NEWSLETTER MAY 2007
Safeguarding patient services, maintaining cost-effectiveness.
Decontamination of Medical Devices
GPC-LMC Secretaries meeting - 19 April
RCGP paper - The future direction of general practice roadmap
Setting up new business entities – pensions consideration
Flexible careers scheme and retainer scheme
Safeguarding patient services, maintaining cost-effectiveness.
This year's DDRB report heralded a second year with no increase in funding to GP practices for the core elements of the contract, despite rising costs and inflation. Its decision will put practices across the country under considerable financial pressure. There can be no doubt that GPs’ first priority will be to safeguard patient services from the effects of a reduced practice income and in spite of financial pressures they will also wish to continue to reward practice staff fairly.
Despite comments to the contrary in the Medical
Press the GPC is taking what action it can over this issue. However,
there are a number of legal constraints which prevent the GPC or LMCs
calling for collective action. Before calling for any collective action
the BMA would have to ballot its members on such action. The feeling at
present is that there would not be enough support from grassroots GPs.
They also have to bear in mind that public opinion perceives GPs as NHS
"fat cats" and it is unlikely that any action would carry the
sympathy of the public. Against this background the GPC has produced a
document entitled "Safeguarding patient services, maintaining
cost-effectiveness". All GPs and practice managers should read carefully
through this document.
While it may not be possible to bridge the gap between rising costs and
a zero increase in practice income, it is likely that GPs will want to
review their practice workload and costs to explore decisions and
actions they could take when trying to balance the practice’s books. In
much the same way that tight NHS budgets have resulted in pressure on
hospitals to review their services, primary care providers will now need
to take tough business-minded decisions to minimise the effects on both
the practice and patient services. This guidance identifies a number of
measures to help practices with their business planning and can be
accessed
here.
Practices should be aware that many of last year's DESs finished at the end of March 2007 (details can be found at the back
of this guidance). To date there has been no national discussion about replacing
these DESs in England. GPs across the UK are under no obligation to
continue to provide the services covered by expired DESs. In fact, to do
so risks these services becoming part of "custom and practice" and
therefore more difficult to stop in the future. Stoke-on-Trent PCT has
indicated that it will commission a Local Enhanced Service for both
access and Choose and Book as there is no sign of a negotiation on a
national DES at present. We hope to have more details and a firm
commitment on this in the next few weeks.
Colleagues should bear in mind that one of the central planks of the new contract was the ability to say "no" to new and unfunded services. The GPC recognises that saying no can be very difficult when it involves direct patient care and puts the doctor/patient relationship at risk. However, to maintain cost effectiveness GPs will have to pay more attention to the bottom line.
The intention of the GPC is to concentrate on negotiating contractual issues with the DoH, but to leave the pricing of services and the contract to the DDRB. Looking back over the years since its inception the DDRB has recommended pay increases which have in general kept general practitioner on a par with comparator professions even though this year it recommended a zero pay increase for general practitioners. To achieve this the DoH should have given a cost of living increase to contract prices.
Referrals to Secondary Care
The LMC has discussed the issue of channelling referrals through the Clinical Assessment Service on a number of occasions since its inception. We continue to hold the view that GP colleagues should be free to refer directly to secondary care. We have concerns over the triage system and also have asked to be reassured about the standard of care provided by GPSIs. However, despite repeated requests for this information we have had no response from Stoke-on-Trent PCT.
The University Hospital of North Staffordshire has informed us that it is able to process referrals which are sent directly and do not go through the C & B system.
Social Service Forms
We are having discussions with the Stoke-on-Trent Social Services over the redesign of their referral forms and the ACP4. It is hoped that in the near future a redesigned form will be produced in a similar format to the hospital referral letters and which can also be produced electronically.
At a recent meeting, the GPC in consultation with the Small Practice Association (SPA), agreed to produce guidance on best practice and options in relation to a contractor who is an individual medical practitioner and their retirement. This was in response to a primary care trust (PCT) that had developed a blanket policy not to replace single-handed vacancies with single-handed practitioners. Although the guidance is geared towards single-handed GP issues, many of the contractual issues raised in this guidance are relevant to GPs in general. Information on practice mergers and advertising of vacancies is also included. A copy can be found here.
Decontamination of Medical Devices
The GPC are aware that there has been a great deal of confusion with
regard to sterilisation and decontamination of medical devices from 1st
April 2007.
The situation is still not entirely clear so, for your information, they
have produced a document which sets out their understanding of the
current situation, outlines some of the key implications for practices,
and links to some sources of further information. A copy can be found
here.
PMS Contracts
The GPC has produced a guidance note which sets out the options available to PMS practices when PCTs seek to review existing contractual arrangements. This is an update of the GPC guidance issued to PMS and APMS contractors providing essential services in April 2006. A copy can be found here.
The Mental Capacity Act 2005
The Mental Capacity Act 2005 for
England and Wales will come into force in 2007. This act governs
decision-making on behalf of adults, where they lose mental capacity at
some point in their lives or where the incapacity condition has been
present since birth. Although parts of the Act will be available from
April 2007, including the introduction of the Independent Mental
Capacity Advocate (IMCA) service and guidance on principles, assessing
capacity and determining best interests, most of the Act will come into
force in October 2007.
The BMA Ethics Department have produced guidance for health
professionals on the Act which is available here:
http://www.bma.org.uk/ap.nsf/Content/mencapact05
This guidance gives a good overview of the Act however it is unlikely
that it will impact significantly on GPs until October 2007 and through
the BMA’s Professional Fees Committee (PFC), work is ongoing to
negotiate the associated fee for undertaking Court of Protection work.
The GPC and the PFC will issue further guidance over the summer on the
practicalities of completing the new Court of Protection assessment of
capacity form which will replace the current CP3 medical certificate.
The GPC is aware that many GPs have been told that they have to attend
mandatory courses on the Mental Capacity Act 2005. There is no
requirement on GPs to attend these courses but they may, of course,
attend if they wish. Provided GPs continue to do any work associated
with the Act with full understanding and within their capabilities as
defined by the GMC, there should be no need for additional training.
Practice Based Commissioning
The GPC has issued two new guidance notes on practice based commissioning. One gives a detailed summary and analysis of 2007-08 PBC policy according to the latest Department of Health guidance 'PBC: practical implementation' published in November 2006. The other gives a more concise summary of this DH guidance, focussing on the key issues. Note that each guidance note cross-refers to the other, so whichever one someone reads, they should be aware of the other. Copies of these documents can be found via these links.
Practice based commissioning in 2007-08: key issues
Practice based commissioning in 2007-08: detailed analysis of policy and guidelines
A document on employment of staff for PBC and service provisions has
been produced by the BMA, this document is available only to BMA members
who should be able to access it online via the following address:
http://www.bma.org.uk/ap.nsf/Content/Hubcommissioningserviceprovision
Items from the GPC
GPC-LMC Secretaries meeting - 19 April
Around 150 GPC members and LMC secretaries met at the Brunei Gallery, School of Oriental and African Studies on Thursday morning for a meeting that covered a lot of ground and allowed LMC secretaries to exchange opinions on the feelings among GPs in their area.
The morning started with some brief presentations and a panel Q&A session which involved not just Hamish Meldrum and Laurence Buckman, but also Jon Ford, Head of the BMA's Health Policy and Economic Research Unit, Linda Millington, BMA Head of Media Relations and Jonathan Waters, BMA Head of Legal Services. This allowed LMC secretaries to ask about the GPC's media policy, the legal limitations on the GPC and LMCs in terms of taking action and advising practices on what action they can take, as well as background information on why the DDRB was an important mechanism for the GPC to continue to use.
The meeting continued with LMCs detailing and discussing the situation in their areas. It became clear that there were a broad range of issues that GP practices were concerned about and that went beyond the 0% DDRB recommendation. In particular there was disquiet about the current state of the NHS, the amount of political and managerial interference in everyday professional practice, and the very vulnerable position of PMS practices who were being squeezed by PCTs. The recent GPC guidance document was welcomed and supported and there was a greater understanding about the issues around industrial action and media and legal constraints. It was recognised, that while practices may wish to take some kind of action, and in particular to protect their practices' income and patient services, there was no single way in which this could be executed, and that such decisions were best made at local level, tailored to local circumstances. Choose and Book was a case in kind, where in some areas it works well for practices and is considered an enhancement to patient services, while in others there is now no funding, there are many problems and GPs would prefer to discontinue participation. There was consistent agreement that any decisions taken must not harm patients.
Negotiations update
There has been really no progress on negotiations in England since last month, although there has been communication with ministers about more general issues. The GPC has suggested that it would like to see negotiations about new incentives and service changes separated from annual pricing of the contract, which should be undertaken by the DDRB.
GPC survey of GPs
The GPC discussed the content of the forthcoming GPC survey of GPs. This survey of GP opinion is partly a response to the DDRB’s zero pay award for GPs and the breakdown of negotiations between the GPC and NHS Employers for 2007-08. However, it is also a good opportunity to survey GP opinion on a wider range of current issues such as professional morale and NHS reforms. A national survey of GP opinion was last carried out by the GPC in 2001 as a precursor to the nGMS negotiations and repeating some of the questions asked in this survey will make certain comparisons possible. The intention would be to survey the whole profession across the UK, including GP registrars and sessional GPs, as was done in 2001. It is hoped that the results of this year’s survey will provide:
· engagement of the profession in the decision-making process
· important information to support our DDRB evidence
· an analysis of GPs’ opinions about the NHS which can help inform BMA policy and our press work
· guidance on GPs’ appetite for further action, including industrial action, in the future
We anticipate that the survey will go out to GPs around the end of May, with results in early July. The GPC will do its best to encourage GPs to respond to the survey. LMCs will also have an important role to play in encouraging GPs to take part.
Discussions are taking place in the wider BMA about a survey of public opinion and a survey of other doctors. It is expected that a number of common questions on NHS reforms will be used in all three questionnaires.
RCGP paper - The future direction of general practice roadmap
The GPC has agreed to support the Royal College of General Practitioners on its paper, "The future direction of general practice roadmap". This paper aims to put forward ideas for the future of general practice and patient care, by providing a framework for developments in quality, education and workforce. With a few minor amendments to the current draft paper, the GPC/BMA logo will be added in support and the GPC chairman will offer to write a joint foreword with Professor Lakhani.
Setting up new business entities – pensions consideration
The GPC is aware that some GPs are considering setting up new business entities, such as companies limited by shares, for parts of their business. In some cases this may follow advice from accountants that operating through such a business will confer tax advantages over traditional arrangements. It is very important that before setting up any new business entity, GPs consider the implications of doing so for their (and their staff) NHS pensions and seniority payments as some business types will cause payments to be lost or income to be ineligible for pension purposes in the NHS. The regulations surrounding the interaction between GMS, PMS and the NHS Pension Scheme are complex and not all accountants will be aware of the full implications that may apply in each area.
The Department of Health, the NHS Pensions agencies and the BMA are in the process of producing guidance for the more common scenarios, but this is an emerging field and not all possible variations will be covered. Doctors who are considering changing the way that they operate or thinking about setting up companies should therefore always contact the NHS Pensions Division (Policy Development Unit) for advice in respect of access to the NHS Pension Scheme. The BMA Pensions department will assist with communications where appropriate.
VAT on Medical Services
Further to previous GPC News items, practices should be aware that Parliament has approved the implementation of VAT on medical services from 1 May. Those practices already registered for VAT are advised to familiarise themselves with the details of items for which they will have to charge VAT from 1 May. We would be grateful if LMCs would bring this to the attention of their local GPs.
Detailed guidance can by found by visiting HMRC's website:
www.bma.org.uk/ap.nsf/Content/VATonmedicalservicesFAQs?OpenDocument&Highlight=2,VAT
HMRC was required to consider the Morganash ruling during the implementation process for the ruling on VAT on medical services. This was a VAT tribunal case that considered whether medical services relating to certain insurance transactions could be exempt under the VAT exemption for insurance. The tribunal decided that the service was exempt from VAT under the UK (but not EU) insurance exemption. HMRC did not appeal against the tribunal decision and accepted that medical services provided in connection with the bringing together of parties to an insurance contract and the administration of policies, including the handling of claims, fall within the current UK insurance exemption as insurance-related services. This means that nearly all insurance work will continue to be exempt from VAT.
Further information is given in the insurance section of the HMRC Public Notice 701/57 and the Revenue & Customs Brief announcing implementation of the changes (available on the HMRC web site). This states that medicals and reports provided purely for the purposes of valuing policies for tax reasons, for example, in relation to inheritance tax, are liable to VAT at the standard rate. We understand that this is a small area of insurance work but the HMRC guidance states that the following insurance areas qualify as an exempt supply of health in principle:
· Health screening under private medical insurance policies - these are regular check-ups to detect early signs of disease.
· Income/credit protection insurance - medical services where the policy holder has fallen ill (as opposed to losing his/her job) and which are aimed at assisting the individual in returning to a normal life.
· Motor insurance - where medicals services are provided under a policy to assist in enabling an injured motorist to return to full health and/or work. (Note - this does not include medicals undertaken for DVLA purposes to ensure initial or continued fitness to drive which are liable to VAT at the standard rate).
· Any other medical service provided in connection with an insurance policy where the principal aim is to assist in restoring the health of the individual.
We understand that this exemption for VAT applies to the current fees we agree with the ABI for life assurance policies and income protection policies. ABI have indicated that insurers are aware of the small areas of insurance that are subject to VAT and are likely to identify that the work is vatable when contacting GPs. Once again GPs are advised to keep careful records and to take professional accountancy advice regarding their individual circumstances.
Flexible careers scheme and retainer scheme
Please note that, while the funding for new recruits to the flexible careers scheme has ceased in many areas, practices who still have a FCS doctor on the three year scheme will continue to be reimbursed in line with the SFE. In addition, recruitment to the GP retainer scheme should remain unchanged.