November 2011

Stoke on Trent CCG has produced a "inter-practice agreement" which it wishes all practices to sign up to. I have looked at this document and consider it to be totally unacceptable. It is a poorly drafted quasi-legal document which places the onus on practices to agree to and implement CCG policies. It gives the CCG the power to expel any practice which fails to meet the CCG financial targets or is at significant risk of failing to do so. Although as all practices have to be a member of a commissioning group, it is unclear what would happen to such underperforming practices.

A similar document was sent to North Staffs CCG practices earlier this year. Neither documents have been reviewed by the LMC and although the tone of the North Staffs document is softer. colleagues are urged to take advice before signing up to such "agreements".

The advice I have received from the Chair of the Commissioning and Service Development Sub-Committee of the GPC, who represents the GPC at the DoH Commissioning Team, is that practices should not sign this document.

There is no need for such agreements and whilst some of the clauses in the documents may be reasonable, there are many which are not. There are no current plans which the GPC is aware of, which will allow a CCG to expel a practice. Any action to be taken if a practice is in a serious dispute with a CCG will be outside the CCG's remit.

Clinical Commissioning Groups should be working with practices by collaboration and persuasion rather then by producing unfair, one sided agreements for practices to sign up to.

There is no contractual obligation for practices to sign up to such an agreement and I strongly advise that practices do not sign up to this one.

Oxford Scores

As reported in the last newsletter, Stoke on Trent CCG has dropped the requirement for the completion of Oxford Score prior to referral of patients for knee and hip replacement. North Staffs CCG has refused to drop this requirement. This is regretful as it both against the wishes of their constituent GPs, the LMC and NICE guidance.

GP Earning and Expenses Enquiry 2009/10

The GP Earnings and Expenses Enquiry 2009/10 has been published by the NHS Information Centre.

The EEQ for 2009/10 states that for contractor GPs in the average net profit was:

£100,400 for GMS GPs (an increase of 1.2% since 2008/09)
£97,300 for GMS non-dispensing GPs (an increase of 1.4% since 2008/09)
£117,000 for GMS dispensing GPs (an increase of 0.4% since 2008/09)
£115,300 for PMS GPs (a decrease of 0.8% since 2008/09
£113,000 for PMS non-dispensing GPs (a decrease of 0.8% since 2008/09)
£131,100 for PMS dispensing GPs (a decrease of 0.8% since 2008/09)

£105,700 for all GPMS GPs (an increase of 0.8% since 2008/09)

The GPMS expenses to earnings ratio (the proportion of an individual’s gross turnover that is consumed by business expenses) was 59.8% in 2009/10. This is an increase of a further 0.5 percentage points on the 2008/09 expenses to earnings ratio of 59.3% reflecting that expenses have increased further while earnings have continued to decrease.

Average net profit for contractor GPs in 2009/10 by country was:

£109,400 in England (a decrease of 0.1% since 2008/09)
£91,400 in Northern Ireland (an increase of 1.9% since 2008/09)
£89,500 in Scotland (an increase of 3.5% since 2008/09)
£93,500 in Wales (an increase of 3.1% since 2008/09)

GP Contract 2012/13

The GPs’ contract for 2012/13 has now been agreed and announced by the Department of Health. Changes to the contract include:

a 0.5% expenses increase delivered to all through QOF
the piloting of arrangements that will allow commuting patients in three cities a greater choice of which GP to use
changes to practice boundary rules for patients moving a short distance
the introduction of a new scheme that aims to reduce avoidable Accident and Emergency (A&E) visits
revisions to the Quality and Outcomes Framework (QOF)

The relevant documents so far published are

Letter to the Profession 2012/13 contract agreement

QOF 2012-13 agreement

QOF Summary of changes

QP - A & E Guidance

Further guidance will be published by the GPC in the coming weeks.

Good Medical Practice

The GMC has launched a major public consultation on the new draft of the guidance "Good Medical Practice".

"Good Medical Practice", the GMC's core guidance for all doctors, sets out the standards, principles and values expected of doctors. You can take part by completing an online questionnaire on the GMC's website at www.gmc-uk.org/gmp2012 The closing date for responses is 10 February 2012.

National Reporting and Learning Service

The National Patient Safety Agency manages a "national reporting system" of confidential reports of patient safety incidents from healthcare staff across England and Wales. They have recently produced a review of the Serious Incidents Requiring Reporting that involved medicine in 2009 and 2010. The main points from the document are:

One hundred and three SIRIs involving medicines were reported by 30 different organisations to the SHA via UNIFY during 2009 and 2010.
47% (48) of reported SIRIs that involved medicines resulted in harm to patients.
During the period, there were 16 fatalities associated with the use of medicines.
The range of medicines involved in SIRIs resulting in patient harm in the West Midlands is broadly similar to those identified nationally as being the most likely to cause harm.
The quality of SIRI reports received was often very poor. Additional details were requested for the majority of reports.
The majority of reports of SIRIs involving medicines are received from secondary care trusts. It is likely that there is significant under-reporting of SIRIs from primary care.

GPs are encourage to report serious incidents involving medications through the NPSA reporting systems. Further details including an on-line reporting from can be found on the NPSA website here.

Hospital Doctors and Sickness Certification

The Department of Works and Pensions has issued guidance for hospital doctors on the issuing of "statements of fitness to work". The following are some statements from the document.

Many hospital doctors are still unaware that they should also, if appropriate, issue Med 3s. Not issuing Med 3s denies patients the best care and leads to unnecessary duplication and extra work for GPs. In many cases it is the hospital doctor who is best placed to give advice on a patient’s fitness for work.

The duty to provide a Med 3 rests with the doctor who at the time has clinical responsibility for the patient.

For an out-patient this will generally be the hospital doctor, except where the GP retains responsibility, for example where the patient has been referred to a hospital for an opinion or advice on their health condition. In cases where the patient’s GP has not taken over responsibility for the incapacitating condition the treating clinician should issue any subsequent Statements for an appropriate forward period.

Form Med 10 should continue to be issued to cover any period that a patient is in hospital. On discharge from hospital the doctor who has clinical responsibility for the patient should provide them, if appropriate, with a Med 3 to cover a forward period. This is to avoid unnecessary referrals to GPs solely for the purpose of sickness certification.

Examples where hospital doctors should consider issuing a Med 3:

when a patient has received treatment in Accident & Emergency and the treating doctor believes that the patient will be unable to work for over 7 calendar days, it would be appropriate to issue a Med 3 for a period consistent with the anticipated incapacity;
when a patient is receiving treatment at a fracture clinic and so does not need to see their GP for any clinical reason;
when discharging a patient from hospital, as well as issuing a Form Med 10 to cover the in-patient period, doctors should consider if the health condition will affect the patient’s fitness for work for a forward period; and
patients who have mental health conditions and are under regular review could also have their sickness certification integrated into this review in cases where the hospital doctor maintains clinical responsibility.

A copy of the guidance can be found here, and I have sent a copy to the medical directors of our local hospital asking that they should ensure the guidance in implemented. A copy of a poster which can be displayed in GP surgeries can be found here.

I have sent a copy of the guidance to the Medical Directors of our local hospital requesting that they ensure implementation of the DWP guidance.

GPC-West Midlands Website

GPC-West Midlands (formally the Regional Local Medical Committee) has just re-launched its website. This site contains an archive of many documents relating to primary care, including all the relevant regulations and contracts. The site can be found at www.gpcwm.org.uk.

Items from GPC News November 2011

QOF achievement and prevalence data 2010/11

The 2010/11 QOF achievement and prevalence data have been published by the NHS Information Centre, including a statistical bulletin, an online database and a set of detailed data tables. We are pleased to report that the average achievement has increased from 93.7% in 09/10 to 94.7% in 10/11. The information is available from the NHS Information Centre website.

Pensions Day of Action - November 30

We have received a number of enquires regarding the decision by NHS trusts to insist on their staff submitting medical certificates if they are absent on 30 November even if the absence is for less than 7 days. The BMA and GPC consider this to be a completely inappropriate use of doctors’ time. Some GP practices will already be under strain because of industrial action by staff. Adding an unnecessary administrative task to their workload is unacceptable and would undoubtedly make it harder for patients to get appointments. There would also be a significant cost to the NHS.

It may be technically within the rules for trusts to demand this, but the vast majority of staff who take sick leave on 30 November will be genuinely ill and should be trusted to self-certify. Nonetheless, GPs and practices should bear in mind the effect on the doctor/patient relationship of a decision not to comply with a patient's request for a private certificate in these circumstances.

The BMA has drafted a series of FAQs on the Day of Action and these are available online.

Training requirement for fitting contraceptive implants – update

Late last year the Faculty of Sexual and Reproductive Healthcare (FSRH) of the Royal College of Obstetricians and Gynaecologists sent out a letter regarding the 'amnesty arrangements for medical providers of contraceptive services', which set out the training requirements of fitting contraceptive implants. The GPC was concerned that the letter stated that there was a requirement to have a FSRH Letter of Competence (LoC) and a Diploma, and that there were no other alternatives.

This issue was brought up with the Royal College of General Practitioners (RCGP) who subsequently confirmed that FSRH LoCs and Diplomas were in fact not a requirement for fitting of contraceptive implants. Since then the RCGP has been working with the FSRH to look at the alternative routes for achieving the standards and are currently drafting a revised letter of competence to ensure that high quality training and assessment is maintained. They are also developing pathways for training to fit SDIs and IUTs that recognise the needs of experienced doctors who currently do not hold the LoCs.

Flu vaccine procurement for 2012/13

The Department of Health has confirmed that even though a consultation has been held on the future procurement of flu vaccine, GPs will remain responsible for ordering their vaccine for the flu vaccination programme for the winter of 2012/13. The BMA responded to the consultation (Review of the procurement of the seasonal flu vaccine) in August, highlighting our concerns about the proposals to move to central procurement of seasonal flu vaccines in England. We await the formal response to this consultation.

Practice nurse indemnity

Following the Royal College of Nursing (RCN) announcement that indemnity cover for work undertaken by practice nurses as part of their employment will no longer be provided by the RCN indemnity scheme, we again remind practices to check their indemnity arrangements to ensure that the work carried out by their practice nurses and all practice staff is appropriately covered.

Revalidation

We have heard reports of some PCTs using the planned introduction of revalidation to justify implementing more stringent appraisal frameworks. Revalidation is currently due to be introduced from late 2012 and the evidence requirements have not yet been confirmed or agreed. PCTs therefore should not be implementing new appraisal frameworks on this basis.

It has also been brought to our attention that some PCTs have been attempting to implement locum ‘exit reports’, whereby health providers complete reports on any locum doctors who have been contracted by them for over a week. This is arising from the Revalidation Support Team’s Organisational Readiness Assessment Tool (ORSA), which currently recommends that designated bodies should have these reports in place by the end of 2012/13. This implies a level of performance management that goes beyond what we understand revalidation to involve. We do not accept that locum GPs' clinical care requires more quality assurance than their salaried or GP partner colleagues, or that locum GPs should face more scrutiny than others as part of the revalidation process. We have also been informed by the Revalidation Support Team that the section relating to locum exit reports is likely to be removed from the next version of the ORSA.

Parliamentary and Health Service Ombudsman report

The Parliamentary and Health Service Ombudsman (PHSO) recently published its “Listening and Learning” report on complaint handling by the NHS, focusing on unfair patient removals.

The report shows that complaints about GPs accounted for 2,581 (17 per cent) of the 15,066 complaints received by the Ombudsman in 2010-11. The report also highlighted a 6 percentage point increase from 2009-10 to 2010-11 in the proportion of investigated complaints about GPs relating to patient de-registration.

GP practices are reminded about the BMA guidance on this issue, available on here. Other than in exceptional circumstances, patients must be warned that they are at risk of removal from the patient list within the period of 12 months before removal. It is also recommended that the decision to remove a patient from the list should only be made after careful consideration of alternatives. Practices should also have in place adequate procedures for dealing with complaints.

You can access the PHSO report on the their website.

Antipsychotic drugs

The Right Prescription is a call to action on the inappropriate use of antipsychotic medication for people with dementia, which seeks to ensure all people with dementia receiving antipsychotic medication have their treatment reviewed by March 2012.

180,000 people with dementia are on antipsychotic medication, however a review in 2009 by Sube Banerjee, Professor of Mental Health and Ageing at King’s College London, found two thirds of these prescriptions are inappropriate. Professor Banerjee’s review found use of antipsychotics resulted in increased rates of stroke, and caused an estimated 1800 deaths a year.

90% of people with dementia will experience behavioural and psychological symptoms of dementia (BPSD). Appropriate person-centred care and non-pharmacological interventions can usually help alleviate these symptoms without the need for use of antipsychotic medication. While antipsychotic medication may be appropriate in some cases, they are too often used as a first line response to BPSD.

The Right Prescription is a key aspect of the QIPP programme and is being coordinated by the Dementia Action Alliance, a coalition of over 60 national organisations who have committed to improving the care of people with dementia, and is supported by the NHS Institute for Innovation and Improvement. Rather than focussing on compliance, the Right Prescription sets commitments and actions individuals from across health and social care can take to ensure reviews happen.

To support The Right Prescription, the NHS Institute have set up a social networking and information sharing platform; National Field. This platform enables close working in local areas and across sectors. This platform and more information on the call to action can be accessed online.

In addition, the charity Alzheimer’s Society, working with the Royal College of General Practice and others have developed guides on appropriate use of antipsychotics and best practice in responding to BPSD for health and social care professionals and for patients. These materials can be accessed at on the Alzheimer Society’s website.

NORTH STAFFORDSHIRE

LOCAL MEDICAL COMMITTEE

Newsletter November 2011

Clinical Commissioning Groups and Practice Agreements