NEWSLETTER DECEMBER 2002
Child and Adolescent Mental Health Services
GPC negotiations bulletin: latest edition
Advice on out-of-hours implementation: update
Editorial
As the New Year approaches GPs face an uncertain time. Will the “New Contract” deliver on its promises, should we move over to a PMS contract, how will we cope with the decreasing workforce and increasing bureaucracy and workload? On the positive side the New Contract should bring new opportunities for primary care. Not least among these will be the freedom from PCT control of the majority of our funding. When we are again showing forecasts of underspending on GMS budgets to the tune of £230,000 in Stoke on Trent it is clear that PCTs have failed general practice. They are being manipulated entirely by Government agenda, financial constraints and secondary care. Primary Care is again being starved of funds to enable PCTs to balance their books at the year-end. It is regretable that this is done in a covert way and PCTs refuse to come clean on this.
New Contract
This will be published in January and the GPC will be holding a series of "Roadshows" prior to a ballot being taken during February. The result of this should be know in March with implementation of the majority of the contract from April 2003 if accepted. This is an extremely tight timetable. The GPC have agreed to hold one of these "Roadshows" in Staffordshire. This will be held at Stoke Town hall on 30th January. More details later. There will also be an opportunity to discuss the "New Contract" in a more informal setting on Tuesday 28th January at 1.00pm at Britannia Stadium.
The pricing of the New Contract will be crucial to its acceptance or rejection. Practices will need to compare their forecast earning under the New Contract with their current situation. You are advised to collect information concerning this in the near future. You will require details of all directly reimbursed income and of items paid on your behalf by the PCT (e.g. rates, water rates etc) as well as sums paid directly to the practice. The GPC is planning to produce a "ready reckoner" to enable practice to forecast potential earnings under the contract.
Violent Patients
The PCTs have been given a deadline of 31 January 2003 to have agreements with local providers that ensure that all GPs are able to refer to, or have access to a secure facility for the treatment of violent patients. Progress on this in North Staffordshire is slow. An Action Plan has been drawn up and the police have been approached with regard to providing secure facilities within police stations. The action plan also includes provision for the training of GPs and their staff on issues relating to violent patients.
Colleagues are also reminded of the importance of informing their PCT when patients are removed following violent or aggressive behaviour whether physical or verbal. Unless this action is taken the PCTs cannot pass on warnings to the patient’s future GPs. The PCTs have very little evidence of episodes of violence in general practice and practices are urged to report all incidents to their PCT in writing.
GMS Underspends
The committee has learnt that the underspend forecast by the Stoke on Trent PCTs on GMS budgets amounts to a massive £230,000. This is totally unacceptable. PCTs have control of these budgets and are failing in their duty to ensure that primary care receives the funds designated to it. Last year we received promises that the underspends would not occur once PCTs were established, yet we have the same situation again. Time and time again when General Practitioners suggest areas for investment e.g. for asylum seekers and nursing homes, we are told that the money is not available. We would like to hear from any practice, which has been refused investment and would ask practices to put in bids against these funds. Newcastle and Moorlands PCTs have not so far responded to our request for this information.
Child and Adolescent Mental Health Services
We have recently met with Dr Jonathan Lovatt who is the clinical lead for the CAMHS. There are currently three teams providing a service in North Staffordshire. Dr Lovatt at Newcastle (for Newcastle PCT), Dr Dover at Blurton (for Stoke South PCT) and Dr Katwala at Abbey Hulton (for Stoke North and Moorlands PCTs). It is hoped that a separate team will be established in the Moorlands in the near future. The inpatient service at Wall Lane House, Cheddleton is operated primarily as a tertiary service and all referrals should initially go through the CAMHS teams. We discussed difficulties colleagues have been having with the insistence on the completion of referral proforma and with the refusal of some referrals. Dr Lovatt has confirmed that a referral letter is acceptable to the service as long as the significant clinical detail is given. He has also agreed that if the team feels that a referral is inappropriate, a telephone discussion with the referrer should take place to discuss the problem and provide a mutually acceptable way forward.
The service is in the process of establishing a Joint Operational Policy for the whole of North Staffordshire and is reviewing all practices and procedures. The current referral proforma will be reviewed and hopefully re-drafted to be more concise. They also intend to produce information leaflets for referrers and patients, advising them of the remit of the service. Each CAMHS team now has a Primary Mental Health Care Worker who should be available for referrals and who can work with Health Visitors to make further assessments of problems.
Ritalin
Shared care guidelines for the treatment of patients with Ritalin have been drawn up locally. According to these the GP is expected to regular monitor the height, weight, blood pressure and heart rate of the child. Secondary care, give workload issues as the driving force behind these guidelines. Colleagues should consider their own workload issues before agreeing to take on this extra work. You are under no obligation to take on this extra work. We have informed the Child and Adolescent Mental Health Service of our own workload issues and imminent manpower crisis.
Psychosexual Service
We have recently had discussions with the Trust and PCTs on this. Currently there is no NHS provision of psychosexual counselling following the retirement of the doctors who provided the service. The service had been provided on an ad hoc basis and was not formally funded. Consultation is to take place on the future provision of the service and its relationship with "Relate" and the erectile dysfunction service. Dr Paul Scott will be representing the LMC on this issue.
Termination of Pregnancies
The surgical side service is currently being provided by a private clinic in Stockport. This arrangement was put in place because of the pressure on beds and gynaecological surgical services at the City General Hospital. It is recognised that there are problems with these arrangements and plans are being drawn up to bring the service back to the City General Hospital. This may have to wait until extra theatre capacity is introduced in 2004. The plan is for the operations to be performed on a Friday evening and Saturday morning. The pre-op counselling service may be provided in community clinics. Doctors who do not wish to sign the "Blue Form" are reminded that patients can also access the NHS service via the Family Planning Clinics although arrangements should be in place for both parts of the form to be signed in secondary care.
Medication Review Guide
The Medicines Partnership and Medicines Management Services have produced a new briefing and guide to medication review. It focuses on the practice of medication review in primary care, with the needs of older people and people with long term conditions particularly in mind. It is hoped that the guide can support health professionals, managers and patients to improve medication review by:
· Proposing a common set of definitions and principals for medication review
· Suggesting standard ways to record different models of review
· Disseminating good practice through practical case study examples
· Providing a website with a range of useful tools and materials for practitioners and patients
· Offering ideas about how the skills of a range of health professionals can be deployed to make resource issues more manageable.
The briefing, guide and tools are all available for viewing and downloading from www.medicines-partnership.org/medication-review.
Blue Badge Claim Forms
Colleagues continue to have problems with these. I have recently received an application with a photocopied claim form and hopefully the Social Service Department have agreed that we should not be financially penalised for their inefficiencies.
Workload Issues
Following our correspondence with the Defence Organisations, we have taken the advice of the MPS and written to all PCT Chief Executives with our concerns and suggestion. A copy of this letter can be found here.
Good Medical Practice
The General Practitioners Committee and the Royal College of General Practitioners have jointly produced the document "Good Medical Practice for General Practitioners". This sets out the standards for revalidation of GPs and has the support of the GMC. Starting from the GMC's "Good Medical Practice" the document describes why each particular aspect of care is important for GPs. These are described under seven broad headings of:
· Good clinical care
· Maintaining good medical practice
· Relationships with patients
· Working with colleagues
· Teaching and training, appraising and assessing
· Probity
· Health and the performance of other doctors
No GP can be expected to provide an "excellent" standard of care all the time, but the excellent GP will meet the "excellent GP" criteria all or nearly all of the time; a good GP will meet most of the "excellent GP" criteria most of the time and a poor GP will consistently or frequently provide care described by the "unacceptable GP" criteria. Revalidation aims to ensure that all GPs are working to an acceptable minimum standard. It is recognised that all GPs will, on occasion, provide care that may appear to be unacceptable by these standards. Except under the most unusual circumstances, only those GPs whose care falls consistently or frequently below the standards expected will be at risk of failing revalidation.
Colleagues are advised to familiarise themselves with this publication which was circulated to all in October. Further details on revalidation can be found at http://www.revalidationuk.info.
Student Health and Conduct
The GMC has produced a revised version of "Student Health and Conduct". A copy of this document can be found on their website at www.gmc-uk.org. This document was first published in 1997, the revised version is shorter and concentrates on areas where the GMC has statutory responsibilities. It sets out the respective responsibilities of medical schools, medical students and doctors who work with them. "Student Health and Conduct" should be read in conjunction with "Tomorrow's Doctors" and will be incorporated into that document at the next print run in 2003.
Help Wanted
We are looking for a new venue for the LMC meetings. The boardroom in Heron House where meetings are currently held is soon to be converted into offices. We need a venue which has room for a meeting of about 20 - 30 people and is available on the afternoon of the second Thursday of the month. Any suggestions to LMC office.
Website
A reminder about the LMC website which can be found at www.northstaffslmc.co.uk. I aim to keep this a simple useful site and you will not find sophisticated graphics and animation which take a long time to download. All newsletters from March 2001 can be found on the site together with other useful documents produced by the LMC and links to local and national sites which may be of interest. Items are posted on the website, in the latest news section, prior to their collation and publication in the newsletter. Please visit the site regularly to be kept up to date.
Items from the GPC
GP contract negotiations
At the last GPC meeting, the negotiators gave the committee some detail on the work of each of the contract working groups. Since then progress has been made in a number of areas, including the criteria for standards in the quality and outcomes framework; support for remote and rural GPs; ending enforced patient allocations; the shape of the allocation formula; and demand management proposals. However, there are other areas where progress has been delayed.
It was intended that a joint letter from the GPC and the NHS Confederation negotiating teams should be sent to PCOs, and copied to LMCs, on preparations that could be undertaken now, ahead of implementation from April 2003 should the new contract be accepted by the profession. Unfortunately, the Departments of Health have held up the letter. The Departments are keen that this letter is issued with details of the support available to PCOs in managing the new contract; it is the latter which is still the subject of discussion. Both teams are disappointed at this lack of progress and appreciate the difficulties this is causing at local level. It is anticipated that a letter will shortly be sent to PCOs.
One of the main difficulties at present is the lack of immediately available data on practices' current resources, including gross fees and allowances and direct reimbursements of staff costs. Until this information is available it is not possible to cost and price the new contract or devise a suitable transitional scheme, and practices would not be able to compare their current and possible future resources. It is recognised this is essential if colleagues are to make an informed choice in the ballot on the final contract. The urgency of resolving this matter and the unacceptability of any avoidable delay have been impressed upon the Departments.
It is the negotiators' belief that much of the contract, at least on an interim basis, could be implemented via secondary legislation by April 2003. However, the Department of Health, which is the agent responsible for instructing parliamentary draftsmen, believes that primary legislation would be required to effect substantial implementation. There have been discussions with the Department's lawyers to ensure that as much of the contract as possible could be implemented through secondary legislation. Both negotiating teams are taking all necessary steps to facilitate progress and both sides share the ambition to implement as much as possible on 1 April 2003.
A meeting with Ministers has been sought to impress upon them the gravity of the situation. At its meeting yesterday, the GPC wished 'to make it clear to the Government that any delay in implementation of a substantial part of an agreed new contract beyond 1 April 2003 is unacceptable. Such delay will lead to a further disastrous collapse in morale amongst general practitioners and their practice teams, and to irrevocable damage to the fabric of the NHS.'
GPC negotiations bulletin: latest edition
The November 2002 edition of the GPC negotiations bulletin can be found on the GPC web pages. This provides an update on negotiations with the Health Departments.
Advice on out-of-hours implementation: update
With the last GPC news, the GPC secretariat issued a question and answer sheet on the out-of-hours implementation regulations. This was based on information received from the Department of Health. However, this advice was subsequently challenged and legal advice on the DoH's information was therefore sought.
The current situation is that the DoH is now being consulted again on the basis of the legal advice and the DoH's response is awaited. Chasers have been sent to the DoH to remind them of the urgency of this.
The aim is for a revised Q & A sheet to be sent out as soon as possible.
Non-principals' pensions
Many GP locums are still unable to contribute to the NHS pension scheme. Despite initial reassurances that all locum work would be superannuable, locum GPs have to be "exclusively" self-employed in order to contribute. NHS Pensions Agency rules currently prevent GPs who are employed, no matter how minor their sessional work, whether as a non-principal or as a principal, from superannuating their locum work. The major reason cited for this is 'gaming' – the perceived ability for GPs to do locum sessions for one another and claim inappropriately. The GPC does not believe that there is any evidence of this practice and strongly objects to the implication of a lack of probity amongst non-principals.
The principle of additional pay for additional work and responsibility, whatever the contractual status, has long been established within the NHS. The GPC feels that the government has reneged on its original commitment to bring all locums into the NHS pensions scheme and will continue to press for full pension rights for all salaried GPs.
Weekly prescriptions
The Prescribing Subcommittee discussed the increasingly frequent problem of patients asking for weekly scripts as pharmacists press for them for remuneration for the filling of dosette boxes. While it was accepted that GPs can find themselves in a difficult position when the patient is sitting in front of them, this is nevertheless a pharmacy problem. The Prescribing Subcommittee does not sanction doctors giving seven-day scripts except when clinically necessary (ie to give more tablets would be a danger to the patient through possible self harm).
Specialised appliances
The Prescribing Subcommittee looked at the issue of specialised appliances being supplied to patients directly by manufacturers and the relevant company then asking the doctor for the corresponding FP10 to be sent to them. It was recognised that appliance therapists have expert knowledge and can advise the patient appropriately. However, the prescription should go first to the patient, who can then take it to whoever they want for supply. Doctors should ensure that a mechanism is in place where pharmacy contractors can only give out appliances with an FP10 in hand except for emergency situations.
DDA guidelines
It was brought to the attention of the Rural Practice Subcommittee that the Dispensing Doctors' Association's revised guidelines – Quality in practice, clinical guidelines 2002 could be used by regulatory bodies to judge the practice of doctors. There is evidence that this is already happening. In light of this, the subcommittee would advise doctors (both dispensing and prescribing) to give the guidelines consideration. Parts of the guidelines – including those relating to controlled drugs - can be accessed on the DDA website at: www.dispensingdoctor.org. For a full set please ring the DDA on 01751 430192.
Dr P Golik
Secretary