CEO Email Update - Feb 2014
Date sent: Saturday 1 February 2014
I am writing this email sitting in my office at the LMC looking out at the dark sky and persistent rain. Thankfully despite the dreadful rain we have not had to endure the flooding that many of you may have been subject too.
With most children being off for half term, the roads are much clearer but I suspect we should spare a thought for those of you who are trying to entertain your children under these circumstances.
At our recent Practice Managers conferences (yes we held 2 in one week to cover the whole patch), we were inspired and humbled by a talk given by Simon Weston OBE, the Welsh Guardsman who was so badly burnt when the Sir Galahad was bombed and destroyed in Bluff Cove during the Falkland War in 1982.
Simon talked about his life from childhood to the present day. For most of us life would have ended following the horrific burns that he suffered. Yet we heard someone talk about the problems he faced, the despair he felt over the weeks and months following the life changing event. He then talked about all the things he been able to achieve and the difficulties and prejudice he has overcome.
The key messages I heard were that life is not always fair, it is unpredictable, bad things happen even to the best people, we have to face up to the challenge and our future is largely in our hands, we have the opportunity not only to influence our futures but to take charge of it.
For a short time his story put all the challenges we face into perspective.
1. Medical Director - Goodbye and Hello
Dr Andrew Mostyn will shortly be leaving the LMC to take up a new challenge in Bangladesh and will be replaced by a Portsmouth GP, Dr Sally Ross.
2. Minimum Practice Income Guarantee (MPIG)
If you are a GMS practice your funding will change over the next 7 years as there is a move to “equitable” funding. MPIG will disappear by 2021, how will this affect your practice?
3. PMS equitable funding and reviews
As with GMS practices PMS contracts will be reviewed and there is a process which has been nationally determined to deliver equity between GMS and PMS. More details below.
4. Partnership changes
The Government will introduce changes to the taxation of partnerships and partners from April 2014. Please see below for more details.
5. Local QoF schemes
What are the implications to the Devon and Cornwall QoF deal and what has happened in Somerset?
6. Business Continuity Plans
What would you do if your practice flooded?
7. Practice Managers
More information about PM supporters and PM appraisals.
8. Practice Nurses
This group of professionals, need to be developed and supported to ensure general practice not only survives but thrives. The LMC has started the ball rolling with some education and training and now we are moving on to appraisals and revalidation.
What are you doing in your practice?
Changes to the taxation of Limited Liability Partnerships (LLPs)
1. Medical Directors – Goodbye and Hello
Goodbye - Dr Andrew Mostyn has been a Medical Director at the LMC for the last 9 years. He started his medical career in the Navy and after a short service commission joined a practice in SE Hampshire. After a couple of years he left the practice to work in the private sector where he gained an MBA. He then worked in Canada for a couple of years before returning to the UK and joining his current practice in Whitely. He was a Medical Director for Health Call before becoming a Medical Advisor for the Health Authority. It was in 2005 when he saw the light and joined the LMC.
In April he is moving to Bangladesh (which is the other side of France I believe!!) to work for the Foreign and Commonwealth Office. I understand their medical services are overstretched, they have lots of rain and floods and somewhat unpredictable weather – so not sure why he is leaving because we have got all that here!
Andrew has helped and supported a large number of GPs over that time and has worked tirelessly on behalf of the profession. His quiet nature, in depth knowledge of the regulations, his ability to analyse a problem and find a positive solution are all attributes we shall miss.
I will personally miss his wisdom and friendship and his ability to keep calm in a crisis – I am sure you will all join me in wishing Andrew and his family good health and happiness for the future.
Hello – Dr Sally Ross, a GP from Portsmouth is joining the LMC in March to replace Andrew. Sally has been a GP in Portsmouth for a number of years and is currently a trainer and an appraiser. In the past she has held many leadership roles. Sally will be a great asset to the organisation and to the wider profession.
2. Minimum Practice Income Guarantee (MPIG)
There is a significant variation in the funding that practices receive. Following the introduction of nGMS in 2004, a significant number of practices would have been subjected to a cut in income if it were not for the introduction of a Correction Factor (CF) and the MPIG.
Over the last 9 years the number of practices who were in receipt of a CF has decreased significantly. We are led to believe that now most GMS practices have either no CF or one which is small in the context of the total funding available.
There are over 4,500 GMS practices in England of which about 2,800 were in receipt of a CF in October 2012, which is when the modelling was undertaken.
Starting in April this year practices in receipt of an MPIG will have this reduced by 1/7 each year for the next 7 years. The money removed will be added to a national pot and then recycled to the global sum (GS) of all practices, so each year the £/patient of the GS will increase as a result of the recycling.
Price per weighted patient
£66.25 (actual amount for global sum equivalent last year)
In must be remembered that between 2013/4 and 2014/5 funding has been transferred from QoF to GS and a number of enhanced services have also been added to the GS.
The process of change has been described as equitable funding but there remain a number of issues with this process:
e. Consulting when English is not a first language
Essential services are funded via the GS, yet we know that in different parts of the country practices are not providing the same level of service.In some areas leg ulcer care, post op removal of sutures, drug monitoring, phlebotomy etc. are funded as a LES in others these are provided by practices and unfunded.Equity can only be delivered if a practice is funded and provision of services is aligned.
Weighted capitation: We know certain factors have an impact on workload and these include:
- Weighting of patient population can mean that practices with a young population can have funding as low as £51 per weighted patient.
We are told that there are 98 practices in England who will have a significant loss of funding.
We are about to start some discussions with the Area Team to try and identify those practices that have the greatest impact.
If your practice has a large MPIG, please can you contact the LMC so that we can gain a greater understanding of the issues and put ourselves in a position to help practices.
3. PMS equitable funding and reviews
£325m of "premium" PMS expenditure has been identified by NHS England as the amount by which PMS expenditure exceeds the equivalent items of GMS expenditure. The premium will reduce to £235m over the seven years to 2021/22 as GMS correction factor funding is phased out and global sum funding increases.
Area teams will have two years from April 2014 to review their local PMS contracts, with the pace of change on the redeployment of funding following the reviews being left to local judgment.
They will invest the premium funding in GP services according to criteria set by NHS England, which are that the investment should:
• reflect joint Area Team/CCG strategic plans for primary care
• secure services or outcomes that go beyond what is expected of core general practice or improve primary care premises
• help reduce health inequalities
• give equality of opportunity to all GP practices
• support fairer distribution of funding at a locality level.
The guidance gives area teams discretion about how the funding should be invested within these criteria.
The GPC’s position is that the premium expenditure should have been redistributed to core GP funding, providing greater certainty for practices and allowing them to invest for the future with greater confidence, for example by employing long-term staff and taking on new partners.
In largely leaving decisions about the process and timescales to area teams, the guidance will create further uncertainty for practices and potentially create further inequity between practices in different areas.
4. Partnership changes
The Government intends to make significant changes to the taxation of partnerships and partners therein from April 2014. The draft Finance Bill 2014 contained further details on the proposals. Under current legislation all partners in an LLP (known as members) are regarded as self employed for tax and NI purposes. The GPC has obtained advice from a leading firm of tax experts and this can be found at Appendix 1.
5. Local QoF schemes
There has been quite a lot of publicity about the agreements about QoF, which have been reached in Devon and Cornwall and Somerset.
The Devon and Cornwall scheme allowed practices to stop working on QoF areas that we be removed next year. The practices in return have to implement the named GP for those aged 75 or more and also the new DES for admissions avoidance.
This seems entirely sensible and many LMCs have met their Area Teams to see if this can be replicated in their area.
The LMC has discussed the matter with the Area Team and they have decided that the timescales are too short to implement this and therefore rejected the option.
Somerset LMC, CCG and Area Team are in the process of developing an alternative to QoF. The intention would be that this could reflect local priorities.
I personally think this is a dangerous route to go down. There are many drawbacks with QoF, some of which have been addressed in the contract changes this year. But the advantage of a national QoF is that it is largely evidence based, has been developed with significant expert involvement and all practices meet the same standards.
A locally agree deal is very dependent on the relationships with the Area Team and the CCG.
My personal view is that we need a national contract with local flexibility. The local flexibility should be delivered by additional funding via local contracts for GMS plus work.
6. Business Continuity Plans
All practices have developed plans to help their organisation in a crisis. The recent floods have resulted in some practices being flooded and having their plans put into place. These practices have told us that the reality of doing this is quite different from the planning.
Can I suggest you think about this in your practice – you arrive in your practice on a Monday and you find your surgery has been flooded and there is no electricity and you are unable to access your computer.
What would you do next? How would you manage your patients on that day and for the next week?
A template business continuity plan is available on our website, for more details click here.
The LMC is receiving lots of questions about this topic, largely because of the national publicity the subject is attracting.
The use of patient data was part of the Health and Social Care Act.
It is quite lawful for the Government to extract data from our clinical systems and use the data in a way that benefits the wider population. The problem is that the practice as the Data Controller may be held responsible if anything goes wrong.
Some practices have considered opting out all patients. Do not do this as you will be breaking the law, as you have not been authorised to undertake this action by your patients.
What can you do protect yourself against a complaint to the Information Commissioner?
Put up an informative poster in your waiting room.
Put information on your practice website.
Add a URL on prescriptions so patients can access information on your website.
If your practice has a Twitter or Facebook account use this to inform patients.
Discuss with your Patient Participation Group.
If you have email addresses or mobile phone numbers of patients on your clinical records – consider sending them information via SMS or email
I would strongly suggest that any information should be accurate and balanced and you should avoid expressing your personal view whether that is pro or anti the initiative.
8. Practice Managers
The LMC is really concerned about the number of practice managers who are leaving. There are many reasons for this but many are saying that the job is becoming impossible to manage.
As I have said repeatedly as GPs we need to support our managers.
The LMC has funded 6 practice manager supporters and this initiative has gained widespread support within Wessex but is also receiving some national attention.
GP appraisal in my view is still a formative process, and if used correctly can be of great value is sharing ideas, peer review and support and stopping a feeling of isolation.
Most Practice Managers undergo an annual appraisal in their practice. This is not an appraisal as GPs would recognise but is more like a performance review.
The LMC has worked with the Thames Valley and Wessex Leadership Academy to develop PM appraisals
So far 6 Practice Managers have been trained, and resources are now available via myLMC in terms of learning logs and multi-source feedback. More info is on the LMC website http://www.wessexlmcs.com/practice_manager_appraisal.html
So for a practice you might consider supporting your practice manager by funding a peer appraisal. There will undoubtedly be benefits to your practice as well as your practice manager.
9. Practice Nurses
GPs have professional bodies that are very supportive to them as individuals and also to the wider profession including the LMC (clearly the most important!) the General Practitioners Committee of the BMA (GPC) and the RCGP.
Practice Nurses do not have a network of support in the same way. Their representative body namely the Royal College of Nursing has never been perceived as being supportive of the branch of practice which works in General Practice.
The LMC although a body whose statutory responsibility is to represent individual GPs and the wider profession and has expanded its role to help, support and represent Practice Managers as well as individual practices.
The LMC recognises that we need to do more to help and support GPs and Practice by doing more for Practice Nurses. We are currently considering what shape and form that help should take.
The LMC has, as part of our Education and Training Department developed a comprehensive training programme for new and established nurses. This ranges from infection control, leg ulcer care, vaccination and immunisation and travel medicine. The LMC arranges an annual Practice Nurse conference and will shortly hold an HCA conference both with Health Education Wessex.
The LMC has been successful in bidding for funds for Practice Nurse training and is looking for innovative ways to support Practice Nurse support and development.
This work is helped by strong links to the Nurse leads in the Wessex and Severn Deanery.
Turning to the future, nurses will follow the model of professional regulation and will be issued with a license to practice and undergo a process know as revalidation, which will include annual peer led appraisals (does this sound familiar). The Nursing and Midwifery Council (NMC) that is the equivalent of the GMC for nurses, have just completed their consultation on the subject.
It seems highly probably that the format for revalidation for nurses will largely follow the doctor model.
The LMC has been working closely with a small group of Practice Nurse, the Appraisal Service in Wessex Deanery to support and develop Practice Nurse Appraisal. The LMC initially arranged a ½ day conference focused on nurse appraisal, initially allowing for 20 – 25 delegates, but due to demand (eventually over 120 nurses attended the training) we had to find a larger venue.
There are now 12 Practice Nurses who are fully trained to provide peer appraisals and our intention is to expand this number.
Some GPs have told me that their nurses currently have annual appraisals and therefore this initiative is unnecessary. I believe that most nurses have an annual performance review led by a Practice Manager and occasionally by a GP. But this is not the same as a peer led appraisal.
We need to encourage nurses to explore their learning needs, reflect more on their clinical work and set some shared goals for the forthcoming year. This should not only be focused on the needs of the individual but should also reflect the needs of the practice and the annual performance review should be used to align these issues.
For the sake of our future we need to develop and improve the quality, experience and skill of this essential part of our workforce.
The LMC has been working with Fourteen Fish to develop myLMC to have resources available for Practice Nurses. There is now a multi-source feedback for Practice Nurses, the Learning Diary is also available and we are working to develop the GP revalidation toolkit to make it more appropriate for Practice Nurses. The toolkit is currently being used by the Nurse Appraisers to test the functionality.
Looking to the future, the LMC is bidding for funding to roll out Practice Nurse appraisals and ensure that Wessex remains a head of the game.
What can practices do?
I would suggest you discuss this with your nurses and support their development along the lines detailed above.
We intend to hold some events in the next few months to explain and promote nurse appraisals as a key component of workforce development
Dr Nigel Watson
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
Hants. SO53 1JB (Registered Office)
Attached file: appendix-1.doc