General Practice has never really liked Alternative Provider Medical Services (APMS) contracts. This is because they are the only GP contracts that can be negotiated with those who are not NHS GPs, such as foundation trusts and commercial organisations. But, writes Ben Gowland, they may be about to experience a resurgence…

APMS contracts were introduced really as a mechanism to enable NHS commissioners to market test General Practice against the private sector. But fears the APMS contract was going to lead to the privatisation of General Practice proved unfounded. Research by The King’s Fund^[1] found use of APMS contracts by PCTs was limited and very few APMS contracts had been awarded to independent providers.

There is no specified maximum contract length for an APMS contract, but they were typically awarded for a five-year period. This is in stark contrast to the unlimited contract length of the main GMS and PMS contracts. This drew criticism from the profession as providers would not make long term investments, or tackle long-standing problems such as premises leases. A 2015 study published in the Journal of the Royal Society of Medicine found APMS practices provided worse quality care than practices on GMS or PMS contracts, even when demographic differences such as age and deprivation were taken into account.

But change is afoot. A hospital foundation trust in Chesterfield has been awarded a 15-year APMS contract to run three GP practices serving more than 20,000 patients in Derbyshire. 15 years, and with an option to extend for a further 3 years! The APMS directions do not specify a maximum contract length and a contract exceeding 5 years can be agreed locally, but even a few years ago this would have been unheard of.

Now, as with all aspects of integration, using the APMS contract in this way creates issues for commissioners. The 2013 APMS directions[2] state the APMS contractor is required to be a member of the CCG. So by deduction Chesterfield Royal Hospital must now be a member of the local CCG. Equally, when the APMS contractor makes a decision to refer a patient it must ‘do so without regard to its own financial interests’. Choice and integration are not easy bedfellows.

But North Derbyshire CCG are not alone. Other CCGs, e.g. Blackpool CCG[3], have also been considering APMS contracts of 10-15 years (interestingly the same length as the new multispecialty provider, or MCP, contract). Clearly, something has changed.

The world has shifted since 2004, when APMS contracts were first introduced. Then the focus was on competition and market testing. In our post-Five-Year-Forward-View-world there is a new game in town: integration. APMS contracts are changing from a tool to enable competition to a tool to enable integration. Hence the sudden shift from short to much longer term contract durations. Blackpool CCG explicitly stated that ‘longer term contracts offer stability and an incentive for providers to participate/engage in CCG strategy, new models of working and integration in neighbourhoods’.

Suddenly APMS contracts have a new lease of life, as an enabler to integration. The 15 year APMS contract award in Chesterfield was met with local LMC approval. General Practice antibodies to the APMS contract appear to be dissipating (although lingering concerns over the contract value relative to GMS/PMS inevitably remain). Extending the term of the APMS contract, keeping it within the NHS ‘family’, and using it as a building block for the new models of care, mean it may be about to become much more prevalent than ever before.

[1] Walsh N, Maybin J, Lewis R (2007). ‘So where are the alternative providers in primary care?’ British Journal of Healthcare Management, vol 13, no 2, pp 43–36.

[2]https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/183370/apms_directions_2013_acc.pdf

[3] http://blackpoolccg.nhs.uk/wp-content/uploads/2015/10/Item-6-APMS-Paper-Oct-PCCC.pdf