NEWSLETTER NOVEMBER 2006
CPNs and the Psychiatric Service
GMS Standard Contract - variations
Age discrimination legislation guidance
Hepatitis B and immunisation for University students
Quality and Outcomes Framework results 2005/06
Access DES Patient Experience Survey
Information Management and Technology (IM&T) update
Editorial
We have recently had yet another reorganisation of the management of the Health Service. As usual, it starts with the promise to improve the running of the health service. Time will tell whether it will, but past experience does not bode well. The health service now appears to be in a worse state than I can ever remember. Although waiting times have undoubtedly reduced the financial restrictions, bureaucracy and systems currently in place are causing more frustration than long waiting lists for secondary care have ever done.
These frustrations are produced at three levels, national, PCTs and local trusts. Just looking at the process for referring of a patient to secondary care alone produces a long list of problems. At a national level we have the implementation of Choose & Book, a system which seems dedicated to making the referral process more difficult both for the GP and the patient. It may work well where there is a real choice of local provider, but in North Staffs, where most patients wish to be treated at the local hospital it is a longwinded unnecessary process which doesn't allow the patient to see the consultant of their or their GPs choice. Having said that, patients deciding to go elsewhere may concentrate a few minds at the UHNS to be more responsive to the needs of patients and their GPs.
The PCT adds to the frustration with its “referral centres” and the “single point of access” systems, where our decisions to refer patients are inspected, judged and interfered with. Having done this, we are not informed of the outcome and experience shows that we cannot be sure that our patients are being referred on appropriately, if at all.
Once the patient gets to hospital, at UHNS, we have an organisation where communication back to primary care seems to be an enigma. The time taken to receive reports from some departments, cardiology and x-ray come to mind, is unacceptably long and makes patient management difficult if not dangerous. The hospital is now incapable of sending letters back to branch surgeries as they can only cope with one address per GP! Then having been seen once, the patient is then either discharged before the problem has been diagnosed, treated and appropriately managed, or given a follow up appointment which is lost in the black hole of the “partial booking” system. The number of patients who attend our surgeries purely to find out what is happening about their hospital appointment, investigation or follow up is increasing by the day.
Practice Based Commissioning is, of course, supposed to solve all these problems, but the initiative locally is moving at a snail’s pace. How we are supposed to manage our general practice workload, practice based commissioning, take on secondary care follow up work and also, according to the latest government initiative, provide surgical operations is a challenge to say the least.
We continue at the LMC to take these and other problems up with the appropriate trusts but progress is frustratingly slow. We are attempting to seek better ways of communication with the new chief executives with a hope that some of our frustrations will be relieved.
CPNs and the Psychiatric Service
There has been a lot of rumour and speculation recently about the future of the CPN service. It is difficult at times to separate the rumour from the truth. I think it is true to say that the PCTs and Combined Healthcare are looking at the way the CPN service is provided and that there are ways to make it more cost effective. Some patients who are seen by the CPNs could be managed by others. The PCTs and Combined Healthcare have been made aware that GPs greatly value the service currently offered by the primary care CPNs and that is service must continue in the future. If it is decided that some services can be provided more cost effectively by others, then we should be informed of the changes and it should be ensured that the alternative services can cope with the demand.
The Single Point of Access for psychiatric services is causing problems in Stoke-on-Trent, it has yet to be introduced into Staffs Moorlands. One of the main drivers of the introduction of the single point of access was to ensure that patients are treated by the appropriate professional. Once again GPs were perceived as making inappropriate referrals. However, the current system is causing severe problems. Once patients have been referred we are not informed of any action taken and the time scale for patients being seen is unacceptably long. We have taken up these concerns and been promised that the service will become more responsive, however the threat of cuts to the CPN service still loom.
The completion of health reference forms for prospective registrants with the General Dental Council
The General Dental Council (GDC) have
introduced a requirement that states all prospective registrants must
have a health reference form completed by their GP. The BMA has a
number of concerns regarding the current guidance notes to doctors and
the wording of the application form and has met with the GDC to
highlight these concerns. The GDC has confirmed that it will be
reviewing the documents and will consult the Association on these
changes.
The Professional Fees Committee notes that the completion of health
reference forms does not form part of a GPs terms and conditions and
therefore an appropriate fee may be levied by the GP to the patient
concerned.
The GPC is aware that these forms are causing some confusion. Practices are reminded that completion of these forms is not part of GMS or PMS contractual work and practices do not have to offer this service unless they choose to. Any practice that does choose to undertake this work should make a realistic charge for it.
Charges for non-NHS work
I have received a number of comments, questions and complaints recently around the charges GP practices can make for services. This is quite complicated area, in general patients cannot be charged for medical services but can for the provision of some forms, certificates and medicals. Immunisations in connection with travel abroad is one area of confusion. Items for which we were paid under the old "Red Book" cannot be charged for but others can. Kent LMC has produced a detailed document on this issue which can be found here.
We cannot charge for
(a) the provision of any treatment whether under the contract or otherwise; or
(b) any prescription or repeatable prescription for any drug, medicine or appliance, except in the circumstances set out in Schedule 5.
For your information I reproduce schedule 5 below.
The contractor may demand or accept a fee or other remuneration -
(a) from any statutory body for services rendered for the purposes of that body's statutory functions;
(b) from any body, employer or school for a routine medical examination of persons for whose welfare the body, employer or school is responsible, or an examination of such persons for the purpose of advising the body, employer or school of any administrative action they might take;
(c) for treatment which is not primary medical services or otherwise required to be provided under the contract and which is given -
-
pursuant to the provisions of section 65 of the Act (accommodation and services for private patients), or
-
in a registered nursing home which is not providing services under that Act,
if, in either case, the person administering the treatment is serving on the staff of a hospital providing services under the Act as a specialist providing treatment of the kind the patient requires and if, within 7 days of giving the treatment, the contractor or the person providing the treatment supplies the Primary Care Trust, on a form provided by it for the purpose, with such information about the treatment as it may require;
(d) under section 158 of the Road Traffic Act 1988 (payment for emergency treatment of traffic casualties)[76];
(e) when it treats a patient under regulation 24(3), in which case it shall be entitled to demand and accept a reasonable fee (recoverable in certain circumstances under regulation 24(4)) for any treatment given, if it gives the patient a receipt;
(f) for attending and examining (but not otherwise treating) a patient -
-
at his request at a police station in connection with possible criminal proceedings against him,
-
at the request of a commercial, educational or not-for-profit organisation for the purpose of creating a medical report or certificate,
-
for the purpose of creating a medical report required in connection with an actual or potential claim for compensation by the patient;
(g) for treatment consisting of an immunisation for which no remuneration is payable by the Primary Care Trust and which is requested in connection with travel abroad;
(h) for prescribing or providing drugs, medicines or appliances (including a collection of such drugs, medicines or appliances in the form of a travel kit) which a patient requires to have in his possession solely in anticipation of the onset of an ailment or occurrence of an injury while he is outside the United Kingdom but for which he is not requiring treatment when the medicine is prescribed;
(i) for a medical examination -
- to enable a decision to be made whether or not it is inadvisable on medical grounds for a person to wear a seat belt, or
- for the purpose of creating a report -
 |
relating to a road traffic accident or criminal assault, or |
|
that offers an opinion as to whether a patient is fit to travel; |
(j) for testing the sight of a person to whom none of paragraphs (a), (b) or (c) of section 38(1) of the Act (arrangements for general ophthalmic services) applies (including by reason of regulations under section 38(6) of that Act);
(k) where it is a contractor which is authorised or required by a Primary Care Trust under regulation 60 20 of the Pharmaceutical Regulations or paragraphs 47 or 49 of Schedule 6 to provide drugs, medicines or appliances to a patient and provides for that patient, otherwise than by way of pharmaceutical services or dispensing services, any Scheduled drug;
(l) for prescribing or providing drugs or medicines for malaria chemoprophylaxis.
The GPC has produced a document listing services which it feels should not be provided under GMS/PMS. A copy of the document can be found here.
Contract Related Documents
Copies of most documents relating to GMS and PMS contracts can be found on the West Midlands Regional Local Medical Committee website at http://www.wmrlmc.co.uk/gms2/index.htm.
nGMS Standard Contract - variations incorporating the new Directed Enhanced Services
The contract addendums are now on the DH website and can be viewed at -
These provide an optional set of contract variation documents that may be used by practices and PCTs as a means of incorporating the DES arrangements into the standard GMS contract, modifying the standard GMS contract by agreement. The document has been posted on the DH website as an aid for PCTs amending the standard GMS contract but will recognise that there is no legal obligation on either party to the contract to adopt its words.
Guidance on the implications of the new age discrimination legislation
Following the new Employment Equality (Age) Regulations which are due
to come into force in October, it will be unlawful to discriminate on
the grounds of age. The BMA has produced some guidance which sets out
the key changes and explains the implications. The transitional
provisions may have implications for practices in August. A copy of this
can be found
here.
BMA Regional Services are producing separate guidance which they intend
to circulate to all practices. Any questions about the regulations
should be directed to either askBMA or Regional Services in the first
instance.
GP Returners - Guidance from the GPC
In order to work as NHS GP in the UK, a doctor needs to be on the GMC’s new GP register, and be on a PCO’s Performers List in the country where they are working or intend to work.
Up until earlier this year funding was available in England for the GP returners’ scheme. This was an excellent mechanism for encouraging qualified GPs (particularly those who had taken a career break for family reasons) back to work. It provided a funded placement for the returning doctor normally for six months on a full-time basis or 12 months part-time in a practice experienced in offering support and training. It also represented very good value for money to the NHS. Unfortunately, the funding for the GP returners’ scheme has been withdrawn by the English Department of Health, although some deaneries have retained local sources of funding for returners’ schemes. The BMA has made numerous representations about the withdrawal of the funding to the Health Department, including a meeting with Lord Warner, Health Minister.
In the meantime, this guidance is designed to advise GPs who wish to return on the current situation while no new central funding is available for the GP returners’ scheme. A copy of the guidance can be found here.
GPC News Items
Flu vaccine supply
Practices should all have received a letter through the public health link highlighting the fact there are delays in the vaccine supplies coming on stream and the need to prioritise vaccination in line with the CMO letter of 29 June which laid out the key priority at risk groups.
The GPC has been informed by the Department of Health that, by the end of October, 9 million doses should be out with practices (compared to 10 million last year), by the end of November there will be 13 million doses distributed and the remainder will be delivered by the end of December. Flu co-ordinators have been instructed to help practices across PCO areas utilise their vaccines as best as possible.
Although the possibility of the likes of Morrisons offering vaccines to the worried well seems more than inappropriate in the circumstances, in reality 96% of all vaccine production is going to the NHS. There is no regulation that stops manufacturers selling and providing vaccine to private enterprises.
Apparently the public health flu campaign will be fed through gradually to take into account that this year the flu campaign will be delayed in practices. The BMA issued a press release encouraging patients not to contact practices seeking information about flu vaccinations but instead to wait until the practice contacts them.
The GPC has also received the following message from the DH on the issue of flu vaccine supply:
"If surgeries are encountering problems ordering influenza vaccine, they should contact the six suppliers as the Department of Health is aware that some suppliers now have vaccine available for sale. Further stocks may also become available as the season progresses.
The six suppliers and their contact details for ordering vaccine are:
Sanofi Pasteur MSD 0800 085 5511
Novartis Vaccines 08457 451 500
GlaxoSmithKline 0800 783 0470
Masta 0113 238 7500
Solvay Healthcare 0800 358 7468
Wyeth Vaccines 0800 089 4033
The Department of Health will not be purchasing contingency stock for the 2006/2007 season."
Hepatitis B and immunisation for University students
The GPC have been receiving reports of the first letters appearing advising medical students to seek Hep B immunisation from their GP. Some of these letters also advise that this service is available free of charge. It is not possible for a GP to charge a registered patient for the Hep B immunisation, though a fee can be charged to an independent third party or to patients who are not registered with the practice.
The BMA advises GPs that the responsibility for immunisation required for occupational purposes lies with the employer, which for students is the educational institution. It is however difficult to get anything enforced when there is no one single organisation to take this forward with and when many GPs continue, out of goodwill, to provide this service free of charge. However occupational health services do have some sympathy with this matter and some universities are making progress so the GPC continues to work to try to ensure that we may see others follow.
Quality and Outcomes Framework results 2005/06
28 September saw the release of the 2005/06 QOF results in England. These proved that GP practices have demonstrated even better quality care patient care than 2004/05 with results almost 5% higher. The average score out of a possible 1050 was 1010.5 compared to 958.7 in the first year of QOF. In the devolved nations the average scores were 1026.3 in Scotland, 1003.3 in Wales and 1027.6 Northern Ireland. This good news story received a fair amount of press coverage which is encouraging. The GPC would like to congratulate all practices who have worked extremely hard to get these results.
Access DES Patient Experience Survey
The GPC has passed the following motion on the revised directed enhanced service for improved access.
"In the light of what the GPC considers to be a breach of the original agreement on the Access DES questionnaire, the committee now rejects the DES on the basis that the DES's integrity has been so discredited".
GPC negotiators had reluctantly agreed to the use of a patient survey to assess achievement in the revised access directed enhanced service for 2006/07, on the grounds that it was this only way to retain the £108 million for access in the GMS contract. For some months now, it has participated in the Board set up to implement the survey, which is to be carried out by Ipsos-Mori, and has felt increasingly alarmed at stated Government intentions to include extra questions in the survey questionnaire which had not been agreed in negotiations on the DES.
Although these questions will not be linked to GP pay, they are potentially pejorative and appear to invite patients to offer negative feedback about appointment arrangements in GP practices, no matter how they may have responded to the agreed questions relating to achievement in the DES. The extra questions also risk confusing patients and raising their expectations about extended opening hours even though these are not part of GPs' contractual arrangements and have not been the subject of negotiations. Indeed, the Department of Health has admitted that it cannot resource extended opening hours.
The whole committee has now had an opportunity to discuss these extra questions, and believes that their imposed inclusion in the survey questionnaire has now completely discredited an already unpopular DES.
The GPC has produced a "Focus On" guidance document which can be found here.
Contract negotiations update
Since the September 2006 GPC news report, negotiations with NHS Employers on stage 2 of the GMS contract review, intended for implementation in April 2007, have not progressed. The GPC has maintained regular contact with NHS Employers but no formal negotiations have taken place. The GPC has made it clear that it could only agree to negotiate on new services if the investment for them was available over and above the resources needed for a fair inflationary uplift across the contract.
As this looks extremely unlikely, the GPC has submitted detailed evidence to the DDRB asking it to recommend an inflationary uplift across all aspects of the GP contract. This evidence was made public this week and is available on the BMA website at www.bma.org.uk/ap.nsf/Content/DDRBevidence2006. Both NHS Employers and the Department of Health have also submitted evidence though this does not contain specific detailed information on GPs working under the GMS contract. Instead it states that “NHS Employers is currently in negotiations with the BMA’s General Practitioners Committee regarding the arrangements for independent GMPs throughout the UK under the GMS contract for 2007/08. The negotiating parties will provide an update for the review body as part of supplementary evidence.”
The GPC believe that submitting evidence and a request for an inflationary uplift to the DDRB was in the best interests of the profession. This will hopefully ensure that if parties cannot reach agreement, particularly on issues of inflation and efficiencies, the DDRB can offer an independent view. The GPC believes this course of action is preferable to negotiating a deal that is unacceptable to the profession, particularly following the efficiency savings offered in 2006/07 in return for an agreement that value for money issues associated with the contract would not be revisited.
Information Management and Technology (IM&T) update
Endorsement for GP2GP
JGPITC has endorsed the use of the updated version 1.0 Emis product for Emis to Emis record transfers in practices beyond those involved in the ‘Early Adopter’ Gateshead project. At the same time, the committee has also endorsed the use of the version 1.0 Vision 3 product for Vision to Vision record transfers in practices beyond those involved in the ‘Early Adopter’ Isle of Wight project.
QOF datasets and business rules
A list of remaining problems that we are aware of with Version 8.5 of the Business Rules and Datasets has been compiled. Recommendations and agreements are then noted where reached. If you know of any recent problems which you would like to raise, e-mail arivett@bma.org.uk
Data Accreditation
A meeting of the accreditation board is due to take place shortly. Further details will be released after the meeting and made public by the end of the year.
PCT funding of IT equipment
It has been brought to our attention that some PCTs are still refusing to fund the purchase of IT equipment and upgrades. We would ask to be kept informed when this occurs so the JGPITC can assist. Details should be sent to arivett@bma.org.uk
Pensions dynamisation
Following previous correspondence from the Department of Health suggesting the imposition of a cap on the pension dynamising factors arising from the first three years of the new contract, the GPC last week received further communication from Lord Warner, Minister of State (NHS Reform), setting out a revised proposed method for implementing the GP pensions dynamising factor for 2003 – 2006. The GPC has modelled the effect this would have on GP pensions and is clear that this revised method would not deliver what was agreed under the original contract arrangement, and would particularly disadvantage those GPs that have retired since April 2006.
The GPC made clear in its response to Lord Warner that failure to honour full dynamisation using the original agreed method and over the agreed timescale would be seen as a breach of the agreement between the NHS Confederation, Department of Health and GPC in 2003. Whilst the GPC is prepared to continue discussions to try to resolve the issue, the principle of honouring agreements is one that the GPC holds in high regard. Should the eventual decision remain unsatisfactory, the GPC will use every possible legal, economic and political weapon at its disposal to defend the new contract pension agreement. The Government will make no decision on pensions dynamisation until the end of November.
PMS and superannuation
This week the GPC became aware that Worcestershire PCT, following pressure from the LMC, will be funding PMS practices fully for 14% superannuation employer contributions. The GPC position has always been that, in accordance with the superannuation clauses in the PMS (Lockharts model) agreement, it is clear and unequivocal that PCTs entering into this contract are bound to pay these contributions. There is no discretionary element; this is a clear contractual obligation. Whilst this advice is based specifically on the Lockhart’s model, there may be other contractual clauses that bind PCTs to pay full employer contributions.
Cases have been filed for dispute resolution on this matter and the GPC believes that the determination has always been in the favour of the practice rather than the PCT. Practices that want further information about whether their practice may be entitled to a similar claim, or the arguments used to pursue these claims, should contact their LMC or the GPC office directly.
Choose and Book
It has been brought to our attention that the Choose and Book website (www.chooseandbook.nhs.uk) now has a form where problems with the system can be raised with the team who will investigate accordingly.
Health information from DPP
Developing Patient Partnerships (DPP) is a charity partly funded by the Department of Health. Specialising in health information, the DPP produces a growing range of unbiased high quality, user-tested leaflets, booklets and posters designed to meet the needs of patients and nurses.
Covering a wide range of topics - from heart health to minor ailments, missed appointments to COPD - DPP provides health information packages to GP surgeries, primary care organisations, hospital trusts, walk-in-centres, minor injury units and other interested organisations. All the health information resources are road tested by members of the public, go through a rigorous consultation process with an expert medical panel and translations are available in key languages.
To find out more, visit: www.dpp.org.uk or call: 020 7383 6824.