NEWSLETTER February 2008
Methotrexate and DMARD Prescribing
0844 numbers - information for surgeries
Medicines administered in nurseries
Contract Issues
Copies of correspondence from the GPC concerning the current difficulties with contract negotiations have been circulated by email. Copies of the various letters can be found by following the links below. The LMC held a meeting on 5th February which was attended by approximately 120 GPs. A presentation of the then current position was made followed by a discussion.
The forthcoming poll created a lot of debate as to how the question should be phrased. It was felt important that we should have the option of indicating our feelings that neither option was really acceptable even if we felt that accepting A under duress was better than rejecting and having B imposed. There was a strong feeling that the question should be a matter of just accepting or rejecting the offer rather than having any positive vote for option B. Colleagues also suggested that there should be a separate question about having no confidence in the government and its running of the NHS.
Quite a few GPs felt we should continue to try and negotiate with the DoH because there are clearly practical problems with such a rigid enforcement, these included
 | Access to rented premises during extended hours – who is going to open up PCT owned health centres |
| Security for GPs/staff working late at night |
| Employment law problems in changing staff hours |
| The impact on other services provided by GPs – out of hours, GPSI clinic, PBC etc. |
| Increases in defence union subscription for part-time doctors forced to work more hours |
There was support for not co-operating with the DoH particularly stopping C & B, using smart cards, persuading patients against having their medical histories uploaded on to the spine etc. Neither the GPC nor LMC can make suggestions which can be construed as industrial action, and practices will have to make up their own minds as to whether they continue work which is not funded or non-contractual.
At the end of the meeting a show of hands showed a 1/3 split for accepting the offer A and 2/3 against. Since the meeting the GPC has discussed both options further and come to the conclusion that the acceptance of the Department's offer (option A) will be less damaging to practices. Whichever option we end up working under, the provision of extended hours will be optional.
Laurence Buckman, Chairman of the GPC has produced a letter to GPs concerning the current positions regarding contract negotiations and the forth coming poll of GPs. This has been distributed electronically to GPs who are registered with the BMA and can be found on their website at http://www.bma.org.uk/ap.nsf/Content/letterprofessionfeb08. It is important that GPs read carefully this letter and the associated documents.
This doesn't answer all our questions about the options available and no doubt some points will not become clear until the DoH publishes the details of the extended hours DES. It is not clear as to whether GPs must be open 8 – 6.30 Monday to Friday before they can qualify for any extended hours DES/LES payments, neither does it clarify whether extended hour sessions have to be additional capacity. Until the actual DES specifications are published the definite answer to these questions will not be known
The advice about whether to provide PCTs with details about current surgery hours, doctors, nurse sessions etc. remains the same. i.e. do not provide information at present.
The GPC will be seeking the views of the entire profession, via a poll taking place between the beginning of the week commencing Monday 18 – Friday 29 February, about their contractual options for 2008/09 and their opinion about the current state of the NHS and it is vitally important that all GPs respond.
A copy of the letter sent out by Dr Lawrence Buckman on December 20th can be found here.
A copy of the letter sent out by Dr Lawrence Buckman on January 8th can be found here.
A copy of the letter sent out by the GPC on 25th January for practices to give to patients can be found here.
A copy of the letter and documents giving more information about the current state and the poll of GPs can be found on the BMA website by following the link http://www.bma.org.uk/ap.nsf/Content/letterprofessionfeb08.
The GPC has prepared a patient newsletter for practices to display in their surgery waiting rooms to encourage patients to support their GP practices a copy can be found here.
Elections to the Committee
There has been a good response to the request for nominations for half the places on the LMC. 14 nominations have been received for 10 places. You should receive voting papers soon. Voting is counted by a Single Transferable Vote System. You should mark your choices in order of preference. Papers need to be returned to the LMC Office by Tuesday 18th March.
GP Systems of Choice
The GPC recommend that practices should sign up to the GPSoC scheme. As a committee we had reservations over this given the problems experienced with Choose and Book and our worries therefore that any transfer over to centrally hosted services would result in an unworkable system. However, we are assured that no practice will be forced to change their GP system supplier or to use a centrally hosted system unless their are happy to do so.
PCTs are being asked by NHS Connecting for Health (CfH) to include all practices in a GPSoC “call off agreement" There will be no change to the system that the practice uses and this is a technical exercise in order for the PCT to secure the necessary funding for GPSoC and to continue funding their obligations for current practice IT support. GPC considers this to be a sensible and efficient method of proceeding on the basis that GPSoC delivers what the profession asked for in the 2003 negotiations.
It could be the case that some practices will not be signed up because their system is not GPSoC Level 2 compliant. If this is the case, the practice concerned should approach its PCT to discuss its options. These would include checking whether the supplier of the practice’s current system is planning to provide a GPSoC Level 2 compliant version or, potentially, to begin the process of migration to a GPSoC Level 2 compliant system.
In the event that a practice has taken a business decision not to be involved in GPSoC, the onus would be on the practice concerned to inform the PCT of its decision in writing. Technically, PCTs would still have a responsibility to fund those practices that decline to join up, but there will be increasing pressure to move onto GPSoC, or LSP (Local Service Provider) contracts due to financial pressures and compliance requirements. GPC cannot envisage circumstances in which a practice would take a business decision not to be involved in GPSoC, given that it delivers what the profession asked for in the 2003 negotiations
The PCT-Practice Agreement has now been approved by GPC, the SHAs and the GP IT system User Group chairs. This Agreement clarifies both PCT and practice responsibilities under GPSoC and is applicable to all practices, whether GMS or PMS, and not just those who wish to move systems. For practices who do not intend to change systems, it clarifies the rights and responsibilities of the PCT and practice. For practices that are intending to change systems it clarifies the process to be followed. It also details the dispute resolution arrangements. The PCT-Practice Agreement is independent of the practice’s GMS or PMS contract.
The PCT-Practice Agreement will have to be signed by all practices who are signed up to GPSoC. Signing up by PCTs and practices will be undertaken subsequent to PCT sign up to the Call Off Agreement and CfH have set a deadline of the end of April 2008 for practices and PCTs to sign their agreements. Detailed guidance on the PCT-Practice Agreement will be issued by the GPC shortly.
It is important to note that practices are still the data controller under GPSoC.
Further information about GPSoC can be found at:
www.connectingforhealth.nhs.uk/systemsandservices/gpsupport/gpsoc
Improving Care Pathways
This is joint paper produced by the General Practitioners Committee (GPC) and the Central Consultants and Specialists Committee (CCSC) which discusses how commissioners can assess whether resources and capacity within the NHS are utilised efficiently and where this is not the case, that care pathways are put in place to support practice based commissioning (PBC) and the development of care closer to home initiatives. A copy can be found here.
Practice Based Commissioning
The GPC has produced two new guidance notes:
| The dual role of practice based commissioner and GP provider: avoiding conflicts of interest and ensuring probity; and |
| Practice based commissioning in 2008-09. |
Methotrexate and DMARD Prescribing
There has been an ongoing discussion with the Rheumatologist concerning shared care agreements for patients who they are treating with methotrexate and other drugs. A shared care agreement has now been drawn up which details the responsibilities of the Specialist, General Practitioner and Patient. This should be introduced in the near future when some glitches in the system for ensuring we receive copies of the relevant pathology reports have been sorted.
Practices will receive copies of blood results performed as part of the monitoring of patients by the Rheumatology Clinics. These should be clearly marked "Rheumatology Monitor". The Rheumatologists will act upon any abnormal results, however, they appreciate that GPs receiving these results may also feel that they have to act on abnormal results. Please note that we will receive these result by the pathlab links system before the rheumatologists. Please do not alter any rheumatology prescription without liaison with the department unless it is a clear emergency. Colleagues who wish to check that any abnormal results have been received by the department and that appropriate action is being taken, can contact the Rheumatology Monitoring Clinic on 556283.
Shared care agreements for the prescribing of other DMARDs will follow.
Colleagues are reminded that following a recent incident in 2003, in which a patient took an accidental overdose of Methotrexate tablets, the Local Pharmaceutical Committee and the LMC agreed that as a matter of policy, only 2.5mgs tablets should be prescribed and dispensed. The PCT pharmaceutical advisors agreed with this policy and wrote to their GPs and Pharmacists concerning this. I have heard anecdotal evidence that some patients in North Staffordshire are receiving prescriptions for 10mgs tablets. Practices are recommended to review their patients who are on Methotrexate and to abide by this policy.
Darzi Review
Stoke-on-Trent PCT has consulted with the LMC on the provision of the practices it is required to provide following the Darzi Review. Two new practices will be created these being sited in Meir and Middleport. Specifications for the practices are being drawn up and are expected to include
| An expectation the GP will be allocated the majority of patients within Nursing Homes and required to carry out pro-active ward rounds |
| An expectation that a number of patients considered to be frequent flyers into acute care will be cared for. |
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An expectation to receive allocations of patients that are difficult to place |
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An expectation to pick up pro-active care to the housebound and pro-active care in sheltered housing. |
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An expectation to perform "QOF plus" standards within the contract value. |
These new practices will be expected to have combined lists of about 18,000 patients. It is recognised that this will result in there being less patients on other practice lists. This will give GPs a better working ratio with patients. However, in order for GPs not to lose income a system is being devised to reward practices meeting "QOF plus" standards. It has not been decided yet as to what the "QOF plus" standards will be but these will be in place prior to the first of the new practices being open. The standards will be discussed with the LMC prior to implementation. The PCT wish there to be a level playing field and an opportunity for other GPs to continue to earn at existing levels for improved quality. All practices will be given the opportunity to perform to QOF plus standards and receive remuneration for this.
LES for Follow up patients
Stoke-on-Trent PCT has now circulated a LES for the follow up of some patients discharged from the haematology or gastroenterology departments of the UHNS. North Staffordshire PCT is still considering introducing a similar LES. The LMC hopes that all practices will take up this LES. It is an opportunity to bring resource into general practices and we argued strongly that this LES route should be taken rather than the alternative of providing the follow up services via alternatives such as GPSI clinics.
Items from the GPC
The GPC debated the current options (A and B) for contractual change for 2008/09 proposed by the Government. Option A is the governments’ offer which in England, Scotland, and Wales includes a proposed extended access Directed Enhanced Service (DES). In Northern Ireland extended opening is not a priority. Option B is the alternative that will be imposed in England, Wales and Northern Ireland if option A is not accepted, and an alternative proposal in Scotland based on option B. The possible consequences of accepting or rejecting the Governments’ proposals were discussed.
In the coming weeks a poll will be sent to all GPs in the UK to seek the views of the profession on these proposals. Details of the proposals in all four countries will be clarified and sent out with the poll documents. The GPC will continue to work with NHS Employers to clarify the details of the options and the wording of the extended access DES and continue to seek improvements to the terms of the DES.
The GPC debated and passed the following motion –
That the GPC has come to the conclusion that Option A is less damaging for general practice, because the alternative option will harm the underlying fabric of NHS general practice more quickly and more lastingly.
This was after an assessment that, whilst both options were highly undesirable, Option B would remove significant amounts of funding from the contract, particularly through the permanent removal of 135 QOF points, and would not guarantee that the governments would not try to do the same or worse next year. The GPC negotiators believe future negotiations would be more difficult if imposition B was to be the final outcome and would not result in the Department re‑opening negotiations. It was felt that this was not the ideal battleground on which to engage and the public debate needs to be focused more on the wider threats from the increased privatisation agenda and the implementation of the Darzi proposals rather than extended hours.
The GPC continues to have serious concerns about Option A and that GPs are having to select from two options, both of which it considers to be unacceptable. However, it was decided that the committee should take a view on the options as many GPs were asking for the GPC's opinion in advance of the poll.
Of particular concern with Option A is the rigidity of the DES for extended hours and the way the Government is approaching this whole issue. The negotiators will continue to push for changes to the DES, because, as it stands, it is believed few practices would be able or willing to do it. There will be increased efforts to convince MPs and patients that Government plans are misguided, and that attempts to micromanage practices from Westminster are a recipe for increased patient dissatisfaction.
A third letter to the profession from the GPC chairman analysing the options and their implications will be sent via email to all GPs next week, prior to the start of the poll. The committee also discussed the questions to be included in the poll, which will now be finalised and the poll sent to all GPs later this month.
Further information is available on the BMA website here:
www.bma.org.uk/ap.nsf/Content/Hubthenewgmscontract
The committee discussed a paper that looked at potential changes to the calculation of the QOF prevalence calculation. LMC Conference policy states:
That conference believes that the GPC should address injustices in the QOF including the need for a disease prevalence formula that reflects true workload and avoids the inequities in the present system.
In order to address the inequities of the present system, the GPC and NHSE have been investigating the possibilities for change. This initial paper looked at removing the 5% cut off and the square rooting calculation. This would result in a redistribution of current monies across practices that more accurately reflects actual workload. For many practices the change in calculation whether up or down, would not have a major effect. There was however some concern that for a small minority of practices the change in calculation could result in significant losses. The committee was happy to continue to pursue this issue in principle but will look at it again when the GPC has received more statistical data showing the real financial impact across practices. The NHS Information Centre is providing the key information for making these judgements and the BMA's Health Policy and Economic Research Unit is analysing the data and the impact.
NHS Connecting for Health (CfH) has informed us that in Spine release 2008-A, they will amend patient data in the Personal Demographic Service (PDS), such that the patient will be registered with the practice rather than a GP. This is to align the PDS with the 2004 GMS Contract Regulations.
In the course of preparing the Spine update, CfH has identified that a number of GPs have not registered for a smartcard. Whilst this is their prerogative it is possible that their lack of registration could lead to problems in them being identified by the "Exeter" payments agency for Item of Service type payments and for the maintenance of their patient lists.
Those GPs without smartcards will be contacted in the next few weeks asking them to consider applying for a card.
We would be grateful if LMCs would advise their constituents about this issue and the consequences of not having a smart card.
If there are any concerns about this issue please contact Matthew Isom in the GPC Secretariat at misom@bma.org.uk.
0844 numbers - information for surgeries
There was a recent parliamentary debate on the charges patients are paying when ringing practice 0844 numbers, in particular when they are using mobile phones. We have since looked into this matter further. It would appear that where 0844 numbers are used by practices, there should be mention of the charge for phone calls in the practice's information leaflet. There is no need, however, for a message on the actual telephone system itself. While patients' telephone providers may have a variety of charges, in any practice information the price relevant to most consumers should be stated. We are aware that there are probably few practices aware of this aspect of advertising practice so we would ask LMCs to cascade this information.
Pandemic Flu
The Department of Health recently brought out revised guidance on responding to an influenza pandemic. This included a revised National Framework and guidance specific for healthcare in a community setting aimed at PCTs and primary care professionals. As both these documents are over 100 pages long, the GPC has created two summaries for LMC to read and share with GPs and a covering letter highlighting the key elements addressed. These documents are:
Appendix 3 - Pandemic flu summary front sheet
Appendix 4 - Pandemic flu national framework summary
Appendix 5 - Pandemic flu care in community summary
Unlike seasonal flu a pandemic could strike at any time and will put severe pressure on existing services. It is important therefore that LMCs involve themselves in the key decisions around surge capacity, the transfer of responsibilities, maintaining practice continuity as far as possible across the health care community and aiding practices with service continuity plans and exercises.
The full set of pandemic influenza documents can be downloaded from: www.dh.gov.uk/en/PandemicFlu/index.htm
Medicines administered in nurseries
It has been brought to the attention of the Clinical and Prescribing Subcommittee that the revised 'The Early Years Foundation Stage Statutory Framework' which governs the standards of institutions looking after and educating children, includes a paragraph under specific legal requirements - medicines, that states: 'Medicines should only be taken to a setting when this is essential and settings should only accept medicines that have been prescribed by a doctor, dentist, nurse or pharmacist.' We are aware that in some areas this is resulting in parents making unnecessary appointments to seek a prescription for an OTC medicine just so it can be taken in nursery.
The Clinical and Prescribing Subcommittee reminds GPs that the MHRA licenses medicines and classifies them when appropriate as OTC (P or GSL). This is to enable access to those medicines without recourse to a GP. It is appropriate for OTC medicines to be given by parents as they consider necessary in the home or nursery environment. It is a misuse of GP time to take up an appointment just to acquire a prescription for a medicine wholly to satisfy the needs of a nursery. The Clinical and Prescribing Subcommittee wrote to the Department of Children, Schools and Families seeking an amendment to this paragraph in the Statutory Framework and we have now heard from that Department. They will amend their guidance to stay consistent with current national standards for day care and childminding whereby non-prescription medication can be administered when they have parents' prior written consent. Should anyone find that this continues to be a problem in their area, we can send them a copy of the letter from the Department of Children, Schools and Families that clarifies this situation.
GP Systems of Choice (GPSoC)
The draft PCT/practice agreement for GP Systems of Choice has been published on the Connecting for Health GPSoC website at the links below. This has been the result of a year's worth of negotiation between GPC and Connecting for Health.
Once implemented this agreement will be central to the process for practices and PCTs. We would be grateful to receive your comments as there will still be time to incorporate changes before final implementation.
Please send your comments to Matthew Isom at misom@bma.org.uk.
www.connectingforhealth.nhs.uk/systemsandservices/gpsupport/gpsoc/news/pctpractice.pdf
The link below is to the section of the GPsoC website which contains downloads of the GPSoC official guidance, letter to PCT Chief Executives, explanatory powerpoint presentations, and other guidance about GPSoC.
www.connectingforhealth.nhs.uk/systemsandservices/gpsupport/gpsoc/contacts
NHS Choices
Almost 3500 practices have now registered with the practice profile editing facility and nearly 1000 practices have published their own data.
There have been some issues with data entry and capture, which have caused frustration to some users. Therefore, in response to feedback, technical maintenance will be undertaken to the backend of the editing tool which should improve the situation. They would like to thank practices for their supporting for this initiative and request that if you have any questions, or would like assistance with editing your profile, to contact the helpdesk at gp@nhschoices.nhs.uk or 0845 4023089.