NEWSLETTER FEBRUARY 2005
Out of Hours Telephone Call Transfer
Sharing information with NHS Direct
Payments to GPs with a Special Interest
Future of IT.. update for Midlands and NW Cluster doctors
QOF and the Freedom of Information Act (FOIA)
Quality and Outcomes Framework: National Prevalence Day
Lithium ranges in QOF Mental Health indicators
Access and the Primary Care Access (PCAS) Questionnaire
GP retainer scheme model contract
Out of Hours Telephone Call Transfer
All Primary Care Trusts in North Staffordshire are keen that GP practice should use a system of direct call transfer to the "out of hours" services. As you will know from previous emails the LMC had some concerns and reservations about the proposed system. The Department of Health require PCTs to introduce a system of single number access during the out of hours period, however this is not a mandatory requirement for General Practitioners. The PCTs have addressed all of the concerns raised by the LMC. Specifically they have assured us that the reimbursement of the costs associated with the system is legal and PCTs will pay the cost of installing the system and any additional costs incurred as a result of diverting calls. The costs for this will be part of the overall cost of commissioning out of hours services. BT have advised the PCTs that the "Smart Divert" system is the best system to install. This requires having an access number and a PIN. Further details can be requested from BT on 0800 400 400. A PDF file showing details can be found here. The divert will need to activated and de-activated by the practice. The PCTs are not aware of any reliability problems with the system.
PCTs will reimburse the cost of installing the diversion system and additional costs incurred. Claims should be addressed to the Director of Finance at the appropriate PCT. Practices will need to request itemised billing from BT and will find that the diverted calls are grouped together on the bill, which should help the administrative burden.
Practices using the system will be able to claim the relevant QOF points. Practices are advised to notify the out of hours services of an ex-directory telephone number which can be used to contact the practice should a divert not be de-activated at the appropriate time
Patients will hear a recorded message before the call is answered by the out of hours service advising them that their call has been diverted. This system does have the disadvantage that a "personalised" message cannot be recorded by the practice, however as it is government policy to introduce such a system and PCTs are performance managed on this we would now advise that practices co-operate with the introduction of the system.
Sharing information with NHS Direct
Practices have received a letter from North Staffs Urgent Care requesting the sharing of information with NHS direct. They request that information about certain groups of patients is shared with NHS direct using form NP027 for entry on to the NHS direct computer system. Such patients include
 | The terminally ill |
| Dangerous or unusual illnesses |
| Violent or abusive patients |
| Severe mental illness |
| Those who may fraudulently attempt to obtain a prescription |
| Children subject to child protection legislation |
| Frequent callers. |
The committee had concerns about this request and patient confidentiality and because of this we asked the opinion of the medical defence organisations.
The MPS advise that when making disclosures of this kind doctors should seek consent where practicable and they give the following specific advice.
- In the case of competent patients who are terminally ill, have severe mental illness or unusual illnesses, consent should be sought. Verbal consent would suffice but it should be clearly documented in the records and it would be good practice to share the information being disclosed with the patient
- In respect of incompetent patients who are terminally ill, have severe mental illness and a dangerous or unusual illness, any disclosure must be justifiable on best interest principles.
- In the case of violent or abusive patients and those who may fraudulently attempt to gain a prescription, doctors must be comfortable that they can justify any disclosure made without consent on the grounds that it is not practicable to gain consent.
- In the case of children subject to child protection legislation, doctors should use their discretion and if they feel it is practicable to gain consent then they should do so. However, if it is not practicable to gain consent any disclosure of this nature should be justifiable on the grounds that it is in the best interests of the child
- In the case of frequent callers, it would be difficult to justify disclosure without first obtaining appropriate consent.
The MDU advises that in those cases where it is either impractical or inappropriate to obtain patients consent, the patient confidentiality and the Data Protection Act need to be considered. They quote from the GMC document "Confidentiality: Protecting and Providing Information". "Disclosure of personal information without consent may be justified in the public interest where failure to do so may expose the patient or others to risk of death or serious harm. Where the patient or others are exposed to a risk so serious that it outweighs the patient's privacy interest, you should seek consent to disclose where practicable. Where it is not practicable to seek consent, you should disclose information promptly to an appropriate person or authority. You should generally inform the patient before disclosing the information. If you seek consent and the patient withholds it, you should consider the reasons for this, if any are provided by the patient. If you remain of the view that disclosure is necessary to protect a third party from death or serious harm, you should disclose the information promptly to an appropriate person or authority. Such situations arise, for example, where disclosure may assist in the prevention, detection or prosecution of a serious crime, especially crimes against the person such as abuse of children."
With regard to the Data Protection Act, then this requires all data processors to only process personal data "fairly and lawfully". In the case of sensitive personal data then the DP Act requires at least one of the conditions in Schedule 3 to be met. Under Schedule 3 the processing of data is allowed for medical purposes if undertaken by a healthcare professional or a person who owes a duty of confidentiality which is equivalent to that which would arise if the person were a health professional.
The MDU go on to advise that the most appropriate way of disclosing information is to obtain consent, but in the event of this being impracticable or inappropriate then the GP might wish to seek advice from their medical defence organisation so that they can demonstrate that it was a considered decision.
Since the original circular North Staffs Urgent Care have informed us that access to this data will be limited to nurses, call handlers and team leaders and will be subject to a three monthly review.
Colleagues are advised to obtain patient consent whenever practicable and in case where consent can not be obtained to follow the advice given by the medical defence organisations.
Payments to GPs with a Special Interest
The PCT have reviewed the payments to GPwSIs and suggested a sessional fee of £250. (3 hours clinical and 0.5 hours audit). The Committee discussed this at its last meeting and felt that the fee per session should at least cover the cost of providing a locum in a GP surgery and also recognise the extra skills these doctors have acquired. The PCTs have been reported as paying locums in the region of £110 per hour. The committee felt that this should be used as a benchmark for GPwSI payments with the employer's national insurance and superannuation costs also being paid by the employer. GPwSIs see between 6 and 8 new patients and some follow ups during a session. The "payment by results" tariff for hospitals put payments for an outpatient attendance at £83 - £183 per patient. This is equivalent to £498 - £1464 per session. We have written to the PCTs with our comments.
Choose and Book
The GPC remind doctors that there is no contractual requirement for GMS practices to participate in Choose & Book, PMS practices will have to check in their contract whether there are any clauses about participating in new initiatives or the equivalent. The GPC advises that practices should not take on any work that they are not contracted to do, are not happy to do or for which they do not feel they are being properly resourced. The main concerns about this, are the lack of clear information on the programme, the implications for workload and concerns about patient confidentiality, together with a belief that the government's version of Choose and Book is not the best way to offer our patients appropriate choices about their treatment.
The Department of Health have recently imposed new targets for the implementation of this programme and also their ebooking programme. Without a massive investment in IT, training and resourcing of practices to undertake this work these targets are unachievable. The "incentivisation" money recently announced by the DoH will only be paid to PCT on achievement of targets and there is no guarantee that the money will find its way into primary care.
EMIS Templates
Some new templates have been added to the list. These include:
| Epilepsy Clinic Referral Form |
| Douglas McMillan Home Service Referral Form |
| Moorlands Hospital Physiotherapy Referral Form |
| Moorlands PCT Community Addiction Service Referral Form |
| School Nurse Referral Form |
| North Staffs Palliative Care Communications Form |
| Updated TIA clinic referral form |
These can be downloaded from the "Emis Templates" Page.
Future of IT.. update for Midlands and NW Cluster doctors
Report from Staffordshire and Shropshire GPC representative, Steve Edmunds
I attended the IT cluster meeting for "senior clinicians" recently run by CSC Alliance and saw their presentation of our IT future. Their own figures said 87% of clinicians had reported that they feel uninformed about these issues. I personally doubt even 13% have the first clue about what lies ahead. I certainly did not.
Firstly, to say the meeting was "PCT/Acute Trust-centric". Very few Gps in audience. Lots of PCT managers and interested clinicians from trusts and laboratories. On the overheads there was more mention of embedded billing and insurance in the future IT software than of primary care. As GPs we need to remember that despite the prevalence of IT in our practices and the fact we do 90% of NHS work, the major thrust of the CSC contracts and cost will be concentrated in Acute Trusts.
CSC Alliance have only a passing interest in what we (or the Trusts) already have IT-wise. The current fatal flaw is perceived by them to be the fragmentation of IT and the over-arching strategic need for an IT structure that will integrate every single nook and cranny of health (and they hope social services) via an IT Data Spine. Their contract is for £1.08 billion.
Conservative true costs are likely to be x3 greater, (my guess).
EMIS wasn't mentioned all day. Informally raised it was still a non-issue for CSC. The nGMS promise for a choice in IT software was to use CSC's own words, a "Hobson's choice". Practices wishing to stay with old systems could but would probably be neglected for support and upgrades. Access to newer services for patients/practices would come preferentially via iSoft products, namely Lorenzo.
Lorenzo itself is very smart and a computer buffs delight. Potentially it is a nightmare for Luddite doctors and EMIS happy clinicians. I judge it will be very time-consuming to assimilate and sift the huge amount of data it is envisaged will be placed before the clinician at every turn. It will be alert rich and "decision support assisted" and of course very demanding in data entry. Even when the patient is away from you they have bundles of good ideas about how to alert you if a script isn't filled or a blood sugar not recorded digitally by the patient on time. (I cant wait). Microchips on taps and fridge doors, online Digital TV virtual dosette boxes, reminders via digital TV screens and text messaging etc will all control both patients and clinicians alike.
iSoft say it can be made to be so simple we can all use it and not add to consulting time. Their own demonstration was a poor example as it was complex and ran overtime. By the end of the day, with this and other presentations as the famous saying goes "I was much better informed but non the wiser".
Hope is expressed in some quarters that EMIS will be able to keep up and offer the same architecture and functionality that Lorenzo has. EMIS have indicated their desire to do just that and are risking investment to try and outperform Lorenzo. To match performance and price without the insider detail and Trust aspects is going to be very challenging. I think it highly likely that a) EMIS will be financially forced to partner iSoft and co-produce a matching product or b) that institutional and financial pressure will force all parts of trusts, PCTs and practices to become adopters of iSoft products.
Either way we will have IT systems that will be unrecognisable as EMIS by the end of 2008. I think the training and use of consulting time by the new system looks very daunting. Perhaps there is a crumb of comfort in that it is so Utopian and ambitious that it is unrealistic to expect it on time or even at all in the form presented. There are no working products available.
I haven't even touched upon Choose and Book or issues of confidentiality but if I am disheartened by the lack of appreciation of GP IT issues then I am even more shocked at how they expect us to toe the line and just "do" Whatever expected on Choose and Book and Data Spines irrespective of cost to clinician and staff time and irrespective of the sanctity of the consulting room.
I hope you don't mind this update, but everywhere I go I am asked about EMIS and the future. In summary, I strongly recommend sitting tight for the present and NOT accepting unpaid pilots/projects or IT upgrades UNLESS they come with no strings.
Small Practices Association
The local Small Practices Association (SPA) has been running for the last four years. The group meets regularly every two months. There are approximately 20 - 25 doctors who regularly attend some of whom are from group practice. All are welcome to attend. The main aim of the SPA is to provide a good network between GP practices, to facilitate debate about key issue and to support each other. The group frequently extends an invitation to LMC representative to attend meetings and this is mutually beneficial. The local association has links with the National Association who provide a very informative and excellent website at www.smallpractices.org.uk. If you wish to join the SPA please contact Dr Reddy who has recently been awarded a Honorary Doctorate by Staffordshire University for various areas of his work including technology, on 01706 620920 or 01782 200740 or by email at vijay.reddy@nshawebmail.nhs.uk
Financial Allocations
The Department of Health has announced the financial allocations for the next two years,. 2006/7 and 2007/8. In the next two years Newcastle PCT will receive increases of 8.4% and 9%, Stoke North 9.2% and 8.6%, Stoke South 9.3% and 9.3% and Moorlands PCT will receive 8.1% and 8.8%. This will result in 2007/8 of an allocation of £1384 per head of population in Newcastle, £1618 in Stoke North, £1504 in Stoke South and £1347 in Moorlands against a national average of £1388.
GPC News Items
QOF and the Freedom of Information Act (FOIA)
The GPC is aware that in England, PCTs are receiving a number of requests to release practices’ aspiration points, and interim achievement results following QOF visits. Currently there is confusion among PCTs and practices about what information they need to make available under the Freedom of Information Act (FOIA). The GPC has agreed with the Department of Health that where all the information was formally recorded with the PCT, and is available in complete form, as is the case with aspiration payments, then this should be released under the Freedom of Information Act. However, there is reservation about interim achievement results being released, especially given that not all QOF visits have been completed and the accompanying guidance that should go with achievement results has not yet been agreed. Further advice is being sought and NHS Employers will be issuing guidance to PCTs about how to respond to FOIA requests shortly. The GPC will in turn issue guidance to GPs.
Quality and Outcomes Framework: National Prevalence Day
As LMCs will be aware, Disease Prevalence Day, 14 February, is less than a month away (though data relevant to the period up until and including the 14 February will continue to be collected until the 31 March – National Achievement Day). The link below to Department of Health guidance gives a useful overview of disease prevalence and how it is calculated. NB. This guidance applies to England only.
www.lmc.org.uk/prevalence_guide_v12.pdf
GPs might also find it helpful to re-read the ‘Focus on QMAS’ guidance note as produced by the GPC secretariat in October 2004.
www.bma.org.uk/ap.nsf/Content/FocusQMAS1004?OpenDocument&Highlight=2,focus,on,QMAS
The GPC will be producing a ‘Focus on achievement payments’ document in due course.
Tidying of QOF data
Practices should remember that prevalence factors that exist on 14 February 2005 will be used as the prevalence factors in calculating the year’s payments. The calculation of the prevalence factors that applied on 14 February 2005 will not take place until 31 March 2005. The data are collected for automated practices on 14 March allowing practices to bring all data up to date. However, we strongly suggest that practices should not leave the tidying up of data to the last minute and should begin the process as early as possible. Further information is available in the ‘Focus on QMAS’:
www.bma.org.uk/ap.nsf/Content/FocusQMAS1004
Normalisation
Following queries from LMCs that, despite increases in list size, some practices have been receiving lower payments in one quarter for their global sum than in a previous quarter, the GPC has written to the Department of Health outlining a potential problem with the application of the normalisation process. In these instances, practices’ actual list sizes have increased but the weighted lists were going down with a consequent decrease in the global sum payments, yet no dramatic changes in patients characteristics have occurred.
The Department of Health has confirmed that, through a fault in the Exeter payment system, a new normalisation factor each quarter was being calculated and applied, rather than applying the factor calculated at the beginning of the year, throughout the year. Appropriate software changes to the Exeter payment system have been agreed and, in areas where payments were made mid month, a decision has been taken to delay payments in quarter 4, in order to correct this. Practices can expect to receive accurate quarter 4 payments very soon, if they have not already done so.
Quarter 1 payments should have been correct, however payments for quarter 2 and 3 will be incorrect, and practices with increasing populations have been underpaid for this period, and those with decreasing populations have been overpaid. The Department of Health and ‘Exeter’ are running tests on possible solutions to correct this problem. Additionally the GPC will be meeting with the Department of Health to discuss potential solutions to deal with the over and under payments later this month. This problem is limited to England and Wales, and is not an issue in Scotland and Northern Ireland.
Lithium ranges in QOF Mental Health indicators
Practices have raised concerns about the lithium range specified in the QOF and QMAS (0.6 - 1.0) where there are different local therapeutic ranges.
Although the achievement score and payment will initially be calculated by QMAS using the specified range, the PCT has the ability to amend a practice's achievement score after the 31 March. It can amend the numerator and denominators for the practice to show the correct figures as calculated using a local range.
There are two routes to this: the practice can approve its achievement and the PCT then amend it before payment (a revised score/payment will be presented to the practice for reconfirmation); alternatively, and probably the most sensible route, the PCT can make the alterations before the practice approves its achievement.
All this is predicated on the practice/PCT knowing the correct numerator and denominator figures for patients monitored using the local therapeutic range, for which an alternative extraction tool will need to be used.
Interim Dynamising Factor
The interim pensions dynamising factor for 2005-06 has been agreed. An estimated factor of 12.0% has been confirmed and at a 90% confidence level, the interim dynamising factor will be 7.3%. This means that the total dynamising factor estimated for 2003-06 is potentially over 30% which is in line with initial predictions. The GPC will be updating the ‘focus on dynamising factor’ guidance shortly to reflect these figures.
Access and the Primary Care Access (PCAS) Questionnaire
A new question on the PCAS return for the November survey in England, which asked how far in advance patients are able to book an appointment with a GP led to a number of enquiries from GPs. The main concern for the GPC was that we had not had advance sight of the question for which the list of potential answers included allowing for patients to book up to four weeks or longer in advance. This clearly goes further than the 24/48 hour access covered by the specification for Access Directed Enhanced Service.
This was raised with the Department of Health before Christmas, and it has now confirmed in writing that practices’ responses will not have any bearing on the access bonus payment under the QOF for 2004-05, and that this will be based on actual performance as reported through PCAS on the established questions for the period December 2004 to March 2005. The Department also confirmed that practices need only comply with the current DES specification or with any local variation already agreed with the PCT.
GP retainer scheme model contract
The GPC's model contract for the GP retainer scheme has recently been revised and is now available on the BMA website (www.bma.org.uk/ap.nsf/Content/Hubretainerscheme). This is based on the minimum terms and conditions for salaried GPs employed by a GMS practice or PCO since April 2004 (the model salaried GP contract) with some enhancements. It also takes account of the specific conditions of the retainer scheme. We advise that the retainer model contract is read in conjunction with the GPC's ‘Focus on salaried GPs’ guidance note.
GP appraisal
We have recently written to the Department of Health asking for appraisal form 4 to be revised to ensure that it is clear that the form must contain the appraisee's name, GMC number and signature. This is to ensure that the form is attributed to the correct person, as there was an example of an appraisee only signing the form and the form then being attributed to the wrong person! In the meantime, GPs undertaking their appraisal should ensure that the correct information is contained on their appraisal form 4.
Chickenpox vaccination
On 4th December 2003 the Chief Medical Officer issued a circular regarding the new chickenpox vaccination policy. This recommended that all non-immune healthcare workers in general practice who have direct patient contact should be offered the vaccine and that it is for PCTs to implement a timetable which reflects local circumstances and resources. We are aware of some PCTs who have not yet offered this vaccine to those with direct patient contact in primary care. Given that the CMO’s circular was issued over a year ago, we have asked the Department of Health for a deadline to be set by which time all PCTs should have implemented this.
Tax Guidance
The BMA have recently updated the following tax guidance on the website:
Tax guidance 1: Tax for the newly qualified doctor Tax guidance 2: Income tax and the employed doctor Tax guidance 3A: Income tax and partnerships Tax guidance 3B: Income tax for general practitioners Tax guidance 3C: Income tax for consultants Tax guidance 4: Capital gains tax guidance 5: Personal pensions Tax guidance 6: National insurance contributions
These are available on the BMA website at
http://www.bma.org.uk/ap.nsf/Content/Hubasktax?OpenDocument&Login
Please note that you will need to log on to the BMA website in order to access this information - if you would like a reminder of your user name and password click on the following link - https://www.bma.org.uk/UVAR.nsf/passr?OpenForm