NEWSLETTER March 2008
GMS contract negotiations update
National Audit Office (NAO) report
Model Contract and Variation Notice
Quality and Outcomes Framework
Interface between NHS and private treatment
Restrictions on private GP referrals
Contract Issues
You will be aware that the result of the recent poll was that GPs voted overwhelmingly to protect quality care and income and selected the least worse of the two unsatisfactory options. It is extremely unlikely that any formal directions or SFE amendments will be in place for 1st April as it is expected that there may be some negotiation between the DoH and the GPC, although no significant changes are expected. There has been a small concession in that the hours are to be rounded to the nearest 15 minutes rather than rounded up, but a recent letter to SHAs has brought in the concept of seeing "walk-in" patients as well as pre-booked appointments. The DoH has also stated that there can be concurrent GPs appointments in exceptional circumstances agreed by the PCTs. The DoH is still insisting that there is no reduction in "in-hours" GP appointments.
The GPC continues to advise that practices should not supply PCTs with any appointment information until signing up to the DES. They are clarifying with the legal department what information it would be reasonable to provide if a practice does sign up to the DES.
Practices should note that:
1. The DES remains voluntary. Practices should discuss internally whether they wish to implement extended hours. As with any DES, practices will wish to consider their costs and expenses before deciding whether or not to participate.
2. Practices in Stoke-on-Trent should consider the offer from the PCT to put in bids for the provision of some extended hours. This scheme is likely to be more flexible than the DES by not stipulating a precise number of hours to be provided and allows a more pragmatic choice. We are not aware yet of any move on behalf of North Staffordshire PCT to offer anything other than the DES.
3. If a practice does not wish to offer extended hours, the funding remains with the PCO and so practices should work with PCOs to make alternative use of this funding for practices by developing locally enhanced services that provide better for the needs of their patients.
Elections to the Committee
Following the recent ballot the following were elected to the committee for a four year term commencing April 2008.
 | Dr Paul Golik |
| Dr Ian Leese |
| Dr Chandra Kanneganti |
| Dr Bandu Kulkarni |
| Dr James McCarthy |
| Dr Prasad Rao |
| Dr Paul Scott |
| Dr Pravin Shah |
| Dr Paul Unyolo |
| Dr Harald Van Der Linden |
Drs H Borse, J Edwards, A Green, D Hughes, L Hussain, G Morgans, U Pathak K Samal, M Shaikh and A Talpur continue on the committee and their term of office ends in March 2010.
Choose and Book DES
The Choose and Book DES along with the Access DES finish on 31st March. Both North Staffordshire and Stoke-on-Trent PCTs plan to introduce a Local Enhanced Service to take over from the Choose and Book DES. Practices will have to decide whether they wish to take up this offer.
Darzi Clinics
Stoke-on-Trent PCT is proposing to open two clinics, both in areas of perceived need. One will be in Meir and one in Middleport. They have contacted and discussed the proposals with the GPs in the areas concerned. It is envisaged that the service in Meir will be up and running by December 2008 and the Middleport one by Autumn 2009. The PCT recognise that some practices will lose funding as these services impact on list sizes. The PCT is, therefore, planning to introduce a "QOF plus" scheme through which practices will be able to obtain funding based on certain quality standards being achieved. This scheme will be available to all practices in Stoke-on-Trent not just the ones directly affected by the new surgeries. The LMC will be involved in the process of setting up the service specifications for both the new surgeries and "QOF plus".
Health Inequalities
It is a well known fact that the health of the population of Stoke-on-Trent falls well below average. In some wards people have eight years less life expectancy than average. Health indicators in the index of multiple deprivation show that Stoke-on-Trent is the 12th worst PCT in the country. Although health has improved over the years the gap continues to widen. The PCT is classified as a "Spearhead" PCT which means that it receives additional support to address health inequalities. The PCT recognises the importance of primary care services in reducing mortality and morbidity and in mitigation against the consequences of deprivation. The PCT has recently produced a "Primary Care Strategy" which although it contains some criticisms of general practices does show a commitment to the development of practices and stresses their importance in the drive to improve the health of the city.
Primary Prevention Registers
The Health Care Commission expects that all practices within Stoke-on-Trent PCT to have CHD Primary Prevention registers. Both NICE guidance and the CHD NSD also recommend primary CHD prevention within primary care. The PCT have obtained Oberoi software which can be installed on practice systems to enable the development of instant CHD primary prevention registers. The PCT has also produced a package of support for practices who wish to undertake CHD primary prevention. Given the poor health status of the population of Stoke, practices are encouraged to support these initiatives.
Items from the GPC
GMS contract negotiations update
Extended hours DES
‘Walk-in’ appointments
The GPC negotiators met with NHS Employers on Wednesday 20 March and sought clarification on the issue of ‘walk-in’ appointments as mentioned in the letter from Ben Dyson to SHAs. NHSE stated that this was intended to provide flexibility for practices to reserve a number of appointments in their extended hours period for “last-minute” bookings if they wish to. It is stated in the DES specification that the majority of appointments in the extended hours period should be pre-booked appointments but, where practices wish to, they can split their available appointments in the extended hours period between “pre-booked” and “last minute” appointments.
This will be elaborated on in Department of Health guidance on the Extended Access DES which is currently being developed and will be shared with the GPC negotiators before it is issued. The guidance will also make it clear that responsibility for urgent care remains with the PCT and that the urgent care service will run in parallel with extended hours consultation time. The GPC will also be issuing its own ‘Focus On’ document to assist GPs in implementing the DES.
DES Directions
The directions to lawyers have been drafted and it is hoped that the directions will be finalised as soon as possible. However this will mean that all the legal details of the DES will not be finalised by 1 April. We acknowledge the frustration this will cause where practices wish to begin preparing for and delivering the DES, but unfortunately the timescale of negotiations and the poll was such that this was unavoidable.
LESs
The GPC continues to urge LMCs to negotiate LESs using the GPC guidance “What the poll outcome means for your practice”. If practices do agree a LES in advance of the DES directions being issued, there will be provision in the DES for the PCT to make payment under the DES if the LES meets its requirements – or continue with the LES. Practices need to ensure that any LES does leave it open for the practice to opt to do the DES instead, should that be their preference.
The GPC recommends that, when negotiating a LES, practices seek reassurance from PCTs that the flexibility for practices to change the way consultations are offered in-hours will remain even if extended hours are offered. The legal advice about not supplying the PCO with any appointment information until signed up to the DES remains. The negotiators are clarifying with the legal department what information would be reasonable to provide in the circumstances that a practice does sign up to the terms of the DES.
Ahead of 1 April these are steps that practices should take:
1. The DES remains voluntary. Practices should discuss internally whether they wish to implement extended hours. As with any DES, practices will wish to consider their costs and expenses before deciding whether or not to participate.
2. If practices do wish to offer extended hours, practices and LMCs should start conversations and use the “flexibilities” within the DES and/or encourage their PCO to commission a LES to address remaining concerns about safety and quality of the consultations – for example concurrent doctor time and funding for nurses to be present too. Alternatively, a separate LES could be negotiated for all aspects. However, there is, of course, no requirement for LMCs or practices to start any discussion as they can wait for the DES.
3. If a practice does not wish to offer extended hours, the funding remains with the PCO and so practices should work with PCOs to make alternative use of this funding for practices by developing locally enhanced services that provide better for the needs of their patients.
Discussions are continuing in Scotland and Wales, both of which seem to be making more progress in terms of getting flexibilities into their DESs. However, similar principles in terms of deciding how to progress would apply.
Pensions Judicial Review
The BMA was successful in the judicial review against the government’s action in reneging on its decision on how GPs pensions would be calculated from the years 2004 - 06. The Department of Health has received permission to apply for leave to appeal. The BMA was awarded costs and is seeking further details from the Department of Health regarding how they intend to implement the JR decision and requesting that the work which will be necessary to finalise the dynamising factor for 04/05 and 05/06 be put underway as soon as possible. The GPC will keep you updated on any developments.
National Audit Office (NAO) report
The NAO report on new contracts for general practice services in England was released on 28 February. It criticised the new contract, particularly GP income and lack of improvement of "productivity” and recommended that MPIG be phased out and local variations to the QOF be introduced. The GPC attempted to correct any inaccurate reporting in the press, and many of the GPC’s comments on the positive findings of the report - increased recruitment of GPs, improvements to patient care amongst others - were picked up on.
Model Contract and Variation Notice
The Department of Health has made some technical changes to the GMS Standard Contract which were agreed with the GPC and the NHS Confederation to bring them in line with the updated Regulations.
The terms of that contract are now published and can be downloaded from the Department of Health website at the following link -
www.dh.gov.uk/en/Healthcare/Primarycare/Primarycarecontracting/GMS/DH_4125638
Quality and Outcomes Framework
The details of the changes to QOF for 08-09 and GPC guidance will be made available to practices before 1 April. The changes include removal of 58.5 points from the holistic points, patient experience and organisational domain, other changes to indicators based on the evidence review and expert panel recommendations, and some additional changes to the financial arrangements. The GPC will be issuing further guidance for the profession when these changes are made public.
Revalidation of GPs
The chairman of the Royal College of General Practitioners (RCGP), Professor Steve Field, attended the GPC meeting to explain the RCGP's work on revalidation.
The RCGP wants to ensure that the revalidation process is supportive and developmental, is profession led and is beneficial to patients. The RCGP is keen to continue to work with the GPC to ensure that the appraisal and revalidation process is fair and equitable to all GPs (including GPs with special interests, salaried GPs, locum GPs and those who are taking a career break or are out of work for a period of time).
The RCGP considers that appraisal is the key. It wants to avoid compulsory all-day multiple choice assessments of knowledge, and instead wants GPs to be able to demonstrate their performance and use of knowledge. GPs will be able to demonstrate that they are up-to-date through participation in continuing professional development, and a support package called "Essential General Practice". This will include the ability to do a knowledge test at home or in their surgery so that they can prove they have the appropriate standard. Once they have reached the standard they will be able to print out a certificate which can then form part of a GP's appraisal folder.
It will continue to be essential for GPs to keep up-to-date with clinical developments. The RCGP's aim is for GPs to be able to demonstrate this through credit-based CPD, multi-source feedback and GP appraisal. Professor Field further explained that:
· all GPs will need to show that they have achieved 50 CPD credits per year, which is likely to equate to 1 credit per hour of learning;
· the multi-source feedback will be via properly developed questionnaires;
· it is essential for GP appraisal to be quality assured and supported; and
· GPs should receive regular updates on clinical practice guidelines that are relevant to GPs.
The revalidation process will be piloted before it is slowly rolled out to all GPs.
For your information, the RCGP has recently published its 'Principles of GP appraisal' which is available at www.rcgp.org.uk/pdf/corp_Principles%20of%20GP%20appraisal.pdf.
LMCs and GPC members will also shortly be consulted on the draft revised version of the GPC/RCGP's Good Medical Practice for GPs, which it is hoped will be finalised and published in June 2008. Both of these documents will provide a helpful background to the formation of the appraisal/revalidation process.
Interface between NHS and private treatment
The committee discussed a guidance paper produced by the BMA Ethics Department exploring the interface between NHS and private treatment.
The boundary between public and private sector healthcare in the UK is beginning to blur. Many practitioners are concerned at the extent to which patients can move between the two, while the increasing instances of patients topping up their NHS treatment raises many ethical questions regarding the equality of healthcare provision. In addition, the introduction of new models of primary care provision is likely to make the situation more complex.
In light of these changing features to the UK healthcare environment, the BMA Ethics Department will be updating its guidance.
Restrictions on private GP referrals
The GPC considered the issue of private insurance companies restricting GP referrals to hospitals or consultants in their networks only. The BMA has received a number of letters from GPs expressing concern that they are unable to exercise clinical freedom or in ensure continuity of care for long-term patients when compelled to refer them to unfamiliar, unknown or anonymous specialists; patients only receive full reimbursement by their insurer if they accept a referral to the company’s preferred consultant or hospital within their network.
GPC believes that this policy runs counter to the patient choice which was formerly the major benefit of choosing private healthcare. The latest initiative of the insurance companies seems to place commercial considerations about clinical considerations of patient care. The referral process, whereby GP uses independent judgement based on specific clinical need to refer a patient to a named consultant has served patients well both in the NHS and the private sector. The erosion of this process in either sector is not in the best interests of patients.
The GPC's view remains that GPs should retain the right to refer to named consultants, whether for NHS or private care, where they believe this to be in the best interests of their patients.