NEWSLETTER May 2008
Extended access and salaried GPs - GPC Guidance
Focus on Quality and Outcomes Framework
Promoting Sugar Free Medicines
Improving Communication with Pharmacists
Involvement with Private Companies
GMS contract negotiations update
Doctors and Dentists Review Body (DDRB)
Public Accounts Committee Inquiry
Darzi Clinics
As previously reported Stoke-on-Trent PCT is planning two Darzi GP centres, one in Meir and one in Middleport. It has yet to find a location for its GP led Health Centre. North Staffordshire PCT is planning to open a GP led Health Centre in Newcastle town centre.
According to the DoH patients have told them that they want:
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GPs and Reception staff to have better soft skills |
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Staff and Surgeries to be clean and tidy |
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Appointments to be easier to make and when convenient for them |
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Lifestyle advice |
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Longer opening hours |
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Modern buildings |
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Co-location of other services on site |
Life expectancy is linked to the number of GPs in an area and poor outcomes are related to poor access to services. The life expectancy gap between the most and least deprived areas has widened. The West Midlands is the second most "under-doctored" SHA area in the country.
Despite Lord Darzi stating recently that local health services should decide what is right for their areas, there are a number of dictats which the local PCTs must deliver, these include two Darzi GP practices for Stoke-on-Trent and a new GP led Health Centre in every PCT area. These must deliver new capacity and are not allowed to be an expansion or replacement of existing surgeries. The new Health Centres have to be GP led and anyone (regardless of where they are registered) should be able to get bookable GP appointments or walk in services. There should be a GP present at these health centres during their opening hours of 8am to 8pm every day of the week. All these new services are most likely to use APMS as the contracting route.
It is clear that the DoH has not thought through the detail of their proposals, for example, how the new GP led health centre who have to offer a walk in service can plan to cope with demand over Bank Holidays, how they link in with out of hours services and how they can have a permanent GP presence on their staffing quota of 3 GPs.
The advertisement for expressions of interest to provide these services will be place in the next editions of the BMJ and HSJ (Health Service Journal) Anyone who is considering tendering for one or more of these services must respond and submit an expression of interest by 9th June.
The principle of Darzi in bringing in extra GP capacity to under doctored areas has to be supported. However, the way of doing so leaves much to be desired. There is a threat to all traditional GMS and PMS practices in the way Darzi is to operate and the GPC has recently circulated GPs with information on action it wants to take to publicise this widely.
It is, however, unlikely that the DoH will backtrack on the Darzi reforms and practices must gear themselves to adapt to the threat. One area which the LMC will be considering next month is to look at the standard of service which we offer and of ways to ensure that it tries to meet the criticisms which are levelled at us.
Support your Surgery Campaign
Details of a national
“Support your Surgery” campaign to defend and promote NHS GP services in
England, have been announced by the BMA.
GPs are worried that government plans to introduce more commercial
providers into general practice could destabilise existing services,
depersonalise care and put some GP practices at risk of closure. The
number of private firms winning contracts for GP practices is growing
and, at the same time, Primary Care Trusts (PCTs) have been instructed
by the government to set up new health centres, or polyclinics, that
commercial providers can bid for. In many areas there has been little or
no prior consultation on the need for these super surgeries.
The BMA will be sending all GP practices a campaign pack containing
posters, leaflets and stickers to help them inform the public about
local plans. Practices will also be asking their patients to sign a
petition that will be presented to Downing Street in June as a giant
birthday card celebrating the NHS at 60. Other activities will include
advertising, open days in surgeries, and making contact with local MPs.
A copy of the letter sent out by Laurence Buckman can be found
here.
Pandemic Flu
The GPC and the NHSE employers have reached agreement on the maintenance of GMS practice resources in the event of an influenza pandemic. This ensures that practices responding to a pandemic emergency will not be disadvantaged if some or all routine GMS work needs to be suspended. The details can be found in two documents which are on the BMA website at http://www.bma.org.uk/ap.nsf/content/hubinfluenza.
Extended access and salaried GPs - GPC Guidance
The GPC are aware that many salaried GPs are being asked to change their hours of work as a result of practices taking on, or considering taking on, the extended hours DES or a LES. The GPC, in conjunction with BMA Regional Services, has therefore produced a guidance note for salaried GPs which can be found on the BMA website at: http://www.bma.org.uk/ap.nsf/Content/exthourssalgps0408 .
This covers:
1. What action a
salaried GP should take if their employer wants to change their hours of
work
2. Points for the salaried GP to consider before making a decision
3. How an employer may change the salaried GP's hours/terms and
conditions
4. Points for the salaried GP to consider in responding to the
employer’s proposal
5. Action to take if their hours are unilaterally changed
6. Action that the salaried GP should take if their hours are changed
with their agreement
7. BMA support available to BMA members.
While the guidance note is specifically for salaried GPs, practice employers may also find it helpful.
Focus on Extended Access 2008
This ‘Focus on Extended Access’
guidance has been produced by General Practitioners Committee (GPC) to
help GPs and Local Medical Committees (LMCs) understand the changes that
have been made to the GMS contract for 2008/09. The implications for
England, Scotland and Wales are covered.
The GPC advise practices to use the guidance to inform their decisions
on whether they wish to participate in extended access proposals, by
taking up the Extended Access Directed Enhanced Service (DES) or
negotiating a Local Enhanced Service (LES). This will be the only
document on Extended Access released by GPC at this time, so it is
important that practices use the document to inform their decisions on
how they wish to progress. Practices should aim to begin any
negotiations with their PCO immediately. A copy of the document can be
found
here.
The Department of Health and NHS Employers will be releasing interim
guidance for PCOs and GPs shortly, followed by the DES Directions and
SFE in due course.
Focus on Quality and Outcomes Framework
The GPC has produced a new "Focus on Quality and Outcomes Framework
guidance" This guidance document has been produced to help GPs and Local
Medical Committees (LMCs) understand the changes and developments that
have been made to the Quality and Outcomes Framework for the 2008-09
period.
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. A copy of the document can be found
here.
The GPC has also produced amended QOF guidance for 2008. This takes into account all the changes agreed in recent negotiations and will ultimately be released in the Statement of Financial Entitlements. A copy of this guidance can be found here.
Managing Disputes with PCTs
The GPC has produced a guidance note which sets out the dispute resolution procedure needed to resolve issues that arise within the contract, for example, a dispute as to whether a contract provision has been properly performed by either the PCO or the providers, or a dispute involving financial entitlement under the contract. A copy of the document can be found here.
Promoting Sugar Free Medicines
Our dental health colleagues are concerned about the amount of sugar in the medications we use for children. If we can increase prescription of sugar-free medicines it will contribute to a wider preventive strategy to decrease levels of dental decay. Prescribing information on a number of ‘indicator’ medicines (those coming into contact with teeth, were there is a sugar-free alternative and prescribed for children) for GP practices show the proportions of sugar-free medicines prescribed ranged from 10.5-93.4%. Obviously there are successes in some medicines and areas for improvement in others. The cost implication to the Stoke-on-Trent PCT of changing prescribing to sugar-free of these medicines is £2800 and therefore considered very small. Colleagues are, therefore encouraged to use sugar-free medicine wherever possible. In the West Midlands the old North Stoke PCT area, Newcastle PCT area along with Herefordshire are the top three PCT areas for dental caries in the under fives.
A link has been demonstrated between the use of sugar containing medicines and dental caries. Use of liquid oral medicines is more prevalent in the populations than may be anticipated. Liquid oral medication is taken on average 1 week in 8 by children age 3 - 11 years with 55% of these being prescription only medicines. There is also increased use of liquid oral medicines in the elderly. The lowest proportions of sugar-free prescribing are seen in Chlorphenamine, Amoxicillin and Paracetamol and yet Paracetamol and Amoxicillin are the most frequently prescribed prescription items.
The PCTs are happy for work to take place to try and promote sugar-free alternatives. Previous research suggests that prescribers find it most helpful if they are reminded by computer systems to prescribe sugar-free, such as by having sugar-free alternatives at the top of a pick list or highlighted. Discussions are taking place with the PCTs to enable this.
Improving Communication with Pharmacists
The General Practitioners Committee
(GPC) of the British Medical Association (BMA) and the National Pharmacy
Association (NPA) have produced a workbook entitled ‘Improving
communication between community pharmacy and general practice’ to help
facilitate local dialogue between the two professional groups, helping
to improve patient care.
The workbook describes various Community Pharmacy-GP interactions, and
highlights some principles of good practice. The intention is that
groups of pharmacists and GPs should work through this book together to
identify local challenges and formulate solutions. A copy can be found
here.
Involvement with Private Companies
The GPC has produced a list of "FAQs" in relation to involvement of GP practices with private companies and other health professionals. A copy can be found here
Charging Patients
The GPC has produced a list of "FAQs" in relation to charging patients. A copy can be found here.
IM & T DES
The DoH has decided to extend the IM & T Directed Enhanced Service to the end of 2008/09. The directions for this have recently been agreed and published. Practices in Stoke PCT who have signed up the Local Enhanced Service will need to decided which of the two options is best for them.
GPC News Items
GMS contract negotiations update
QOF changes for 2008-09
At the end of March, changes to QOF for 2008-09 were announced and a Focus On guidance note to explain these changes was published: www.bma.org.uk/ap.nsf/Content/focusQOF0308
The QOF changes include the reallocation of 58.5 QOF points to new QOF indicators in the patient experience domain to reward patient satisfaction with access. The QOF payment for these points will be dependent on the results of access questions in a new patient experience survey on 48 hour access and advanced booking. The QOF payments related to the outcome survey will be completely separate from the payment tied to the extended hours access DES. Other changes to indicators are based on the evidence review and expert panel recommendations, and there are some additional alterations to the financial arrangements. All of these changes took effect from 1 April 2008 and apply UK wide.
All the clinical changes and subsequent updates to the guidance are complete although the GPC is continuing to negotiate with NHS Employers and the Department of Health on the details of the patient experience indicators and the national survey. When the details of the patient experience indicators have been signed off, the revised 2008 QOF will be published in its entirety.
Extended Access Directed Enhanced Service (DES)
Department of Health guidance on the extended access arrangements – which details in full the precise specification of the DES and what practices will have to do to meet the criteria – will be published shortly.
The GPC continues to have significant concerns about the DES in England, particularly about the lack of flexibility for concurrent GP time and nurse appointment availability. These issues are being addressed more practically in Wales and Scotland.
The GPC has issued its own Focus On document which is available at:
www.bma.org.uk/ap.nsf/Content/Focusextendaccess0408
This sets out the areas about which the GPC is most concerned and urges LMCs to discuss with their PCOs how these can be addressed via local solutions. LMCs should also be aware that, whilst the PCO is obliged to offer the DES, practice participation is not compulsory. Practices can opt not to provide extended hours at all, to do the DES, or to provide the service through a Local Enhanced Service (LES). In England, PCTs are required, within their operating framework, to ensure that at least 50 per cent of GP practices in their area offer extended opening to their patients. This does not mean that 50 per cent must take up the DES.
Scotland and Wales are continuing their discussions separately on the finer details and further information will be available to GPs in those countries in due course. Extended access is not considered to be a priority in Northern Ireland.
National Investment Offer
As part of option A, which GPs selected as unacceptable but the least worse option in the contract poll, GMS contractors were offered a 1.5% national investment offer that would be made available to practices for 2008/09. It was agreed that the first call on this money would be for any DDRB uplift recommendation. The DDRB has now reported and stated that, following its recommendation, the overall impact of the award is estimated as a 0.2% average increase in payments to GP practices. The GPC has serious reservations about the competence and legality of its recommendation in respect of GMS contractors. Until such time as this has been clarified and the financial effect of the DDRB recommendation is known, discussions about the remaining funding available as part of the National Investment Offer, which would have been invested into new clinical DESs and other local access priorities, have been put on hold.
Doctors' and Dentists' Review Body (DDRB): Thirty-Seventh Report 2008
The DDRB report was issued on Monday 7 April. A letter summarising the GPC’s view on the report can be found at: www.bma.org.uk/ap.nsf/Content/ddrblet0403.
In respect of GMS contractors, the GPC has now had time to analyse the DDRB report and has serious reservations about the competence and legality of the DDRB recommendation, particularly in relation to the reduction of the correction factor. The BMA has written to the Health Secretary expressing its serious concerns that the DDRB recommendation for GPs, accepted by the government, is not legally deliverable under current regulations. GPs will be kept up-to-date with developments as they occur.
With regard to PMS contractors, it is the GPC’s view that if a PMS contract refers to an uplift recommended by the DDRB, these contractors should seek to receive the full 2.7% uplift to their baseline payments in line with their contract entitlement. If the contract does not include such a clause, the uplift will require local negotiation. The Department of Health may issue its own guidance for PMS contractors although this may be tied to any outcome following the GMS issues.
Salaried GPs, GP educators, GP trainers, and GP registrars were all were awarded a disappointing below inflation uplift of 2.2%. The GPC firmly believes that, despite all the uncertainly contractor GPs face in respect of the GMS contractor recommendation, practices should honour their commitment to pay salaried GPs and other staff fairly and increase their salaries to reflect the Review Body recommendations from 1 April 2008.
Feedback will be given to the DDRB later this month and the GPC will express concern about the DDRB’s apparent misunderstandings and misinterpretations about the workings of the GMS contract. The GPC is also considering how best to engage with the DDRB process in the future in light of this year’s recommendations.
GP trainers: £750 CPD payment
In addition to the disappointing 2.2% uplift for GP trainers, the DDRB did helpfully confirm that the £750 payment for continuing professional development should continue to be paid on an annual basis to GP trainers with a trainee. This means that GP trainers, in addition to the £750 payment for the years 2005-06 and 2006-07, should also have received such a payment in 2007-08 and should now receive such a payment in 2008-09. This is provided that within any part of these years they had a GP trainee.
While we recognise that many deaneries will not have budgeted for the 2007-08 payment and thereafter, the GPC will be working to ensure that eligible trainers receive these payments as soon as possible. We have advised GP trainers that if they do not receive the outstanding payments by the end of July 2008, then they should inform the LMC so that this message can be forwarded to the GPC secretariat for action.
The DDRB has also clarified that the £750 CPD payment should be paid for one year if a trainer is not allocated a trainee. This means that if a GP trainer has been without a trainee for a whole year from and including 2005-06, they are entitled to receive the £750 for that ‘fallow’ year but would not receive a further £750 if they had another ‘fallow’ year later. However, they would be entitled to the full payment for the relevant years when they did have a trainee.
We would like to point out that we are aware that so far at least one deanery has not passed on the full £750 CPD payment to their trainers. This is on the basis that the money has been withheld to fund educational courses. This is grossly unfair. The GPC has obtained legal advice that if a trainer was led to believe that the course would be free of charge and he/she attended it on that basis, then the deanery cannot charge for, or recoup the cost of, this course at a later date. To do so could amount to a misrepresentation claim. The GPC is currently in correspondence with one particular deanery about this. However, if you are aware of such practice, please contact the GPC secretariat.
Skin cancer NICE guidance
The GPC discussed problems being experienced by LMCs in various PCT areas with the NICE guidance on ‘Improving outcomes for people with skin tumours including melanoma’ published February 2006 and due for implementation this year. In particular the guidance is particularly threatening to GPs in relation to treating BCCs in primary care. The ability to disrupt services, if not wipe out primary care minor surgery, was considered the key major failing of the guidance. The committee was made aware that at the end of last year when PCTs in Kent went to introduce the guidelines at local level the consequences were so overwhelming that the guidance had to be withdrawn. Many other LMCs are still grappling with how it might be implemented. The GPC, as a result of the discussion, will clarify to what extent the guidance is optional and if indeed initial feedback from Kent does mean the national cancer team have withdrawn or suspended the guidance.
Further discussion in the committee focused on the work of NICE in general and the GPC is going to reconsider how best to engage with the organisation and contribute to their guidance appropriately.
Population Health Screening
On 1 April the government announced that a national screening programme to identify vulnerability to vascular diseases will be offered for everyone aged between 40 – 74. The GPC was not consulted in advance of release of the information to the media and a letter is being sent to Alan Johnson to express some reservations about the evidence base for the measures, and concerns that excessive pressure will be put on an already overstretched general practice, both in terms of workforce, premises and other resources. This will also draw attention to the work already taking place in practices through the QOF to record the blood pressure of patients aged 45 and over and other opportunistic screening. The GPC has advised that is happy to discuss how evidence-based, appropriately resourced, and clinically effective screening could operate in primary care, in addition to the valuable work already undertaken by practices to check vascular risk factors for at risk patients. The Chairman has had a meeting with the English Departmental team that are taking this work forwards and further meetings are planned.
Public Accounts Committee Inquiry
The GPC produced a factsheet to clarify why and how the GP contract was introduced and the benefits to patient care it has delivered. This was in response to The National Audit Office's (NAO) recent report NHS Pay Modernisation: New Contracts for General Practice Services in England, a report on the GP contracts in England, and was also submitted as evidence to the Public Accounts Committee Inquiry 'Pay Modernisation in this NHS - GP contracts' which took place on 26 March 2008. This factsheet "The value of general practice" is available on the BMA website. Although the GPC was not permitted to give oral evidence at the enquiry, a number of GPC members and LMC representatives took the opportunity to brief their local MPs, who were members of the Inquiry, and this was much appreciated.
Motor Vehicle Allowance - Guidance for GP specialty registrars
The Schedules to Direction to Strategic Health Authorities concerning GP Registrars (2003) were amended 31 July 2007 to alter the provision for reimbursement for the business use of a private vehicle for GP Specialty Registrars (GPStR) in England. The full Schedule to the Direction is available on the NHSE website here - www.nhsemployers.org/pay-conditions/pay-conditions-469.cfm
The GPC has issued guidance for GP registrars on the new arrangements for payment of the Motor Vehicle Allowance in England. The guidance is available for BMA members at the following link –
www.bma.org.uk/ap.nsf/AttachmentsByTitle/PDFGPregsMVA0408/$FILE/MVAApril2008.pdf?Open&login
Pending amendment to the relevant statutory legislation, GPStRs in Scotland and Wales should still be receiving the previous allowance. We are aware, and remain concerned, that GPStRs in Northern Ireland are at present not receiving either the old or the new allowance for reimbursement for the business use of their vehicles. Discussions in relation to this are ongoing between the BMA and the Northern Ireland Medical and Dental Training Agency (NIMDTA), and the GPC will continue to push for resolution to this issue.
Pharmacy White Paper
The Pharmacy White Paper was published on 3 April. Although predominantly relating to community pharmacy, it does have a section devoted to dispensing GPs. The precursor to the White Paper was a review of the "control of entry" regulations undertaken last year by Anne Galbraith, former Chair of the Prescription Pricing Authority. The GPC submitted detailed written evidence and oral evidence to Anne Galbraith and her committee and have been awaiting the White Paper since.
The contents of the chapter on dispensing doctors (Chapter 8) does, on first reading, look intimidating but the chapter concludes with a section in bold text:
"... the Government proposes that any changes to dispensing doctor market entry arrangements should be part of a wider consultation on elements of the "control of entry" system itself, as proposed here (in the White Paper). The consultation will also consider whether current regulatory arrangements can be streamlined so that dispensing consent in future is sought under a single regulatory route".
The negotiators have worked very closely with the DH and NHS Employers on dispensing doctor issues for the very many years and will strongly defend the rights of dispensing GPs. The consultation is unlikely to begin until after the final Darzi report as the two are supposed to be closely aligned. It is impossible to know at this stage what, if anything, will emerge from this White Paper. Any legislation is unlikely to be before Parliament before next year.
Full details of the White Paper are available at the following link - www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083815