November 2009

Individuals aged between six months and up to 65 years in the current seasonal flu vaccine clinical at-risk groups
All pregnant women, subject to licensing conditions on trimesters
Household contacts of immunocompromised individuals
People aged 65 and over in the current seasonal flu vaccine clinical at-risk groups
Frontline health and social care workers.

Details of the deal include -

Practices will receive £5.25 for every H1N1 injection given

No changes to QOF indicators or thresholds in 2010/11

28 points identified by NICE to be released for recycling in 2011/12 and agreement to discuss further changes including thresholds. New clinical areas will be piloted

Final date for childhood immunisation targets for the third quarter to be delayed by six weeks to mid-February

If a practice's uptake rate for this vaccination campaign is 3% greater than the average 2008/09 UK seasonal flu uptake rate in at risk groups, the practice will be granted a 10% drop in the upper and 20% drop in the lower thresholds of PE7 and PE8

District nurses will vaccinate all housebound patients

Local enhanced services funding will not be withdrawn to pay for the programme

There is an agreement from all parties that this arrangement, made in unique circumstances, sets no precedent for the future.

A copy of guidance produced by the BMA/NHSE can be found here and along with a set of FAQs here. Contrary to previous advice that two doses would be needed for the H1N1 vaccines to take full effect, the Chief Medical Officer (CMO, England), has now announced that there are in fact different rules for different groups as set out below:

Pandemrix (manufactured by GSK)

For all children aged from 6 months of age to less than 10 years of age:

Two half dose (0.25mls each) should be given with a minimum of three weeks between doses.

For individuals aged from 10 years to less than 60 years of age:

One dose (0.5ml).

For individuals aged 60 years and over:

One dose (0.5ml) (may be reviewed after further evidence)

For immunocompromised individuals aged 10 years and over:

Two doses (0.5ml each) should be given with a minimum of three weeks between doses

Celvapan (manufactured by Baxter)

For children from 6 months of age and adults

Two doses (0.5ml each) of should be given with a minimum of three weeks between doses.

H1N1 vaccination for locums

Locum GPs are frontline health workers but are unlikely to be offered H1N1 vaccination by occupational health services. The GPC suggests that in the first instance they contact the practice with whom they are registered and request they are included in the list of patients to be vaccinated. The practice will not receive a fee for vaccinating locum GPs and no charge should be made to the locum for this service.

Alternatively locums may wish to ask a practice in which they are working to be vaccinated if supplies are available. Similarly the practice will not receive a fee for vaccinating a locum and no charge should be made to the locum for the service.

The medical defence organisations have confirmed that GPs are covered to vaccinate individuals who are not registered with them. It is important to ensure that when a locum is vaccinated by a practice they are not registered with, their registered GP is informed.

The GPC encourages practices to provide this service to locum colleagues to ensure they are able to access H1N1 vaccination.

H1N1 vaccinations administered by GP staff

The DH has confirmed that, as with other vaccinations delivered in general practice, GPs can delegate responsibility to carry out the H1N1 vaccinations to any appropriately trained person [including practice nurses and healthcare assistants (HCAs)]. The GP takes overall responsibility for the procedure as a prescriber. As long as the GP is content with the health professional’s competence to vaccinate and has a written practice protocol in place, they can delegate responsibility for the procedure to them - they are acting as the GP’s agents/employees and the GP carries the medico-legal responsibility.

Patient group directives (PGDs) are not required when a practice is treating its own registered patients, however many practices find it useful to use PGDs as a protocol for their nurses to perform certain procedures. PGDs are necessary only when a non-prescriber is performing the procedure and there is no individual with prescribing authority taking overall responsibility for the procedure.

The DH is planning to publish PGD and patient specific directions (PSD) templates on their website shortly.

Second phase of H1N1 vaccinations

It has recently been announced that healthy children aged from 6 months up to 5 years (around 2.7 million) are to be included in the second phase of H1N1 vaccinations. This is due to an increase in GP consultation rates amongst school-aged children after half term, and a substantial increase in the number of under 5s in hospital, including in critical care. The CMO also announced that carers (1.5 to 5 million) are to be added to the group of front line health and social care workers to be prioritised for vaccination in the second phase.

The NHSE has indicated that it wishes to discuss the vaccination arrangements for the under 5s with the GPC. However, formal negotiations have not begun and there are not yet any arrangements in place for how the work will be organised or recognised.

There have been suggestions that phase one is expected to be concluded by mid December, but the GPC has stressed to the DH that it is more likely that the first phase will conclude in mid January, after which time the second phase can commence. Until the first phase is finished, vaccination of the healthy under 5s should not begin.

Performance Issues

PCTs are taking an increasingly keen interest in the performance of GPs both locally and nationally. We are being increasingly monitored across a wide range of parameters. At the same time we are being snowed under with a mountain of guidelines and clinical pathways to which we are expected to adhere. It is likely that a number of colleagues will come under the spotlight for a variety of reasons.

Stoke PCT holds regular meetings to discuss concerns which have arisen concerning any of its professional contractors. Concerns are bought to these meetings from a variety of sources, but most commonly as a result of a complaint. Minor complaints may result in a detail review of a practice should investigation raise other causes of concern.

A common problem uncover, is poor record keeping. Whilst we cannot be expect to write an essay for each consultation it is extremely important that our note keeping is adequate. It is important to record an adequate history, details of examination (a record of absent or negative finding may be important) as well as details of treatment and the follow up action/plan. Remember, if there is a complaint, you and others will be relying on your medical record to answer and judge the complaint.

I apologise if I appear to be teaching colleagues to suck eggs here but the number of incidences of poor record keeping which are uncovered is unacceptable and cannot be defended. The importance of good record keeping cannot be overstated.

The PCTs and LMC are willing to help any colleagues who find themselves in difficulties and there are systems in place to help rectify problems.

NHS Complaints Procedure

A document has been produced by the BMA to provide practices and GPs with guidance on the requirements of the NHS complaints system, including advice on how to deal with complaints that come into the practice. This guidance also addresses some of the concerns GPs and practices may have about the way the complaints system operates and offers advice on ensuring that the system works for GPs and practices as well as patients. A copy can be found here.

Constitution and Membership of the Committee

I have recently revised the constitution of the committee to reflect changes which were necessary in the ever evolving healthcare world. A copy of the original constitution can be found here, and the updated version here. There is nothing significant in these changes which effects the everyday working of the LMC. Whilst reviewing the constitution we also took the opportunity to look at its membership. The committee is currently made up of 20 representatives from across North Staffordshire. It is a sad fact that all the members are male GP principals with over 50% being over the age of 50. This situation cannot be allowed to continue. We have no representation from two large sections of the community, i.e. females and salaried/sessional GPs. We believe these two groups would be able to make valuable contributions to our discussions.

The constitution allows the committee to use its best endeavours to ensure the fair and equitable representation of each class of represented member. We therefore propose that there should be four places reserved for female members and two places reserved for sessional/salaried doctors. We recognise that this is not proportional to their share of the GP workforce, but this is a start and there is no reason why a larger number should not put themselves forward for election.

Elections for half of the committee occur every two years; it is proposed that from the next elections in March 2010, two places should be allocated to female members. However, we need to encourage our female colleagues to stand for election. We are willing to provide any information or help they require in making a decision to stand and they would be welcome to attend a meeting of the LMC to obtain a flavour of the business we discuss

It is hoped to have a separate constituency for the two salaried/sessional representatives who would be nominated and elected solely by their salaried/sessional GP colleagues, but this will depend on obtaining the relevant information from the PCTs. Again we are will to provide any information or help they require and also extend an invitation for any prospective candidates to attend an LMC meeting.

Elections to the LMC

As mentioned above the next elections to the committee will take place in the New Year. We will be seeking nominations in January and colleagues are asked to give consideration to standing.

PE7 and PE8

Following last years disappointing survey results, practices who appealed should have been notified of the success or otherwise of their appeals. The committee is satisfied that these appeals were held fairly with the same criteria being used for all practices across both PCTs. However if you are still unhappy with the outcome an appeal to be Family Health Services Appeals Unit can be made as detailed in the last newsletter.

The reason most appeals failed was because practices were unable to produce data which contradicted the official PE7 and PE8 survey results. Practices did do their own surveys last year but whilst their in-house survey asked about the ability to obtain an appointment within 48 hours, none included a question about the ease of obtaining an appointment in advance. Practices are advised to take action now, to perform their own in-house surveys and to ensure that they ask the relevant questions about access. The questions asked in the QOF survey are:

PE7: The percentage of patients who, indicate they were able to obtain a consultation with a GP within 2 working days

PE8: The percentage of patients who indicate they were able to book an appointment with a GP more than 2 days ahead.

These are worth 23.5 and 35 QOF points respectively.

Implanon

The LMC has been discussing the discrepancy in fees paid by the two North Staffordshire PCTs for the insertion of implanon. North Staffordshire PCT is unlikely raises it payment to the level of that paid by Stoke PCT. Colleagues in North Staffordshire PCT area will have to consider the cost effectiveness of providing this service over and above that of referring patients to the Family Planning Service. As with all services which are outside the basic GMS/PMS contracts it has to be a practice decision whether the remuneration on offer is worth the cost of provision of the service. If we continue to be willing to provide a service for little remuneration there is no incentive for the PCT to increase payments, on the other hand if we demand too great a fee, there is every incentive for the PCTs to look to other providers. It is probably unlikely that any other provide would provide an implanon fitting service for the fee currently offered by North Staffordshire PCT.

Vetting and barring scheme

The GPC will shortly be issuing guidance for all GPs (including what a GP employer should do) on the new vetting and barring scheme.

This scheme came into play on 12 October 2009, and is being introduced in stages. From now, the following applies:

It will be a criminal offence for a person who is on a barred list (e.g. the PoCA, POVA and/or List 99) to seek or undertake 'regulated activity'. Regulated activity includes working as a GP, as a practice nurse and may also include working as a healthcare assistant. It applies to those who are already in post or are seeking a new post.
It will be a criminal offence for a practice knowingly to appoint a barred person to a 'regulated activity' post. Also practices should require an enhanced CRB check of all new recruits and of those changing jobs who will be undertaking 'regulated activity'. Please note that the PoCA, PoVA and List 99 are being replaced by two new barred lists managed by the Independent Safeguarding Authority (ISA) - one for barred from working with children, and one for barred from working with vulnerable adults. The enhanced CRB check will now provide information held on these two ISA barred lists.
Employers have a duty to inform the ISA if they have believe that an individual has caused harm, or posed a risk of harm, to children or patients that they work with.

Please be aware that no central funding available to practices for CRB checks. Therefore the question of who pays for the check will be one for the employer and the applicant.

As noted above, GPC guidance on the new scheme will be issued in the very near future.
The ISA's website is: www.isa-gov.org

NICE QOF Indicator Advisory Committee

This committee has recommended the following indictors for removal from the QOF. The removal of these indicators is predicted to have a low risk on clinical care

CHD 5 - The percentage of patients with coronary heart disease whose notes have a record of blood pressure reading in the previous 15 months

DM 5 - The percentage of patients with diabetes who have a record of HBa1c or equivalent in the previous 15 months

DM 11 - The percentage of patients with diabetes who have a record of blood pressure reading in the previous 15 months

DM 16 - The percentage of patients with diabetes who have a record of total cholesterol in the previous 15 months

STROKE 5 - The percentage of patients with TIA or stroke who have a record of blood pressure in the previous 15 months.

The follow indicators have also been recommended for removal but are recognised to have a potentially higher risk on clinical care

DM 22 - The percentage of patients with diabetes who have a record of estimated glomerular filtration rate or serum creatinine testing in the previous 15 months

MH 4 - The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months

THYROID 2 - The percentage of patients with hypothyroidism with thyroid function tests recorded in the previous 15 months.

Recommended new indicators for inclusion in the QOF include

The percentage of patients with diabetes in whom the last blood pressure is 150/90 or less

The percentage of patients with diabetes in whom the last blood pressure is 140/80 or less

The percentage of women with epilepsy under the age of 50 who are taking antiepileptic drugs who have a record of information and counselling about contraception, conception and pregnancy in the previous 15 months (unless not clinically necessary)

The percentage of patients on the Learning Disability register with Down's syndrome age 18 and over who have a record of blood thyroid stimulating hormone in the previous 15 months (excluding those who are on the thyroid disease register

These new indicators should be piloted before introduction and it has been agreed as part of the swine flu vaccination deal that there should be no change in the QOF indicators or thresholds for 2010/11

Practice succession

There is concern that smaller practices are being replaced by aPMS practices when the current GPs retire. The GPC is advising that single handed practices should enter into partnership arrangements either by taking on a partner or by forming a partnership with other similar practices so that should a vacancy arise, the remaining partner will be responsible for the practice and the appointment of a successor rather than the PCT. The GPC recommends that action is taken now, rather than waiting until a situation arises. The BMA can provide expert advice on the types of acceptable arrangements.

The GPC is also keen to see practices take on new partners rather than employing salaried doctors. We have a responsibility to our younger colleagues to ensure that they too can take an active part in the development of general practice and are rewarded appropriately for their work.

Focus on Patient Registration

The GPC has updated this guidance. It covers a range of issues including eligibility, ID provision, allocation of patients and removal of patients. A copy can be found here.

Referrals to Complimentary Therapists

The GPC has produced guidance in response to evidence of continuing interest amongst patients in the use of treatment modalities which are currently outside NHS healthcare provision but which are delivered by professionals who have statutory regulation in place. A copy of the guidance can be found here.

The Cameron Fund

The Cameron Fund is the only medical charity which provides help and support solely to general practitioners and their dependants. It aims to meet needs that vary considerably from the elderly in nursing homes to young, chronically sick doctors and their families and those suffering from unexpected and unpredictable problems such as relationship breakdown or financial difficulties following the actions of professional regulatory bodies.

Anyone who knows of someone experiencing difficulties, hardship or distress is urged to draw attention to the Cameron Fund’s existence or alternatively to contact Jane Cope, the Services Manager.

E-mail: janecope@cameronfund.org.uk Phone: 020 7388 0796

Address: Tavistock House North, Tavistock Square, London WC1H 9HR

Items from GPC News - October/November 2009

DDRB evidence

NHS Employers and the Department of Health have now submitted evidence to the DDRB. The Department has recommended a 1% uplift for salaried GPs and GP trainers, no uplift to the GP educator payscale and retention of a 45% supplement for registrars. NHS Employers called for a reduction to 40% of the registrars supplement.

Both the NHSE and the Department of Health have asked the DDRB for very small gross uplifts to GMS contract values. They have stated that the increase should cover practice expenses but that this is predicated on GPs delivery efficiencies. NHSE has recommended an uplift of ‘less than 1%’ and the Department has suggested a gross uplift of 0.5%. The Department’s recommendation was calculated to result in no uplift to net income while the NHSE’s recommendation is intended to result in a net increase only if practices deliver efficiencies and improved productivity. The smaller the uplift available, the less willing GPC negotiators will be to see differential distribution through a ratio model.

Abolition of practice boundaries

Although there have been no details following Andy Burham's proposal to abolish practice boundaries, the GPC and the task-orientated subcommittees are considering the concept in detail so that the committee is in a position to respond effectively should the Department of Health seek to pursue this idea.

Revalidation

The RCGP is undertaking a pilot examining the implications of revalidation for sessional GPs and doctors in small and remote practices. The project will be carried out by the Northern Deanery - it was awarded to the deanery following interviews which were held at the end of September.

The challenges to be examined by the pilot include:

the collection of audit information
reporting of formal complaints
undertaking multi-source feedback.

GPs involved in the pilot will have taken part in regular annual appraisals and be in a position to assess their readiness to collect the range of evidence detailed in the RCGP's Guide to Revalidation. The pilot will explore the difficulties and assess the feasibility of evidence gathering for these GPs. It will also recommend the best revalidation portfolio for locum GPs and GPs in small and remote practices.

The RCGP has recently published the first version of its guide to the credit based system for continuing professional development. The main principle behind the system is to allow GPs to record their CPD based both on the time spent on the activity and the impact it has on patient care. Under the system, each recorded hour spent on a CPD activity counts as a credit, while additional credits can be earned by demonstrating the impact of the learning. The guide can be found on the RCGP website. The GPC is looking into the proposals in the guide, and will be feeding back to the RCGP on this in due course.

NHS Choices

Laurence Buckman met with officials from NHS Choices recently and they provided him with an update on progress with the website since patients have been able to post comments and rate practices.

As of 13 November there were:

3060 live comments
560 rejected comments
77 'alerts' requesting comments be removed
131 practice replies

Only a small number of practices in receipt of comments have taken the time to respond to comments so far. Those practices with comments are advised to read and consider responding; NHS Choices automatically notifies practices when comments have been posted. It is important to remember that the website is a public one and any comments which are, for example, factually incorrect will leave a false impression if there is no response from the practice concerned.

Please note also our previous advice that practices regularly check their profiles regarding the accuracy of information about opening hours, staff details and services available to patients.

Practices that do not currently edit their own data on NHS Choices can do so by obtaining a login/password from the dedicated GP help desk on 0845 402 3089.

Locum GP pension contributions

In order for locum GPs' pension contributions to count towards the NHS pension, they should be paid within 10 weeks of the corresponding work being completed. It has been brought to our attention that some practices may not have been paying locum GPs within this 10 week period for work carried out in their practice, leading to locum GPs missing the contribution deadline.

On looking into how this would affect locum GPs’ pension contributions, although some PCOs are more strict on this than others, a PCO certainly can decide not to pension contributions sent outside of the 10 week limit. Although it is our view that locum GPs would not be forced to opt out of the NHS pension scheme as a whole in this circumstance, they would lose out on pension benefits for that specific piece of work.

It is therefore important that practices pay locum GPs within this timeframe, and preferably much earlier than this.

NORTH STAFFORDSHIRE

LOCAL MEDICAL COMMITTEE

Newsletter November 2009

H1N1 Flu