NEWSLETTER JANUARY 2004
GMS2 Implementation Monitoring Group
Child and Adolescent Mental Health Services
GP registrars and out-of-hours training
Training practices and the summarisation of patient notes
Recommended standards for NHS HIV services launched
Doctors’ and Dentists’ Review Body
Editorial
It is now only 11 weeks until the “New Contract” comes into effect. At this stage practices are still unaware of the amount of funding they will receive from 1st April. We still await information on our Global Sum or Minimum Practice Income Guarantee, although we can estimate this from last year’s income. We can estimate our Quality and Payments from the Interim Aspiration Utility which we should have received from the PCTs but have no idea of any income which will come from the provision of enhanced service apart from those directed enhanced services which we may wish to continue to provide. PCTs are equally uninformed about these payments. Information from the DoH is slowly filtering out. Typically they published a lot of information on their website on 19th and 23rd December just prior to the Christmas holiday. In the next few weeks there is a lot of work to be done and it is certain that all preparatory work for the new contract will not be completed prior to 1st April. It remains to be seen whether the New Contract will achieve its objectives of improving the morale of existing GPs and stimulating recruitment. The signs are not good so far. Please notify the LMC of any problems you may have over the implementation of the New Contract.
Problems arising from the shortage of GPs in North Staffordshire have again been highlighted in the local press. This is a problem which is not going to be solved in the near future. In the meanwhile it is important that PCTs recognise the problem and do not exaggerate their successes in appointing PCT employed PMS doctors. Equally we have to be careful that painting a more gloomy and realistic picture does not have an adverse effect on recruitment.
Let us hope that by the end of this year General Practitioners will be better off in terms of morale, workload and finance.
New Contract
The Department of Health has issued a number of important documents since 15th December. These include:
· Draft Regulations (103 page document)
· Interim Aspiration Utility
· Statement of Financial Entitlements (116 page document)
· Draft standard contract between the practice and the PCO (235 page document)
Draft Regulations
These are the draft regulations which underpin the operation of the new contract. They can be found on the DoH website at www.doh.gov.uk/gmscontract/implementation.htm
Interim Aspiration Utility
This enables practices to calculate their 2004/5 aspiration payment under the Quality and Outcomes framework. PCTs should have sent out a practice specific excel worksheet to each practice by 15th December. This needs to be completed and returned to the PCT by 16th January. Remember, this is asking where you expect the practice to be at 31st March 2005 not how many points you score now.
The GPC has produced guidance on the completion of this document which can be found here. Computer suppliers are producing software to help with the quality part of the new contract. This is not yet perfect and there is a lot of work to be done to ensure correct coding and data entry.
Aspiration payments will be made from April, with a third of the total being payable in monthly instalments and the remainder at the end of 2004/5. Practices will then be paid for the points actually achieved whether higher or lower than their aspirations. It is in the practices best interests to aim high and improve cash flow, however, PCTs have to approve our aspirations and have a duty to ensure that they are reasonable.
Statement of Financial Entitlements
This is the new "Red Book" and replaces the Statement of Fees & Allowances. It details all the payments to which practices are entitled. It is another draft document and will no doubt be updated in due course. This document is also available on the DoH website at http://www.doh.gov.uk/gmscontract/implementation.htm.
This sets out in detail the way in which payments will be calculated and made to practices, including the arrangements for:
· the Global Sum
· the Minimum Practice Income Guarantee
· quality payments
· some directed enhanced services
· the out-of-hours opt-out
· PCO-administered services.
Draft Standard Contract
This is a long document and the basis on which the contract practices will have to sign up to with the PCT will be based. It contains all the mandatory regulations which apply to the contract. It will have to be adapted to a practice's own needs to reflect the services they wish to offer. This contract has been approved by the GPC's legal team and should not require a further legal view. Again this contract can be downloaded from http://www.doh.gov.uk/gmscontract/implementation.htm
The GPC has sent the following email to LMCs concerning
this document:
"The draft standard contract is a long document. This is because it is a
stand-alone document and must reflect all the mandatory terms from the
regulations that will apply to the contract between practices and PCOs.
The standard contract has been drafted by Counsel, and Departmental and GPC
lawyers have double-checked that it accords with the regulations which
faithfully reflect the new contract as agreed between the negotiating parties.
Practices that use the standard contract containing these terms are therefore
protected.
Contract terms
A great many of the contract terms are mandatory and therefore cannot be
amended. Practices and PCOs should not attempt to negotiate on these.
Other terms, whilst not mandatory, have been subject to the agreement between
the negotiating parties and these terms should not therefore need amending in
any way.
There are a small number of terms which will be particular to each practice and
will need to reflect the agreement between the practice and the PCO, and which
practices will therefore need to pay particular attention to. The main areas
relate to:
· what additional services the practice will be opting out of, if any
· what enhanced services the practice will be providing
· what level of quality the practice will be aspiring to
· whether or not the practice will be opting out of out-of-hours services"
Hard copies of the above documents will be printed this month and sent to all practices and PCTs. The GPC will be producing specific guidance for practices in due course.
Draft Guidance
This has been drafted by the Department of Health and
has been subject to negotiations between the GPC the NHS Confederation and the
Department of Health. Chapters of the guidance will focus on:
· the provision of services
· the quality framework
· HR and infrastructure issues
· finance
· the contracting process.
These chapters are not stand-alone documentation and must be read in conjunction
with the source legal documents, i.e. the regulations, the standard contract and
the SFE.
The Department will ensure that all practices receive a paper copy of the
contract guidance. Paper copies are, however, very unlikely to be with practices
before mid-January because of print timetables. We have pressed the Department
to produce all documentation on CD-ROM both in their draft forms and when the
final documentation is available.
What to do now
It is important that practices read and understand the new contract
documentation. This can be daunting given the combined length of the documents.
We suggest breaking the reading down into manageable pieces and then continuing
discussions with your Primary Care Organisation about reaching provisional
agreements on your contract.
Once all the documentation is published, we would suggest the following in order
of priority:
Step One
Read the contract guidance. Chapter one, which summarises everything in the
guidance, and chapter seven, which sets out the various timetables for
discussion and agreement on the contracts between practices and PCOs, are the
best places to start.
Step Two
Consider the standard contract and continue discussions with your PCO about
the services you will be providing under the new contract for agreement in your
contract.
Step Three
Aim to sign a practice contract with your PCT by the end of February. If
contracts cannot be agreed, there will be arrangements for a 'default contract'
to take effect. However, if there are outstanding issues, such as final
agreement over the price of a local enhanced service, or the exact level of the
overall budget, it will be better to sign a practice contract, highlighting the
areas of disagreement, so that the contract is in place by 1 April. This will
benefit practices in two ways:
· it will deliver better financial rewards into the practice sooner than
under the default contract
· it will enable you to use the contract dispute resolution mechanism if
there is an outstanding problem.
Any areas of disagreement can be dealt with through the dispute resolution
procedures which will be set out in the contract guidance.
We will be providing further information and guidance for practices very
shortly."
PMS Arrangements
The DoH has published a document on the future of PMS. This is a 115 page document concerning the future of PMS practices in light of the new GMS contract. This can be found at http://www.doh.gov.uk/pmsdevelopment/pmsarrangementsdec03.htm
New Contract Meeting.
The LMC is holding a meeting on Tuesday 3rd February at Stoke on Trent Moat House Hotel. We hope to provide more information on the new contract and will attempt to answer any questions arising from it. The PCTs have been invited to attend and be involved in the meeting.
LMC Elections
Elections are now under way for half of the LMC membership.
Amongst other matters, the duties and remit of the committee include:
Provide authoritative advice on all matters relevant to general practice in the area
· To maintain a continuing and appropriate relationship with the North Staffordshire PCTs and its executives, and advise them on all matters relevant to general practice
· To liaise, advise and consult with those bodies relevant to the interests of primary care in the region.
· To maintain close liaison with University, academic and other educational establishments as appropriate
· To consult, advise and co-ordinate activities between various interest groups in the area and co-ordinate responses to District and Regional initiatives pertaining to primary care
· To nominate suitable experienced general practitioners to membership of working parties and advisory groups concerned with health care.
The Committee consists of 20 general practitioners and usually meets on the afternoon of the second Thursday (bi-monthly) in The Masonic Building, Shelton. There is also a quarterly Locality Meeting when LMC members meet with PCT Chief Executives and PEC Board Members (currently held at Bucknall Hospital also on a Thursday afternoon).
The Term of Office is four years and members are paid an attendance allowance (currently £93.25) and travel expenses
Nomination Forms have been distributed and if you wish to stand, or to nominate a colleague, the last date for return to the LMC office is Friday 6 February 2004.
GMS2 Implementation Monitoring Group
The implementation of the New GMS Contract presents a major challenge to PCTs, therefore, to ensure that best practice is shared and to try to prevent duplication of effort, it has been agreed that a GMS2 Implementation Monitoring Group be established. It is proposed that PCT leads for implementation, together with colleagues from the LMC will meet on a regular basis in the run-up to the New Contract and for as long as it appears fruitful to continue. An LMC member attends the Steering Group meetings in each of the four PCTs.
Clinical Interface Group
The new Clinical Interface Group which provides a point of liaison between clinical colleagues in primary care, PCTs, the LMC and clinical colleagues from the Hospital Trust is now meeting monthly to discuss issues of joint interest. This replaces the old GP Liaison Group and has more formal ties and accountability. It is jointly chaired by Dr Pat Chipping and Dr James McCarthy. It is hoped that this group will be in a position to inform the commissioning process and also solve difficulties at the interface between primary and secondary care as they develop.
Emis Referral Templates
A number of templates, including the 14 day wait cancer referral templates have been uploaded on to the LMC website and are available for colleagues to download and use. They can be found in the "Emis Documents" section.
Cremation Forms
The Home Office has issued advice to practitioners completing cremation forms B & C, commonly referred to as parts 1 and 2. They have also issued recommendations to crematoria medical referees. The most significant recommendation is that the Home Office considers that an affirmative answer to at least one of questions 5 to 8 should also be expected. Experience has shown that this need not introduce significant delay to the completion of the Form C or to the funeral arrangements. Nevertheless, Question 5 should be answered in the affirmative only if the signatory of Form C has seen and questioned a medical practitioner other than the signatory of Form B.
It is recognised that these changes cannot be implemented overnight and the crematoria referees will be informing GPs, undertakers and the local crematoria of a date from which cremations will not be allowed unless these forms are competed as recommended. Colleagues should take time to read the document which can be found here
Child and Adolescent Mental Health Services
We have recently had correspondence with Dr Lovett who is the clinical lead for the CAMHS service in North Staffordshire, concerning referrals. The CAMHS team have the view that often there is not enough information included in the referral to help them decide the most appropriate action. The sort of information that usually helps is such as the time course of the problem, any associated difficulties, whether there have been any adverse life events that might have precipitated the difficulty, whether any other interventions have been tried (including simple parenting advice) and the social and family background to the case. Such information will assist the CAHMS team in prioritising the referral.
Dr Lovatt's personal opinion regarding the management of behavioural problems is that an under 5 year old should in the first instance be dealt with by referral to the Health Visitor for parenting advice. Behavioural problems in school age children might, on occasion, be similarly helped, but additionally, if there are only problems at school, the suggestion should be made that the school involve the relevant educational behavioural support team and/or the School Psychological Service. If the behavioural problem is very extreme at home and the child is completely out of control of the parents, then it would be appropriate to refer to Social Services although a simultaneous referral to CAMHS might also be appropriate.
Child Psychological Service
The Child Psychological Service provides a number of different options in addition to the Specialist CAHMS teams, at least in Stoke-on-Trent. All the Sure Start areas have First Steps Psychological Services which enables all children under the age of four to be referred, provided that they are within a Sure Start area. A new service is starting which will cover the rest of Stoke-on-Trent from a training and consultancy perspective and will provide a direct clinical service in Meir and Ball Green. This will be for children up to the age of seven. It is a long term hope to attract funding to develop an Early Intervention Service, such as is provided through Sure Start for children across the age range.
Items from the GPC
GP registrars and out-of-hours training
The JCPTGP has recently discussed its policy on out-of-hours training and agreed that it should remain unchanged so that GP registrars should continue to be trained in out-of-hours work. However, this will remain under active review throughout the implementation of the new GP contract which will allow practices to opt out of responsibility for the delivery of out-of-hours work and transfer the responsibility to primary care organisations. The GPC's Professional & Educational Development and GP Registrars' subcommittees are also keenly interested in any developments in this area which will feature in future subcommittee discussions.
Authorising ‘homely remedies’
The prescribing subcommittee discussed recently produced guidance by the Royal Pharmaceutical Society of Great Britain whereby GPs are being asked to authorise lists of ‘homely remedies’ for patients in care or residential homes. The prescribing subcommittee takes the view that patients living in the community do not need authorisation to use OTC medicines and those in care or residential homes should be treated no differently. This is not considered to be an acceptable use of GP time or a relevant clinical request. All doctors are advised not to accede to requests from care homes to authorise ‘homely remedy’ lists.
Training practices and the summarisation of patient notes
The GPC has been informed that the drive to increase training capacity, and funding allocated to deaneries to facilitate this, means that many deaneries are able to provide support to training practices, or those practices aspiring to become training practices.
Such support can include funding for the summarisation of records, or the transfer of summaries from paper to computer. This would have beneficial effects in the context of the new contract.
Training, or potential training, practices might consider clarifying the situation in their own deaneries with a view to applying for such funding where possible and appropriate.
Recommended standards for NHS HIV services launched
The Medical Foundation for AIDS & Sexual Health (MedFASH), a charity supported by the BMA, has launched new Recommended standards for NHS HIV services for England. A cornerstone of the National Strategy for Sexual Health and HIV, the standards are endorsed by the Department of Health, the British HIV Association (BHIVA) and the National Association of NHS Providers of AIDS Care and Treatment (PACT), who all funded their development.
The recommended standards are relevant not only for HIV specialists, but for all those with a role to play in the diagnosis, care and support of people with HIV, including general practitioners and the primary care team. They cover prevention, diagnosis, empowerment of people with HIV, clinical care, primary healthcare, social care integrated with healthcare, sexual health care, HIV and pregnancy, care of families with HIV, emergency care, admission to hospital, respite, rehabilitation and palliative care. Each standard offers an evidence-based rationale, key interventions, implications for service planning, guidance on practice, and suggested audit indicators. Reading lists for supporting evidence, policy documents and professional guidelines are appended. Containing one standard specifically for managed service networks, the whole document should encourage multidisciplinary and multi-sectoral working.
The standards are informed by the views and experience of people with HIV, as well as by the knowledge and expertise of a wide range of professionals who participated in their development. They will provide a tool for planning and auditing service development, a framework for commissioning and a resource for partnership between service users and providers.
You can download the document from www.medfash.org.uk or order it from MedFASH, BMA House, Tavistock Square, London, WC1H 9JP. Email: info.standardsproject@medfash.bma.org.uk. Tel: 020 7383 6345. (Send cheque for £1.50 p&p per copy if ordering 4 or more. Bulk order rates available over 10 copies.)
Doctors’ and Dentists’ Review Body
The BMA has submitted written evidence to the Doctors’ and Dentists’ Review Body as part of the usual Review Body evidence round for pay for 2004/05. The evidence covers: salaried GMPs, GMP registrars’ salary and supplement, GMP trainers and educators, GMP/clinical assistants working in community hospitals, GP clinical assistants and hospital practitioners not working in community hospitals, personal medical services GMPs, and sessional fees for doctors in the community health service and fees for work under the collaborative arrangements between health and local authorities. Supplementary evidence on the revised role of the technical steering committee will be submitted in due course.
Dr P Golik
Secretary