MARCH 2002 NEWSLETTER

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The Conference of LMCs

The LMC Conference is just around the corner once again. The Conference via your LMC is the yearly opportunity that all GPs have to try and influence policy.

Motions to Conference have to be submitted through LMCs to the GPC office by noon on 29 April. If you have any burning issues you wish to take to Conference please either contact your local LMC rep or fax/email the Medical Secretary at the office. The main Committee, or its Executive, will consider all contributions:

Fax: 01628 481173 or 01628 474731.
Email: christopher.tiarks@bblmc.co.uk .

The New Contract

I refer to the contract negotiations in my letter overleaf. The GPC is holding a special LMC meeting in London on April 19th at which the framework of the new contract will be presented to LMC Chairmen and Secretaries. After this there will be a series of Roadshows across the country where the Negotiators will give presentations to GPs locally.

This is particularly important as the contract negotiations are being staged. That is the pricing is not going to occur before the principles are voted on and accepted by the profession. This is not universally popular as some doctors wish to see the fully priced package before voting.

As the venues identified thus far are not very convenient for our two counties, the Secretariat is arranging a meeting for all GPs in Berks & Bucks to be held in The Vere Suite at Adams Park, Wycombe Wanderers Football Club, High Wycombe, on Tuesday, 21 May 2002.

Dr Laurence Buckman, GPC Negotiator, will be the guest speaker and the meeting will start at 8.00 pm. PGEA has been sought.

The meeting, although about GMS, will be of some interest to PMS practices wishing to decide whether or not their pilots should become permanent.

See the Flyer enclosed with this Newsletter and return your reply slip as soon as possible in order to secure your place.

The Secretary has approached the Oxfordshire LMC Secretary to enquire if Oxfordshire GPs would also be interested in attending the meeting.

The New Local Reference Committees

The new arrangements for representing GPs at a local level are progressing well. It has become clear that the Local Committees need additional members to be a robust voice of GPs locally. In those areas, in both counties, where additional representation is needed we are writing to all GPs. This will be followed up by the present members of each Committee with constituent practices. We have already had people putting themselves forward which is very pleasing.

We must encourage our younger colleagues to pick up the representative reins as the profession moves into difficult times. Future leaders of the profession are out there somewhere.

Welcome To Gillian

We are delighted that Mrs Gillian King joined the Secretariat Team as a part-time Office Assistant on 04 March 2002.

Gillian has already settled in well and provides much needed help to our office secretary.

Letter from the Secretary

Dear Colleague

As the end of the current configuration of Health Authorities approaches so guidance is coming from the centre to PCTs on several issues. Thames Valley comes into being on 1 April and it is yet to be seen how much an influence it will try to exert on the Primary Care Trusts. Inevitably these organisations will feel that they must take the helm in the delivery of FHS although the legislative framework will not be in place until the end of the year.

Two of the hot issues are GP Appraisal and the three-year Implementation Plans for the Carson report on OOH.

GP Appraisal is supported by the profession but only if properly resourced. Nigel Crisp, the CE of the NHS, has recently sent guidance to PCTs directing that all parts of appraisal must be resourced including preparation time, appraisal time, time for possible peer review and reappraisal time. There is the usual 'cop out' however with the caveat that the money available for appraisal has already been allocated in the unified allocation.
GPC has published helpful guidance around what the profession believes is the necessary time to make appraisal a meaningful process:

• Preparation 8 hours (including time for PDP preparation)
• Appraisal Interview 1 ½ hours
• Preparation for follow up appraisal 1 hour
• Possible Follow up appraisal interview ½ hour (as part of the initial process)
• Possible Peer Review 1 hour
• Possible follow up appraisal following peer review 1 hour.

This equals maximum 13 hours and minimum 9 ½ hours. Word has it that the Department does not agree these figures and the final documents are still under negotiation. No one should start taking part in the process until the national guidelines have been agreed and the local funding properly identified.

The Department has sent guidance to PCTs concerning the implementation of the Carson Report on OOH services. Each PCT has to prepare a three-year Implementation Plan. Legislation is not yet in place to change the OOHDF into the OOH Quality payment and the financial implication for GPs' remuneration and the subsequent negotiations with GPC are nowhere near complete. We must not allow over enthusiastic PCTs to assume that the OOHDF is available to them to use in their overall planning. They must still consult with the LMC to agree the mechanism for its distribution.

The contract negotiations must be nearing completion and various snippets of information are reaching the medical press. Bucks LMC in January and Berks LMC in February debated the possible implications for the future set against the background that it is expected that the negotiations will only produce a set of principles rather than a complete package. This would clearly need further work to produce detail. The profession may well be asked to approve the principles and then again the complete package at a later date.

As everyone knows there has been a working party in GPC looking at possible ways that GPs could provide services to patients outside the traditional NHS contract. Many GPs will believe that there are no viable options and some will not ever wish to abandon the principles of the NHS (no matter how far the current labour administration may be distancing itself from them).

Both county LMCs unanimously believe that the GPC should publish the findings of the Special Advisory Group no later than the completed negotiations so that all GPs (especially those who voted yes to the possibility of resignation) may make a reasoned decision. The Chairman of GPC has been sent the views of the two LMCs.

The establishment view is that the publication will prejudice the negotiations and show bad faith. The counterview is that the publication will strengthen the negotiators' hand, as the other side will realise that there are possibilities of GP life outside the NHS. It seems strange to spend a lot of energy researching other strategies and then keeping them covert. Before rejecting a package GPs will wish to know how they may earn a crust and protect their pensions. To deny them the opportunity to soak up the information could be construed as pressure from the negotiating team for them to accept the deal.

The GPC considered the matter at its recent meeting and voted overwhelmingly that they did not wish to see the conclusions of the SAG and thus it will not be available to the profession as a whole at present.

It is becoming clear that the government's targets for PMS will not be reached. The word is that the Department is throwing large sums of growth money at the scheme in order to try and achieve their targets before the contract negotiations are complete.

There are advantages to PMS but these are not universal. The advice is therefore, as before, if you are contemplating entering a PMS contract make sure that it will have identifiable advantages financial or otherwise and that you have a return ticket to your old arrangements in case PMS doesn't deliver the goods for you.

The Secretariat Officers are here to help you through the process should you so wish. Please don't hesitate to contact the office should you need any help or advice.

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
Mrs Gillian King, Office Assistant
Email addresses:
christopher.tiarks@bblmc.co.uk
jane.solomon@bblmc.co.uk
pauline.green@bblmc.co.uk
linda.butler@bblmc.co.uk

Web site: www.bblmc.co.uk [please contact the Office for passwords]

News

• Childminders

Ofsted now has the responsibility of regulation of Childminders. It has negotiated with the BMA what is thought to be a satisfactory mechanism for approval of childminders. While Ofsted is the regulator and not the employer the BMA agreed that it is the applicant or their potential employer that must be responsible for the Fee.

The applicant has to complete a suitably worded questionnaire, which is sent to the GP with a signed consent. The GP is sent a Medical questionnaire, which is assessed by suitably qualified doctors employed by Ofsted.

The BMA has negotiated with Ofsted a fee of £44 as being appropriate. Should there then be the need for access to records then a further fee of up to £50 will become due.

• Problems With Secondary Care

The office is receiving more and more complaints about secondary care provision across both counties. As the responsibility for commissioning the majority of services now lies with PCOs it is important to collect evidence to inform them of gaps in the services they are commissioning. A bundle of evidence is more compelling than the single anecdote.

I am making dossiers for both counties. Please let the office know if you are having problems with secondary care. The dossiers will be passed on to the appropriate commissioning PCT for action.

• Allocation of Patients

As the manpower problem becomes more acute so GPs are increasingly closing their lists. This means that Health Authorities are allocating more patients. The task is becoming more trying for the managers and very irritating for GPs. Many GPs feel that they are being allocated more patients than their neighbours although this probably doesn't happen.

Some staff at the TVPCA have been verbally abused by angry and frustrated GPs to whom they have made allocations. This is of course unacceptable and mustn't happen. Recall the old adage about "not shooting the messenger".

I am meeting with the TVPCA and PCTs in Berkshire to get a fuller understanding of the problem and the current mechanisms and will report back. The LMC will only support a system that is fair and transparent.

• Private Fees

Bucks LMC have asked the Secretary to compile an up-to-date list of suggested fees for private work. The BMA is still not permitted by the Office of Fair Trading to publish lists of recommended fees for private work and it is likely that the LMC would be similarly constrained. However there are some fees negotiated with government bodies, these are available on the BMA website www.bma.org.uk to members only, e.g. Ofsted and the £44 for Childminders. Also the fees paid by insurance companies are a benchmark.

When arriving at a fee level for private services for your practice you must take into account all expenses of your practice infrastructure in addition to the fee for your time.

• Health and Social Care Act Implementation

The LMC Secretary has been involved on your behalf in trying to make the process of implementation as user friendly and unthreatening as possible whilst observing the letter of the law.

In addition to the new supplementary lists all GPs currently on the GMS list (PMS GPs will be similarly affected later in the year) are required to make a declaration about their past in relation to their criminal record and professional conduct and performance. You will also have to sign an undertaking to notify any changes in any of these areas within 7 days.

Great care is going to be taken to preserve confidentiality in dealing with what may be extremely sensitive information. Any information that could possibly affect a doctor's ability to practice will be considered, suitably anonymised, by a panel of people from across the new Thames Valley Health Authority that will make a recommendation to the host PCT which will have the ultimate responsibility for holding the list.

When filling your return if you have anything to declare please give as much detail as possible about any past problems which will allow the panel to take a balanced view taking into account the nature of the problem and the length of time that has elapsed and particular circumstances at the time.

The Act requires all Principals joining the list to make a similar declaration, as do all non-principals. Additionally all GPs joining the list will have references taken out whereas the onus on the authorities to take up the references on non-principals is discretionary. However all GPs employing non-principals will have to take up references on anyone they employ and ensure they are on a supplementary list. The references will have to be taken up yearly.

• References

Many GPs will have their names given to the Primary Care Authorities as referees by non-principals applying to go on the supplementary list. A standardised form has been compiled to cover the points in the legislation. Although the form is not too onerous there are areas where referees will be unable to make a sensible comment. Please just complete the questions you feel able to answer with confidence. The Committee that agreed the format shied away from a brief letter to the current questionnaire, I was in a minority of one that would have preferred a briefer document.

However if you are asked for a reference please remember that your colleague's inclusion on a list and therefore their ability to earn depends on a prompt response.

• Berkshire Four Way Agreement

GPs with experience of treating patients on Methadone replacement treatment sit on the Shared Care Monitoring Group.

The Purple Guidelines recently published by the Group are comprehensive. There are some GPs still prescribing Methadone outside the four way agreement or who have not had the agreed training in this area which is regarded as intermediate care.

There have been one or two tragic cases where GPs acting in good faith have fallen foul of the law when prescribing methadone.

It is recommended that all GPs prescribing Methadone do so within the agreement and undergo the appropriate training.

GPC Slot

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

The GPC has rejected the opinion of both Berkshire and Buckinghamshire LMCs that before there is a ballot on proposals for a new NHS GP contract GPs should see any non-NHS options for the future of general practice that have been identified by the GPC's Special Advisory Group.

At the February meeting of the GPC I explained to the Committee's members that the representatives of GPs in both counties felt that their constituents should be permitted to consider all their options and that asking GPs to vote on a new contract without this information would not only be wrong, it would be patronising. As one GP put it to me "The GPC should treat us like adults". I am sorry that I was unable to sway the GPC on your behalf. GPs in the two counties will now have to decide whether or not to accept the new contract with it not only un-priced (pricing will only occur if the principles of the proposals are accepted by GPs) but also without the chance to see whether non-NHS options would be better for their patients and themselves.

***

GPs have now received two letters about GP appraisal, one from Dr John Chisholm, the Chairman of the GPC, and one from Sir Liam Donaldson, the Chief Medical Officer. Appraisal will become an annual terms of service requirement for GPs from April and the government's intention is that all GMS and PMS principals will have undergone the process by April 2003. Appraisal will be linked ultimately to the process necessary for revalidation by the GMC.

If performed properly, with enough time spent on the process and with GP appraisers who are adequate to the task, appraisal ought to be a positive experience. It would give GPs the time and the opportunity to consider the way they practise, identifying those areas in which they have weaknesses and helping them to formulate plans to rectify these problems.

The GPC has negotiated hard with the Department of Health and has emerged with an agreement that makes it completely clear that if PCTs do not provide adequate funding for appraisal, then GPs are under no obligation to submit themselves to the process.  Furthermore, work on appraisal is to be seen as being instead of GPs' other responsibilities rather than additional to them. Adequate funding means funded locum cover for the whole of appraisal, including preparatory work and all meetings. The Chief Medical Officer's letter calculates that this will mean 4.5 to 6.5 hours of cover for each GP. The GPC calculates that up to 13 hours of cover will be necessary for those GPs who need to do additional post-appraisal work leading to further meetings with their appraiser.

What this means for GPs is that their PCT must pay them for locums employed to cover their absences due to appraisal work. Practices may engage external locums but they are also permitted to cross-cover within their partnership. If an external locum cannot be found, the remaining partners may cover the work and must be paid for it by the PCT. This represents an area of compromise between the GPC and the Government. The ideal situation would have been for GPs to be able to decline to submit to appraisal if a funded locum could not be found by their PCT. The reality is that there are too few locums available. This is why the Department of Health agreed that internal cover should be funded.

PCTs are fully aware of their responsibilities. If PCTs do not fund locums, external or internal, GPs can (and should) refuse to take part in appraisal. PCTs will complain that additional funding has not been made available by the Government for appraisal. Frankly, this is not our problem. Appraisal will be the first big test of the way that PCTs will deal with GPs under any new contractual arrangements if these are accepted by GPs. Any failure by them to deal fairly with GPs on the issue of funding appraisal will bode ill for the future of the NHS GP contract.

It is likely that PCTs will argue that funding cover of practices by the local GP co-op will be sufficient, with all GPs in a practice undertaking appraisal-related work at the same time. I would urge strongly that GPs do not accept such a proposal. Firstly, cover of this type deals only with emergencies. Consultations are simply shifted to other days when the GPs are available. Secondly, for appraisal to be useful it must be individual. To require all GPs in a practice to do work for their appraisals on the same day may suit managers but it is unlikely to suit GPs.

It is vital that GPs do not allow themselves to be bullied into accepting any local variation to the funding arrangements that are less generous than the nationally agreed terms. Similarly, GPs must not agree to an appraisal process that does not allow them enough time to do it properly. Please let either myself or Dr Christopher Tiarks at the LMC know of any pressure from your PCT put on you or colleagues to agree to unacceptable arrangements for appraisal.

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

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