NEWSLETTER DECEMBER 2005
Reconfiguration of the Health Service
PMS contracts and superannuation funding
IT Service Level Agreement (SLA)
GPC practice based commissioning (PBC) guidance
Annual certificate of pensionable earnings
Your Health, Your Care, Your Say
Nurse and pharmacist prescribing
Practice based commissioning (PBC)
Firearms and shotgun certificates
Editorial
At the close of 2005 the local health economy finds itself in the worst financial crisis ever. We are under increasing pressure to take actions to help balance PCT budgets. No doubt this pressure will intensify in the coming month. Whilst we may be sympathetic to the PCT’s plight and can take some action to help, we must remember our contractual duty to provide services to patients. We should not put ourselves in a position were we may be accused to failing to comply with our contract by failing to appropriately refer or treat a patient. It is likely that next April will see some hard bargaining with PCT over Locally Enhanced Services and we will need to take a firm stance on the principal of the “New Contract” that all work we undertake must be adequately resourced.
Last year, I identified Agenda for Change and Practice Based Commissioning has particular challenges for this year. Neither seems to have moved very far during the course of the year and they remain challenges for the coming year. Practice based commissioning will only succeed if GPs are signed up to the principals and if start up and running costs are adequately resourced; One has to hope that it is more successful than the current PCT led structure.
Next year will see the re-configuration of PCTs. It is important that GPs make their views on the re-configuration known to the Strategic Health Authority. Although the current configuration is just beginning to be effective in some areas, it has not been an overwhelming success particularly on the financial front. We now need a structure which will work best for North Staffordshire.
Finally details are just beginning to emerge about the Contract Review negotiations, which can be summed up as no more money without more work. There is to be no increase in the Global Sum and no increase in the value of QOF points. There will be some redistribution of points from the non-clinical domains to new clinical domains, i.e. more work needed to obtain the same number of points. New Directly Enhanced Services are to be introduced for Choose and Book, Practice Based Commissioning, IM & T. and access. The document from NHS Employers giving details of the changes can be found here.
I wish you all a Happy Christmas and a Prosperous New Year.
Reconfiguration of the Health Service
The Department of Health has published its consultation documents on the reconfiguration of Primary Care Trusts, Strategic Health Authorities and Ambulance Services. Consultation takes place from 14th December to 22nd March.
Strategic Health Authority
This consultation relates a change to organisational boundaries and does not include any proposals for service change. The proposal being consulted on is to bring together Birmingham and The Black Country SHA, Shropshire and Staffordshire SHA and West Midlands South SHA to establish one SHA for the West Midlands which is coterminous with the Government Office of the Region.
The consultation document can be found here.
Ambulance Service
This document sets out a proposal to establish eleven ambulance trusts across England.
For the West Midlands it is considered that the optimum configuration to achieve this national proposal would be for the current four ambulance trusts (Staffordshire; Coventry and Warwickshire; West Midlands and Shropshire; Hereford and Worcester) to be replaced by one ambulance trust covering the whole of the West Midlands. The consultation document can be found here
Primary Care Trusts
This consultation relates a change to organisational boundaries and does not include any proposals for service change. Consultation is on two proposals:
Option 1 to create four PCTs:
Bring together the current two PCTs of North Stoke PCT and South Stoke PCT to form one PCT covering Stoke City local authority area.
Bring together the current six PCTs of Cannock Chase PCT, South Western Staffordshire PCT, Burntwood, Lichfield and Tamworth PCT, East Staffordshire PCT, Staffordshire Moorlands PCT and Newcastle under Lyme PCT to form one PCT covering Staffordshire County local authority area.
The two PCTs of Shropshire County PCT and Telford & Wrekin PCT remain as currently configured.
Option 2 to create five PCTs:
Bring together the current two PCTs of North Stoke PCT and South Stoke PCT to form one PCT covering Stoke City local authority area.
Bring together the current two PCTs of Newcastle under Lyme PCT and Staffordshire Moorlands PCT to form one PCT in North Staffordshire.
Bring together the current four PCTs of Cannock Chase PCT, South Western Staffordshire PCT, Burntwood, Lichfield and Tamworth PCT, East Staffordshire PCT to form one PCT in South Staffordshire.
The two PCTs of Shropshire County PCT and Telford & Wrekin PCT remain as currently configured.
The consultation document can be found here
The LMC believes that option 2 will provide the best option for North Staffordshire but this is not the preferred option. We will be formulating a response to the consultation document early in the New Year expressing this view. Although there is support across Staffordshire for this option, it does not fit with the objective of having co-terminus boundaries across health and local authorities, it is therefore vitally important that if colleagues wish to see this option implemented, as many colleagues as possible should respond to the consultation document.
Agenda for Change
The GPC has produced guidance for practices/LMCs on Agenda for
Change. It is written as an aid to practices who may be considering
implementing AfC for their practice staff. It reiterates that practices
are not obliged to give AfC terms and pay to their practice staff and
also that there is no additional funding for this for individual
practices.
The guidance is available now on the website -
http://www.bma.org.uk/ap.nsf/Content/focusagendaforchange
Oxygen Cylinder Supply
As noted in the last newsletter, the system for the supply of domiciliary oxygen changes on 1st February. GPs will be able to order oxygen from the new supplier (Air Products) by completing a Home Oxygen Order Form (HOOF) and contacting Air Products on 0800 373500. They should respond within 4 hours if the request in urgent. FP10s issued to patient prior to 1st February 2006 will remain valid until 31st July 2006. GPs are asked to ensure that patients have sufficient cylinders to avoid them running out during the hand over period. PCTs need to identify existing patients and contact them to obtain their permission to pass their details on to Air Products. PCTs have requested practice to provide these details. Some practices have expressed reservations around confidentially with regard to this request. This was discussed with PCT Cheif executives and Local Representative Committee representatives recently and the feeling was that the GMC guideline concerning "circumstances where patients may give implied consent" would apply here. Most people understand and accept that information must be shared within the health care team in order to provide their care. If any practice is unhappy about providing patient details, then the PCT may ask the practice to contact their patients.
The October Drug Tariff has introduced a payment for 200 bar cylinders, which can be prescribed by GPs and other clinicians immediately. These cylinders will increase the capacity of existing cylinders by 50%, meaning that they will last longer before needing to be refilled. Allied Respiratory and Air Products cylinders are already approved for use at 200 bar.
The threshold at which patients should be considered for concentrators has been changed to anyone who is using oxygen for more than two hours. This change has immediate effect, and GPs and other clinicians are advised to review their prescribing practice and prescribe concentrators for patients using oxygen for more than two hours per day (providing this modality is clinically acceptable).
Cancer Referrals
In July 2005, NICE updated its guidelines on referrals for suspected cancer. We should all be familiar with and comply to these guidelines. They were sent out to all GPs earlier in the year and can be found on the NICE website at http://www.nice.org.uk/page.aspx?o=261649 As a result of these some of the criteria for referral via the 2 week wait pathway have changed. The referral proforma are currently being amended to reflect these changes and will be circulated to GP practices shortly. NICE states that primary health care professionals should use local referral proformas were these are in use. The 2 week wait proformas should not be used for patients who do not fulfil the NICE referral criteria. If a GP is seriously concerned that a patient has a malignancy but does not fall within the guideline there should be prior discussion with the appropriate consultant prior to referral.
There are other implications of the NICE guidelines particularly around giving information to patients. A group of primary care and secondary care colleagues are currently working on this and will be producing more information in the next few months.
Jury Service
Section 321 and Schedule 33 of The Criminal Justice Act 2003 came into force in England and Wales on 5 April 2004 and amended the law relating to juries. The revision of Schedule 33 of the Act means that doctors, as well as judges, lawyers, politicians, vicars, bishops and peers are eligible to sit on a jury. Previously, under the Juries Act 1974, doctors, among other groups, had the right to be excused from jury service. The new government policy was introduced to expand the pool of potential jurors to ensure that juries properly reflect the community they serve.
In July 2005, representatives of the general practitioners, senior hospital doctors and junior doctors committees attended a meeting with Her Majesty’s Courts Service to discuss doctors’ concerns about how completing jury service may affect them. These include how this may impact on waiting lists, emergency cover, service provision, significant delays in completion of undergraduate and postgraduate training, continuity of care and staff shortages – especially in the specialties. The meeting was constructive and prompted the production of guidance, which is aimed at medical practitioners who have received or may receive a jury summons. It explains the professional and financial implications serving on a jury may have, and the process of applying for deferral or discretionary excusal should this be necessary. This guidance can be found on the BMA website and here.
Items from GPC News (Dec 05)
Normalisation
The GPC considered a detailed paper from the Department of Health on the background to the normalisation errors and the steps taken to correct them. This paper will be sent to all PCTs with instructions on the process for repayment of monies to practices. These payments should be made in December or January. For practices that owe PCTs more than £2000, recovery payments will be staggered over the remaining four months of the financial year.
PMS contracts and superannuation funding
From 1 April 2004 the total funding and responsibility for pension costs was moved to the independent contractor, which included the 14% employer contributions. The additional funding needed for employer and employee superannuation contributions was transferred into PMS baselines and GMS global sum payments and through increased Quality & Outcomes Framework payments. Further information on the background of this transfer of funding can be found in the GPC guidance note ‘Focus on superannuation contributions – second update’ as follows:
www.bma.org.uk/ap.nsf/Content/FocusOnSuper0904
For many practices, the GPC is aware that the additional funding was insufficient to cover the increased costs of employer contributions fully. However for PMS practices, certain locally agreed contracts include a clause that sets out a clear obligation on the PCO to reimburse fully the 14% of superannuation contributions. The obligations on the PCO are dependent on what is stated in each locally agreed contract and, although the GPC believes that these costs should be reimbursed in full where stated, because PMS contracts are negotiated on a local basis, the Department of Health is unable to issue national guidance on this matter.
However, a successful legal challenge has been made on this issue recently and if practices, whose contracts include the appropriate clause, have firm evidence that has not been paid, this could be one such route to take. The GPC would be happy to advise on such cases.
Superannuation Payments
Two new documents have now been published on the NHSPA website
regarding the Revised GP Annual Certificate and the Tax status of
employer contributions. These will be of interest to your accountant.
http://www.nhspa.gov.uk/HMRC_IssueWebNotice.doc
http://www.nhspa.gov.uk/HMRC_RULING_IMPACT_ON_CONTS_AND_GP_CERT.doc
The new certificate and completion guidance notes are available here
http://www.nhspa.gov.uk/GPCompletionForms.cfm
Any queries received from accountants should be referred to these
documents first and then to the NHSPA for any unanswered questions.
IT Service Level Agreement (SLA)
The GPC discussed the latest draft of the SLA which has been redrafted by the Department of Health’s lawyers. Following the redraft the document now reads more like guidance for PCTs and practices. This was not what was envisaged in the original contract agreement and the GPC will continue to press for a legally binding service level agreement document. In the meantime, the current document will be published early in the new year to provide greater clarity on IT issues than has previously been the case.
National Care Record
The GPC briefly discussed the new electronic National Care Record, which will be phased in from the summer of 2006. In particular, the arrangements for patients to either opt-in, or opt-out of having their electronic records placed on the national computer system (the “spine”) were discussed. The GPC will discuss this matter in more detail at its January meeting.
GPC practice based commissioning (PBC) guidance
The Commissioning and Service Development Subcommittee has been working on practical guidance for GPs on PBC with the original intention of publishing this guidance by Christmas. We now understand, however, that there will be new Department of Health guidance on PBC in January, hopefully with further detail on the shape of the PBC DES thereafter. As a consequence, we feel it would be sensible to finalise the GPC guidance after this date, so that it will be cognisant of the various strands of the process and therefore be more meaningful and useful for GPs.
Annual certificate of pensionable earnings
Following the difficulties experienced by many practices in completing the annual certificate of pensionable earnings, compounded by the ruling by HMRC that the employers’ contributions for GP partners may not be tax deductible, a way forward has now been found, for this financial year, at least. The form has been revised and having agreed to the amendments, it is now available on the NHS Pensions Agency website at www.nhspa.gov.uk/GPCompletionForms.cfm. The form includes a 'represcription notice' from HMRC to place at the back of the note for all accountants, GPs and local tax officers to see and thus avoid possible arguments.
What has been agreed is that although, at the moment, the employers’ contributions for partners have to be shown in GP accounts and hence as income, they will be fully tax allowable even though to be so they breach the £15,000 limit. The only additional payment that GPs will have to make is for National Insurance payments on the employers’ contributions which will, on average be about £140 per GP. For those certificates that have already been completed with deductions, they will still be correct for pension purposes and will not necessarily need to be re-visited.
This solution subsequently means that the problems for 2004-05 and 2005-06 have been resolved. However, we have agreed this solution for one year only, due to the urgency with which GPs need to complete this year’s returns. We are continuing to try to get agreement for subsequent years so that there will be no additional NI payments for GPs, an approach that the Department of Health supports.
Items from GPC News (Nov 05)
Your Health, Your Care, Your Say : Improving Community Health and Care Services – White Paper consultation
The committee received a copy of the BMA’s submission to the White Paper consultation, which had been written and coordinated by the GPC.
The consultation period has now officially ended and 998 people attended the culminating public event held in Birmingham on 29 October 2005. Regarding the four main themes identified as those which would have an impact on GPs, the Department of Health had already made announcements on extended surgery opening hours, and the concept of health ‘MOTs’ via GP consultation was now understood as unlikely to feature as a Government priority. Proposals relating to the remaining two areas, dual registration and access, were yet to emerge.
There was some discussion on how the committee would respond to the publication of the White Paper and any Government demands in due course. It was agreed that to promote the interests of patients was ultimately to work towards improving the situation for GPs and that any new initiatives should be judged against a set of principles. These principles should include tackling health inequalities, providing services based on patient need, ensuring that investment in the NHS was cost-effective and maintaining continuity of care.
These ideas will be developed by the GPC negotiators, relevant subcommittees and the committee as a whole, following publication of the White Paper.
Nurse and pharmacist prescribing
The committee discussed the recent announcements from the Secretary of State for Health that nurse and pharmacist prescribing would be opened up to encompass the whole of the BNF. A meeting has been arranged with Ministers to discuss this. The committee recognised that there were a number of key issues that needed to be clarified, with regard to expanding nurse and pharmacist prescribing:
1. There were important responsibility and liability issues – the committee felt that the relevant nurses/pharmacists should take complete legal responsibility for their actions.
2. Who is going to pay to indemnify nurses/pharmacists – medication error is already a key medical indemnity issue.
3. Whose budget will they be prescribing from – it was felt that the relevant nurses/pharmacists should be working from their own budget.
It was agreed that there was a wide range of nursing competencies and in certain situations it might be more than appropriate they have the opportunity to prescribe where they were currently unable to.
Extended opening hours
The statement by the Secretary of State for Health in a speech to the NHS Alliance that she wishes to see more GP surgeries open for longer hours was discussed by the GPC. Although some felt many GPs may want to provide extended opening hours provided they were funded to do so, others did not share this view. Current mechanisms are available to do this, but very few primary care organisations have taken the opportunity to make use of them. The committee did not believe it was a satisfactory solution to close during weekdays in order to provide an evening or weekend service, as this risks disadvantaging some patients. The GPC would continue to discuss all access issues with the Department of Health and NHS Employers, but it would continue to press for resolution of the capacity and resourcing restraints that were a large part of the problem.
Practice based commissioning (PBC)
The committee commented on a draft plan of further GPC guidance on PBC as compiled following consultation with the GPC negotiators and the Commissioning and Service Development Subcommittee, also incorporating comments and suggestions made at the LMC Secretaries Conference on 10 November 2005. It is anticipated that the first round of this guidance will be available by the end of December. A further guidance note will be produced in 2006, following the publication of the White Paper and the Department of Health’s own further guidance on PBC.
IT update
QOF and QMAS
An update to the QOF and QMAS qualifying code sets and business rule sets has been published to take account of critical analysis of the original sets and any updates to the national Read Codes. Seventy eight codes have been added to those that qualify for QOF and four removed. A couple of clinical indicators prescribing timing thresholds have been relaxed. These will be implemented by suppliers in December/January. They will then apply to the monthly QMAS reports and the final 2005/6 year end submission.
Electronic Transmission of Prescriptions (ETP)
ETP has now been renamed the Electronic Prescriptions Service. It continues to make steady progress.
Choose & Book (C&B)
At the time of publication approximately 20,000 bookings have been made. Five percent of these have been made with the fully integrated version of C&B. However PCTs have placed orders with suppliers for fully integrated versions on behalf of 80% of England’s surgeries.
The National Audit Office has undertaken a survey Knowledge of the Choose and Book Programme Amongst GPs in England which was presented to the Public Accounts Committee of the House of Commons on 31 October 2005. The full report can be accessed at
www.nao.org.uk/publications/gp_survey_2005.pdf
The secretariat has received a number of enquiries regarding GPs’ contractual obligations in relation to Choose & Book. There is no obligation under the GMS contract to undertake Choose & Book; it is entirely voluntary. This is also the case for PMS contracts, unless specific clauses have been negotiated and introduced locally between practices and PCTs.
Choice
We have received reports that PCTs are encouraging practices to sign up to provide the government’s choice of five hospitals when referring to the secondary sector. This is entirely voluntary and we would advise GPs that they should continue to refer, where clinically appropriate, as they always have done, offering choice where local circumstances permit and if it is in the best interests of the patient.
Freedom of Information Act
GPC members were given a very comprehensive presentation on the Freedom of Information Act by Alex Ganotis of the Information Commissioner’s Office. Several important points emerged from this presentation:
· All members of practice staff should have a basic understanding of the Freedom of Information Act as the time limit for responding to a request for information is counted from receipt of the request by the public authority (i.e. the practice).
· All practices should have a publication scheme outlining the type of information available, how it will be made available and the cost of the information. It makes good sense to keep the publication scheme up-to-date, including frequently requested information, because items listed in the publication scheme can command a reasonable charge. Model publication schemes for GPs in England, Wales and Northern Ireland are available on the Information Commissioner’s website:
www.informationcommissioner.gov.uk/eventual.aspx?id=8279
· The Information Commissioner recommends that an internal complaints procedure relating to the Act should be included in the publication scheme. Wherever possible, disputes that cannot be solved by the practice will be resolved by the Information Commissioner. In these circumstances, the Information Commissioner can request the information needed to make a judgement but will never pass this on to the applicant. The Information Commissioner’s decision can be taken to appeal.
· The Information Commissioner’s Office website contains lots of procedural and exemptions guidance to help practices make decisions about implementation of the Act and requests received for information under it.
www.informationcommissioner.gov.uk/eventual.aspx?id=74
There is also a helpline available on 01625 545745. GPs can use this helpline to obtain help in making decisions, though the Information Commissioner will not be able to make decisions on a GP’s behalf.
· The Information Commissioner’s Office will provide speakers to explain the Act to sufficiently large groups. Practices could also consider approaching their PCT for further information.
Flu vaccine shortage
If there are any practices or local areas where there is a flu vaccine shortage with neither suppliers, pharmacists, nor any other source being able to supply the vaccine, please could you forward details to sblass@bma.org.uk. We have a contact in the Department of Health who has informed us that they are monitoring the situation and we will pass on any information we receive.
Avian Flu
The GPC Chairman attended a recent meeting with the CMO to discuss the UK Influenza Contingency Plan, and raised a number of points about ensuring adequate preparations for a flu pandemic. It is clear a lot of work is being done by the Department of Health and Health Protection Agency in planning for a pandemic, however it may be difficult taking the principles in the Contingency Plan guidance and applying it at PCT and practice level.
The GPC agreed that the GPC and RCGP did have a role to play in terms of professional leadership on this matter, and it was suggested that the GPC and RCGP have a working party to take forward work on advice specific to practices.
PMETB
We have received assurances from the Postgraduate Medical Education Training Board (PMETB) that all CCT applications, as well as SER (Article 11) applications where the applicant had completed all necessary training, previously submitted to the Joint Committee of Postgraduate Training in General Practice (JCPTGP), have now been finalised. If there are any outstanding problems, please ensure that these are brought to the attention of the GPC secretariat.
Flexible Careers Scheme: funding problems
Unfortunately the responsibility for funding the flexible careers scheme has been devolved by the Department of Health to deaneries but without the necessary funding. This means that all deaneries throughout the UK have had to postpone the appointment of new FCS GPs. However, practices that already have an FCS GP in post should be unaffected since the payment to practices is contained in the Statement of Financial Entitlements (SFE).
The GPC has written to the Department of Health with its grave concerns over the current funding crisis. We hope that this will be resolved in the near future, as the FCS is a highly valued scheme.
Firearms and shotgun certificates
We have been asked to remind GPs that the BMA ethics department has guidance on firearms applications available at:
www.bma.org.uk/ap.nsf/Content/Firearms
In exceptional circumstances a doctor may have good reason to believe that an individual either applying for a firearms certificate, or already in possession of one, may represent a danger either to themselves or to others. In these circumstances doctors should strongly encourage the applicant to reconsider or revoke their application. If the applicant refuses, the doctor should consider breaching confidentiality and telling a senior police officer – usually the Chief Constable of the County or the Commissioner of the Metropolitan Police – of their concerns. Consent should initially be sought from the applicant for contacting the police, but if it is not possible to obtain consent, the doctor should consider making his or her concerns known without consent wherever feasible. It is good practice to discuss the reasons for this with the applicant beforehand.
Reporting change of GP
In some areas there have been problems with a lack of co-ordination in the transfer of patient’s records when they transfer to a different GP practice. Consultants’ clinical letters regarding patients who have left a practice should be forward to the PCO, and not returned to the consultant.
Health Professions Council
We are aware that GPs are often approached by health professionals for certification of fitness to practise. This is owing to a Health Professions Council requirement that health professionals obtain a medical report from a GP, for which the individual is expected to pay.
GPs are under no obligation to undertake this work and, although it is not a contract issue, they should be very wary of doing so. GPs should not sign any forms indicating fitness to practise unless they are completely satisfied about the accuracy of the report. The GPC is working with the Cabinet Office’s Better Regulation Executive to try to resolve these issues.
Pensions
On pensions, there have been suggestions by some tax inspectors that the employers’ contributions for GP partners will not be tax deductible because of the way they are dealt with in GP accounts. We have been told that, even in a worst-case scenario, these contributions would still be tax allowable, although there could be a small, adverse impact on National Insurance payments. Scotland is near to reaching a final agreement on superannuating the new GMS contract work. Clearly there is an urgent need for clarity on these points due to the need to fill in and submit the forms. Because of this, we have been pressing the DH and HMRC to reach an agreed position, and we are expecting the DH to announce that final position very soon.
With regard to the NHS Pensions Agency GP Annual Certificate process, the form is still on the Pensions Agency website, along with accompanying guidance. The form was produced with two large specialist medical accountancy firms, both of whom have large numbers of GP practices on their books. It was signed off by them, the Department of Health, the Pensions Agency, HPERU and ourselves. Before its release, it was road tested on a few accountants to ensure it was appropriate. The form has always been seen as a work in progress, with anomalies expected to crop up. Feedback was welcomed, and has been received from accountants and the Scottish PA. We have fed such concerns back to the Department, the Pensions Agency and our accountants and are awaiting their response. In the meantime, the website states that, although the form will be updated taking feedback into account, the current form is the one to use.