NEWSLETTER NOVEMBER 2004
Infertility Treatment Information Requests
Quality and Outcomes Framework – visits and the Data Protection Act
Payment for Child Protection Work
New Contract Local Issues
Enhanced Services
Nursing Homes - We are continuing to press the PCTs to fund a Local Enhanced Service to provide proactive services to patient who are resident in Nursing Homes.
Smoking Cessation - A number of practices have expressed concern about the funding and working of the Local Enhanced Service for Smoking Cessation. It is felt that the funding of the service does not cover the costs involved in providing the service. Discussions are continuing with the PCTs on this issue with a hope of altering the funding of this service from April 2005. If practices continue to feel that they are not adequately funded for this service, they will have to make a decision whether or not to continue the service.
Neonatal Checks- PCTs are continuing to report problems with the training of midwives to take over this activity from January 2005. We have advised the PCTs that GP colleagues will not agree to this activity continuing to be funded by the "basket" of services from 1st January. We have informed the PCTs that should they wish GPs to continue with this service after 1st January it will have to be paid on a item of service basis.
Out of Hours
Preparations for the transfer of responsibility for the out of hours service to the PCTs continue to progress. PCTs are currently asking practices to formally request to opt out of out of hours responsibility. This is necessary to keep to the letter of the regulations.
Colleagues have been concerned over the lack of Thursday afternoon cover and during 6.00 to 6.30pm under the new system. It is intended for this cover to continue after 1st January. Funding for this will initially come from the financial reserves of the GP co-op which will be wound up. This source of funding should last about nine months. Negotiating on the future of Thursday afternoon cover will have to continue during this time.
The business case for moving to a new premises has been approved and this is now moving to the next stage.
Ambulance Service
Following the recent problems experienced by colleagues in arranging urgent transport of patients to the University Hospital of North Staffordshire, the LMC Officers met with the Chief Executive of the PCTs, Ambulance Trust and the UHNS to discuss the causes and possible solutions. The cause of the critical situation which arose last month appears to have been multifactorial, but the workload of all services and lack of sufficient resources no doubt played a part. There is also a need to improve communications between all parties. It was agreed that representatives of all groups should meet within a short timescale to look at the problems surrounding the booking and transport of patients for whom the GP has arranged urgent hospital admission or assessment. This group met the following week and produced some proposals to make changes to the booking system which would make the process simpler and hopefully iron out the peaks in demand for transport. Regretfully these proposals have been put on hold following the intervention of the Chief Executive of the Ambulance Service. We await further developments.
Pension's Meeting
I have summarised below the main points from Andrew Deardon's presentation to the meeting on Tuesday 26th October. If you have any further points or queries you may find the answers in the focus on documents recently issued by the GPC. If you have any further queries please let me know
Superannuation:
• Pre 1st April 2004
– 6% - paid by employees
– 7% - paid by employers
– 7% - paid by Treasury
• 1 April 2004 date of Indexation Transfer
– GPs responsible for 20p in the £ (6+7+7)
This amount was:
• Added to GS - April 2004
• Pounds per patients uplifted to £50 - £54
• GSE adjusted too - no effect on correction factor
More recently:
• Additional £88m for superannuation (England)
• £28 million 04-05, £60 million 05-06
• Superannuation for new income paid through GS & QOF.
– adds 21p to GS per patient (42p next 6 months)
– £2.50 per QOF point
– Money for 04-05, likely to be paid with achievement payments
Where is the money?
• Existing staff / partners – via old GS increase (£50 to £54)
• QOF - via new increase to GS and QOF
• Enhanced services – via new GS and QOF increase and by any negotiation of ES price locally
• New staff (since 1/04/04) - out of total practice funding
In PMS Practices
• Equally responsible for payment - 20p / £
• PCOs have funds from Indexation Transfer
– Local negotiations - how distributed to practices
• Superannuation for new income
– PCT allocations uplifted but how distributed?
– Same QOF increase of £2.50 per point
– QOF - 174 points offset drops to 168
– awaiting draft documents for clear guidance
Superannuable Pay and Profit
• Work with Accountants is advanced now
• “NHS work” is superannuable
• Private income & expenses incurred effect calculation of superannuable pay
• More pension effective to reduce private and increase NHS work via QOF!
• Almost agreed mechanism for calculating annual superannuable pay
• Remember now paid on “what we earn”
Dynamising Factor
• Now related to profession’s actual profits
• Mechanism:
– DF determined when total GP profit known
– After end financial year - accounts
– For 2003-04, Interim DF in August 2004 and Actual DF known in spring 2005
– Repeated each year
– Interim available in March / April
• Calculated / estimated by TSC
• Then Interim DF decided – 90% confidence that Actual DF will be higher; very unlikely to be lower
• Estimated Interim
• 2003-04 8.8% 7.2% @90% confidence
• 2004-05 10.8% 6.1% @90% confidence
• ( 7.7% @80% confidence )
• ( 8.3% @75% confidence )
Out of hours work
• If not-for-profit provider - NHS pensionable
• For-profit provider - not NHS pensionable
• If salaried, employer contribution paid by provider
• If ICS / freelance, paid by you
• Rates must reflect this.
In 2004-05, employer superannuation contributions for locum work will be paid by the employer (including GP co-operatives), except for practice-employed locum work, where these will be paid by the PCT. More details of sessional GPs superannuation can be found on the National Association of Sessional GPs website at www.nasgp.org.uk
Prescribing Issues
Colleagues have recently raised a number of issues regarding prescribing. These include requests for GPs to prescribe either unlicensed preparations or to prescribe licensed preparations for unlicensed uses The BMA has recently updated its advice on this issue in guidance which is arranged in a series of themed questions and answers. It is well worth reading this document. Key points are
A patient is entitled under the NHS to drugs which the doctor believes are necessary, not what the patient feels should be prescribed.
GPs are responsible for all prescribing decisions they make and for any consequent monitoring that is needed as a result of the prescription given.
It is the doctor who signs the prescription who carries the legal responsibility not the doctor who suggested it.
A GP can write a private prescription for a patient but cannot charge for it if the patient is registered for NHS care with that GPs practice. The only exceptions to this are when the GP writes a private prescription for drugs that are requested by a patient "just in case" of the onset of illness whilst outside the UK or when a private prescription is issued for the prophylaxis of malaria.
In general the doctor who has the clinical control of any aspect of the patient's management should accept the responsibility for prescribing except where another doctor has willing agreed to take some of that responsibility under a "shared care agreement".
There is no reason why prescriptions cannot be issued by a hospital doctor and posted to a patient who lives at a distance from the hospital.
Any GP has the right to refuse to prescribe a drug that they are not prepared to take clinical responsibility for
Pressure on a GP, where it may be inferred that a patient will not receive a treatment, if the GP does not agree to prescribe is unacceptable.
The NHS accepts responsibility for supplying ongoing medication for temporary periods abroad of up to three months. If a person is going to be abroad for more than three months then all that the patient is entitled to at NHS expense is a sufficient supply of his/her regular medication to get to the destination and find an alternative supply of that medication.
Doctors provide prescriptions for intervals that they feel are medically appropriate, taking into account such factors as possible reactions, a possible need for a change in prescription and consequent waste of NHS resources, patient compliance, and any necessary monitoring.
The request for 7 day repeat prescriptions to defray the pharmacist’s costs for the filling of medidose systems has become an increasing pressure for GPs. Our advice is to resist such demands unless there is a clinical reason for restricting supply to 7 days
There are some travel vaccinations (previously described in Paragraph 27/Schedule of the GP Statement of Fees and Allowances) for which NHS GPs are paid for providing on the NHS. These include smallpox, typhoid, cholera, polio and infectious hepatitis.
All other travel vaccinations can be charged for under Schedule 5 Fees and Charges of The National Health Service (General Medical Services Contracts) Regulations 2004. The prescribing or providing of malaria chemoprophylaxis can also be charged for under Schedule 5.
You need to consider carefully the consequences of using licensed products for unlicensed indications, if something goes wrong or the patient lodges a complaint. We would strongly advise against it.
The complete document can be found here.
Infertility Treatment Information Requests
GPs have to provide detailed information
about any of their patients who are seeking infertility treatment. The Human
Fertilisation and Embryology Act (1990) - section 13(5) - states that;
"a woman shall not be provided with treatment services unless account has
been taken of the welfare of any child who may be born as a result of the
treatment (including the need of that child for a father), and of any other
child who may be affected by the birth".
This information must therefore be provided as part of the referral process to any hospital, NHS or private, in order to comply with the Act. The Terms of Service oblige you to provide this information free. However, this is a legal and ethical minefield. You will have to make reference to subjects such as;
age, medical history and family history
commitment to having children
domestic circumstances
ability to support a child
history of criminal activity or child abuse
special risk factors such as drug or alcohol abuse
estimated risk of abuse of the child
who will be the legal parents of the child
any other major concerns
any other reason why, in your view, this couple should not receive IVF treatment
These are all potentially sensitive areas and your disclosure could result in a refusal to treat the couple. You should therefore provide the information based upon your objective knowledge of the patient that is recorded in the notes. You should generally avoid hearsay evidence since the patient will almost certainly challenge this, particularly if it is likely to result in an adverse outcome. Hospital will often produce a proforma for completion which may be sent with a consent form signed by the patient. Such consent may or may not be legally valid.
Before providing the data to the hospital you would be well advised to see the patient, show him/her what you intend to disclose and explain that you are obliged by law to reveal to the clinic any data that would be relevant to the future welfare of a child. You must then obtain the patient's valid legal consent to third party disclosure.
Details in your patient's notes should not be revealed to his/her partner without explicit consent! Even though the couple are going together for IVF treatment, there may still be confidential information that you may not reveal without consent. If you believe you must reveal such details to the clinic in the interests of the unborn child, you must explain this to the patient. The patient must be told that his/her partner will almost certainly have to be told the confidential information before treatment would be permitted under the law.
You may be torn between your obligations to your patient and to the unborn child. At least the patient has a chance to discuss the issue, but the child depends entirely upon your professional judgement. Litigation on the child's behalf remains a possibility, even many years after the event! If in doubt seek prior specific legal advice from your defence organisation.
You are not obliged to fill in any specific form, but you are obliged to provide the information. If a particular form is required to facilitate the hospital or clinic's procedures The GPC has advised that you may charge a private fee, but not otherwise.
GPC News Items
Practice based commissioning
Committee members discussed the Department of Health’s paper ‘Practice based commissioning: engaging practices in commissioning’ published on 5 October 2004. Practice based commissioning is currently an England only initiative and the Government’s proposals set out that from April 2005, all practices/groups of practices will have the right to receive an indicative budget from the PCT at any stage in-year and thereafter. Commissioning decisions will then be made by practices/groups of practices within the context of agreed Local Delivery Plan (LDP) and PCTs will hold the budget and be responsible for contracts with secondary care providers. Fifty percent of savings made can be held at practice level, which must then be used for developing or providing services for patients.
Members highlighted various areas where clarification and further detail was needed from the Department, however the committee welcomed the opportunities that practice based commissioning would provide GPs and their practices. The issues raised during the debate included those surrounding equity, the potential financial risk to practices, the move to a weighted capitation formula within three years and the importance of procedures being in place to ensure even-handedness at all stages of the process.
The paper can be found at the following website address:
The Department intends to issue formal guidance following the consultation period in early 2005. The committee agreed that the GPC should also respond formally and although it had not been involved with the initiative thus far, should engage with the Department of Health in shaping the forthcoming guidance and aiding with its implementation.
Access and PCAS questionnaire - England
The GPC has received a number of enquiries about a new question on the PCAS return for the November survey in England, which asks practices how far in advance patients are able to book an appointment with a GP. The list of potential answers includes allowing for patients to book up to four weeks or longer in advance.
The GPC did not have advance sight of this question and it clearly goes further than the 24/48 hour access covered by the Specification for the Access Directed Enhanced Service. We will be taking this matter up with the Department of Health (England) on the basis that the answer to this particular question should not affect practices’ achievement of the access targets under the Access DES.
Practices should not be obliged to answer this new question on the PCAS return. However, under paragraph 5.26 of the Statement of Financial Entitlements, eligibility for access payments under the Quality and Outcomes Framework depends on a practice’s participation in and performance under the survey. Therefore, to avoid any question about whether QOF payments are due to the practice, we would advise practices to fill in the survey but to make it clear this has been done on the basis that the practice’s response to this question will not affect their achievement of the access targets or their payments.
We will issue further information and guidance once we have a response from the Department.
Appraisal Funding
The English Department of Health has now issued its guidance on appraisal funding. This can be found at:
- GMS practices will receive an appraisal premium (26 pence) to their global sum. This is for the appraisal (including preparation) of GP providers and their salaried GPs.
- where GMS practices have already received a contribution (prior to 1 July 2004) to cover appraisee costs, PCTs should as a minimum honour existing appraisal payment arrangements
- where GMS practices had not received any appraisal funding in the first quarter of 2004/05 then a local adjustment will be needed (e.g. paying an additional quarters payment before the financial year end or uplifting monthly payments by a third).
- locum GPs should receive a contribution towards their costs (and this is specified in the DH guidance). Ideally locum GPs should not be out of pocket as a result of participating in appraisal and therefore their loss of income should be covered. The guidance specified that PCTs will need to agree the precise details of payments to locums in the case of their appraisee costs. Again, if PCTs have previously agreed a level of payment, this should as a minimum be honoured.
To give you an indication of how much time the whole appraisal process of time will take, as we stated in our original appraisal guidance and based on our independent research on the likely preparation time for a first appraisal, we estimate the following minimum times for appraisal per GP:
Preparation time
Completing the pre-appraisal forms (and reflection time) - 3.25 hours
Identifying and collating the documentation required for the forms - 2 hours
Preparing an outline personal development plan - 1 hour
Total preparation time - 6.25 hours
Appraisal interview - 1.5 hours as previously agreed by the DoH
[Possible peer review - 1 hour]
Appraisal review preparation - 1 hour
Appraisal review interview - 0.5 hours as previously agreed by the DoH
Total - 9.25 hours [10.25 hours with possible peer review]
These estimates are higher than the Department of Health's. The Department previously estimated that appraisal will only take between 4 ½ and 6 ½ hours. We believe that our estimates are a much closer match to the true requirements. Indeed, the Chief Medical Officer's letter of 1 March 2002 to all GPs stated that, in the first full year of appraisal, the time commitment may be higher as everyone adapts to the new system.
- The payment/reimbursement for GP appraisers will be set by the PCT, and should be agreed after consultation with their LMC. It is therefore likely that there will be regional variations. Previous payments should, at least, be honoured. We recommend (as previously) that GP appraisers should be fully reimbursed for any out-of-pocket (including locum) expenses that they incur and also receive proper remuneration for their time, commitment and skills while training and appraising. We strongly suggest that appraisers contact their PCT before undertaking any training or appraisal work to check what reimbursement and payments they will receive. We advise that GPs should only undertake this work if they are fully reimbursed and remunerated.
To give you an idea of the amount of time required for appraisers to prepare for and undertake an appraisal, we have estimated the following minimum times:
Preparing for each appraisal - 1 hour
Appraisal interview - 1.5 hours as previously agreed by the DoH
Preparing for appraisal review - 0.5 hour
Appraisal review - 0.5 hour as previously agreed by the DoH
Total estimated time for appraisers - 3.5 hours
PMS contractors should receive the same level of payments as their GMS colleagues. The DH's guidance indicates that PCTs are expected to use the available funding for appraisal on a fair and equitable basis for all GPs.
Report of the Ayling Inquiry
The GPC considered this distressing report of how a GP sexually abused many patients over more than two decades and was shocked by the details of Ayling's activities. The report raises complex issues that have implications of the entire profession. The committee welcomed the recommendation on clearer NHS policies on chaperoning, for example, and will undertake further work on this topic with other bodies, such as the BMA Patient Liaison Group. However, it also had reservations about the practicality of always having fully-trained chaperones available in the general practice setting and was unsure whether close family members were necessarily inappropriate chaperones, as the report concludes. The committee was also concerned that the report's findings might be used further to vilify single-handed practitioners.
Freedom of Information Act
The Freedom of Information Act comes into force on 1st January 2005. This will oblige NHS GPs to respond to requests about the information that they hold and have recorded in any form and will create a right of access to that information. GPs have 20 days in which to respond to a query. It has recently been announced that, for the majority of requests, a fee cannot be charged. Practices should have prepared publication schemes and it is hoped that the majority of requests can be dealt with by referring the enquirer to the practice publication scheme or other related websites. The GPC will be producing a second guidance note on the Act.
Choose and Book
‘Choose and Book’ is a National Programme for IT (NPfIT) deliverable, which will give patients the opportunity to be able to book the time and place of their hospital appointment when they are referred by their GP. Further information about Choose and Book is available at: http://www.chooseandbook.nhs.uk/.
The GPC recognises that this is a major initiative and could benefit patients. We are willing to work with the ‘Choose and Book’ team to help make it work. However, the GPC is very concerned about the workload implications and the practicalities of arranging out-patient appointments within a 10 minute consultation time. Furthermore no additional resources have been identified for the additional work involved. The GPC will make it clear that a national fee should be agreed for the additional work, including any necessary shift in resources. The GPC has raised these concerns with the Department of Health and have recently received a positive response, inviting the GPC to be involved.
In the meantime, Choose and Book is not part of a GP’s terms of service and therefore, GPs can decline to do this work. If asked to be involved in Choose and Book, practices should ask their PCTs how it will work and what additional resources will be available. The Joint GP IT Committee has not yet been invited to vet or assess the technical aspects of Choose and Book. Therefore the committee cannot guarantee its security and confidentiality. Until the committee has been involved, GPs should not presume that Choose and Book is fit for purpose. The GPC would be interested in receiving details of positive, as well as negative local experiences of Choose and Book.
Quality and Outcomes Framework – visits and the Data Protection Act
The committee discussed the QOF visits, patient confidentiality and the implications of the Data Protection Act. It was noted that at the most recent meeting with the Departments and the NHS Confederation, the negotiators had reiterated their position that, in the absence of complete anonymisation, patient express and informed consent should be obtained. The negotiators also pressed the urgent need for clear guidance until either an IT solution to anonymisation was found or the legal position was agreed. The Department reported that they were working on an IT solution to enable complete anonymisation of patient records and they hoped that a pilot version, to be available to all in England, might be ready as early as the end of November.
Strategic health authorities have been informed by the Department that PCOs should take a pragmatic approach to the QOF visits, allowing delays to the visits or at least to that part of the visit that required access to patient-identifiable data. We have been assured that this message is being passed down clearly to PCOs. If practices or LMCs experience problems they should refer their PCO to the SHA, which should make the agreed position clear.
The GPC has produced guidance on this issue available on the website at: www.bma.org.uk/ap.nsf/Content/__HubGMScontractquality.
Many PCOs are taking a sensible approach either by allowing postponements, taking a very ‘light-touch’ approach to the visits or obtaining patient consent prior to the visits. However, reports were given at the GPC meeting of continuing problems in some areas. Following discussion at the meeting, it was agreed that further guidance would be issued by the GPC. This will be available shortly.
Payment for Child Protection Work
The BMA's Ethics Department have recently been receiving an alarming number of queries relating to GPs refusing to undertake child protection work until they have been paid. As a result of this, they have produced the following statement of guidance and have asked us to draw this to your attention to the BMA guidance on this issue.
"The BMA has recently received a number of inquiries relating to GPs refusing to undertake child protection work, such as responding to Section 47 enquiries, until they have received a fee. This has arisen as a result of sometimes protracted delays in doctors being paid for this work in the past. The BMA believes that in all cases relating to the care and welfare of a child, a doctor's ethical duty is to put the interests of the child first. Where a service falls outside a doctor's terms and conditions of service, it is unacceptable to withhold information relating to vulnerable children that has been requested by proper authorities until payment has been received. Having said this, the BMA believes that local authorities, and other bodies who commission such work should provide payment promptly, and certainly no later than 28 days from receipt of the information."