NEWSLETTER AUGUST 2006
Discharge of patients from Hospital Follow-up
Health Care Commissions Diabetes Survey
Choose and Book/Outpatient referral targets
Rheumatology Monitoring Path Lab Reports
Pneumococcal vaccinations in childhood immunisations
Discharge of patients from Hospital Follow-up
The PCTs are actively encouraging secondary care provides to decrease their ratio of follow up to new patients. The main driver for this, of course, is cost. Under the "payment by results" system the PCT pays for each attendance at the hospital. The LMC have made it clear to PCTs that they cannot expect general practice to pick up any extra workload arising from such action without adequate resource being put into primary care.
Follow up patients fall broadly into three groups. Firstly those whose condition is stable and for whom there is likely to be no change in treatment or need for further investigation/examination at follow up. These patients are clearly being inappropriately followed up and should be discharged back to the care of the GP. Secondly there is a group who require specialist/close monitoring due to the complex/unstable nature of their illness and who needed to be under secondary care follow up. Between these two groups there is a third group whose condition is stable but who require monitoring at regular intervals by either examination and/or investigation. This group could be discharged to primary care with a clear shared care agreement with agreed parameters as to when re-referral to the secondary care consultant is appropriate. However, the monitoring of such condition is not part of General Medical or Personal Medical Services. The LMC believes that the PCTs should commission a Local Enhanced Service from General Practice to perform these tasks. The alternative is for PCTs to arrange for these patients to be monitored in clinics run by GPs with a special interest. We believe that the best way forward is the commissioning of a LES both for patient care and also in attracting funding into primary care. We have had a meeting with the Stoke PCTs and agreed the principle that any patient who requires follow up via a recall system falls outside GMS. These will include patients who have chronic bowel, liver, renal or haematological disease and who require regular monitoring.
The PCTs have still to arrange appropriate follow up for patients who are going to be discharged from secondary care follow up. However, we are aware that patients are starting to be discharged from the UHNS back to GPs with requests that follow up investigation are carried out. PCTs have been asked to stop this prior to new arrangement being put in place, although I suspect that the process is now unstoppable. I have written to the UHNS asking that this process is stopped until a system has been arranged to safely institute their follow up in primary care. It would be helpful if colleagues could let the LMC office have details of any patients who are discharged/have been discharged who require follow up.
IUCD Fitting
We have had discussions over the last few months with the PCTs over the accreditation of doctors who perform IUCD insertions. The advice we have received from the Faculty of Family Planning and Reproductive Health Care is that doctors who perform these procedures should do a minimum of 12 per year. The PCTs have, therefore, come to the conclusion that as from 1st April 07 they will not commission IUCD fittings from GPs who do not fit the required number per annum. Discussion are ongoing as to how those patients who will no longer have access to IUCD fitting at their own GP surgery will be managed. This may be via the family planning services or via another local General Practice.
Health Care Commission's Diabetes Survey
There has been considerable discussions among LMCs nationwide about the
Health Care Commission's Diabetes Survey.
Below, are summarise the key points GPs will wish to know. In particular
your attention is drawn to point 5. There are relevant posters and
leaflets available on the Healthcare Commission website if you scroll
down at:
http://www.healthcarecommission.org.uk/nationalfindings/surveys/patientsurveys/diabetessurvey/informationforpcts&approvedsurveycontractors.cfm#publicity:
1. GPs may involve themselves in the
Healthcare Commission survey looking at diabetes care as its aim is to
improve services in the public interest.
2. Those handling the patient
identifiable information must be subject to confidentiality undertakings
if they are not health professionals. We have been given assurances that
those involved have signed up to the Caldicott rules.
3. No honorary contract is necessary -
GPs should not sign the honorary contract that PCTs may have sent them.
4. All practices taking part in
disclosing patient names and addresses must keep a record of the reasons
for doing so.
5. All practices should make it clear in
their surgeries through leaflets and posters exactly how patient
information is being utilised. This is good practice, irrespective of
whether or not the practice is taking part in the Healthcare Commission
survey.
Fair processing means that practices
should do all that is reasonable in the circumstances to ensure that
patients are aware of what is happening to their information and even in
certain circumstances, contact those patients directly for consent where
it is not unreasonable to be expected to do so. (see 6.)
6. If a practice has only a handful of
diabetic patients and it is relatively easy to contact those patients to
inform them of the disclosure, then the practice should do so. GMC
guidance could be interpreted that consent is sought from all patients.
However the legal position allows some flexibility around what is
reasonable. All practices should be aware of the joint Department of
Health and General Practitioners Committee Code of Practice on
Confidentiality and Disclosure which can be found at:
http://www.bma.org.uk/ap.nsf/Content/codepractice?OpenDocument&Highlight=2,Code,Confidentiality
7. Section 60 of the Health and Social
Care Act is usually reserved for drastic or emergency cases and in the
light of the interpretation of the DPA, should not be applied here.
GP Workload Survey
Around 4000 GP practices across the UK are to be sent a survey by the Information Centre for Health and Social Care's Technical Steering Committee. The survey will take place in two phases in September and December and aims to collect information on the distribution of work for all the different groups of staff in general practice. Participation staff will be asked to complete a short questionnaire and a diary sheet to record the amounts of time spent on different activities at the practice for one week. The survey is being undertaken on behalf of the BMA, NHS employers and the Department of Health. It is important that any practice asked to take part in this survey agrees to do so. The information obtained from this survey will be used as evidence for future funding of general practice.
Choose and Book/Outpatient referral targets
The "Choose and Book" systems and the impact of outpatient wait targets has resulted in a number of concerns for local GPs. These were discussed with Kay Breen at the July LMC meeting. Although some of the issues are now a little clearer the situation is far from satisfactory and will no doubt continue to give rise to difficulties due to misunderstanding and frustrations both in primary and secondary care.
We were informed that should a patient need re-referral to a specific consultant for a condition for which they had previously been treated, then this should be done by a paper referral direct to the consultant. In these cases the patients does not have "choice" of provider, but this is a clinical decision and can be justified. If the patient wishes to see a different consultant then the referral should be made via the C & B system.
The problems with cardiology clinics at the University Hospital not being available via the Choose and Book systems was also discussed. This is not a problem attributable to C & B, but a result of the UHNS not being able to meet the target wait times for this speciality. We were told that patients can still choose to attend the UHNS and wait more than the target time, however the mechanism for doing this is unclear. It is not acceptable for GPs to create extra work for their practices by holding onto referrals until these slots become available. Fortunately having raised the issue with the PCTs, the UHNS is now again offering appointments in cardiology.
Another major concern of some local GPs is the use of "Clinical Assessment Services" to triage referrals and direct patient to what the PCT feels is the most cost efficient and appropriate service. The committee was divided in its view of these services. Whilst there is sympathy for the GP who finds that his referral to a local consultant ends up with a GPSI, there is also a view that we do not necessarily know all the services which are now available and that in these days of dire financial crisis we should make every effort to use the most cost efficient service. GPs do have an ability to refer direct to consultants but if doing so must be aware of the financial consequences. The committee has asked that the Clinical Assessment Services improve their communication back to the GPs about their decisions on referrals. It would also be helpful if the PCT made available detailed information on services, perhaps on their websites.
GPs are reminded to ensure that enough detail is given in referral letters to enable referrals to be triaged to the appropriate provider. Some concern has recently been raised regarding the poor quality of some referral letters.
Rheumatology Monitoring Path Lab Reports
Practices will now be receiving copies of blood results performed as part of the monitoring of patients by the Rheumatology Clinics. These should be clearly marked "Rheumatology Monitor". We have been assured by the Rheumatologists that they will act upon any abnormal results, however, they appreciate that GPs receiving these results may also feel that they have to act on abnormal results. Please do not alter any rheumatology prescription without liaison with the department. Colleagues who wish to check that any abnormal results have been received by the department and that appropriate action is being taken, can contact the Rheumatology Monitoring Clinic on 556283. Please note that because results are transmitted download the lablinks system we may receive the result before the clinic.
Targeted Insurance Reports
The BMA's Professional Fees Committee (PFC) has been informed by the Association of British Insurers of their intention to introduce targeted reports and are aware that the reports are being piloted. The PFC has received a number of queries recently, indicating that they are now in wider use. The Committee has not supported the introduction of these targeted reports, and therefore there is no fee agreement with the ABI. Whilst the BMA-ABI agreement remains in place for the GP and supplementary reports, PFC would suggest that doctors charge at their own rate for undertaking targeted reports - although, there is no obligation on the doctor to undertake the work.
Copyright and the DoH
You may be aware that the NHS Executive has not renewed its central copying licence this year with the Copyright Licensing Agency (CLA). For several years, the DoH purchased a licence from the CLA to enable staff to make and share copies from books, magazines and journals more freely than they otherwise would have been able to. This licence covered the whole of the NHS and cost the DoH in the region of only £2.4M per annum.
However, due to greater use of digital material, concerns about the value which the NHS was obtaining for the licence and pressure on budgets, the DoH decided not to renew this licence when its term expired in March 2006.
The copyright law will be breached if anyone
 | takes more than a single copy of any document or circulates it to colleagues and to journal clubs or other circulation list; |
| copies two or more articles from a single magazine or journal; |
| requests copies from libraries without following the administrative requirements required by law; |
| circulates copies of copyright material received from document suppliers or press cuttings agencies; |
| uses copies of copyright materials in training packs; |
| sends copies of copyright material to patients and their carers and to members of Designated Committees; |
| scans and emails extracts of copyright material. |
GPC News Items
Contract negotiations update
Discussions on stage 2 of the GMS contract review, intended for implementation in April 2007, have continued over the past few months. A meeting was held between NHS Employers and GPC negotiators on 13 July 2006.
The GPC entered this round of negotiations with a clear mandate from the LMC Conference about what the profession expected and what it would not accept for 2007/08. The GPC has consistently taken the approach that any deal for 2007/08 must include, as an absolute minimum, an inflationary rise to the contract. It has been made clear that any further release of QOF points for replacement with harder work, or any attempt to erode MPIG by awarding inflationary rises only to practices with no correction factors would be unacceptable.
The GPC has also pressed for negotiation of an expanding practice allowance, a variety of premises issues, revised payments for temporary residents, mechanisms to ensure the continuation of a UK contract and timely implementation of the survey of PCOs on discretionary payments as agreed last year.
Whilst discussions have been held on some of these issues, the search for mutually acceptable solutions is proving a challenge. The GPC has remained firm that the agreement reached for 2006/07 dealt with the perceived value for money issues associated with the 2003 nGMS deal and has resisted any further significant concessions. Negotiations are at a difficult and delicate stage.
IM&T update
Document Management Systems (DMS)
As part of the GP2GP project, some third party document management systems are currently unable to extract and pass on scanned documents in electronic format. As a result, practices are having to send paper copies. We are working with third party suppliers to ensure that this is resolved and practices are able to transfer these documents along with the core clinical record. We are recommending to CfH that DMS should be considered as ‘core’ GP IT systems and that controlled implementation of GP2GP should begin.
QOF Assessor Toolkit Apollo Software
The GPC IT team has recently reviewed the QOF assessor toolkit software. Some LMCs and GPs have expressed concern about patient identifiable data leaving practices. We have confirmed this is not the case and LMCs and GPs can be reassured that the software is safe to use.
QMAS/QOF coding
LMCs have reported a number of QMAS/QOF coding and business ruleset problems. These have been forwarded to the NHS Confederation and we are awaiting a response.
Practice IT funding
We are not aware of any PCTs refusing to fund core practice IT equipment at the moment but would be happy to deal with any brought to the attention of the secretariat (arivett@bma.org.uk).
Guidance on sending electronic attachments
Guidance on issues regarding sending attachments to GP records in electronic form can be found here.
CMO’s report
Last month the CMO published a major review of medical regulation, prompted by the Shipman inquiry. The document Good doctors, safer patients contains 44 recommendations including proposed devolution of some of the GMC’s powers to a local level and the creation of a new framework for revalidation. It can be found online at www.dh.gov.uk/assetRoot/04/13/70/78/04137078.pdf
This review is clearly of great interest to the profession and the BMA will be submitting a detailed response to the recommendations. The document will be discussed in detail at the September meeting of the GPC and given careful consideration by relevant GPC subcommittees.
Good Medical Practice
The GPC has contributed to a BMA response to four pieces of supplementary guidance recently published by the GMC:
1. raising concerns about patient safety
2. maintaining boundaries
3. reporting convictions
4. conflicts of interest.
This guidance is available on the GMC website www.e-consultation.net/gmc/.
GP trainers' grant
For some time the GPC has been seeking a review of the GP trainers' grant. We are therefore pleased that an initial review has now been conducted by the Department of Health, involving BMA representation. Further research is also required, and we hope that this will be conducted in time for this to be considered by the Doctors and Dentists Review Body.
We will continue to push for an increase in the level of remuneration for GP training practices in order to reflect, for example, the level of commitment required, the continuing professional development costs, premises costs and administration costs.
Performing rights licences
GPs should remember that they need a performing rights licence to have radio or television on in their practice. These licences are not expensive and are simple to obtain from the Performing Right Society www.prs.co.uk (phone 0800 0684828).
Pneumococcal vaccinations in childhood immunisations
Details of the agreement reached with NHS Employers on the introduction of the pneumococcal vaccination in the childhood immunisation programme have been published by the CMO. GPs will be remunerated £15.02 per child for the delivery of the pneumococcal vaccinations and the additional vaccination visit at 12 months to deliver the combined Hib and Men C vaccine. Payment for the catch-up programme will be £7.51 per vaccination. This will be introduced on 4 September 2006. Further details of the changes can be found on the CMO’s section of the Department of Health website.
Flu pandemic planning
Following the release of a practical guide on infection control to help GP practices plan for and respond to the threat of pandemic flu, produced by the joint RCGP/GPC Emergency Planning Group, the GPC is continuing work to ensure that, should a pandemic arise, practices are clear what policies and procedures are in place. Issues raised include prescribing and availability of anti-viral drugs, availability and effectiveness of flu vaccines, repeat prescribing and dispensing of regular medication, indemnity for GPs following government directives and the protection of GP income.
We have raised these issues with NHS Employers, with view to reaching agreements particularly around GP terms and conditions of service, and also with the various Emergency Planning Committees that are in existence to formulate such plans. Peter Holden has been attending these on behalf of the GPC and throughout has been insistent that all such strategies should be UK wide.
Flu vaccine shortage
Practices should all now have received the letter from the CMO warning of a potential delay, and even shortage, of flu vaccines this winter. This is the result of a manufacturing problem that is affecting all vaccine suppliers. It is a problem faced by Europe and America and is due to the difficulty in manufacturing a particular component strain of the vaccine. We have been in discussion with the Department of Health about this, and they agreed to provide warning of the potential problem as early as possible to enable practices to make appropriate plans. We will not know until the end of July the full manufacturing picture. The Department has promised to keep us informed and discuss the situation with us and we, in turn, will pass any information on to you as soon as we have it.