NEWSLETTER APRIL 2005
Out of Hours Telephone Call Transfer
Immunisation and Travel advice
Confidentiality and Disclosure of Information
Age Related Macular Degeneration
Medical reports for gyms and health clubs
Salaried GPs and practice letterheads
Understanding performance difficulties in doctors
The Shipman Inquiry – Fifth report
Reducing the bureaucratic burdens of sharing information
National Men’s Health Week 2005
Out of Hours Telephone Call Transfer
The Out of Hours system is experiencing difficulties with the number of calls transferred to the service between 8am and the opening of surgeries. A recent analysis has shown that about 200 calls are being received per day and as many as 270 on a Monday morning. This system was "forced" upon practices by PCTs eager to comply with a directive from the DoH and which was introduced in a hurry, ignoring the advice and warnings about potential problems given to them by the LMC. In other parts of the country PCTs have interpreted the directive in a different way and publicise a "one call number" in surgeries and the local media. Practices then continue to use ansaphones on their own telephone lines, which serve as a filter for calls made shortly after surgery closes and opens. The problem of the number of calls between 8am and 9am will have to be addressed and North Staffs Urgent Care is looking at ways to do this.
It is of great concern that because of the volume of calls between 8am and 9am, most are going unanswered and this could leave practices open to complaints. It is obvious that some form of filtering system must be introduced or arrangements made for GP surgeries to cancel their call diverts at 8am. Whilst discussions are taking place on this problem it would be worthwhile practices using the "divert on no answer" option on their system. This allows the phone to ring for 15 seconds before a message is given to the caller stating "calls to this number are being diverted please hold the line". This system does have the disadvantage of taking longer to get through to the service and also increases the risk of staff not remembering to cancel the divert when surgery opens. However, it may encourage patients who phone early in the morning to hang up and try again later. Practices will need to check with their telephone service provider that this works on their system. On BT systems this can easily be set up by using *61*01782719100# rather than *21*01782719100#. #61# is used to cancel the divert. Practices who have "smart" divert and can change their call divert remotely should consider using their system to cancel the divert at 8.00am
Whatever the definitive solution is, it must not be at the expense of GPs who have introduced a system at the request of the PCTs and who could revert back to using their previous system with only the loss of a few QOF points.
Choose and Book
Yet another wonderful idea to "improve" the care given to our patients! As this system is implemented it is becoming more and more obvious that it is a bureaucratic nightmare which, although it is claimed to have reduced waiting times, does little to improve patient care but increases the demands on General Practice and puts barriers in the way of patients seeing the consultant which we know is best for our patients. In the Stoke PCTs one of the major problems with the system is the instruction that patients should contact the patient care centre five days after we have decided to refer them. This give practices just a few days to dictate, type and post the referral letter. A target which puts intolerable burdens on already overloaded practices. Sending referrals electronically, although helping with the time scale is not practical unless we have high speed IT links. To compound the problems, the Stoke PCTs have now informed consultants who have seen patients privately that they cannot bring patients who are unable to continue funding private care back to their NHS lists without sending them back to their GP who will have to refer them back so that they can go through the choice initiative. They will then be advised of the commissioned provider options and make their choice. If the patient indicates that they wish to be cared for by the consultant that they have seen privately they will be advised that their referral will be forwarded to a provider unit that the consultant operates at, but they cannot name consultants for their care as the PCTs do not commission for named consultants. We have been informed that this system was introduced at the request of the consultant leaders. How can the "choose and book" system improve patient care if it denies patients access to named consultants who we may recommend to patients and have an interest in their problem?
In the longer term, with introduction of fast electronic links the system will be easier to operate, but General Practice cannot take on yet another time consuming innovation without extra resource to fund it.
Immunisation and Travel advice
There is a lot of confusion about when a practice can charge for vaccinations. We may charge patients for vaccinations where a fee was not payable under the old GMS regulations. This has led to a lot of confusion which urgently requires simplification and clarification. However, although the GPC is negotiating with the Department of Health about this, I don't think we will see a solution in the near future. Kent LMC has produced a detailed document which lists all immunisations currently in use and details when a charge may be made. It is a very comprehensive attempt to bring some clarity to the situation. They have agreed that this document may be shared by all GPs and a copy can be found here. The situation around charging patients for travel advice is still a grey area, although our contract now clearly states that patients may be charged for prescriptions for anti-malarials. Patients can also be charged for services such as prescriptions or travel packs which are for use in anticipation of illness while on holiday.
We have received reports of confusion where GPs have exercised their right to refuse immunisation or the supply of anti-malarial prescriptions for travel purposes and left patients unclear as to where they can obtain these services. Any practice can provide such a service privately to any patient. At present I am not aware of any practice who will provide this service to patients of another practice. This is an area which could be developed.
PGEA
No doubt you will have heard about the case of Dr Cornel Fleming who won his case against Islington PCT to claim a full year’s PGEA following the start of the new contract. The legal advice the GPC sought on this matter, last year, suggested that there was no case to do this. The whole crux of this matter hinges upon whether PGEA was paid in arrears or advance. You may remember that PGEA was taken from seniority payments by Mr Clarke and was paid as PGEA if we went on approved courses. The GPC's advice is that we started getting payments at the end of the first quarter of the first year and that it was only if GPs did not subsequently keep up to date with their courses that they stopped getting the allowance in part or in full..
Following legal advice and internal discussions, the GPC has come to the conclusion that the ruling can not be applied generically to all GPs because:
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it would not apply to PMS GPs who have different arrangements and is not likely to apply to new GPs post 1990-91, but more importantly,
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it would only apply to those who could present evidence themselves that they had been paid in arrears, and
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they know of other GPs who can provide evidence that they had not been paid in arrears.
Thus, it would not be possible for the GPC to take a legal or negotiating action on behalf of the whole profession at this stage. The only way to take a class action would be to have a large group of GPs all of whom could provide evidence that they had been paid annually, in arrears. Furthermore, it is important to note that the summary judgement in favour of the claimant's case came about because the PCT could not provide evidence that the doctor had not been paid in arrears.
It is important to note that the judgement ruling on Dr Fleming’s case is only relevant to this one particular case. Therefore this does not set a precedent for all doctors to claim this money; however what it does do is indicate that any other GP in the same situation as Dr Fleming may be successful in a challenge - the GPC’s current advice is that only those who can provide evidence that they had been paid in arrears might have a case.
QOF Points
PCTs will be publishing the total Quality and Outcome Framework points gained by each practice. They are currently debating whether to do this in a named or anonymised form. No matter what they decide each practice's achievement will enter the public domain. The DoH has a website on which these figures will be published and they will also be released them under the Freedom of Information Act. If you have any views on how the PCTs locally should publish these figure please let me know.
QOF Disputes
Some PCTs are refusing to allow QOF points to practices where they have not agreed a policy or protocol. The QOF points are rewarded to a practice for having certain policies, there is no stipulation that these should be "approved" by the PCT. Practices who cannot reach agreement with their PCT over the points achieved in the Quality and Outcomes Framework should appeal to Paul Burns Chief Executive, FHSAA(SHA) Appeals Unit 30 Victoria Avenue, Harrogate HG1 5PR. From 1st April it will technically be The Director of Appeals, NHSLA at the same address.
Contract Variations
A series of amendments to the GMS contract and PMS agreements regulations have also been agreed. PCOs will be expected to incorporate these amendments into GMS and PMS contracts by April 14th or as soon as possible thereafter, They are set out in the National Health Service (Primary Medical Services) Miscellaneous Amendments Regulations 2005, which will also soon be on the HMSO and DoH websites. The variation notice to the standard GMS contract can be found here
PMS Uplift Statement
The GPC have issued a statement on PMS uplift which PMS practices may find useful in their negotiations with the PCTs. This document can be found here.
Confidentiality and Disclosure of Information
The GPC has managed to agree with the Department of Health a code of practice that, although not entirely satisfactory, is agreeable to all parties. Although the GPC are still not completely happy with the final version, it does go someway further than it had previously with regard to assurances that disclosure of patient information is conducted within the parameters of the Data Protection Act and that information should only be disclosed when certain conditions are met. Now that the Code of Practice is public the GPC will be producing further guidance for LMCs setting out under what circumstances records might be disclosed, which can then be used to inform patients. This will be done in conjunction with the BMA Ethics Department. A copy of the document can be found here.
New Pharmacy Contract
From 1st April community pharmacists are operating under a new contract. The structure of the contract very much follows that of the nGMS contract with services organised as essential, advanced and enhanced. There are elements within the contract that directly affect their working relationship with GPs, in particular repeat dispensing and medicines use review. The LMC will be discussing these with the LPC in the near future. Some of the professional fees paid to pharmacists will be stopped from 1st April, most of these are for services which are rarely used these days but they do include the fee for dispensing prescriptions marked urgent by the prescriber. There will not be a nationally agreed call out fee for dispensing these urgent prescriptions and pharmacists will have to negotiate local arrangements with the PCTs.
Age Related Macular Degeneration
The committee has received several complaints from local GPs concerning the refusal of the University Hospital to accept referrals of patients who are suspected by their optician or GP to have age related macular degeneration. AMD is the most common cause of blindness in the UK and wet AMD is the most aggressive form. About 10 - 15% of patients will have the wet variety, this group is itself divided into two groups, classic and occult. Most of these (70+ %) have the occult type. The 30% who have classic wet AMD are suitable for treatment with verteporfin photodynamic therapy. Patients who have wet AMD require fluorescin angiography to determine whether they are suitable for verteporfin photodynamic therapy. Because of the aggressive nature of this condition these patients need treatment within a few months of presentation. The North Staffs PCTs have not been commissioning a fast track assessment service for these patients. Discussion between the commissioners and the University Hospital to provide this service locally have not been successful. The PCTs hope to have this service commissioned from Derby and Wolverhampton hospitals from 1st April. There will be a system in place for direct referral by the patients optometrist.
GPC News Items
IT Update (March 2005)
QMAS continues to be an overall success. The final QMAS report will automatically run on 1st April 2005. Practices should not stop the automated 1st April report. If practices collect data prior to 1st April 2005 but are unable to enter it onto their system until after 1st April 2005, they should still allow the automated report to run as planned on 1st April 2005. The practice will then need to discuss a variation of payment with their PCT for any qualifying data that has been entered retrospectively.
The Joint GP IT Committee welcomed a presentation from representatives from the Electronic Transmission of Prescriptions (ETP) team at their recent meeting. The ETP team is working with a group of GPs, including representatives from the GPC, who will provide advice and guidance and review the impact of the ETP service on working practices within surgeries.
Representatives of the Joint GP IT Committee have visited Bletchley Data Centre. This is where decrypted data will be held centrally for National Programme for IT initiatives such as Choose and Book and the NHS Care Record. It was therefore important for the GPC to see the physical protections that exist around this information. Those visiting were reassured that the data centre has adequate physical access controls and more than adequate support resilience. Representatives did not visit the mirror centre but accept that the protections there are equivalent. Representatives from the Joint GP IT Committee have also been invited to Choose and Book pilot sites to view the systems and speak to the GPs who have been involved with the pilots. The GPC is planning a further meeting with the Department of Health to discuss policy issues surrounding Choose and Book. The GPC has given the Department of Health a list of suggested changes that would make the process more acceptable to GPs.
There were reports at the Joint GP IT Committee that practices and PCTs are still not aware of the English NHS Licensing arrangements for Microsoft products. NHS organisations in England (including GP practices) are covered by the national licence and are therefore entitled to free access to Microsoft products - Word, Access, Excel, Outlook, PowerPoint and FrontPage. Practices should contact their PCT if they wish to take up this offer. If practices encounter any problems they should contact Rachel Merrett (rmerrett@bma.org.uk).
Revalidation
The committee discussed the Chief Medical Officer, Sir Liam Donaldson’s ‘Call for ideas – Clinical Performance and Medical Regulation: Chief Medical Officer’s review following the Shipman Inquiry reports’, which can be accessed via the following link:
In addition to feeding into the BMA-wide response, it was agreed that the GPC would provide a separate response which would be based on committee debate and then further considered by the negotiators, and the educational and professional development subcommittee. The deadline for the response is 11 April 2005.
The committee felt the GPC response should emphasise the purpose of appraisal and revalidation, and highlight that, although the same evidence may feed into both, appraisal is predominantly an educational and supportive process and is therefore distinct from revalidation. Fitness to practise is about performance, rather than competence and knowledge, and the development of a no-blame culture would enhance patient safety. The committee discussed that professionalism should not only be limited to doctors, but should also apply to other professions. The committee felt it vital the response stressed that any arrangement put in place should not introduce an onerous workload, as this would pose a threat to general practice recruitment and retention. It should also be made clear that an extensive system of re-training and revalidation would need adequate resources. Members re-emphasised the importance of joint working with the Royal College of General Practitioners on these and other matters.
Medical reports for gyms and health clubs
As a result of the NHS campaign to encourage the general public to take more exercise, there have been a number of queries about GPs’ obligations to provide medical reports to certify fitness to exercise and how to respond to requests for information from gyms and patients advised to see their GP before using the gym facilities.
In most cases the statement of patient’s fitness from a GP is required for the liability insurance cover of the health club or gym. It is the BMA view that unless there is a direct clinical referral of the patient to the gym/health club as part of the patient’s rehabilitation programme, then a charge is reasonable. This service is not covered under the new GMS contract and therefore the GP should be properly remunerated for the work which often involves the screening of the full patient medical record. The BMA is able to suggest fees for this work which can only be done by the patient’s own GP or other attending doctor. The BMA suggested fee for this work is currently £11.50 for a straightforward certificate of fact and £19.50 - £41.50 for more complex certificates. Revised fees are due to be announced shortly. The GP does have the discretion to waive the fee after considering the implications to the doctor-patient relationship.
Where a gym or health club instructor is concerned about the health of one of its members, for example high blood pressure, it would be good practice for the gym to put details of the concern in writing to the GP. However, the gym should seek written consent from the patient before sharing this specific information.
Salaried GPs and practice letterheads
There have been a number of enquiries regarding practice letter heads and whether or not salaried GPs can be included in any letter heading.
Under The Business Names Act 1985 a business is required to include all the names of its partners on the letter heading if they are not included in the Business Name. All those partners carry joint liability in relation to their business.
Practices are able to include the names of other members of staff (eg salaried GPs) on their letter head. However, it is important that they put a qualifier by their name (eg salaried GP, staff GP) so as to distinguish them clearly from the partners. Failure to do so could leave these doctors/staff members open to carrying joint liability with the partners.
Understanding performance difficulties in doctors
The National Clinical Assessment Authority has recently published a report entitled “Understanding performance difficulties in doctors”. The report represents a centrally important point in a programme of work which the NCAA has led. The aim was to understand more fully the factors other than clinical competence which can affect a doctor’s performance. Although this is a continuing programme, the report draws together learning which the NCAA has derived from its work with the NHS over the past three years, as well as a review of earlier published work. This report is designed very much as a practical guide for those in the NHS who are faced with the challenging job of managing performance difficulties. Each chapter deals with a discrete area of concern, identifies the tools available locally to access that area of concern, and suggests some possible approaches to addressing the difficulty.
The bibliography is on the NCAA website: www.ncaa.nhs.uk and the full work is being published as a book by Radcliffe press.
NHS Pensions Review
The consultation period on the NHS Pensions Review is currently in operation. The potential changes are being presented throughout the BMA and the consultation is being lead by the BMA Pensions Department. GPs are encouraged to read the information available on the Pensions Review, to send their views to the Pensions Department and to complete the BMA survey on the key issues. The following motion was passed by the committee in relation to this discussion:
That the GPC believes the proposed changes to the NHS pension scheme for doctors:
i) should not adversely affect current members of the scheme and allow them to maintain all of the current benefits, including retiring aged 60, if they so wish
ii) affect different branches of our profession in different ways and the GPC supports a robust BMA wide response to this consultation.
Further information is available, for members, on the BMA website at: www.bma.org.uk/ap.nsf/content/nhsview
There is still some confusion about the current pension arrangements for salaried GPs, in terms of how they are regarded for NHS Pension Scheme purposes. Salaried GPs (PCO and practice-employed) are pensioned under the practitioner method (as per GP principals/providers) rather than under the officer method (as per hospital employees). In GMS and PMS, all salaried GPs will continue to be regarded as assistant practitioners for NHS Pension Scheme purposes and the relevant PCO will be their employer for NHS Pension Scheme and NHS Injury Benefit Scheme purposes. Therefore, contrary to the belief of some, salaried GPs will not automatically be pensioned under the final salary scheme. This is set out in the NHS Pensions Agency Technical Newsletter 5/2004, available on their website, under the library section, at www.nhspa.gov.uk/
The GPC guidance ‘Pensions Questions and Answers’, published in October 2004, further explains the current situation with regard to GP pensions. www.bma.org.uk/ap.nsf/Content/pensionfaqs
IT update (February 2005)
Choose and Book
The GPC have met with representatives of the Department of Health to discuss Choose and Book. We have also sent to the National Program for IT a ‘ten point plan’, listing changes which we believe are needed to make Choose and Book more useable.
GP2GP
The testing of the electronic transfer of GP patient records between different GP clinical systems is currently underway. Clinicians have been engaged in this process, particularly in the quality assurance work. Hopefully the GPC will receive a demonstration of GP2PG at its April meeting.
Service Level Agreement
The Service Level Agreement (SLA) detailing the service that PCTs must provide to practices is still pending. The Joint GP IT Committee have sent further comments to the National Programme for IT and is still awaiting a response. A liability statement detailing who is responsible for replacing equipment, for example in the event of theft or damage, is close to being finalised and will be attached as an appendix to the SLA. This is an ‘England only’ agreement, however, it is expected to be adapted for use in Wales and Northern Ireland. Scotland already has an agreement in place.
QMAS
The majority of practices (97%) are sending in their reports, with only a small proportion reporting difficulties in submitting reports. The Co-Chairman of the JGPITC wished to congratulate this success on the work of the NPfIT on the successful roll out of this project.
Patient Confidentiality
The Committee considered a letter to the Chairman of the BMA, James Johnson, and a letter from the Patient Liaison Group Co-Chair, Barbara Wood, regarding the issue of patient confidentiality. It was agreed by the GPC that it would be beneficial to discuss this issue in as open a forum as possible, and that appropriate arrangements should be made to bring these proposals about.
Accreditation of Future Systems
Under the new GMS contract, the Joint GP IT Committee is responsible for ensuring that future systems are fit for the purpose. Representatives from the Joint GP IT Committee are meeting with the National Programme for IT to discuss the practicalities of the accreditation process in the first week of March.
The Shipman Inquiry – Fifth report
The Committee discussed the report of a joint Statutes and Regulations Subcommittee and negotiators meeting on The Shipman Inquiry's Fifth Report - Safeguarding patients: Lessons from the Past - Proposals for the Future. In general the Committee approved of the conclusions reached by the Subcommittee and negotiators and there was consent that the Chairman and negotiators should work with the relevant personnel at the Department of Health and the Royal College of General Practitioners to ensure a proportionate response to Dame Janet's recommendations and a way forward that engaged the support of GP colleagues.
Reducing the bureaucratic burdens of sharing information
Further to our work with the Cabinet Office on reducing bureaucracy on GPs, the Cabinet Office Public Sector Team in partnership with the Department of Health is undertaking a project to reduce the bureaucratic burdens associated with sharing data between health and social care. A key element of this project is a questionnaire to identify bureaucratic burdens and possible changes to processes and paperwork that will reduce or remove burdens. The questionnaire can be found at: www.cabinetoffice.gov.uk/regulation/pst/projects/mad/data.asp
Local practices are encouraged to complete the form.
There will also be workshops with front line health and social care staff to further explore these issues. If you would like further information on this project, or would like to take part in one of the workshops, please contact the Cabinet Office project manager Ed Moses at: ed.moses@cabinet-office.x.gsi.gov.uk
National Men’s Health Week 2005
We have been contacted by the Men’s Health Forum about National Men’s Health Week (NMHW) 2005 which will follow broadly the same model as previous Weeks, and will run from the 13th to the 19th of June. The key objective is to increase men’s awareness of weight and obesity issues and to encourage services to work more effectively with men on weight. It is expected the 2005 week will be the most successful yet, with a major national conference and the launch of the Haynes HGV Manual both planned for the week. The HGV Manual is being written in conjunction with the key organisations in the area, and will be the definitive guide to men and weight/obesity – not only will the content be comprehensive but the design will also be well-suited to a male readership.
Completing the registration form will ensure regular updates about the week as well as details of a free resource pack. Further details are available at www.menshealthforum.org.uk.