The role of Primary Care Appeals

Date published:

Jonathan Haley is the Head of Appeals at NHS Resolution and leads the work of the Primary Care Appeals service. In this blog he discusses the important role that his team play in providing fair resolution of appeals and contracting disputes in primary care.

The role of Primary Care Appeals

During my many years working at Primary Care Appeals, it is clear that the service has an important role to play.  First and foremost we are independent from NHS England, the Department of Health and Social Care (DHSC) and the recently formed integrated care boards (ICBs) and this is valued by those using our services. As the body responsible for the fair resolution of appeals and contracting disputes between primary care contractors (or those wishing to provide primary care services) and the commissioners of primary care services, that independence is vital.

Parties to an NHS Contract have the right to utilise the NHS dispute resolution procedure as an expeditious and cost effective mechanism for determining disputes. This is the role that Primary Care Appeals undertake and we have been in existence in some shape or form since 1991. NHS Resolution received delegated authority to undertake the role on 1 April 2005 and since then Primary Care Appeals has been one of its core functions.

We deliver a wide range of work, including appeals relating to applications to open NHS community pharmacies, to relocate or change listing, and against performance sanctions such as breach or remedial notices. Common disputes relate to entitlement to payments including GP premises rent reimbursement, against breach or remedial notices, variation or termination of contract and regarding suspension payments (GPs and dentists only).

Ultimately our decisions directly impact on and benefit patient care.  This could be as a result of:

  • granting NHS community pharmacy applications which secure improvements or better access to services;
  • ensuring NHS monies are paid in line with the contract which is used to provide services; or
  • that local commissioner decisions involving the delivery of services, including those relating to patient safety, are lawful, fair, reasonable and proportionate.

Feedback from our service users

Parties utilise our appellate and dispute service to achieve resolution of cases in a timely and effective way.  We listen to our stakeholders and make service improvements where necessary. We have a commitment to quality and quality assurance is hardwired into the team’s operating model.

In our most recent stakeholder conversations, a range of regular users of our services were asked their views of the impact, efficiency and robustness of Primary Care Appeals. Respondents’ comments included the following:

I have confidence in the whole appeals process – real quality of the work is in the final decision.

Appeals is an absolutely vital organisation; acts as a safety net.

You know that by this stage [i.e. with Appeals] you are not going to be let down

The Appeals team deals very well compared to a lot of organisations. Always willing to improve, drive things forward.

A range of regular Primary Care Appeals users

Why we are important to primary care?

We use our longstanding knowledge and expertise to interpret and apply complex primary care regulations to ensure that decisions taken by the commissioner regarding contracting matters are correctly applied using the statutory framework.

We have vast experience in primary care disputes and have built this while remaining a constant entity in the health service landscape. Given our functions cover all of England, we see the full range of disputes and as such, are in a position to  provide data and insights to key stakeholders as a catalyst for improvement and to help develop capability and robust local decision making by the commissioner which supports fair and just outcomes for those involved in disputes.

We are open and transparent in the way in which we determine cases and publish all decisions. (These are also available via a monthly email update.) Without Primary Care Appeals’ effective dispute resolution service managed within the NHS, parties would have no other recourse but to the courts which is expensive and time consuming.

We provide information regarding our work, our procedures, our approach and relevant decisions to those interfacing with our services so they are best placed to make informed decisions and to understand the processes involved. We publish guidance based on our insights from decision making, which is available from our resources webpage including our high-level resource, Primary Care Appeals – Who We Are and What We Do, which provides a succinct overview of the service.

Primary Care Appeals’ strategy moving forward

NHS Resolution is a year into its three-year Strategy: Advise, resolve and learn: Our strategy to 2025 and Primary Care Appeals’ focus is on the priorities where we can make a difference.

These are:

  • to deliver fair resolution
  • to share data and insights as a catalyst for improvement.

With this in mind, Primary Care Appeals has five priorities for 2023-24:

  • That our appellate decision making continues to be transparent, impartial, robust and defensible, timely and takes into account case law and judicial review guidance;
  • That we maintain engagement across all four primary care functions at NHS England and that we seek to engage with the recently created ICBs;
  • That we further understand the operating environment in order to identify emerging issues linked to the quality of local decision making / potential spikes in cases coming to Appeals;
  • That we further develop our Equality, Diversity and Inclusion agenda including the analysis and publication of appellant demographic data; and
  • That we continue to seek opportunities to enhance operational efficiency and user experience.

As stated above, Primary Care Appeals has a history of delivering fair resolution of appeals and contracting disputes, we listen to our service users’ feedback and are trusted in delivering our important role. We hope to develop relationships with the newly formed ICBs and to continue to work closely with all our stakeholders to deliver our priorities.

The following case story demonstrates the work of Primary Care Appeals

Dr A was a GP sole practitioner, who held a contract with NHS England, to provide General Medical Services. The Practice was placed in special measures and assessed as ‘overall inadequate’.  NHS England issued a remedial notice under the Contract. The Care Quality Commission carried out a further inspection and rated the Practice as ‘overall inadequate’ and it remained in special measures. Following two further remedial notices, NHS England served Dr A with a termination notice. Dr A referred the dispute to Primary Care Appeals.

This was a complex dispute in which Primary Care Appeals;

  • applied its longstanding experience of public law, taking into account Dr A’s arguments of procedural impropriety and that he had been unfairly treated; and
  • used its knowledge of contractual rights finding that NHS England could rely on one of two clauses to terminate the contract, and that it been appropriate for NHS England to rely on the relevant clause.

As a result, the Adjudicator’s decision found in favour of NHS England ensuring that patient safety was maintained and NHS monies were used effectively.