NHS Shared Business Services

Sanger House,5220 Valiant Court,Gloucester Business Park

Brockworth, Gloucester GL3 4FE

Tel No: 020 8536 3009, Email:

GP JOINER/ LEAVER/ CHANGE OF CIRCUMSTANCE PRO-FORMA

If a new partnership is to be created or an existing partnership wishes to change or vary its contract by:

  • Varying commitment (within the same Practice/Partnership)
  • A new partner joins an existing partnership
  • A partner leaves an existing partnership due to resignation, full retirement, or 24 hr retirement
  • Employment of/ changes to current assistant GPs

Then it is requested that the following pro-forma is used to process the change. Please ensure that any change of circumstances, with regards to the list above, isONLY submitted through this pro-forma. Please ensure that Annex A, Estimate of NHS Pensionable Profit/Pay Form, is also completed when applicable.

In order to initiate a partnership change, please complete the pro-forma and submit2-3 months in advance of the start/end date of the proposed change/variation. This is because the NHS ENGLAND AREA TEAM needs to approve the change/variation to the practice/partnership contract before any further action can be taken. Please submit the pro-forma in the following manner:

  • Forward pro-forma by e mail with estimated pensionable pay form to or by post to NHS Shared Business Services, Sanger House 5220 Valiant Court Gloucester Business Park Brockworth Gloucester GL3 4FE

Summary of Actions

  1. Practice/ partnership complete pro-forma and submitwith a covering letter to the NHS Shared Business Services 2-3 months prior to start date.
  2. NHS SBS process changes in accordance with the pro-forma.
  3. NHS SBS to inform NHS England Area Team for Devon,Cornwall and Isles of Scilly (DCIOS) of the changes.
  4. NHS SBS to notify practice partnership of completion.

Version: November 2013Page 1

NHS Shared Business Services

Sanger House,5220 Valiant Court,Gloucester Business Park

Brockworth, Gloucester GL3 4FE

Tel No: 020 8536 3009, Email:

GP JOINER/ LEAVER/ CHANGE OF CIRCUMSTANCE PRO-FORMA

To be completed in full in cases where:-

(i)A new partnership is created

(ii)A new partner joins an existing partnership

(iii)A partner leaves an existing partnership due to resignation, full retirement, or 24 hr retirement

(iv)Employment of/ changes to current assistant GPs

Practice Details

Practice Name: / Practice Code: / CCG:
Practice Manager: / Telephone No: / PMS/ GMS
Practice Managers Email:
GPs CURRENTLY AT PRACTICE
Local Code / Name / GP Type (eg: Principal/ Salaried)
Summary of Variation
Does this variation represent a change in the number of clinical sessions currently provided? / Yes/ No
  1. PARTNERSHIP - NEW PARTNERS

GP SURNAME / GP FORENAME / GMC No / DOB / SD Number (Optional) / NI Number / Sessions per Week / NHS Pension Scheme / Annual Salary
Member / AVCs / AVC % / Tier / AVC wef
Yes/ No / Yes/ No
Yes/ No / Yes/ No
Yes/ No / Yes/ No
Yes/ No / Yes/ No
Yes/ No / Yes/ No
Yes/ No / Yes/ No
Yes/ No / Yes/ No
Date Partnership Changes Effective From ( ie start date of new GPs):

2.PARTNERSHIP - GP LEAVERS/ RETIREMENTS

GP SURNAME / GP FORENAME / Leaving Date / 24 hr Retirement / If YES / Patient List Transfer Required*
Date off list / Date of Return
1. / Yes/ No / Yes*/ No
IF SENIOR PARTNER LEAVING, WHO WILL BE THE NEW SENIOR PARTNER:
Remain on Performer List as a Locum: Yes/ No / If Yes, specific work area for GP:
Home address of GP if Locum:
Telephone No: / E mail:
2. / Yes/ No / Yes*/ No
Remain on Performer List as a Locum: Yes/ No / If Yes, specific work area for GP:
Home address of GP if Locum:
Telephone No: / E mail:
* If YES please advise details of patients to be transferred to this GP (**DO NOT SEND PATIENT LISTS)
For advice on the method of patient transfer please contact NHS SBS Registrations on or 01726 627 661
  1. EMPLOYED/ ASSISTANT GPS (Salaried, Retainers)

GP SURNAME / GP FORENAME / GMC No / DOB / SD Number (Optional) / NI Number / Sessions per Week / NHS Pension Scheme / Annual Salary
Member / AVCs / AVC % / Tier / AVC wef
1. / Yes/ No / Yes/ No / £
Date Effective From:
2. / Yes/ No / Yes/ No / £
Date Effective From:
3. / Yes/ No / Yes/ No / £
Date Effective From:
  1. DECLARATION/ SIGNATURE

Form Completed By: / Designation:
Declaration:
We give an undertaking to notify the Area Team of any changes to the partnership details which may result from resignations, retirements or employment of assistant GPs and understand that failure to do so may put our contract at risk.
Signature:
On behalf of the partnership: / Date:
  1. FOR NHS SBS/ NHS ENGLAND AREA TEAM USE ONLY

Pro-forma received by NHS SBSPerformer List Team : / Yes/ No / Date:
NHS SBS Performer list team notified NHS SBS Payments& Pensions Teams : / Yes/ No / Date:
NHS SBS Performer List Team notified Registrations Team / Yes/ No / Date:
NHS SBS Performer List Team notified NHS SBS Call/Recall/Screening Team
NHS SBS Performer List Team notified NHS SBS Pensions to send AW8 form to GP / Yes/ No / Date:
NHS SBSPerformer List Team to notify practice partnership of completion / Yes/ No / Date:

Version: November 2013Page 1