NEWSLETTER DECEMBER 2004
The Shipman Inquiry – Fifth report
Alternative Provider Medical Services
Treating patients out of the core hours period
Editorial
This year has been very busy with the introduction of the New Contract. It is disappointing that it has not really addressed the issue of workload. Indeed, with the introduction of the quality framework the workload has no doubt increased. It has given GPs the option to say no to some work, but this often runs against the ethos of General Practice, where we try to do the best for our individual patients and in general put their needs first. Hopefully next year we will begin to reap the financial rewards with the "achievement" payments. Whether his will improve recruitment into General Practice remains to be seen. General Practice does have a lot to offer in terms of job satisfaction and working environment, but I feel we are still fighting a uphill struggle to sell our speciality to young doctors and undergraduates.
Next year will bring some challenges too, with the implementation of "Agenda for Change" and "Practice Based Commissioning". The first will see the restructuring of the pay structure of our management, administrative and nursing staff, whilst PBC will give us the opportunity to becoming involved in the commissioning process and perhaps influence the commissioning of services via primary care rather than secondary. The introduction of "Payment by Results" in the secondary care sector will be a driving force to encourage PCT to support this shift.
I wish you all a Happy Christmas and a Prosperous New Year.
Ambulance Service
Following the recent problems GPs experienced with arranging ambulance transport, Paul Scott has worked on our behalf with the Emergency Care Network Board to produce some changes to the system to help alleviate some of the problems. A document which sets out the detail and has been approved by the relevant Chief Executives has been circulated to practices. The main changes are in a flexible range of hourly time limits from immediate 999 to 2, 3, 4, 5 or 6 hours. Urgent ambulance pick up can be arranged and has been agreed through liaison with UHNS and Staffs. Ambulance Trusts. This especially allows the MAU to manage their twin flows of patients from GPs and A+E transfers. Please note that if a patient needs to be in hospital within less than two hours, then an immediate 999 response is required. There will no longer be segregation of calls into emergency and doctors' urgents.
Smoking Cessation
Negotiations with the PCTs on the future funding of this service are nearing completion. The service will be commissioned on a sessional basis with practices expected to see a defined number of new and follow up patients in each session. The number of sessions will be commissioned on an annual basis and practices will be free to arrange sessions in the way they feel to be most appropriate, e.g. they may wish to provide more of their sessions immediately after the New Year and perhaps less in August. This system will have the advantage of being more cost effective for practices and PCTs will have the benefit of better budgetary control. If demand for the service exceeds the number of sessions offered in a practice, then referral to another provider, e.g. the pharmacy led service or the creation of a waiting list may be appropriate. Subject to approval of the scheme at PCT board level and acceptance by practices, the new system should be implemented in April 2005
Neonatal Checks
The committee agreed at the start of the New Contract that these would be included in the "basket" of services for the first six months of the contract. The original plan was that PCTs would assess whether there is a clinical need for such checks and would commission either secondary care or community midwives to perform these examinations. As we have previous reported this plan ran into delays in training midwives and we agreed reluctantly to extend the period for performing these examinations to December 31st. PCTs have still not managed to finalise arrangements for the transfer of this work. They have agreed that from 1st January they will pay an item of service fee for GPs to perform these examination when they have not been perform prior to the mother and baby being discharged from hospital. Staffordshire Moorlands and Newcastle PCT do have some community midwives who are qualified to perform neonatal checks and practices can refer to these if they wish to do so and they are available. The fee for doing this work will be based on the fee scale suggested in the Intrapartum Care National Enhanced Service documentation of £50 with appropriate uplifts applied . It is unlikely that the final documentation for claiming these fees will be available by 1st January. Colleagues are, therefore, asked to continue to provide this service and PCTs will honour payment in due course.
IT
The committee has been concerned at the level of service provided by PCTs in replacing broken down IT equipment. There have been considerable delays in obtaining replacement PCs, monitors etc. Such equipment is of vital importance to the running of practices and we cannot function without adequate IT support. This matter has been raised with the PCT and we are pleased to report that South Stoke PCT has introduce a system whereby a store of essential IT kit is held centrally for immediate use should a practice experience a problem with its IT equipment. This equipment may either be used to replace essential items or used on a temporary basis whilst repair of the original item is undertaken. The three other PCTs in North Staffordshire have agreed to introduce the same system in their areas.
Agenda for Change
Agenda for Change aims to provide a career and pay structure for
nurses that will reward and therefore encourage them to choose to remain
in nursing. At the same time, nurses will be appropriately rewarded for
enhancing their skills and knowledge so that patient services can be
improved. The RCN and GPC wish to advise GPs that while they have the
choice on whether or not they implement Agenda for Change they will be
competing for a shrinking number of nurses who, in the
future may be better rewarded in their local NHS organisation. Agenda
for Change replaces the current Clinical Grading and Whitley terms and
conditions systems, which many GPs currently use as the basis for
employing nurses. Come December 2004, Clinical Grading will no longer be
used within the NHS and as such GPs, as employers will need to consider
alternative mechanisms on which to base the rewards for practice staff.
It is therefore timely for GPs to look at the terms and conditions of
their practice nurses, consider the benefits to them and their practices
that Agenda for Change will bring and agree with their staff on the best
possible way forward.
A copy of the joint letter from the GPC and RCN concerning this can be found here.
Practice Based Commissioning
Practice based commissioning is a new, currently England only, initiative and the Government’s proposals set out that from April 2005, all practices/groups of practices will have the right to receive a firm indicative budget from the PCT at any stage in-year and thereafter. The Department of Health’s paper is intentionally non-prescriptive and states the Government’s wish to see early experience of the scheme informing its later development. The GPC's guidance on this scheme can be found here.
Freedom of Information Act
The Freedom of Information Act 2000, which came about as a result of one of the major commitments in the Labour Party’s 1997 manifesto, creates new rights of public access to information held by public authorities, as defined under the Act. The Act specifically defines GPs as public authorities. The Information Commissioner, who regulates the Act, has ruled that GPs may act co-operatively within their practice structure to discharge their obligations under the Act. From January 2005, the Act will oblige each practice to respond to requests about the information that they hold and have recorded in any form and will create a right of access to that information. The GPC has produced further guidance about this act which can be found here The model publication scheme for general practitioners from the information commissioners website can be found here.
GPC News Items
The Shipman Inquiry – Fifth report
The GPC has discussed the Shipman Inquiry’s Fifth Report – "Safeguarding Patients: Lessons from the Past – Proposals for the Future". Concerns raised ranged about from the general negative tone of the document to the specific recommendations. It was felt unfortunate that there had not been greater input from patient groups other than those directly affected by Shipman and from the current working members of the GMC fitness to practise panels.
While many of the recommendations were viewed as a continuing development of good working practice, there was also concern that some showed misunderstanding of primary care realities.
The GPC has long been calling for the introduction of individual prescribing numbers for all GPs and this recommendation was welcomed. The committee also supported single handed practitioners getting the support they needed. There was general, if not qualified, support for the recommendation of mortality monitoring. However, in other areas, it was felt that the capacity of PCOs was over estimated.
The recommendations relating to the complaints system met with concern, as they appeared to move away from recent moves to ensure that complaints were resolved locally wherever possible without the need to involve PCTs.
There was general concern about the possibility of altering the appraisal and revalidation system at this point in time and the committee decided that an evolutionary approach was preferable.
Overall it was recognised that how the government responds to the report will be very important, and the GPC response needed to be measured and proportionate. The GPC will be in discussion with the RCGP, GMC and patient groups about the way forward. The statutes and regulations subcommittee, the prescribing subcommittee and the education and professional development subcommittee will look at recommendations most pertinent to them and the negotiators would take forward the GMC issues. The BMA as a whole is likely to respond to a tranche of the recommendations as changes to the GMC and appraisal and revalidation process would be likely to affect all doctors. The GPC’s response will draw particular attention to those issues that will have the greatest impact on the workings of and recruitment into general practice.
A summary of the report can be found here
Alternative Provider Medical Services (APMS)
PCOs can enter APMS (health board primary medical services in Scotland) contracts with any individual or organisation that meets the provider conditions set out in the Directions (please see below). These individuals/organisations include the:
 | Independent sector |
| Voluntary sector |
| Not-for-profit organisations |
| NHS trusts (in England & Wales) |
| Other PCOs |
| Foundation trusts (in England & Wales) |
| GMS/PMS |
There are two main areas of possible impact on general practice as a result of the promotion of APMS:
a) It further encourages any member of the private/voluntary sector (e.g. not GMS or PMS contractors) to bid for enhanced services and thus increases the fragmentation of general practice
b) It opens up the provision of essential services to providers other than GMS and/or PMS practices, although it is anticipated that APMS will be used initially for specialised clinical services such as additional/enhanced/OOH services
The areas of risk relating to enhanced services are not wholly unfamiliar to GPs following the introduction of enhanced services under the new contract. However, those relating to essential services require further consideration.
Treating patients out of the core hours period
We have received reports that some GPs are unclear as to whether or not they can treat their patients out of the core hours period if they are no longer responsible for their patients’ out-of-hours care. The core hours period runs from Monday to Friday, 8.00am-6.30pm, but there is nothing to stop a practice that has opted out of out-of-hours work to run an evening or Saturday morning surgery if they wish to do so.
Is jury service proving a problem issue for GPs?
At the last meeting of the statutes and regulations subcommittee the issue of jury service was raised. Discussion focussed on whether it was becoming a problem for GPs to serve on juries due to either the cost of providing a locum, or owing to the stringent guidelines making it difficult for GPs to defer their service.
Given that the first ten days of jury service are reimbursed at a rate of up to £52.63 per day to cover loss of earnings (rising to up to £105.28 thereafter), the loss to a practice could be considerable. Doctors were exempt from jury service until 2 April this year, when major changes to the Criminal Justice Act came into force..
If you have any feedback regarding this issue please email Anna-Marie Davis: adavis@bma.org.uk.
Choose and Book
The GPC has prepared a guidance note on Choose and Book. This can be found here
Paul Golik
Secretary
North Staffs LMC