NEWSLETTER JUNE 2006
Hepatitis B and Medical Students
Reconfiguration of the Health Service
Alternative Providers of Medical Services
Referrals to complementary therapists
Practice based commissioning (PBC)
Financial Crisis
The local PCTs have drawn up plans to correct the overspends in their budgets. Invariably they are planning cuts which will directly affect patient services. GP colleagues have serious concerns that these cuts will increase workload in General Practice. The PCTs have been informed that any service decommissioned from the secondary sector cannot automatically be provided by primary care. Of particular concern is the pressure on the hospital service to decrease the number of follow up appointments and the suggestion that patients who, for example, have stable chronic diseases should attend their GP practice for annual review and blood tests. We have made the PCTs aware that this is not GMS and that practices in general are not geared up to pro-active recall and necessarily aware of which blood tests etc are required. These services will need to be commissioned from primary care through a local enhanced service and shared care agreement.
Colleagues will have to be vigilant and not provide services for which we are not resourced. Patients who find that services they require are no longer commissioned by their PCTs should be advised to take up the matter with the PCT, their PALS organisation and their local MP. We have tried to leave the PCTs in no doubt that they cannot dump work they decommission into the lap of GPs.
Smoking Cessation Services
Colleagues have raised a few concerns about these. Firstly, there are concerns that the LES commissioned by PCTs this year does not cover the costs of actually providing the service. This is being looked at in detail by a group of practice managers and if this is the case then the choices are
- PCT review the LES and increase funding
- Practices stop providing services
- Practices continue to provide the service at financial cost
We would not recommend option three.
Secondly, there are an increasing number of patients receiving counselling in secondary care who are presenting at their GP surgery requesting the prescription of NRT. This raises two issues. GPs are clinically and legally responsible for any prescription they issue. In this case they have no control over the quality of service provided to the patient and for this reason alone should refuse to provide scripts of NRT in these circumstances. Secondly, the cost of the provision of NRT should have been taken into account when these services were commissioned. By providing these items in primary care, the NHS is paying twice for the service. Given the pressure on our prescribing budgets, this cost should not be passed on to us.
Hepatitis B and Medical Students
I wrote to Birmingham Medical School about their policy of asking prospective medical students to attend their GP surgery to have their immunisation status checked and if needed to be immunised against Hepatitis B and Rubella. This is a responsibility of the Medical School's occupational health service not General Practice. Apart from increasing the work of GP surgeries it also puts unnecessary cost on our overspent PCT budgets. I have received a reply from the Medical School stating that the reason for their request is that medical students are exposed to clinical practice within a few weeks of commencing their studies. They are discussing ways to resolve this issue and may have to put back the clinical attachments to ensure that their occupational health service can provide a full service. They will undertake the appropriate testing and immunisation should a prospective students GP be unwilling to provide the service. The GPC has issued guidance which states "Medical Schools are legally responsible for providing a full occupational health service to their student. This should include appropriate training for example in risk reduction and coping with needle stick injuries. By providing a Hepatitis B immunisation, a GP could place inexperienced healthcare students at risk by providing a false sense of security and potentially exposing them to clinical risk of other blood borne infections including HIV and Hepatitis C before they have received appropriate training." Of course the same principles apply to other healthcare workers.
Reconfiguration of the Health Service
The Department of Health has announced that there will be three PCTs in Staffordshire with the two Stoke PCTs, merging and Newcastle and Moorlands PCTs merging to form a North Staffordshire PCT. The remaining PCT will cover the four existing PCTs in the south of the county. This was the option preferred by the LMC and avoids any need for reorganisation of the Staffordshire LMCs.
Blue Badges
Stoke on Trent City Council has altered the way it processes applications for "Blue Badges". They have decided to use an independent medical assessor to process the applications. Applicants who qualify automatically under the scheme will not be affected. Stoke-on-Trent residents who wish to apply for a "blue badge" should be directed to the city council.
Pathology Results
You are probably aware that the Pathology Lab has a responsibility to pass on seriously abnormal results to General Practitioners or their deputies as soon as they become known. When such results become known outside normal GP working hours, this means contacting North Staffs Urgent Care who then have a duty to take the necessary action. NSUC receives on average two such results each night and about seven on a Thursday afternoon. In a large percentage of these cases, the pathology lab is unable to pass on enough detail about the patient to enable them to be readily identified and contacted. The minimum data requested by the laboratory does not include the address or telephone number of the patient. Obviously in these circumstances a lot of time and effort is spent identifying the correct patient. Following discussion with NSUC and the path lab, we have agreed to request that GPs include at least the first line of the patients address on the request form and preferably a telephone number as well. In the next few months the request forms will be re-designed to accommodate these data fields. We have also agreed that should NSUC be unable to identify and contact a patient, they will phone the GP who requested the investigation for assistance. This should be a rare occurrence if we provide the data requested.
The pathology lab is now identifying all requests from the Rheumatology departments clearly on their electronic reports. The Rheumatologists have assured us that they will be responsible for acting on abnormal results.
Pandemic Flu Guidance
The joint RCGP/GPC Flu Pandemic Emergency Planning Group have produced a practical guide on infection control to help GP practices plan for and respond to the threat of pandemic flu. The paper entitled 'Infection Control for General Medical Practices' is now available on the BMA website under Flu Pandemic. It can also be accessed through the following link http://www.bma.org.uk/ap.nsf/Content/Hubflupandemicpreparations
Collaborative Fees
Collaborative Arrangements
Following the 2006 DDRB report recommendation that doctors engaging in work under the collaborative arrangements should set their own fees for 2006/07, the BMA’s Professional Fees Committee (PFC) has released initial guidance for health professionals on this matter.
The release of this guidance has raised some further questions, particularly around the point that it is illegal for individual doctors even to discuss their fees with anyone outside the practice and about whether an LMC is prevented from negotiating a collective agreement with local authorities.
The Professional Fees Committee of the BMA is seeking legal advice on these issues at present and, until then, in order to avoid any potential problems with competition law etc it is advising a cautious position. The GPC is fast-tracking the legal issue with regard to LMCs setting rates with PCOs for their area.
It should be noted that the initial guidance from the PFC is intended to give initial advice only and cannot cover all circumstances. A more detailed guidance note is currently being prepared by the Professional Fees Committee secretariat and will be published as soon as possible.
Practice Based Commissioning
There is still some confusion over the allocation and use of any freed up resources from PBC. The GPC believes therefore that there is an absolute necessity for practices not to enter into any commissioning arrangements without written and signed confirmation from the PCT, in advance, that they will be guaranteed their share of freed up resources at the end of the financial year, regardless of the PCT’s financial situation. They have issued a guidance document concerning this which can be found here. The GPC have also issued a document entitled 'The commissioning plan and an agreement with the PCT'. This can be found here
Guidance on Consortium Working has been produced by the GPC and can be found here.
Alternative Providers of Medical Services (APMS)
GPC guidance that provides a factual background on APMS and suggests ways in which GPs can best harness this new contracting route in the interests of their patients and primary care has been released by the GPC. It offers guidance on tendering for APMS contracts, working for APMS providers and contracting care through this route.
The document also highlights areas where inequities may arise and suggests ways in which GPs and LMCs can work to ensure a level playing field between different types of provider. As APMS is a rapidly developing area of health policy, this guidance will evolve over time and should be regarded as a living document.
The guidance on APMS which can be found here.
BMA copyright notice: explanation of usage
The GPC has started to put a BMA copyright notice on the guidance notes it produces for LMC because it has become aware that some of this guidance, on PBC, APMS and partnership agreements in particular, contains information that could be of commercial value to firms or individuals outside of the LMC/GP and BMA network. The copyright notice has been included to assist in preventing this guidance and the information contained within it from being used by those who are not contributing to its production.
All guidance printed off the BMA website in HTML format does have an automatic copyright of the BMA printed on it. The GPC is now adding this notice to PDF versions of new guidance which are also made available via the website.
GPC guidance is produced to inform and aid LMCs, BMA members and GPs; the copyright notice does not mean that LMCs should stop circulating this guidance among their members/constituents.
IM&T DES
The GPC guidance note Implementing the IM&T DES: data accreditation has recently been published and can be found here.
PMS
Guidance for PMS practices and APMS GPs following publication of Department of Health guidance on non-GMS contracting arrangements for 2006/07 can be found here.
Overseas Visitors
The BMA has produced revised guidance on "Overseas Visitors - who is eligible for treatment". This can be found here.
LIFT Guidance
The GPC has produced guidance for those practices involved in LIFT schemes. This can be found here.
Referrals to complementary therapists
The GPC has produced guidance on referrals to complementary therapists. This can be found here.
The Suspended GP
The GPC has produced guidance on the arrangements covering suspension of GPs. Practices are advised that they may need to review their practice agreements in order to take full advantage of the financial arrangements. A copy of the document can be found here.
Items from the GPC
GP Pay
Many members of the GPC and LMC secretaries have been giving radio, TV and newspaper interviews to redress the balance following widespread and misleading media coverage of medical accountants' claims that some GPs are earning £250,000 under the new contract. It has been stressed that, if these claims are correct, the GPs concerned will be very few in number and working in exceptional circumstances, and that the profits of the average partner are, according to estimates produced by the Technical Steering Committee for 2005/06, considerably less than half this figure. The GPC Chairman said in the official BMA press statement, "The new GP contract was introduced in April 2004 to bring GP pay up to date and to attract more family doctors at a time of severe shortages. For the first time it linked pay to delivering quality targets in healthcare. As a result of high performance, the average GP income in England is around £95,000. This covers a 52.5 hour week".
24 hour retirement
Following the confirmation of a change in understanding of the requirements for GPs to 'retire' for 24 hours and be able to return to practice, subject to not exceeding 16 hours a week for the first month, from each of the Pensions Agencies in the four countries, we are still awaiting the release of the technical newsletter detailing this.
We are aware that this is causing problems in some areas where PCTs are stating that they are unaware of these changes. We have therefore written to the Pensions Agencies to seek the approximate timescale for producing the Technical Newsletter and have requested that, in the absence of a full technical newsletter, they advise employers of the current position.
A further question has arisen about whether it is necessary for GPs to come off the performers list for 24 hours to confirm their retirement. We believe that this is not a requirement and will ask the Pensions Agency to clarify this as part of the Technical Newsletter.
Contract review
The changes to the Statement of Financial Entitlements (SFE) that support the contract revisions in England came into force on 1 April 2006 - the revised SFEs in Scotland, Wales and Northern Ireland will follow shortly. The revised SFE has been published on the Department of Health’s website and the GPC has issued an accompanying guidance note to detail where the main changes have been made that is available here: www.bma.org.uk/ap.nsf/Content/focussfe
All practices and LMCs should now have received two hard copies of the Joint GPC-NHSE guidance detailing the revisions that have been made to the GMS contract in England. New DESs in Wales, Scotland and Northern Ireland have now been signed off and details of the contract changes are available from the relevant Health Department websites.
The DES directions to support the new agreed DESs will be issued in June 2006. Even without the Directions currently in place, PCTs still must offer all DESs, unamended, to all practices. However we are aware of reports that, for practice based commissioning, certain PCTs are proposing revised LESs in place of the agreed DESs for 2006-07 and asking practices to sign up to these as alternatives. The GPC's position on this is that PCTs must offer the agreed DESs to practices and cannot alter the content of the nationally agreed DESs. This is quite clear from the joint guidance that was issued on the contract review. PCTs can, of course, issue an additional LES for work over and above that agreed for the DES.
The GPC is also aware that some problems are arising with the implementation of the choice and booking DES, including problems with availability of appointments for booking that are beyond practices’ control, and these have been raised with the Choose and Book national team. Additionally we are aware that there are still some problems with the introduction of eGFR, as some labs across the country are currently not providing eGFR results required for the CK1 indicator in the revised QOF. SHA leads were given clear instructions to implement this and the GPC will be working to ensure that all have complied. With regard to dispensing, discussions are nearing closure on the new Dispensary Quality Scheme.
Stage 2 of the contract review negotiations will take place during 2006-07. Negotiations have not yet begun on stage 2 although the GPC negotiators met with NHS Employers to identify the main areas for discussion. This includes the conclusion of the formula review and any relevant issues arising from the White Paper. The negotiators will continue to discuss further the strategy on how to approach stage 2 of the contract negotiations and report to the profession in due course.
Practice based commissioning (PBC)
An email was sent to all strategic health authority (SHA) PBC-leads by the Department of Health’s PBC implementation team on 5 April 2006, reemphasising that practices should receive or access a minimum of 70% of freed up resources and that only the remaining percentage should be retained by PCTs at the end of the year, regardless of their financial position. The relevant extract of this guidance has been pasted below:
“We expect PCTs to adhere to the agreement that of any resources freed up against the practice budget under PBC, at least 70% should be available to the practice for reinvestment in patient services, and up to 30% to the PCT. Adhering to this agreement is important in providing appropriate incentives for practices to take up PBC and to progress service redesign.”
It is also available online via the following website address (go to the ‘PBC news’ section then the ‘Statement on budget setting’ article):
www.dh.gov.uk/PolicyAndGuidance/OrganisationPolicy/Commissioning/PracticeBasedCommissioning/fs/en
The committee welcomed this further clarification from the Department of Health, but agreed that it could have been more strongly worded and would not necessarily prevent misinterpretation on this point at a local level. As a result, the GPC will issue guidance in due course which will suggest some clauses for practices/consortia to include in their contracts with PCTs in order to avoid disagreement on the division of freed up resources at the end of the year.
NHS pensions review
GPC pensions negotiator Andrew Dearden reported on the ongoing NHS pensions review negotiations. The current pension scheme, with the current benefits and a normal retirement age of 60, would remain safe. No member of the current scheme would be forced to change to the new scheme unless they wished to do so after seeing the outcomes of negotiations on the new scheme. Details of how this will be done are yet to be decided.
Dr Dearden gave an update on progress on various issues, such as historic (pay reform) and future (longevity) cost pressures on the scheme. He sought guidance from the committee on several points, having done so with BMA Council and the BMA Pensions Committee as well.
These included the disproportional benefit that the higher earners and those with better pay/career progression get from the NHS scheme compared to the lowest earners. Figures show that higher earners, such as doctors, get a far better “return” on their superannuation payments than the lower paid staff in the NHS. Dr Dearden felt that there is a moral argument for the BMA to consider tiered contributions, so that the less well paid contributed proportionately less and the higher earners paying more. The committee gave general support for the idea that, in an effort to reduce the cross subsidy from the lower paid to the higher paid, tiered contributions should be considered.
He also asked the committee about the potential introduction into the current scheme of “commutation”. Commutation is the choice to take a larger tax-free lump sum on retirement with an appropriately reduced annual pension. This was one of the options being discussed. The committee again gave an indication that it would like the choice for GPs to be able to “commute” their pensions, if they wished to do so, to be made available.
In terms of the structure of the NHS pension scheme for new entrants, both Final Salary and CARE (career average scheme) are being discussed as options. In terms of future costs of the overall NHS scheme, a final salary scheme for new entrants is more likely to increase the direct costs to the staff / employees than a CARE scheme.
Discussions on the shape of the new scheme continue.
Department of Health White Paper on care outside of hospitals
In March 2006, the Department of Health published a ‘Partial regulatory impact assessment (RIA)’, which sets out the Government’s considered early assessment of the likely impact of the policy initiatives set out in the White Paper. It can be accessed online, at the following website address:
The committee noted that many of the areas covered in the RIA, such as extended opening hours for GP surgeries, would be included in the GPC negotiators’ strategy that would inform the negotiating framework with the NHS Employers in 2006-07. Those areas in the RIA not covered by this strategy would be looked at more closely by the committee/subcommittee accordingly. Members raised a number of issues with the paper, including reference to the development of multidisciplinary teams in order to improve the care of patients with complex needs when it was widely recognised that such teams had existed in the past, but in most areas had been disbanded over the years against the wishes of GPs.
The new BMA cross-craft working group ‘Incentives and changing services’, which will monitor the work of the Department of Health’s ‘Care Closer to Home Demonstration Group’ chaired by Lord Warner, has now been set up and will be holding its first meeting on 26 April 2006.
IM&T
Support Services Guidance (SLA)
The IM&T Support Services Guidance (previously referred to as the Service Level Agreement or SLA) is now available on the Department of Health’s website at the following link:
www.dh.gov.uk/assetRoot/04/13/38/67/04133867.pdf
System Choice
LMCs can access the recent guidance issued on system choice at the following link:
Read Codes for the new QoF
The Read Codes for the new QoF can be accessed at the following link:
www.primarycarecontracting.nhs.uk/145.php
Freedom of Information Act (FOIA)
The Information Commissioner (IC) has decided to extend the lifetimes of current publication schemes for at least two years. This will mean that there will not be a requirement for practices to rewrite their schemes and submit them for approval by October this year. There remains a requirement for practices to keep their existing schemes up to date and notify the IC of any changes or deletions to them.
The IC will be producing guidance about the anomalous position regarding the records of deceased patients (in England and Wales only – the position in Scotland is clearer). A date for the publication of this guidance has not yet been made available. However, the IC will give advice on a case by case basis, should practices require it.
Salaried GPs: prescribing numbers
Following pressure from the GPC sessional GPs and clinical and prescribing subcommittees, we are pleased to report that salaried GPs are now entitled to have their own prescribing number. PCOs can apply to the NHS Information Centre (GMS Team) for an individual unique number for each of the salaried GPs on their Performers' List. We therefore advise salaried GPs to contact their PCO for a prescribing number.
We continue to make representations for locum GPs also to have a unique prescribing number.