DECEMBER 2001 NEWSLETTER

Letter From The Secretary

Dear Colleague

It seems just a few weeks ago that I was sending you seasonal good wishes, how time flies. It has been a turbulent year for the NHS and GPs in particular. However, as this is a time of year when we should focus on goodwill I must just pause to reflect on all those people suffering, directly or indirectly, as a result of the war and terrorism stemming from the events of September 11th. Let us hope that 2002 brings a speedy resolution to conflict and the humanitarian crisis in Afghanistan.

The NHS Reform Bill has been published, received its second reading on November 20 and is now in the committee stages. It complements the Health and Social Care Act, which received Royal Assent on May 12 this year.

The main provisions are for the setting up of Strategic Health Authorities and making the PCTs the main commissioner of NHS services locally.

Local Representative Committees are recognised in the legislation so LMCs will continue to serve a statutory function. They must relate to at least one PCT but may choose to relate to more than one in a configuration to be decided locally. It leaves huge flexibility and will require careful thought to get the configurations right.

The relationship that LMCs will have with SHAs is also catered for in the legislation but is non-specific to allow a variety of solutions. When the Chief Executives have been appointed all will become clearer. The 4 county GPAC may well be a vehicle to deliver an interface but of course without Northamptonshire which is going to have allegiances with Trent.

CHI is given greater powers. As well as having a remit to investigate failing practices it will have the right, along with patients, to enter and inspect premises of GPs, or indeed any privately owned premises, that provide NHS services. Details of the Bill and a summary of the proposals are available on the DOH and GPC websites respectively. www.doh.gov.uk and www.bma.org.uk/.

Both counties have had successful AGMs. John Chisholm visiting Bucks and Ian Bogle coming to Berks. Both meetings were well attended enjoying very differing presentations. However, the message is clear that government, through the NHS Plan and new legislation, is tightening its grip on our Profession. The contract negotiations with the NHS Confederation are being joined in a spirit of co-operation but the outcome is by no means a fait accompli. In April next year the GPC will present to the Profession the outcome of the negotiations for approval, or not, as the case may be. GPs made it clear at the meetings that providing a high standard of care was their priority and that much needed to be done to enable us to deliver and that less regulation, rather than more, is needed. This does not mean that should be without the quite proper accountability that government demands but only flexibility will allow delivery of services in a cash limited but open ended service. It was also clear that we have limits and they are clearly in sight. Government, and PCOs as their agents, ignore this at their peril.

The LMC Secretary's Conference was held at BMA House on November 8th. It was attended by over 100 Secretaries or members of their team. LMCs function from a very part-time organisation run by a GP one or two sessions a week to a full-time Secretariat similar to our own. No matter what the size of the organisation the messages at the conference were similar. It is imperative to engage with PCTs and ensure representatives on Local LMCs have access to training to prepare themselves for possible local negotiations. The need for a network to manage information emerged so that LMCs all over the country can exchange information rapidly, gain from best practice and avoid pitfalls. Further work is underway to establish such a network.

More in the New Year. With best wishes and the seasons greetings to all of you and yours from all of us at the Secretariat.

Local LMC Sub-Committees

Work goes on apace to form local Sub-Committees of the LMC to relate to PCOs.

Agreement has been made in principle with all Chief Executives and it is becoming increasingly clear that these local groups, now supported in the draft legislation, will be critical vehicles for taking GP views to management.

Events are also showing that PCOs either do not understand fully their statutory obligation to consult with LMCs or are not doing so on purpose. It depends whether you support the conspiracy or cock up theory. Take your pick!

The Secretariat depends on you to let us know when you think GPs are not being treated fairly and the new groups will take your legitimate concerns rapidly through to the PCO.

We have been having meetings locally to try and inform GPs what is happening and when one is held in your area please try to attend and, if you are unable to do so, ask another member of your Practice. Whilst everyone believes this concept to be good we will need GPs in some areas, where there is under-representation, to be prepared to do the work (honorarium payable!), so please think about it. To plagiarise JFK, "think not about what your colleagues can do for you but what you can do for your colleagues".

By the next Newsletter the inaugural meetings of all the Sub-Committees will have been held and we will report back.

The following dates have already been agreed:

• Friday, 14 December 2001 - Milton Keynes
• Tuesday, 22 January 2002 - Reading
• Wednesday, 23 January 2002 - Aylesbury

We confidently expect to hold Slough's first meeting during January 2002.

Below follows a list of agenda items in which the new groups will have an interest:

Contractual Issues

• PMS
• GMS
• The supplementary list.

GMS Infrastructure Funding

• PCIP
• SaFF
• LDS
• Development Funds
• Staff
• Premises
• Computers.

OOH

• OOHDF
• OOH Quality payments
• SLAs.

Commissioning of Services

• Workforce/Manpower
• Community and Hospital Services
• Specialist GP services
• Shifting of services from Secondary to Primary Care
• Service provision for the care of violent patients.

Professional Issues

• Performance
• Complaints Management
• Appraisal
• Revalidation
• The suspended GP
• Occupational Health Scheme.

General Issues

• Highlighting concerns in relation to any NHS activity which impinges on the GP profession
• Representing the view of GPs in relation to joint working with Social Services, Local Government and Voluntary Agencies
• Consulting with all NHS Trusts on behalf of GPs.

Emergency Capacity Management System (ECMS)

I am sure you have all heard about ECMS (Emergency Capacity Management System). This is a system developed in Surrey to manage the flow of emergency admissions to Acute Trusts to try and ensure appropriate use of beds and even flow thus improving the service to patients.

The idea is good but the way the pilot, as it is to be, was worked up and the proposed implementation plan introduced was simply appalling. There had been no relevant consultation with GPs whatsoever although the idea had been floating around since the spring.

The system is to be in the whole SHA area covering the three counties and at first glance it seemed possible that there might be inappropriate admissions of patients to distance hospitals with the knock on difficulties of repatriation on discharge and inconvenience to families. The greatest anxiety perhaps was around the jeopardy to continuity of care. The Surrey experience, which is valued by GPs in the West of that county and less so by GPs in the East cannot necessarily be transposed to Bucks/Oxon/Berks.

When the news about ECMS broke informally many GPs in both counties became very exercised by the proposals and the LMC and others made strong representations to Berks HA, which is leading, and those with the task of implementation came to the LMC.

Apologies were offered and accepted for the inept handling of the issue and reassurances given that although the ECMS infrastructure for information collection about bedstates will go live as planned on 3 December, the full programme is to be delayed until a full scoping exercise has been undertaken. GPs and LMCs will be involved with others in this exercise.

The LMC is confident that, after the necessary alterations to the original proposals have been incorporated, the ECMS may well be a useful tool in providing a smoother and more efficient method for emergency admissions.

The Committee was reassured that there will always be a clinical over-ride allowing a GP to bypass the system should they feel it necessary. This also operates in Surrey but is apparently infrequently used.

You will all be receiving letters about the system. Should you wish the LMC to take your comments forward please contact the office.

Report From Jane Solomon

The Secretariat of the LMC has recently had sight of the proposed Read Notes Summarisation project pack which is a project currently being undertaken in the Vale of Aylesbury and is intended to be rolled out in both the Wycombe and Chiltern and South Bucks area.

It is yet another 'good idea' that will have a profound effect on General Practice workload and for which participating practices are being paid a derisory amount of money. In the first instance practices will be paid, in advance, 95p per notes summarised for the first 500 notes these will then be submitted for audit using a 'traffic light' system. Once these have been checked and successfully passed the control system, the practice will be expected to summarise a further 1000 notes with payment withheld until they are completed.

Summarisation is expected to be undertaken within the practice by a trained member of staff. Some practices may wish to use suitably qualified clinical staff and others will use administrative staff.

Whichever personnel they use it will:

1 Take existing staff away from their usual duties
2 Require the practice to take on additional staff to meet the workload
3 Incur the practice in additional expense.

All these schemes, however laudable, need to be properly resourced. If practices are to be only paid 95p per set of notes, employing someone, on even the minimum wage, would result in the practice being out of pocket and lead to further erosion of practice profits. General Practice cannot and must not allow this to go on happening. If there is no money forthcoming to adequately resource such schemes then there is no reason whatsoever that GPs should carry them out.

The time has come to take a stand.

NEWS

Guidance for Solicitors on Advising Accident Victims to Visit GPs in Personal Injury Cases

The Cabinet Office's recent Guidance on the above has been included as in insert in this edition of the Newsletter for information.

BMA's Junior Members Forum 2002

The Secretariat has been invited to submit nominations to the above Forum, which will be held in Aberdeen on 13 and 14 April 2002 .

The BMA's poster advertising the Forum is included as an insert in the Newsletter.

Further details are available from the BMA, or the Secretariat Office, on request.

NB: The deadline for receipt of nominations by the BMA is Friday, 18 January 2002.

Thames Valley Primary Care Agency

The Secretary met with others at the TVPCA to rationalise their procedures bringing Oxford and Berks into one system.

The suggestions agreed will not affect the cash flow of any GPs and largely it was a matter of Oxford moving to methods currently used in Berkshire.

There are proposals for PMS Practices to include notional rent to be in the contract price and sickness/confinement payments to be claimed by PCTs as an additional allocation. All PMS practices will be consulted on this proposal before it is instituted.

The only area where Berks GPs may be affected is around the Quality payment. This is currently only measured against higher target payments and none of the other quality markers although a set of protocols was agreed in 1999 between the LMC and the Health Authority.

This may not conform to the necessary audit requirements. The Oxford and Berkshire protocols will need to be compared and if appropriate will be rationalised and taken to the LMC for consideration.

The Oxford experience is that there is more discretion using the protocol and GPs missing one target on one occasion may not forfeit payment but each case will be considered on its merits set against the agreed protocol.

Violence

All GPs in Berkshire should have received a letter from the Secretariat concerning this difficult issue.
Everyone will have noticed the Secretary of State's edict about Zero Tolerance of violence and abuse in the NHS.

The LMC wishes to reinforce its advice to think very carefully before entering into the contract on offer.

Quotable quotes from NHS managers in West Berkshire on violence:

"Why shouldn't GPs use their incentive monies to provide secure premises?"

"Why is all this effort being spent on the issue of violence - there are other priorities you know?"

If managers get to read the Newsletter I wonder if they will recognise themselves! Certainly it shows they work in protected environments on limited access premises - a few days in a busy general practice, or an A & E perhaps, should be required preparation for NHS management.

The Local Modernisation Reviews in both counties have Mental Health and Access as their priorities. Surely that should lead someone in high places to put the two together and come up with a solution to Violent Patients.

So much for joined up thinking!

A Note To Practice Managers

Newsletter Distribution

If your practice would be interested in receiving future editions of the Newsletter by email (you would need to have 'Publisher' software to be able to open them in this format although, alternatively, they could be sent as a plain text file in 'Word'), rather than by post, please email Pauline Green at:

pauline.green@bblmc.co.uk

Email Communications

The Secretariat is keen to enhance the speed of its communication with, and the range of services on offer to, its constituents and is currently exploring the possibility of extending its use of emails.

To this end, we would be very grateful if you could please email your surgery's current email address to Pauline Green at:
pauline.green@bblmc.co.uk

Thank you.

GPC Slot

These views are a personal expression and not necessarily shared by the LMC

The GPC has issued a list of its aims for the New Contract:

• Pay must be part of the answer to recruiting and retaining GPs
• The core contract (and any future core contracts) must be nationally negotiated with the GPC at UK level, with local flexibility
• Adequate resources must be made available to enable a high quality of general medical care to be made available to all those in need, without compromising the wellbeing and health of GPs
• GPs' time must not be regarded as infinitely elastic - proposals must ensure that the workload of individuals is at a level consistent with the safety and wellbeing of both patient and practitioner
• Of the range of activities undertaken by a GP, the primary diagnosis and treatment of illness must be paramount - Government objectives and priorities must not take priority over the care of patients who are ill or believe they are ill
• The focus must be on delivering a high quality service to individual patients - it must be recognised that the most valued resource is a skilled primary care workforce
• Proposals must reward and recognise skills, responsibilities, job weight and job volume
• Proposals must be consistent with the promotion of family-friendly practice
• The diverse nature of the GP population and the consequent variations in aspiration and need must be recognised
• The new contract must maximise the role of the GP and the role of other primary care workers
• The gatekeeper role of the clinical generalist must be strengthened
• The contract must promote equity for and prevent discrimination against GPs.

GPs will differ as to which of these aims they regard as the most important. Our pay has fallen steadily in comparison with professions of similar standing. In Berkshire and Buckinghamshire the cost of housing of the type in which newly-trained GPs might reasonable expect to live is now beyond their reach, which in part explains why it is so difficult to fill empty posts.

Workload is a major issue for most GPs, and in particular the intensity with which we are now expected to work. We are able to offer far more worthwhile interventions than was the case just a few years ago - for example, the care of coronary heart disease and diabetes have been transformed recently - but are still expected to do so within absurdly short consultations to which patients bring increasing numbers of separate problems for our attention "whilst I'm here, doctor".

I believe that the need to recognise the "variations in aspiration and need" of GPs, as expressed in the fourth bullet point from the end, is also vital. I have detected little optimism amongst fellow GPs that the New Contract will be much of an improvement on the one we have at the moment. There is a real risk that a significant number of GPs will conclude that life as a NHS GP is set to get a lot worse and will leave early.

At present, because of the virtual monopoly on general practice that the NHS exerts, GPs are effectively offered a stark choice. They can either be a GP within the NHS or they can stop being a GP altogether.

In the future, this must change. GPs should be able to do what dentists have always been able to do, maintaining a NHS list of manageable size whilst also serving larger lists of non-NHS patients than currently. The present system of allocation of patients to GPs by health authorities - even if the GP's list is "closed" - prevents this. If there are not enough NHS GPs in an area, the health authority still just piles on the patients to the GPs' lists. If GPs were able to set their NHS lists at a maximum size of their choosing, with better-off patients in excess of that number having to register privately, GPs would be able to cope far better. The extra patients would bring in more income, allowing GPs to employ non-principals far more readily than at present. GPs would also be able to adjust their working patterns so that income could be maintained whilst work intensity reduced. Twenty-minute appointments would be much more bearable than eight minute ones. Burn-out would reduce, retention would improve. Recruitment would become easier again. The "one size fits all" NHS is not just bad for patients. It damages general practice too.

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@btopenworld.com

CHRISTMAS OPENING HOURS

Please note that the Secretariat Office will be manned as follows over the Christmas and New Year period:

 24 December: 9.00 am - 12.00 pm
27 December: 9.00 am - 12.00 pm
28 December: 9.00 am - 12.00 pm
31 December: 9.00 am - 12.00 pm
02 - 04 January: Normal opening hours.
 

NB:

The Secretary's mobile number will be available on our answerphone for use should an emergency occur outside these hours.
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:
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jane.solomon@bblmc.co.uk
pauline.green@bblmc.co.uk
linda.butler@bblmc.co.uk
Web site:
www.bblmc.co.uk
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