NEWSLETTER NOVEMBER 2005
Limiting Numbers of follow up patients
Fast Track Fracture Liaison Clinic
Patient Confidentiality and Audit
Briefing Note on Allergies for GP IT Systems
Hazardous Waste Regulations 2005
Report on main negotiating issues
Out-of-hours training for GP registrars
PMETB and summative assessment for Article 11 doctors
Payments to GPs undertaking work on PMETBs behalf
Financial Crisis
As you are probably aware the PCTs and Trusts in North Staffordshire are in financial crisis. A number of measures are being taken to try to resolve the situation. Unfortunately there are some who see passing work on to General Practice as an easy option to save on their own budgets. Fortunately the New Contract enables us to say no to this extra work. If a procedure can be done in a primary care setting it does not mean that it is part of general practice or should be passed onto general practice without resource. Any change in services should be planned and discussed with those involved. The UHNS is in the habit of withdrawing services without informing either GPs or PCTs. PCTs do not appear to be aware of what is going on.
I have had a number of issues brought to my attention in recent weeks. Please notify the LMC if any further issues arise. The ones we know about include:
Family Planning Drug Budgets
The North Staffordshire Family Planning Service has a predicted overspend of approximately £80,000 for the current financial year. The main items of expenditure contributing to this overspend are the increased use of Mirena coils, the introduction of Implanon devices and Cerazette. The Family Planning Service have proposed that patients who require either a Mirena coil or Implanon device should request that their GP prescribes the item and then returns to the Family Planning Clinic for fitting. This is unacceptable and the family planning service have been informed of this. GPs should not be responsible for prescribing treatment which is to be used in settings beyond their control. This is also a false economy as the overall cost of the service to the PCT remains unchanged. The issue has been raised with the PCTs and meetings are taking place to try to resolve the situation. In the meantime, colleagues are advised not to acquiesce to these requests. However, you may wish to consider fitting mirena coils where appropriate and a fee can be claimed from the PCT for this. Newcastle PCT will pay a similar fee for the fitting of implanon, but the Stoke and Moorlands PCTs will not pay GPs for this service.
Limiting Numbers of follow up patients
The acute trust are under pressure from the PCTs to decrease the number of follow up patients they see and thus increase the ratio of new to old patients. As a result some patients are not being offered follow up. It appears that some are taking the view that all follow ups should cease.
I have raised the issue of gynaecology patients being asked to attend their GP for post-operative follow up with the PCTs. If they wish us to perform these follow up it is important for us to know whether there are any specific issues to look out for, to have a fast track back if necessary and to be resourced adequately.
Secondary Care Referrals
There is some misunderstanding among consultants about inter-consultant referrals and a number are being passed back to GPs. According to the PCTs consultants can refer patients from Staffordshire Moorlands and Newcastle PCT on to secondary care colleagues directly without passing them back to the GP. In the Stoke PCTs the situation is different in that the PCTs have instructed that patients who require further referral should be given a choice of provider and should go through the "Choose and Book" system. Consultant are able to send referrals to the "Clinical Assessment Service" for this purpose and again they do not need to be sent back to the GP. The reason for using this system is that patients then have to be seen within the target time of thirteen weeks whereas there is no target waiting time for direct inter-consultant referrals and this as resulted in unacceptably long waiting times. Not surprisingly consultants are confused over this issue and as a result are referring patients back to their GPs for onward referral. The UHNS does not have the will to change this and use the appropriate referral pathway for each individual PCT.
A few months ago we were informed that consultants who suspect a patient has a malignancy can refer to their colleagues using the standard 14 days wait referral pathway. We are now told that they cannot do so, but we are unable to ascertain were this directive originated. The whole area of consultant to consultant referral is confusing with no one taking responsibility and the UHNS and PCTs blaming each other for the chaos. In the meanwhile patients are caught in the middle and our workload is unnecessarily increased.
Fast Track Fracture Liaison Clinic
I understand that for the last eighteen months patients over the age of 50 who have sustained a low trauma fracture have been invited to attend a one stop fast track clinic where they have had a DEXA scan and an osteoporosis risk factor assessment. Apparently funding for this scheme has now ceased and as a consequence GPs are being requested to arrange DEXA scans and osteoporosis risk factor assessment. I have raised this issue with the PCTs. Again there seems to have been no discussion on the implications of sudden withdrawal of a service and the work lands on our desks. The NICE guidance is incorrectly quoted in the letter sent out by the Rheumatology Centre. Although the pragmatic view may be to start a bisphosphonate immediately, the NICE guidance suggests it use based on the result of a DEXA scan.
We are attempting to resolve these issues but with no clear leadership from the commissioners or providers this going to be difficult.
Mentorship for Nurses
The committee is concerned over the payment for GPs providing mentorship for nurses. Firstly the amount on offer does not reflect the amount of work involved and secondly there is no flexibility to allow practices to be paid for any nurse not completing the course and no flexibility to allow practices to share the work. The payment of £1000 will only be made when the GP has provided 150 hours of mentorship. We have made representations about this over the last year and have not been able to achieve any change. The LMC feels that because of these problems GPs should refuse to carry out this work until a more flexible and appropriate system is put into place.
Wheelchair Service Criteria
I have received some complaints about the inability of some patients to obtain a wheelchair on the NHS. I have obtained the criteria used in North Staffs for the allocation of wheelchairs and these can be found here.
Disposal of Diabetic Sharps
A number of GP colleagues have raised the issue of PCTs asking practices to arrange for the disposal of sharps from diabetic patients. There are some serious practice difficulties for GP practices around this and it might seem more sensible for these to be returned to pharmacies. However, legally pharmacists cannot receive sharps from diabetic patients, but general practitioners are allowed to take them as they have an exemption under the Waste Management Licensing Regulations. I understand that councils are able to collect these from patients who are housebound but not those who are mobile.
If sharps boxes are to be returned to surgeries, it is obviously unadvisable for practice staff to handle these boxes and equally they have to be disposed of in a secure area prior to removal by the waste collection service. Collection of sharps is not part of our GMS or PMS contracts and should be funded by the PCTs. The picture nationally seems to be equally confusing and unacceptable.
PCT Drug Budgets
I have been taken to task over the statement I made in the last newsletter concerning the wisdom of changing patients to the cheapest drug available. It is feared that this may undermine the work done by the Area Prescribing Committees who state that the inappropriate use of certain lipid lowering agents, particularly at high dose, can have profound financial implications for the local health economy and potentially increase the risk of side effects. I would agree wholeheartedly with this view but my main concern is the changing of patients over from one drug to another purely on the grounds of drug cost. There are other costs to this exercise in terms of GP time, lab tests etc. as well as the GP bearing the brunt of any comments/complaints by patients. No doubt in some circumstances a change of preparation would be desirable and in all instances care should be taken when initiating long term therapy. Prescribing of high dose expensive statins by consultants does not help.
Controlled Drugs
The BMA has produced information from the DH on changes to the misuse of drugs act that have recently come in regarding computer generated prescriptions. This can be found here.
Patient Confidentiality and Audit
A number of colleagues have recently asked about patient confidentiality in respect to audit projects. We have sought the views of both the MDU and MPS on this. Both have quoted the GMC approach whose published guidance is as follows:
"Where an audit is to be undertaken by the team which provided the care, or those working to support them, such as clinical audit staff, you may disclose identifiable information, provided you are satisfied that patients:
 | have been informed that their data may be disclosed for clinical audit, and their right to object to the disclosure; and |
| have not objected. |
If a patient does object you should explain why information is needed and how this may benefit their care. If it is not possible to provide safe care without disclosing information for audit, you should explain this to the patient and the options open to them.
Where clinical audit is to be undertaken by another organisation, information should be anonymised wherever that is practicable. In any case where it is not practicable to anonymise data, or anonymised data will not fulfil the requirements of the audit, express consent must be obtained before identifiable data is disclosed"
The MDU advise that in the event that a patient is now deceased, consent must be sought in the usual way using the Access to Health Records Act, 1990 and by seeking consent from the next of kin or executor of the estate.
A number of organisations in North Staffordshire are approaching GPs with requests for patient data to facilitate their audits/research. From the advice we have obtained, patient consent is necessary before disclosure of any patient identifiable information. Although this has serious implications for many audit projects, I am afraid the GMC advice cannot be ignored.
Oxygen Cylinder Supply
From 1st February 2006 oxygen cylinders will no longer be prescribed on an FP10 and dispensed by local pharmacists. In the West Midlands the oxygen supplier will be Air Products and a special order form will need to be completed. PCTs now need to ascertain from practices details of patient who are currently receiving supplies of oxygen cylinders. Patients will have to give consent to the PCT for their details to be passed on to the oxygen supplier.
Hospital Admissions
As you will know the Acute Trust has been under
severe pressure with acute admissions recently. I, therefore, repeat the advice
we have previously given, that whilst sympathising with their plight,
GPs have a duty to refer patients when their condition requires it. Not to do so is against our Terms of Service and I would not
advise any GP to put themselves in such a position.
General Practice is also facing strain and we cannot take on the responsibilities of the secondary care sector, neither should we deprive patients of the care they need by not referring them. Studies have always shown that the vast majority of acute referrals to the MAU are “appropriate” and so there is no leeway in this. If a hospital refuses to accept a referral the advice obtained by the GPC is that the GP should send the patient to the local Accident and Emergency Department with a letter of referral. This discharges the duty of referral under paragraph 12(2)(d) of our “Terms of Service.”
Briefing Note on Allergies for GP IT Systems
The note I included in the last newsletter was open to some misinterpretation. Paul Cundy from the GPC who was responsible for the initial report has made the following comment. A briefing note that I issued via GPC News has provoked a considerable response. A number of people have commented that the note could be interpreted as meaning that users should change from their system specific mechanism for recording allergies to read coding alone. I'm grateful for this being brought to my attention. This was not the intention. The note was clearly not written as succinctly as it should have been. I am sorry and apologise for this. The note was intended to suggest that users should begin to record allergies as read coded entries IN ADDITION to whatever system specific mechanisms they currently use. As the note pointed out, different systems handle this information in different ways and if these are abandoned then patient safety would be at risk. Users should continue to record information about allergies according to their system supplier's recommendations but are asked to consider making additional entries as read coded data for both drug and non drug allergies.
Hazardous Waste Regulations 2005
These came into force in July 2005. Most practices will have been required to register. Practice are able to recover the cost of registration from their PCT and should, therefore, write to their PCT claiming reimbursement.
Items from the GPC
Report on main negotiating issues
GMS contract review negotiations
Discussions on the GMS contract review have been progressing over the past month. There are, however, still a number of major areas that need to be agreed that will affect the whole contract package. Therefore, at this stage it is not possible to give full details of the exact nature of the deal that is being negotiated, mainly because providing partial information could be potentially misleading The next plenary meeting is due to take place on 3 November and we hope to be in a position to provide further information shortly afterwards.
Normalisation
Following the Department of Health’s continuing difficulties in sorting out the mechanism for correcting the over and underpayments that were made to practices’ global sums due to errors in the Exeter software which led to faults in the quarterly calculation of the normalisation index 2004-05, the GPC wrote to the Department expressing severe dissatisfaction and frustration with the process. The Department has stated in response that it fully understands GPs’ frustration, apologises for the delays and reports that it is currently working to ensure that the calculations are 100% correct before publication.
Childhood Immunisations
The GPC has discussed the issue of the change in the calculation of immunisation targets for the under twos. The problem is that the number of qualifying immunisations in the 2005 onwards SFE (section 8 – childhood immunisation scheme refers) has gone from four (DTPolio, HiB, Pertussis, MMR) to two (new pentavalent vaccine and MMR).
If all the immunisations were taken up equally this would not present a problem, but with MMR uptake often being significantly lower, this impacts seriously on practices’ ability to reach the higher target. We have been collecting information about the level of impact that the change from a 25% to a 50% weighting for MMR vaccinations is having.
We had already agreed with the Department of Health that this issue would be revisited during the 2005-06 negotiations as part of the overall vaccinations and immunisations review and this will continue to happen. In the meantime, the GPC chairman has written to the CMO expressing serious concerns about the problem.
Premises Underspends
The GPC wrote to the Department of Health back in July expressing concern at reports of some PCTs not spending their share of the £108 million allocated for 2004-06 on primary care premises capital developments. We have received a response to this letter which reaffirms our understanding that the £108m has been allocated to PCTs in a way that prohibits it being used for anything other than qualifying capital developments.
The letter also seeks to give reassurance by stating that the Department of Health is closely monitoring the use of these monies to ensure that they are not lost or spent elsewhere and that SHA colleagues will be reminded that the £108m can only be spent on private sector capital grants/premises improvements. However, where there are concerns about PCTs not spending these allocated monies properly, then the Implementation Coordination Group (ICG) will investigate further. Please send any information to your local liaison officer.
DDRB evidence
The GPC has this week, as part of the wider BMA evidence, submitted its evidence to the Doctors and Dentists’ Review Body (DDRB). It has not submitted any evidence relating to GP principals due to the current ongoing negotiations. In the event of the parties being unable to reach agreement on the contract negotiations there would be an opportunity to submit evidence at a later stage, or as part of the oral evidence.
Practice Based Commissioning Guidance
The Department of Health had been planning to provide more detail on PBC management support to PCTs and general practice in October. We have been informed that following feedback from the NHS, the Department of Health has now decided to provide more comprehensive information to support implementation. The plan is to get this out as soon as possible, and they hope it will be in November/December.
The GPC would also like to stress that, if adequate funding is not available locally for preparatory management costs, practices should not feel obliged to enter into PBC agreements regardless. The GPC is seeking to agree separate funding for this purpose and those who feel they would be financially disadvantaged by moving forward now should wait for further details. The GPC also recommends that if practices are considering signing PBC agreements with their PCTs now, they should add a clause stating that if later national negotiations result in a more favourable rate than the one agreed locally, that the local contract should be amended accordingly.
Londonwide LMCs have produced a series of helpful briefing notes on Commissioning a patient-led NHS, which include an issue on practice based commissioning. These are attached for information.
Appendix 1 - Competition, change and challenge
Appendix 2 - Practice based commissioning, an LMC view on PBC across London
Appendix 3 - Practice based commissioning, appendix.
Freedom of Information Update
The Department of Constitutional Affairs (DCA) published the first edition of its Information Rights Journal on 22 September 2005. This is available at www.dca.gov.uk/foi/irj.htm In addition, the DCA has commissioned Northumbria University to run a range of courses on Freedom of Information from next September. The Health and Social Care Information Centre, which has replaced the NHS Information Agency, may also prove to be a valuable resource for the profession.
There are currently problems with the applicability of the Data Protection Act to deceased patients, meaning that their records may be disclosable in England under the Freedom of Information Act. The DCA is working with the Information Commissioner (IC) to investigate ways in which exemptions in the Freedom of Information Act may be used to prevent disclosure of deceased patients’ records. It is hoped that guidelines will be produced in the near future. We also expect DCA guidance on disclosure logs and IC guidance on refusal notices to be published soon.
Publication schemes will need to be reaccredited by the IC in 2007. Submissions from GPs will be accepted from June until October 2007. It is thought that the IC is likely to be more prescriptive about the content of publication schemes during this second round.
GPs’ duty to refer
Concern has been raised about PCTs who are insisting they want to see a percentage reduction in referrals to secondary care. In particular, there were serious worries that GPs in some areas thought they needed to comply with this. It was pointed out that GPs should be reminded that they had a professional and ethical duty to refer their patients as they believed was clinically necessary. GPs should not compromise their clinical duties to meet PCT financial initiatives.
Flu vaccines – can they be provided to those outside the DES?
Every year there are queries about the issue of providing flu vaccines privately or to patients who request it.
It is clear under the flu DES what it is the NHS is prepared to provide - flu vaccination for the over 65s and at risk groups. GPs get their flu vaccines for this through central suppliers, they claim a PA fee for each vaccination given and a DES payment. The Joint Committee for Vaccinations and Immunisations will be involved in determining the number who could be at risk and ensuring that the relevant amount of vaccines are ordered to cover those groups. Therefore companies like Farillon should have enough stocks available for the over 65s and at risk groups.
GPs always have clinical discretion to vaccinate outside this ie: if there is a patient who continually had flu the previous year, spent weeks off work etc who the GP may think could benefit from having a flu vaccine. Under such circumstances, it may be worthwhile providing it through an NHS prescription and then administering it, as it will not then affect the vaccines supplied and bought specifically for the at risk groups and over 65's.
GPs can certainly advise patients that they may be able to get the vaccination privately and there may be a reciprocal arrangement with other practices in the area where they vaccinate each others patients privately. GPs cannot of course charge their own registered patients for either providing a private prescription or administering a flu vaccine privately.
We would also not advise giving a private prescription to vaccinate free of charge. There are times when GPs give private prescriptions to non exempt patients because the cost of a drug is actually lower than the prescription charge. If this happens we always advise the GP also gives an NHS prescription which they are entitled to under the NHS. The patient then makes the choice.
Avian Flu
During the GPC meeting the Chairman, Hamish Meldrum, informed the committee he had spoken with the CMO regarding the Department of Health’s response to an avian flu pandemic. GP practices should have received information for patients and should be receiving more information in the coming weeks. The Chairman, expects to speak to the CMO again on this matter in due course. The committee raised a number of issues they would like clarified including: will a state of emergency be declared which allows GPs to better deal with the task in hand when it is unlikely regular services can continue.
Out-of-hours training for GP registrars
At the last meeting of the GP registrars subcommittee on 16 September 2005, it was reported that many GP trainers and VTS course organisers were still unclear on GP registrars’ training requirements in out-of-hours (OOH) care.
The nationally agreed guidelines for GP registrars OOH experience is contained in a COGPED position paper ‘Out-of-hours training for GP registrars’, which states that GP registrars will be required to undertake a benchmark of 12, six hour sessions of OOH training. This paper also sets out the responsibilities of each stakeholder in the provision of out-of-hours training and it will be modified in light of experience and development of OOH services. However, the paper does make clear that GP registrars will continue to be expected to undertake training and demonstrate skills and competencies in OOH services (whether or not their trainers undertake such work). Various models exist as to how this will actually happen and all deaneries should have an action plan in place.
The COGPED paper can be accessed online as follows: www.gpkss.ac.uk/who/deanery/zfr_policy.htm
We gather that there is also some confusion over who is responsible for organising OOH sessions and we believe that arrangements currently differ across the country. Ideally, the GP trainer will take measures to facilitate the process, but ultimately it is the responsibility of the GP registrar to ensure that they complete the required number of OOH sessions.
The GPC is aware that GP registrars in some areas have had problems accessing OOH sessions and in particular in PCO areas where private providers have been commissioned to cover the OOH period. OOH remains a core competency of GP training and PCOs should agree both the contractual and financial provision for training with providers of OOH care from the outset. A letter from the Department of Health setting out the requirements on PCOs was issued on 28 April 2004 and this correspondence has been appended to the COGPED guidance as referred to above. The GPC has intervened in a few such cases which have since been resolved. COGPED has advised all Deans of Postgraduate GP Education to contact the GPC where such problems persist.
GP trainers’ pay
The DDRB’s 34th report recommended that a separate payment of £750 should be made to all GP trainers in recognition of their CPD costs. We are pleased to report that the Health Department has now said that this payment will be made to all GP trainers this year. This follows letters to the Health Department about the delay in the payment and more recently a letter to Lord Warner, Health Minister, expressing our anger and dismay at news that the payment might not be forthcoming at all.
We are currently awaiting confirmation from the Health Department on when and how GP trainers will receive the £750.
PMETB CCT delays
The Postgraduate Medical Education Training Board (PMETB) took over the issuing of certificates of completion of training (CCTs) on 1 October 2005. The procedure for the awarding of a CCT by the Joint Committee of General Practice Training (JCPTGP) used to take a maximum of 10 working days. However, the PMETB has said that it will take three weeks to award a certificate. We have also heard of some GP registrars who submitted their application to the JCPTGP prior to 30 September and have not yet received a certificate. This is unacceptable and is obviously of grave concern to the GPC. It means that GPs who have passed summative assessment and are therefore fully qualified will not be able to have their name included on a PCO’s medical performers list in a timely manner and therefore are unable to start their career posts. Unlike junior doctor specialist registrars, a CCT is needed in order to practise independently as a GP. The GPC and the RCGP have written jointly to the PMETB about this and the need for a far speedier process. The next step will be to raise this with the Health Minister, Lord Warner.
PMETB and summative assessment for Article 11 doctors
The PMETB previously agreed that doctors who apply for a CCT under the equivalent experience route of training (Article 11) would have to undergo summative assessment, in the same way as GP registrars who apply for a CCT under the prescribed experience route of training (Article 5). However, we have now heard that the PMETB has reversed this decision and so Article 11 doctors are not now required to undertake summative assessment. The GPC is concerned that this raises questions of quality assurance, and we will be raising this further.
Payments to GPs undertaking work on PMETB's behalf
Following a letter from the GPC, the PMETB has agreed that it is crucial for GPs to be able to participate in the PMETB's work and that it will make sure the arrangements are there to encourage that. The PMETB chairman will be recommending to the next Board meeting that it undertakes a review of its policy on payment for various kinds of work that stakeholders undertake on PMETB's behalf and the assistance that they give on committees, etc. The PMETB is making arrangements for GPs on visiting panels to be reimbursed locum costs by deaneries.
NSPCC/EduCare Programme
GPs and their support staff are to be targeted as part of the NSPCC's biggest ever child protection training exercise. GP surgeries will have been receiving free copies of EduCare, a child protection awareness distance learning programme. This is part of a much wider campaign to mobilise people to act to end child abuse. It is about recognising the possible signs of abuse and ensuring GPs and their staff know how to act if they have concerns about a child.
The programme is available as a PDF document and is on the BMA website at www.bma.org.uk/ap.nsf/Content/NSPCC2005.