Personal Medical Services Pilots Research Articles

Do Personal Medical Services contracts improve quality of care? A multi-method evaluation

To assess whether the new contractual arrangements of first-wave Personal Medical Services (PMS) practices in England improved their quality of care, compared with changes in care provided in a control sample of General Medical Services (GMS) practices. Controlled 'before' (at or near 1 April 1998) and 'after' (at or near 31 March 2001) quantitative observational study in a sample of 23 PMS and 23 GMS practices. Quantitative data focused on access, chronic disease management, mental health care, primary care of older people, costs and patient evaluation using the General Practice Assessment Survey. Case studies were also undertaken in all PMS pilots, involving interviews with general practitioners, nurses, practice managers and Health Authority and Primary Care Group/Trust managers, documentation review, and analysis of site-specific data. There were improvements in quality of care in PMS sites in all areas of care evaluated, but improvements in care over and above those found in GMS sites (the 'PMS effect') were only statistically significant for angina care (P = 0.05) and elderly care (P = 0.04). Teamwork, shared culture, clear objectives and leadership were important catalysts for quality improvement in PMS sites. Improvements in PMS practices came at additional financial cost. There were concurrent improvements in GMS practices. No PMS site succeeded in meeting its aims without successfully introducing effective leadership and management, and changing relationships within the practice (e.g. equalising power between nurses and doctors). Small but steady improvements were observed in English primary care. PMS contracts facilitated quality improvements in specific areas over and above these broad improvements (the 'PMS effect') during the study period. New contractual arrangements for health care can be used to improve quality of care. However, the mechanisms that resulted in quality gains, while facilitated by the new contractual arrangements, were not specific or unique to the PMS experiment. Factors such as effective management, clear objectives and flexible professional relationships within practices are likely to be important in determining whether new contractual arrangements result in improved outcomes. The context within which care and services are provided is as important for quality innovations as specific contractual arrangements.

Personal medical services: local organizational developments

Devolved accountability for primary care has been introduced into the UK through a range of local contracts for personal medical services (PMS) authorized by the 1997 NHS (Primary Care) Act. These four exemplary case studies illustrate the PMS pilot programmes and represent a diversity of emerging organizational developments that appear to be responding effectively to different health care needs and environments. This is particularly apparent at those sites targeting the most marginalized patient groups where interprofessional collaboration and interagency partnerships are characteristic of a new and broader primary health care approach. Elsewhere the PMS pilots retain and indeed may extend some of the more restrictive practices of the conventional primary medical care model. Future policy formulation, therefore, needs to promote flexible management structures and processes which can support, through local contracts, the further development of more comprehensive and population-based primary care.

Improving the quality of mental health services in Personal Medical Services pilots: a longitudinal qualitative study

Improving the quality of mental health services in Personal Medical Services pilots: a longitudinal qualitative study

Contracting for quality or local fixes? Two Personal Medical Services pilots

As an alternative to the national contract with general practitioners (GPs), Personal Medical Services (PMS) is a way of contracting with GPs for providing primary care, intended to enable individual contracts with practices which are appropriate to the specific needs of their populations. The national plan for the NHS (2000) strongly supports the extension of PMS as a means of improving the quality of primary care. This paper reports two small pilots which found PMS a useful mechanism for achieving desired changes within the practices. In one case, the GPs are now employed by the local community trust and the primary health care team has been expanded, with some clinical functions redistributed among the team. In the other, the primary health care teams of two practices have developed a tool for assessing the health and needs of older people during a home visit. Participants in both pilots expressed satisfaction with the results, although there were some dissenting voices. In both cases, the pilots were unable to demonstrate in detail any improvements in patient care or to quantify the work-load implications of the changes. Perhaps because of their ‘pilot’ status, the initiatives tended to be inward looking, and opportunities for learning across the local health economy have been missed. PMS' value as a driver for improving the quality of primary care is not demonstrated by these two examples.

Personal medical services in London: new solutions for an old problem?

A number of inquiries over the last 20 years have found London's primary care to be deficient when compared with the rest of the country, notwithstanding several development programmes aimed at addressing this inequity. Personal medical services (PMS) pilots were introduced in 1998 to replace the national contract for general practitioners and were intended to offer planners and providers of primary care with more flexibility in meeting local health needs. PMS pilots have proved particularly popular in London. This paper describes the results of a review of 13 first-wave PMS pilots in London. The pilots have resulted in new and flexible primary care organizations, more resources for the primary care workforce and greater access to services for deprived or underserved populations. However, little evidence was found to suggest that PMS pilots impacted greatly on service quality. Personal medical services pilots involve the development of local contracts, although contract management processes remain underdeveloped. Nevertheless, personal medical services pilots may prove successful in addressing some of the relative deficiencies in London's primary care and offer a powerful new tool to the commissioners of primary care to meet the diverse needs of Londoners.

Personal medical services in London: new solutions for an old problem?

A number of inquiries over the last 20 years have found London's primary care to be deficient when compared with the rest of the country, notwithstanding several development programmes aimed at addressing this inequity. Personal medical services (PMS) pilots were introduced in 1998 to replace the national contract for general practitioners and were intended to offer planners and providers of primary care with more flexibility in meeting local health needs. PMS pilots have proved particularly popular in London. This paper describes the results of a review of 13 first-wave PMS pilots in London. The pilots have resulted in new and flexible primary care organizations, more resources for the primary care workforce and greater access to services for deprived or underserved populations. However, little evidence was found to suggest that PMS pilots impacted greatly on service quality. Personal medical services pilots involve the development of local contracts, although contract management processes remain underdeveloped. Nevertheless, personal medical services pilots may prove successful in addressing some of the relative deficiencies in London's primary care and offer a powerful new tool to the commissioners of primary care to meet the diverse needs of Londoners.

Receptivity to Change in a General Medical Practice

AbstractIn this paper, Pettigrew, Ferlie and McKee's concepts of receptive and non receptive contexts for change are examined using data from an evaluation study of a general medical practice implementing a Personal Medical Services Pilot between 1998 and 2001. Four questions concerning the applicability, associatedness, temporality and dynamism of the eight factors Pettigrew et al. identified as constitutive of receptivity are used in the analysis, which extends the original model through an operationalization yielding 21 ‘focal questions’. Although the process of change at the fieldwork site was stalled, the receptivity model is shown to have been a useful tool in identifying the factors blocking change. The analysis shows that when the eight factors are conceptualized in terms of the strength, direction and continuity of their influence, the receptivity metaphor provides a distinctive tool for the analysis of change. The paper concludes that further refinement of the model could provide a basis for the derivation of change management typologies.

An evaluation of personal medical services: the times they are a changin'

The Personal Medical Services (PMS) pilot sites, launched in England in 1997 by the Secretary of State for the then Conservative government, introduced a local contract for primary care, aimed at promoting flexibility, innovation and policy participation. As part of the National Evaluation of PMS, this paper considers the professional and organisational relationships established between service providers working in those PMS sites which specifically set out to address inequalities in access to primary care for vulnerable populations. The introduction of PMS enabled a change of cultural values in primary care, particularly regarding GPs’ relationships with nurses and practice staff. However, PMS has not necessarily led to equal partnerships within primary care teams. Rather, in the selected sites evaluated new interprofessional relationships emerged. There was evidence of intra and interprofessional partnerships being forged, providing the basis for further improved intersectoral collaboration. There was also evidence that the GP based medical model made way for a community oriented/public health model with emphasis on health maintenance for the vulnerable.

Is GP Restratification Beginning in England?

English National Health Service general practice is being restructured through the introduction of primary care groups (PCGs) and trusts (PCTs), and the personal medical services (PMS) schemes. Theories of GPs’ professional organization have to be modernized accordingly. Past theories have tended to concentrate on the occupational level rather than consider the effects of different forms of market and quasi–market on practitioners’ income and their ability to control their everyday practice. This paper extends the theory of professionalization, as an occupational group’s strategy for control over its work, to cover these matters, and thereby hypothesizes an explanation of GP responses to current changes in NHS primary health care. Case study data from four PCGs and four PMS pilots suggest that general practitioners are responding in some cases by defending enclaves of traditional general practice; in others by concentrating on clinical rather than managerial interests; and in others again by forming a new dominant coalition with NHS managers. Restratification seems to be beginning in NHS general practice although other policy developments may yet prevent it. Researchers should monitor this potentially important change as PCTs form.

Nurses and personal medical services pilots

The Kings Fund has published a new document describing the lessons learnt so far from the several nurse led PMS pilots. Nurse-led Primary Care. Learning from PMS Pilots (Lewis, 2001) is an inspiring read and should serve as a useful guide to those interested in the improvement of PHC services. While the term ‘modernisation’ is much over used and an irritant to the cynics, there is little doubt that fundamental change in both the structure and essence of primary health care has to evolve if the nation is to have better access and improved care.

Public health physicians' knowledge of core skills and current policy: clinical audit by questionnaire.

The aim of this study was to facilitate the assessment of the knowledge of general public health physicians on a range of topics relating to everyday areas of work and core skills, and to encourage learning in the process, by means of an educational clinical audit exercise. A group of experts in different aspects of public health were asked to contribute multiple-choice questions. These were developed into a questionnaire that could be marked by computer. The questionnaire was circulated to all members of the Faculty registered for Continuing Professional Development (CPD) and to specialist registrar members, but participation was voluntary. The experts marked answers according to a marking scheme against model answers agreed. A total of 499 public health doctors returned answer sheets. There was no 'pass mark' as this was a learning exercise, not an examination. However, although the negative marking system meant that the possible range of scores was -100 per cent to 100 per cent, no one had a negative score. The median uncorrected result was 44 out of 80. Questions on communicable disease and critical appraisal had the highest scores, and one on Primary Care Trusts the lowest. Participants thought the most interesting questions were those on epidemiology and evidence-based medicine, whereas the most unpopular was on Personal Medical Services pilots. Most comments were favourable to the approach but several commented that the whole exercise was too general and questions outside their current area of specialization were irrelevant. The general public health physicians who took part in this audit appeared to be mainly competent in their knowledge of core skills and up to date with current health policy issues. However, the audit raises a debate about what 'core' knowledge is required in the post-training period. The place of UK-wide CPD initiatives over national or regional, or local approaches needs consideration, as do potential regional or national variations in CPD. This will receive further impetus because of revalidation and the need to demonstrate valid CPD activities in public health medicine.

The long term importance of English primary care groups for integration in primary health care and deinstitutionalisation of hospital care.

This article reviews the impact of successive experiments in the development of primary care organisations in England and assesses the long-term importance of English primary care groups for the integration of health and community and health and social care and the deinstitutionalisation of hospital care. Governments in a number of Western countries are attempting to improve the efficiency, appropriateness and equity of their health systems. One of the main ways of doing this is to devolve provision and commissioning responsibility from national and regional organisations to more local agencies based in primary care. Such primary care organisations are allocated budgets that span both primary and secondary (hospital) services and also, potentially, social care. This article is based on a systematic review of the literature forthcoming from the UK Government's Department of Health-funded evaluations of successive primary care organisational developments. These include total purchasing pilots, GP commissioning group pilots, personal medical services pilots and primary care groups and trusts. Primary care organisations in England have proved to be a catalyst in facilitating the development of integrated care working between primary and community health services. Conversely, primary care organisations have proved less effective in promoting integration between health and social care agencies where most progress has been made at the strategic commissioning level. The development of primary care trusts in England is heralding an end to traditional community hospitals. The development of primary care groups in England are but an intermediate step of a policy progression towards future primary care-based organisations that will functionally integrate primary and community health services with local authority services under a single management umbrella.

Personal Medical Services pilots: two years on

Last year in the British Journal of Health Care Management, we published an article looking at early learning from a local evaluation of four London Personal Medical Services pilots (Jenkins, Lewis, & Gillam 1999). We now return to examine how these pilots are now faring in their third year of operation. How far have they achieved the aims and objectives set for them of improving accessibility, initiating new roles and increasing skill-mix?

Two years’ experience of a nurse led pilot scheme: patients’ perceptions

Residents of a deprived inner city area of Salford have welcomed a nurse-led personal medical services pilot scheme. Alison Chapple reports on patient evaluation of the scheme more than two years on

Principal-agent relationships in general practice: the first wave of English Personal Medical Services pilot contracts.

To investigate how far English National Health Service (NHS) Personal Medical Services (PMS) contracts embody a principal-agent relationship between health authorities (HAs) and primary health care providers, especially, but not exclusively, general practices involved in the first wave (1998) of PMS pilot projects; and to consider the implications for relational and classical theories of contract. Content analysis of 71 first-wave PMS contracts. Most PMS contracts reflect current English NHS policy priorities, but few institute mechanisms to ensure that providers realise these objectives. Although PMS contracts have some classical characteristics, relational characteristics are more evident. Some characteristics match neither the classical nor the relational model. First-wave PMS contracts do not appear to embody a strong principal-agent relationship between HAs and primary health care providers. This finding offers little support for the relevance of classical theories of contract, but also implies that relational theories of contract need to be revised for quasi-market settings. Future PMS contracts will need to focus more on evidence-based processes of primary care, health outputs and patient satisfaction and less upon service inputs. PMS contracts will also need to be longer-term contracts in order to promote the 'institutional embedding' of independent general practice in the wider management systems of the NHS.

Applications invited for third-wave PMS pilots

The government is increasing the number of personal medical services (PMS) pilots in primary health care.

Who contracts for primary care?

The implications of the 1997 NHS (Primary Care) Act have been largely overlooked in the rush to establish Primary Care Groups. Allowing health authorities to develop local contracts for primary care has far-reaching implications and is an important departure from the national system of negotiation that has characterized general practice to date. This paper describes a content analysis of a sample of Personal Medical Services (PMS) pilot contracts. In the first year little attention has been given to achieving cost savings or greater efficiency and few contracts promote clinical guidelines. The difficulties of specifying services sensitive to local health needs are highlighted and the national Statement of Fees and Allowances (the 'Red Book') may not be swiftly supplanted. However, the pilots have introduced innovations such as salaried general practitioners, nurse-led services and NHS trust-managed care. The development of local contracts provides a valuable learning experience for general practitioners and health authorities in advance of the establishment of Primary Care Trusts.

Evaluating personal medical services pilots

Personal Medical Services pilots are using local contracts to tackle health inequalities, particularly in areas such as the inner city, where General Medical Services are seen to have failed. The King's Fund has been working with four London pilot sites on their local evaluations, and this paper presents early messages from the first year of data collection.

Guest editorial

An important article about personal medical services (PMS) appears on pages 10– 13 of this edition. It is highly topical because NHS Executive regions are currently scrutinising 400 bids for the second wave of PMS pilots. Most observers are surprised at the size of the response. Considering the huge amount of energy needed to get Primary Care Groups (PCGs) under way, it is extraordinary that people are still interested in becoming a second wave PMS in October.