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CHAPTER2 Practicemanagement
Partnershipagreements
Partnership disputes are common. Aproperly drafted partnership agreement may prevent disputes and, if they do occur, may lessen their impact.
Partnership at will A partnership without an up- to- date written
agreement is a ‘partnership at will’, governed by the 1890 Partnership Act.
A‘partnership at will’ is a very unstable situation as:
• All partners are deemed to have equal prot shares, unless there is clear
evidence to the contrary
• Decisions are made by simple majority
• Notice may be served by any partner on the others without their prior
knowledge or consent
• Dissolution of the partnership may take immediate eect, and no
reason needs be given to justify it
• Dissolution may result in the forced sale of all partnership assets
(including the surgery premises) and redundancy of all sta
• There is nothing to prevent any partner, or group of partners, from
immediately forming a new practice/ partnership to the exclusion of the
other partner(s) once the practice is dissolved
Partnership agreements Should be drawn up every time a new
partner joins or leaves a practice. Employed doctors and retainers also require contracts of employment. An agreement checklist is included in Box
2.1. Detailed guidance is produced by the BMA, and further guidance can be
obtained from local BMA oces and LMCs.
Partnership disputes However good a partnership agreement is, dis-
putes still occur. Advice on partnership and employment matters is available
from the BMA and LMC, and the BMA also provides conciliation services
(contact local oce). Legal battles are expensive, and the BMA will not fund
partnership disputes. Try to resolve matters amicably.
Discrimination It is unlawful for any partnership to discriminate on
grounds of age, gender, marital status, colour, race, nationality (including
citizenship), ethnic or national origins when appointing a new partner or
in the way they treat an existing partner. The BMA will consider backing
GPs to take such matters to industrial tribunals— contact the local oce.
Applications should be made on forms available via local Job Centres and
must be made within 3mo of the last act of discrimination.
Contracts of employment for salaried GPs Model terms and
conditions of service for a salaried GP and a model oer letter of employment are available from the BMA or DH websites. Nationally agreed salary
scales apply and are compulsory for GMS, but not PMS, practices.
Practice responsibilities towards employed GPs E p. 38
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PARTNERSHIPAGREEMENTS
Box 2.1 Partnership agreementchecklist
• Business detail Purpose of the business; premises and basis of
occupation. If premises are owned by the partners, state procedure
for valuation, payment of the retiring partner, and investment of the
incoming partner
• Assets Specify assets, their ownership, arrangements for valuation and
interest payments. It is illegal to sell goodwill in NHS practices
• Income and allowances Denition of practice income; allowable
expenses
• Prot sharing Distribution of practice NHS income and other NHS
allowances; distribution of income from non- NHS work
• Accounting Accounting and banking arrangements; bill paying; access
to accounts and bank statements
• Taxation Arrangements for paying tax; obligations of each partner
• Pension arrangements
• Retirement/ suspension/ expulsion Reasons for suspension/ expulsion;
process of suspension/ expulsion; mechanisms of voluntary leaving/
retirement; division of assets in the event of retirement. May include
a restrictive clause preventing the outgoing doctor working in the
practice area for a period of time after leaving— seek legal advice
• Leave Holiday entitlement; basis of deciding who has holiday when;
study leave; sabbatical leave; sick leave; maternity, paternity, and
adoption leave; compassionate leave
• Obligation NHS obligations; non- NHS work within the practice; other
work outside the practice; educational activities; obligations to each
other; hours of work
• Decisions and disputes Decision- making process; process to manage
disputes; process to dissolve partnership. Ensure that who pays legal
fees for who in the event of a dispute is included
• Correct procedure Ensure each partner has signed and dated
the agreement and that their signature has been witnessed. It is
recommended that each partner should take independent legal advice
and not rely on the ‘practice solicitor’ for sole advice
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Further information
BMA M www.bma.org.uk
Equality and Human Rights Commission Equality Advisory and Support
Service (EASS). F 0808 800 0082; Textphone:0808 800 0084; M www.
equalityhumanrights.com
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CHAPTER2 Practicemanagement
Practicepremises
Funding of premises GPs may either own or rent the property in
which they practise:
• GPs who own surgeries GPs may own surgeries by themselves or in
partnership. They receive a payment (‘notional rent’) for allowing their
private buildings to be used for NHS purposes. Payment is based on
the current market rental (CMR) value of the property as assessed by
the district valuer. When a new GP partner joins a practice, he/ she may
be expected to buy into the practice to contribute a share of previous
investment in the practice premises and equipment
• GPs who rent surgeries Can claim reimbursement from their PCO
for the rent they pay as long as it is ‘reasonable’ as assessed by the
district valuer
• Cost rent scheme This scheme is no longer available, but some
surgeries remain on it. Finance for building, refurbishment, or
modication of GP premises was originally raised by the partners. The
PCO reimburses the interest payments on the loans taken out to do this
• Improvement grants Available via PCOs in some circumstances
0 New premises/ refurbishments must meet national minimum standards.
Disabled access The Equality Act (2010) gives disabled people rights
of access to goods, facilities, and services. Adisabled person is dened as
‘someone who has a physical or mental impairment that has a substantial
and long- term adverse eect on his or her ability to carry out normal dayto- day activities’. Practices must:
• Not refuse to take disabled people onto a practice list or provide a
lower standard of service due to their disability
• Make reasonable adjustments to their premises and the way they deliver
their services so that disabled people can use them
Building regulations and access for disabled patients The
building regulations exist to ensure the health and safety of people in and
around all types of buildings. Part M deals with access/ facilities for disabled
people. All new buildings/ alterations to existing buildings must be accessible to and useable by anyone, including those with disabilities.
Health and safety The basis of British health and safety law is the
Health and Safety at Work Act 1974. The Act sets out the general duties
employers have towards employees and members of the public, and employees have to themselves and to each other.
Responsibilities ofGPs asemployers The Management of Health
and Safety at Work Regulations 1999 (the Management Regulations) give
clear guidance about employers’ duties towards their sta.
1. Employers with ≥5 employees must carry out a risk assessment and
record the signicant ndings. HSE leaet ‘5 Steps to Risk Assessment’
gives more information
2. Make arrangements for implementing the health and safety measures
identied as necessary by the risk assessment
3. Appoint competent people (usually the practice manager) to help
implement the arrangements
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PRACTICEPREMISES
4. Set up emergency procedures (e.g. re drills)
5. Provide clear information and training to employees
6. Work together with other employers sharing the same workplace
Other important pieces ofhealth and safetylegislation
• Employers’ Liability (Compulsory Insurance) Regulations 1969 Require
employers to take out insurance against accidents and ill health to their
employees and display the insurance certicate
• Health and Safety Information for Employees Regulations 1989 Require
employers to display a poster, telling employees what they need to
know about health and safety
• Workplace (Health, Safety and Welfare) Regulations 1992 Cover a
wide range of basic health, safety, and welfare issues, such as ventilation,
heating, lighting, and seating
• Reporting of Injuries, Diseases and Dangerous Occurrences
Regulations 1995 (RIDDOR) Require employers to notify certain
occupational injuries, diseases, and dangerous events
• Health and Safety (Display Screen Equipment) Regulations 1992 Set out
requirements for work with visual display units (VDUs)
• Personal Protective Equipment (PPE) Regulations 1992 Require
employers to provide appropriate protective clothing and equipment
• Provision and Use of Work Equipment Regulations (PUWER) 1998
Require that equipment provided, including machinery, is safe
• Manual Handling Operations Regulations 1992 Cover moving of
objects by hand or bodily force
• Health and Safety (First Aid) Regulations 1981 Cover requirements for
rst aid
• Control of Substances Hazardous to Health Regulations 2002
(COSHH) Require employers to assess the risks from hazardous
substances and take appropriate precautions
• Gas Safety (Installation and Use) Regulations 1998 Cover safe
installation, maintenance and use of gas systems and appliances in
domestic and commercial premises
Computers in practices PCOs directly fund 100% of IT costs. All
practices now use computers on a daily basis. All specialist GP systems must
be approved by the DH (termed ‘Systems of Choice’). The software covers
all aspects of practice from appointment systems, through clinical care, to
audit and reporting.
Electronic GP records Most GPs maintain all records on computer. Read
codes are used to code all aspects of patient care. Characters in the code
can be numerical or alphabetical. The huge number of possible combinations ensures there are enough unused Read codes to accommodate
changes. SNOMED Clinical terms (CT) are a new coding system that will
eventually replace Read coding. The aim is that all healthcare systems in the
UK will use the same coding system, allowing a single unied patient record.
Further information
Health and Safety Executive M www.hse.gov.uk
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CHAPTER2 Practicemanagement
Practicesta
Practices employ an array of sta. Sta costs are included in the Global Sum
(E p. 32) paid to a practice.
Recruitingsta
• Review the post— does the post need to be lled or the duties changed?
• Prepare a job description stipulating duties and hours of work
• Prepare a prole of the person required
• Decide on a salary range; the BMA can give advice
• Advertise the post
• Set a closing date for applications
• Shortlist candidates
• Interview— decide who will interview, what points must be covered,
and who will ask questions; ask similar questions to all candidates, and
score the responses at the time
• Make a decision on the preferred candidate— if in doubt, defer the
appointment or re- interview preferred candidates
• Conrm the job oer by letter asking for a formal written acceptance by
email or letter in return
• Plan an induction course for the new employee; a probationary period
can be helpful for both employer and employee
• Produce a contract of employment
Employment law Very complex eld which changes rapidly. If in doubt,
contact your local BMA oce for advice. Major points:
Contract of employment Sample contracts are available from the BMA.
Employees have a contract of employment from the day they accept their
job— even if it is not written. All employees must be provided with a written
statement of the main particulars of their employment <2mo after their
start date. This must include:pay, hours, holidays, notice period, disciplinary
and grievance procedures.
Pay Workers must be paid at least the national minimum wage for every
hour worked. Deductions can only be made if authorized by legislation,
contract of employment, or in advance in writing by the employee. All employees must receive an itemized pay statement at, or before, the time they
are paid, including all deductions.
Notice After 1mo employment, an employee must give ≥1wk notice. An
employer must give an employee ≥1wk notice after 1mo, 2wk after 2y, 3wk
after 3y, and so on up to 12wk after ≥12y, unless longer notice periods are
specied in the contract of employment.
Redundancy pay After 2y continuous employment, employers must make
‘redundancy payments’ related to employee’s age, length of continuous service with the employer (to a maximum of 20y), and weekly pay.
Time o Employees are entitled to time o for illness; antenatal care; emergencies involving a dependant; certain public duties (e.g. jury service); to
look for another job; and for approved trade union activities.
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PRACTICESTAFF
Working time Parents of children <6y or disabled children <18y and carers
may request exible working patterns; employers have a duty to consider
their requests. Working Time Regulations (1998) apply to agency workers
and freelancers as well as employees and include:
• Average working week ≤48h (although individuals can opt to work
longer)
• Aminimum of 1d o each week
• Aminimum of 5.6wk paid annual leave (28d for a full- time worker)
• 20min in- work rest break if the working day is ≥6h
• 11 consecutive hours’ rest in any 24h period (night workers must
work ≤8h/ d)
Pensions All employees must belong to a pension scheme. The NHS pension scheme is available to practice employees.
Maternity leave All pregnant employees are entitled to 52wk maternity
leave (26wk ordinary maternity leave + 26wk additional maternity leave)
regardless of length of service. Women are entitled to return to their own
or an equivalent job after their leave. Similar arrangements are in place for
adoptive mothers.
Paternity leave Employees who have worked for their employer for ≥26wk
by the 15th wk before the baby is due and up to the birth of the child are
entitled to 1– 2wk paternity leave which must be completed within 56d of
the birth. Fathers may also claim additional paternity leave for up to 26wk
from 20wk to 1y after birth/ adoption to look after their child if the mother
returns to work.
Parental leave After 1y employment, employees are entitled to 13wk unpaid
parental leave for each child born or adopted up to the child’s 5th birthday
(or 5y after adopted). Parents of disabled children can take 18wk up to the
child’s 18th birthday.
Health and safety ofsta E p. 36
Discrimination Employers must not, either directly or indirectly, discrim-
inate against their sta on the basis of age, race, gender, or disability.
Unfair dismissal Employees of >1y standing (or on maternity, paternity, or
adoption leave) are entitled to a written statement of reasons for dismissal.
Employers must not dismiss an employee unfairly.
Further information
ACAS Provides advice for employers and employees, downloadable employment tools and checklists, free e- learning on employment matters and
an advice helpline. F 0300 123 1100 M www.acas.org.uk
Equality and Human Rights Commission Equality Advisory and Support
Service (EASS). F 0808 800 0082; Textphone:0808 800 0084; M www.
equalityhumanrights.com
HM Government Information about ‘Employing people’. M www.gov.uk
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CHAPTER2 Practicemanagement
Registration ofpatients
Practice area and boundaries E p. 4
Practice leaets Each practice is required to produce a practice leaet
to distribute to patients. In Wales, the practice leaet must be in Welsh and
English. The practice leaet informs patients about the practice, the services
provided, and how to access them. In addition it informs patients of their
rights and responsibilities. Most practices also include general health information and information about self- management of minor illness.
Registration process Patients can apply to join a practice list by
handing in their medical card at the practice or completing an application
form. For children, a parent or a guardian can make the application.
• Open lists Practices with open lists must consider all applications to join
their list
• Closed lists Practices with closed lists can only consider applications
from immediate family members of patients already registered
List closure Practices wishing to close their lists must inform the PCO
in writing. The PCO must then enter into discussion with the practice to
provide support to keep the list open. If that is not possible, the list will
be closed for a specied period of time or until the list size falls below a
set limit.
Newly registered patients When a patient has been accepted onto
a practice list, the practice must oer the patient a consultation for a
routine health check (the ‘new patient check’) within 6mo of registration.
Temporary residents Patients may register with a practice on a short-
term basis for treatment or advice if they are living temporarily (for >24h
but <3mo) in the practice area.
Emergency and immediately necessary treatment Practices
must provide services required in core hours for the treatment of anyone:
• Injured or acutely unwell at any place in its practice area
• Whose application for inclusion in the practice list (as a permanent or
temporary resident) has been refused and who is not registered with
another provider in the area
Assignments PCOs may assign patients to any open practice list if the
patient has problems registering with a practice. PCOs can only assign patients to closed lists if all other local practice lists are also closed.
Removing patients fromthe practice list Practice policies for re-
moving patients from the practice list should be stated in practice leaets.
Situations that justifyremoval
• Violence Physical violence or verbal abuse towards doctors, practice
sta, premises, or other patients by patients or other household
members
• Crime and deception e.g. deliberate deceit to obtain a service or
benet; obtaining drugs under false pretences for non- medical reasons;
stealing from practice premises
• Relocation to an address out of the practice area Unless the practice is
participating in the Patient Choice Scheme E p. 4
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REGISTRATION OFPATIENTS
Situations that never justifyremoval
• Costly or dicult treatment
• Age General practice is about looking after patients from cradle to
grave. Although patients >75y do result in higher costs, this is reected
in allocation of funds to the practice
Situations that do not normally justifyremoval
• Disagreement with the patient’s views Patients must have freedom to
choose whether to accept a GP’s advice
• Critical questioning and/ or complaints Complaints via normal in- house
channels can be constructive and help improve services; they do not
usually justify removal from the practice list. However, personal attacks
on a doctor or allegations that are clearly unfounded indicate a serious
breakdown in the doctor– patient relationship and could justify removal
Other family members Removal of other family members should not
automatically follow removal of a patient from a practice unless ongoing
care of the rest of the household would be impossible.
Removing patients fromthe practicelist
• Warn the patient Patients must have received a warning and
explanation for the reasons why a practice is considering an application
for removal from the practice list <12mo before an application for
removal is made to the PCO. Exceptions to this rule are violent patients,
patients who have moved outside the practice area, and those for
whom it would be unsafe or impractical to issue a warning
• Inform the PCO in writing of your decision Except in the case of
violent patients, removal will not take eect until the 8th day after
the request is received by the PCO unless the patient is accepted by
another GP. The patient will be notied by the PCO
• Write to the patient about the decision and reason for removal (take
advice from your medical defence organization, if needed). Include
information on how to register with another practice and reassurance
that the patient will not be left without a GP. Take care to ensure
reasons given are factual and the tone of the letter is polite/ informative
Immediate removal ofviolentpatients
• Notify the police (or, in Scotland, either the police or the procurator
scal) about the violent behaviour
• Notify both the PCO and the patient of the removal in writing The
PCO has a duty to provide alternative primary medical care services
by commissioning specialized directed enhanced services, e.g. GPs with
secure facilities for consulting
Patients’ rights to change doctor Patients also have a right to
change their doctor. They are not required to give reasons or any period of
notice, and there is no requirement for the GP to be notied.
Eligibility for free healthcare Eligibility for NHS care is likely to
change once the UK leaves the European Union. However, all emergency
care is likely to remain free of charge to all patients regardless of country
of origin or residence entitlement, and whether delivered in 1° or 2° care.
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CHAPTER2 Practicemanagement
Out- of- hoursservices
What is urgent care? Urgent care refers to the range of responses
that the health and care services provide to people who need, or perceive
that they need, urgent advice, care treatment, or diagnosis. Urgent ‘same
day’ appointments currently account for 1 in 3daytime consultations in general practice, so all GPs must have the skills/ knowledge to manage patients
with a perceived urgent care need. Eective GPs can manage patients with
urgent care needs so that ‘dangerous diagnoses’ are not missed and A&E
and acute hospital services are used eciently.
What are OOH services? Urgent primary medical care is currently
provided by out- of- hours (OOH) services from 6.30 p.m. to 8 a.m. on
weekdays and throughout weekends and public holidays— a total of at
least 70% of every week. In England alone, every year primary care OOH
services:
• Receive 8.6million calls
• Complete 6.8million assessments— 3million in OOH primary care
centres (44%), 2.9million by telephone (43%), and 0.9million through
home visits (13%)
• 1.5% of the calls dealt with are considered ‘life- threatening’ emergencies
and 15% are classied as ‘urgent’
‘Opting out’ of OOH Both PMS and GMS practices can ‘opt out’ of
providing an OOH service. The decision must be made for the whole practice; individual doctors within a practice cannot ‘opt out’ alone. The cost of
opting out is 7% of the Global Sum (or PMS equivalent).
OOH work by‘opted out’ practices There is nothing to stop prac-
tices that have opted out from oering surgeries or consultations within the
time periods specied as OOH. These services can be paid for through the
practice Global Sum or under the ‘extended opening’ arrangements with
local commissioners. With government promises of extended day- time and
weekend availability of routine GP services, and emergence of new models
of care, the division between within- hours urgent care provision and OOH
care is becoming increasingly blurred.
OOH and urgent care providers PCOs can consider a range of pro-
viders as long as accreditation standards are met. Only where a practice
is exceptionally remote, is the PCO able to require a practice to provide
OOH care. Special arrangements for payment then exist. Several schemes
currently operate side by side:
• In- practice rota Traditional model of cover that is now very rare; usually
organized in a rota between practice GPs; largely based on home visiting
• Extended rota GPs on- call in rotation for a small group of practices.
Some extended rotas still operate in rural areas
• GP cooperative GPs within an area grouped together (often >100
practices in a co- op or federation) to cover urgent/ OOH care either
between themselves or by employing other GPs and allied health
professionals; often several individuals are ‘on call’ at any time, e.g. one
doing visits; one taking calls; one seeing patients in a clinic, etc.
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OUT-OF-HOURSSERVICES
• PCO or commercial urgent and/ or OOH care provider Employ GPs,
paramedics, physician’s associates, and specialist nurses to provide both
surgery- based and home visiting services
• Hospital- based OOH/ urgent care clinics GPs, advanced nurse
practitioners/ physician associates, and primary care nurses
attached to A&E
• NHS walk- in centres Walk- in clinics tend to oer nurse consultation
and use NHS diagnosis and management algorithms; most are sited in
urban areas and aim to provide easier access to medical care
0 Since 2014, GP practices in England have a responsibility for monitoring
the quality of OOH services for their registered patients.
NHS 111 and NHS 24 24h nurse- led telephone advice service avail-
able throughout England (NHS 111), Wales (NHS 111 Wales), and Scotland
(NHS 24). Provides a single point of contact for patients requiring urgent
medical advice or treatment; telephone services are supported by websites
providing healthcare information.
Challenges forhealthcarepractitioners
• There is a higher proportion of very ill patients in urgent and OOH
settings; healthcare practitioners may need to commence resuscitation
or critical illness management protocols more frequently
• Despite better sharing of medical records, there is often no information
about patients apart from the information that the patient/ carer
provides when a patient is seen in an urgent or OOH setting
• Team size:OOH and urgent care providers often have a much larger
team than healthcare practitioners may be used to when working
in traditional general practice. Workers may not know other team
members and may be unfamiliar with their working environment
• Healthcare practitioners may work alone for a high proportion of their
time doing home visits or manning an OOH clinic
• Access to drugs and some services may be limited
• First contact is almost always over the telephone and good
communication skills are needed to provide accurate assessment, triage
to appropriate care, and ensure safety netting
Pre- hospital emergency care To meet calls for increasing sophistication of
pre- hospital emergency care, a new subspecialty in that eld has been created. For GPs, particularly those working in urgent care settings or with
populations that are geographically remote from acute specialist services,
expertise in this subspecialty would clearly be benecial. However, currently GP training does not allow GPs to meet the basic entry requirement
for this subspecialty. Changes in GP training in the future may remedy this.
Further information
NHS 111 F 111 M www.nhs.uk
NHS 24 F 111 M www.nhs24.scot
NHS Direct Wales F 0845 4647 M www.nhsdirect.wales.nhs.uk
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