SECRETARIAT NEWSLETTER - AUGUST 2001
Letter from the Secretary
Where are we going?
Life for GPs seems to becoming more complex by the day. Since the election all sorts of different signals have been emerging. The most recent announcement by the Secretary of State that he intends to devolve contract negotiations to the NHS Confederation caught everyone by surprise. There have been several reactions to this ranging from 'a cautious welcome' to 'the moment GPC sits down with the Confederation national negotiation comes to an end'. In any event should this registered charity take up contractual negotiations on behalf of the government, and therefore taxpayer, it seems likely that much more local flexibility is likely to be introduced.
The GPC accepted, at its meeting on 19 July 2001, that negotiations with the NHS Confederation are a fait accompli. Enclosed with this Newsletter is the Chairman's speech setting out the profession's position.
The profession is no clearer to the extent of involvement of the private sector in the provision of health care. The politicians speak mostly of the secondary sector but no doubt if the political imperative gains momentum the private-public partnership is likely to be all embracing and may well fill in the gaps in the NHS Plan that the State is unable to fill.
To compound the confusion we await the legislation in the autumn, which will clarify the role of the much heralded new Strategic Health Authorities, and define what and how functions are devolved to Primary Care Organisations.
You will have seen much in the comics about the consequences of resignation from the NHS of significant numbers of GPs. There will always be a need for Primary Care physicians with all the special skills that only you can provide. No matter how much may be devolved to other health care professionals there will remain that foundation of diagnostic skill with an overview of management that is unique to your training and experience.
It is against this backdrop that new contractual negotiations will be taking place and GPs will be deciding whether to jump the GMS ship and seek refuge in the fourth wave of PMS pilots. In this Newsletter I write further about SHAs, the future of representation of GPs and how local negotiations may develop.
SHAs
Just when we all thought that the configuration of the new SHAs had been settled the LMCs received a consultation document, with a turn around time of 17 days, suggesting three possible configurations affecting our two counties. Word has it that a three county SHA of Bucks/Berks/Oxon is what region has settled upon. However the three C/E of the three counties have proposed the following options for consideration:
1. Bucks/Berks/Oxon (1 SHA)
2. Bucks and Oxon, Berks alone (2 SHAs), geographic horizontal split
3. West Berks/Oxon, East Berks/Bucks (2 SHAs), geographic vertical split.
When considering the three possible configurations the consultees were asked to take into account the following factors:
- Patient Flow
- Clinical networks (with an emphasis on cancer treatment)
- Coterminosity
- Sustainability
- Span
- Geography.
Berkshire LMC had the opportunity of discussing the options. Bucks, however, because of timing has not been able to do so; their Executive has individually examined the configurations.
Whilst no single configuration wins on all the six criteria the overwhelming body of opinion supports BOB, with the vertical split coming second and virtually no support for the horizontal split leaving Berks on its own.
Liaison with Oxfordshire now is a pressing matter for the LMC to ensure robust representative structures to meet the new challenges.
The LMC of the Future
With so much uncertainty hanging over General Practitioners the LMC is trying to establish a relevant and stable structure to meet all possible challenges. When planning for the future the Committees need to take into account the following factors:
- New Strategic Health Authorities
- How to relate to PCTs
- How best to serve the interests of all the emerging different contractual arrangements
- Preparation for local negotiation if the national negotiating structure is undermined.
Whilst the countywide Committee in current circumstance is crucial in providing an overview of opinion; the autonomy of PCTs with their likely expanding role with the transfer of FHS responsibilities from HAs, demands local consultation processes dealing with local issues.
Both counties attach great importance on the ability to have a countywide view on important matters but also recognise the need for local consultation. The Secretariat is going out to consultation with all the PCOs in both counties with a suggestion of setting up local Sub-Committees of each LMC to advise on statutory and contractual matters.
The county LMC will take an interest not only in the activities of the smaller groups which will be accountable to it, but also in matters of a medico political nature which affect the profession as a whole such as revalidation and performance.
The county LMC will also have to engage in concert with which other LMCs are under the umbrella of the new SHA whatever its configuration.
The new Health Act expected in the Autumn will no doubt spell out much more about the future representative structures open to GPs when dealing with the ever-changing management structure within the NHS. The role of the new SHAs as yet to be defined is likely to include such roles as approving OOH organisations notwithstanding PCTs are likely to hold the Service Level Agreements.
Should the LMC be central to future local negotiating structures, in the event of national negotiations taking a diminishing role, the issue of trade union status will have to be scrutinised carefully as the protection in this area currently lies with the BMA.
The dates of the AGMs of both LMCs are in this Newsletter. Please try and attend to listen to the two high profile speakers and let us know whether the proposals for the LMCs of the future are relevant to your needs.
GP Registrars' Annual Conference
A one day Conference to be held at BMA House, London, on Saturday, 22 September 2001.
BERKSHIRE & BUCKINGHAMSHIRE NEWS
Berkshire
Following an Independent Review Panel one of the recommendations to the HA was that the LMC should assist the Authority in reminding GPs of their responsibilities towards refugees. HSC 1999/018, paragraph 27 states:
"A refugee given leave to remain in the UK should be regarded as ordinarily resident. A refugee who is in the UK awaiting the result of his or her application to remain in this country should also be regarded as ordinarily resident" and therefore both categories of person are entitled to NHS care.
- Ex-Pats
A constituent brought to the Committee the problem of patients who spend the bulk of their time abroad and come back to the UK for treatments and prescriptions.
Only people who are normally resident in the UK are entitled to free NHS care. The exception to this is EU residents that are in possession of the appropriate form. All other patients should be treated on a private basis save for the provision of emergency and immediately necessary treatment which you must provide to all comers.
A GP is entitled, should they wish to do so, to register any person who comes into their surgery, either as a temporary resident or as a resident. This does not necessarily entitle people to free secondary care and the GP should warn patients of this. GPs should remember that they should only issue prescriptions for their patients for the duration of their residency in the UK and, apart from holidays, not for travel abroad.
However, if a patient is on your List you must give treatment and prescriptions within the bounds of your practice policy. It is not up to you to police whether people are cheating the system or not.
- July LMC Meeting
The last LMC meeting had three presentations; two concerning Performance Indicators and one about Electronic Patient Records. One of the Performance Indicators presentations was concerning prescribing indicators comparing the various PCOs. The figures were interesting and well received by the Committee. Clearly this sort of exercise can be used positively to influence clinical performance, and is likely to figure highly among the tolls for controlling cost particularly as Prescribing is the single largest drain on NHS resources in Primary Care.
- Electronic Patient Records
Paperless practice is now becoming more widespread since terms of service changes were introduced in October 2000. However there are various criteria that must be fulfilled:
- Permission is required from the Health Authority
- Your system must either be RFA4 or RFA99 accredited.
- Must be upgraded to RFA99 within six months
- You must have suitable security (fireproof safes for backups)
- You must comply with the "Good Practice Guidelines for General Practice Electronic Patient Records" available on www.doh.uk/gpepr/guidelines.pdf.
If you need further help contact Dave Aston at the Health Authority.
- Annual General Meeting
ANNUAL GENERAL MEETING
Tuesday, 06 November 2001
7.30 pm, Postgraduate Centre, Royal Berkshire Hospital, Reading.
Guest Speaker: Dr Ian Bogle.
Buckinghamshire
- Aylesbury Vale Housing Issues
The Secretary met with Aylesbury Vale District Council Housing Department to clarify their policy on Housing Applications and Medical Evidence. The Department are going to send a letter to all AVDC practices spelling out their current policy. They have made, at the suggestion of the LMC, one or two alterations to their policy, which will clarify the system for the clients and make the GPs' contribution more meaningful. Unfortunately there are still likely to be problems around evidence for application for 'transfers' the cost of which rests with the client/patient.
The cost for the provision of evidence on 'vulnerability of the homeless' and 'overriding medical priority' is borne by the Council.
- LMC
Following a broad debate the Committee has agreed in principle to develop local Sub-Committees to relate to the PCOs. This is in keeping with other LMCs across the UK. The Secretariat will be going to consultation with the PCOs as to how best to organise business. This will run in parallel to adjusting the Constitution to allow for changes that will occur when Strategic Health Authorities occur in April 2002.
In 2003 Regional Offices will disappear to be replaced by a handful of Chief Executives to oversee the functioning of SHAs across England. Public Health will continue to be overseen on the current regional basis.
The shape of the representative structure will be clearer after the publication of the next Health Bill in the Autumn.
- Annual General Meeting
ANNUAL GENERAL MEETING
Wednesday, 17 October 2001
7.30 pm, Floyd Auditorium, Stoke Mandeville Hospital, Aylesbury.
Guest Speaker: Dr John Chisholm.
GPC Slot
These views are a personal expression and not necessarily shared by the LMC
At its meeting on 19 July the GPC voted to enter into negotiations over a new contract with the NHS Confederation. One GPC member voted against. I abstained, one of a handful of members to do so.
The vote in favour of negotiating with the NHS Confederation was not a ringing endorsement. However, most members of the Committee took the view that Milburn, having announced his decision to delegate responsibility for negotiations to the NHS Confederation very publicly, was not likely to be swayed by the GPC voting against this. They reasoned that if we did so, talks would stall.
This may well have been the case and it is important that this does not happen. However, I could not in all conscience vote for a move that lowers the status of GPs in their relationship with the government, especially as Milburn's decision was an act of expedient political cowardice.
The Secretary of State realised that he was between a rock and a hard place, with the Treasury on one side and GPs on the other. He could see that it will become increasingly obvious that the new contract demanded by GPs will be costly. A quality service with GPs able to provide consultations of an acceptable length to their patients is going to cost a great deal. Paying for GPs to spend time on appraisal and revalidation, which the GPC will insist upon, will require a great deal of money. Paying GPs properly, to improve recruitment and retention, will be far from cheap. Milburn knows that he will not be able to get the Treasury to swallow this.
He also knows that the profession will not accept a contract which is simply a slightly tarted up version of the current one. In GPs he is dealing with a sophisticated group who will be able to analyse a proposal quickly and effectively to determine whether or not it will bring the benefits which he (or the NHS Confederation) promises. GPs are not going to have the wool pulled over their eyes, especially when it comes to workload issues.
Milburn knew that he cannot deliver. The Treasury simply will not accept an increase in funding which is significantly and sufficiently above the miserable £6.50 per head of population per month that the state pays currently. So he side-stepped, and in a move of breath-taking cynicism made a fall-guy out of the NHS Confederation. One almost feels sorry for them.
Membership of the NHS Confederation is open to NHS Trusts and Health Authorities. It is predominantly a secondary care organisation although an increasing number of PCTs are joining. It is led by Stephen Thornton, a man who seems to have little love for doctors in general and GPs in particular and no understanding of the realities of primary care. When the DDRB was collecting evidence for the latest pay award the Confederation said that PMS GPs should get a pay rise, GMS GPs should not.
Although John Chisholm, the chairman of the GPC, has been upbeat about the involvement of the NHS Confederation, I do not believe that its involvement brings any advantages to GPs. The NHS Confederation negotiators will have to check back with Department of Health officials repeatedly, which will slow the process and add another layer between GPs and the only really important department in the whole process, the Treasury. Milburn's move also attempts to alter our relationship with the NHS, moving us more towards the position of employees and placing the Confederation in the position of employer. The press releases from the government and the Confederation made this quite clear. This is no accident. The government dislikes the power that independent contractor status gives us and takes every opportunity to reduce it.
Negotiations will go ahead. I believe that Christopher Tiarks, our very experienced LMC Secretary, was correct when he warned both LMCs that GPs should begin now to think about how they might organise their practices in a post-NHS world. GPs should not be anxious about this eventuality. Many GPs who spend a bit of time working out the sums and thinking about the advantages to both patients and doctors of GPs escaping political control will ask the question "Why didn't we all resign from the NHS years ago?"
The GPC negotiators have also set up a Special Advisory Group to help create systems which will allow GPs who resign from the NHS to continue to provide medical care to their patients.
My own suggestion for a new contract "The Guernsey Option", has been referred to the Special Advisory Group. Although it is a proposal for a new NHS Contract it will be relevant to the working of the Group as it advocates the introduction into the UK of the system which exists on Guernsey. This is an insurance-based private system in which the government pays for the health care of the poor. GPs on Guernsey have more time with their patients, more job satisfaction and earn more. GPs wishing to read "The Guernsey Option" can find it at http://www.schin.ncl.ac.uk/GPUK/UKMed3/goregix.htm.
Contact your GPC representative about any general practice matter that you want raised there:
Dr Jonathan Reggler, The Doctors' House, Victoria Road, Marlow SL7 1DN
Work: 01628 484666 Fax: 01628 891206 Home: 01494 529839 Mobile: 07855 370970
Email Jonathan.Reggler@ukgateway.net
Your Secretariat Team
Dr Christopher Tiarks, Medical Secretary
Ms Jane Solomon, Director of Development & Liaison
Mrs Pauline Green, Administration & Information Manager
Miss Linda Butler, Secretary
Email addresses:
christopher.tiarks@bblmc.co.uk
Website:
www.bblmc.co.uk [please contact the Office for passwords]
Documents Available from the Secretariat Office or GPC Website
- The Mental Health Act 1983 - Guidance for GPs
- A Proposed Generic Scheme for Approving Paperless Practice - Guidance for GPs
- GP Registrars' View on their Training and Job Satisfaction - Results from the BMA cohort study of 1995 medical graduates.
Thank You
Our thanks go to Lloyds TSB Bank for their continuing sponsorship of the production costs of these Newsletters.
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