NEWSLETTER MARCH 2004
Personal Medical Services Agreements
Partnership agreements guidance
Copying of Letters to Patients
Mental health care for students and NHS professionals
Jury summoning guidance consultation
New Contract
It is now less than two weeks before this New Contract is due for implementation. PCTs will be asking practices to sign the new contract without having time to study it in detail and without agreement in all areas. There is still a lot of uncertainty around the financial aspects of the contract. However, we do not have any real choice as to whether or not to sign this contract. If practices fail to sign, they will operate on a default contract which is far more restrictive and denies them the right to provide and be paid for any enhanced services and payment for the quality and outcomes targets. The GPC informs us that "If there are outstanding issues on any contract terms, e.g. final agreement over the price of a local enhanced service, indicative budgets or the opting out of additional services, the GPC’s lawyer strongly advises that practices should sign the standard contract “subject to dispute”, highlighting the areas of disagreement, to ensure that the contract is in place by 1 April 2004".
Enhanced Services
Agreement has been reach with the PCTs for payment of a "portfolio" of services to ensure that services continue after 1st April. This is an interim arrangement and will be under review in the future. Practices are not expected to provide services which they do not currently offer even if these appear in the "portfolio", equally practices should note that the agreement is for the provision of the current level of service. Levels of activity in these areas will be monitored from 1st April and the system reviewed during the course of the year. Any new work in these areas will have to be resourced separately. Details of the LMCs negotiations with the PCTs on enhanced services have recently been sent out to practices.
Travel Immunisations
There is some confusion over whether or not GP's can charge for these after 1st April. According to the GPC's FAQs on the New Contract "Patients can be charged for services such as prescriptions or travel packs which are for use in anticipation of illness while on holiday; this is an improvement of the current terms of service paragraph 38. They may also be charged for vaccinations for which no fee is payable currently, i.e. one which has not been transferred into the global sum. This is equivalent to the present situation."
The vaccinations for which a fee is currently payable are Smallpox, Typhoid, Paratyphoid, Cholera, Poliomyelitis and Infectious Hepatitis.
NHS body Status
I have been asked a number of times about whether practices should elect to become an NHS body. One of the main issues here is that if you opt, as a practice, to become a Health Service Body contract disputes will be dealt with through the NHS dispute resolution regulations. There will be no alternative and practices will not be able to take the dispute to court. I have asked a number of times whether there are any advantages in becoming an NHS body and have not received any positive replies. The GPC view on the issue is available in their "Focus on health service body status" document
IT
· IT Funding
An additional £30 million of IT funding has been allocated to PCTs in England together with guidance on how the funding must be spent. The guidance lists the hardware and software practices can expect to receive funding for under the new GMS contract. The guidance has been agreed with the GPC and will shortly be circulated to LMCs, as soon as it has been made public. In addition, John Hutton has written directly to GPs informing them of the allocation, from the £30 million, which has been made to their local PCT.
· System Choice
John Hutton has written to all MPs providing assurance that there has not been any intention to scrap current systems, and a one size fits all solution will not be imposed. When new systems are developed, the GPC will have a vital role in ensuring they are fit for purpose and letters have been sent to the Department of Health and to each of the LSP Regional Implementation Directors reminding them of this GMS contract agreement. The GPC already has representation on one LSP and we are expecting the other LSPs to follow.
The National Health Service (Personal Medical Services Agreements) Regulations 2004
These regulations were published on 11 March and can be accessed at the HMSO website at www.hmso.gov.uk/si/si2004/20040627.htm They carry across much of the regulatory framework of the new GMS contract to PMS. The Department of Health has yet to issue final guidance to PCTs and PMS practices on how PMS will change following implementation of the new GMS contract. The latest guidance remains that contained in “Sustaining Innovation Through New PMS Arrangements”, which is at www.dh.gov.uk/assetRoot/04/07/01/55/04070155.pdf However, crucial PMS issues are still awaiting central clarification, such as the final quality points offset figure; that is the number of points that will be deducted from the achievement payment of PMS practices that choose to adopt the national GMS quality and outcomes framework.
Out of Hours
We have received confirmation from the PCTs that they are only prepared to fund the out of hours service for the hours stipulated in the New Contract i.e. from 6.30pm - 8.00am on weekdays, all weekends and Bank Holidays. Thus if GPs required cover from 6.00pm on weekdays and on Thursday afternoons, arrangements will have to be made with the new out of hours service and GPs will be responsible for funding this added cover. PCTs and the Co-op are currently assessing the demand for this extra cover. We were hoping that PCTs would see the benefits to GP morale, recruitment and retention by providing the existing level of cover.
Partnership agreements guidance
The GPC is currently working on amended partnership agreements guidance. The guidance is dependent on the final form of the regulations, the drafts of which were published in December, which is in part why it has been difficult to produce anything before now.
The guidance will not take the form of a model agreement as, given the flexibility in the makeup of a practice and the way it provides its services under the new contract, a 'one size fits all' model is inappropriate. It is currently taking the form of guidance about those issues that should be considered when drafting or updating a partnership agreement. It is, however, a complex matter which needs legal input and we are currently taking legal advice about the guidance.
A partnership agreement is not necessary to enter into a nGMS contract and PCOs should not therefore refuse a contract in the absence of an agreement. We advised on this in our "Focus on the nature of the contract" guidance produced some months ago. Having said that, the partnership guidance will strongly recommend that practices should have a partnership agreement.
Producing the guidance is very much a priority for us and we hope to have it available in the next few weeks. We will circulate the guidance to GPC and all LMCs and will post it onto the website as soon as it is available.
LMC Levy
With the advent of the "New Contract" there has been a need to reconsider the way the levies which finance the LMC are collected. The LMC collects both a statutory and a voluntary levy. The statutory levy can be used to finance the statutory functions of the LMC, whilst the voluntary levy is used to finance the "political" aspect of the committees work, this is mainly used to pay the LMC's levy to the GPC. Details of the statutory functions of the LMC can be found here and of the non-statutory function here. Currently, the levy is raised as a small percentage of superannuable remuneration, changes to the superannuation system make this method impractical. In the future LMCs will either have to collect a percentage of global sum or a capitation based price per patient system. Both systems have their advantages and disadvantages. After consideration of this, the committee has decided that in future levies will be collected on a capitation based system with the majority of the levy being collected as a statutory amount and a small amount, to cover our levy to the GPC, as a voluntary levy. This is felt to be the fairest system available at present. The proposed amounts levied will be 20p per patient per annum as a statutory levy and 6p per patient as a voluntary levy. This equates to the average amount collected by LMCs nationally.
With the change to practice based, rather than practitioner based payments, new mandates for the voluntary levy will be circulated to practices shortly. We hope that these will be returned promptly.
Copying of Letters to Patients
The Department of Health wishes patients to be copied into all correspondence between health professionals from 1 April 2004. There are a number of concerns about this process which have yet to be answered.
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Does consent have to be obtained? If so, how often does it have to be obtained? |
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What about confidentiality? Other members of the family may have the same name and address. |
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What constitutes a letter? Should they receive copies of information from GP out of hours services, walk in centres etc? |
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What about problems in interpretation of medical information? |
What about the costs involved? One estimate is that it will cost the NHS at least £1 per letter copied. Taking into account the millions of letters sent annually, this money would be better spent on direct patient care.
Some specialities at the Trust are to begin sending out copies of their letters to patients soon. We have made it clear to the Trust that these letters should ask the patient to contact the sender, if they have any queries regarding the correspondence. The local PCTs are not well informed about this DoH wish and have been informed by us that sending copies of letters to patients is not in our old or new contract and will require extra funding if it is to be implemented.
Referral Proforma
We have received a number of complaints about the proformas recently circulated by "Services for Older People with physical illness" and "Services for Older People with Mental Illness". Unfortunately these were drawn up and circulated without discussion with the LMC. These proforma request an unreasonable amount of information which it is not the duty of the referring doctor to provide. The threat that a patient's treatment may be delayed or the referral be returned to the GP if the form is not completed is totally unacceptable. GP practices are at the forefront in the use of computers in their surgeries. These forms take no account of that and cannot readily be completed electronically. I have written to Combined Healthcare over these issues and advise GPs to continue to refer patients in their usual manner until the problems have been resolved. The LMC should be informed immediately should any referral be rejected or delayed because of non-compliance with referral proforma.
Respiratory Strategy (item submitted by Dr Charles Pantin)
The aim of this strategy is to provide a high quality network of care across the district. Most patients with respiratory disease do not go into hospital or attend hospital clinics. We have been working for years with our colleagues in Primary Care to bring a service which does not recognise barriers to care. The early discharge team for chronic obstructive pulmonary disease, asthma team, respiratory failure nurse are all fruits of this policy. Recently the McMillan service has agreed to provide palliative care support in the community for respiratory patients. Primary Care Trusts have been reviewing and implementing care pathways in asthma and COPD.
The overall outcomes will be:
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Standards are high across the district
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Chronic: only the complicated and severe patients are seen by the specialists
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Acute: good quality care in the district will lead to less patients being admitted to hospital beds
2004 is the year for major integration of the service.
The routes which patients take for management of respiratory disease will be plotted across the district. the aim is care as near home as possible
Directorate staff will work closely with their PCT counterparts. Clinics will be held in the PCTs. Directorate staff will help each PCT to plan the respiratory service. The care routes planned will be adapted by each of the four PCTs to fit their service.
Specialised clinics: tuberculosis, lung cancer, sleep, ventilation, interstitial lung disease, severe and brittle asthma, COPD, cystic fibrosis and hyperventilation will be reviewing their pathways to smooth the patient's journey,
Acute services are being reviewed in the route planning to enable as many patients to be treated at home or in their local community hospital.
This work will never finish as we constantly review our services. However, 2004 will see the pattern of service become clear.
Items from the GPC
BMJ's Clinical Evidence
The BMJ's Clinical Evidence is freely available to all NHS staff in England through the NeLH (http://www.nelh.nhs.uk/clinicalevidence) and Wales through Howis (http://www.wales.nhs.uk, see 'Evidence Based Resources') .
It provides a concise account of the evidence on the prevention and treatment of nearly 200 clinical conditions. It is easy to use and regularly updated. The hard work of searching, appraising and summarising has been done for you, so that you can use it to:
| Check or confirm the effectiveness of treatments |
| Discuss treatment options with your patients |
| Inform your discussions with colleagues |
| Keep up to date with the latest practice changing research |
The Clinical Evidence site has just been redeveloped. Topics can be searched in several ways and the presentation of the evidence is clearer and more user friendly. You can easily keep up with the latest evidence, and you can register for monthly email alerts.
GPC Non Principals Newsletter
This newsletter was published on 16th February and will not be circulated in paper form by the GPC, so please pass the weblink on to any non-principals that you may know. Viewers will need to log in to the site to access this link.
For any further information about the work of the subcommittee or if you would like to raise any issues with the subcommittee please contact Taryn Harding at the GPC office on tharding@bma.org.uk
Mental health care for students and NHS professionals
The BMA’s Occupational Health Committee, with the assistance of HPERU, has undertaken a survey of current practice in relation to services for doctors and medical services students referred for mental health assessment and treatment. This has identified a wide disparity of provision for this group. The Occupational Health Committee believes that “best practice” should be a system which:
· is consultant delivered
· is efficient and confidential
· allows referring GPs to have a choice of consultant psychiatrists
· allows rapid and timely access to a consultant psychiatrist for diagnosis and management
· provides a residential facility if deemed appropriate by the consultant
· is available outside the area where the doctor works professionally, if deemed appropriate
· involves occupational health physicians where available.
The GPC discussed this model and the relationship between mental health care for doctors and occupational health. It was suggested that the best practice model should include a mentoring process as well as confidential access to drug and alcohol services. It was recognised that personal health issues were not always related to occupational health, and that the relationship between doctors’ mental health and occupational health needed to be further considered.
NHS cervical screen programme – Data Protection Act requirements
A number of LMCs have informed the GPC that local practices have been informed, by PCTs, that all members of the practice team involved in cervical screening must sign a “special exception” form relating to section 60 of the Data Protection Act. The programme has been granted special exception under section 60 of the Act, such that patient and clinical data can still be held and used for explicit purposes. To comply with this special exception it is now a national requirement.
Given the number of staff and clinicians involved in the cervical screening programme, the request has generated considerable disquiet. Having contacted the Department of Health, The GPC have been informed that revised guidance was issued to PCTs on 22 December 2003. This informed PCTs that the need for practices formally to sign up to the Data Protection Act disclaimer has been waived, so long as lead PCT commissioners sign up and copy the guidance to practices. Any local practices who are asked to sign up on an individual basis should be advised to contact their PCT quoting this revised guidance.
Stamp Duty Land Tax
The Stamp Duty Land Tax arrangements will result in increases in duty payable by leaseholders signing new leases. However, three main areas are exempt from liability to pay the new increased duty - designated disadvantaged areas, net present lease cost values up to £150,000 and public bodies. The first two categories will result in some 60 % of commercial leases being exempted from SDLT which will benefit a significant proportion of GPs seeking to agree leases for modern practice premises. On the third category, the Department of Health had discussions with HM Treasury to explore whether all independent GP contractors might be exempted in the same way as are public bodies, such as Primary Care and NHS trusts. However, this is not permitted under the relevant legislation which defines public bodies.
This presents a real financial disincentive to GPs who wish to agree leases for modern practice premises to provide better patient access to services. The GMS contract negotiations have included discussions on how premises costs should be addressed, including the new SDLT arrangements effective from 1 December 2003. The new premises costs arrangements (see related item on premises costs directions) will allow Primary Care Trusts to reimburse SDLT costs on leases for modern practice premises where a new GMS Contract is in place and PCTs will also be able to reimburse SDLT costs to PMS contractors.
Premises costs directions
The National Health Service (General Medical Services - Premises Costs) (England) Directions 2004 have now been published and are available at www.dh.gov.uk/PolicyAndGuidance/HumanResourcesAndTraining/ModernisingPay/GPContracts/fs/en
Climbie Inquiry Report
Sir David Hall briefed the GPC on those recommendations of the Climbie Inquiry which will affect GPs. These are:
Recommendation 72 – that no child should be discharged from hospital without an identified GP/health visitor being assigned to them.
Recommendation 86 – deals with issues to do with confidentiality in relation to children and how information is shared between health professionals.
Recommendation 87 – requires that GPs be trained in the recognition of deliberate harm to children. The RCGP is advising on revised training for GP registrars and for vocational training every three years for continuing professional development.
Recommendation 88 – requires the education of all GP staff in the awareness of harm to children.
Recommendation 89 – requires that all GP staff have the contact details available to be able to report if a child is at risk.
A training package has been developed by the Royal College of Paediatrics for all new SHOs in child paediatrics, GPs, A&E staff and child psychiatrists as a result of the Climbie Inquiry recommendations.
The committee agreed that continuity of care was best organised through the primary care team and patient centred care. The following resolution was carried:
“In view of the Victoria Climbie Inquiry healthcare recommendations, that GPC requests the Department of Health that health visitors should remain an integral part of the primary care team based at the practice.”
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Jury summoning guidance consultation
Proposals regarding doctors serving on juries were first made in November 2003 (Section 321, Criminal Justice Act 2003). The effect of this new law will be to remove doctors' right to be excused from jury service. This was despite strong opposition from the BMA when the proposals were first made. Nevertheless, doctors may still be able to defer or excuse themselves from jury service in certain circumstances. A consultation document on Jury Summoning Guidance, to which the BMA has responded, set out draft Guidance for the staff at the Jury Central Summoning Bureau for use when summoning jurors and when considering applications for deferral and excusal.
Counter terrorism: clinical action cards for GPs
We have been informed by the Health Protection Agency that clinical action cards will be distributed to GPs in England in the second week of April. Scotland, Wales and Northern Ireland will be making their own arrangements.
The following points may help in answering any queries:
· The cards, entitled New Diseases, New Threats, are a CMO initiative and have been produced to raise awareness of CBRN (chemical, biological, radiological, nuclear) among GPs.
· The work has been taken forward by the Health Protection Agency's Emergency Responses Division (based at Porton Down).
· The cards were written by/researched with GPs and have the endorsement of the RCGP.
· They are slightly bigger than A5 size, and will be laminated and spirally bound.
· The set of cards will have visuals of unusual symptoms of diseases not normally seen by GPs - smallpox etc, and will also alert GPs to the contact details of their local Health Protection Teams.
· A media plan is being prepared for their launch.
· A programme is being developed to educate healthcare professionals including GPs.
Dr P Golik
Secretary