September 2010

The GPC has written to all GPs concerning the recent White Paper and the proposed changes to the way the NHS works. A copy can be found here along with a BMA summary here.

The Department of Health (DH) has published three further consultations, titled Transparency in outcomes - a framework for the NHS, Increasing democratic legitimacy in health and Commissioning for patients. Each of the consultations and the White Paper can be accessed and responded to via the following link to the DH website: http://www.dh.gov.uk/en/Healthcare/LiberatingtheNHS/index.htm

The Committee has discussed at length how we can move towards the vision laid out in the white paper. The committee's view is that we do not rush ahead into new arrangements without careful consideration of the configuration of commissioning consortia which will deliver the best health care across the whole of North Staffordshire. There is a general feeling that consortia need to be at least the size of the current PCTs, if not both together. We do not support the view that an early implementer consortium would be of benefit to the area and view this potential development as divisive.

We will be holding a meeting on Thursday 30th September to which all GPs and practice managers will be invited.

Following its meeting on the 20th August the GPC has issued a position statement on GP commissioning. A copy of this can be found here.

X-ray Requests

The UHNS has recently circulated GP Practices informing them that they will no longer perform Lumbar spine x-rays and other investigations. This has led to some confusion as there are some clinical situations where these investigations are appropriate. The Royal College of Radiologists guidelines on appropriate investigation can be found at http://mbur.nhs.uk. Note that this website can only be accessed from the NHS net.

Scriptswitch

Scriptswitch is a medicines management programme which has been offered to practices by both North Staffordshire and Stoke PCTs. The aim is to promote cost effective and safe prescribing. The messages given out by scriptswitch are decided by the local medicines management teams and can be ignored if the prescriber so wishes. There are some very simple switches which can save a considerable amount of money, for instance, a change from Prednisolone E/C to plain prednisolone tablets would save North Staffordshire PCT alone around £180,000 (There is no evidence that the enteric coated medication has less adverse effects than the non coated product)

The more contentious changes are the suggestions to prescribed branded drugs in some instances. For example a prescription of a "Ventolin" inhaler costs less than a generic prescription for salbutamol. This is because of a quirk in the reimbursement system which reimburses the dispenser a tariff price for salbutamol rather than the actual cost. When a branded drug is dispensed only the actual cost of the drug is reimbursed, thus as "Ventolin" costs less than the tariff price there are considerable savings to be made by switching.

There has been considerable discussion about the suggested changes both at the Area Prescribing Committee and at Medicine Management Committees and there is a split in view between those who feel that this is step too far, as it goes against the generally held principle of generic prescribing and could result in frequent changes of recommended brand and those who feel that in today's climate of severe financial pressure that we have a duty to prescribe cost-effectively, as supported by GMC guidelines, and that we should do our utmost to make effective use of limited resource. Given the amount of pressure on the prescribing budget I personally support the latter view. However, it is for each prescriber to make their own decision.

Patient Group Directives

The GPC has reviewed the complex legislation surrounding the administration of medicines and has clarified the advice on the use of Patient Group Directions (PGDs) in general practice. Note that this guidance will be updated as and when further issues are raised. Please email info.gpc@bma.org.uk if you have further queries on this issue. A copy of the guidance can be found here.

Vetting and Barring Scheme

The GPC has issued further guidance on the Vetting and Barring Scheme. This guidance explains the steps that GPs need to take individually and as employers to ensure that they comply with the Safeguarding Vulnerable Groups Act 2006. A copy of the guidance can be found here.

Focus on the NHS standard contract for community services

In April 2010, the NHS introduced a standard contract for acute, community, ambulance and mental health services. The contract is designed to cover agreements between PCTs and all types of providers that deliver NHS funded services. This guidance note is designed to alert GPs and LMCs to what this change will mean in practice.

This guidance is available on the BMA website. Please note that this is a benefit of membership and has been restricted to BMA members and LMCs only

Important information for GPs completing DWP DBD36, DS1500 forms and GP factual reports

The Department of Work and Pension’s Pension, Disability and Carers Services (PDCS) have asked the BMA to inform GPs of changes to and information regarding DBD36 forms, GP factual reports and DS1500 forms. Full details can be found here.

Revised tax guide following the emergency budget

Following the announcement of the emergency budget on 22 June, specialist accountants have now reviewed the Focus on New Tax Bracket guidance. The previous advice about superannuation has been removed as it is no longer applicable as well as the spreadsheet illustrating how the tax could affect income for the year 2009-10 as it is out of date. Otherwise the advice remains the same and practices are urged to seek advice where necessary from an accountant. The revised guide is available here.

Appraisal Toolkit

We have been informed by the Department of Health that they will be allowing their contract with SCHIN, the providers of the NHS Appraisal Toolkit, to expire at the end of October. Following this, they do not intend to hold a contract with one appraisal toolkit provider or fund one particular appraisal system centrally. It is their intention to promote a situation where the NHS has a choice of tools to support appraisal and eventually revalidation.

Upon hearing about this decision, the GPC made representations to the Department of Health, asking them to reconsider their decision to not fund one particular appraisal system centrally. This request was unfortunately turned down.

This development clearly raises a lot of questions, and the GPC will be approaching SCHIN and the Department of Health for more information about how this is going to work and the practical implications of this.

It appears that it will be possible for individuals to pay a subscription to the site in order to continue using the facility. This has been estimated as being likely to be in the order of £50 - £100. It is also possible that the PCT may decide to pay this subscription on behalf of its GPs, at least for the next twelve months. We should hear more about this in the near future.

Cervical Cytology

Below are some notes from following a meeting between the GPC and the Director of NHS Cancer Screening Programmes.

Brian Dunn, Bill Beeby and Surendra Kumar met with Professor Julietta Patnick, Director of NHS Cancer Screening Programmes on 28 July to discuss a number of longstanding issues related to cervical screening.

Vault cytology

It was confirmed that the responsibility for follow up care of women who required vault cytology lay with their gynaecologist, not the GP. GPs do not have the skills or the equipment to be able to provide failsafe care for these women, of whom there will only be a minute number per practice.

Full guidance can be found in ‘Colposcopy and Programme Management - Guidelines for the NHS Cervical Screening Programme, Second edition’. We raised the point that these guidelines could be interpreted ambiguously on the follow up of women who had undergone hysterectomies, with the risk of inappropriate delegation to GPs. This was accepted and the NHS Cervical Screening Team will amend them accordingly.

Cervical cytology re-training requirements

The NHS Cervical Screening Team will not budge from their belief that it is necessary for GPs to update in cervical cytology every three years. However, they accept that “re-education” in the process of taking smears should not be necessary unless the sampling method changes, and the updating is more around some of the other issues that change with regard to screening. They seem open to discussion with the BMA on how to make such training more appropriate for GPs, including the use of e-learning modules. It is hoped that we can work together in order to press for national standards for GP updating. The Screening Team will also send suggested training topics to PCTs on an annual basis, appropriate for experienced smear takers in general. The Screening Team has no direct influence on PCT training requirements or content.

Patient age and processing of smears by laboratories

There should be a leeway of 3 months in age for laboratories to accept smear samples for processing. Therefore, they should accept screening samples from women aged from 24 years and 9 months, and those aged up to 66 and three months. Similarly, smears taken a few weeks early should be accepted, but those taken way outside the screening program guidance will continue to be rejected. The guidance for laboratories analysing smears was in the process of being re-written, and should make these tolerances clear.

The minimum age for smear taking will remain 25 years in, as per the World Health Organisation International Agency for Research on Cancer recommendations. An audit is underway to examine the cases of women under the age of 30 who have developed cervical cancer, in order to identify any distinguishing features between the cases. It is thought that most will have had other symptoms.

Opt-outs from NHS Cervical Screening Programme

We have received some reports of patients being asked to complete substantial forms in order to opt-out of the cervical screening programme.

If a woman truly does wish to opt-out of the programme, then she must give written consent, making it clear that she has been made fully aware of the potential implications of this decision i.e. that she will never be recalled for a smear in the future.
However, a woman who simply does not wish to undergo a smear during one recall period does not need to provide any written consent. If she remains happy to be invited for smears in the future then she will remain within the screening programme.

It is important that audits are carried out to ensure that no women eligible to be screened for cervical cancer have been inadvertently removed from the programme. GPs could opportunistically discuss this with any women who fall into this category.

Smear invitations

When a practice is participating in the national screening recall programme, a letter and reminder will be sent out via the national system. It is therefore only necessary for participating practices to send out one final invitation letter, in order for patients to have received three invitations. Practice invitations for smears should include full information about what a smear would involve and why it was necessary – for example, by including an information leaflet.

QOF Cervical Screening indicator – CS1

The advice that women could be removed from the denominator if they have failed to respond to three invitations to have a smear taken should not be confused with the removal of a woman from the cervical screening programme altogether; nor is it necessary that the three invitations be sent by the practice (see above). This matter will be discussed by the QOF subgroup.

National Cleanliness Specifications

The National Patient Safety Agency (NPSA) has now published guidance on cleanliness in the NHS for primary care providers, which is aimed at helping primary care providers set up simple, easy-to-follow processes to ensure that their premises are clean and safe.

Using these specifications is not mandatory, but may be a useful guide for providers and may help towards registration with the Care Quality Commission (CQC) from April 2012.

The National specifications for cleanliness: primary medical and dental premises is available on the NPSA website: http://www.nrls.npsa.nhs.uk/resources/patient-safety-topics/environment/?entryid45=75241

The NPSA has also produced Q&As which explain the how the cleanliness specifications work. These can be found here

Items from GPC News July 2010

White Paper Equity and excellence: Liberating the NHS

The GPC held the first of many discussions on the government’s White Paper Equity and excellence: Liberating the NHS, published on 12 July. There will be time to consider the main proposals in more detail once the government publishes its supplementary report on commissioning. This is expected before the end of this month and may come out as early as next week. At this point the White Paper prompts many more questions than it answers. During the next few weeks, the GPC will collate a list of questions on the government’s proposals, including those questions posted to the GPC and LMC listservers. Please do use these listservers to share any questions you have. If we are unable to answer them we will endeavour to get answers in our discussions with NHS Employers, the Health Departments and Ministers over the coming months.

We are currently giving urgent consideration to the role of the GPC and BMA in supporting the transition to consortium commissioning. We have several meetings planned across the BMA to discuss the implications of the White Paper for the profession as a whole. The GPC recognises the crucial importance of GPs working collaboratively with consultants and others, including medical and health care professional colleagues and NHS managers, to ensure the best possible patient care, as these proposals develop. Externally, we intend to work with other health organisations to share and develop our own vision of how commissioning should operate. The GPC chairman will write to GPs about the White Paper within the next few days. Most importantly, the GPC will now consider what guidance the profession will need to equip it over the coming months and in the longer term. It will draw on the existing expertise in BMA Law and on the political understanding and practical experience of GPC members. We aim to start releasing guidance as soon as possible and maintain a stream of information in the form of ‘how to’ guides for as long as necessary.

Negotiations

We met NHS Employers last week for this year’s first negotiating meeting. These discussions are in their very early stages. We are however likely to face fairly intense negotiations over the coming months to put into place the initial transition arrangements required by the White Paper.

In the light of the public sector pay freeze, the DDRB’s role in pay recommendations this year is unclear. Assuming that it will report on GPs, it is our intention to aim for joint evidence if a negotiated settlement can be reached on other contractual issues.

Summary Care Record

The GPC considered the recently published evaluation report of the Summary Care Record (SCR) by UCL and passed the following two resolutions:

GPC believes that, after consideration of the UCL Report in respect of the Summary Care Record (SCR) in England:

the clinical benefits are insufficient to justify continuation at present, particularly at a time when patients are being denied proven clinical services on the grounds of expense;
the clinical benefits are insufficient to justify the creation without fully informed explicit consent;
the clinical benefits are insufficient to justify GPs consenting to the upload of data on behalf of patients who have not expressed consent;
the creation of SCRs in England should be halted until the full review of the model, and other models, has taken place to address cost-effectiveness and the need for informed and explicit consent of patients.

GPC believes that in view of the risks to patient safety caused by the failures of SCRs to be reliably and consistently updated, access to existing SCRs should be immediately suspended by the government until all patient safety issues have been fully investigated and satisfactorily resolved.

The GPC believes that it is for individual practices to decide whether they wish to proceed with uploads to the SCR.

FP69s & SCR uploads

Where practices participating in SCR uploads have received FP69s from their PCT due to undelivered PIP (Public Information Programme) letters, they should also have been advised to flag the records affected as “not for upload” until processing has been satisfactorily completed.

Sessional GPs Representation Working Group Report

The recommendations of the Sessional GPs Representation Working Group Report, available on the BMA website, were overwhelmingly endorsed at both the LMC conference and BMA's Annual Representative Meeting. We will now start to implement these recommendations. Elections for the new sessional GPs subcommittee will be advertised shortly.

GP Patient Survey

An update from the GPC on the GP Patient Survey can be found here. This aims to explain the results process for the 2009/10 survey, directing LMCs and practices to sources of information and helping to prepare for the release of final survey data for this year. This update applies to England only and the timetable and process will vary in Scotland, Wales and N Ireland. The PE7 and PE8 easements referred to below however do apply to the UK as a whole.

Patient survey and calculating eligibility for QOF PE7 and PE8

The patient survey results have been released and full details can be found online.

PCTs will now use the patient access data in the survey for calculating practice payments under the QOF. As part of the H1N1 vaccination DES, those practices that meet the minimum target for vaccinations will receive a 10 per cent drop in the upper - and 20 per cent in the lower - thresholds in PE7 and PE8.

Practices should be aware that the ImmForm Swine Flu data extraction programme, which has been used to assess uptake levels for the QOF easements, calculates the denominator on the age of the eligible patient population at the date of extraction, rather than the age of the patients at the time of vaccination,

This is likely to have a minor impact on the number of patients in the six months age range because those who were previously not eligible, will now appear as eligible. This is not expected to be a large number and will mainly impact on those practices that are close to the 50.7 per cent target.

Practices who do not believe that the figures are an accurate reflection of their eligible patient population can, with the agreement of their PCT, perform a manual calculation to work out if they have qualified for the patient experience easements.

Practices can use the data extraction report as a template to perform this calculation. An example of the report and details of the formula to be used, are available in annex 4, page 15 of the H1N1 vaccination DES guidance, available on the BMA website.

By July 30, the ImmForm programme team will have archived the swine flu vaccination data from October 09 to February 10 to free up storage space on the ImmForm system. This means that the vaccination data for this period will no longer be accessible to the practice (although it will remain available to the PCT). The March data, which will still be available, is cumulative so includes the uptake figures from October - February. The March data will remain accessible until the end of October 2010 at which point the data will only be accessible via PCTs and SHAs.

In the event that a practice is disputing their figures, a copy of the extraction reports could be useful, and as such the practices should save a copy of the report on their internal system to ensure they can access it in the future if necessary.

CQC registration

CQC registration will apply for NHS GPs from April 2012. However, we have had reports of some PCTs telling practices that, because of CQC, they must fully comply now with the Health and Social Care Act 2008: Code of Practice for the NHS on the prevention and control of healthcare associated infections. There is an ongoing consultation on how the Code of Practice will relate to primary care but at the moment it is guidance only.

Pension contributions

In 2007, the GPC agreed that for the year 2008/09 there would be a one off arrangement between the Department of Health and BMA that GP tiered contributions would be based on their 2006/07 pensionable pay as declared on their annual end of year 2006/07 certificate regardless of what they actually earned in 2008/09. If there was no 2006/07 certificate available then the 2005/06 certificate was to be used as a yardstick. If there were no certificate or if the GP was newly qualified then the NHSPS regulations stated that the 2008/09 tiered contributions rate would have to be agreed between the PCT and the GP and be based on the GP's estimated 2008/09 income.

However, it is very difficult to project a GP's income because no-one really knows what their practice profits are going to be or how much they may earn doing other GP work such as out-of-hours or locum work, both of which can increase total pensionable earnings considerably.

If a GP started at a practice in July 2008 and it turned out that they earned £35k (in total) between July 2008 and March 2009 it is understandable that they may question a 8.5% tier being imposed. With tax relief the real figure is less than 8.5% and in most cases it's probably not unreasonable for the PCT in July 2008 to believe that a GP may earn more than £35k over the following nine months.

Unfortunately under such circumstances there were always going to be some winners and losers for that year. For members at the extremes of these losses then the BMA pensions department will of course be happy to provide support and lodge a claim through the NHS Pensions Agency's internal dispute resolution procedure. Please contact pensions@bma.org.uk for such support.

The guidance which was published at the time of the agreement is available on the BMA website.

Review of prescription charges

In 2008 Professor Ian Gilmore, President of the Royal College of Physicians, was asked to lead an independent review on how a prescription charge exemption for people with long term conditions should be implemented, including how it would be phased in. The report recommends an extension of the list of conditions that are exempt, and a review of wider policy “with an open mind towards either abolishing prescription charges altogether, or wider reform”. The BMA welcomed the proposals but believes that the fairest system would be for prescription charges to be abolished

The report is available on the Department of Health website.

National Diabetes Audit

The National Diabetes Audit Executive Summary and the Paediatric Report have been published. The reports are available online.

This will be the fourth year where an automated data extraction is available to gather data for the audit. As in previous years, the audit keeps identifiable data to a minimum and has NIGB Ethics and Confidentiality Committee approval to hold and link patient level data (using NHS number). All the analysis is produced at aggregated level for GP practice, PCT or SHAs. As part of the extract process the Information Centre will write to every GP practice to let them know that the audit extract will be taking place, how to participate without the automated extract and the key dates for the audit period. Practices should expect to receive this letter shortly.

Goodwill and dispensing

A briefing has been drafted to clarify whether GPs can sell goodwill in terms of the dispensing element of their contracts. It is imperative that practices do not fall foul of the goodwill rules because by doing so, a breach in the regulations could result in a criminal offence. This briefing is available on the BMA website.

The King’s Fund Inquiry into the Quality of General Practice

The initial results of the King’s Fund inquiry are now becoming available. The King’s Fund is very keen to gather the personal views of the profession on the research they have commissioned, so that they are able to frame their ideas for the final report.

Details of the reports that have been published to date are below; the King’s Fund would welcome your comments and feedback.

There is an on-line resource page.

NORTH STAFFORDSHIRE

LOCAL MEDICAL COMMITTEE

Newsletter September 2010

White Paper