Expression of Interest to Pilot Personal Medical Services under the NHS (Primary Care) Act 1997

Name Project

A Grouping of Single-Handed Practices for Dacorum PCG
Dacorum Alliance of Single-Handers. DASH


Dr Gerard Bulger at present


52 High Street, Bovingdon, Herts


01442 833380. Fax 01442 832083



Health Authorities

West Herts Most patients
Bucks 450 approx.

Project Proposers

Dr Colin Andrews 3000 Berkhamsted
Dr Shaelindra Bhatt 2100 Hemel Hempsted
Dr Gerard Bulger 2400 Bovingdon
Dr Christopher Side 2200 Tring

Detail of Service issues to be addressed

Single handed practice is often regarded as an anachronism within a new modern dependable NHS. There are issues about clinical governance and audit. There seems to be a lack of peer review. Single-handed doctors find it difficult or impossible to get away for meetings associated with the Primary Care Group, let alone liaise properly with social services, and give time to be a true partner in the wider Primary Care team

Single-handed practices can often find it difficult to play a full role in the modernised NHS because of their size constraints. This is particularly important in relation to meeting their responsibilities in relation to clinical governance

There are advantages of single-handed practice which we will not outline here other than to mention greater personal knowledge of patients, consistency of care, and greater access to same day appointments than may be seen in most group practices. We would not wish to lose this.

A grouping arrangement under the PCT/G, or by forming a PMS Partnership Agreement, will resolve some of these inter and intra-professional problems. We would be able to employ an extra doctor.


The supportive arrangement of small practices into a Personal Medical Services pilot would provide practices with a framework within which they can provide high quality, well co-ordinated services and benefit from some of the economies of scale enjoyed by larger practices. This would also enable individual practices to take a lead for specific areas of work, and participate more fully in local processes, such as clinical governance and taking forward national priorities such as National Services Frameworks, which they are keen to do.

Part of this proposal will include bringing in additional GP resources since our list size would normally qualify for such a person.

The grouping would then wish to develop other services for certain deprived groups:

1. Travellers. These patients are disadvantaged in that they find it difficult to register, and they have to go through the same registration process at each practice. They do not develop a Health record. Our mainly rural small town/village practices means that at any one time we have travellers somewhere. We would offer a single service, with one medical record available securely on the NHSNet to each other for these patients. If funding was available we could extend this service to patients other than strictly within our current A41 patch.


At any one time there is at least one settlement in our group with 60-100 patients. The rate of change and the lack of a common record are a major problem in their care.

  1. Drug Dependency. Now no longer confined to towns, one of our members can specialise in this area and co-ordinate care amongst the group and with Drug Link. This would be following the Shared Care Scheme as defined recent Consultation Document (May 2000).
  2. Isolated Elderly: This is work that we would do with Social Services to encourage health check and befriending schemes, pharmaceutical checks and delivery. We have identified some 200 lonely and at risk patients who need a more comprehensive service.

The group would also be able to tackle:

  • The group will address cost and poor Quality of Service from Commercial Deputising Service urgently. This would be achieved by acting as a single negotiating group, and by doing a proportion of our own on-call and call vetting. We would continue to work with the current co-ops.

Relationship with NHS Direct and Triage Services to be addressed by the group as a whole. We would seek some funding from NHS Direct. Dr Bulger is already in discussions about direct booking of patients into surgery. We are looking at offering NHS Direct Staff a more hands on, within practice experience of using NHS direct systems for the group.

Range of Services

  • Continue high Quality GMS element of services
  • A PMS Plus element of not much larger than the current ex-fundholding virements for in-house services to provide current in-house services and to give consultant input on patient management (particularly of chronic and disabling conditions)
  • A service (perhaps by nurse visiting sites) for travellers
  • A record system for travellers
  • Liaison with Social Services and other groups for our isolated Elderly
  • Drug Dependency with Drug Links
  • Improved out of hours service
  • Improved Teamworking: for the first time there will be a doctor working in all the practices, and discovering the weakness and strengths of each, which will require addressing.
  • Centralised data collection for PCG Clinical Governance. This would require enhanced data input onto our current systems, and ensuring correct working of Miquest. We may post data to one of our servers accessible on NHSnet.
  • Improved On-call Arrangements.
  • Near-miss reporting service and enhanced audit procedures.

These projects will require a co-ordinator & administrator and a data input clerk.

Contractual Changes Sought

A mix of Salaried (employed by PCG/T) and independent contractor G.P.s to one Group. A PMS Agreement forms one NHS body. The DASH PMS would then contract directly, or preferably with The Primary Care Trust, for a doctor to provide services within the group surgeries: to include :

Working almost exclusively at each practice for a minimum of 4 weeks. Occasional cover of morning surgeries after nights on call. Working with the administrator/co-ordinator in developing the clinical audit systems for PCG clinical governance issues.

This post(s) could be shared with a University. Discussions on these lines are underway.

A standard GMS partnership cannot be formed along a wide "A41" corridor, even though we are within the same PCG.

Smaller practices joining up with nearby larger practices would reduce consumer choice.

A PMS pilot offers the flexibility of retaining the small practices, but joined into a cohesive group within the PCG.

Should the PCG wish to make major reconfigurations, then this PMS Pilot could act as a vehicle for change with a salaried service.


A grouping of doctors would entitle under MPC rules to have an extra GMS partner.

The doctor(s) would work full time for a least 4 weeks at each practice, and have an audit clinical governance role at the PCT and or University of Hertfordshire.

During the preparatory phase we would be looking at the possibility of extending the salaried component to include any of the current practitioners. We did not have time to discuss this option prior to this application since we only had three weeks notice of the latest PMS wave. However at least one doctor would be employed by the PCT.  

How Fits In to Service Developments

Development of a Team amongst diverse small practice to enable better deployment of all PCT/HIMP objectives.

The NHSNet linkages make geographical spread less of a problem in developing a team than used to be the case.

The time and resource implications for a single-handed practice in following the latest audit and clinical governance requirements are overwhelming, quite apart demonstrating that we are following HIMP and National Frameworks. A grouped approach on data collection and implementation will improve patient care and simplify the PCGs role, as the number of audited practising Units is reduced to the one PMS.

From whom will we seek opinions

  • Primary Care Group
  • Local NHS Trusts
  • Prof. Townsend or her replacement, University of Herts
  • Community Health Councils
  • Parish or Town Councillors Borough, Town and Parish Councils
  • Social Service Departments
  • NHS Direct
  • Nurse Management
  • Own staff
  • Our patients
  • Voluntary Sector
  • All the care Team members serving patients of our surgeries.

Patient Benefits

  • Confidence that the G.P.s are not working in isolation
  • Greater Access to a G.P. second opinions
  • Improved out of hours service
  • Health benefits from improved audit and shared information systems
  • More effective representation of patients concerns at PCG level

Initial Discussions

PCG and HA
Own staff
Other PMS schemes locally, including Michael Croft, PMS salaried G.P. in West Herts.

Strategic development and Resource Implications

  • Extra GMS doctor(s) under MPC rules that would be employed by PCT to work with the Group. This would require development monies to tackle this "issues" of single handed practice
  • Grouped Quality of Care & Audit Admin
  • Nurse or other professional) for work with the deprived groups
  • Miquest Server to group together data from all practices
  • PMS plus element to include current allocation and a little more following discussions with local trust in developing an assurance scheme of quality of in-house services and patient management.