The services an NHS GP Practice is obliged to provide to patients
This Chapter contains:
4. Core hours.
1.1 This chapter seeks to identify which medical services GP Practices are obliged to provide as part of NHS funded treatment and where a GP is entitled to refer a patient to another NHS provider. Section 83 of the National Health Service Act 2006 (“the NHS Act”) provides:
“The Board must, to the extent that it considers necessary to meet all reasonable requirements, exercise its powers so as to secure the provision of primary medical services throughout England”
1.2 “The Board” in the above section is a reference to the National Health Service Commissioning Board, known as NHS England. The Board is referred to within this chapter as NHS England but citation from statutes refer to it as “the Board”. Section 83(1) means that NHS England is under a statutory duty to secure the provision of primary medical services throughout England. Sections 83(5) and (6) provide:
“(5) Regulations may provide that services of a prescribed description must, or must not, be regarded as primary medical services for the purposes of this Act.
(6) Regulations under this section may in particular describe services by reference to the manner or circumstances in which they are provided”
1.3 The relevant regulations under section 83 are the National Health Service (Primary Medical Services) (Miscellaneous Amendments and Transitional Provisions) Regulations 2013 (“the 2013 Regulations”). However several sets of Regulations were made under the statutory predecessors of section 83 which remain in force to the extent that they have not been amended by the 2013 Regulations.
1.4 The 2013 Regulations make extensive changes to the National Health Service (General Medical Services Contracts) Regulations 2004 (“the GMS Regulations) and the National Health Service (Personal Medical Services Agreements) Regulations 2004 (the “PMS Regulations”). These Regulations define the contents of GMS and PMS contracts (and have been updated on numerous occasions since they were first published). There are no Regulations for APMS contracts but the form of these contracts usually follows the GMS/PMS model, with amendments made to the model as required.
1.5 The current definitions of what are and are not “primary medical services” for the purposes of section 83 are contained within the GMS Regulations. These Regulations define the services that those delivering primary care within the NHS are obliged to provide. These definitions take effect as terms of practice contracts with NHS England held by GP practices. The definitions of primary medical services include:
a) essential services;
b) additional services;
c) enhanced services; and
d) emergency services.
2.1 The current definition of “essential services” for primary care is set out at Regulation 15 of the GMS Regulations as follows:
“(1) Subject to paragraph (1A), for the purposes of section 28R(1) of the Act (requirement to provide certain primary medical services), the services which must be provided under a general medical services contract (“essential services”) are the services described in paragraphs (3), (5), (6) and (8).
(1A) The services described in paragraphs (3), (5), (6) and (8) are not required to be provided by the contractor during any period in respect of which the Care Quality Commission has suspended the contractor as a service provider under of the Health and Social Care Act 2008 (suspension of registration).
(2) Subject to regulation 20, a contractor must provide the services described in paragraphs (3) and (5) throughout the core hours.
(3) The services described in this paragraph are services required for the management of its registered patients and temporary residents who are, or believe themselves to be—
(a) ill, with conditions from which recovery is generally expected;
(b) terminally ill; or
(c) suffering from chronic disease,
delivered in the manner determined by the practice in discussion with the patient.
(4) For the purposes of paragraph (3)—
“disease” means a disease included in the list of three-character categories contained in the tenth revision of the International Statistical Classification of Diseases and Related Health Problems; and
(a) offering consultation and, where appropriate, physical examination for the purpose of identifying the need, if any, for treatment or further investigation; and
(b) the making available of such treatment or further investigation as is necessary and appropriate, including the referral of the patient for other services under the Act and liaison with other health care professionals involved in the patient's treatment and care.
(5) The services described in this paragraph are the provision of appropriate ongoing treatment and care to all registered patients and temporary residents taking account of their specific needs including—
(a) the provision of advice in connection with the patient's health, including relevant health promotion advice; and
(b) the referral of the patient for other services under the Act”
2.2 The PMS Regulations do not contain a definition of essential services for primary care. However most PMS contracts provide that GP practices are required to provide essential services following the defined terms set out in the GMS Regulations.
2.3 The above provisions need to be interpreted in the light of the whole of the NHS Act as a whole which divides healthcare services into different categories. Acute medical services come within Part 1 of the NHS Act and primary care services fall within Part 4 of the NHS Act. Other parts of the Act provide for dental and pharmaceutical services to be delivered as part of NHS funded care.
2.4 Although there is an inevitable measure of overlap between acute services and primary care services, where services are classified as “acute services” under Part 1, they are generally not primary care services under Part 4. Acute services are widely defined in section 3(1) of the NHS Act as follows:
“(a) hospital accommodation,
(b) other accommodation for the purpose of any service provided under this Act,
(c) medical, dental, ophthalmic, nursing and ambulance services,
(d) such other services or facilities for the care of pregnant women, women who are breastfeeding and young children [as the group considers] are appropriate as part of the health service,
(e) such other services or facilities for the prevention of illness, the care of persons suffering from illness and the after-care of persons who have suffered from illness [as the group considers] are appropriate as part of the health service,
(f) such other services or facilities as are required for the diagnosis and treatment of illness”
2.5 Where a CCG commissions relevant services under section 3(1) of the NHS Act, a GP can discharge his or her obligations as a provider of primary care by referring an NHS patient onto another NHS provider where his or her patient requires one of those acute services. The “essential services” that are required to be provided by GPs are therefore a much narrower group of services.
2.6 The core requirement on a GP who provides essential services to NHS patients is “the management of” such patients. “Management” of a patient includes:
a) offering consultation and, where appropriate, physical examination for the purpose of identifying the need, if any, for treatment or further investigation; and
b) the making available of such treatment or further investigation as is necessary and appropriate, including the referral of the patient for other services under the Act and liaison with other health care professionals involved in the patient’s treatment and care.
2.7 This is expanded by Regulation 15(5) which provides that management of the GP’s patients includes the provision of appropriate ongoing treatment and care to all registered patients and temporary residents taking account of their specific needs including:
a) the provision of advice in connection with the patient's health, including relevant health promotion advice; and
b) the referral of the patient for other services under the NHS Act (which normally means referral for acute and community services under section 3 of the NHS Act).
2.8 These definitions need little further explanation because they define the essential core obligations of a GP working in the NHS. These are however the contractual obligations that a GP practice owes to NHS England under a GMS Contract or a PMS Contract which imports these definitions. There is a separate legal duty in tort (i.e. negligence) to the patient which exists alongside the contractual duty. The doctor’s duty in tort will obviously be very substantially informed by the contractual duties owed by the practice under the relevant practice contract. How those precise non-contractual duties work themselves out is examined in the chapter on negligence.
3.1 The persons to who the GP is obliged to offer this “management” service are:
a) The patients on the list for the GP practice held by NHS England;
b) Temporary patients.
These are precisely defined terms under the GMS Regulations. For more details about how practice lists operate please see chapter 6.
3.2 The GP practice is not obliged to offer “management services” to every patient on their list for every minute of the core hours (because that would be an impossible task to fulfil and would mean offering services where they were not needed). The contractual duty is to provide services to patients who are, or believe themselves to be:
a) ill, with conditions from which recovery is generally expected;
b) terminally ill; or
c) suffering from chronic disease.
3.3 The expression “illness” is widely defined in section 275 of the NHS Act as follows:
““illness” includes any disorder or disability of the mind and any injury or disability requiring medical or dental treatment or nursing”
3.4 Thus a GP practice is obliged to see and offer a management services to a patient who believes himself or herself to be ill even if that person is not, in fact, suffering from any diagnosable illness. The wide definition means that, for example, a drug addiction is likely to be an “illness” because drug addiction changes the brain in fundamental ways, disturbing a person's normal hierarchy of needs and desires and substituting new priorities connected with procuring and using the drug. The resulting compulsive behaviours that override the ability to control impulses despite the consequences are similar to hallmarks of other mental illnesses. The behaviour can be classified as an illness in ICM 10 within the International Statistical Classification of Diseases and Related Health Problems and thus GP practices have the same management duty to such patients as they have to patients with any other illness.
3.5 A GP is obliged to provide a management service to a patient “in the manner determined by the practice in discussion with the patient”. Thus the patient is entitled to be consulted about the way in which general medical services are provided to the patient but the final decision about the manner in which services should be provided (including the location at which the services should be provided) rests with the GP.
4.1 The GMS Contract (and virtually all PMS Contracts) provides that the contractual duty on the GP practice to provide the essential services is only operative during “core hours”. These hours are defined in Regulation 2 of the GMS Regulations as follows:
“core hours” means the period beginning at 8am and ending at 6.30pm on any day from Monday to Friday except Good Friday, Christmas Day or bank holidays”
4.2 However the GMS Contract does not require the GP practice to make a GP available in person to provide routine services to patients throughout the core hours. Under Regulation 20 the duty to provide services within core hours has 2 parts, namely:
a) to provide the essential services within core hours, “as are appropriate to meet the reasonable needs” of its patients; and
b) to have in place arrangements for its patients to access such services throughout the core hours in case of emergency.
4.3 Thus if GP practice premises are closed at any point during the core hours, the GP practice either must provide a means for patients to be able to access one of the practice GPs throughout that period or must make arrangements with an out of hours provider to provide emergency GP services to patients during that period. There are no set surgery hours within the GMS GP contract but the opening hours need to be sufficient to “meet the reasonable needs of its patients”.
4.4 There is considerable discussion in the professional press about practices which do not provide sufficient surgery slots to meet the needs of patients and thus patients find themselves having to wait for an appointment time. The Labour government had a policy that patients should have a maximum period of waiting of 48 hours before seeing a GP. However that target was abandoned by the coalition government in 2010. The present position is that there is no specific time target but the NHS website states:
“Your surgery should be able to offer you an appointment to see a GP or other healthcare professional quickly if necessary. However, if it is more convenient, you should also be able to book appointments in advance”
4.5 GP practices which fail to provide a sufficient number of surgery appointments to meet the reasonable needs of their patient populations are probably acting in breach of the contractual requirement to provide services to “meet the reasonable needs of its patients” and could find that NHS England serves a Remedial Notice to require them to extend the number of surgery appointments.
5.1 Patients who seek assistance from their GP are ill (or at least consider themselves to be ill). Some of these patients will be too ill to be able to attend the surgery premises or, if they have an infectious condition, it may not be medically appropriate for them to attend the GP surgery because they may spread their condition to other patients. Thus treating patients at their own home has always been part of the work of a GP.
5.2 The GMS and PMS contracts have the following provisions which define when a GP is obliged to treat a patient outside the surgery premises:
“(1) In the case of a patient whose medical condition is such that in the reasonable opinion of the contractor—
(a) attendance on the patient is required; and
(b) it would be inappropriate for him to attend at the practice premises,
the contractor shall provide services to that patient at whichever in its judgement is the most appropriate of the places set out in sub-paragraph (2).
(2) The places referred to in sub-paragraph (1) are—
(a) the place recorded in the patient's medical records as being his last home address;
(b) such other place as the contractor has informed the patient and the Board is the place where it has agreed to visit and treat the patient; or
(c) some other place in the contractor's practice area.
(3) Nothing in this paragraph prevents the contractor from—
(a) arranging for the referral of a patient without first seeing the patient, in a case where the medical condition of that patient makes that course of action appropriate; or
(b) visiting the patient in circumstances where this paragraph does not place it under an obligation to do so”
5.3 Thus a patient is entitled to medical treatment from the GP practice if, in the reasonable opinion of the GP practice, two conditions are satisfied, namely:
a) attendance on the patient is required; and
b) it would be inappropriate for him to attend at the practice premises.
5.4 At the stage that the GP is making this assessment it is likely that the GP will not have seen the patient and therefore can only make this decision based upon the information that the patient has given to the GP practice (or has been provided on the patient’s behalf) and on the medical history of the patient as set out in the notes. It seems clear however that the decision whether to make a home visit is a matter for the GP’s judgment and is not something that could properly be left to reception staff or even the practice nurse because the contract requires the contractor to make the assessment. The first test is whether the patient requires “attendance” which must mean whether the patient has a need for the provision of the type of patient management services defined in the essential services. The second test is whether it is inappropriate for the patient to attend at the practice premises. There is no limit to the reasons why a GP might consider that it could be inappropriate for the patient to attend at the practice premises. It may be that the patient is too ill to attend, has an infectious illness which makes it inappropriate to attend or has a medical such as agoraphobia which makes it difficult for the patient to attend the surgery. This provision could also be used to manage a violent patient who the GP practice does not wish to remove from its list but nonetheless wishes to treat in a location where there is a measure of protection for the GP (such as a room at a local police station if he police were to agree to that arrangement).
5.5 Once the GP practice has reached the opinion that the patient needs treatment (from a GP) outside the surgery, the place at which the GP must offer treatment is set out in the Regulations. It must be offered at the “most appropriate” of the following places:
a) at the patient’s home;
b) at another place agreed between the GP practice and the patient; or
c) at some other place within the practice area.
5.6 The final provision appears to be a catch all provision but that place must still pass the test of being the most appropriate place to provide services to the patient.
5.7 A GP practice which asserted that it did not offer home visits under any circumstances or applied a requirement for a patient who sought a home visit which was different to those set out above would be acting in breach of contract and could, in an extreme case, have the contract cancelled by NHS England.
6.1 Until 2004 GP practices were required to provide essential service to patients at all times of the day and night. Many practices used deputising services to provide services to patients outside of core hours. Thus, in practice, prior to 2004 many patients would not see their family doctor if they sought GP services out of hours (OOH”). However as part of the changes in 2004 GP practices were entitled to opt-out of responsibility for providing OOH services. The vast majority of GP practices did so and accordingly the responsibility for OOH GP provision fell to primary care trusts to arrange.
6.2 The present duty to commission OOH primary care services lies with the CCG and not NHS England. It follows that CCGs need to be careful to observe the rules on conflicts of interest in any contract process where one of the bidders includes GPs who work within a local GP practice (and are therefore members of the CCG).
6.3 Primary care trusts entered into contracts with a wide range of OOH providers. Some were GP co-operatives such as Devon Doctors, who arranged for out of hours cover to be provided by their on GP members or by GPs who were contracted to the service provider. There have been a series of scandals and problems with OOH providers, such as the case involving a German doctor, Dr Daniel Ubani, who came to the UK for the weekend to do a double OOH shift and gave a patient 10 times the normal dose of morphine, resulting in the death of the patient. There have also been serious problems with OOH providers failing properly to record management data and thus seeking to hide their shortcomings.
6.4 A GP practice that does provide OOH services must meet the quality requirements set out in the document entitled “National Quality Requirements in the Delivery of Out of Hours Services” published on 20th July 2006: see paragraph 11 of Schedule 6 to the GMS Regulations.
6.5 The government has indicated its intention to move responsibility for out of hours cover back to GP practices. If this happens it seems highly unlikely that GP practices will agree to cover all OOH periods themselves, and is far more likely that contracts with local OOH providers will remain in place. However, even if a GP practice has a contract in place, GP practices will remain contractually liable to NHS England to provide these services.
7.1 GPs are not para-medics and will not usually be called to a medical emergency within their practice area. However the GMS Regulations provide that GP practices must provide a limited range of emergency services. Regulations 15(6) and (7) provide:
“(6) A contractor must provide primary medical services required in core hours for the immediately necessary treatment of any person to whom the contractor has been requested to provide treatment owing to an accident or emergency at any place in its practice area.
(7) In paragraph (6), “emergency” includes any medical emergency whether or not related to services provided under the contract”
7.2 This is an obligation to react to requests for assistance made at any time throughout the core hours. The contractual duty to provide services only comes into effect if the GP practice has been “requested” to provide emergency primary care services in the event of an accident or emergency taking place anywhere in the practice area. The identity of the person making the request is not specified in the Regulations and the request therefore could be made by the police, fire brigade, paramedics or a member of the public (whether a patient on the practice list or not). The Regulation does not specify what sort of service the GP is required to provide beyond saying that the GP must provide primary medical services. Thus the GP has to provide the same type of “management” services for the patient in an emergency situation as he or she would provide in the surgery. This includes:
a) physical examination for the purpose of identifying the need, if any, for treatment or further investigation; and
b) the making available of such treatment or further investigation as is necessary and appropriate, including the referral of the patient for other services under the Act and liaison with other health care professionals involved in the patient’s treatment and care.
7.3 It seems clear that, in order to comply with the contractual obligation, the practice would have to send out a qualified GP who could administer such services as could be reasonably expected from a GP as opposed to a specialist in emergency medicine. The contractual obligation is likely to be fulfilled if the GP arrives at the scene of the accident or emergency reasonably promptly and provides a primary medical service whilst, at the same time, calling for help from specialist emergency practitioners.
7.4 The second type of emergency service that a GP practice is required to provide “immediately necessary treatment” to someone who is not on the list of patients for the practice and is not a temporary patient but who comes within certain specified categories. Regulation 15(8) to (10) provides the contractual duty is as follows:
“(8) A contractor must provide primary medical services required in core hours for the immediately necessary treatment of any person falling within paragraph (9) who requests such treatment, for the period specified in paragraph (10).
(9) A person falls within paragraph (8) if he is a person—
(a) whose application for inclusion in the contractor's list of patients has been refused in accordance with paragraph 17 of Schedule 6 and who is not registered with another provider of essential services (or their equivalent) . . .;
(b) whose application for acceptance as a temporary resident has been rejected under paragraph 17 of Schedule 6; or
(c) who is present in the contractor's practice area for less than 24 hours.
(10) The period referred to in paragraph (8) is—
(a) in the case of paragraph (9)(a), 14 days beginning with the date on which that person's application was refused or until that person has been subsequently registered elsewhere for the provision of essential services (or their equivalent), whichever occurs first;
(b) in the case of paragraph (9)(b), 14 days beginning with the date on which that person's application was rejected or until that person has been subsequently accepted elsewhere as a temporary resident, whichever occurs first; and
(c) in the case of paragraph (9)(c), 24 hours or such shorter period as the person is present in the contractor's practice area”
7.5 The contractual duty on a GP practice to provide emergency services is thus limited in 3 ways:
a) It is not a duty to provide a full primary care service to these patients but only to provide immediately necessary treatment to such patients. There is clearly a measure of judgment that the GP practice will have to make as to what services are within this requirement and which services can be left for another GP to provide in due course;
b) The duty is limited to those categories of patients set out in Regulation 15(9) namely individuals who have applied to join the practice list and been refused, who have been rejected as temporary residents or are in the practice area for less than 24 hours;
c) The duty is time limited in that for patients who have been rejected from the practice list either as permanent or temporary patients, the duty only lasts for a maximum of 14 days but can come to an end if the patient secures another GP in that period and, in the case of a person only in the practice area for 24 hours, is limited to a maximum of 24 hours.
7.6 A person who has been accepted onto the practice list and is then removed from the list because, for example, the patient has been violent to staff members, does not come within Regulation 15(8) of the GMS Regulations unless that person applies to re-join the practice list and is refused. Equally, a person who has applied to join the practice list but has not yet been accepted or refused does not come with this provision. The GP practice is therefore under no contractual duty to provide services to such a patient.
7.7 The Regulations do not explain what happens if, at the end of the 14 day period, the rejected patient presents at the surgery seeking a further course of “immediately necessary treatment”. It seems likely that the duty under Regulation 15(8) of the GMS Regulations is a “one off” duty to an individual and that, once the period specified in Regulation 15(10) has ended the GP practice has no further duty to provide medical services to that individual. If it were otherwise a patient who had been refused entry onto the practice list as a result of violence to staff could, for example, keep seeking services under this provision and thus remain a threat to staff.
8.1 Essential services are the range of services that GP practices are obliged to provide as a minimum to their practice patients and temporary residents. However GP practices can contract to provide extra services to patients and thus avoid the need for the GP practice to refer patients who need such services elsewhere. Services which are extra to the essential services (as described above) are classified as “additional services” and “enhanced services”. GP practices are not obliged to contract to provide additional services but they are paid additional sums (usually as part of the global sum) where they agree to do so.
8.2 “Additional services” are defined in the standard GMS Contract as follows:
““additional services” means one or more of-
(a) cervical screening services;
(b) contraceptive services;
(c) vaccines and immunisations;
(d) childhood vaccines and immunisations;
(e) child health surveillance services;
(f) maternity medical services; and
(g) minor surgery”
8.3 The standard GMS Contract provides details of the way in which each of services are required to be provided. Hence, for example, GP practices that agree to provide contraceptive services are required to provide services in the following way:
“The Contractor shall make available the following services to all of its patients who request such services:
(a) the giving of advice about the full range of contraceptive methods;
(b) where appropriate, the medical examination of patients seeking such advice;
(c) the treatment of such patients for contraceptive purposes and the prescribing of contraceptive substances and appliances (excluding the fitting and implanting of intrauterine devices and implants);
(d) the giving of advice about emergency contraception and where appropriate, the supplying or prescribing of emergency hormonal contraception or, where the Contractor has a conscientious objection to emergency contraception, prompt referral to another provider of primary medical services who does not have such conscientious objections;
(e) the provision of advice and referral in cases of unplanned or unwanted pregnancy, including advice about the availability of free pregnancy testing in the practice area and, where appropriate, where the Contractor has a conscientious objection to the termination of pregnancy, prompt referral to another provider of primary medical services who does not have such conscientious objections;
(f) the giving of initial advice about sexual health promotion and sexually transmitted infections; and
(g) the referral as necessary for specialist sexual health services, including tests for sexually transmitted infections”
8.4 There are extended definitions in the Standard Contract for the services to be provided by GP practices that contract to provide other additional services.
8.5 The contract can specific that the GP practice should provide additional services to the practice patients and persons accepted by the GP practice as temporary residents. However the GMS contract can also be extended so that such services are provided to a wider range of patients. Hence, for example, a GP practice could develop a specialism in minor surgery or be contracted to provide contraceptive services to a wider range of patients than just those on its practice list.
9.1 Enhanced services are defined in the standard GMS Contract as follows:
““enhanced services” are-
services other than essential services, additional services or out of hours services; or
essential services, additional services or out of hours services or an element of such a service that a contractor agrees under a contract to provide in accordance with
specifications set out in a plan, which requires of the contractor an enhanced level of service provision compared to that which it needs generally to provide in relation to that service or element of service;
9.2 There is no limit on the type of enhanced services that a commissioner and a GP practice can agree to be provided to NHS patients, provided that the service can properly be considered to be part of the health service. The terms fall to be agreed between the commissioner and the provider.
10.1 Part 1 of Schedule 6 to the GMS Regulations provide a list of other services that GMS contracts must specify all GMS practices must provide to their patients. There is a similar list in the PMS Regulations. The following paragraphs summarise these requirements.
10.2 Premises: The contract provides that the contractor shall ensure that the premises used for the provision of services under the contract are:
a) suitable for the delivery of those services; and
b) sufficient to meet the reasonable needs of the contractor's patients.
10.3 Telephone lines: NHS GP practices are prohibited from using premium rate telephone numbers which start with the digits 087, 090 or 091 or consists of a personal number, unless the service is provided free to the caller. There are also provisions to prevent NHS GP practices using other types of premium rate telephone services.
10.4 New Patients: GP practices must take steps to ensure that any patient who has not previously made an appointment and attends at the practice premises during the normal hours for essential services is provided with such services by an appropriate health care professional during that surgery period. There is an exemption to this obligation for new patients who have to be referred elsewhere, in which case another appointment should be booked.
10.5 A slightly overlapping provision is that patients who are new to the practice list (but not temporary residents) must also be offered a “consultation” with the GP practice within 6 months at which the GP must make such inquiries and undertake such examinations as appear to it to be appropriate in all the circumstances. The wording of this requirement (in paragraph 4 of Schedule 6 to the GMS Regulations) is as follows:
“(1) Where a patient has been—
(a) accepted on a contractor's list of patients under paragraph 15; or
(b) assigned to that list by the Board,
the contractor shall, in addition and without prejudice to its other obligations in respect of that patient under the contract, invite the patient to participate in a consultation either at its practice premises or, if the medical condition of the patient so warrants, at one of the places referred to in paragraph 3(2).
(2) An invitation under sub-paragraph (1) shall be issued within six months of the date of the acceptance of the patient on, or their assignment to, the contractor's list.
(3) Where a patient (or, where appropriate, in the case of a patient who is a child, his parent) agrees to participate in a consultation mentioned in sub-paragraph (1) the contractor shall, in the course of that consultation make such inquiries and undertake such examinations as appear to it to be appropriate in all the circumstances”
10.6 Patients who are not seen for 3 years: Where a registered patient between the ages of 16 and 75 who has not attended the surgery for 3 years requests a consultation the GP practice must take advantage of the opportunity to this individual attending the surgery to “make such inquiries and undertake such examinations as appear to it to be appropriate in all the circumstances”. However there is no duty on the GP practice to seek out patients who have not attended for 3 years to offer them a check-up. The duty only arises if the patient requests a consultation.
10.7 Patients over the age of 75: The time period of non-attendance which needs to elapse before the GP practice has a duty to “make such inquiries and undertake such examinations as appear to it to be appropriate in all the circumstances” is reduced to 12 months. However once again, there is no duty on the GP practice to seek out patients over the age of 75 who have not attended the practice for 12 months to offer them a check-up. The duty only arises if such a patient requests a consultation with the GP practice.
10.8 Clinical Reports on patients on the list of another practice: Where the GP practice provides any clinical services, other than under a private arrangement, to a patient who is not on its list of patients, it shall, as soon as reasonably practicable, provide a clinical report relating to the consultation, and any treatment provided, to NHS England. Thus every time medical care is provided to a temporary resident or emergency care is provided to a patient who is not registered with the practice, a report should be sent to NHS England explaining what care has been provided and the clinical findings. NHS England then has the task of sending the report to the patient’s own practice so that it can form part of the clinical notes for that practice.
10.9 Storage of vaccines: GP practices must ensure that all vaccines are stored in accordance with the manufacturer's instructions and that all refrigerators in which vaccines are stored have a maximum/minimum thermometer and that readings are taken on all working days.
10.10 Infection control: Each GP practice must ensure that it has appropriate arrangements for infection control and decontamination. The content of Infection Control policies are a matter for each GP Surgery. However NICE has published Guidance about infection control in primary care. Whilst there is a measure of discretion, GP practices would have to have good reasons for adopting policies which departed from the infection control guidance published by NICE.
10.11 The MPS has identified the following as the highest areas of breaches of infection control in GP practices:
a) The cleaning of premises was inadequate because no schedule of cleaning was available;
b) Reception staff were handling specimens at the reception desk;
c) Hand washing was not addressed within the practice;
d) Risks associated with clinical waste and the management of sharps. For example not using pedal operated clinical waste bins, clinical waste bins not being provided in the consulting room and inappropriate storage of clinical waste awaiting collection;
e) GP practices were not providing spillage kits, either purchased or made up in-house, for dealing with spillages such as body fluids, blood and mercury (if applicable);
f) Failing to provide staff training on infection control;
g) Waiting room toys that were not cleaned routinely. The Guidance observed that soft toys are hard to disinfect and tend to rapidly become re-contaminated after cleaning and that conversely, hard toys can be cleaned and disinfected easily.
10.12 Duty of Co-operation: Paragraph 12 of Schedule 6 to the GMS Regulations provides that GP practices which do not provide additional services, enhanced services or OOH services must co-operate with those providers who do deliver those services for NHS patients. The GP practice must:
a) co-operate, insofar as is reasonable, with any person responsible for the provision of that service or those services;
b) comply in core hours with any reasonable request for information from such a person or from NHS England relating to the provision of that service or those services; and
c) in the case of out of hours services, take reasonable steps to ensure that any patient who contacts the practice premises during the out of hours period is provided with information about how to obtain services during that period.
10.13 However these obligations do not extend to requiring the GP practice to make care for its patients available during the out of hours period.
10.14 Handover requirements: Where a contractor is to cease to be required to provide to its patients a particular additional service, a particular enhanced service or out of hours services, either at all or in respect of some periods or some services, the GO practice is obliged to comply with any reasonable request for information relating to the provision of that service or those services made by NHS England or by any person with whom NHS England intends to enter into a contract for the provision of such services.
 The electronic version of the National Health Service Act 2006 on the www.legislation.gov.uk website has not yet been updated to show all the changes to the 2006 Act made by the Health and Social Care Act 2012. Hence the present publicly accessible version of section 83 at http://www.legislation.gov.uk/ukpga/2006/41/section/83 still refers to the duty to provide primary care services being a duty resting on primary care trusts.
 Under the NHS Act 2006 as originally passed this duty rested on primary care trusts. It was transferred to NHS England in April 2013 as a result of amendments made in the Health and Social Care Act 2012.
 Transitional provisions mean that Regulations made under the equivalent of section 83 in the National Health Service Act 2006 continue to have effect./
 The electronic version of the National Health Service (General Medical Services) Regulations 2004 on the www.legislation.gov.uk website has not yet been updated to show all the changes made by the numerous amending regulations made since the Regulations were introduced in 2004. The original Regulations are at http://www.legislation.gov.uk/ssi/2004/115/contents/made but the wording quoted in this chapter is the version which is current at 1 January 2014 when this chapter has been written.
 “Section 28R” is a reference to section 28R of the National Health Service Act 1977 which was brought in by section 175 of the National Health Service (Community Health and Standards) Act 2003. This provision is now in section 85 of the National Health Service Act 2006 is a consolidating Act and thus references in these Regulations to sections of the 1977 act are required to be read as references to the relevant provision of the National Health Service Act 2006, which in this case is section 83. See section 17 of the Interpretation Act 1978 and Schedule 2 to the National Health Service (Consequential Provisions) Act 2006.
 This chapter is being written by Jonathon Jones QC and will be put on the website when completed.