NEWSLETTER MARCH 2006
Rheumatology Shared Care Guidelines
On-line mental health directory
Consultant to Consultant Referrals
List of the guidance on the GPC website
Financial Implications of increasing list size
Patients presenting with dental problems
PMS contracts and superannuation funding
Department of Health white paper on care outside of hospitals
A new deal for welfare: Empowering people to work
Dispensing GPs in England & Wales – VAT Registration
General practice business model
Forthcoming equality legislation
GP trainers - £750 CPD payment
Locum GPs: pension arrangements
Bichard vetting and barring scheme
Elections to the Committee
Eleven nominations were received for the ten vacant places on the committee. The committee, therefore, decided to co-opt the additional nominee on to the committee.
Rheumatology Shared Care Guidelines
The committee has been consulted over the difficulties surrounding the prescribing and monitoring of rheumatology drugs. Historically the rheumatology department has monitored the drugs and we have been asked to prescribe. With increasing awareness of prescribing responsibility this system cannot continue as it is. Continuing the current systems with shared care agreements is seen to be the best way forward with the blood monitoring results being made available to GPs. It is possible to arrange for these results to be sent to practices via the "lablinks" system. However we would need to be clear where the test had originated. This is not currently the case, at least with the EMIS system. Discussions have taken place with the path lab and in the near future such result should be readily identified as being as "rheumatology monitor".
Cancer Referral Proforma
The 14 day rule referral proforma have all been reviewed recently to take into account new guidance .These have been distributed to practices by email along with templates for integration within the EMIS system.
On-line mental health directory
An on-line directory of service for patients who need services and support outside general practice to improve their mental health and wellbeing has been developed. This can be accessed for information on a range of services and organisations.
The directory is:
 | Free to access |
| Quick and easy to use |
| Allows you to print off information for patients to take away |
| Contains details of specialist mental health services |
| Also has information on more general community-based services (e.g. housing, leisure and recreation, employment, education) for people with non-medical issues. |
The website address for Staffordshire is www.staffordshirementalhealth.info and for Stoke is www.stokementalhealth.info
Both sites are maintained by the Staffordshire Mental Health Helpline who offer a telephone support service 2pm -2am Sat & Sun and 7pm- 2am Mon-Fri 0808 800 2234
Within North Staffordshire, a small group of practices will be developing mental health promotion options for their practice populations using a toolkit developed by Doctors and endorsed by the Department of Health. In the North East, where it has been most widely used, the toolkit has helped practices by
· giving GPs more options
· reducing workload through reduced repeat attendance and reduced mental health referrals to GPs from practice nurses
The participating practices will receive free training and signposting resources. If you are interested in becoming involved, please contact Kate Edwards, Programme Leader – Mental Health at the Directorate of Health Promotion on 01782 400533.
Consultant to Consultant Referrals
The PCTs have instructed the University Hospital to restrict the number of consultant to consultant referrals. The reason given for this is that the patients must be given choice of provider as dictated by the DoH policy. Another reason, of course, is to try to prevent unnecessary referrals of patients who could be treated adequately by their GP. There is confusion about the policy amongst the consultant staff and consequently some colleagues have reported some inappropriate requests for referral. Consultant to consultant referrals are still allowed in the following circumstances:
| Suspected cancer referrals |
| Emergency/urgent referrals from A & E/MAU/SAU |
| Referrals related to HIV, AIDS or sexually transmitted infections |
| Clinically urgent referrals (inpatient or outpatients) |
| Cross specialty referrals related to the original condition |
| Referrals to a service which only accepts Consultant referrals (e.g. specialist children's services) |
All consultants should have received a letter detailing this policy in December. A copy of this letter can be found here.
QOF Comparison
Grant Ingrams, Secretary of the West Midlands Regional Local Medical Committee has produced a document detailing the changes in the QOF. This document can be found here.
GPC Guidance
The GPC has produced a large number of guidance documents in the last few weeks: These are:
a. List of the guidance on the GPC website.
You may find this of help when trying to locate documents. The list can be found here.
b. Financial Implications of increasing list size
The GPC has also produced guidance on the financial implications of increasing list size which can be found here
c. Partnership Agreements.
The GPC guidance can be found here. A similar document from the BMA on Medical Partnerships under the NHS can be found here.
d. Agenda for Change
The BMA has produced a document "Focus on Agenda for Change and practice staff" which can be found here and an appendix entitled "DH national job profiles" which can be found here.
e. New Contract
The GPC has published three more documents in the "Focus on" series.
Focus on Choice and Booking DES Focus on Revisions to the GMS contract 2006/7 and Focus on Access
f. Practice Based Commissioning
The Department of Health has issued further guidance in the form of a document entitled "Practice Based Commissioning: achieving universal coverage". A copy of this document can be found here. A further document "Practice based commissioning, early wins and top tips" was issued on 8th Feb and can be found here.
Following the publication of the "Towards Practice Based Commission Directed Enhanced Service" specification, the GPC has produce a "Focus on" guidance note. This can be found here.
g. New Contract Review
A number of documents have recently been published regarding the New Contract Review. These are:
'Revisions to the GMS contract, 2006/07 - Delivering Investment in General Practice' (PDF File)(20/02/06)
Focus on the Quality and Outcomes Framework 2006 (20/02/06)
Focus on the Quality and Outcomes Framework 2006 - Appendix 1 (20/02/06)
Focus on the Quality and Outcomes Framework 2006 - Appendix 2 (20/02/06)
QOF Guidance 2006 (20/02/06)
h. Referral Management Centres
The GPC has produced a FAQs on referral management centres. A copy of this document can be found here.
i. New QOF indicators
In
the light of the increasing degree of speculation about the contents of the
new QOF, the GPC has listed all the new indicators that will be in the
QOF from April 2006. The list can be found
here.
They would not advise GPs to start to gear up for this without the
relevant guidance. They are currently working on the draft guidance. It
is by necessity a slow, considered process and will be published it as
soon as it is available.
j. Contract Review
The following documents have been released in relation to the "Contract Review"
SUMMARY OF GMS CONTRACT REVIEW NEGOTIATIONS 2005/06
NHS Employer Press release: Agreement reached on changes to the national GMS contract
Letter to the Profession (Hamish Meldrum)
Key elements of the agreement
The key features include:
| No inflationary uplift across the contract for 2006–07. |
| Changing the Quality and Outcomes Framework. 138 recycled points allocated to new clinical areas; 28 points will strengthen existing indicators. |
| New investment in enhanced services to support national priorities for patient services. For England, this includes practice-based commissioning, offering choice to patients and adopting Connecting for Health’s IM&T programme. |
| In England, a new access DES that absorbs the existing DES and current access points in QOF, and extends its scope. |
| In England, a new independent patient experience survey will be developed that will trigger payments to general practice for access and choice. |
| In England, £132m will be available for premises and IT. |
| In England and Wales, a new system for paying dispensing doctors from 1 April 2006 that removes the link between pay and drug costs, and is now based on one fee per item. This is coupled with improvements to the system for reimbursing VAT, with new incentives for dispensing doctors to maintain and improve standards in dispensing medicine. |
| Across the UK, some changes to childhood MMR payment weightings. |
| No changes to the Carr Hill allocations formula for 2006–07. The current review of the formula will continue and the outcomes will be reflected in stage 2 of the review process. |
Further details can be found in the documentation. The GPC has issued a paper which shows where the points have been removed from and where they have been allocated to. This paper can be found here. The new indicators with the relevant guidance will be released in due course.
k. Patients presenting with dental problems
The GPC has issued updated guidance on the treatment of patients presenting with dental problems. The document can be found here.
GPC News Items (Mar 06)
PMS contracts and superannuation funding
The Londonwide LMCs have produce guidance on PMS contracts and employer's superannuation, this can be found here.. This should be helpful for those PMS contractors using the model Lockharts’ contract agreement that includes a clause that sets out a clear obligation on the PCO to reimburse fully the 14% of superannuation contributions. For those practices not using the Lockharts’ contract, the obligations on the PCO are dependent on what is stated in each locally agreed contract. However, this guidance note should be helpful in identifying the type of clause that may allow for full reimbursement to be made.
eGFR
There is some concern about the new chronic kidney disease indicator CKD 1 in the QOF. CKD 1 states that ‘the practice can produce a register of patients aged 18 years and over with CKD’. This register will include patients with a last estimated GFR or GFR of <60ml/min/1.73m2. The QOF guidance states that from 2006, eGFR will be included with creatinine testing and that this would be used to populate the register. Despite the reassurances given during negotiations, there are some problems with the introduction of eGFR, as many labs across the country are currently not providing eGFR results.
This problem has been discussed at length between the negotiators and also with NHS Employers. NHS Employers are also concerned about this issue and are working to ensure that the system is in place without significant delay. The negotiators’ view remains that eGFR should be widely available, so are very keen to avoid negotiating an alternative solution that will require more work from practices, including any manual calculations.
The potential impact on practices of labs not providing this service is appreciated. However, at present, this problem needs to keep in context. As pointed out on the listserver, the QOF year ends on 31.3.07 and even if labs begin providing eGFR late, GPs do not need to complete the work straight away. Additionally, the CKD register has no specific size and many CKD patients are known already.
Work will continue to try to get this resolved as soon as possible. Additionally, if it gets to the stage where it looks as if some laboratories really cannot or will not get this sorted within a reasonable timescale, we will discuss further options. However, at the present time, there is the concern that if, alternative solutions are suggested now, that will take the pressure off the labs and be less likely to achieve a satisfactory resolution. Work on this issue will continue and the GPC will be kept updated.
Pneumococcal immunisation
The Department of Health intends to implement changes to the childhood immunisation programme, to include a new vaccine to protect against pneumococcal infection and an additional booster dose of Hib vaccine as well some amendments to the Men C vaccination schedule are implemented later this year, possibly in June.
Changes to the schedule and the implementation of this policy will be discussed with NHS Employers to ensure that GPs and their staff are properly resourced to provide these additional immunisations. The negotiators will also discuss with NHSE ways to ensure that there is effective communication.
Mantoux testing
A PCT prescribing development group had raised the issue of the new TB vaccination schedule, part of which involves the introduction of Mantoux testing – because Heaf tests are no longer available. Although the Mantoux tests would still be administered and read by school nurses, the problem is that the Mantoux test is technically an unlicensed medication and the suggestion was being made that, for every child, a form would have to be signed by the GP to authorise this.
Our view on this is that GPs should not be signing such authorisations. The product is unlicensed and GPs are unlikely to know the child, the indications for giving it, or who is giving it etc. GPs should not be expected to accept the full clinical responsibility for this test and the GPC would support any GPs who refuse to sign these forms.
IT – GP2GP Transfer
Last year, the GPC was asked how it wanted the GP2GP transfer system to work; either to request transfer immediately on a patient’s registration, or to have a delayed but potentially more complete transfer. The GPC chose the former option and the system has now been constructed that way.
GP2GP transfer is now proven to work between EMIS sites and separately between InPS (In Practice Systems) sites. Transfer from EMIS to InPS and vice versa is being piloted in Croydon later this year. Transfers between these systems and Isoft systems will then follow, early in 2007. Each of these developments will result in changes, revisions and refinements. During this iterative process things will change, the eventual Any system to Any system process may look and feel very different from those currently in place.
The GPC has been asked whether it wishes to see incremental versions implemented as they become available, or whether it should wait until the Any2Any systems option is completed. After a debate, the GPC has supported the incremental system as the committee wants the profession to benefit from GP2GP transfer as soon as it becomes available.
Department of Health white paper on care outside of hospitals
The committee considered a draft GPC work-plan on the white paper, which aims to highlight the areas where initial committee activity in response to some of the most relevant proposals in the white paper might focus. The GPC and negotiating team will use the work-plan as an internal, working document from which to develop the negotiating strategy in keys areas. It was noted that a large part of any possible activity at this stage would form part of the negotiating framework with the NHS Employers in 2006-07. However it was agreed that this should not prevent the committee/subcommittees from being proactive in taking forward any relevant areas of work.
The work-plan also outlined some of the BMA cross-craft work already underway especially that in relation to chapter 6 of the white paper, ‘Care closer to home’. The Chairman of Council has been invited to join the Department of Health’s ‘Care Closer to Home Demonstration Group, chaired by Lord Warner, which will oversee the demonstration sites in the six chosen specialties to lead the way in increasing the provision of care in community-based facilities. The Department of Health’s working group will meet monthly over a year, beginning in March. A BMA cross-craft working group will be set up which will also aim to meet monthly in order to develop policy, monitor the work of the Demonstration Group and advise the Chairman of Council accordingly.
There was some discussion over how effective collaboration between primary and secondary care clinicians could be achieved in terms of taking forward the reform agenda and redesigning services. It was recognised that this could pose a challenge both on the ground and within the BMA, but the establishment of some basic, shared principles would be a positive step, including service redesign being clinician-led, improving patient care, being evidence-based and providing economic value.
The Department of Health recently published a ‘Partial regulatory impact assessment (RIA)’, which provides the Government’s considered early assessment of the likely impact of the policy initiatives set out in the white paper. The document can be found via the website link below and will be discussed at the April GPC meeting:
Cervical screening audit
LMCs have reported on practices being asked by PCTs to fulfil an audit for the NHS Cancer Screening Programmes with regard to women who had withdrawn or become exceptions from the cervical screening programme. Some PCTs were demanding a two week turnaround for a large piece of work. There have been variations across the country in how this has been implemented. The GPC advice has been that the best way forward is to negotiate locally a reasonable timescale for this work, although we recognise this is not a contractual duty, but many practices will consider it clinically valuable. We wrote to the NHS Cancer Screening Programmes about the implementation of the audit and have just received a response which included the following paragraphs:
This audit was initiated by the programme in response to widespread concern over the increasing number of women ceased from call and recall. The audit was discussed with the QA Directors last summer with a view to completion in this financial year. Guidance on how the audit might be achieved was developed in conjunction with PCOs and issued in November. The responsibility for identifying women whose status needed to be checked rested with the PCO. Only the GP, however, could actually check and change or confirm a woman's ceased status.
It is clear that in some areas the execution of the part of the audit which requires GP action has been given a very short timescale by PCOs and also that the numbers of women in some localities are much larger than in other parts of the country. Having discussed the matter with the QA Directors, it would appear best if the deadline for completion of checking is extended to 30 September 2006 in order to make the task more manageable.
'I am grateful for GPs' continued assistance in checking the 'ceased' status of women.'
We would therefore reiterate our advice that LMCs should seek a reasonable timescale for this work.
PMETB fees
The PMETB has announced that for 2006-07 the fees for Article 10 and 11 applications will be £500 and £950 respectively. While these levels are lower than originally proposed by the PMETB, these fees are still far too high. The GPC is still gravely concerned that the PMETB has not accepted that doctors are not the sole beneficiary of certification, and that therefore responsibility for the funding of the Board's work should lie mainly with the Health Departments. The GPC, in conjunction with the BMA's Junior Doctors Committee and other crafts, will continue work to support GP registrars.
Flexible Careers Scheme
In light of the funding problems for the Flexible Careers Scheme, the GPC has produced guidance for practices and LMCs, available here. This sets out the current situation, and well as next steps.
GPC News Items (Feb 06)
Practice based commissioning
The GPC remains supportive of the principles of PBC and the opportunities it presents to improve services to patients. Following publication of the recent DH guidance "PBC: Achieving Universal Coverage" (26 January 2006), however, the committee has some serious concerns that central policy has changed direction and that this could make implementation more difficult. This guidance replaces the February 2005 DH guidance "Making PBC a reality: technical guidance" and GPs and LMCs should be mindful of this in their discussion with PCTs. The GPC has also considered the final specification for the PBC Directed Enhanced Services, that will be made public early next week.
Debate of these issues resulted in a motion being passed stating that "The GPC has concerns that the specification for the PBC DES undermines the development of PBC" A rider was add stating "and that the GPC could not commend it to the profession in view of the recent guidance".
It is important to note that one major concern surrounding the DH guidance was an ambiguity in paragraph 48 concerning the use of freed-up resources to offset PCT deficits. We have now received clarification that this does not apply to the 70% of freed-up resources that practices can reinvest in further improvements to services. It only relates to a last-resort use of the 30% that PCTs can retain. This will be clarified soon on the Q and A section of the Department's PBC website. Although the motion passed still reflects the wider concerns of the GPC on the direction of PBC policy, it (particularly the rider) should be viewed partially in this context of this ambiguity in the guidance.
A new deal for welfare: Empowering people to work
A new deal for welfare: Empowering people to work, a recently published Department of Work and Pensions (DWP) consultation document, was considered by the GPC. The central aim of the document is to remove one million people from incapacity benefit by 2010. The government’s ideas herald a major change in the way that claimants will be handled, with general practice playing a substantial role in this. One of the main ideas floated is that of employment advisors sitting in on GP surgeries to offer help and support. The GPC did not oppose the principle, but there were many questions regarding the practical implications of doing so that will need to be answered by the DWP. Many Committee members suggested that occupational health advisers would be more appropriate and emphasised that GPs should not be involved in incapacity benefit assessment.
PMS issues
There is some ambiguity about termination of PMS agreements in the agreement regulations 2004 (schedule 5, paragraph 100). These regulations state that either party may terminate the agreement by serving notice in writing but do not specify the notice period. Like the regulations, the majority of PMS agreements replaced after 1 April 2004 also fail to specify a period for termination of the agreement by notice.
It is widely assumed that when PMS became permanent on 1 April 2004, PMS contracts became permanent. GPs should be aware however that there is a possibility PCTs wishing to terminate PMS contracts without cause may use the regulations to do so (though arguably, if no date is set out in the agreement, the implication may be that the agreement can only be terminated for breach, as with GMS). The issue is debatable until it is clarified in the PMS regulations. In the mean time, GPC would like to know if any PCTs attempt to terminate PMS agreements without cause under these regulations.
Dispensing GPs in England & Wales – VAT Registration
Following changes in Department of Health funding effective from 1 April 2006, dispensing doctors who wish to recover VAT incurred on the drugs they dispense will need to register for VAT. This decision has been imposed by the Department of Health & Welsh Assembly Government.
Information on how to register for VAT is now available on the Revenue and Customs (HMRC) website at the link below. It is also available here.
This Information provides:
• Advice about how doctors can register for VAT.
• Information about the VAT treatment of the goods and services they provide.
• Advice about how much VAT can be recovered on purchases.
We would encourage all dispensing practices in England & Wales to visit the HMRC website as soon as possible and follow the advice to register for VAT.
This information applies to dispensing GPs only operating under GMS or PMS contractual arrangements.
Please note that the BMA does not provide specialist advice on VAT; practices should seek the advice of their accountants.
GPC News Items (Jan 06)
IT Update
National Care Record
The GPC discussed the electronic National Care Record following a presentation from the National Clinical Leads at Connecting for Health. The committee voted:
|
That the GPC supports the creation of Summary Care Records on the national database. |
|
That the GPC insists that clinical data should not be uploaded to the summary care record without the valid informed consent of the data subject, i.e. “opt in” |
|
That the GPC works with the Department of Health and Connecting for Health to ensure that an appropriate publicity campaign is mounted. |
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That the GPC continues to monitor the situation |
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That doctors should not be deciding the best options for patients and that these issues should be decided by Parliament (in the context of this debate). |
National Programme for IT
Owing to continuing IT maintenance upgrade funding issues with PCTs, the Joint GP IT Committee of the GPC and Royal College of GPs has agreed with the National Clinical Leads and Connecting for Health that a test case will be taken to the nGMS Implementation Co-ordination Group (ICG).
GP2GP testing in the Isle of Wight between InPS sites is scheduled to begin shortly. Further discussions will focus on how this process should proceed.
IT Service Level Agreement (SLA)
The SLA will be published shortly; there are still a number of minor legal issues which need to be resolved.
Advice form the GPC – Allergy recording in GP clinical systems
Advice on allergy recording in GP clinical systems was supported by the GPC .This has been developed following discussions and consultation with the GP2GP team, system user group suppliers and the GPC’s legal advisor to highlight the importance of correctly Read coding diagnoses within the patient record, so that the accurate translation of information from one system to another can potentially take place. A copy of the updated advice can be found here
General practice business model
The committee debated two discussion pamphlets prepared by Professor Paul Corrigan, the recently appointed special health adviser to the Prime Minister.
The first paper, “Size matters - making GP services fit for purpose”, emphasises that there should continue to be small businesses providing GP services, and that, in many circumstances, this model provides excellent care. However, Professor Corrigan argues that in a diverse society where people live very different lives, primary care needs to be organised in different ways. Whilst the GPC had concerns about some of the detail, it was widely recognised that the paper’s options for change, particularly regarding the ability of primary care to handle work transferred from secondary care, were worthy of serious consideration.
There was less support for Professor Corrigan’s second paper, “Registering choice: how primary care should change to meet patient needs” and it was noted that the paper contained a number of inaccuracies. In particular, there was concern about a fundamental premise within the document: that the service should be based on patient wants rather than patient needs.
Committee members are in regular contact with Professor Corrigan and will be continuing to discuss these crucial issues with him.
Forthcoming equality legislation
GPs should be aware of imminent equality legislation including the Disability Discrimination Act 2005, Employment Equality (Age) Regulations 2006 and the Equality Bill.
The Disability Discrimination Act will entail the most immediate changes for NHS organisations as Disability Equality Schemes must be in place, and ready to put into action, in public bodies within a year.
The Act includes a new general duty on public authorities to eliminate unlawful discrimination against disabled persons and promote equality of opportunity between disabled persons and other persons. The major difference from previous legislation is that 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’
Further information on the implications of the legislation can be found at the following link -
GP trainers - £750 CPD payment
Following Lord Warner's assurance that the £750 CPD payment to all GP trainers would be made in 2005/06, the GPC chairman has written twice to seek details of when exactly this payment would be made. Lord Warner has confirmed that the allocations will be made to Strategic Health Authorities in January 2006 and trainers should receive payment by late February.
Job planning guidance
The sessional GPs subcommittee has produced a helpful guidance note for both salaried GPs and their employers on job planning. This is available on the BMA website under the salaried and freelance GP section. The development of a job plan is a core component of the model salaried GP contract. A job plan translates expectations of employee and employer into a working schedule, and ensures that the post delivers its aims and the requirements of the contract of employment are met.
Locum GPs: pension arrangements
It has been confirmed that the employers' superannuation contribution for locum GPs remains with the PCOs "for the foreseeable future". The regulations for locum GP pensions have not changed and locum GPs should continue to claim for this in the normal way. Please note that locums should check that the organisation that engages them as a locum is an approved NHS pension scheme employing authority to ensure that pay will be superannuable under the NHS scheme.
Bichard vetting and barring scheme
We have received information from the Department of Health and Department for Education and Skills regarding the Bichard vetting and barring scheme. The Bichard report was published in 2004 following the inquiry into the investigation of the failures around the Soham case. Specific work has ensued regarding the arrangements for registration of those wishing to work with children or vulnerable adults.
Although the details are not yet finalised, we have received confirmation from the DfES that doctors will be involved in the scheme, in that the arrangements will “probably” cover them. However, they would not be required to assess individuals or provide information about them. We will keep you informed of future developments.