appointments, consisting of bookable and walk-in services and other services for registered and nonregistered patients.2

The objective of these PCT procurements is to provide greater access to NHS primary medical care services through additional capacity that will be affordable and give value for money. Emphasis will be placed on accessing the hard-to-reach groups that are reluctant to access traditional primary care services, such as younger patients, males, and black and minority ethnic groups.

GP-led health centres will be opening in locations across England from April 2009; but how much do we, as nurses, know about the process and the specific stages that organisations go through to enable them to be awarded these service contracts? And what do we know of the organisations who are awarded these multimillion pound contracts?

The process
A memorandum of information (MOI) is issued by the PCT. This gives an overview of their procurement plan and should provide potential bidders with sufficient information on the procurement to allow them to make an informed choice about whether they wish to participate.

  • The individual bidders submit an expression of interest (EOI). This is done in a format decided by the PCT and with a deadline attached.
  • A bidder information event ensures all potential bidders are given an equal opportunity to fully understand the requirements of the procurement process (see Figure 1).
  • A pre-qualification questionnaire (PQQ) is issued to all bidders who submitted an EOI by the deadline date. This consists of a series of questions that potential bidders have to provide answers for regarding their suitability.
  • The invitation to tender (ITT) contains all the terms and conditions of the contract and the full clinical service specification, as well as the Alternative Provider Medical Services (APMS) contracts and schedules. It contains detail on the criteria that will be used for future contract monitoring.

[[Figure 1 access]]

In my role as Nurse Manager for DMC Healthcare it is my responsibility to provide information on nursing issues to the business team preparing the procurement documents. This can range from addressing infection control issues to giving advice on specific strategies to engage the under-24s in the National Chlamydia Screening Programme.

I also advise on the nursing skill mix required so that the centres will run effectively and efficiently. This provides me with the opportunity to put forward innovative suggestions for new ways of working that can sometimes be quashed in traditional general practices, which operate under unique financial regulations and may not have the infrastructure to deliver redesigned services. For example, at one of our centres we are going to operate a mobile medical clinic, which will be manned by GPs, practice nurses and nurse practitioners, and allow outreach into communities beyond the traditional catchment area of a GP practice. The unit will operate six days a week to a published timetable, to enable patients to access the full range of services at a convenient location within their local neighbourhood. Others plan on having fitness centres and physiotherapy suites.

It is important for nurses to be aware of the procurement process and to know that they have a valuable contribution to make. It is vital for those employed by organisations involved in this process to actively engage in it, as they are going to be the people directly delivering the core services and service developments that are being suggested in the procurement documents. It is the nurses who will turn these proposals into a reality for patients and make the service a success.

Although it will not be possible for all nurses to be directly involved in the process, it is important that the profession as a whole has an understanding of the complexity of procurement, so that individuals are aware of why and how contracts to run GP-led health centres are awarded across the country and what these new centres aim to deliver in terms of patient care.

Six months ago I had my first experience of the procurement process for the equitable access scheme. Following my appointment, one of my first challenges was to go to an ITT bidder interview. The interview panels vary in number but usually consist of 10 or more people, representing all arms of the PCT, including finance, clinical, premises and patient.

The interview usually begins with a presentation from the bidders, followed by questions from the panel on any points arising from the presentation. A series of set questions are asked to all potential bidders. Examples of these are:
1.    What will you do if the practice list does not grow as anticipated?
2.    How will you provide continuity of care?
3.    What governance issues are associated with a walk-in centre?
4.    What services will you offer under practice-based commissioning and how will you develop practice-based commissioning?

It was my role to give an overview of the nursing input that would go towards addressing the health needs of the local area and explain in detail how the nursing team would be supported and developed.

This includes:

  • Integration into the local community – working with acute trusts, community and voluntary groups and the PCT.
  • Skill mix – ensuring the right people are doing the right job.
  • Continuing professional development – support and development for the nursing team.
  • Career pathways – training for staff so career progression is available within our organisation.
  • Clinical governance – ensuring all our work is underpinned by clinical excellence.

Once the contract has been awarded to the successful bidder, the time has come to implement what was written in the ITT. From my perspective the most important priority is the recruitment of the nursing team.

Concerns about GP-led services
DMC Healthcare has been awarded the contracts for two GP-led health centres and nurse recruitment has become of paramount importance. Getting the skill mix right is essential if the service we provide is to be cost-effective as well as efficient.

Many GPs acknowledge that practices would not run as efficiently without the input from the nursing team and support from the expanding role of the nurse. There is a perception that the new centres are a cheap way to replace GPs and that a higher ratio of nurses to GPs will lead to second–rate care.
However, most do see the new services as a natural progression of the nurse's role and believe that nurses can provide high-quality care with the support of GPs. Generally, nurses are trained to know what their scope of practice is and have no problems in seeking help and advice when needed. Similarly, the evolving role of the healthcare assistant allows nurses the opportunity and time to develop these roles.

There are also fears that there are not enough nurse practitioners out there to staff these services. Happily for me, that has not yet been the case and recruitment for not only nurse practitioners but also other members of the nursing team is going extremely well.

During interviews there were understandable anxieties about working for an organisation perceived to be outside the NHS. It is important for nurses to realise that organisations awarded these contracts are accountable to the PCT and are still seen as part of the NHS family. They represent the new face of the NHS, delivering equitable care at the very highest level. By being employed by these organisations, they are working within an established framework that supports service delivery and provides the opportunity for training and education, thereby facilitating career development.

The nurses I have employed have come from traditional GP surgeries, walk-in centres or minor injury units and are relishing the opportunity to help shape and develop the services being delivered. This may be seen to be further destabilising general practice; but weren't the same things said when the first nurse-led walk-in centres were opened?

Many people see GP-led health centres as a threat to existing general practices and a duplication of services. However, the intention is to integrate them into the local community; to have a stronger partnership with social services; and to provide a service to the local population where it is deemed there is need for additional provision. This includes working with the homeless and the younger population in tackling the growing problem of the rise in sexually transmitted disease and teenage pregnancy.

An important question is whether or not these centres will be able to provide continuity of care to complement the enhanced access they are designed to allow. Many worry that the workforce will be made up of salaried GPs rather than the traditional partnership, and that this will have an effect on continuity. However, it could be argued that continuity is achieved with the amount of time worked, whether you are salaried or a partner. Development of a committed workforce is essential, without relying on locums or out-of-hours services.

From a nursing perspective, these new centres may also provide benefits beyond improvements to patient care. As the number of organisations within the marketplace increases, it is expected that salaries will be driven up, as employers seek to recruit and retain experienced and competent nursing staff from a limited pool.

Organisations are required not only to go through the procurement process, but also to meet stringent risk assessment criteria before service commencement. This consists of hundreds of specific points, which aim to ensure that providers have robust policies and procedures in place, covering all aspects of staff management and health and safety issues. The services delivered will have to meet the specification set by the PCT and will be closely monitored and audited by them.

Conclusion
Only time will tell as to whether these GP-led services will deliver on the aims of improving equity and access laid out in the EAMPC scheme. DMC Healthcare has every intention of delivering services that will meet these clear aims and will be auditing and evaluating our service provision on an ongoing basis to ensure we achieve this. I aim to summarise our progress in a follow-up article in Nursing in Practice in six months' time.

References
1. Department of Health (DH). Our NHS, Our Future. London: DH; 2007.
2. Department of Health (DH. High quality care for all: NHS Next Stage Review final report. London: DH; 2008.
3. Department of Health (DH). Equitable Access to Primary Medical Care (EAPMC). London: DH; 2008. Available from: http://www.dh.gov.uk/en/Procurementandproposals/Procurement/Procurementa...