SUPPORTING GUIDANCE TO HSC 1998/139 - DEVELOPING PRIMARY CARE GROUPS

SECTION 1: ORGANISATIONAL DEVELOPMENT AND HUMAN RESOURCE ISSUES

ORGANISATIONAL DEVELOPMENT

1.     For organisational development to be successful, GPs and Health Authority staff, as well as NHS Trust clinicians and managers, will need to identify and develop change management skills and the competencies necessary to deliver change. 

2.     Plans for developing Primary Care Groups must be part of the Health Authority's wider organisational development change plan. The plans for the first year should support the priorities of the Shadow Primary Care Groups, taking account of likely future development.

3.     It will be necessary to develop and agree organisational development change plans with all interested local organisations and the Health Authority has a key role in facilitating this process. Some organisations, especially Local Social Services Authorities, are already working well together to develop their plans for managing the changes and this needs to happen across the country.

4.     To help with the management and delivery of change the first edition of an Organisational Development Starter/Resource Pack will be available shortly. The aim of this pack is to provide practical help and assistance which complements and supports guidance on Primary Care Groups as it is issued. The pack will include general information as well as examples of local initiatives and innovative practice. 

5.     In addition to this resource material, a programme of central support is being developed which will provide a menu of possible organisational development activities that can be targeted to meet the specific development needs identified within each Primary Care Group. This will include Regional Offices working with Primary Care Group leaders to support them in establishing these new organisations. This will need to address the development of new ways of working, building the teams who will deliver the Primary Care Group agenda. As the people joining each Primary Care Group will come with a different set of skills and experiences, the menu of activities will cover a range of priorities from which individual Primary Care Groups and their members will select.

6.     Clearly the Organisational Development needs of Primary Care Groups must stem from the individual requirements of each Group in taking forward the responsibilities and objectives agreed with their host Health Authority, Identification of the development requirements for each Primary Care Groups should therefore be associated with the delivery of the programme of action and support which will be undertaken by the Primary Care Group in their first year.

7.     There should be an awareness of the evolving and developmental nature of Primary Care Groups. Staff/operational appointments should therefore be made according to the skills and competencies required for each stage of the process. For example, the requirements at "start up" may not be those for later and ongoing phases.

Further information

8.     If you have any comments or require further information about organisational development (or to obtain details of the Organisational Development Starter/Resource Pack), please contact:

Mr Andrew Kent, NHS Development Unit , 1N35D, Quarry House, Quarry Hill, Leeds, LS2 7UE, Tel: 0113 254 6436. Email : akent@doh.gov.uk

HUMAN RESOURCE ISSUES

Introduction

9.     This section provides advice on managing the changes in staffing arising from the establishment of Primary Care Groups, the recruitment and appointment of staff to work within Primary Care Groups. It is based on four key principles:

all staff at risk of losing their jobs through the replacement of the internal market in the NHS should be treated fairly

the process for filling Primary Care Groups' posts and handling displaced staff should be fair and transparent

staff and their representatives should be involved throughout the planning and implementation process

redundancies should be avoided wherever possible so that valuable skills and experience are not lost to the Service and transitional costs are kept as low as possible

10.     Staff likely to be affected by these changes are:

those employed to carry out duties in relation to the management of the fund

those dealing with fundholding practices either as part of performance management or through the contracting process in the wider NHS

those working in GP or Health Authority locality commissioning arrangements

11.     Ministers have made clear that every opportunity is to be afforded to displaced staff to find alternative employment within the "NHS Family", They will also be writing to Health Authority Chairs and NHS Trust Chairs asking them to support this employment strategy to keep experienced staff within the "NHS Family".

12.     For the purpose of this guidance, the term "NHS Family" includes:

a general practitioner

staff who are employed by:

a general practitioner or the practice

an NHS Trust

a Health Authority

a Primary Care Act Personal Medical Services Pilot

13.     All employers in the "NHS Family":

are strongly encouraged to minimise the incidence of redundancy byeffective planning and providing good advice to staff

are expected to act in accordance with good employment practice and to comply with existing legislation

have statutory responsibilities for providing equal opportunities in recruitment and selection procedures. Discrimination on the grounds of race, sex and disability are prohibited under the Sex Discrimination Act 1975 and 1986, the Race Relations Act 1976 and the Disability Discrimination Act 1995

should involve all staff who may be affected by the introduction of Primary Care Groups and their representatives in the planning and implementation process

14.     Although individual GP practices have the main responsibility for consulting with fundholding staff about the implications of organisational change, Health Authorities should play a leading role in ensuring that all staff at risk of redundancy, or whose posts will suffer material change, are identified at an early stage and informed of the options available to them.

FORUM

15.     Health Authorities should consider establishing a forum which could helpfully provide a useful vehicle to discuss local human resource and organisational development issues, particularly for community nurses, and provide a means to co-ordinate the development of Primary Care Groups in that area. The forum would consist of representatives from the Health Authority, each (shadow) Primary Care Group and local representative staff organisations (and could also usefully include representatives from each local NHS Trust).

THE CLEARING HOUSE SYSTEM

16.     The concerns of displaced staff are best addressed by having a clearing house in place prior to the abolition of the GP fundholding scheme and the replacement of the internal market. The aim of the clearing house is to do what is sensible, fair and in the interests of staff and the NHS. Staff likely to be displaced will be able to register their interest in finding alternative employment within the "NHS Family" and will be expected to co-operate actively with efforts made to find them suitable alternative employment. Further information on the process for establishing a clearing house is contained in appendix 1 at the end of this section.

What is a clearing house ?

17.     A clearing house is designed to assist staff who are faced with redundancy. Clearing houses will have a key role in helping staff and their representatives by aiming to ensure that:

valuable skills, knowledge and experience are retained and redeployed wherever possible

individuals find alternative employment or other opportunities in the NHS which best match their skills, experience and personal preferences

Who will be responsible for establishing and managing the clearing houses?

18.     Health Authorities will be responsible for the management and staffing of clearing houses and, as part of the process they should consult with staff side representatives. Clearing houses can be established either by an individual Health Authority or by a group of Health Authorities, and will be a matter for local decision based on local circumstances. In all areas, Health Authorities are encouraged to cooperate in the establishment and operation of clearing house arrangements. Regional Offices will want to satisfy themselves that appropriate clearing house systems are in place. All staff affected by the changes should be given the opportunity to register with the clearing house for local NHS vacancies.  Staff also need to be assured that they will be treated equally and fairly, and their relevant experience and qualifications taken fully into account.

19.     Not all Health Authorities will have the appropriate experience or expertise to deal with human resource issues. Health Authorities are, therefore, encouraged to draw on the experience of their local NHS Trust(s) in these matters. Health Authorities will wish to discuss the level of human resource support which can be made available by the local NHS Trust(s) to ensure the process is a success and NHS Trusts will be expected to co-operate. The expertise within Community and Mental Health Trusts will be particularly valuable as they will be more conversant with Primary Care and its interface with Community Practitioners.

20.     The cost of the clearing house facility should be met from Health Authority resources, including any transitional monies (ie ex-practice fund management allowance monies retained by a Health Authority in order to assist with the management of the change process locally) retained by the Health Authority which are available.

21.     Health Authorities:

will wish to ensure that all GP practices and NHS Trusts within their area, are aware of the clearing house facility and of the help it could provide in filling posts

will want to ensure that all employers within the "NHS Family" take full advantage of the clearing house arrangements to fill any vacancies as soon as possible

should liaise with Local Medical Committees to ensure they are fully awareof the arrangements

will need to ensure there is a named contact within the Health Authority who has the responsibility for the day-to-day running of the clearing house

22.     The NHS as a whole should ensure, wherever possible, that skills, knowledge and commitment of NHS staff who cannot be redeployed locally are not lost to the service. Adherence to these principles should promote good human resource management practice and help ensure that redundancy is only a last resort.

Duration of the clearing house system

23, Ideally a clearing house system should be in place from September 1998. The duration of the clearing house will continue for as long as the Health Authority considers it necessary, however, they are expected to formally close on 31 July 1999. Health Authorities should ensure that all parties are aware of the duration of local schemes.

The principles of a good clearing house

24.     The basic principles of a good clearing house include:

regular, full and open communication with those staff and theirrepresentatives affected by the changes

fair, consistent and transparent procedures for selecting staff for posts, including a mechanism for dealing with grievances arising from the selection process

providing support, including training and development

consider locally if a period of secondment is an option

consider at local level the availability of trial periods to help establishwhether employment is "suitable"

establish a process for feedback for clearing house candidates if not appointed

As part of their performance management responsibilities, Regional Offices will monitor these arrangements locally.

Who is entitled to register?

25.     A clearing house will provide those staff who are identified as being at risk with an opportunity to look for alternative employment within the NHS. In those cases where GP practices cross Health Authority boundaries, staff should be given the opportunity to join clearing houses covering the relevant Health Authorities.

The clearing house is open to:

GP fundholding staff who are directly funded through practice fund management allowance

staff directly involved in the contracting and/or commissioning process (including locality commissioning); or in fundholder performance management and monitoring

staff employed by private companies in that locality whose main, or sole, function is the management of fundholding (examples would be management of multifunds or former total purchasing projects)

The clearing house is not open to:

staff working for a private company for whom this is a strand in their business portfolio

staff who are looking for a change of career

26.     In the interests of ensuring that displaced staff are given every opportunity to find employment within the NHS, local vacancies in GP practices, Health Authorities (including Primary Care Groups) or NHS Trusts ought not to be filled without first referring to the clearing house. Health Authorities will need to make early contact with local employers in the "NHS Family" to ensure that suitable vacancies are registered with the clearing house. All local NHS employers should be encouraged to contact the clearing house in the first instance when suitable vacancies arise.  The decision on what vacancies are considered suitable will depend on the skill mix of those registered in the clearing house.

27.     In dealing with staff during this time of uncertainty, employers in the "NHS Family" are expected to take note and act upon, not only their statutory and contractual obligations, but also good practice procedures which have been discussed with professional organisations and staff representatives. Given the expertise of the local NHS Trust management and staff associations on staffing issues, Health Authorities would be well advised to consult these organisations and seek their advice where appropriate. The following information is aimed at all employers within the "NHS Family" so that similar procedures may be adopted when dealing with displaced staff.

The process for filling vacancies

28.     Employers in the "NHS Family" will want to fill their vacancies as quickly as possible so it is in everyone's interest that the clearing houses allow for a quick turn around of information. They are also advised to take firm action to avoid unnecessary bureaucracy. NHS employers will already have local procedures in place for dealing with staff who are at risk of redundancy. However, to ensure all staff are treated fairly and sensitively during the change process, the NHS Executive recommends the following action is taken by Health Authorities when dealing with all staff who have registered with the clearing house.

(a) Displaced staff

arrange an interview with the member of staff

have a clearing house information pack available

complete the competency form

arrange training/staff development if appropriate and possible, eg  information and technology skills (the cost of which should be borne by current employer)

establish a database on which to register details of individuals and their competencies so that it is possible to match individuals to vacancies

(b) Keep ing people informed

establish regular meetings with those staff affected. Set a timetable where necessary. Ensure surplus staff have realistic expectations in gaining employment

keep staff side representatives involved and informed. They may have experience in these areas which may prove helpful. If NHS Trust staff are registered with the clearing house, then the NHS Trust staff side representatives will need to be consulted

make available a regular progress report to all interested parties

NHS Trust and/ or Health Authority staff who may be made redundant

29.     In the event of redundancy in Health Authorities, the Whitley Council rules will apply. NHS Trusts will need to follow their own local policy unless staff are still on Whitley contracts.

Transfer of staff

30.     It is unlikely that TUPE (Transfer of Undertakings Protection of Employment Regulations 1981 ) will apply in the case of staff moving to work with Primary Care Groups although it is recommended that employers follow good employment practice and take legal advice where appropriate. If the preferred model (as set out in paragraph 44) is followed and Primary Care Group staff are to be employed on Health Authority terms and conditions, although they may be different it is unlikely that Health Authority terms and conditions will be any worse.

Pension information for GP practice staff

31.     GP practice staff became eligible to join the NHS Pension Scheme with effect from 1 September 1997. All former GP practice staff who secure a post either with a Primary Care Group, a Health Authority or an NHS Trust will continue to be a member of the NHS Pension Scheme if they wish. There will be no need for a 8 transfer of pension rights. Staff who become employees of a Health Authority or NHS Trust will be entitled to additional benefits eg benefits on redundancy, voluntary early retirement with the employers consent, and cover under the NHS Injury Benefit Scheme.

REDUNDANCY - A GUIDE FOR GP PRACTICES

32.     Redundancy should always be the last resort. Employers are strongly advised to consider all other feasible options such as voluntary reductions in hours, changes in duties, restructure or reorganisation of the organisation and retraining. In the event that staff are unhappy about any decision taken, an appeal or review procedure is generally regarded by an Industrial Tribunal as an important element of any redundancy policy.

33.     The golden rules are:

the Employment Rights Act 1996 defines redundancy as "a dismissal wholly or partly due to the cease of business for which the post was created or a decline in demand for employees of that kind "

redundancy must be fair to the employee and to the organisation

it is the post that is redundant NOT the person - redundancy must not be used as a means of dismissing staff considered to be unproductive

careful attention is given to each employee's contract of employment document and any organisational policies and procedures. If in doubt, you are advised to seek specialist advice

Right to redundancy

34.     In the event that redundancies need to be considered, GPs as employers will need to be aware of the statutory rights and existing contractual entitlements of their staff. All employers are encouraged to seek specialist advice on any areas of uncertainty. The Advisory, Conciliation and Arbitration Service advises the following good practice:

give as much warning as possible

consult with the Trade Unions or employee representatives in an attempt to avoid the need for redundancies

try to achieve it fairly with as little hardship as possible

look for alternatives such as the availability of other posts

establish, in consultation, with any union or employee representatives, the selection criteria for identifying redundant staff, how the criteria are to be applied and ensure that the criteria are fair and objective. This may be necessary if there is no clear distinction between the duties of fund and non-fundholding staff in the practice because the practice may have to review part or all of its staffing structure

Further guidance can be found in the Advisory, Conciliation and Arbitration Service publication "Redundancy Handling" which can be obtained by telephoning 01455 852225.

35.     Current legislation means that an employee has to have two years continuous employment with the same organisation in order to be entitled to a statutory redundancy payment although the European Court of Justice is currently considering a challenge against the compatibility of UK legislation with European law. Employers should therefore seek advice when considering entitlement to statutory redundancy payments as decisions made by the European Court may impact on UK legislation. Further details are at appendix 2 at the end of this section. Part time staff have the same rights as full time staff when calculating their length of service. Employees with less than two years service can be dismissed using the notice period on their contract or their statutory rights to notice whatever is the greater.

Payment in Ileu of notice . .

36.     In order to make a person redundant lawfully, proper notice of dismissal must be given. Section 86 of the Employment Rights Act 1996 sets out minimum periods of notice according to length of service but the contract of employment may give employees rights to greater notice. If, in a redundancy situation, the employer does not give the required period of notice, then there must be payment in lieu of notice.  This payment will be equivalent to the salary which the employee would have received had they been permitted to work out the notice period. If there is a fixed term contract but no provision for termination by notice the payment will be equivalent to the salary which the employee would have received had the contract expired normally. Employers in the "NHS Family" will need to check the contracts of all staff who are likely to be displaced on or before 31 March 1999 as a result of the end of fundholding and the replacement of the internal market in the NHS.  They will wish to ensure that proper notice is given where redundancy occurs.  Failure to do this will incur unnecessary costs as payment in lieu of notice will have to be made.

Redundancy policy

37.     Redundancy payments are the responsibility of the current employer. Health Authorities are bound by the terms and conditions of the Whitley Council Handbook and NHS Trusts by whatever terms and conditions they have agreed with their staff, unless staff are still on Whitley contracts. General Practitioners are obliged to make any payments due under a contract of employment, including any contractual entitlement for compensation for redundancy. However the liabilities of the allotted sum for payments to redundant fundholding or practice management staff are limited to the costs of statutory redundancy payments (ie employers' minimum liabilities under the Employment Protection (Consolidation) Act 1978, as amended). Any costs over and above the statutory redundancy payment will need to be paid from the GPs own (or practice) income.

38.     Where there might be individual anomalies between the obligations under an employment contract and the requirements of the National Health Service (Fundholding practices) Regulations 1996 (as amended in 1998), then these individual cases should be discussed with the Health Authority. Where necessary further advice on these individual cases should be sought from the NHS Executive.

39.     The NHS Executive wish to ensure a level playing field regarding movement between employers within the "NHS Family", therefore, staff from the "NHS Family" should not be able to commence employment with another NHS employer for four weeks after the receipt of a redundancy payment. This requirement mirrors that contained in Section 45 in the General Whitley Council Handbook.

ConsuItation

40.     The Arbitration, Conciliation and Advisory Service suggest best practice is to involve union representatives as soon as possible when redundancies are being considered and to have a meeting with all staff and their representatives to discuss the possibility of redundancies. The organisation can then go on to have individual meetings with those likely to be affected as required. The NHS Executive recommends this course of action in all circumstances where redundancies are concerned.

Rights of employees

41.     NHS employers and GP practices should comply with the principles of employment towards good employment practice regarding employees' rights in a redundancy situation. These are that: l the reasons for redundancy must be fair, reasonable and non-discriminatory l consideration should be given to whether there is any suitable alternative work available for that person in the organisation. At all stages the employee and the employee's representative will be involved in the process of identifying the suitability of actual and potential vacancies l employees' due to become redundant have the right to reasonable paid time off work to look for another job or to arrange training l employees' have a right to representation

Contracted services

42.     There may be instances where individuals currently provide healthcare services to GP fundholding practice under a contract for services. This is not a contract of employment. After the abolition of fundholding, where there are existing contracts for services for healthcare provision which have not yet expired, these will be either taken over by the Health Authority or, exceptionally, allowed to remain with the former members of the fundholding practice and the Health Authority should reimburse costs. When considering any new contracts for healthcare services, Health Authorities and Primary Care Groups should ensure that the contracts are placed only with State Registered personnel, where a profession is so regulated.

RECRUITMENT TO PRIMARY CARE GROUPS

Employment of Community and  Practice Nurses

43.     Unlike Primary Care Trusts, Primary Care Groups as committees of the Health Authority, can not directly employ staff. Staff who are currently employed in GP practices or who work in GP practices as a result of a contract with a Community NHS Trust (such as community nurses) will continue being employed by their current employer. Although Primary Care Groups may have nurses represented on their governing boards, the Primary Care Group itself will not employ any nurses or clinical staff.

Preferred method of empIoying staff in Primary Care Groups

44.     It is expected that Health Authorities should be the employer of Primary Care Group management and administrative staff unless there are clear reasons to support some alternative arrangements. Such employment would be on Whitley Council terms and conditions of service. The lines of accountability in this model would be the Health Authorities as the employer with national terms and conditions prevailing and the staff being accountable to the Primary Care Groups governing board through the Primary Care Group Chair, for carrying out the duties delegated to the Primary Care Group.

TimescaIe for filling posts in Primary Care Groups

45.     Vacancies for posts in Primary Care Groups are likely to start being advertised from October onwards. The NHS Executive strongly recommends that posts are advertised via the clearing house in the first instance and those registered with the clearing house with the requisite skill will have the first opportunity to apply.

46.     As there may be residual work to be carried out within GP fundholding, it is anticipated (subject to forthcoming legislation) that GP fundholding staff, appointed to work within Primary Care Groups, might be loaned back by their new Health Authority employer to their former practice. Clearing houses may be best placed to play a role in identifying and facilitating this process so as to ensure an orderly and proper basis for GP fundholding practices to make suitable arrangements to finalise accounts, whilst ensuring fundholding management staff are able to apply and be appointed to work on the establishment and development of Primary Care Groups,

47.     However, the majority of staff will be appointed to Primary Care Groups to become operational on 1 April 1999. It is therefore likely that staff who do not have a position on 1 April 1999 will be made redundant under the terms of their contract of employment. They may however, continue to be registered with the clearing house in order to find alternative employment within the NHS.

Identifying skills and competencies

48.     Once the level at which a Primary Care Group will operate has been approved, it will need to start thinking about the appropriate staffing levels, the skills and the competencies which will be required. Appointments should reflect the nature and duration of the tasks to be undertaken.

49.     Many organisations are developing their own local job descriptions and identifying core skills and competencies for staff working within Primary Care Groups. Examples of local initiatives and useful examples will be included in the Organisational and Development Starter/Resource Pack.

Recruitment of staff

50.     Once Primary Care Group governing boards have been established and are considering recruiting staff, both they and their Health Authority will want to ensure that proper care and attention are paid to good recruitment practices. This means that for all Primary Care Group posts there should be a job description, person specification and the posts should be appropriately advertised. The NHS Executive strongly recommends that posts are advertised initially through the clearing house to give potentially displaced staff an opportunity apply for new Primary Care Groups posts for which they may have ideal experience and qualifications. If that process is not successful recruitment can then be opened to all other interested candidates.  The recruitment process should be transparent and auditable in order to show that appointments have been made fairly and appropriately.

51.     The NHS Executive does not expect any Primary Care Group posts will be identical to existing Health Authority posts or to existing fundholder posts. All Primary Care Groups posts will need to be filled through competition and advertised, in the clearing house in the first instance. Although the Health Authority in normal circumstances will employ the staff who work in the Primary Care Group, any selection processes and appointments will be made by a panel of Primary Care Group members, in accordance with existing Health Authority procedures, and will include a Health Authority representative. HSC 1998/065 set out the suggested arrangements for the appointment of staff to Primary Care Groups. This advises that the interview panel should consist primarily of people drawn from the proposed Primary Care Group, with the Health Authority represented either as an assessor or as the employer of Primary Care Group staff.

52.      In order to ensure fair treatment of candidates, recruitment policies should include:

fair, consistent and transparent procedures for recruitment

a clear process for producing person / job specification

details of eligibility to apply for posts

objective selection procedures

details of process for short listing

details of interview process to be followed

details of the composition of interview panel

staff recruitment training, particularly in equal opportunities issues, for those involved in interview panels

all NHS employers are expected to have and operate an equal opportunities policy

Equal opportunities

53.     All equal opportunities policies should be clear that employees are afforded equal opportunities in employment, irrespective of their age, gender, marital status, race, religion, creed, sexual orientation, colour or disability. In operating all policies, employers and their employees should positively develop and practice the concept of equal opportunities for all. This policy should be applied to all recruitment procedures to Primary Care Group posts.

Recognition of previous service in GP practices

54.     There is no legal requirement for NHS Trusts and Health Authorities to recognise continuity of employment for staff previously employed in GP Practices. However, in the interests of employment preservation and the concept of the "NHS Family", NHS Trusts and Health Authorities are requested to consider recognizing previous service with a GP practice for statutory redundancy, unless there has been a redundancy payment and the required break in service (see paragraph 38). This recognition should only apply for statutory redundancy purposes and there is no read across to any other Whitley provision where continuity of service is recognised. This will ensure that staff moving into the NHS as a result of the abolition of fundholding will be no worse off in the event of being in a redundancy situation in the future.

TimetabIe of events

End July 1998	Health Authorities establish Primary Care Groups
September & October	Appointment of Primary Care Group governing board and the governance arrangements and set up clearing houses
From October 1998	Develop the organisational and staffing structures for Primary Care Groups
November/December 1998	Advertise and recruit to posts in Primary Care Groups

Further information

55.     If you have any comments on other human resource issues which you think should be addressed in future guidance, please send your comments to:

Mr Godfrey Perera, 2W26, NHS Executive, Quarry House, Quarry Hill, LEEDS LS2 7UE Tel 0113 254 5757

STATUTORY REDUNDANCY PAY - A GUIDE FOR GPs

It is recommended that GPs take legal advice on redundancy issues, however, it should be noted that:

service under the age of 18 or over normal retirement age does not count

service between the ages of 18 and 22 is calculated as half a week's pay per year

service between 22 and the employee's 41st birthday is calculated at one weeks pay per year

service between 41 and 64 is calculated at one and a half weeks pay per year

redundancy pay after 64 is reduced by 1/12th for each month by which the employee approached 65. If the normal retirement age of the Practice is less than 65 there is no reduction made

only complete years count when calculating redundancy

only the lump sum is gross. Any other payments (eg, payment in lieu of notice or to compensate for annual leave) is net

A weeks pay

The statutory limit on a weeks pay is capped at £220 (gross) per week. Employees earning more than this amount are not entitled to redundancy pay based on their normal weekly wage - only £220. Employees earning less than £220 are entitled to redundancy pay based on their actual weekly pay.

A weeks pay is calculated as the average hourly rate payable in the period of 12 weeks prior to redundancy date. If the employee has been absent earlier weeks should be taken into account. Where overtime has been worked, any enhancement to the normal hourly rate can be discounted.

The date of actual redundancy is the date on which the termination of contract takes effect, This is at the end of the notice period or what would have been the notice period if it has been paid off in lieu. Calculation of redundancy pay should include the notice period as part of the employees service.

Advice on good practice and grievance and redundancy procedure is available from Advisory, Conciliation and Arbitration Service.

SECTION 2: THE INVOLVEMENT OF STAKEHOLDERS

INVOLVING STAKEHOLDERS

56.     Primary Care Groups must seek to actively involve and engage all stakeholders in shaping the decisions and policies of the Group. Primary Care Groups will therefore need to adopt processes and structures which will allow participation by groups, organisations and individuals who are not represented on the governing board of Primary Care Groups. It will be for individual Primary Care Groups to determine themselves how they can best ensure such involvement, Experiences from total purchasing, GP commissioning arrangements and from NHS Trusts suggest that the best models are those that are based around structures which might be focused on:

geographical service or health interests (ie locality based) or community interests (eg ethnic, religious or cultural groups)

performing functional tasks (eg budget setting, needs assessment etc)

commissioning services (eg the elderly, children and adolescent services, primary and community care)

clinical areas or specific client groups (eg diabetes, mental illness etc)

57.     In establishing these types of arrangements they will better facilitate involvement of specific interest groups (the voluntary sector, patient groups, local government agencies etc) or those with a specific knowledge of the subject area. This will facilitate great involvement in the decision making process, ensure specific interests are recognised and represented, and permit individual GPs (or others) to be involved in areas where they might wish to be actively involved. Such an inclusive approach will best demonstrate the maturity and capability of Primary Care Groups to progress and develop to take on increased responsibilities from their host Health Authority.

Framework for involvement and development

58.     The wider involvement of health professionals in the operation and development of Primary Care Groups can have an important role in informing and shaping the decisions that Primary Care Groups will need to make. Amongst other things, they will enhance and develop professional alliances within Primary Care Groups by bringing a range of skills and experiences which can be utilised in planning the delivery of care to individual client groups and the wider community.

59.     Primary Care Groups will be working with the framework of implementing the Health Improvement Programme to which it will have been involved in preparing.  Key to achieving effective delivery of the Group's functions is to ensure the wider group of stakeholders have ownership of the local programme for implementing the Health Improvement Programme. The involvement of professionals whose work affects and is affected by evolving local strategies and implementation plans, including the development of clinical standards, will be crucial in meeting this challenge. An inclusive process will facilitate Primary Care Groups to build on the successful recent developments in primary care and reduce the sense of isolation felt by some NHS professionals working in small practices and as non-principals.

60.     It is important that those responsible for the good governance of Primary Care Groups recognise that each profession has a contribution to make to the commissioning and provision of health services. Equally, NHS Trusts and other employers (or self-employed contractors) should ensure that health professionals are encouraged and facilitated to take part in the work of Primary Care Groups as this will benefit the NHS as a whole. Unless alternative arrangements are agreed with the relevant employers or individual professionals, the traveling and other personal expenses of professionals not employed by a Health Authority but involved in working with Primary Care Groups should, where appropriate and possible be recognised and reimbursed accordingly from the management resources available to that Health Authority or Group.

61.     Health Authorities and NHS Trusts already have well established mechanisms for engaging with health professional organisations and representatives: these include statutory Local Representative Committees, and local professional advisory committees. Health Authorities and their Primary Care Groups should consider how to ensure the involvement of these professions in the new agenda and how best to make use of existing arrangements for engaging with key stakeholders. A list of health professionals is contained in appendix 1, they, by virtue of their specialised training in health care and experience in other health work, will offer Primary Care Groups a range of professional perspectives.

THE NURSING, MIDWIFERY AND HEALTH VISITING CONTRIBUTION TO PRIMARY CARE GROUPS

62.     Nurses, Midwives and Health Visitors  will make a significant contribution in delivering the functions of Primary Care Groups, not only as representatives on the governing boards, but also at an operational level. This will require the active development of supportive networks and structures by Primary Care Group boards, Health Authority and NHS Trust managers.

63.     For Primary Care Groups to be established properly and to function effectively, Health Authorities, NHS Trusts and GPs will need to work in partnership with nurses locally to:

consult and actively involve ail nurses in their establishment and development

ensure that effective communication systems and networks are developed to support and inform the active involvement of nurses within Primary Care Groups in the planning and policy making process

secure a partnership with other professional groups and organisations

identify and respond to the learning and development needs of nurses (and other staff) by working in collaboration with education consortia

Contribution to Primary Care Groups at board level

64.     Guidance on governing arrangements and the appointment of up to two nursing representatives to the board of Primary Care Groups are set out in paragraphs 19-20 in the main guidance. This emphasises that nurses in each Primary Care Group will have a vital role to play both in strategic planning and in policy making. It will be important to ensure that those appointed have, or have the potential to acquire, the range of skills that will be required and are able to access supportive professional networks to inform the nursing contribution.

65.     In accordance with paragraph 23 of HSC 1998/065, nurses locally will decide who is to represent them in the governing arrangements for Primary Care Groups. If the number of applicants dictates formal selection, the process must be established and agreed by the Health Authority who must ensure that nurses are in the majority on the selection panel.

66.     It is important to stress that it is not intended that nurse board members should represent a particular speciality, organisation or other constituency, but rather that they should be able to reflect the views, knowledge and experience of nursing, midwifery and health visiting professionals. To do this effectively and to play a full part in the Primary Care Group's strategic planning and decision making, nurses will need to have access to extensive professional networks to support and inform their contribution.

67.     Primary Care Groups will not be able to employ staff directly. Nurse members of the Primary Care Group governing body will continue to be employed by NHS Trusts or in the case of practice nurses by the GP. This will require discussions between the Health Authority, NHS Trust or the GP to ensure that the community or practice nurses are provided with clear objectives, the time required to fulfil their role on the Primary Care Group governing board and that where necessary, the GP practice receive resources to enable them to cover replacement costs. It is also important to emphasise that nurse members of Primary Care Group governing boards will not, as part of that role, directly manage community or practice nurses.

68.     The key to an effective nursing contribution will be collaboration to ensure that all board members are fully appraised and able to play an active and meaningful part in Primary Care Group corporate decision making. Like other board members, nurse members should be able to contribute to the full range of issues for which Primary Care Groups will have responsibility including:

securing inter-agency planning and working

workforce planning at the primary health care team and Primary Care Group levels

the development of education, training and development programmes and liaison with Health Authority and NHS Trust colleagues on education consortia

enabling the involvement of local people and patients in service planning and seeking their views on service quality

69.     To assist the nurses at Primary Care Group board level, and ultimately the effective functioning of Primary Care Groups, it is expected that a network should be established which will enable all nurses to bring a wide range of skills, professional knowledge and experience to assist the Primary Care Group to improve health and health inequalities.

70.     Nurses should contribute to groups or forums operating below board level, developing policy, providing clinical leadership and management advice. Involvement will need to reflect the appropriate balance of interests to ensure that the tasks of the Primary Care Groups are undertaken by those with the greatest knowledge and experience of the field concerned (eg midwives will need to be involved in planning maternity services; the advice of specialist nurses such as continence advisors; and Macmillan nurses) will equally be required to inform the planning and decision making on specialist service configuration, provision and quality. The groups will provide the opportunity to address issues associated with health and health care across primary, secondary, social and voluntary care. This sharing of expertise and knowledge will in turn provide valuable information to support Primary Care Group board members.

THE INVOLVEMENT OF LOCAL SOCIAL SERVICES AUTHORITIES

71.     Local Authority social services are a key component in the public service supporting many of the most vulnerable people in our society. They work with those most in need - the old and the frail, people with learning or physical disability, people with mental illness, neglected or abused children and their families, and with offending children and their families. These groups of people are also often those who have the greatest health need and can place great demand for care and support on primary care provision.

72.     The involvement of Local Social Services Authorities in the governing arrangements for Primary Care Groups underpins the establishment of a new partnership between primary and social care. Providing a positive opportunity to draw primary care and social services together to develop a comprehensive approach to both the commissioning and provision of health and social services. Local Authority members will have an enhanced opportunity to influence at a strategic level by influencing the development and implementation of Health Improvement Programmed in their community. The arrangements for involving social services at an operational level, within the development of Primary Care Groups, aims to ensure that the social services perspective is borne in mind in the development of health and community services locally and in the development of local implementation plans for the delivery of the priorities set out in the Health Improvement Programme.

73.     Local Social Services Authorities will have been closely involved with the development of Primary Care Group configuration in their locality and the relevant Local Authority should now be approached to nominate officers to represent the social services on the Primary Care Group. The arrangements for obtaining social services representation on the governing arrangements for Primary Care Groups are set out in paragraph 21 of the main guidance. The level of officer nominated will depend on the agreed local configuration of individual Primary Care Groups and local circumstances; but it is expected that this would be an operational manager associated with the Primary Care Group area in question.

74.     The Local Authority will need to make clear what level of delegation the nominated officer will have. Will the social services representative be able to speak on behalf of the Local Social Services Authority and to make decisions without referral back to the Local Authority? (Local Authorities in considering this will need to bear in mind that some of the Social Services representatives could be budget holders themselves. ) In considering the level at which to appoint officers, the Local Social Services Authority should also bear in mind that the officer will, as an employee, be accountable to the Local Authority but as a member of the Primary Care Group board, they will be collectively accountable, as will all other board members, to the Health Authority for the performance of the Primary Care Group.

75.     The role of the local social services representative will develop as the Primary Care Group matures. Dependent on the stage of development the Primary Care Group has reached, the Social Services representative's role could range from sharing information to assist the Primary Care Group in mapping the needs of, and the services available to its residents; to developing plans which take a holistic view of future developments that will assist the Primary Care Group to shape service provision to achieve better integrated care for local people and influence the Health Improvement Programme. Primary Care Groups will be pivotal to the development of Joint Investment Plans. Joint Investment Plans will contribute to the preparation and delivery of Health Improvement Programmed by putting into operation health improvement strategies that span the health/social care interface.

76.     Overall the Social Services representative will act as a conduit between the Primary Care Group and Social Services. The Social Services input will bring a unique perspective and skills to the Primary Care Group. Enabling Primary Care Groups to:

capitalise on Social Services experience of consultation processes, involving users and carers and to draw on the good relations that Social Services and Local Government have built up with users and carers

draw on Social Services expertise of working with non-statutory providers of services

increase their knowledge of each others roles and organisations and how each might help the other in discharging their individual and collective responsibilities

77.     Primary Care Groups will also need to build up its partnership with wider local government. There are a number of ways they could approach this and the social services representative would be well placed to advise on how these partnerships could be established (eg the Primary Care Group may wish board members other than the social services representative) to lead on specific aspects of partnership.  In some areas the social services representative may be able to act as a gateway to other local government departments eg environmental health, housing education. But this may not be an option where the Local Authority function is the responsibility of a different Local Authority.

THE INVOLVEMENT OF OTHER HEALTH PROFESSIONALS

78.     Primary Care Groups will need to engage a wide range of health professionals if they are to achieve the delivery of care to their patients and wider population.

Primary Care Groups will need to:

identify and actively involve these key stakeholders in the policy and decision making process

take advantage of their networks of contacts, including those across Local Authority and the voluntary sector

harness their unique skills and competencies, and work together to form an effective partnership

With this involvement, Primary Care Groups will be able to gain the support, ownership and responsibility from these health care professionals. Guidance on the role of the public health specialist will be set out in the autumn guidance.

Dentistry

79.     There is a need for dentists to be involved in the development and integration of NHS dentistry at the local level and for dentistry to become more closely integrated with the NHS as a whole. Primary care dentists can:

contribute to the oral health component of the Health Improvement Programme

promote oral health, including a reduction in inequalities

provide and develop primary dental care services, to improve access

contribute to clinical governance and the development of high quality dental services

advise on the appropriate commissioning of secondary dental services

80.     Primary Care Groups should establish mechanisms for facilitating dental involvement in their work on oral health. Primary Care Groups will also wish to access the expertise of the Health Authority consultant in dental public health.

Optometry

81.     Primary care optometrists have a valuable role to play in the provision of primary eye care. Some optometrists have extended their role beyond providing general ophthalmic services to become involved in locally funded shared care schemes.

Areas of activity where optometrists have a valuable contribute to make include:

monitoring the eye health of diabetics

monitoring the eye health of patients with glaucoma/ocular hypertension

provision of selected Low Vision Aids

children's eye care

contributing to the pre and post-operative care of cataract patients

treatment of anterior segment eye disease

82.     Some Health Authorities have appointed Optometric Advisers who, together with the Local Optometric Committee, have assisted the Health Authority in developing higher quality, more cost effective primary and secondary eye care. Each Health Authority will wish to consider with each Primary Care Group and the profession locally how optometrists can contribute to the role of the Primary Care Group in developing primary eye care and how this will fit in with district strategies for the improvement of eye health.

Community Pharmacies

83.     Millions of patients make use of the nationwide network of community pharmacies every day. As well as ensuring that they get them quickly and conveniently, community pharmacists help patients use their prescribed medicines safely and effectively. For many people, pharmacies are the first port of call for immediate help and advice with minor ailments, and increasingly for advice on maintaining a healthy lifestyle.

84.     Arrangements for mainstream community pharmaceutical services are based on a national contract, administered by Health Authorities. Primary Care Groups will not have a direct role in that contract. But the national contract by no means exhausts the contribution which community pharmacies can make and Primary Care Groups should consider service agreements with pharmacies as among the ways of delivering the services for which they are directly responsible. For example:

community pharmacists are an obvious source of advice on cost-effective prescribing and many GP practices already benefit from such advice

many Health Authorities are contracting directly with community pharmacies to extend local NHS services or improve their cost-effectiveness. Often this involves a structured role for pharmacists in medicines management - for example, targeted medication review, domiciliary visiting or adherence counseling - to help prescribers and patients make the most cost-effectiveuse of their medicines

Health Authorities have also invested in schemes to use pharmacies in local health promotion campaigns and as part coordinated action on certain minor ailments. This is in addition to long standing arrangements such as needle exchange and disposal of waste medicines

85.     The Government will be publishing a strategy document later this year setting out ways of implementing its aim of expanding the contribution of community pharmacy.

86.     Primary Care Groups need also to be aware that decisions they may make on, for example the adoption of local formularies, shared repeat prescribing policies or developments in community nursing services and hospital discharge arrangement will impact professionally and commercially on local community pharmacists, In considering issues which may affect community pharmacies, Primary Care Groups should, as a minimum, consult the Local Pharmaceutical Committee.

THE INVOLVEMENT OF USERS AND THE PUBLIC

87.     Greater user and public involvement in the NHS is an important priority in order to rebuild confidence in the NHS as a service accountable and open to users and the public and which is shaped by their views. This can only be achieved by ensuring that there is a strong public voice in decision making within the health service.  Primary Care Groups can play a key role in communicating with local people and ensuring public involvement in decision making about local health services.

Why user and pubIic involvement?

88.     There are a number of good reasons for the development of greater user and public involvement in NHS planning and decision making processes. It can:

contribute to greater openness and accountability in the NHS

develop a greater local understanding of the issues involved in major local service changes

help to strengthen public confidence in the way major changes in local health services are planned

develop a greater sense of local ownership and commitment to health services

lead to better quality and more responsive services through listening to and understanding the needs and wishes of health service users and involving them in service planning, development and monitoring

enable local people to have access to better information about health and health services which can lead to more appropriate use of services

89.     Primary Care Groups will need to determine locally how best to achieve effective involvement of users and the public. However, in keeping with the intention of a more open and accountable NHS that works collaboratively and in partnership with others, as a general principle, user and public involvement should be regarded as an integral part of Primary Care Groups' activities. It should not be seen as an "add on", nor as being fulfilled by a one off activity such as an annual public meeting. The aim should be to develop a continuous dialogue with local communities.

Primary Care Groups should:

put in place plans for the early, systematic and continuous involvement of users and the public

be able to demonstrate how in carrying out their role they have involved users and the public

provide feedback to users and the public on the outcome of their involvement

Primary Care Groups should draw on their Health Authority's experience of involving users and the public.

91.     As part of the national programme to develop a "new NHS", the Government intend to make decision making within the NHS more open and transparent. Ministers are therefore committed to making the governing arrangements of NHS organisations more representative of local communities. As part of this process Primary Care Groups will have individuals on the Primary Care Group board who can effectively represent the local community and users' and carers (these arrangements are set out in paragraphs 22 - 23 of the main guidance).

92.     To assist Primary Care Groups, and their Health Authorities, in considering how to take forward the involvement of the public in the work to be carried out by Primary Care Groups, a synopsis of useful publications about methods for obtaining involvement will be contained on the Organisational Development Starter/Resource Pack which will be available shortly.

Community HeaIth Councils

93.     Community Health Councils have a statutory responsibility for representing the interests of the public on health service matters in their area. The functions and responsibilities of Community Health Councils are not affected by the establishment and development of Primary Care Groups. In particular, the establishment of Primary Care Groups does not extend the powers and remit of Community Health Councils to cover general medical service provision nor the actions and delivery of services by Local Social Services Authorities. Community Health Councils have a statutory right to be consulted by Health Authorities on substantial service developments in the health service and variations in services that Health Authorities have under consideration. This will include substantial developments and variations in hospital and community health services which are proposed by Primary Care Groups.

94.     Community Health Councils can also play a valuable role in assisting Primary Care Groups in carrying out the functions that Health Authorities will devolve. They have considerable knowledge of the operation of health services in their districts, direct knowledge from representing patient interests where standards of service can 25 fall down, and are able to provide an informed view of the issues causing patient concern. Community Health Councils will, therefore, need to develop effective working relationships with Primary Care Groups as part of their strategic approach to user and public involvement.

Complaints

95.     Any complaints relating to how Primary Care Groups have carried out the functions delegated to them by Health Authorities should be dealt with through the normal complaints procedures operated by Health Authorities.

THE MEANING OF "HEALTH PROFESSIONALS" IN THIS GUIDANCE

Clinical Services Professions, including:

Audiologists

Chiropodists/Podiatrists

Chiropractic

Clinical Psychologists

Complementary Therapies

Dietitians

Health Promotion Specialists

Occupational Health Staff

Occupational Therapists

Orthoptists

Osteopaths

Physiotherapists

Psychotherapists

Speech and Language Therapists

and

Specialist Nurses such as:

Continence Promotion Nurses

Stoma Care Nurses

Tissue Viability Nurses

Chronic Disease Nurses

Community Pediatric Nurses

Diabetes Nurses

Asthma Nurses

Macmillan Nurses

The Independent actor professions other than General Practitioners:

Dentists (for the purposes of this guidance only references to dentists includes general dental practitioners, community dentists, personal dental services dentists, salaried dentists and professionals complementary to dentistry)

Optometrists

Community Pharmacists

Additional professional groups are listed in HSG(95)11

SECTION 3: CLINICAL GOVERNANCE ARRANGEMENTS

"The new NHS": Principles of Clinical Governance

A quality organisation will ensure that . . . .

quality improvement processes (eg clinical audit) are in place and integrated with the quality programme for the organisation as a whole

leadership skills are developed at clinical team level

evidence based practice is in day-to-day use with the infrastructure to support it

good practice, ideas and innovations (which have been evaluated) are systematically disseminated within and outside the organisation

clinical risk reduction programmed of a high standard are in place

adverse events are detected and openly investigated and the lessons learned promptly applied

lessons for clinical practice are systematically learned from complaints made by patients

problems of poor clinical performance are recognised at an early stage and dealt with to prevent harm to patients

all professional development programmed reflect the principles of clinical governance

the quality of data gathered to monitor clinical care is itself of a high standard

96.     For the health professions, quality of patient care has always been of great importance. Yet there is a good deal of variability in quality, partly because 'NHS professionals have not always had the tools or expertise to advance the quality agenda, "The new NHS - Modern and Dependable" outlined how quality issues might be considered across the service. The recently published consultation document "A First Class Service" took these issues further. This section explains some of the ways Primary Care Groups should take forward the agenda for quality in relation to clinical governance.

97.     Use of information, clinical audit, use of clinical effectiveness material and continuing education as part of continuing professional development are very familiar. Grouping the principles in this way, as part of a concerted programme of clinical governance within primary care, is new.

98.     A number of workshops, meetings and many informal discussions around the country have' already been held. Early outputs from these suggest that a common agenda is emerging; first of all the process of Clinical Governance is inclusive -there can be no opting out. Secondly the process should gain the confidence of participants, both in the topics and the process. Thirdly that clinical governance will improve the many - or care for the many - and that it will begin to tack/e the unacceptable.

99.     Further aims should be for achievable change, with a focus on specific issues. There should be early involvement of patient representatives or groups. The whole process should aim to be reflective and supportive for doctors, nurses and other health professions operating within Primary Care Groups.

100.     It is self evident that not everything needing attention can be addressed at once; clinical governance (like other functions to be undertaken by Primary Care Groups) is a developmental process. It is suggested that Primary Care Groups, in the first instance, apply the principles to one national issue of importance and one area of local concern to the Group in the first year. In subsequent years Primary Care Groups are expected to build in further areas for consideration and development.

National topics

101.     The criteria for selecting areas of national importance are that:

the issues affect all patients and practitioners

there is a substantial burden of morbidity attached

the areas are of current interest elsewhere in the NHS

102.     Under this criteria the topics chosen are:

Antibiotic prescribing

Cancer services

Mental Health Services

Coronary Heart Disease

103.     The first of these has been the subject of several recent reviews, including a Committee of the House of Lords discussing antibiotic resistance in bacteria. The report of the committee said that:

"...ln general practice, where most antimicrobial in human medicine are prescribed, there are wide variations in practice; many such prescriptions (witnesses offered figures ranging from 5 to 50 per cent in different settings) are unjustified on strictly clinical grounds, and where a prescription is justified the drug used is often inappropriate (and more expensive than necessary )..."

In other words, there is an important problem in clinical practice, which may be amenable to action through clinical governance. Although the House of Lords 29 committee drew attention to cost, the important issues include antibiotic resistance and appropriateness of prescribing.

104.     The other priority areas are:

the Calman-Hine Report on cancer which was published in April 1994 and implementation is now under way

National Service frameworks are being developed which will cover mental health services and Coronary Heart Disease. Emerging findings will be published in the autumn, with the first draft of the National Service Framework in Spring 1999. This will enable implementation to begin during 1999/2000

However, these areas might be too wide to take on as a whole. Therefore,particular aspects of clinical care, such as prescribing, might serve as a focus.

Local topics

105.     These should fit with the Health Improvement Programme but beyond that they are at the discretion of the Primary Care Group. But they might include, if appropriate, addressing health problems experienced by black and minority ethnic populations or problems that such populations may experience in accessing high quality general health services. The principles of clinical governance also apply to the organisation and standards for the more general delivery of a service, eg telephone triage, arrangements for access to care in or out of hours.

Local action to promote clinical governance

106.     Each Primary Care Group should appoint a senior doctor or nurse to take responsibility at board level to ensure that a proper process for clinical governance is in place. That person will therefore take responsibility for formulation of an agreed action plan. Each practice within the Primary Care Group will also wish to ensure that one person is remitted to take forward the plan. Individual practices may wish to, and the Primary Care Group will, show what action has followed Clinical Governance principles through an Annual Accountability Agreement.

107.     In order to formulate the plan there should be engagement with local experts (and, where appropriate, budget holders) in national, clinical and practice audit, postgraduate education and training, evidence based care and organisation.  Frequently this expertise may be at or accessed through the Health Authority, NHS Trust and possibly local academic units or College faculties. However, in utilising these resources the action plan should remain under the direction of and firmly owned by the members of the Primary Care Group.

108.     Key stakeholders, especially patients, should be involved at an early stage. Some will involve other professions outside the direct remit of the Primary Care Group; it would be helpful, for example, to engage with community pharmacists and hospital microbiologists to put together the policy for antibiotic prescribing. Actions on quality of care are, however, subject to a degree of expert knowledge and Primary Care Groups will wish, at times, to work closely with other interested Primary Care Groups, especially where particular expertise is held there, Primary Care Groups will also wish to work together in order to share developing ideas and learning.

National action to promote clinical governance

109.     Regional conferences will be organised to bring together clinical governance leads and to discuss taking the issues forward, sharing common experience and expertise. By early autumn, we intend to put together material which will outline models for clinical governance and relate this to data on clinical effectiveness in, say, prescribing on a chosen national topic areas.

110.     There are many contextual issues including Lifelong Learning, the Health

Improvement Programmed and National Service Frameworks. These will be subject to separate guidance. After consultation on "A First C/ass Service" and legislation which will follow it there will also be a number of other issues relating to utilising the outputs of the National Institute for Clinical Excellence and the expertise from the Commission for Health Improvement.

SECTION 4: HEALTH IMPROVEMENT

THE HEALTH IMPROVEMENT PROGRAMME

Description of a Health Improvement Programme

"... the local strategy for improving health and healthcare. It will be the means to deliver national targets in each Health Authority area. The Health Authority will have lead responsibility for drawing up the Health Improvement Programme in consultation with NHS Trusts, Primary Care Groups, other primary care professionals such as dentists, opticians and pharmacists, the public and other partner organisations. "

The new NHS - Modern and Dependable

111.     This section should be read in conjunction with forthcoming detailed guidance on the development of local Health Improvement Programmes.

112.     At a strategic level the Health improvement Programme will cover:

the most important health needs of the local population, and how these are to be met by the NHS and its partner organisations through broader action on public health

the main healthcare requirements of local people, and how local services should be developed to meet them either directly by the NHS, or where appropriate jointly with Local Authorities

the range, location and investment required in local health services to meet the needs of local people

113.     The Green Paper, "Our Healthier Nation", advises that:

"New Primary Care Groups will be responsible for planning and developing services for smaller populations that will be sensitive to local health needs. Their contribution to drawing up and implementing Health Improvement Programme will be vital, reflecting the perspective of the local community and building partnerships with key local organisations. "

The role of Primary Care Groups

114.     Whilst Health Authorities will be responsible for developing the Health Improvement Programme and securing partner involvement, Primary Care Groups should be invited to participate in the process in a pro-active and "open" manner. It is important that shadow Primary Care Groups are engaged in this process in advance of April 1999, as they inevitably hold a key role for delivering the objectives that will be contained within the Health Improvement Programme.

115.     Primary Care Groups will be held to account by the appropriate Health Authority in delivering action that is consistent with the Health Improvement Programmes objectives and principles. An individual Primary Care Group may agree with their Health Authority to tackle additional problems and perceived priorities specific to their local circumstances but they should not be an alternative to, nor to the detriment of, the overarching Health Improvement Programme priorities and objectives.

The role of Hea Ith Authorities

116.     Health Authorities will be expected to ensure that shadow Primary Care Groups have maximum opportunity to engage in the process in advance of April 1999 and also to have plans that allow Primary Care Groups to make a growing input to the development during 1999/2000 of a fuller Health Improvement Programme beginning April 2000.

117.     As a committee of the Health Authority, the Primary Care Group will be accountable to the Health Authority for delivering its contribution to the Health Improvement Programme. The Health Authority will be responsible therefore for performance managing the process locally and should actively monitor the activity and decision making processes of the Primary Care Group thus ensuring consistency with the Health Improvement Programme.

118.     Primary Care Groups, by there very nature, will often be best placed to be aware of, and understand, the needs and characteristics of their local communities. Health Authorities should recognise this local strength and ensure that it is adequately reflected in the Health Improvement Programme process and objectives.

THE NHS PERFORMANCE ASSESSMENT FRAMEWORK

119.     The Accountability Agreement should seek to assess the impact of Primary CareGroup plans on performance across the six areas of the NHS Performance Assessment Framework. Details of the Framework can be found in the consultation document which was distributed under cover of EL(98)4 and which signalled a move away from counting activity and financial efficiency towards assessing performance across a broader front as set out in the six areas:

Health improvement

Fair access

Effective delivery of appropriate healthcare

Efficiency

Patient/carer experience of the NHS

Health outcomes of NHS care

120.     The consultation document proposed a set of high level performance indicators based on information which is currently available at Health Authority level (responses to the consultation are being considered in parallel to the results of a road test of the practical application of the framework with the intention of publishing a revised framework in the autumn). Not all these indicators will be appropriate at Primary Care Group level because the information may not be available for these populations and even where it is available, it may relate to small, statistically insignificant data. In addition, there may be locally available data which is more useful to assess performance in the six areas and, if so, this should be used. Where no hard data is available, Health Authorities and Primary Care Groups should make use of softer information to ensure that performance is considered across all the six areas,

NHS LONG-TERM SERVICE AGREEMENTS

121.     The NHS Executive will be issuing guidance shortly on NHS long-term service agreements. Service agreements will be the means through which national and local standards and targets, as set out in national guidance, National Service Frameworks, National Institute for Clinical Excellence guidelines, local Health Improvement Programmed, are put into operation:

they will focus on service delivery objectives, addressing health and quality objectives as well as cost and volume

they will be dynamic, incorporating levers for improving quality and efficiency, promoting improved performance along all 6 dimensions of the performance framework: funding will be conditional in part on satisfactory progress against key targets

they will be developed by clinicians in Primary Care Groups, hospitals and community settings, based increasingly on programmes of care and care pathways, where possible taking account also of social care provision. The views and experiences of users and carers should also be taken into account

they will be "two-way", incorporating commitments from both primary and secondary care (and other parties) to their part in the care pathway. As part of this, they will reflect shared responsibility for risk management and appropriate service utilisation, ensuring activity does not get out of kilter with funding, and shared incentives to improve efficiency

122.     The new arrangements will make it possible to review in depth and renew a number of agreements each year, in place of the current annual contracting round. Renewal of agreements will depend on satisfactory progress, and there will be scope for Primary Care Groups to signal their wish to change the nature of an agreement or the service provider they use, as part of the Health Improvement Programme. But if problems arise, the emphasis will be on seeking first to improve existing local services, rather than adopting the market "solution" of switching to a more distant provider. The Commission for Health Improvement will serve as an important new support to ensure that local services are of a consistently high standard.

How NHS service agreements will work

123.     Expected number and coverage: The new approach is to be increasingly patient/service based, rather than institution based. It follows that NHS service agreements will need to be developed at a level below the whole NHS Trust. In the first instance, this may mean NHS service agreements based at Clinical Directorate level, although at local discretion, long term service agreements might be developed at a more disaggregated level, or in forms that cut across Directorates or Institutions. In those instances it will of course remain necessary for NHS Trust management and Clinical Directorates to work closely together to ensure that the NHS service agreements are deliverable in aggregate.

124.     Care pathways: As part of the move towards better integrated, patient-centred care, service agreements should move towards pathways and agreed packages of care for specified conditions. Primary Care Groups should be well placed to develop this sort of approach and to extend it to embrace better integrated working with social care. This approach should be extended over time to cover increasing amounts of the morbidity in the population, and ensure the delivery of appropriate and evidence based care to meet this need. These will draw on evidence from the National Institute of Clinical Effectiveness and National Service Frameworks.

125.     Performance monitoring: A vital ingredient in a service agreement will be jointly owned measures of performance. These will form the basis for monitoring and review and should be linked to targets for continual improvement. Benchmarking a service with other organisations performing at a higher level will be the key to this. Each service should be measured comprehensively against the important dimensions. This can be done by linking the agreement to the six elements of the National Performance Framework (health improvement, fair access, effective delivery, efficiency, patient/carer experience and health outcomes).

Preparing for 1999/2000

126.     Objectives are:

(i)     to map existing patterns of expenditure under NHS contracts and through extra-contractual referrals (ECRs) into the new arrangements for specialised commissioning and service agreements, including provision for the new Out-of-Area Treatment arrangements. The transition from past to future patternsof funding flows should be clear and stability maintained

(ii)     to agree the levels at which responsibility for commissioning should rest

(iii)     to develop new NHS long-term service agreements for selected services for 1999/2000 and plot the future development path

127.     For 1999/2000, service agreements will flow from the Health Improvement Programme. An element of expenditure should be covered by fully-developed NHS long-term service agreements for the remainder, with more basic agreements needed for other services, pending development of a fuller portfolio of NHS long-term service agreements on a rolling basis.

Levels of commissioning

128.     Potentially, commissioning could be carried out at a range of levels:

specialised services commissioning, at national, regional or sub-regional level

supra-Health Authority (where the service at issue is outside the specialised services definition, but the Health Authorities and Primary Care Groups concerned agree to act together to commission it)

Health Authority level

Primary Care Group level (with potential for practice-level sensitivity, eg in commissioning of some community services)

129.     The White Paper principle of aligning clinical and financial responsibilities and putting doctors and nurses in the driving seat points to devolving maximum responsibility to Primary Care Group level. Decisions and responsibilities will be discharged within the framework set by the Health Improvement Programme. However there will be a number of considerations to take into account including, initially, the readiness of Primary Care Groups locally to take on these new responsibilities. Other key issues will be:

the appropriate population base for the service being commissioned

risk management considerations (rare, but expensive conditions may be better commissioned at a more aggregate level)

available expertise: Health Authorities and Primary Care Groups may want together to take a pragmatic view of where the expertise on a particular service is concentrated (eg commissioning of dental services may be more appropriately done at Health Authority level because of the expertise available

130.     At whatever level commissioning is undertaken, the principle of the fullest possible clinician involvement applies - especially in terms of Primary Care Group engagement. To meet adequately the objectives of the Health Improvement Programme, it will be more appropriate in certain areas to commission services at aggregate level. However, commissioning at a level other than that of the Primary Care Group will be a conscious choice.

131.     Where commissioning is at Health Authority level it should preferably take the form of "collective commissioning" by Primary Care Groups working together, or if necessary, by the Health Authority with Primary Care Group involvement. The full resources should be identified to Primary Care Groups, even where the Group is required or chooses to return some money to the Health Authority for collective commissioning. This will make all commissioning decisions transparent at local level.

132.     The balance from Health Authority level to Primary Care Group level commissioning is likely to shift over time as Primary Care Groups grow in confidence and experience.

NHS service agreements for 1999/2000

133.     The expectation is that each Primary Care Group will aim to develop - either itself or in partnership with others - several NHS long-term service agreements beginning 1999/2000. Health Authorities would be expected to offer assistance during this preparatory period. Some - eg Primary Care Groups aspiring to Primary Care Trust status - might well aim to achieve more.

134.     In terms of national priorities, action on some elements of cancer services (where this is appropriate for local commissioning) could build on work already undertaken in response to Calman-Hine. Development of NHS service agreements on Coronary Heart Disease and Mental Health seems best undertaken on a slightly slower track, so that full account can be taken of the new National Service Frameworks to contribute to NHS service agreements beginning 2000/2001 .

SECTION 5: INFORMATION MANAGEMENT AND TECHNOLOGY

135.     This section outlines planning that can usefully be undertaken now by Health Authorities and Primary Care Groups, and actions that would best be delayed until later. More detailed guidance will be issued in the autumn, based on an analysis of Primary Care Group functions which will also take account of the new lM&T strategy for the NHS.

136.     lM&T planning needs to involve Primary Care Groups, Health Authorities and NHS Trusts as changes in systems and procedures will be needed to allow effective exchange of clinical information and administrative information. Similarly, Local Authorities and other agencies will need to share information to support integrated packages of care across General Practice, Hospital, Community and social care boundaries.

137.     It is not proposed that there will be a Primary Care Group computer system in the same way that there was a standalone GP Fundholding system. Neither is it expected that fully functional systems supporting all Primary Care Group business functions will be available on 1 April 1999. Primary Care Groups and Health Authorities should view the development of systems as part of an evolutionary process based within a wider context of the need to update Primary Care Computing. No major IT investment should be made for specific Primary Care Group systems before the functions, information and data processing needs have been agreed. Distribution of any central funds for IT development will take into account any difference in the starting points between areas.

138.     lM&T planning should focus on the information needs of all the local stakeholders taking into account the need for Primary Care Groups and Health Authorities to fulfil their role in providing information for central data requirements. Central data will continue to be required for monitoring, accounting and policy development purposes. This will be clarified in later guidance. Throughout this process the fundamental principle is that the basic building block for lM&T planning for Primary Care Groups remains the GP Practice unit.

Clinical systems for Primary Health Care Teams

139.     The key short term priorities for clinical systems are the need to upgrade systems to meet the requirements of Year 2000 compliance, and the White Paper targets to connect all practices to the NHSnet for the electronic delivery of hospital test results. Announcements on funding arrangements for these priorities will be made separately in conjunction with publication of the new NHS lM&T Strategy.

140.     In meeting these priorities, Primary Care Groups and practices should also consider future developments, which will include:

increased use of templates or protocols to prompt and standardise data entry

providing good quality data to support GP clinical audit

providing full system access to all members of the Primary Health Care Team

sharing or exchanging data with Community Trust and Social Services systems

flexible and easy to use query, analysis and data extraction facilities

141.     Any upgraded GP practice systems must comply with Version 4 of Requirements for Accreditation of GP Systems (RFA) in order to qualify for reimbursement (FHSL (97) 47). In addition, it is essential that all practice system components eg operating systems, Local Area Networks, and servers are confirmed to be compliant as defined in the BSI document "A definition of Year 2000 conformity requirements" (BS-DISC PC2000-1 ). Copies of this document are available from the NHS Standards Help Desk.

142.     RFA4 Basic status is awarded to systems which conform to all the mandatory requirements in RFA, on completion of all the relevant tests. RFA Basic functionality includes year 2000 compliance, X400 and NHSnet capability. Registration Phase 1 and Items of Service. RFA4 Plus status is awarded to systems which also complete the tests for one or more of the optional messages (Registration Phase 2, Organ Donor, Cervical Cytology Target Payments and Prior Notification Lists, Pathology and Radiology Reports, and Discharge Summary). Information on the latest status of each system may be obtained from the GP Systems Accreditation Team at IMC and is also available on the FHS Website http://www.fhs.org.uk

143.     RFA4 Plus testing for Pathology Report messages (relating to biochemistry and haematology) is expected to commence in August 1998, and accredited products from some suppliers are expected to become available during the last quarter of 1998.

144.     Unless there is a strong consensus amongst all GPs in a particular Primary Care Group for the need to move to a single integrated clinical system for the Group, the presumption must be in favour of the further development of systems supporting Primary Health Care Teams at the practice level, with communications links and data exchanges between them to provide the required integration. If replacement systems are being considered practices should consult with colleagues in the Primary Care Group and Health Authority.

Data quality and data sources

145.     One aim of Primary Care Groups is to improve the quality and standard of care provided to patients. This will be achieved through the development of clinical governance, which in turn will require the collection of high quality data. Further guidance on the most appropriate sources of information to support Primary Care Group functions is currently being developed and will be available in the autumn.

146.     In the short term, to improve the quality of data practices should consider putting in place procedures for carrying out regular audits of their data recording procedures, to ensure that data held on the practice computer system is accurate and complete, or to identify areas which need attention. Local audit advisory groups, public health advisors and GP computing facilitators are valuable sources of guidance and recommended procedures on the use of GP systems.

147.     Greater co-ordination of care requires a strategy of moving towards clinical systems which support all primary health care team members, where data is entered once only. An important aspect of meeting these needs will be the consistent use of systems that support the recording of activity by all members of primary health care teams, including GPs, practice nurses, and the wider group of community health nurses and other community workers. In the long term these systems should provide shared access to authorised users with a need to know information on patients, their condition, disability and domestic circumstances, care plans, the care provided by each team member, changes in the patient condition and expected outcome.

148.     However, in the short term it may be necessary to make more effective use of existing systems, eg by agreeing common local data recording standards for community nursing activities in both practice and community systems, and/or by installing additional terminals on to GP practice systems with suitable data entry templates for the use of community nurses and Health Visitors.

149.     Health Authorities and Primary Care Groups may wish to consider the additional benefits of having PACT prescribing data delivered electronically to practices via NHSnet, by the use of EPACT, currently under trial by the Prescription Pricing Authority.

Deriving information from Primary HeaIth Care Team clinical systems

150.     MIQUEST is the recommended method of expressing queries and extracting data from different types of GP practice or primary health care team systems using a common query language. MIQUEST has advantages over other data extraction methods where a group of practices using different systems wish to compare and aggregate data.

151.     MIQUEST is supported by and used within the Collection of Health Data from General Practice (CHDGP) project. This project is also developing and testing guidelines on consistent data recording, data quality audit, methods for training and support of facilitators, and data extraction and comparative analysis, working with several local pilot schemes.

Confidentiality

152.     Privacy, confidentiality and data protection considerations must be borne in mind when making clinical systems more widely accessible within a primary health care team, cluster of practices or Primary Care Group, and in designing data exchange procedures. Those responsible for designing systems and procedures must be aware of existing guidance on confidentiality.

HeaIth Authority and provider systems

153.     It is not expected that Primary Care Groups will need to develop or procure separate new systems to support their commissioning activities, so that they are in operation by April 1999. Health Authorities and Primary Care Groups should consider how most effective use can be made of the databases and information systems which have been implemented locally to support commissioning and contracting, service planning and health needs assessment.

154.     In future, patient activity data will need to be identified to and aggregated by individual Primary Care Groups, in both Health Authority and providers' systems.To support this, within the standard Organisation Codes Service package of reference files, it is proposed to introduce new NHS Organisation Codes for Primary Care Groups. These files will also record the GP practices within each Group.

155.     Health Authority information systems will include databases supporting a time series of admitted patient care minimum datasets, which may provide a valuable source of information for analysing variations in access to and use of secondary care services across all practices within a Primary Care Group and between Primary Care Groups. This analysis is likely to be necessary to support the development of commissioning plans. These databases also support outpatient, waiting list and accident and emergency minimum datasets. Some Health Authorities may use simulation modelling tools based on this information to inform their future service plans and these may similarly be of value to Primary Care Groups. The comparative information on providers' service prices and costs used previously by Health Authorities in their own contracting and to establish budgets for fundholding practices should also be available to Primary Care Groups.

156, Health Authorities and other agencies such as Local Authorities are also likely to maintain information on the mortality, fertility, morbidity, demographic and socio-economic characteristics of local populations which will be of assistance, alongside information from practice systems, in assessing health and social care needs within Primary Care Groups. Where this type of information has been used in determining the target resources to be allocated to Primary Care Groups, this should be readily available. Health Authorities should also consider how comparable national or peer population information of this type, from sources such as the Public Health Dataset, may best be made available to Primary Care Groups.

157.     In considering how most effective use can be made of these databases and systems, consideration should be given to: l the use of NHSnet to provide electronic access to applications and databases l the types of support services, and in particular analytical support, that may be needed by Primary Care Groups to make most effective use of this information

DATA COMMUNICATIONS/NHSNET

Uses of the NHSnet

158.     There is a growing need for NHS organisations to share information, as well as benefits in reducing the amount of paper that is handled. Key applications where GP practices could make use of electronic communications links include :

pathology /radiology/investigation requests and reports

hospital referral and discharge information

shared electronic patient record

non-urgent patient transport requests (eg ambulance)

patient registration (with GPs)

screening programmed access to information sources such as Prescription Pricing Authority (PPA) pricing and costing information, clinical knowledge bases and library services

waiting list enquiries

payment/ordering of goods

Good CIinical practice

159.     Health Authorities and Primary Care Groups should consider how the use of communications technology and IM&T can improve access for primary health care team members within Primary Care Groups to bibliographic sources of evidence of good clinical practice. These will be of importance in reviewing the clinical effectiveness of commissioning plans and developing good practice in primary care.  They are used most efficiently when they can be accessed from the immediate workplace, which will mean considering :

providing access to online sources such as knowledge bases through NHSnet

providing communications links to allow remote access to local education centre libraries, Medical schools, PostGraduate Libraries and Health Authority resources

Connecting to the NHSnet

160.     Currently, data communications technology used by GPs and Dentists within the NHS is low speed dial-up communications designed to provide reliable, but basic electronic messaging for Items of Service (IoS) claims and GP/ Health Authority patient registration. Whilst this approach has historically met the needs of the current method of GP and Dental community working, the advent of Primary Care Groups will necessitate the use of high speed secure networking and messaging services conforming to National and International standards that are available on the NHSnet.

161.     Following an extensive open procurement process NHS Telecommunications Branch has procured network services from British Telecom and Cable and Wireless, and messaging services from Syntegra. Collectively these services form NHSnet and are designed to meet the future communications needs of the NHS and will allow for effective communications between all Primary Care Group members. Suppliers are currently developing a number of products to meet the different business requirements of Primary Care Groups.

162.     The NHS Executive is developing an implementation plan to meet the White Paper Target of connecting every GP practice and hospital to NHSnet to receive some hospital tests over NHSnet. Discussions are currently underway with the NHS, the Professions and Clinical Suppliers. Until these discussions are concluded it would be inappropriate for local initiatives on networking to commence. Further guidance in meeting the target will be issued as soon as the position is clear.

163.     Messaging services for Items of Service claims and GP/Health Authority patient registration should migrate to NHSnet. Individual practices should discuss with their Health Authority, and, where appropriate, local NHS Trust(s), their use of networking services to agree where possible a common approach to planning data communications. Practices will need to consult their local NHS Telecommunications Branch for advice on how to obtain a connection, what they need to do to comply with the NHSnet security code of connection, and for advice on the optimum configuration in their particular local circumstances.

164.     NHSnet provides controls for access between organisations but it remains the responsibility of the connecting organisation to ensure that the appropriate local access controls and data protection measures are maintained. Technology alone cannot be relied upon if the security of the network is to be maintained and that is why access to the NHSnet is governed by a strict code of connection.

165.     NHS Telecommunications Board have commissioned a review of the way the NHSnet code of connection operates to ensure that it meets the requirements of end-users of the network without compromising the privacy and confidentiality of data.

166.     The tariff structure of the NHSnet is kept under continuous review to ensure best value for the NHS. Options for funding network services are being considered as part of the current review of the lM&T Strategy.

GP FUNDHOLDING SYSTEMS

167.     Existing fundholding systems should be maintained for the time being, as set out in regulations (statutory instrument 706, Schedule 2 paragraph 3). The normal process of entering activity and cost data into systems should continue until GP fundholding accounts have been audited. As fundholding systems contain valuable information, no data should be lost from systems. Fundholders should ensure that IT support contracts are maintained until fundholding accounts are completed.  Guidance on the retention of GP fundholding data for analysis purposes to support planning will be issued following discussions with system suppliers on the best way to retain it under the new arrangements.

SECTION 6: PREPARATORY COSTS

168.     Guidance on preparatory costs for Primary Care Groups was issued to Health Authorities on 26 June 1998. This is replicated below,

What is the money for?

169.     The cash limit adjustment that each Health Authority has received is a central contribution towards the management and support costs involved in setting up Primary Care Groups this year. It also includes support costs for any GP Commissioning Group pilots in your Health Authority.

170.     Ministers have made it clear that local doctors and nurses must be in the driving seat for Primary Care Groups and it is for them to decide, in agreement with the Health Authority, how this money should best be spent.

171.     The allocation does not allow for IT costs, and the money should not ordinarily be used on IT equipment. (This exclusion does not apply to office equipment such as faxes and photocopiers. ) Guidance on information and computing needs of Primary Care Groups will follow later this year, and it would be unwise to make large investments in IT capital before it is clear what is required, or what any computer system will need to do.

172.     The money in the 29 May allocation is intended to help with this preparatory work, alongside that which Ministers expect Health Authorities to make available locally.  Together these resources are expected to enable doctors and nurses to set up the groups. Ministers also expect involvement in this work from Community Trusts, Social Services and other local government or health agencies, and that all these organisations will contribute to the establishment of Primary Care Groups, in most cases through staff time.

173.     It is expected that as GP fundholding winds down GP fundholders will be able to contribute towards the establishment of Primary Care Groups: drawing on their allocation of Practice Fund Management Allowance (PFMA), perhaps to contribute real resources but more likely to free up staff or GeneraI Practitioner time. In allocating scarce resources it has been assumed that a contribution of 7.5% from PFMA will be available locally. Where fundholders are able to offer real resources from PFMA, they should return ("recycle") those funds to the Health Authority to aid flexibility in developments for the whole Primary Care Group area.

How should the amount be allocated to Primary Care Group areas?

174.     The overall allocation includes a sum for GP Commissioning Group pilots. There is scope to vary the level of allocation to GP Commissioning Groups, on the advice of local doctors and nurses, as they see appropriate and taking account of the preparatory costs of Primary Care Groups. However, it is not expected that Health Authorities will allocate less than the amount confirmed within the GP Commissioning Group pilot bid except by prior agreement with the pilot.

175.     The remainder of the allocation should be spent directly to support Primary Care Group preparatory costs in the Health Authority area. It is important to ensure that local doctors and nurses are in the lead in deciding how Primary Care Groups are set up, and it is for them to decide with the Health Authority how much of the money is allocated to each shadow Primary Care Group area, whilst taking into account the contributions that might be made by GP fundholders and GP Commissioning Groups locally. The Health Authority will need to put in place appropriate mechanisms for involving local doctors and nurses. Where the Primary Care Group has a shadow governing committee, this may be the most appropriate vehicle.

176.     There are a range of activities or functions to which the Health Authority, on the recommendation of local doctors and nurses, may wish to spend part of this money. For example, the money could be used:

to appoint additional staff such as a shadow project officer or shadow chief executive, to forward the development of the Primary Care Group (any appointments of such staff should proceed as outlined in HSC 1998/065)

to contribute to GP Iocum costs to allow GPs to be engaged in the Primary Care Group

where appropriate, other payments to support the involvement of GPs and nurses in the Primary Care Group

office equipment

177, The aim should be to use the money in the most appropriate way to ensure that Primary Care Groups will operate effectively in 1999/00, and to ensure that there is positive engagement in the Primary Care Groups by local professionals, including GPs and community nurses. GPs who take on key developmental responsibilities should be appropriately supported for the time and effort involved in preparatory work. Money should be allocated on the basis of relative need.

178.     Health Authorities will also need to bear in mind how expenditure from this new allocation should be handled when reporting Health Authority costs. This is covered in the letter of 26 June to Health Authority Chief Executives.

Book Title: NHS Circulars