September 2011

As you are probably aware Dr David Hughes stood down as Chairman of the LMC in April 2011 when he took up the role of Chair of North Staffordshire Clinical Commissioning Group. Dr Paul Scott was appointed to succeed him.

Dr Gerald Morgans has now stepped down as Vice-Chair of the Committee and Dr Jack Aw has been appointed to succeed him.

Dr Paul Golik will be stepping down from the post of Medical Secretary to the Committee at the end of March 2012 and Dr Harald Van Der Linden has been appointed to this post. Harald will be working in capacity of Deputy Secretary from 1st October 2011 until he takes over completely on 1st April.

Elections will be held in the first quarter of January for half (10) members of the LMC. If any colleague wishes to attend LMC meeting prior to then to obtain a flavour of what is involved. Please contact the LMC office.

Enhanced Services Claims Templates

The PCTs issued a revised claims template last month along with a statement that it had been approved by the LMC. The LMC has not "approved" the template issued and has written to the PCTs with a number of comments concerning the template. There is an error in template concerning the number of days allowed for a practice to complete a neonatal examinations. The PCT proposed changing this to two days earlier this year, but agreed to return it to seven days after it was pointed out that two days was impractical particularly around Bank Holidays. This is not reflected in the template.

The committee is also concerned about the quantity of detail required by the template, not all of which is necessary to monitor enhanced service claims. We have suggest to the PCTs that the template should collect only data which is relevant to enhanced service claims and within that, only data which is necessary to monitor the claim. They should not, for example, be requesting 8 items of data for the alcohol DES when national guidance suggests only 4 items are necessary. Practices do not routinely code activity under the portfolio LESs. To do so would involve a disproportionate amount of work, indeed there are no specific codes for the majority of this work.

The committee is very aware of the amount of data collection being requested from practices, both from PCTs and commissioning groups. We have stressed to all that this causing a workload problem for practices and that all data requests should be relevant, necessary, useful and easily retrievable.

Oxford Scores

Following representation made by the LMC the commissioners have now removed the requirement for GPs to complete an "Oxford" score prior to referral of patients for hip and knee replacement surgery.

Seasonal Flu Vaccination Programme 2011

Below is the text of a letter from the BMA concerning the flu vaccination programme

Evidence collected over the last few years has shown that patients in at-risk groups were 11 times more likely to die from seasonal flu than otherwise healthy individuals, which shows the importance of the flu vaccinations for those groups. Evidence also showed that in 2010-2011, uptake in the at-risk groups in patients under 65 was much lower (50.4%), than that recommended by the WHO (75%). Uptake in pregnant women was only 38%. Earlier this year the Chief Medical Officer (England) suggested that ‘A reasonable trajectory for increases in uptake in clinical risk groups and pregnant women might be 60% in 2011-2012, and 70% in 2012-2013, so that an uptake of 75% can be reached or exceeded in 2013-2014'.

We would therefore like to encourage practices to ensure that those in the at-risk groups are given priority if at all possible.

At-risk groups:

All patients aged 65 years and over
Chronic respiratory disease aged six months or older
Chronic heart disease aged six months or older
Chronic kidney disease aged six months or older
Chronic liver disease aged six months or older
Chronic neurological disease
Diabetes aged six months or older
Immunosuppression
Pregnant women
Carers

More detailed information about the at-risk groups as well as the data on the relative risk of seasonal flu to the different clinical risk groups is given on page three of the CMO (England) letter on the seasonal flu vaccination programme sent out in May, and in a similar letters in the devolved nations.

The seasonal flu immunisation programme 2011/12 DoH Letter

In the letter from the CMO (England), it also shows that uptake by healthcare workers was only 34.7% at the end of February 2011. We are concerned that this is a very low level of uptake in those that work with patients on the front line, and we would encourage practices to ensure that staff are better protected.

You may also find the BMA's web pages on influenza a useful resource

Items from GPC New July 2011

NHS reforms

The GPC discussed recent developments on the NHS reforms and was informed about the statement
agreed by BMA Council at its meeting the previous day (available on the BMA website).

Various significant reports had been published since the meeting of the GPC in May, including the
BMA’s submission to the Future Forum, the report of the NHS Future Forum and the
Government’s response to the NHS Future Forum report. The BMA has provided briefings for
the Health and Social Care Bill Committee Re-committal Stage, which are available on the BMA
website.

Committee members discussed their concerns about some of the Government’s recent changes to
the reforms, fearing, in particular, even greater bureaucracy through new administrative tiers and
increasing costs. Many local experiences of implementation had not been positive, with some
described as shambolic.

The GPC was given an update on commissioning issues which has been shared with LMCs and we
will provide details of key developments on the website shortly.

Governance of GP consortia

The GPC has produced guidance putting forward examples of possible models for the governance of
consortia and advising that, as a minimum, specialists should be involved in the design of patient
pathways. The guidance can be found here.

Ensuring transparency and probity: GPC guidance to ensure the honest and
transparent operation of clinically led consortia

The GPC released guidance that sets out how consortia can ensure their governance arrangements
have the confidence and trust of the public. It also calls on the government to scrap the proposal to
pay consortia a performance-related payment if they perform well financially. The guidance can be found here.

Care pathways for outpatient referrals and emergency admissions indicatorsQP6-QP11)

Following a number of queries asking whether the care pathways for Outpatient Referrals and Emergency Admissions indicators need to be new or not, please see the following clarification of the issue.

The QOF guidance (fourth revision), p168, which is in the SFE states:

8.1 GPs in the practice must actively respond to the care pathway development process for the purpose of this indicator. This may, for example, involve attending meetings with other health professionals concerned with the care pathway or commenting to the pathway group electronically. The three care pathways cannot be the same as those identified for indicator QP11. Where possible, the focus of the care pathways should be on long term conditions. Practices must then follow the agreed care pathways in the treatment of their patients, unless in individual cases they can justify clinical reasons for not doing this.

However, the joint GPC / NHS Employers supplementary Quality and Productivity guidance, issued in May, states:

14. Do the care pathways for QP6 to QP11 have to be newly developed or can they be ones that are currently in development at the time the indicators were published?

The QOF guidance/SFE is clear that the pathways to be developed should be new.

However, where a pathway is still in the development stages and allows the opportunity for practices to engage in development, then subject to agreement between the PCT and practice, this would be acceptable.

The wording of indicators QP8 and QP11 in the SFE stating that ‘The practice engages with the development of and follows three agreed pathways’ does not necessarily imply a completely new pathway. The intention is to give practices a say in what pathways are developed, and what they finally look like and to avoid unacceptable ones imposed upon them, but to also give some flexibility to use acceptable ones that are being developed but not yet fully implemented. The SFE and supplementary guidance were designed to prevent PCO imposition of pathways whilst allowing GP groups to use whichever pathway they believe to be the most appropriate.

For the avoidance of doubt: There is therefore some flexibility for practices to use developing pathways already in existence as long as they are in the development phase as far as the practice is involved. What you cannot do is to designate a pathway you already use as a “new” pathway for the purpose of QOF.

Chronic kidney disease FAQs

The GPC and NHSE have published an updated set of questions and answers in relation to chronic kidney disease and the Quality and Outcomes Framework (QOF) indicators. First published in November 2009, these FAQs have been updated to take into account current issues and the latest available evidence in line with NICE guidelines for this disease area.

In particular, the updated guidance includes new sections on 'management of CKD: a summary' and on stages and complications of the disease. It also includes two new annexes on 'what should practices do if they do not have access to eGFR?' and a 'glossary of terms' at the back of the document. The updated guidance can be accessed here.

Care Quality Commission registration

The committee discussed how to respond to the Department of Health consultation on delaying CQC registration for most primary medical services providers, which is available on the Department of Health website. The response will be submitted shortly, and will be available on the BMA website once this happens. We would remind practices that they should not undertake any work on registering at this stage, nor enter into any kind of agreement with a third party to do so.

The CQC is sending out an update letter to all primary medical services providers in light of the proposed changes.

The GPC has produced a Care Quality Commission (CQC) toolkit. We would encourage all LMCs to draw the attention of practices to the foreword in the toolkit which makes it clear that practices should not do any significant preparatory work at the moment, but it is worth reading the toolkit in order to be aware of might be required in the future. The toolkit is available on the BMA website.

NHS Choices website

In May we reminded LMCs that practices are notified of a comment pertaining to them on the NHS Choices website following the publication of the comment. An alert is sent to a named recipient at the practice in question (usually the practice manager although this will be designated by the practice). Practices then have two options:

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

Following some concerns which have recently been raised again about the NHS Choices website, we would like to reiterate our advice to GPs regarding negative comments on the site. We want to encourage GPs to respond constructively to the website when a comment is posted about them, in order for them to be able to correct any misrepresentation and also to show their professionalism under these circumstances. As long as the reply is positive and carefully constructed, rather than defensive, it should help and not hinder GPs in these particular situations.

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

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

Refresher training in taking cervical smears

We have been made aware of a number of PCTs insisting that all GPs working in their areas undertake either a half day or a full day's update training in taking cervical smears. Many have been told that this is a contractual requirement and therefore mandatory and others that successful completion of such a course is a requirement of their PMS contract.

We believe that this is an unreasonable requirement, given that the training for undertaking cervical smears is already included in the GP curriculum covered during the period of vocational training for general practice. Further requirements in this area would serve to distract GPs from other areas of education identified in their personal learning plan through their annual appraisal which may be more helpful, or take up time which could be spent on clinical care.

If a GP felt that he/she required refresher training in taking cervical smears then they could obtain this through their continuing professional development either through attending an appropriate course or using other training materials.

Both the RCGP and GPC have concerns about this issue, and we are writing to the Department and NHS Employers, asking that this practice should be discouraged.

We know that in Scotland this training is done using DVDs and that e-learning modules have been set up in some areas, including Leeds, an example of which is available online.

JCVI advice on the pneumococcal vaccination programme for over 65s

Earlier this year the Department of Health (DH) informed us that, following a review by the Joint Committee on Vaccination and Immunisation (JCVI) of the evidence on the impact of the pneumococcal vaccination programme and on the clinical effectiveness of pneumococcal polysaccharide vaccine (PPV), the protection the vaccine provides was poor and not long-lasting in older people. The JCVI advised that there was little benefit to continuing the programme and that it should be stopped.

The DH sought views on the JCVI advice from various stakeholders, and the GPC responded accepting the JCVI evidence, but asked whether the DH had considered reviewing the vaccine rather than withdrawing it, and whether further guidance to help GPs make a judgement whether to provide the vaccine to over 65s with risk factors could be produced.

Following a number of comments from various stakeholder and new independent analyses of UK epidemiological data on invasive pneumococcal disease, the JCVI concluded that, whilst there remains some uncertainty about the effectiveness of PPV, there is now better evidence of the vaccine suggesting that PPV provides some moderate short term protection to those aged 65 years and older, although protection may be less and wane faster in older age groups and for some clinical risk groups. The new analysis also showed that the programme remains cost effective, despite the limited effectiveness of the vaccine, and may be more cost effective than implementing a risk group-based programme. For these reasons, the JCVI has advised that the existing routine programme for those aged 65 years and older should continue, although be kept under review.
Professor David Salisbury has written to the profession to inform them of this, and the letter is available here.

Updated patient participation DES FAQs

The GPC issued a set of FAQs on the new Patient Participation DES in June. A new and extended list of FAQs has now been published jointly with NHS Employers. The FAQs are available here.

National Association for Patient Participation

A leaflet from the National Association of Patient Participation (NAPP), which is the umbrella organisation for patient-led groups within general practices can be found here. NAPP are providing support to practices to meet the Patient Participation Directed Enhanced Service (DES) requirements in the GMS contract.

Guidance for practices using 084 numbers

In response to a question in Parliament, the Health Minister Anne Milton told Parliament that “since April this year, GPs have not been allowed to use a number that charges patients more than the cost of an equivalent geographical call.”

This is not strictly accurate, and we wanted to update LMCs and practices, in case they are contacted by PCTs pressuring practices to move away from using 084 numbers.

The GMS and PMS regulations were amended in April 2010. The regulations:

make clear that, from 1 April 2010, any practice entering into a new contract for telephone services must ensure that calls to the practice will not cost patients more than calls to an equivalent geographical telephone number, and
outline steps that practices with existing contracts must take before April 2011 to establish whether or not a person calling their practice pays more than the cost of a call to an equivalent geographical telephone number, and the steps that practices must take following that review.

We recognise that many practices will have long term contracts with telephone providers that contain penalty causes and that, as a consequence, some practices may not reasonably be able to extract themselves from their contract. In cases such as this, we believe that it is entirely within the regulations for practices to continue with their current supplier for the duration of their current contract, before moving to a new contract that meets the requirements of the GMS regulations.

The GPC has produced detailed guidance which can be accessed here.

NORTH STAFFORDSHIRE

LOCAL MEDICAL COMMITTEE

Newsletter September 2011

Change in LMC Officers