NEWSLETTER FEBRUARY 2007
Information Management and Technology (IM&T) update
Seniority payments following retirement
NHS pension schemes review update
Carers’ right to request flexible working
Statement of Financial Entitlements (Amendment) (No 6) Directions 2006
Psychiatric Services
The PCT will be producing a consultation document in the near future on proposed changes to mental health services. As we are aware, there are plans to decrease the number of CPNs in the area and increase the use of "graduate workers" thus providing a more "cost effective" skill mix. There is a lot of concern among colleagues and LMC members over the current provision of mental health services. Whilst it can be argued that it may not be appropriate for someone at the level of a CPN to provide some interventions, it is far from clear who will provide services and what services they will be capable of providing. The main driver for change appears to be financial considerations rather than patient care. It will be important for as many GP's as possible to respond to the consultation document when it is published.
Collaborative Fees
Following the DDRB’s recommendation in the 2006 Report, the BMA’s advice to individual doctors and GP practices is that they should establish their own fees for work under the collaborative arrangements. They should also notify their primary care organisation in writing that, as there is no longer a DDRB recommended fee, any request for collaborative work received after a set date will be charged at their own fee rate (the BMA recommends that a notice period of at least three months be set).
The BMA is very aware that doctors are the only individuals who can undertake many of the items of work under the collaborative arrangements. Therefore, doctors will need to strike a balance in setting their own fee making sure their remuneration levels and overheads are charged on a time basis. There is nothing under competition legislation that prohibits doctors from publishing their individual fees to their Primary Care Organisation, but fee levels must be reasonable, transparent and be subject to scrutiny where necessary. The BMA strongly advises that fees should be set out in writing and agreed in advance of the work being undertaken.
In accordance with the framework of the law laid down by the Competition Act 1998, the BMA is prevented from publishing suggested fees for services which can be provided by any doctor. Therefore, the Association will be unable to make any suggestion on fee rates for work in this area. Advice regarding collaborative fees has recently been published and a copy can be found here.
DLA Fees
The Department for Work and Pensions has agreed to an increase in fees paid to GPs for the completion of factual reports for disability living allowance and attendance allowance and has confirmed that a new fee of £33.50 will be effective from 1 January 2007
VAT on Medical Services
HM Revenue and Customs has announced that the implementation of VAT on medical services will take effect from 1st May 2007, subject to House of Commons approval. Essentially, the ruling means that if the principal purpose of the medical service is the protection, maintenance or restoration of the health of an individual then the services will continue to be exempt from VAT. Primary heath care provided through either the NHS or the private sector will remain VAT free. However if the purpose of a medical examination or report is to enable a third party to decide a course of action the medical services will not be VAT exempt, but subject to VAT at 17.5%
Therefore, medical practitioners whose (VATable) taxable income exceeds the VAT registration threshold (currently £61,000) will need to register for VAT. Similarly medical practitioners who are already VAT registered, for example as a result of dispensing changes, will also need to ensure that they account for VAT on any affected services from 1st May 2007. Further details of the announcement and general information on the ruling can be found in the fees section of the BMA website at http://www.bma.org.uk/ap.nsf/Content/VATonmedicalservices
Ethnicity Recording
Dr Giri Rajaratnam, Director of Health Policy, Stoke-on-Trent PCT has requested that practices make every effort to record the ethnicity of their patients. Although we may feel that recording this information is unimportant, it is necessary to enable to the PCT to provide accurate data and thus bid for adequate funds to resource the health problems which may be more prevalent in some ethnic groups.
Charges for Non-NHS Work
The BMA has produced a document detailing the circumstances where GPs may or may not charge patients. A copy can be found here.
Connecting for Health
The BMA has produced a note as part of a series of guidance documents on Connecting for Health. Connecting for Health will significantly impact upon your working practices and therefore it is important that you are fully aware of developments. This guidance note provides an update on the NHS Care Records Service (NHS CRS) following the publication of the Ministerial Taskforce Report in December 2006. This note also provides answers to some frequently asked questions. The NHS Care Record Service is under development so this guidance represents the current position and will be updated to reflect future changes. This can be found on the BMA website at http://www.bma.org.uk/ap.nsf/Content/taskforcereport
Pensions
Most GPs will now be aware that the Secretary of State has announced her intention to limit the dynamising factor (DF), used to uprate GPs’ pensionable earnings for the period 2003-2006. She has declared that the figure will be set at 48% and, additionally, that this increase will be spread over a five-year period (2003-2008) instead of the 3 years (2003-2006) that GPs have earned the income and paid the equivalent contributions for their pensions. The BMA has produced a FAQ on this, a copy can be found here.
Locum Fee Guidance
In 1999 the BMA stopped publishing "suggested fees" for locums following advice from the Office of Fair Trading that such action was anti-competitive. The BMA in conjunction with the National Association of Sessional GPs has now produced guidance for negotiating fees for locum services in general practice. The document is intended to inform GPs and other providers who engage locums of the range of professional expenses incurred by locums, as well as ensuring that locums recognise their true value. The document can be found on the BMA website at http://www.bma.org.uk/ap.nsf/Content/locum
Excessive Prescribing
The GPC has produced a guidance note on Excessive Prescribing. This is in response to queries they have had, where there clearly seem to be a difference in opinion between LMCs and PCOs in relation to Annex 8 of the Revision to the GMS Contract 2006-07. The guidance can be found here.
Patient Experience Survey
The "Focus on PES" document issued by the GPC in October has been amended and the new version can be found here.
The advice issued about Health Reference Forms required by the General Dental Council has also been updated and the updated version can be found here.
GPC Items
Information Management and Technology (IM&T) update
NHS Summary Care Record
Lord Warner announced the findings of the Ministerial Taskforce on Monday 18 December. The report suggested a process that involved a compromise between the pure opt-in and opt-out positions.
Essentially it recommended an immediate start to the national publicity campaign, which is something the BMA has been calling for for 2-3 years. There will then be local campaigns when the summary care record (SCR) is due to go live in a specific area. At that time, patients will be encouraged to view their summary via HealthSpace, on a print out or directly. There will be a reasonable period (yet to be defined) during which the opt-in position will be the default position. Patients will be encouraged to agree that the summary they have looked at is accurate and consent for this information to be shared via the SCR. After this ‘reasonable’ period those patients who have not expressed any opinion will be deemed to have given implied consent for sharing a summary, which, in the first instance, will only cover drugs and allergies.
However, there are a number of unresolved issues. Firstly the ability of patients to truly prevent an upload to the spine needs to be dealt with. We have made public statements to this effect. It is hoped that the establishment of a new advisory group on the implementation of the SCR, to be chaired by Martin Marshall, Deputy Chief Medical Officer, will address this. Putting in specific codes at this stage may not be the best approach as they can be ignored if the system creators so wish and may not offer patients protection.
The workload issues relating to discussions about the upload also have to be addressed. Whilst the BMA is actively pushing for an opt-in process, we are aware that this brings huge additional workload implications. We have said that practices would rather see this than an opt-out process with minimal workload and a breakdown in patient trust in their GP. It should be underlined that only pilots are being proposed at the moment but we are absolutely clear that we have to see this additional work resourced. At the moment the IT DES covers data accreditation, but it does not cover connecting to the spine, or the patient discussions about this. Only practices that have gone through the data accreditation process successfully will be in a position to upload any data at all.
Despite Lord Warner’s statements, nothing has been agreed, and we await the results of the pilots to see how things work in practice.
GP2GP
Version 1.0 of the GP2GP system (allowing same system patient record transfers between practices using either EMIS LV or INPS Vision 3) is now live in almost 300 practices and rollout will continue in the New Year. Version 1.1, which allows transfers between different systems, is now live in a small number of early adopter INPS Vision 3 practices in Croydon, which will be joined by EMIS LV practices early in 2007. Once testing of the interoperable version is complete in Spring 2007, rollout will commence, and the GP2GP project team will be looking to recruit participating practices from early in the year. Interested practices should liaise with their PCT as the preference is to roll the system out across communities (ie in clusters of practices rather than individual practices) to maximise the benefit from local patient movements.
IT DES Accreditation
PRIMIS + have recently released a new e-audit tool for GP practices, to support them to achieve accredited data quality standards and ensure their clinical data is ‘fit for sharing’ in the NHS Care Records Service.
Developed specifically by PRIMIS+ on behalf of NHS Connecting for Health (NHS CFH), the tool is designed to support the IM&T DES under the GMS contract. It will also facilitate IM&T adoption within GP practices, will enable ‘paper light’ practices to benchmark and improve the quality of their clinical data and will support delivery of the National Programme for IT, which is being delivered by NHS CFH.
The e-audit, available in the PRIMIS+ CHART software meets a key objective of the IM&T DES and was developed in collaboration with a number of professional organisations, including the GPC, the RCGP and NHS Employers, to ensure the queries to support the accreditation standard are appropriate.
Further information can be found on the PRIMIS+ website: www.primis.nhs.uk
PCT funding of IT equipment
The GPC are aware that some PCTs are refusing to fund the purchase of IT equipment and upgrades. They ask to be kept informed when this occurs so that the JGPITC can assist. Details should be sent to arivett@bma.org.uk
Seniority payments following retirement
There has been some discussion about whether a partner is entitled to seniority payments if they return to work part-time as a GP partner after a period of retirement. The GPC can confirm that any provider who has completed at least two years of service as a GP provider will be eligible for seniority payments. Payment will depend on years of service so retirement years will not count towards this. Therefore a GP who returns as a provider following retirement will be eligible for seniority payments provided he/she has at least two years of previous service as a GP provider. Further information is available in the GPC Focus on seniority guidance note FAQs.
Members received copies of the recent NHS Service Delivery and Organisation Research & Development Programme (SDO) briefing paper ‘Can choice for all improve health for all? The evidence on whether NHS patients can and should become consumers of health care’. Although this document is currently unavailable online, a copy can be found here. The committee also discussed the consultation paper by the RCGP ‘Choice, contestability and competition in general practice services – what does this mean for patients, practitioners and the public?’ which is available online at the following website address: www.rcgp.org.uk/extras/ethicschoice/Contractingoutcollegepaper22Nov.doc.
Both documents received the unanimous and overwhelming support of the committee and members expressed their concern over the widening gap between meaningful patient choice and the Government’s choice agenda. The GPC will develop a position paper, in collaboration with the RCGP and the BMA’s Patient Liaison Group, on patient choice in due course.
The Disability Discrimination Act (DDA) includes a new general duty on public authorities to eliminate unlawful discrimination against disabled persons and promote equality of opportunity between people with disabilities and other persons. The definition of discrimination has been broadened, and can now include ‘not making a reasonable adjustment to the way the public authority function is carried out.’
However, it should be noted that:
• GPs are only public bodies for Freedom of Information Act purposes
• For the purposes of the Disability Discrimination Act, there is no regulation to say that GP practices need a disability equality scheme
• The obligation under the Act is on the PCT
• Like all employers, GP practices should make reasonable moves to comply with the DDA, but this is slightly distinct from having a specific disability equality scheme
Private practice is still significantly restricted under the GMS contract. The regulations prevent contractors from charging their patients for most services. There are however instances where charges may be made. In the current climate, there is an increasing tendency for private companies to provide services to NHS patients and the BMA as a consequence is receiving a growing number of queries in relation to the topic. The GPC will issue guidance to address these queries and to outline the circumstances when charges to NHS patients are allowed. This will be available in early January 2007.
Monitoring the introduction of APMS providers
The GPC is aware that, in some areas, pressure is being put on PCTs to contract with APMS providers or to enter into national tendering arrangements, even in situations where PCTs believe they can introduce acceptable, alternative solutions. The House of Commons Health Select Committee published a report into Independent Sector Treatment Centres (ISTCs) in July 2006. Many of the issues the report raised overlap with the GPC’s concerns surrounding APMS providers. A summary of the key findings are listed below and we would like to encourage LMCs, in the areas where APMS does look set to grow, to monitor the situation with specific reference to the issues raised below and to forward any information to the GPC office:
 | Value for money |
Some ISTC contracts contained financial guarantees whereby they were assured of a certain level of income, irrespective of the number of procedures performed.
| Clinical quality/good practice |
Whilst the report found no evidence to prove that standards in ISTCs differed from those in the NHS, it did reveal failings in the quality of data collection. The Healthcare Commission has previously found private providers’ performance and standards to be no better than the NHS.
| Provision of training |
Phase 1 ISTCs did not generally offer training opportunities.
The first phase of ISTCs was intended for areas where capacity was most needed. Phase 2 however has extended this provision and ISTCs will be used as part of reconfiguration plans. This could mean that hospitals close and ISTCs undertake the elective procedures in their place. Similarly, APMS was originally aimed at targeting a number of areas reported as being ‘under-doctored’ but has also now been extended to incorporate any number of areas.
Advice on tendering
The GPC is currently reviewing its package of guidance and advice available with regard to tendering and bidding for contracts. In the meantime, guidance is currently available on the BMA website, for members only, on bidding for contracts. Whilst this is part of the GPC’s wider guidance on APMS, the principles outlined within this section may be applied when tendering for all contracts. www.bma.org.uk/ap.nsf/Content/apms0406~bidforapms
The GPC is aware that the level of support offered by LMCs to practices on tendering varies throughout the UK. LMCs need to make an individual decision about what advice they give to practices but should be aware that it is important to ensure that all advice offered is unbiased and transparent, ie LMCs should ensure that those they represent are given equal access to the same advice. LMCs should also make sure they are covered by insurance to provide the advice given to safeguard against any future complaint or appeal for compensation about advice.
GPs working for APMS contractors
APMS has considerable implications for sessional GPs who may be employed, by other GPs or by commercial or voluntary sector organisations, to perform services commissioned through APMS contracts. APMS providers are not obliged to employ salaried GPs under the GMS model terms and conditions of employment using the salaried GP model contract. APMS providers may, therefore, choose not to use the salaried model contract in order to contain staff costs. GPs considering employment by an APMS provider not using the salaried model contract should be aware that their terms and conditions may be less advantageous than those employed by a GMS practice. The GPC recommends that APMS providers use, as a minimum, the terms set out in the salaried model contract. The GPC strongly urges GPs considering employment by an APMS provider to contact the BMA for advice. Guidance for GPs working for APMS providers is also available on the BMA website. www.bma.org.uk/ap.nsf/Content/apms0406~workapmsprov
NHS pension schemes review update
The review of the NHS pension schemes is underway in all three schemes (Scotland; Ireland; England and Wales). Communication material has been sent to all NHS employees and much more is available on the internet or by request. The BMA has prepared some explanatory papers including one explaining the reasons for the proposed contribution rate changes, an issue which has caused some concern among GPs. These are available to members on the BMA website www.bma.org.uk/pensions
Members can provide feedback of their comments to the pensions department via dedicated e-mail links for each consultation. Comments are required back by the end of November 2006 to help form the response.
In Northern Ireland use info.nipensionreview@bma.org.uk
In Scotland use info.scottishpensionsreview@bma.org.uk
In England and Wales use info.pensionsreview@bma.org.uk
The outcome of the consultation is expected to be published in January or February 2007. Guidance will be produced to accompany the details of the new scheme at this stage.
GPC workplan
The GPC is embarking upon a programme of strategic work to tackle some of the challenges facing general practice over the next few years. An action plan is being drawn up for the GPC, its subcommittees and the negotiating team.
Carers’ right to request flexible working
The government has recently announced that from 6 April 2007 the right to request flexible working will be extended to carers. This will have an impact on GPs as employers. A carer will be defined as an employee who is or expects to be caring for an adult who:
· is married to, or the partner or civil partner of the employee; or
· is a near relative of the employee; or
· falls into neither category but lives at the same address as the employee.
The Department of Trade and Industry intends to publish further guidance on flexible working for carers in the near future.
PMETB fees consultation
The GPC is currently working with other BMA committees on a BMA-wide response to the latest fees consultation by the Postgraduate Medical Education and Training Board (PMETB). The PMETB is proposing that the fees for a certificate of completion of training (CCT) should rise from £500 to £750, with Article 11 and 14 certificate applications increasing from £950 to £1,250 from 1 April 2007. The Association will be submitting a robust response to these unfair suggested changes, particularly since these fees were increased drastically earlier this year.
Receptionist triage
A number of queries have come into the BMA’s Public Affairs Division in relation to triaging in GP practices. The Public Affairs division is the part of the BMA that deals with queries from patients and the public, and works to promote the image of doctors. It would appear that a number of practices require their receptionists to ask patients why they want to see the doctor, sometimes including details of symptoms, before they will allow them to make an appointment. Patients report this experience as both intrusive and inappropriate. While there are no specific regulations which relate to the way practices choose to offer appointments or triage patients we would like to draw to practices’ attentions the following points:
1. The new GMS and PMS regulations state:
Patient preference of practitioner
18. - (1) Where the contractor has accepted an application for inclusion in its list of patients, it shall -
(a) notify the patient (or, in the case of a child or incapable adult, the person who made the application on their behalf) of the patient's right to express a preference to receive services from a particular performer or class of performer either generally or in relation to any particular condition; and
(b) record in writing any such preference expressed by or on behalf of the patient.
(2) The contractor shall endeavour to comply with any reasonable preference expressed under sub-paragraph (1) but need not do so if the preferred performer -
(a) has reasonable grounds for refusing to provide services to the patient; or
(b) does not routinely perform the service in question within the practice.
2. Any member of staff involved in patient triage should be properly trained or the practice may be at risk of litigation and complaint.
3. While all members of the practice team should be working within a code of confidentiality, patients have the right to decide who they disclose information to. This may be restricted to a few health professionals they trust and have a relationship with.
4. Any triage system should be open and transparent (ie: if there are limited emergency appointments then patients should be made aware that any questions asked are to decide which healthcare professional they should see either the GP or practice nurse.)
5. Telephone triage can be done successfully, as it is in Out-of-Hours services. In such circumstances receptionist staff are appropriately trained and can take a level of detail that enables them to signpost the patient to the correct form of care, whether that is speaking to or seeing the OOH doctor, OOH nurse or referral to A&E.
6. Information on the practices appointment system and how appointments are allocated should be put in the practice leaflet so patients know when ringing what they are expected to be asked and what choices they will get.
Strategy for urgent care
The Department of Health published a consultation in October ‘Direction of travel for urgent care – a discussion document’ which can be found online at the following website address:
A draft GPC submission for inclusion in the BMA-wide consultation response was discussed, as had been prepared following discussion on the issue at the GPC’s Commissioning and Service Development Subcommittee meeting of 2 November 2006.
Members expressed their strong concern over the apparent omission throughout the consultation document of GPs and their involvement in urgent care at present. There was agreement that in fact the majority of urgent care, both in-hours and out-of-hours (OOH), was delivered by GPs; either those working in GP practices or GPs working in OOH services. That many GP practices are no longer responsible for making the provision of OOH services did not affect this position. It was felt that the model for urgent care proposed in the consultation would not be accepted by patients and the public who almost certainly would continue to look to their GP practice as a first point of contact for urgent assessment. There was some discussion about the consequences of removing the urgent care element from general practice, the most significant being the harmful impact this would have on patient care. In addition, this would leave GPs to deal solely with chronic disease management, which would lead to the traditional ‘gatekeeper’ role being lost and one of the key incentives for training to become a GP, the variance and range of work involved, being diminished.
The committee was also keen to highlight the fact that a different and wider range of services were available in-hours compared with the OOH period and that patients should not be led to expect the same level of services OOH as during the day, as this was undeliverable. The NHS should aim to assess need in a timely manner 24 hours a day, 7 days a week to a good and consistent standard, but in relation to the response to this need, this would necessarily differ depending on timing.
The BMA’s Health and Economic Research Unit (HPERU) is coordinating the BMA’s response to the consultation, the deadline for which is 5 January 2007.
Statement of Financial Entitlements (Amendment) (No 6) Directions 2006
The directions which amend the SFE to take account of changes to the childhood immunisation programme have now been signed and are available on the Department of Health website at the following link -