NEWSLETTER SEPTEMBER 2004
Quality and Outcomes Framework Guidance
Confidentiality and Disclosure of Information
Enhanced Criminal Records Bureau Disclosures
New Contract - Local Issues
We recently held a meeting with PCT Representatives at which a number of issues were discussed. Among these were:
Enhanced Medical Care to Nursing Homes and Non-appropriate GP Home Visiting
In the original Enhanced Services negotiations it was agreed with PCTs that the above services would either be commissioned or, in the case of non-essential visiting, replaced by an alternative form of care.
The LMC has produced a discussion document which has been widely distributed and which has been well received by PCTs. We are optimistic that the target date of April 2005 remains a realistic timescale.
Enhanced Service Portfolios
The PCTs are looking to monitor the quantity of service provided under these schemes. This will probably involve asking practices to record procedures undertaken during a one month period.
Neo-Natal Checks
Neo-natal examinations were considered as a non-core activity in negotiations around the new GP Contract. It was agreed that they would be performed within service portfolio 2 until arrangements had been made for midwives to take over this role by September 2004.
We understand from PCT colleagues that there have been delays in training these midwives, to a large extent beyond their control. It is anticipated that midwives will be in a position to perform neo-natal checks by January 2005.
The LMC regrets that colleagues are being asked to continue undertaking checks beyond September 2004. It may be of interest to know that a number of colleagues report that they routinely successfully encourage mothers to bring their babies into surgery for this examination to take place rather than doing a domiciliary visit. This certainly would appear to be appropriate in the vast majority of cases.
Minor Surgery
In order to manage financial risk, PCTs have had to place a cap on the minor surgery enhanced service. The LMC advised PCTs that capping should be based on list size rather than numbers of doctors working within a practice. We understand from PCTs that rather than capping on list size they have chosen to mirror the arrangements under the Red Book, or base their limit on historical data. Practices who find themselves reaching their cap should discuss the situation with their PCT who may be in a position to approve further funding.
Smoking Cessation Services
A number of colleagues have expressed concern that they are to be paid for this work on the basis of the number of patients quitting rather than on the amount of work undertaken. Practices have calculated that they could very well be out of pocket if they offer this service under these circumstances.
A meeting has been arranged to take this forward as it seems likely that many practices will cease to offer smoking cessation unless the issue is resolved.
IT/QMAS/Emis Population Manager
A number of practices are concerned about the discrepancy in points calculated by the QMAS reports as opposed to the EMIS population manager module. Apparently the EMIS system calculates the points using data during the preceding 15 months on a rolling basis, whereas QMAS calculations take 15 months prior to 31st March 2005 as the date range for its calculations. Thus during the coming months the QMAS points should increase to match the EMIS calculations.
Items of Service
We have received reports from a number of practices that PCTs are requesting that they recommence sending IOS claims for childhood vaccinations. The PCT representatives at the meeting had no knowledge of this and this practice does not appear to be happening in other parts of the region. Whilst we do have to produce data to support our enhanced service claims, our clinical computer systems are still capable of producing the required reports in an anonymous report. We are seeking more information about these requests.
QOF Visits
The PCTs are about to embark on a series of visits concerning the monitoring of the Quality and Outcomes Framework. This monitoring is essential if practices are to receive Quality and Outcomes funding. The visit this year is likely to be more onerous than future visits as baseline data has to be collected. The PCTs intend that these should be "high trust" "light touch" but they will require evidence of activities undertaken. They have stated that they will not be requesting to look at patient identifiable information. Patient confidentiality should, therefore, not be an issue locally.
It is important to remember that these visits check on progress and are not determining the final point score. PCTs should be able to point out to practices any areas where attention is needed in order to maximise the achievement payment. The QOF should not be about performance management but about resourcing and rewarding good practice.
List Closures
The issue of "open but full" and patient allocations continues to be a problem. The PCTs are trying to draw up a procedure to address this issue. They have produced a paper which suggests a "short closure" of a practice list for specific criteria approved by the PCT. During this time any agreed enhanced services will continue to be commissioned but no new enhanced services will be commissioned. This time will be limited to a minimum of one month and a maximum of three months. We have a number of concerns about this proposal and its workings. It doesn't address the issue of a GPs choice over workload and probably will cause more problems than it solves. We are meeting further with the PCTs to discuss this issue.
Minor Injuries
It was confirmed with PCTs that the treatment of minor injuries is not included in the portfolios of enhanced services.
PMS Issues
The PCTs have been made aware of the GPC's concern regarding changes to PMS contracts as a consequence of the implementation of the New GMS Contract. They have been given copies of the recent GPC publications on this issue.
If you have any comments or suggestions regarding any of the above or other matters concerning the New Contract please raise them with the LMC
Referral Proforma
Our concerns about the proliferation, relevance and frustrations that these cause have again been taken up with the secondary care trusts. Dr Pat Chipping has written to consultant colleagues suggesting that they discuss any proposed proformas with GP colleagues via the Clinical Interface Group so that GPs can have an input into the design and use of these. She has also suggested that where a letter is sent rather than a proforma information should be transferred over to the proforma by the consultant rather than sending the referral back. We are currently working with the trusts on the issues of electronic referrals and the single point of access projects to try to ensure that these schemes are tailored to our needs as well as the requirements of government and secondary care.
Pensions
The GPC has published four new guidance notes on GPs' pensions, following changes arising from the new GMS contract negotiations. These are:
· Focus on pensions: an overview
· Focus on pension flexibilities
· Focus on the dynamising factor
· Focus on superannuation contributions – 2
Copies of these documents have been circulated to practices via email. Together these guidance notes provide a comprehensive coverage of most of the pensions changes arising from the new GMS contract negotiations, but which affect all GPs. There will be one more guidance note in due course - concerning the calculation of superannuable income - once the details have been finalised. The GPC will also produce a Frequently Asked Questions document covering pensions issues, in due course.
We are holding a seminar on Pensions on Tuesday 26th October, 7.30pm at the Moat House Hotel, Festival Park. Dr Andrew Dearden will be the speaker.
IT Issues
QMAS
QMAS is software, which has been developed for the new GMS contract so that practices can assess their achievement under the new contract and estimate prevalence. QMAS will provide a link to the Exeter payment system to enable quality payments to be made.
QMAS is being rolled out and 4839 practices in England have been connected to date. Practices should be aware that the prevalence estimations are likely to fluctuate quite significantly over the coming months. This is because the calculations are dependent on data received from other practices, not just their own. As more practices use QMAS and submit their clinical reports, this will settle down. A Focus on QMAS is currently being prepared.
System Choice
The National Programme for IT (NPfIT) has recently issued some guidance for existing suppliers. The GPC and RCGP have issued a second statement on system choice to remind LMCs and practices of the policy, which has been agreed with NPfIT. The statement is available on the BMA website at: www.bma.org.uk/ap.nsf/Content/gppracsystemchoice0904
Engagement with Local Service Providers (LSPs)
Five Local Service Providers (LSPs) in England have been tasked, by the National Programme for IT (NPfIT), to work at a local level to develop new systems to deliver the NHS Care Record Service and deal with local implementation issues. NPfIT has agreed to engage with GPs at a local level and we encourage LMCs to become involved and have an input in these important developments, which will help shape future general practice IT. The Joint GP IT Committee has agreed terms and conditions (attached), which we expect to be applied a local level. If you are a GPs with an expertise in IT, who wishes to be involved, please contact Rachel Merrett (rmerrett@bma.org.uk)
eGPR
The Joint GP IT Committee of the GPC and RCGP has approved guidelines on completion of electronic GP reports, which are available on the BMA website at: www.bma.org.uk/ap.nsf/Content/GoodPracGPreports0804/$file/GoodPracGuid0904.pdf It is essential that practices refer to these guidelines before using electronic GP reporting systems.
PMS Contracts
The GPC are hearing worrying reports of PCTs using the need to bring PMS agreements into line with the new regulations as an excuse to impose some very unfavourable financial terms. The legal advice from Lockhart's solicitors should help oppose these attempts. PMS agreements only need to be varied to bring them into line with the variations. This advice can be found here This transitional period does not mean that PCTs can do whatever they wish with practice agreements. This point is also covered in the new PMS guidance from the GPC which can be found here
PMS transitional arrangements
PMS contracts must be brought into line with the PMS Agreements Regulations by 30 September. This can be done by agreeing variations to existing contracts, but some PCTs are seeking to impose new block contracts on all PMS practices in their area. The GPC has received reports of some of these block contracts introducing unfavourable new financial terms to agreements, or of attempts to introduce variations to existing agreements to similar effect.
Legal advice on this issue stresses that the GMS and PMS Transitional and Consequential Provisions Order 2004 (SI 2004/865) does not permit a PCT to change a Pilot Scheme Agreement to any extent beyond that necessary to comply with the PMS Agreements Regulations. A PCT cannot simply vary a PMS Agreement simply because it wishes to introduce new financial terms, or reduce existing provisions.
There is no regulatory authority for varying financial arrangements, other than under Article 66 of the GMS and PMS Transitional and Consequential Provisions Order 2004, whereby the Secretary of State can by directions require that a pilot scheme be varied. This is unlikely to be used extensively, as each direction would be a “one-off” and would require detailed Departmental scrutiny.
If practices cannot agree to the relevant changes by 30 September 2004, they should say so and on or after the 1 October 2004, the PCT will be restricted to changing existing Agreements to ensure compliance with the PMS Agreements Regulations.
It is inaccurate for PCTs to state, as several reportedly have, that they cannot continue to make payments unless the necessary variations are made or unless new contracts are signed. Payments under the existing agreement must continue.
The GPC will offer legal advice on block contracts being offered by PCTs to all PMS practices in an area as part of the PMS transitional arrangements.
PMS out-of-hours opt-out price
The centrally recommended method for calculating the out-of-hours opt-out price for PMS practices has been changed. Original advice suggested a fixed sum of £6,000. However, the method now being proposed is to calculate the average national opt-out price per patient in GMS (for 2003/04 - £3.31) and then to apply this to PMS by multiplying it by raw list size. Access the DoH guidance on this at www.dh.gov.uk/assetRoot/04/08/79/43/04087943.doc
New GPC guidance
The GPC has produced new guidance on PMS which is concerned mainly with the changes to PMS resulting from the new GMS contract. It is available on the PMS section (see “guidance”, then “PMS agreements”) of the GPC website at www.bma.org.uk/ap.nsf/Content/__Hub+gpc+pms+gps
The GPC intend to update this guidance regularly and will be happy to receive any suggestions about how it can be expanded or improved. Please send any feedback to John Maingay at jmaingay@bma.org.uk.
Quality and Outcomes Framework Guidance
The Quality and Outcomes Framework guidance has now been revised to include minor amendments and clarifications, and to amend the Read codes. The revised guidance replaces the original version published in Investing in General Practice - Supporting documentation (the blue book). The amended guidance is available on the GPC website at the following location: http://www.bma.org.uk/ap.nsf/Content/QualityOutcomes and can be found here.
The main change is that the revised guidance does not include preferred Read codes. The Read codes have been replaced by the 'Logical Query Indicator Specification' and the 'Dataset and Business Rules'. This was done in order to minimise confusion, to prevent the misconception that there are 'preferred' codes and to recognise the importance of capturing clinical interaction properly. These Read codes are an NHS standard and must be used to enable QOF reporting. These codes will have been added to your system by your supplier. Other minor amendments and further clarification have also been provided for a number of the indicators. A list of amendments can be found on the GPC website at the following location: http://www.bma.org.uk/ap.nsf/Content/Q%26OFrevisions0804
The Statement of Financial Entitlements (SFE) 2004/05 will be updated shortly through amendment directions to reflect any of the amendments that require it. Further information will be issued shortly.
It is not intended that any substantial changes will be made to the QOF before April 2006, other than in exceptional circumstances e.g. where there is a sudden change in the law that would render a particular indicator inappropriate. These changes will be discussed by the Quality and Outcomes Framework expert review group, which is currently being established.
Further information is available in the General Practitioners Committee guidance, Focus on Review of Quality and Outcomes Framework available on the GPC website at the following location: http://www.bma.org.uk/ap.nsf/Content/FocusReviewQ%26OF.
Confidentiality and Disclosure of Information
This Code of Practice sets out guidance on the confidentiality of information held by contractors who provide General Medical Services (GMS), Personal Medical Services (PMS) and Alternative Provider Medical Services (APMS). It also sets out guidance on the provision of contractor-held information to Primary Care Trusts (PCTs), and access by, and disclosure of, that information to PCTs or a person authorised in writing by PCTs. This Code has been developed by the Department of Health in consultation with the General Practitioners Committee (GPC) of the British Medical Association, and other key stakeholders, including representatives from patient bodies. It makes explicit existing legal and ethical obligations of confidentiality, placing them in the context of new primary care contractual arrangements. This document is well worth reading and a copy can be found here
Good Practice Guidelines
The Joint GP IT Committee have recently published good practice guidelines on the completion of electronic GP reports (eGPR). This guidance is available on the GPC and ethics department websites at the following locations: http://www.bma.org.uk/ap.nsf/Content/GoodPracGPreports0804 and http://www.bma.org.uk/ap.nsf/Content/GPR
Please note however, that currently you must be logged into the BMA website to access this information. Therefore I have place this document on the LMC website and can be found here
NHS complaints procedure - the role of the Healthcare commission
The GPC have been advised that from 30 July 2004, the Healthcare Commission will be taking over the second stage of the NHS complaints procedure in England and will begin independently reviewing complaints about the NHS that have not been successfully resolved locally. This replaces the current system of second stage independent review which is organised by NHS trusts.
The aim of the NHS complaints procedure remains that the majority of complaints be resolved by the local NHS organisation or practitioner concerned. However, if a patient remains dissatisfied after they have received a formal response to their complaints, they have the right from 30 July, under the Health and Social Care (Community Health and Standards) Act (2003), to ask for their complaints to be reviewed by the Healthcare Commission. NHS complaints staff must make this right explicit.
Patients, or those acting on their behalf, who need advice on how to make a complaint about the NHS should contact their local Independent Complaints Advisory Service (ICAS) or the Patient Advice and Liaison Service (PALS) located within their local NHS trust.
The new powers of the Healthcare Commission with regard to NHS complaints are not retrospective, and the Healthcare Commission will not, therefore, be able to re-investigate issues that have been the subject of an independent review under the former system or a Health Service Ombudsman's report.
Any accepted request for independent review under the former system must be completed under that system. From 30 July, all new cases for independent review will be directed to the Healthcare Commission. More details about the Healthcare Commission's role in NHS complaints are available at www.healthcarecommission.org.uk.
Enhanced Criminal Records Bureau Disclosures
Enhanced CRB disclosures “catch up” exercise.
On 1 November 2004, PCTs will begin a special “catch up” exercise to obtain enhanced CRB disclosures from all practitioners on performers lists who have not yet been required to provide one.
This exercise had been scheduled to take place before establishment of performers lists but was delayed due to capacity problems at the CRB. The DoH assure us that it has consulted fully with the CRB and both are confident that the exercise can be completed by February 2005.
What it means for the profession is that all GPs who were transferred automatically to the performers list from the previous lists, and who therefore have not so far needed to provide a disclosure, will be asked (by their PCT) to apply for one.
This includes salaried GPs and locums, who participate in the exercise in the same way as contractors. Disclosures are usually required for employers, but in this exercise they are for PCTs. The fact that the majority of GPs have no identifiable employer is therefore not an issue.
An enhanced disclosure is essentially a check with local police force records in addition to checks with the Police National Computer and government department lists. The Chief Constable of the local force decides what information is disclosed. Enhanced disclosures are for those regularly caring for, training, supervising or being in sole charge of children or vulnerable adults.
Clearly, GPs who have recently applied to the performers list, and who therefore have already supplied an enhanced disclosure, do not need to do so again in the course of this exercise.
The intended process is as follows.
· GPs will receive notification of the exercise from their PCT. They will either send a blank application form or ask the GP to contact the CRB for an application form.
· After completing the application form, the GP sends it to the PCT (as the body requiring the disclosure).
· The PCT verifies the identity of the applicant GP, countersigns the application and sends it to the CRB.
· The CRB then sends the applicant the certificate and sends a copy to the PCT. The GP does not need to send his or her copy to the PCT.
The costs of the exercise will be borne by the PCT.
For step two, GPs can access the guidance on completing forms on the disclosure website (www.disclosure.gov.uk). This will help ensure correct completion of forms, and therefore avoid unnecessary delays. They can also contact the CRB application helpline on 0870 9090 844.
PCTs have discretion to begin the exercise sooner than 1 November, so some GPs may receive notification very shortly. The deadline by which the GP must have made the application should be three months from the date of the letter.
If a GP fails to make an application by the deadline, the PCO is under a legal obligation to remove them from the performer lists. However, the DoH is encouraging PCOs to use this sanction only after taking all reasonable steps to identify the cause on non-compliance.
Appraisal Funding
The GPC office has had reports from a number of LMCs that PCTs have recently sent messages to practices about new appraisal funding arrangements.
Colleagues should note that the GPC, the NHS Confederation and the Department of Health have not yet agreed the issue of appraisal funding. In particular, the following two documents need to be agreed between the negotiating parties:
· an amendment to the Statement of Financial Entitlements
· supporting guidance to PCTs in respect of appraisal funding for both GMS and PMS practices.
Until the SFE is amended, colleagues should note that the figure for the Appraisal Premium has not been finalised (as per paragraph 2.4 of the SFE).