June 2011

The government has now accepted that there needs to be changes to its Health bill and has accepted the report of the Futures Forum. The CQC has issued a consultation document on postponing the registration of GP practices. Both these moves are to be welcome. However, the unrelenting pressure on General Practitioners continues.

The pressure to do more to prevent secondary care referrals continues apace, combined with the increasing work load which secondary care now expect us to pick up.

A group is being set up to consider what constitutes "core" general practice. The workload in General Practice continues to increase and a large part of this is due to the work being transfer from secondary care. Items which spring to mind include, treatment resulting from MRSA screening, pre-admission work-ups, post-operative care, the passing on of investigation results from secondary care (often without any communication apart from the result), issuing of Med 3 to patients who have been/are under the care of the hospital, discharge/outpatients letters not being sent or sent in triplicate and consultant to consultant referrals which are passed via us. On top of this we have the added workload of trying to find the appropriate "pathway" for our referrals. Map of Medicine is supposed to help in decision making but it is cumbersome and slow. I have yet to find it useful. Choose and Book is another obstacle in the referral pathway with clinics often disappearing from the menu or being placed in some obscure corner which increases the time ourselves and staff spend on the referral process with little or no benefit to the individual patient. Please send any views/comments you have on this or any other issue to office@northstaffslmc.co.uk

Soon the ambulance service will be altering its prioritisation of calls to allow transport of patients to Walk-in-centres" and Minor injuries Units as an alternative to the Accident and Emergency Department. These centres must deal with these patients and not refer them back to general practice. If the paramedics decide that a GP appointment/visit is not an appropriate option before transporting a patient to these units, the general practitioner must not be used as the fall back service when these centres cannot provide the care a patient requires.

The commissioners need to realise that moving work into general practice is not cost free and is causing stress in an already pressurised service. With general practitioners now playing a major role in the commissioning process one hopes that this message will not only be taken on board but acted upon.

Bus Pass Applications

A number of patients in Stoke have been approaching their GPs to complete forms in relation to their eligibility for concessionary bus passes. The council are acting contrary to Department of Transport advice in seeking such verification. The Department of Transport issue advice to local authorities in February 2008, a copy of the advice can be found here. The relevant paragraphs are:

Using an applicant's GP to verify that an individual meets the criteria for a
concessionary travel pass is regarded as an unsatisfactory arrangement for both the GP
and the administrators of the scheme. The main argument against this approach is that it
compromises the doctor / patient relationship.
The Department strongly recommends that independent health professionals
should undertake assessments in place of GPs. In the case of assessment of the inability
to walk, for example, occupational therapists or physiotherapists are often best placed to
assess eligibility due to their professional knowledge of mobility. Transferring assessment
to such specialists implicitly suggests the importance of making judgements based on
physical mobility rather than medical conditions.
The Department recommends that, where possible, local authorities run dedicated
assessment centres to assess eligibility. As well as having the potential to reduce costs,
this can help to ensure that a fair and equitable service is provided to all applicants who
are required to have an assessment. Moreover, scope for identity fraud can be reduced if
photographs for use on passes are taken at the time of assessment.
Neighbouring authorities may wish to work together in running such assessment
centres to achieve economies of scale. In assessment centres, or where any specialist is
consulted, an authority will need to satisfy itself of the fitness of the specialist to carry out
the assessment.
In a rural authority, where the population is scattered and accessibility could be a
problem, careful consideration needs to be given as to how medical assessments are
carried out, such as whether people may require additional assistance to attend medical
facilities.
Where, as a last resort, it is necessary to use a GP, the contact should be made
direct by the authority, having secured the applicant's agreement, and the GP should only
be asked for answers to factual questions. They should not be asked for an opinion on
whether someone meets the criteria.

GPs can refuse to provide verification for bus passes and remind the council of the above advice if they persist.

Prescriptions for impotence treatments

Queries about prescriptions for impotence treatments have been raised at a two meetings recently and I have been asked to remind colleagues about the regulations concerning the prescribing of sildenafil and related drugs on the NHS. These are not available on the NHS except for men who

have diabetes, multiple sclerosis, Parkinson's disease, poliomyelitis, prostate cancer, severe pelvic injury, single gene neurological disease, spina bifida, or spinal cord injury
are receiving dialysis for renal failure
have had radical pelvic surgery, prostatectomy (including TURP) or kidney transplant
were receiving caverject, erecnos, muse, viagra, or viridal for erectile dysfunction, at the expense of the NHS, on 14th September 1998
are suffering severe distress as a result of impotence (for this indication can be prescribed in specialist centres only)

GPs may issue private prescription to patient who fall outside the above categories, but are not allowed to charge the patient for the issue of such prescriptions.

NHS Changes

The Government has now published the report of the "NHS Future Forum" which was set up to review the proposed changes to the NHS. A copy of the document can be found here and a copy of the government's response here. The BMA have welcomed the acceptance of the changes, particularly the shift in the role of "Monitor" away from promoting competition. There will be more accountability and transparency around the decision making processes, however more detail is required on this.

Patient Participation DES

The BMA has put together some FAQs to address some of the misconceptions that have arise about the requirements of the DES and point practices towards online resources that they may find useful. A copy can be found here.

QOF Quality and Productivity Guidance

General Practitioners Committee (GPC) and NHS Employers have produced joint supplementary guidance for the 2011-2012 QOF quality and productivity (QP) indicators.

This guidance applies in England only and is intended to assist practices and Primary Care Trusts (PCTs) in understanding and working through the new QP indicators. A copy can be found here.

In addition, NHS Employers, the GPC and the Department of Health have produced a ready reckoner to help PCTs calculate the point achievement for QP prescribing indicators (QP3 to QP5). A copy of the ready reckoner can be found here.

You can also find the information on the NHS Employers website.

Information Governance Requirements

There has been some confusion on the information governance requirements for general practice - both in relation to what these encompass, and what is and is not mandatory.

The information outlined in this document aims to provide some clarification between the Information Governance Toolkit (IG Toolkit) and the Information Governance Training Tool (IG Training Tool).

GPC IT and JGPITC will be working with NHS Connecting for Health (CFH) to ensure that future versions of the IG Toolkit and IG Training Tool are relevant and more user-friendly.

GMC guidance for Doctors making and using recordings of patients

The General Medical Council (GMC) has published new guidance for doctors, Making and using visual and audio recordings of patients.

The guidance comes into effect on 9 May 2011, when it replaces the previous version of the guidance which was issued in 2002.

This new publication provides detailed guidance on situations where doctors make recordings of patients, which may be used for a variety of purposes. These might include, for example:

recordings made as part of a patient’s care
teaching, training, or assessment of health professionals and students
research and development
recordings for use in widely accessible public media, such as on the internet or broadcast on radio or television.

The process to develop the guidance involved consultation with doctors, patients and the public, medical training and education organisations, and others with an interest in this topic. The GMC is very grateful to all who participated in the consultation at various stages throughout the review – this input has had a significant role in shaping the advice we have published.

You can view Making and using visual and audio recordings of patients on the GMC’s website at www.gmc-uk.org/recordings

Information about the development of the guidance is available on the GMC’s news and consultation pages at www.gmc-uk.org/guidance/news_consultation.asp

Items from GPC News May 11

Care Quality Commission registration toolkit - guidance for GPs

From 1 October 2011, all GP practices and other NHS primary medical services providers in England will be invited to apply for registration with the Care Quality Commission (CQC) and will need to be registered by 1 April 2012.

The GPC has developed a toolkit to attempt to reduce the burden of the application process by providing a straightforward, plain English explanation of CQC registration, provide information on applying for registration and suggestions on what you could be doing to meet the CQC’s Essential Standards of Quality and Safety. This toolkit also highlights the current situation regarding demonstrating compliance.
The guidance in this toolkit will be updated if and when the expectations from CQC change. If you have any queries about CQC registration then BMA members can contact the BMA on 0300 123 1233. Local Medical Committees should contact the General Practitioners Committee secretariat.

The toolkit is available on the BMA website.

Changes to regulations regarding NHS availability of antivirals for flu

There have been some changes to the regulations regarding NHS availability of antivirals for flu, adding a new category of patient, to allow GPs to prescribe antiviral treatments on the NHS for patients not in one of the designated ‘at clinical risk’ groups, but who are at risk of developing complications from flu. Therefore oseltamivir and zanamivir may in certain circumstances be ordered for those who are under 65 years of age, who are not pregnant, nor considered to be at clinical risk, but who are considered to be at risk of developing complications from the symptoms of influenza.

The NHS (General Medical Services Contracts)(Prescription of Drugs etc.) (Amendment) Regulations 2011 came into force on 20 April and details of these are also published in Part XVIIIB of the Drug Tariff.

Fitness to drive guidance

The GPC has received some queries regarding the status of changes to the rules regarding driving and diabetes. The confusion appears to have arisen as a result of the DVLA publishing a revised version of their "At a glance guide to the current medical standards of fitness to drive" at the same time as they published the Department of Transport’s consultation on UK driving licence standards, in February 2011.

The ‘At a glance’ document contained some changes from the August 2010 version. These included changing the categories for diabetes “managed by tablets” and accommodating additional criteria for Group 1 and 2 drivers such as, the requirement that the person “must not have had more than one episode of hypoglycaemia requiring the assistance of another person within the preceding 12 months”. The up-to-date guidance can be found online.

The Department for Transport’s consultation document asked for views on changes to UK driving licence standards in order to harmonise with EU directives. Among other items, the consultation recommends that those applying to drive Group 1 vehicles (cars and motorbikes) must not suffer from recurrent hypoglycaemia or impaired awareness of hypoglycaemia - so driving licences would not be issued to, or renewed, for those in this category. For Group 2 vehicles (buses and lorries) they are consulting on the possibility for drivers being treated for diabetes being able to apply for entitlement to drive all group 2 vehicles, but within very strict criteria. Any changes to the regulations would probably only come into force around this time next year - subject to agreement. The DVLA’s “At a glance” guidance would then be updated appropriately.

Joint statement on changes to the ABPI Code of Practice

The BMA has joined 16 other organisations in supporting two key changes to the Association of British Pharmaceutical Industries (ABPI) Code of Practice which was published in March 2011.

From 1st May 2011, the pharmaceutical industry will no longer be allowed to provide branded promotional aids, such as pens, pads and mugs, to healthcare professionals.

From 2012, companies will be required to collect and declare on an annual basis aggregate total amounts paid to health professionals and others for certain services such as speaker fees and participation in advisory boards. Similarly companies will be required to declare sponsorship for attendance at meetings organised by third parties. The first declaration of payments will be in 2013 for payments made in 2012. The Code does not require individual health professionals to be named but does require the total number of health professionals involved to be declared and the total number of meeting attendances sponsored.

A link to the joint statement is available on the BMA website.

Negative comments posted on the NHS Choices website

The GPC has been made aware that there is some confusion concerning the procedures in place when a practice receives notification of negative comments posted on the NHS Choices website.

To clarify, practices are notified of a comment pertaining to them following the publication of the comment. An alert is sent to a named recipient at the practice in question (usually the practice manager although this will be designated by the practice). Practices then have two options:

Post a reply, in order to put across the practice’s views and deal with any issues raised. This will appear immediately below the original comment.
Report the comment to the website moderator as unsuitable.

NHS Choices have a ‘comments policy’ on their website which states that should a comment be flagged by a practice as unsuitable, then this will alert their moderators to take down the comment, consider it, and then either remove it or re-instate it as they deem appropriate.

The following NHS Choices guidance may assist practices in managing any comments they receive:

Managing patient feedback

Best practice – responding to patient feedback

GPC guidance on ethnicity and first language recording

The Ethnicity and First Language DES, which was introduced as part of the 2008/09 contract negotiations, was withdrawn on 1 April 2011. This DES was intended as a two-year catch up to enable practices to record ethnicity and first language for patients already on their list, with a third year extension for 2010/11.

Despite the withdrawal of this DES, it is expected that practices would want to continue to record their patients’ first language and ethnicity as a matter of routine in order to assess the needs of their population. However, this is a practice choice as there is no longer any contractual requirement to do so. Practices cannot be compelled to carry out this work. This guidance highlights the published codes for ethnicity and first language so that practices can continue to record this data.

The GPC guidance on ethnicity and first language recording is available on the BMA website.

Sessional GP and prison GP representation on GPC

GPC has agreed to co-opt 4 sessional GPs and 1 prison GP to GPC for the 2011-2012 session.
GPC has proposed to the BMA’s Annual Representative Meeting that the membership of GPC be formally changed to allocate four seats on GPC to members of the GPC Sessional GPs subcommittee. If accepted, this will take affect later in the year, and the four co-opted sessional GPs will be replaced by the four nominated members of the GPC Sessional GPs subcommittee.

Guidance on the Bribery Act 2010

We would like to draw to the attention of LMCs and practices the government's guidance on the Bribery Act 2010 which has just been published and is available online. The guidance is intended to help organisations understand the legislation and deal with the risks of bribery. The Act comes into force on 1 July 2011.

Items from GPC News April 11

NHS Reforms in England

The GPC discussed recent developments in relation to the NHS reforms and the Health and Social Care Bill. Since the last meeting of the committee, the House of Commons Health Committee has also published its report on commissioning and related matters. The Health Bill has now completed its committee stage in the House of Commons, and will move to the House of Lords in due course. In the face of growing concerns about the reforms, as has been widely publicised, the government has announced a pause in the progress of the Bill to allow a 'listening exercise' with a view to addressing these concerns. The NHS Futures Forum has been established under the chairmanship of Professor Steve Field, to take this forward and this is due to report in June.

The BMA/GPC has continued to highlight concerns about the Bill during its committee stage. In addition many MPs have been briefed and briefing papers on a number of themes within the Bill have been published.

Areas of the Bill the BMA has briefed on or suggested amendments include:

Duties of the Secretary of State
Functions and powers of Monitor, the NHS Commissioning Board, and consortia
Abolition of SHAs and PCTs
Education and Training
Competition, price competition, licensing, designation of services and failure
Foundation Trusts
NICE and the Health and Social Care Information Centre
Public health
Local government
Patient and public involvement
Patient confidentiality and information.

Legal Status of Consortia

There has been some confusion about the legal status of consortia. The Department of Health has issued a document which clarifies the position, a copy of which is attached at appendix 1.

Bearing in mind this document and the day to day and ongoing challenges for shadow consortia, the GPC’s strong recommendation remains that consortia think very carefully before entering into contracts with third parties, in particular those of high value, exposure and/or long duration.

Leadership in clinically-led commissioning consortia

Clinical leadership will underpin the success of clinically-led commissioning consortia (CCC). The defining feature of CCCs will be clinicians leading their peers from the front: engaging professionals in thinking and behaving differently in order to improve the health and healthcare of the consortium population in a sustainable manner. The GPC has produced a new guidance document on leadership that explores these issues, and this is available on the BMA website.

Shadow and Pathfinder consortia: Developing and electing a transitional leadership

A revised version of the GPC's guidance document ‘Shadow and Pathfinder consortia: Developing and electing a transitional leadership’ is available on the BMA website.

Payments to consortia and pensions

Following a number of recent queries, we can clarify that under the current regulations any payments made to GPs or practices from the 'pathfinder' and 'shadow' consortia will not be pensionable. This is because the consortia do not hold employing authority status. Where payments are made directly from the PCT / cluster, they will be pensionable. The government/DH is yet to decide if these consortia will be afforded access to the NHS Pension Scheme.

Business rules and QMAS updates

We have been informed that the NHS Information Centre (IC) is currently working on the April READ code release and the NHS Employers are working with them to look at the code changes they have proposed. This information will form part of the business rules, which is the reason they have not yet been published. The April code release (business rules v.20) is due to be published by the end of April. Please note that the Business Rules v19 has now been published on the NHS primary care commissioning website. This includes the 11/12 indicators and will enable GPSS to update their local searches and templates.

We have also been informed that due to the delay in finalising the GMS contract agreement, it is estimated to take until October for the QMAS updates to be available. This is not due to any changes in the process for developing business rules. The Department of Health and Connecting for Health (CfH) normally expect negotiations to be concluded by the turn of the calendar year, which would allow QMAS to be updated by the second quarter of the financial year to which the changes apply. CfH are currently procuring a new system to replace QMAS - the GP Payments Calculation Service - and one of the key requirements for the new system will be to ensure faster turnaround of changes to the system.

Seasonal flu vaccination programme for 2011/12

All practices should by now have received a letter from the Chief Medical Officer (England), which confirmed that the arrangements for procurement of vaccines for 2011/12 would remain the same as last year. Practices are responsible for ordering seasonal flu vaccine for the coming winter and should start ordering vaccines now, if they have not already done so.

In the letter from the CMO, it states that the government would like practices to order sufficient vaccine to cover 75% of their patients aged 65 or over, and at least 60% of patients under 65 in clinical risk groups (including pregnant women).

We have been informed that so far, practices have not increased their vaccine orders to take into account the localised shortages experienced last winter, and despite a rising number of patients in the at-risk groups.

We would encourage practices to review their flu vaccine orders, to ensure that they have ordered sufficient number of vaccines for their patients in the at-risk groups.

The GPC would again like to congratulate practices on their hard work in relation to seasonal flu vaccinations for 10/11, despite all the potential problems practices faced over the winter.

The letter from the CMO is available on the DH website.

GP Systems of Choice (GPSoC) – future arrangements

The GPSoC Framework Agreement expires in August 2011. Setting up a replacement at this point would have been problematic given that the full implications of the Health and Social Care Bill 2011 have yet to emerge.

Therefore, interim arrangements have been put in place allowing for continuity of provision of GPSoC services through to 31 March 2013. Options for a replacement to the current GPSoC arrangements are under development, with a view to new arrangements being put in place in good time.

The majority of the current Call Off Agreements already extend beyond the end of the Framework, and Connecting for Health (CfH) has decided that new Call Off Agreements can be placed before the Framework expires in August, which will ensure the continued provision of GPSoC services on their current terms. These new agreements will be on a national basis in the form of an amended version of the existing agreement and will be between CfH and each GPSoC Supplier. All locally funded GPSoC Services will be transferred to the new national Call Off Agreements as the existing PCTs Call Off Agreements reach the end of their term.

The attached communication (Appendix 2) from CfH provides further detail on the new arrangements and outlines the actions that need to be taken by PCTs to support the revised arrangements.

Please note, practices could potentially experience problems if PCTs plan changes to service provision where these services, notably IT support and maintenance, are required to underpin GPSoC. PCTs must continue to deliver their obligations under the PCT-Practice agreement.

Seniority factors 2007/08

The final seniority factors for GMS GPs in England and Wales for 2007/08 have been published by the NHS Information Centre. The figures are £90,375 for England and £78,938 for Wales. Further details and an explanation of the methodology can be seen on the Information Centre's website.

Revalidation

Following last year’s revalidation consultation response in which they made a commitment to simplify and streamline the revalidation process, the GMC has now published guidance on the supporting evidence required for revalidation, along with a new framework based on Good Medical Practice. The guidance states that there are six types of supporting evidence that doctors will need to provide over the five year cycle:

continuing professional development
quality improvement activity
significant events
feedback from colleagues
feedback from patients
review of complaints and compliments.

Whereas previously there had been a need to map the supporting evidence to each of the twelve attributes set out in the Good Medical Practice Framework, it will now be assumed that these attributes have been fulfilled by submitting the above six types of supporting information. The guidance is available on the General Medical Council’s website.

The RCGP has published a new version of their revalidation guide and it is available online.

The BMA has published an update on revalidation and it is available on their website.

The GPC continues to lobby the RCGP and other key stakeholders to try and ensure that the revalidation process is proportionate, equitable, and not overly burdensome.

Care after death advice

The National End of Life Care Programme has issued some guidance to help those who care for people after death. This work has been endorsed by the RCN and the Royal College of Pathologists and sets out principles of care that extend beyond physically preparing the body for transfer either to the mortuary or a funeral director. The guidance is focused on the practice of nurses and doctors and encourages co-ordinated working with other groups such as care home staff, funeral directors, the police and coroners and their teams.

The full guidance can be found online.

Anyone interested in finding out more about the National End of Life Care Programme can visit their website.

Migrant health guide

At the end of January the Health Protection Agency launched the Migrant Health Guide - an online resource for GPs and nurses working in primary care. The guide has been developed in consultation with GPs and health professionals from around the country, and is endorsed by the Royal College of General Practitioners and the Royal College of Nursing. It is intended to be a ‘one stop shop’ for information to support GPs and nurses in assessing and treating migrant patients, in recognition of the fact that these patients sometimes have health needs which are more complex than those of UK born patients.

Doctors for Doctors

The BMA provides support to doctors in difficulty through two confidential telephone services, BMA Counselling and the Doctor Advisor Service, which can both be accessed on 08459 200 169. Issues - 10 - dealt with include stress, bullying, GMC concerns, depression, debt and substance abuse. Further information can be found on the BMA website or by writing to info.d4d@bma.org.uk. The GPC next meets on 19 May 2011, and LMCs are invited to submit items for discussion. You may like to review these, beforehand, with the representatives in your area who serve on the GPC. The closing date for items is 11 May 2011. It would be helpful if items could be emailed to William Jones at wjones@bma.org.uk. You may also like to use the GPC’s listservers to exchange views and ideas.

NORTH STAFFORDSHIRE

LOCAL MEDICAL COMMITTEE

Newsletter June 2011

Editorial