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Newsletter August 2002GPs whose Performance Gives rise to Concern Audit commission report: A focus on general practice in England July 2002 IntroductionIt is just three months since Health Authorities merged and PCTs took over day-to-day responsibility for the Health Service. It is already apparent that they not only lack a sense of direction but also a basic understanding of the workings of the health service. It is now extremely difficult to identify who is responsible for what. The system of payments to GPs is unduly bureaucratic and inefficient. It is not always clear what payments are for and PCTs are trying to dictate the use of some payments. PCTs do not have the resources to cope with their responsibilities. They have a heavy agenda of “must does” dictated from the Department of Health and little left over for local priorities. With 80/% on the NHS budget being spent on secondary care the title “Primary Care Trust” is no doubt a misnomer. Whilst the spending on General Practice has risen in real terms by 20% in the last ten years, spending on hospitals has increased by more than three times as much. We struggle to obtain even small amounts of resource into General Practice, witness the difficulties in obtaining modest resource for the care of patients in nursing homes and reluctance to resource the influenza vaccination programme. Yet there is an assumption that General Practitioner will provide any service which we are asked to do. Until we say no to work and implement it we will not be taken seriously when asking for more resources. Most of us are not keen to take such a stance as it will impact adversely on the doctor patient relationship, a relationship which is highly valued. New Contract BallotThe result of the ballot on the “New Contract” has recently been announced. A total of 43,075 ballot forms were sent out to GPs and GP registrars all over the UK and 28,085 valid forms were returned by the ballot deadline of 12 noon on Monday 8 July. This represents a turnout of 65.2 per cent. 75.8% of respondents voted "Yes" with a return rate of 65.2%. The GPC will now go ahead with further negotiation and pricing. Following this a further ballot will be held on whether to accept the priced contract. They also have to sort out key areas such as pensions, an end to the current system of forced patient allocations and the introduction of effective demand management initiatives if the result of the next vote is also to be yes." Investing in Primary CareSome practices have recently received money from PCTs as a “reward” for achieving targets and objectives agreed with their PCT. The covering letter with these payments misleads GPs into thinking that they can only use the money in certain ways suggested by the PCT. These suggestions include “any options you chose for investing in primary care; towards your 4 year action plan and targets; and improving access to services”. They fail to inform practices that they have the discretion to apply the agreed reward monies as they see fit. This could be either as a personal reward for those concerned or used to further extend primary care development. To use this money for the PCTs suggestions is akin to suggesting to their staff that overtime payments are used to finance the purchase of equipment for the PCT office. Flu VaccinationsThe committee has received a draft Local Development Scheme for payment related to the vaccination of patients under the age of 65 in “at risk” groups. This LDS has yet to be approved by the PCTs. Whilst welcoming the extension of the scheme to cover hostel-based asylum seekers, practice and PCT staff, the committee felt that the remuneration on offer should equal that provided nationally for the over 65s. Last year, primary care in North Staffordshire performed admirably, achieving the fourth highest immunisation rate in the over 65’s despite ranking 86th out of 95th in the number of GPs per 100,000 population. Such an achievement shows the amount of dedication, hard work and goodwill available in primary care in North Staffordshire and this should be recognised and rewarded accordingly. Referral ProformaA number of
GPs have raised concerns about the circular from the Bennett Centre which
states that they will only accept referrals using an “initial assessment
form”. This form is three sides of A4 and is clearly not acceptable. I
have made this clear to the Trust and re-iterated our policy that GPs are
free to continue to make referrals by letter in their usual way. Any
refusal by the Trust to accept such referrals will have medico-legal
implications for the Trust should problems arise. Violent PatientsThe Department of Health has written to the chief executives of all PCTs requiring that action plans for tackling violence against GPs and their staff are in place by 31st October. Work was done on this by the former health authority, but the sticking point has been and remains the provision of secure facilities for providing services to violent patients. As yet, such premises have not been identified. The issue is being discussed at meetings with the PCTs. Along with the provision of a secure facility, it is hoped that the previous work done on the care of “violent” patients will be reviewed and re-issued. LIFTThis stands for Local Improvement Finance Trust which is a national programme whose aim is to help improve primary care premises. North Staffordshire has one of the schemes which is part of the first two waves of LIFT. All GPs can be involved in this scheme but no one can be forced to take part. The idea is that LIFTCo will build and refurbish primary care premises which it will own and lease back to GPs and or other parties. It is claimed that the advantages for North
Staffordshire will be
Each PCT is developing its plans and identifying the priority areas for the first wave schemes. £47m has been identified as the initial sum indicated in the bid to the DoH for the LIFT programme. It is expected that LIFTCo will be set up by the autumn of 2003 and the first projects should be delivered 12 – 15 months later. This programme is a great opportunity to get more
investment into the infrastructure of primary care in North Staffordshire
and is supported by the LMC. Further information on LIFT can be obtained from Simon Priestley, Director North Staffordshire LIFT programme on 01782 298051 or simon.priestley@nhsa.wmids.nhs.uk. GPs whose Performance Gives rise to ConcernThe committee was extremely concerned that all GPs were sent letters under this heading, giving their “scores”. Members were concerned that the letter appeared insensitive and threatening. It used a screening tool for a purpose for which it was not designed and had not been validated. The data used was in some circumstances extremely inaccurate. Our views have been passed on to Dr Chesworth. Protopic (tacrolimus)This is a new preparation for the treatment of atopic dermatitis in patients in whom conventional therapies are not adequate. This preparation does not appear in the hospital formulary and attempts have been made to pass the prescribing onto General Practitioners. I draw your attention to the MTRAC opinion that it is not appropriate for GPs to prescribe this product. Staffordshire Support SchemeThe committee is keen to see this continue. It gives a service over and above that provided by the occupational health service. We have identified that money to support the scheme in the current year has been allocated to PCTs. We are discussing with them the continuation of the scheme. AsbestosisThere has been recent publicity about the possible exposure to asbestosis by former employees at Enderley Mills in Newcastle. Not surprisingly solicitors have become involved and one firm is advising clients to attend their GP for assessment of their condition. I feel that this is inappropriate and have written to the firm accordingly. Asbestos can cause fibrosis of the lungs. This may not be seen on chest x-ray, but maybe detected on CT scan. I am concerned that GPs may reassure patients on the basis of a chest x-ray alone and then leave themselves open for complaint. I have suggested to the solicitors that it would be more appropriate for them to arrange the opinion of a respiratory physician. A few items from the GPCPassportsThe BMA has received many queries to the office
regarding the new passport application form and the request that GPs give
their own passport number as part of the photograph/applicant verification
process. The BMA has spoken with the passport office with
regard to the new forms. The
need to put down a passport number is a post September 11 initiative and,
as one of the new anti-terrorism measures, there is no chance that the
rules are going to be altered for a particular professional group.
This means that GP's will have to decide whether they are willing
to sign it and put down their passport number or whether they are not. As filling in such forms is outside the remit of GMS
and applicants can clearly go to a number of people to validate the form,
if a doctor feels worried that the patient will abuse his/her number, or
he/she is concerned about the form, do not fill it in. It is worth noting that as a result of work with the
Cabinet Office - whose second report into reducing burdens on general
practitioners has recently been published
- doctors/general practitioners are no longer mentioned as possible
countersignatorys. It is appreciated that filling in these application
forms is a source of income for doctors but you will be aware with the new
contract work currently going on the GPC are doing everything they can to
protect general practitioners income with regard to the clinical and
clinically relevant work they do. Single-handed
GPs
The GPC expressed
its deep concern that, in the House of Commons on 3 July 2002, the Prime
Minister stated: “There has been a move away over time from single-handed practices so as
to improve the quality of care that people receive. That has been based on a great deal of evidence over a long
time. Of course, the move has
to be done sensitively....” The GPC meeting
also agreed unanimously that it will always stand up for the right of
patients and practitioners in solo practices as well as practices of all
other configurations. The
committee condemned the Government’s stated view, particularly its claim
that this was based on evidence that solo practices offer inferior care,
when no such evidence existed. Indeed,
much evidence demonstrated that solo practices offered satisfaction to
doctors and patients alike, including the Audit Commission report. The chairman of the GPC has written to Mr Blair noting the high quality service provided by single-handers and also seeking assurances that single-handed GPs have a secure future in the new NHS. Audit commission report: A focus on general practice in England July 2002The GPC have considered the audit commission’s
report. The report demonstrates what the GPC has been saying for some
time, that: ·
GP workload has increased. The audit commission points to shorter hospital stays and
increasing numbers of elderly patients, new clinical standards, complex
drug regimens, and greater expectations as leading to this increase ·
NHS Direct and walk-in centres have not eased the demand to
date ·
While more work has shifted out of hospital, there has not
been a corresponding shift in the balance of resources.
Indeed, the audit commission notes that growth in spending on
general practice (not including drugs) has risen by 20% in real terms over
the last 10 years, compared with over 60% on hospitals. ·
There is a GP recruitment and retention crisis – one third
of GPs and practice nurses are approaching retirement age and the number
of new GPs joining the workforce is only marginally higher than the number
leaving. ·
In some inner-city areas, one in five posts are vacant. More than nine out of ten NHS consultations are
carried out in general practice on a budget equal to only one fifth of the
NHS spending bill, which demonstrates that general practice is an
enormously cost effective service. The
audit commission report recognises the tremendous amount of work done and
the value the public places on the service.
It rightly highlights the pressures GPs and their staff are working
under and the dire recruitment and retention problems they face.
Many will empathise with the statement in the report that many
practices are struggling to deliver the government’s health service
policies. The new GP contract the GPC are currently negotiating will
make sure that the money going into general practice matches the needs of
patients. It will enable GPs
to control their workload while also providing incentives through rewards
and investment to offer high quality care. The new system of payments for quality and outcomes should ensure, over time, that all patients benefit from the good quality care offered already by many practices. With the promised investment heralded in the comprehensive spending review, and the right support, the GPC agrees with the audit commission’s conclusion that general practice can meet the challenges of the twenty-first century. Weekly PrescriptionsThe GPC have been advised that GPs are being
pressured by pharmacists to produce weekly prescriptions as a means of
financing the cost of putting medicines in dosette boxes.
Some Health Authorities consider the issue of weekly scripts (for
which a fee is recouped from the PPA) as the use of NHS funds for a
non-NHS purpose. It has also
come to light that Boots now offers monitored dose systems for a fee to
patients. We advise practices not to recommend particular pharmacies to
their patients, as it is up to the patient where they go for dispensing
for “nomad” type services. Until there is centrally funded reimbursement to
pharmacists for providing this service, GPs may be placed in a difficult
position. However, this
should be viewed as a material issue for pharmacists, not general
practitioners, and we urge GPs not to feel obliged to write weekly
prescriptions. GPs are
however, within their terms of service to issue weekly scripts if there is
good clinical reason for doing so. The
GPC has also written to the Department and PSNC outlining the problem for
GPs and advising that guidance has been issued to the profession.
An update will be provided in due course. DR PAUL GOLIKSecretary |
