Core hours contractual requirements and practice self-checklist

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Practices are required to have their doors open during core hours or have a form of alternative access in place if they are not allowing patients into their premises.

Purpose of this guidance

The GP Support team at Londonwide LMCs has been recently assisting several practices who have received contract advisory notices in relation to core hours. These are notices which warn practices that unless they remedy the issue, they could be issued with a remedial/breach notice under the contract. We thought it helpful to remind practices of the relevant contractual requirements and provide a ‘check list’ to aid a system readiness self-check.

The issues

The issues practices have been challenged about by their ICB fall into two categories:

  • Having their front doors closed for any time during core hours (8.00am to 6.30pm). This tends to happen during lunch time to allow staff time to catch up with administrative work, attend training, utilise protected learning time etc, but in most cases we have seen that there is an alternative access system in place as outlined below.
  • Having their telephone lines either switched over to an alternative provider such as a local Out of Hours organisation or having an internal system of a bypass number in the event of an urgent appointment request. This tends to happen first thing in the morning, for example between 8am and 8:30 or 9am, during lunchtime, or sometimes at the end of the day between 6pm and 6:30pm (these are indicative times).

Commissioners become aware of these situations through practices’ annual electronic submissions (e-Dec), core hours information on practice websites, contacting the practices themselves, patient complaints, or reports from other healthcare services, e.g. the London Ambulance Service (LAS). These reports often come through when someone has difficulty getting through to the practice on their bypass number.

The contractual position

You will of course be aware that in the contract regulations ‘core hours’ are defined as 8:00am to 6:30pm, Monday to Friday (not including bank holidays). There have been no changes to core hours for a number of years. The GMS contract/PMS agreement state:

“Core hours” means, subject to clause 26.21.1/53A, the period beginning at 8.00am and ending at 6.30pm on any day from Monday to Friday except Good Friday, Christmas Day or bank holidays”.

The key wording is ‘to meet the reasonable needs of its patients’:

GMS

Subject to clause 8.1.8, the Contractor must provide the services described in Part 8 (namely essential services) at such times, within core hours, as are appropriate to meet the reasonable needs of its patients, and to have in place arrangements for its patients to access such services throughout the core hours in case of emergency.

PMS

The Contractor must provide Essential Services and such other Services that it is required to provide under this Agreement to those Patients, at such time, within Core Hours, as are appropriate to meet the reasonable needs of its Patients. 45 7.3

The Contractor must have in place arrangements for its Patients to access Essential Services and such other Services that it is required to provide under this Agreement throughout the Core Hours in case of emergency.

BMA advice

The BMA states that whilst core hours are set in stone, GMS regulations do not denote that practices must ‘be open at all times’ during core hours, or that they must ‘deliver all services at all times when they are open’ GP access: meeting the reasonable needs of patients.

They do however highlight the importance of ensuring that practices (either themselves or through subcontracting arrangements):

‘… provide services at times that are appropriate to meet the needs of patients’ and that practices ensure arrangements are in place for patients to access services throughout core hours in case of emergency (this allows practices to close, for example, to undertake training or staff reviews)’.

Interpretation of the regulations by London commissioners

London ICBs recognise that the regulations do not state that practices should have their doors open and their phones on throughout core hours, however in our experience their interpretation of the regulations tends to be quite different to that of the BMA or Londonwide LMCs.

In the cases we have seen over the years and more recently, commissioners’ general expectation is that practices should have their doors open and telephones switched on throughout core hours, i.e. between 8.00am and 6.30pm without any gaps. While they accept that the contract regulations do not provide a definition of “reasonable needs”, they consider that this is the best way practices can meet the reasonable needs of their patients and any deviation from this expectation will have to be explained and mitigated appropriately.

If practices have different access arrangements for entry into the building or by telephone for any time during core hours, the onus falls on them to demonstrate that they have systems in place (such as commissioner approved sub-contracting agreements, bypass numbers etc) to ensure patients can access care, advice, or signposting at all times in the event of an emergency during core hours. An example of alternative access arrangements could be that the reception desk may not be staffed at lunchtimes/staff training sessions etc, but, in the event of an emergency, patients can still access the premises by using a doorbell/intercom and the phone lines could have a bypass option.

The importance of using the correct language

Londonwide LMCs believes that the narrative “the practice is closed” during times when the practice may legitimately need to deliver staff training, have clinical or other practice meetings, catch up on their administrative work etc is misleading and unhelpful for patients.

During such times practices are not closed. They simply have alternative access arrangements in place, which enable patients to access the practice by telephone or through physical entry into the building, albeit in a different way to the rest of the time. Online access remains available throughout core hours.

It is important that practices convey this message correctly in their e-Decs and publicise it appropriately and consistently on all their media and physical platforms. Please see below for more details.

Practice self-checklist regarding their core hours access arrangements

This is not an exhaustive list, but hopefully it will help you review your core hours arrangements to ensure your patients’ reasonable needs are met and you are safe from any potential contractual action by the ICB.

We recommend that you:

  • Review your practice website, practice leaflet, waiting room posters/door signs/digital posters to ensure the information regarding opening hours is correct and consistent across all platforms.
  • Ensure your e-DEC is submitted correctly. Please do not declare that you are closed if you have alternative physical and/or telephone access arrangements in place at certain times during core hours.
  • If the practice does operate a different access system during core hours, inform patients through clearly visible signage on the doors, telephone messages, and information on the practice website, including the times when the alternative access system is in place and how patients can obtain urgent assistance during these times.
  • During the times that the practice is providing an alternative process for patient access, you can use an intercom or doorbell to allow patients physical access into the practice to address urgent issues, as appropriate. Staff need to be aware of this and respond to the intercom/ doorbell at all times during core hours.
  • Ensure telephone messages are correct – if your telephone lines are switched over for a period but patients can request assistance in an emergency (by pressing 1 etc), make sure this is clear and this option is offered on the same phone call so that patients do not have to ring back on a different number or at a different time. If you operate this kind of system, please test it regularly to make sure it works at all times and that calls are answered in a timely way without fail. If an emergency number is not staffed at the time a patient calls, it may result in a complaint to the ICB.
  • Check your practice bypass phone lines are working and are sufficiently staffed throughout the day. We have been informed of cases where the LAS or the local hospital called the practice’s bypass number and were unable to get through. This was then reported by the LAS or the hospital to the ICB.
  • Ensure your staff are aware of the practice’s operating pattern and are conveying the correct (and same!) message to patients.
  • Engage with your PPG and seek their feedback on your alternative access arrangements.

The BMA advises:

“If the commissioner believes your hours are not meeting the reasonable needs of your patients, they will likely approach the practice to discuss this.

You should provide information to the commissioner, showing:

– the times of delivering services meet the reasonable needs of patients

– that outside of these hours, there are arrangements so that patients can access services in an emergency

– engagement with your patients (usually via the PPG) around hours”.

Londonwide LMCs has been working on developing a resource for practices regarding patient engagement, which we believe will be helpful in terms of core hours arrangements.

This information is due to be published early in the new year, so please watch out for it in our newsletter.

In summary, please ensure that any alternative access system you have in place during core hours is:

  • Robust
  • Clearly documented and known to all staff
  • Regularly tested and monitored to ensure it is failsafe
  • Discussed with and endorsed by the PPG
  • Publicised correctly and consistently across all physical and digital platforms
  • Adhered to at all times
  • Notified to the ICB (please note that if you have a sub-contracting agreement in place with another provider for in-hours cover, commissioner approval is contractually required)

LMC support

If you have been contacted by your local ICB with a request for information regarding any alternative physical or telephone access arrangements during core hours, issued with a contract advisory or remedial/breach notice, received patient complaints regarding your access arrangements during core hours, or reported to the ICB by the LAS or another healthcare provider because of issues with your bypass number, please contact the GP Support team for expert and confidential advice at gpsupport@lmc.org.uk.