March 2009

Stoke PCT is introducing a Quality Improvement Programme (QIF) which is intended to improve the quality of care in Stoke on Trent by investing in General Practice. The first part of the programme is a baseline assessment of current practice. This is already on going and will be completed shortly. The PCT plan is that the "bottom" 10% of practices i.e.. about 5 practices, will not qualify for inclusion and funding from the main scheme. These practices will be offered help to improve their practice and thus become eligible for the main scheme.

Although it is difficult to argue against a scheme which aims to invest in and improve the standard of primary care, the LMC does have some concerns about the workings of the scheme. We have been re-assured by the PCT that the initial baseline assessment will not be used to remove what are seen as "poorly performing" practices. These will be offered help to improve, however should they decline this or fail to improve the PCT will take further action. Poor practice whether perceived or actual is not in the best interests of general practice.

We also have concerns as to whether the targets set are achievable and as to whether the funding offered is adequate. The funding issue is a difficult one, because there is variation between practices in the amount of funding already received and in the proportion of that which a practice spends on staff, premises etc. The PCT is aware that there may be an issue around the funding allocated and any practice who feels it is inadequate should discuss this with the PCT. The QIF process is voluntary and practices do not have to participate. A sensible cost benefit analysis needs to be made here. The PCT recognises that QIF is not set in tablets of stone and may have to be flexible to take account of problems which arise.

QOF Changes

A reminder that in April there are changes to the QOF with the introduction of new indicators for heart failure, chronic kidney disease, contraception/sexual health, anxiety and depression, cardiovascular disease - primary prevention and the revision on indicators for diabetes and COPD. A list of the changes can be found here.

Urgent Referrals to UHNS

Over the last few months there has been increasing confusion over urgent medical referrals to UHNS. It appears that no matter whether or not a patient's GP speaks to the medical SHO on-call, all patients join the triage queue at the A & E department and the information given in a telephone call or letter is often disregarded. As a result some of us have taken to just sending the patient to A & E without wasting time telephoning in advance. We are informed that from April 7th, yet another new system will be introduced. Patients who are accepted by the medical on-call team will be seen separately on Ward 21 at the North Staffs Royal Infirmary and thus they will not be triaged in A & E.

Referrals to surgical and paediatric teams have always been directed away from the A & E department and the present system using the surgical and paediatric assessment units will continue.

Summary Care Record implementation in Stoke-on-Trent

There are plans to introduce the Summary Care Record to North Staffordshire in the coming months, however, as yet on there are only a few practices who have computer systems (iSoft Synergy) which are compliant. Practices must also have reached the standard of data recording to achieve the IM & T DES before their patient records can be used for the SCR.

The Summary Care Record is a centrally stored health summary, created from a person’s GP record. The current version contains details of medication, allergies and adverse reactions and is accessible on a secured Extranet which will offer connectivity to a wide range of National Health Service staff. Level 2 will offer further options for storage of information but is not part of the current project. The SCR is intended to support care when other records are unavailable or incomplete (e.g. emergency and unscheduled care). It will be accessible from A&E and Out of Hours. HealthSpace is a separate, Internet-accessible technology that allows patients to record and organise their own health data, and via which they will be able to view their SCR. People do not have to have a SCR but if they do not want one, they must actively opt out. HealthSpace is also voluntary but people must opt in. People with no Internet access may ask their GP for a printout of the SCR.

Prior to going live there is a 16 week public consultation on patient consent including writing to individual patients over 16 years.

The preferred approach is to launch the public consultation for the above two practice populations in January 2009 with the view of going live April 2009. The remaining practices will commence as and when their supplying system achieve their accreditation.

GPs may be approached by patients as to whether or not they should have their records uploaded or whether they should opt out. I don’t believe that the vast majority of GPs are well enough versed in the pros and cons of a Summary Care Record to be in position to give enough accurate information to patients to enable them to make an unbiased informed decision. If a patient agrees to inclusion and is subsequently harmed by a centrally authorised misuse of their data, which was not discussed prior to inclusion, or there is a predictable breach of data security, the GP could be at risk. If a patient agrees to exclusion from the central record and suffers clinical harm as a result of that exclusion, a similar risk could easily apply. It would be very difficult for the GP not to allow his or her own opinions to influence the consent process. Colleagues should bear these points in mind if asked for an opinion.

Deaths due to aspirin and NSAIDs

As reported in the last newsletter the coroner is taking a keen interest in deaths which may be due to aspirin or NSAIDs. Representatives from the PCTs and UHNS have met with the coroner and explained the situation concerning the prescribing of these drugs. Although his view may have been modified he has indicated that he will make investigations into any death where aspirin or an NSAID may have played a part. He is particularly concerned over the use of clopidogrel and diclofenac. This matter has been discussed by the LMC and although various issues around this were discussed, the bottom line is that whoever signs a prescription is responsible for the effects of those prescribed items. Steve Fawcett, Chair of Stoke PEC, has circulated a letter to all Stoke GPs in December concerning this and I feel it is worthwhile repeating his points here.

Older people prescribed medicines known to cause GI bleed should be subject to regular routine review to ensure that the continuation of treatment is justified given the risk.
Clear justification for this treatment needs to be given in the clinical system.
Patients treatment should follow national and local guidelines, and the limited role of anti-platelet therapies (low dose aspirin and Clopidogrel) in primary prevention of cardiovascular disease should be reinforced (local guidelines available on our website www.medicinesmanagementstoke.nhs.uk ).
Gastro-protection in older patients with a PPI should be considered in patients prescribed anti-platelets and NSAIDS. It may also be appropriate to consider PPI cover for NSAID treatment on it’s own for older patients.
For those patients with dyspepsia first line anti-platelet therapy in secondary prevention of cardiovascular disease is low dose aspirin and Omeprazole 20mg rather than Clopidogrel. Practices should undertake a review of the use of Clopidogrel to bring it into line with the locally agreed guidelines.
Long term NSAID prescribing should be reviewed in older patients, especially Diclofenac SR/MR. Treatment of osteoarthritis should follow the recently published NICE guidelines which support the use of paracetamol and topical NSAIDS first line to treatment with an NSAID. If an NSAID is chosen the drug with the lowest risk of GI bleeds is ibuprofen, which should be titrated up to a dose of 1800mg per day. Choice of topical NSAID should follow the North Staffordshire Formulary.

Maternity Services Pathology Results

In December GPs received a letter from the Maternity Department telling us that as the department will no longer be receiving their pathology results in paper form, they would be sending us electronic copies of all results for us to action as necessary. The committee felt this was inappropriate and would lead to confusion as to who was responsible and who would act upon any abnormal results. We wrote to the department with our concerns but did not receive a satisfactory reply. We have, therefore, written again informing the maternity department that

GPs should not routinely be sent electronic copies of all pathology results generated by the obstetric department
There should be clarity about who is responsible for taking action on abnormal results, the generally accepted agreement is that it should be the requestor
If GPs are requested to take action on a result this should be communicated in an agreed manner, currently by telephone or fax
There should be discussion with General Practitioners before any changes are implemented.

Child Protection Issue

At recent serious case reviews where young babies have presented with bruises it would appear that the patterns of bruising has not been recognised as probably pointing towards non accidental injury. It is important for us to realise that all babies under the age of 6 months are developmentally unable to move and are therefore unable to bruise themselves. Therefore any bruising seen on a child under the age of 6 months should be considered suspicious and child protection protocols followed. Any child who is immobile should also be considered in the same vein, should they present with bruising.

Pandemic Flu Guidance

The GPC has been working with the Royal College of General Practitioners and the Department of Health (England) Pandemic Influenza Preparedness team to produce guidance and advice for GP practices both in planning for, and in the event of, an influenza pandemic. It is important that all practices should engage in the planning process with their PCT and neighbouring practices. The GPC hopes that practices will identify Buddying Groups (clusters of practices which actively cooperate for pandemic work) and have a Pandemic Flu Contingency plan agreed between the group and the PCT by March 2009.

The document advises practices on what they need to do now and in the future in order to prepare for, and respond to a pandemic flu outbreak in the UK. The guidance is for GPs and their staff and sets out guidelines for business continuity planning within GP practices and introduces new systems such as the National Pandemic Flu Line which will operate in an influenza pandemic. It also explains why there is an urgent need to take action and how this will help minimise the spread of flu in a pandemic and make the best use of limited health resources.

This is the first issue of this guidance document. There are a number of areas in which definitive guidance has yet to be produced and such sections have been clearly marked. The document will be regularly reviewed as discussions continue and are concluded. The guidance is available on the BMA website at this link.

Focus on Salaried GPs

The focus on Salaried GPs guidance has been revised and incorporates guidance for salaried GPs on negotiating their salary and handling requests to change hours of work. A copy of this guidance is available here.

Focus on Seniority Payments

This guidance includes information on what seniority payments are, calculating your payments, claiming your payment for work outside the NHS, appeals, salaried GPs, sabbaticals voluntary overseas service, primary medical services GPs, and a number of frequently asked questions. The document has been updated in January 2009 to include the most up to date seniority figures. A copy of this guidance can be found here.

Patient registration - FAQs

The Patient Registration FAQs have been produced to replace the 'Focus on Patient Registration' and update the previous FAQs. The document covers a range of issues including eligibility, ID provision, allocated patients and removal of patients. A copy can be found here. The BMA have also recently produced a briefing paper on the removal of patients. A copy of this can be found here.

GP referral incentive schemes

There has been concern at the development by PCTs of incentive schemes that aim to reduce referral rates or the cost of referrals from general practice to secondary care. These schemes often take two broad forms; either to encourage GPs to analyse and better understand their practice referral patterns and/or promote the use of alternative referral pathways to hospital services, or to encourage GPs to reduce their level or cost of referrals as an outcome in itself. Such schemes were established with the advent of practice based commissioning, but have become more prominent and widespread in the context of a reported 16% rise in referrals from general practice in the first quarter of 2008/09 compared with this same period last year. The GPC has produced guidance on what it regards as appropriate practice. A copy of the document can be found here.

GPC News Items

Civitas Report on the QOF

Civitas published a report on 19 November claiming that the QOF offers inappropriate financial incentives. We have commented, highlighting the lack of evidence in the report and stressing the benefits the QOF has had for patients, as well as refuting the accusations that GPs are ‘gaming’ the system.

Patient responsiveness

The GPC is beginning some work to encourage practices to ensure that their services are responsive to patients’ needs and offer good ‘customer’ service. In taking this forward, it will be important to be aware of resource implications. However, in promulgating best practice, it is hoped that practices will be in a better position to compete in the changing NHS.

Sickness certification proposals

The Government responded to Dame Carol Black’s review of the health of the working-age population announcing proposals to get people back to work and stay in work. The BMA gave some support to the ‘Fit for Work’ service to help people back into employment but stated the importance of GPs’ role as the patient’s advocate rather than policing the system for the Department for Work and Pensions.

Freedom of Information Act (FOIA) Practice Publication Schemes

Following a review of FOIA publications schemes, in line with section 20 of the Freedom of Information Act, the Information Commissioner has approved a new model publication scheme which should be adopted by all public authorities and will be effective from 1 January 2009. An authority is not required to inform the Information Commissioner that it has adopted the scheme; he will assume the authority has done so unless he hears otherwise.

GP practices are classed under public authorities banner and are obliged to adopt the new scheme.

The timetable for 1 January 2009 implementation has slipped and the Information Commissioner's Office (ICO) will not begin monitoring the new scheme until March 2009.

The guide to information template is now on the BMA website

A specific information leaflet for GP practices is being prepared by the ICO, but publication has been delayed. As soon as we have details of this, we will inform LMCs.

The Working in Partnership Programme: Final Report

The Working in Partnership Programme (WiPP) was set up in 2004 in England as part of the outcome of the nGMS contract negotiations to support general practice with capacity-building resources and strategies. Since then, a wide range of tools and resources has been developed including online training courses, best practice guides, toolkits and frameworks to create capacity and support NHS professionals. The Programme was established because of the strong views of GPs that demand management was a major concern that should be addressed, but the Programme has also addressed making the most effective use of clinicians’ time, new ways of working, skillmix change, public and patient education and empowerment, the promotion of self-care and more appropriate and effective use of NHS services. The intention of the thirteen projects within the Programme has included identifying and analysing workload, reducing demand, addressing unnecessary bureaucracy, promoting staff recruitment, training, development and retention, workload substitution and delegation and increasing practice efficiency.

The Programme ended in June 2008 and has published its Final Report, which can be found on the WiPP website at www.wipp.nhs.uk/uploads/wipp_-_the_final_report_v4-final.pdf

The GPC would like to raise awareness of the very useful outputs and materials available on the WiPP website, which are of considerable potential value to practices and practice managers, not just in England but throughout the UK. Those materials are designed to help practice development, primary health care team development, the promotion of self-care and the management of demand.

Patient survey

The GPC recently wrote to Alan Johnson voicing its concerns about the direction of the development of the patient survey. This letter made it clear that we regard the survey as unfit for purpose and that, despite our presence on the supervisory board, we and other critics have been consistently ignored. We have insisted that any developments affecting GP pay be negotiated in the proper manner.

Prevalence changes

The GPC and the Health Minister, Ben Bradshaw, have exchanged letters about prevalence changes. The GPC has asked the government to ensure that PCOs inform practices about the impact of the prevalence changes and work with LMCs to help badly affected practices. The GPC has also asked NHS Employers to write to all PCOs and SHAs in England to encourage negotiations with LMCs on behalf of badly affected practices as agreed. Laurence Buckman is due to meet Ben Bradshaw in the near future to discuss prevalence changes and the particular problems about the implications for funding in London.

Discussions with NHS Employers

The negotiators have had two informal meetings with NHSE since the beginning of this year. GPC received a report of these discussions, an explanation of NHS Employers’ recent correction factor survey and a presentation on GP practice funding. The committee discussed possible avenues of negotiation for a 2010 agreement.

Members of GPC were reminded that there is a strong commitment from all political parties to reduce practices’ reliance on correction factor payments. NHS Employers has expressed a willingness to work with GPC on possible methods of approaching this for 2010. In the absence of an alternative solution a repeat of the 2009 ratio model or something similar is likely. The GPC discussed guiding principles to inform this year’s negotiations. Most importantly, this includes a commitment to ensure that no practice loses out financially in real terms. GPC members contributed many additional thoughts that will help shape this year’s negotiations.

Practice funding surveys

The negotiators have been at pains to demonstrate to the NHSE and to the Department of Health that there is no clear link between correction factor levels and practice demographics or health inequalities. To this end, the negotiators have been working with NHS Employers to get a survey out from the Department of Health to SHAs which aims to encourage PCTs and LMCs to consider the reasons some practices have high correction factors. An earlier survey to PCTs alone did not collect sufficient information to be of value. This second survey was sent out at the beginning of last week for completion by the end of this month. The short deadline reflects the fact that this is the second time PCTs have been asked for this type of information and also the fact that both sides need this information to inform the forthcoming negotiations. In the view of the negotiators, the survey does not go far enough as it only collects information about extreme outlier practices rather than data from a range of practices - but it is welcome that the NHSE is prepared to test common assumptions about MPIG. We are aware that there are concerns about the short deadline for completion of this survey. The negotiators will discuss this with NHS Employers and ask that they continue to accept responses beyond the official deadline. Since completion of this survey will help inform our negotiations, it is however hoped that NHS Employers will receive responses as soon as possible.

PCTs will require LMCs’ support in completing the survey and we would encourage LMCs to engage with it. This is an important attempt to find out why practices have the correction factors that they do. This survey clearly has limitations but we believe it will be helpful to inform negotiations. We need as much robust information as possible to convince government that there is not a simple link between correction factor and the type of population served.

GP revalidation

The GPC is involved in various high-level groups, including the RCGP revalidation stakeholder group, concerning future revalidation plans. At present the revalidation tools are still to be finalised, and the GPC is working to ensure that the process is fit for purpose and equitable for all GPs. For example, the GPC is concerned that the proposed multi-source feedback from colleagues may be more difficult for sessional GPs. Other issues requiring clarification include whether funding will be provided for remediation and the appeal mechanism. Furthermore, given the proposed reliance on annual appraisals for revalidation, the GPC recognises that some PCOs are not fully supporting NHS GP appraisal and therefore some GPs are not being appraised.

Prescription cost exemptions for patients battling cancer

The Department of Health has advised that it is planning to have the necessary arrangements in place so that the relevant patients will be entitled to exemption from prescription charges in respect of all items dispensed on or after 1 April 2009.

In line with other medical exemptions, entitlement will arise through an exemption certificate. Application forms (FP92A) are being revised to include the new category and will be distributed direct to practices by the NHS Business Services Authority (BSA). Otherwise, the arrangements will be the same as for the current medical exemptions. The BSA plans to distribute sufficient pads of forms to practices so that each doctor may hold a pad. (Additional pads may be ordered via the PCT as usual as can pre-addressed envelopes for dispatch of the forms.) Pads will be distributed before 1 April and applications will be accepted by the PPD as soon as the new forms are available although exemption certificates for cancer patients will not start until 1 April 2009. Locally amended versions of the current application form cannot be accepted.

The PPD will write direct to practitioners in the near future outlining the arrangements and asking them to run down stocks of the current version of the application forms. The PPD will also write to trusts to ask oncology departments or order pads of forms for their current patients. GPs will be asked to give an application form to relevant patients as they present but will not be expected to search through records to identify other patients.

The Department of Health is running a publicity campaign to alert patients to the new arrangements and expect relevant patients to identify themselves to GPs but the Department of Health has stressed that any help GPs and their staff can offer patients to obtain their entitlement to exemption would be helpful.

The use of 084 telephone numbers in the NHS: DH consultation

The Department of Health (DH) in England is considering banning the use of 084 numbers to access services provided by the NHS and has launched a consultation seeking the views from ‘all interested parties’. The GPC has co-ordinated the BMA response to this consultation, with input from other branch of practice committees.

In our response we highlight that we believe that people should be charged as low a cost as possible to call NHS services but that this has to be balanced by the quality of service the patients are accessing. Many practices value the extra functions that a number such as 084 and 03 numbers can provide, as they want to improve access to patients by providing telephone numbers with extra functionality.

Our main concern is that when the new telephone systems were put in with the new 084 numbers, many surgeries had to sign up to a long contract and even if they want to change, they cannot at moment due to contractual obligation.

We also noted that the Department and PCTs actively encouraged practices to adopt the systems that 084 numbers can provide to improve access, which it has done. Practices should not be penalised for following the Department’s advice and as they brokered a deal with the companies before to move them from the old 0870 numbers to 0844, they should be able to do so again by supporting a move back to local numbers.

We would therefore support a voluntary switch for practices to revert to local numbers but if the Government decides to ban the use of 084 numbers, the Department of Health should ensure that practices are allowed to serve out the terms of their contract if 084 numbers are banned.

We also welcome BT’s decision to allow 0845 numbers to be free within their call packages. This suggests that the Government could encourage all telephone companies to review their call charges to NHS services, and include 084 numbers in comprehensive call packages so that patients do not incur additional costs.

NORTH STAFFORDSHIRE

LOCAL MEDICAL COMMITTEE

Newsletter March 2009

Quality Improvement Programme