NEWSLETTER DECEMBER 2007
Lord Darzi’s NHS Next Stage Review: interim report
GPC survey of GP opinion 2007 – results
NHS Choices: Practice Profiles
Change of subcommittee name for GP registrars
Mental Health Act: Code of Practice
Editorial
As we enter the New Year, it is apparent that the bubble has well and truly burst around our pay and workload. I have always believed that after the first year of the new GMS contract and the benefits that brought, that life was likely to get tougher. It is fast becoming apparent that this government is going to turn the screws to bring general practice to its knees again. We will be very lucky to see any increase in remuneration for mainstream GMS this year and will probably be expected to fund pay rises for our staff out of existing income. Thus the government can bribe us to provide the extra services it wants as being the only way to increase our practice income.
The government should remember that one of the main drivers for the increases received with the New Contract was the recruitment shortage. If they continue along the path they are now treading, young doctors will again perceive General Practice as a poor option. They are pursuing the self interests of a few mobile, working patients to the detriment of the majority. They are treating the provision of general practice as a supermarket commodity rather than looking at the value of the personal care which the majority of our patients favour.
However, we must bear in mind that we continue to be portrayed and perceived as rich and idle, a perception which will make it exceedingly difficult to successfully take on the government in its ambition to make us provide extended hours with late evening and Saturday morning working.
The LMC asks for any comments you have about the current problems we face, to enable us to report accurately to the GPC the feeling of local colleagues. We do not wish them to go to war with the government if their is no heart for it amongst the troops. Please let us know your views preferable by email to office@northstaffslmc.co.uk
Lumbar Spine X-rays
Concern has been raised about the number of lumbar spine x-rays performed at the request of local GPs. There is a considerable difference in the number requested by each GP. The amount of radiation which patients are subjected to whilst undergoing this procedure is considerable and is unacceptable. Our attention has been drawn to the guidelines produced by the Royal College of Radiologists which recommends that the only indication for lumbar spine x-ray is the possibility of osteoporotic fracture. Patients with red flag features:
 | Lumbar back pain and known malignant disease |
| Severe or progressive motor loss/Widespread Neurological Deficit in the lumbar spine distribution |
| Lumber back pain and elevated ESR/CRP, weight loss or systemic features |
should be referred urgently for further investigation e.g. MRI scan.
| Patients with features suggestive of intractable nerve root compression with none of the above findings and in which surgery is contemplated should be referred via the back pain pathway rather than for plain x-ray film |
| For patients aged between 20 and 55 years with simple back pain, referral for imaging is unnecessary, physiotherapy and advice on lifting techniques is recommended. |
| Lumbar spine x-ray in not indicated in chronic and recurrent back pain without red flag features in any age group. |
| Adolescent scoliosis should be referred for a specialist opinion prior to any imaging unless it is associated with new onset pain, in which case the patient should be referred for MRI. |
The LMC has discussed the above guidelines and agreed the suggestion that these should be publicised to GPs and other relevant professionals. The number of lumbar spine x-rays requested will continue to be monitored and it is possible that a referral proforma will be introduced should requests for "inappropriate" examination continue to be a concern.
Audit of COPD Patients
Stoke-on-Trent PCT is planning an audit of patients who have COPD to assess their understanding of the disease and the education they have received about their condition. The audit is being conducted by the Audit department of the UHNS which is contracted to conduct audits on behalf of the PCT.
Acute Admissions Crisis
The LMC is very concerned about the ongoing crisis with emergency admissions. The UHNS has been on escalation level 4 (red alert) continually since 8th November. Although we are used to this situation occurring regularly to be at this level for so long is unprecedented. Although there are undoubted pressures on the UHNS other acute hospitals in the region and indeed nationwide have not been under such sustained pressure. We have heard a litany of reasons for this state of affairs, these include unnecessary GPs referrals, GPs sending patients directly to A & E, direct patient demand and bed blockers. Whilst we agree that there may be some room for improvement in some of these pressures we do not believe that our GPs, Ambulance service, patients and social services provide such a poor service and high level of demand to account for the UHNS's inability to cope with its workload. We note that other hospitals in the area and indeed nationwide have not been on this state of alert at any where near the level of frequency as at the UHNS. The LMC have in the past suggested a number of initiatives to help pressure on the UHNS, including
| The provision of urgent consultant led out-patient clinic slots (same day or next day) |
| The commissioning of GP led proactive care to patients in nursing homes |
| The provision of ambulance transport of patients to GP surgeries rather than A & E where appropriate and the resourcing of GP practices to provide this service. |
Regretfully these initiatives have not previously been implemented although some progress is being made with the provision of urgent consultant led out-patient slots.
The current situation is not acceptable to GPs, the public or indeed the hard working frontline staff at the UHNS. The committee recognises the great efforts currently being put in by the PCTs to try to alleviate the situation however, we have written directly to the Secretary of State for Health requesting that he looks at the situation in North Staffordshire and takes appropriate action to ensure that we have a satisfactory level of service for our acutely ill patients.
Requests for Non-NHS work
Colleagues have asked for advice about requests which arise for completion of forms which are not part of our NHS work. Many organisations seems to think that we have to complete whatever form they request us to do. It is suggested that colleagues could produce a standard letter along the lines:
"We have a number of requests for the completion of forms/certificates which are not part of our NHS work. The majority of these come from educational and sports' establishments. in many cases the information requested can be adequately provided by the patients. We are unable to complete these forms due to lack of time and resource. Although each form may take only a short time to complete in total they add up to a considerable workload. Time taken completing these requests detracts from the time we are able to spend providing essential NHS services"
Colleagues may of course see these forms as an area of income generation.
Directory of Cancer Services
The UHNS has updated it directory of cancer services. This is a very comprehensive document running to 126 pages. A copy can be found here.
Improving Communication
"Improving Communication, the exchange of information and patient care" is a joint paper produced by the General Practitioners Committee (GPC) and the Central Consultants and Specialists Committee (CCSC). It offers a number of suggestions to improve two-way communication between primary and secondary care practitioners, for the benefit of patients. Whilst this papers contain a number of suggestion of information flow from secondary to primary care there are also some important points for GPs to consider in their communications. A copy can be found here.
Pension Scheme - added years
The option to purchase added years
will be withdrawn with effect from 1 April 2008 following the review of
the NHS pension scheme in England and Wales.
All existing members of the scheme will have the opportunity to purchase
added years during the period 1 April 2008 to 31 March 2009 but they
must make an application to do so prior to 31 March 2008 as there
will be no further opportunity after this date.
If you wish to purchase added years then the first step is to obtain an
added years quotation from your employer (or PCT/LHB if you are a GP),
this will tell you the amount of added years you are able to purchase
and also the extra contributions required. If you then wish to proceed
with the purchase you should complete the form AB54 (again, this is
available from your employer or PCT/LHB if you are a GP).
Whilst the application to purchase added years must be received by the
NHS Pensions Agency by 31 March 2008 at the very latest, the
contributions will not start to be deducted from your earnings until the
contract starts on your actual birthday. Therefore if you were to send
in your application in by 31 March 2008 and your birthday was 1
January 2009 then the deductions would not begin until then.
From 1 April 2008 a new option will be introduced which will replace
added years. It will enable doctors to make extra contributions in
return for extra annual pension - up to a maximum of £5,000 p.a. This
option will also be available to doctors who have, or are purchasing
added years. The technical details of this additional pension purchase
are being finalised.
Doctors who are currently paying for added years should note that these
contracts will be honoured in full if they intend on remaining in the
existing NHS pension scheme. If you do wish to remain in the current
scheme, there is nothing you need do.
If you are considering buying added years then you may wish to consider
speaking to an independent financial adviser before doing so.
If you have any queries about added years or any other aspect of the NHS
pension scheme review agreement, BMA members can contact the BMA
Pensions Department by telephone: 020 7383 6166/6138 or by email
pensions@bma.org.uk There is also a wide range of information
available on the BMA website at:
http://www.bma.org.uk/pensions
Focus on Salaried GPs
This guidance has been further revised. It now includes a detailed legal view on what counts as continuity of service, as well as on calculation entitlement to maternity pay, sick pay and redundancy pay for those employed under the model salaried GP contract. An updated copy of this document can be found here.
Items from the GPC
Contract negotiations
Discussions have recently begun between the GPC, the government and NHS Employers on extended opening hours. The government’s position on the issue is set out in the interim Darzi report. At this time we would stress that local GPs should not feel pressured into accepting any local arrangements that they do not feel are satisfactory. We will continue to discuss options for central arrangements but would stress that any centrally negotiated outcome should not preclude the operation of more favourable local solutions where these are available. Similarly, any local agreements should include an option to move, should GPs wish to do so, if a preferable national agreement is reached.
Defending general practice
Further to the discussion at the September meeting, the committee considered the development of its strategies to promote and development of general practice. A communications working groups is being set up which will be taking the strategy forward.
Lord Darzi’s NHS Next Stage Review: interim report
The interim report of Lord Darzi’s Next Stage Review was published on 4 October; the report can be accessed online at the following website address:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/dh_079077
A GPC summary of the report, covering the key points and giving more detail on those that are of particular interest to GPs can be found at here.
The Health Policy and Economic Research Unit (HPERU) will be coordinating the BMA’s response to the report and a GPC submission will be made to HPERU on the basis of the comments made at the GPC meeting.
GPC survey of GP opinion 2007 – results
GPC members received a copy of the results of the GP opinion survey, which was published recently. The full report can be found on the BMA website at:
www.bma.org.uk/ap.nsf/Content/gpopionsurvey1007
These results will help inform the committee’s work over the coming year.
IT update
NHS Choices: Practice Profiles
Version 2 of the new online health information service, NHS Choices (www.nhs.uk), will be released shortly. The new release of the website will contain expanded primary care data and practices will have the facility to edit their own profile data on the site. Each practice has a profile page on the site that can be populated with details about individual members of staff, additional clinics and services, and practice videos. It will also include data from the Mori Patients' Survey, but not the details of the results for question nine on extended hours, and selected QOF indicators.
All practices will receive an information pack that will offer the opportunity to take over the responsibility for editing their own data on NHS Choices via an individual secure login and password. The brochure will contain full details of the editing facility, with explanatory notes on how to complete the various text fields etc. Practices will be able to edit their information on a preview site, which will run in parallel with the public site before data on the two sites is integrated in early November.
This initiative provides a good opportunity for practices to ensure that their patients have access to comprehensive, accurate data concerning their facilities, but is not a contractual obligation and PCTs do not have editing rights if practices take up the opportunity to edit their own data.
The information packs contain all of the information practices need to edit their data, including a helpline telephone number.
GP educators' pay
The GPC will be meeting with GP educators' groups on 23 October 2007 to discuss possible ways forward to improve GP educators' pay. The GPC negotiated an improved pay scale for GP educators in 2004 for the 2003/04 period with the understanding that this would be uplifted on an annual basis in line with the DDRB's recommendations for other GPs. The GPC has been pushing for such an uplift, but unfortunately for a couple of years this was not forthcoming. The pay scale may therefore now need a revision to ensure that it recognises the work and commitment of these doctors.
Modernising Medical Careers
The findings and recommendations of the independent inquiry into modernising medical careers, Aspiring to Excellence (the Tooke Report) have now been published. This recommends an extension to GP training, including two years to be spent as a GP registrar following core specialty training. The full report can be accessed at www.consultationfinder.com/econsult/uploaddocs/Consult1/MMC_InquiryReport.pdf. The key parts relating to GP training are at pages 13, 68 to 69, 77, and 98 to 101. The BMA will be submitting a formal response by the deadline of 22 October, and the GPC will feed into that response.
Change of subcommittee name for GP registrars
The GPC has approved a recommendation from the GP Registrars subcommittee that its name be changed to the ‘GP Trainees subcommittee. This reflects the eligibility of all GP trainees to stand for election to the subcommittee, not just those within the general practice part of their training.
Further information on the membership of the subcommittee can be found at: www.bma.org.uk/ap.nsf/Content/gpregrep.
Pensions
Full details of the final agreement on changes to the NHS Pension Scheme in England and Wales can be found at www.bma.org.uk which includes a helpful summary of the key changes.
Publication of QOF figures
The results of the Quality and Outcomes Framework (QOF) were published on 28 September. Results have demonstrated yet again the high quality services being provided by general practices across the UK.
Results were highest in Northern Ireland where, on average, general practices were awarded 98% of the points available. Practices in Scotland achieved a similarly high level of 97%, with England and Wales also demonstrating top quality services with respective averages of 95.5% and 94.7%. All these results were particularly encouraging given that the QOF was revised this year to make it harder to achieve maximum points.
Patient charging
LMC Conference policy dictates that the GPC negotiates with the Department of Health a methodology to allow practices to charge those patients registered with them for certain services that are not available under the NHS. Private practice is currently significantly restricted for GP practices – GMS regulation 24, subsection 2, and the equivalent regulation for PMS and the Directions covering list based PCTMS and APMS, prevent contractors from charging their patients for most services. There are however instances, as set out in the GPC guidance note Charges to NHS Patients, where charges can be made. www.bma.org.uk/ap.nsf/Content/chargestonhspats
The GPC is aware that the inability of practices to charge their own patients for certain routine non-NHS services, for example hepatitis B vaccinations on the grounds of occupational health, is frustrating for both the practice and the patient, who may be inconvenienced if made to visit another practice in the area for a service for which they would be happy to pay their own GP. The GPC is also aware, however, of the risks of seeking changes to the current system that would allow practices to charge patients for any service which the NHS chooses not to fund which may, in turn, disadvantage those patients in poorer areas and lead to greater health inequalities. The GPC is particularly conscious of the need to maintain the trust of patients and will be liaising with the BMA’s Patient Liaison Group on these issues.
The GPC will form a specific proposal for change that serves to balance these views before seeking negotiations with the Department of Health on this matter.
Mental Health Act: Code of Practice
The revised Mental Health Act comes into force in November 2008 and there is a Code of Practice that gives guidance on how the Act should be applied. The consultation process, organised by the Department of Health, for the Code of Practice began on the 25th October 2007, and runs for 13 weeks. This is an important code that will have implications for the way that GPs work. This Code applies to England only, although the Welsh Assembly Government is conducting similar consultation exercises on a Code of Practice and secondary legislation for Wales.
It is important that all GPs familiarise themselves with the code and raise any concerns during the consultation period. The consultation on the code can be found at here.
The chapters which may have particular implications for GPs include:
Chapter 1 – The statement of guiding principles
Chapter 17 – Confidentiality and information sharing
Chapter 25 – Treatment regulated by the Act
Chapter 26 – Second Opinion Appointed Doctors (SOADs)
Chapter 28 – Supervised Community Treatment
The Act could mean that GPs find themselves increasingly responsible for a greater number of mental health patients. Supervised Community Treatment (SCT) is an area that may impact on GP workload as there is likely be some role for the patient’s GP (if they have one) in clinical oversight of the SCT. The Code of Practice does not set out precisely how GPs should be involved in this treatment, nor does it set out the procedures that should be followed to ensure good communication between hospitals, out-of-hours services and GPs. These issues will be raised during the consultation period. GPs' views and opinions are therefore important as they will ensure that the Code of Practice is practical and effective.
The GPC will work to identify and resolve any resource impact with the Department of Health and keep the profession updated on progress. The Royal College of General Practitioners (RCGP) will ensure that training materials are available, and appropriate, for GPs. The RCGP, together with the GPC, will ensure that information about how the new law will work and its impact for GPs’ working practice is developed as necessary.
The GPC urges as many GPs, or groups of GPs, as possible to respond to this consultation on this Code of Practice to ensure that your views are heard.