NEWSLETTER OCTOBER 2003
Allocations Process in North Staffordshire
Computer Generated Referral Letters
Good practice guidelines for General Practice electronic records
Pneumococcal vaccination campaign
GPs working in community hospitals
New Contract
GPs, LMCs and PCTs are all becoming frustrated over the lack of definitive authorative national guidance on the "New Contract". Much is still awaited and will be issued "in due course", this month, the summer, the autumn, sometime. Time is short and there is a lot of work to be done. Until the regulations and exact details of funding are issued practices are in limbo and unable to make advance plans for next year. The GPC is publishing a series of "Focus on" documents about the new contract. The latest was published on 15th October. These can be found on both the BMA and LMC websites. A letter from John Hutton to all PMS doctors detailing advice regarding PMS and the New Contract can also be found on both websites.
By December 2004 PCTs must be in a position to allow GPs to opt out of out of hours services. They become the sole commissioners of OOH services. PCTs will not be able to return the responsibility to practices if they are in difficulty, OOH will no longer by part of a practice's contractual obligation. The service that will be provided will be driven by affordability. 6% of the global sum will be deducted to pay for the opt out, this is equivalent to £6,000 for the average GP. The decision to opt out must be on a practice basis. Practices will be able to seek PCT approval to provide their own out of hours cover but they will have to meet all the quality standards identified in the Carson report. These standards are likely to prove to difficult to meet for individual practices and cost is likely to be the determining factor for groups of practices. The future out of hours services is likely to be "doctor light", with doctors playing a minor part.
Colleagues had been advised to maximise their GMS income during the current financial year to ensure that the maximum amount would be used to calculate their Minimum Practice Income Guarantee. However the latest edition of the "Focus on" series from the GPC states it has been agreed that the "data to be used to determine the Global Sum Equivalent, and hence the MPIG, will be taken from the last three quarters of 2002/03 and the first quarter of 2003/04."
Colleagues do need to do a stocktake of the services they provide to see which come under enhanced services, which are covered by the global sum and additional services and which are not funded. PCTs are asking practices about their intentions to provide enhanced services. Until full financial details are known this can only be an indication. Practices will have to bid for funding of enhanced services, so it is worthwhile preparing such bids in advance. Intentions can always be withdrawn if adequate funding is not available. Colleagues are advised not to provide enhanced services after 1st April if funding is not available.
Enhanced services fall into three categories, Directed Enhanced, Nationally Enhanced and Locally Enhanced. Funding of all these services come out of the Unified Budgets from which the PCTs commission services. PCTs have to commission Directed Enhanced Services. All of these have nationally agreed terms and conditions. Most where previously provided in the past by GPs as part of GMS. Nationally Enhanced Services also have nationally agreed terms and conditions but are not mandatory for the PCTs to commission. Locally Enhanced Services are extra services outside the remit of Essential and Additional Services that are negotiated locally between the practice and the PCT. These have no national terms and conditions. The provision of most Local Development Schemes are likely to be included in this category.
Practices do not have to provide any Enhanced Services and it is up to individual practices to determine whether or not it is financially viable to do so and whether they wish to bid to provide these services. Given the current financial position of PCTs it is unlikely that any new provision will be commissioned. We have stressed to PCTs the importance of commissioning services which are already being provided..
There is still confusion about the funding of IT systems. PCTs are now beginning to approve bids and giving assurances about a percentage re-imbursement for essential replacements and minor upgrades. Unfortunately they have not yet been given the all clear to provide 100% funding or been informed of their exact budget. We anticipate that 100% funding will be available for replacements and minor upgrades in due course and back dated to 1st April 2003. Practices must gain prior approval from their PCT for any IT purchase if they wish to apply for reimbursement.
IT will play a pivotal role in the delivery of the new contract. The system suppliers are working on adaptations to allow the data capture and reporting needed and these will begin to be rolled out in the near future. We are still awaiting national guidance on the minimum specification for systems.
Delays in Payments
A number of GPs have expressed concern about delays in payments by PCTs. We have taken this up with each PCT. The finance agency has been experiencing considerable upheaval recently. The former Health Authority Finance Department has merged with the North Staffordshire Combined Healthcare Finance Department. During this period there has been a high turn over of staff. Fortunately these problems have now been rectified and hopefully the level of performance will improve. However, most of the delay appears to arise in the authorisation process prior to being passed to the Finance agency. A meeting is being arranged with the four PCTs and the finance agency to investigate this matter further.
The problems with Blue Badge and Mental Health Act fees is more complicated, in that the social service department are involved in their authorisation. These claims should be forwarded to either the City or County Council Social Services, who will then authorise payment and return the claim to the PCTs. The PCT then advise the payments service of the fee to be paid. It appears that all concerned process these on a monthly basis, which can mean that overall some claims are dealt with slowly.
Recruitment Crisis
The crisis is becoming ever more acute, particularly in the Stoke on Trent PCTs. As a result of this, there will have to be a radical reshaping of the way General Medical Services are delivered. GPs cannot continue to provide open access to anyone who wishes to see them and cope with the workload. Some sacred cows of General Practice will have to be sacrificed if we are to survive. GPs and the PCTs must work together to find radical innovative solutions to the problem. These solutions will mean hard and maybe unpalatable decisions will have to be made. PCTs are working on the recruitment issue but the crisis cannot be averted purely by concentrating on recruitment issues. The promises of monetary reward alone is not enough to retain GPs in the profession, golden handcuffs, the promise of increased pensions, the new contract do not appear to have had any effect on the numbers of GPs wishing to retire. The New Contract may indeed have lead to an earlier retirement for some. PCTs must look at ways of encouraging colleagues to delay their retirement for a few years. This must involve decreasing considerably the stress involved in our working lives. If this is successful we may buy sufficient time to bridge the gap from now until the increased number of medical students in training come on stream.
Allocations Process in North Staffordshire
The Local Medical Committee has been made aware that a large number of colleagues believe that the current system of allocations is not fair and equitable.
We have passed these concerns on to South Stoke Primary Care Trust who lead on this issue. They, like us, are keen to ensure the system is improved, and we as an LMC are endeavouring to work with them to this end.
One feature of the system that has not helped GPs to see it as equitable is the fact that the numbers of allocations to practices has been considered confidential information and, therefore, colleagues have been unable to see how their allocation load compares with their neighbours. It is with this in mind, at its meeting on 11 September, the LMC agreed the following statement:
“The process should be open and transparent and that the numbers of allocations per practice should not be considered confidential information and should be made available for colleagues to examine as appropriate.”
I hope this meets with your approval as we believe it is an essential plank of any new arrangements.
Influenza Vaccinations
Agreement has now been reached with the Department of Health over the payment for influenza vaccination to "at-risk" patients who are under the age of 65. It has been agreed to introduce payments from this year for practices that can demonstrate that they have an at risk register which allows them to target at risk patients. This brings payments for this work into line with the way GPs are already being reimbursed for immunising patients aged 65 and over. The item of service fee will be at the higher 'B' rate for those patients at increased risk for whom influenza immunisation is recommended and clinically indicated and who are on the practice's at-risk register. The facility to make these new payments will shortly be made available to Primary Care Trusts. GP practices can only claim payments for those patients aged under 65 for whom they have an appropriate disease register and PCTs will be responsible for ensuring these conditions are met. GPs should continue to maximise uptake in the interests of these patients. While this year it is anticipated the payments will largely cover immunisations already planned, some influenza vaccine is still available to increase uptake.
Computer Generated Referral Letters
There has been some resistance at the Hospital Trust to accepting computer generated referral proforma for 2 week wait cancer referrals. I have had discussions with Mrs Hall concerning these and have produced versions of the North Staffs Proforma which can be integrated in to the EMIS system. The layout of these is exactly the same as the proforma circulated by the hospital centre but the details can be typed in through the referral module of the EMIS system. The patients details, past medical history and medication are automatically added. Some practice may wishes to use these, and if so I will be happy to provide copies.
Intermediate Care
The situation regarding the provision of intermediate care in the City remains somewhat confusing. It is still unclear as to who "owns" this service. It is understood that a Dr Gregan, who is employed by Stoke South PCT to provide PMS services is to provide day time cover for patients in intermediate care and that arrangements have been made with the Doctor's co-operative to provide out of hours cover. The LMC believes that no GP should be forced to provide intermediate care and that a deputy needs to be appointed to be available when Dr Gregan is unavailable. We also believe that is problems occurs with these patients a clear route to re-admission should be identified.
We have been given the following contact points for the Intermediate Care/Rehabilitation Services for Stoke on Trent.
Jackie Carnell, Director of Nursing & Operations, South Stoke PCT. Tel: 01782 298152
Sarah Hill, Assistant Director Adult Services, Stoke on Trent Social Services Tel: 01782 235901
Greg Russell, Director of Service Development, North Stoke PCT. Tel: 01782 221150
Items from the GPC
Good practice guidelines for general practice electronic patient records (version 3) September 2003
The Department of Health
has, through the Royal College of General Practitioners Health
Informatics Standing Group and representatives of the BMA's General
Practitioners Committee, produced new "Good
Practice Guidelines for General Practice - Electronic Patient Records".
These guidelines update an earlier version published in August 2000.
The update is in response to the Department of Health, British Medical
Association, Royal College of General Practitioners, and medical defence
organisations receiving steadily increasing number of enquiries from
practices and primary care organisations, on a range of issues not
covered in the August 2000 guidance (i.e. shredding/retention periods/
legal admissibility of scanned documents, accreditation and
re-accreditation of paperless practices, information governance
standards, etc). The new guidance, written by national experts who are
also users of clinical systems in their own practices, also draws on the
experience gained since August 2000, good practice guidance developed by
primary care organisations, as well as reflecting developments in NHS
organisational structure, policy and practice since that time.
The new guidance should provide a framework within which general
practices will be able to move from paper-based patient records to
electronic patient records. It will also act as a source of
authoritative guidance for practices, primary care organisations and
other organisations supporting or advising general practices in the
development and use of electronic patient records.
Practices who have obtained
permission from the old Health Authority or from PCTs to use computer
records and dispense with recording consultations in the Lloyd George
record are required to abide by the advice given in this document.
The guidance is available on the Department of Health, England, website
at
www.doh.gov.uk/pricare/computing/.
Medical Consent Release Form
The GPC have reported that they and the BMA have received a number of complaints regarding the new consent form for releasing information from patient records. Their ethics department are concerned that some GPs are refusing to supply the records because of the form and would ask that you please read the comments below.
BMA/Law Society Consent Form
In July a joint BMA/Law Society consent form was launched in response to concerns by GPs that the consent they received from solicitors was frequently inadequate. The new form, available at: http://www.bma.or.uk/ap.nsf/content/bmalawsocform is intended to ensure that doctors can rely on the consent obtained in the knowledge that patients are aware of the extent of disclosure they are authorising. It is not obligatory for solicitors to use this form but it is good practice for them to do so and there are clear advantages for both solicitors and doctors of having an agreed form. As with any new form there are some teething problems that will need to be addressed when it is reviewed. Some GPs have expressed concern, for example, that the form does not request payment before the information is provided to the solicitor and this will be discussed with the Law Society when the form is revised. Some GPs have also expressed concern that the form does not give the option of providing only partial access to the records. In the past the BMA has advised, from an ethical perspective, that a report should be offered instead of access to the records and that access should be limited to those parts of the record that are relevant to the episode in question. Developments in practice, and in case law, however, mean that this is no longer appropriate advice. Court rules allow the person against whom the claim is made to seek disclosure of any documents which may impact on the case. In most cases, the defendant will seek access to the whole record, primarily to assess whether there is anything in the records to indicate that an existing disorder could have contributed to the injury for which the claim is being made. Given that the full medical record is likely to be sought by the defendant, the solicitor acting on behalf of the patient needs to see the whole record in order to advise the client about the chance of a successful outcome ? failure to do so could be considered negligent. The option of agreeing to only partial disclosure is not, therefore, open to patients in most cases and they will need to decide whether to either agree to full disclosure or not pursue their claim. The form is designed to ensure that patients fully understand the implications of giving consent before they give it. This will be discussed with the patient in advance of information being sought from the GP. Whilst the doctor may wish to point out to a particular patient, that the request will involve the disclosure of very sensitive information, it is ultimately for the patient him or herself to decide whether to agree to disclosure and, if not, to discuss this with the solicitor. The GP's role is to ensure that valid consent has been obtained before disclosing the information. Although solicitors will be encouraged to use the form, GPs may continue to receive some requests for information with the consent in a different format. The situation regarding such requests has not changed. Provided the doctor is satisfied that the consent is valid, information must be provided under the terms of the Data Protection Act.
IT
Funding
The first guidance note focusing on IT funding under the new contract has been published. Funding of £17 million has since been identified by the Department of Health to be allocated to PCTs to top up the 50% reimbursement, for minor upgrades and maintenance which have occurred since 1st April 2003, to 100%. The GPC is aware that many PCOs, LMCs and GPs are extremely concerned about this level of funding. The GPC has disputed this figure with the Department of Health which has consequently confirmed that this figure has not been finalised. The GPC will continue to put pressure on the Department of Health to clarify the situation for both PCTs and GPs. In the meantime, the GPC is looking into the historic level of reimbursement for IT, on which the Department of Health is basing its calculations for this funding. A second guidance note on IT funding will be produced in due course to provide further information.
Read codes
The latest set of Read codes will shortly be available on the BMA website. A full set of Read codes, including codes for exception reporting, are scheduled to be available in October. Some GPs have been cleansing their systems by replacing existing codes with the new contract Read codes. The GPC advises GPs that existing codes should not be deleted (except for clinical reasons when the amendment code should be inserted). Deleting codes in this way could have serious medico-legal implications.
Pneumococcal vaccination campaign
The Department of Health has notified the GPC that there has been some confusion concerning the revised Statement of Fees and Allowances for the pneumococcal campaign. The wording "persons aged 80 years and over from 18 August 2003 to 31 March 2004 who have not previously been immunised" has been interpreted to mean that GPs can only immunise those patients from the day they become aged 80 during the period. The Department will be instructing PCTs to make the payment in respect of all patients immunised who are aged 80 or over by 31 March 2004.
HRT and breast cancer
Further to the television and radio news headlines on 8 August regarding the research showing an increased link between taking hormone replacement therapy and developing breast cancer, the Chairman of the GPC wrote to the Chief Medical Officer in England about the appropriate system for cascading such information to GPs in preparation for enquiries from their patients.
Unsurprisingly, the news headlines will have caused considerable worry to thousands of women, many of whom will have immediately sought advice from their GP. In this case, the Lancet's embargo meant that the system for cascading information to GPs could not be triggered until midnight and, on starting morning surgery, most GPs had received no other information than that they had gleaned from the media. This was unsatisfactory for GPs and patients. We have previously agreed that GPs should have such information 48 hours before it becomes public.
Sir Liam Donaldson in his reply set out the background including the Department's need to adhere to the embargo and the efforts they made to ensure advice to patients and doctors, as well as key stakeholders, was published at the same time as the findings of the research, and that the public health link system, which is designed to cascade information to the NHS, was utilised to transmit messages as soon as possible following the embargo.
Further discussions about effective communications will take place at the next meeting with the CMO.
GPs working in community hospitals
Following a resolution passed at this year’s ARM calling on the BMA to make adjustments to its negotiating arrangements for GPs working in community hospitals, the GPC has assumed responsibility for the representation of GP clinical assistants, hospital practitioner grades and GPs working in community hospitals.
We will shortly be writing formally to the Health Departments and the NHS Confederation notifying them of this change and asking them to determine who will have the responsibility on their side. The Office of Manpower Economics (the DDRB secretariat) is also being informed. The NHS Confederation had previously indicated that negotiations on behalf of GPs working in community hospitals could not form part of the negotiations on the new GP contract, but would need to be undertaken directly with the NHS Pay Branch. The GPC intends to pursue the issue as part of the new GMS contract implementation negotiations.
It will be vital to ascertain precisely the number of GPs working in community hospitals and the nature of their pay and terms of conditions. The GPC intends to do this by means of a survey, which will be undertaken shortly.
Dr P Golik
Secretary