CEO Email Update - April 2014
Date sent: Thursday 10 April 2014
I would like to welcome Dr Sally Ross who has joined the LMC as a Medical Director replacing Dr Andrew Mostyn who has left to become the Senior Medical Officer in South East Asia working for the Foreign and Commonwealth Office.
Sally is a GP in Portsmouth and has lots of experience as a GP, appraiser, trainer and more widely in leadership. I am sure she will enhance our current team and help us to deliver a service to you which is responsive, focused and of high quality.
I would also like to welcome the GPs and Practice Managers of Bath and NE Somerset (BANES) who have joined Wessex LMCs. The change has been precipitated by the shared agenda based around both hospital care (Royal United Hospital Bath, used by Wilshire GPs) and Area Team which covers BANES, Wilshire and Swindon.
Wiltshire LMC will be renamed BANES, Swindon and Wiltshire LMC.
1. General practice in crisis or an opportunity?
2. Integrated Care Teams
3. Changes to the Contract for 2014 - MPIG and PMS
4. Should all awards go to hospitals?
5. Coming Soon – New LMC Website – watch this space!!!
6. PSA is it a good screening test?
7. Revised guidance on the unplanned admissions enhanced service is now available
1. General Practice in crisis or is this an opportunity?
I think we have reached the point that no one could deny that we are facing a real problem with recruitment and retention of GPs and that general practice is going through some really tough times.
The article below is written by a conservative academic who is not unsympathetic to our plight!
What needs to happen to make general practice a great place to work once again?
To me this is the key question that we need to address nationally, regionally, locally and within our practice.
What is it about the job that has change so much?
Below are some of the issues you have shared with us:
- Workload, has increased significantly such that it now is overwhelming, longer working days are a direct result of this.
- Loss of control, you sit in your room and it seems that not only are you bombarded with blood results, hospital letters, QoF but also many others want something from you and rather than leading the primary care team you are its servant.
- Complexity, there is no doubt that within a generation, general practice has moved form a speciality where every GP knows enough about every specialist area that they could manage a surgery with little need to seek help and advice in their practice. Whereas today the generalist role of the GP is increasingly challenged and it is difficult to obtain and retain the skills in all areas. Just think of the change in the last 20 years in terms of diabetic care and medication.
- Loss of team, in many areas community teams have developed their roles and they have been integrated with other services but largely been pulled further and further away from general practice and rather than supporting GPs to deliver community based care they provide a parallel service.
- Redefining roles and services, it seems that every service is under pressure and the only way to survive is to review the service and then reduce demand by restricting the numbers seen by making entry into the service more difficult and discharging people earlier. The only service that seems unable to do this, and picks up the work of those who fail to get a service or are discharged is general practice.
- Negative mood, there is so much doom and gloom around amongst GPs. This is understandable but does not help in recruiting and retaining the next generation of GPs.
- Funding and pensions, it becomes harder to recruit and retain partners when a locum or a salaried GP can potentially earn more than a partner in the same practice. With rising demand and patient numbers practices need additional resources yet we are receiving a smaller % of the NHS budget now than we did 10 year ago. NHS pensions are still very good when compared to private pension, so many GPs in there mid to late 50s are looking at their current income and the comparing this with what they could receive via their pension and the decision becomes overwhelming for some that retirement is the obvious option. Many of these GPs still enjoy seeing patients but have been worn down by the workload and bureaucracy and the sheer hassle of the everyday life of a working GP.
All of this in probably stating the obvious to many of you and I apologise for starting my email off with such a negative description of the current state of affairs. A number of GPs and Practice Managers have said to me recently that this cannot go on much longer as the impact is being felt by an increasing number of practices which is being seen directly in the difficulty or failure to recruit new partners.
The Government strategy for general practice includes a commitment to train more GPs, yet recently the national recruitment programme has been finding it more difficult year on year to recruit GP trainees. This year has been the worse for several years and rather than increased numbers the number of new GP trainees may in fact fall.
It would be easy to be consumed by self pity and feel that everything is conspiring against us and hence the overwhelming negative mood there is in general practice (that coupled with workload is why general practice has become an unattractive career option for younger doctors) but lets look more positively to the future and with any challenge or threat comes opportunity which we need to grasp.
There is a lot going on locally, regionally and nationally and we need to take these the opportunities and where necessary this may require some fundamental change.
Positive culture: I still believe that general practice is a great career choice and the variety, independence and rewards of personal holistic care remain as really positive benefits of this choice. If I started my career again in medicine I would still chose general practice.
I am the Senior Partner in a large practice in the New Forest and so witness first hand many of the issues you do.
The quality and commitment of GPs and Practices (including practice managers) in Wessex remains very high. We need to be positive about the future and celebrate the quality and commitment. We need to find solutions to the problems we face. Changing the culture to a more positive one will bring its own rewards in terms of improving recruitment and retention and making general practice a better place to work.
Contractual changes and QoF: This is a small start in terms of reducing unnecessary work. Some of the less valuable aspects of QoF have been removed and will now form part of a practice core funding and allowing individual clinicians to make decisions that are in the best interest of patients.
Better care fund: Many may be unfamiliar with this fund that has also been called the Integration Transformation Fund. This has been created from resources from both Health and Social Care and totals £3.8 billion nationally and is intended to be invested jointly by health and social care to deliver integrated care. Used imaginatively, this could provide an opportunity in terms of improved care with fewer barriers. GPs frequently complain of the difficultly in delivering high quality care is hampered by this artificial divide between health and social care.
The risk is that this is not new money, it is an attempt to use existing resources better. Now I will show my age, in the 1970’s the Pink Floyd’s album “Dark Side of the Moon” the song Money has the line “share it fairly but don’t take a slice of my pie”. It is a sentiment whenever greater integration between health and social care is discussed. In the current environment, Local Authorities have has their budgets reduced, and they have in turn reduced their budget for social care, the risk is that Local Authorities see the Better Care Fund as a way of recouping the funding they have lost from budget cuts.
CCGs are well aware of these risks and we need them to ensure that this money is invested wisely and delivers real benefits to patients that will in turn help practices.
Everybody Counts: Planning for patients 2014-2019: This funding, if used wisely could provided much needed help and support to practices. The document can be found http://www.england.nhs.uk/ourwork/sop/ the key paragraphs for general practice are 34 – 39. This describes the future in terms of greater integration with community services and also provides a focus on the patients in the 75+ age range.
A sum of £5 per patient or £50 per patient over 75 is suggested as a sum that CCGs will need to invest in plans developed by a practice or groups of practices. Before you get all excited thinking this will be a great way of recouping that income you have lost, the funding will need to be made available by CCGs, the plans need to demonstrate that they could deliver improved care to this age group and will potentially reduce hospital admission.
This funding is another was of incentivising groups of practices to work together more collaboratively.
There is a real focus on the rising numbers and demands placed on the NHS for the patients aged 75 and over.
Some ideas which could be developed in your locality, some of which may already be in place:
- A care co-ordinator – employed by a practice or group of practices who has the responsibility for working with the clinicians to meet the needs of this group.
- Community Matrons have has a mixed reception, the idea was good but the implementation has been variable. Could you or a group of practices employ a Community Matron to work to your agenda and help deliver care to the housebound especially those over the age of 75 and have long term conditions? Could they also help with the increasing number of patients who are resident in a care home?
- Care planning – now part of a DES for avoidable admissions, but what about improving services to care homes with a copy of the patient record being available at the care home (with appropriate consent) and also work with the care home on reducing admissions, improving the efficiency of visits, reducing expenditure on prescribed medication.
I am sure there are many other ideas, there were over 200 bids for the Prime Minister’s challenge fund, so we do not suffer from the lack of ideas.
Please share your ideas with us so that we are able to disseminate these more widely.
I believe the solutions to our problems are more likely to be found locally than they are nationally.
2. Integrated care team (ICTs)
Primary care is defined as general practice and community care but often primary care is used as a term to describe general practice.
CCGs commission service services on behalf of a population. A GP commissions services on behalf of an individual patient.
In the past GPs and District Nurses worked closely together. Over the years the District Nurses have morphed into a new breed of Community Nurses and have been pulled further and further away from the GP. Many believe this has been detrimental to patient care, frequently leads to duplication and makes delivering care at the patient level difficult.
Time has moved on with a greater focus on admission avoidance, early discharge, end of life care, supporting the frail or vulnerable elderly in their own home and also the management of long-term conditions in those who are unable to attend the surgery. These are seen as key drivers to reduce unnecessary hospital admissions and also care for more people in the community. How can this be achieved? Are these important aspects of care happening in your area?
I would argue that the ICT should be GP led, and would integrate community nursing, specialist nursing, therapists and the older peoples mental health service with general practice. General practice cannot expect an ICT at the level of every practice but probably can be delivered at populations of 30-50,000. To be successful the ICT needs to have input from social care and be embedded in individual practices.
3.Changes to the Contract for 2014 - MPIG and PMS
Following my last email I hope that you are now fully aware of the changes that will occur in QoF, it will take some time for this to be reflected in the clinical systems.
Many practices have contacted the LMC about the potential threat that the loss of MPIG will have on their practice. There are about 8,000 practices in England and about 60% of these are GMS.
In response to a Parliamentary question, Dr Dan Poulter (Under Secretary of Health – who was and Obs & Gynae trainee) has said that 98 practices will lose more that £3 per weighted patient per year and 232 practices will lose more that £2 per weighted patient per year.
What this does not tell you is that we have one practice with a weighted list which equated to a GS payment of £52 per patient per year and they have a large MPIG, so the impact of reducing their funding by £2 - 3 per weighted patient a year for 7 years will be devastating.
It is reported that those who will have the biggest loss will largely be small rural practices or practice with a young population.
This does not tell us if the practice employs lots of staff, how many doctors there are/1000 patients or whether the partners are high or low earners.
It would be helpful if there were some practices who were big losers who would be prepared to be used as examples so that we could demonstrate the impact on real practices and real people. If you are such a practice and would be prepared to help, please email me.
Over the next two years the Area Teams are expected to undertake a further review of PMS funding. NHS England recently conducted a review nationally and concluded that the additional money that was invested in PMS Practices above and beyond GMS was not linked to providing any additional services.
Most of the PCTs carried out a significant review of PMS Practices and following this reduced funding. For example Wiltshire PCT remove the growth funding PMS Practices received and used this to invest in a new enhanced service available to both PMS and GMS Practices.
NHS England estimate that there remains £260m of funding in PMS Practices that is above and beyond the equivalent of a GS and the expectation is that this will be “redeployed” over the next 2 years.
NHS England’s review found that overall, PMS practices are paid a ‘premium’ above equivalent GMS practices of £325m for England as a whole, equating to £13.52 above spending per patients registered with GMS practices.
Out of this, it could link £67m to defined enhanced services or key performance indicators (KPIs) but the remaining £258m had no formal link. It also found no link with the additional funding and the level of deprivation.
NHS England said that the £258m would be reduced to £235m over the next seven years with the redistribution of MPIG, but urged area team managers to review all PMS contracts over the next two years to ensure they were value for money.
The reviews will be conducted according to a number of criteria, including that it should reflect strategic plans set out by the area team or the CCG, help reduce health inequalities or support fairer funding distribution locally.
The MPIG review will result in the money that is withdrawn from Practices being reinvested in the GS nationally – hence raising the value of the GS/patient for GMS practice.
The GPC has demanded that any funding removed from PMS practices should also be used to increase the core funding of all practices. The demand has been turned down and NHS England intend to retain this funding at Area Team level to invest in general practice but there is little or no clarity as to exactly what this means.
Should all awards go to hospitals?
Health Education England (HEE) is the body that is now responsible for workforce planning, and education and training. The Deanery is now part of the local part of HEE, which in Hampshire, Dorset and the Isle of Wight is called Health Education Wessex (HEW). The advisory council of the Local Education and Training Boards (LETB) is made up of the local provider organisations.
The annual budget for HEW is approximately £200,000,000. This funds both medical and non medical training and education (the largest part being spent on salaries of doctors and others professions in training.
In many parts of the country there are concerns that the LETB is dominated by Secondary Care providers and has little or no GP representation. Locally primary care and particularly General Practice has a strong voice. The Board has 5 GPs who represent the CCGs, the Area Team and I represent all GPs as providers.
Health Education Wessex is launching the Shine Awards to recognise education and training excellence for the NHS. It would be great if we can have GPs or practices nominated for these awards, we often undersell ourselves, so if there is something fantastic going on in your area please put you name forward or encourage others to do so.
All information is also online at http://wessex.hee.nhs.uk/about-us/shine-awards-2014-and-annual-conference/.
5. Coming Soon – New LMC Website – watch this space!!!
As an LMC we believe an important part of our role is to provide information to GPs and their practices; communication is therefore an essential part of the service we offer to you.
You will receive regular emails from myself, Carole and Lisa. My email is distributed to all GPs and PMs on our database as well as to the CCGs and Area Teams, whilst Carole and Lisa’s emails are sent to Practice Managers who are their target audience. I hope you find these communications focused, informative and helpful.
In addition to email communication another important aspect of providing information is via our website. The LMC website has always received much praise and we are aware that many people access our information from outside Wessex as well as locally.
For some time now, we have thought that the website was looking a bit stale, the content was growing and needed to be reviewed, with out of date advice removed, and the structure and search functionality needed to be updated.
I am, therefore, pleased to inform you that for the past few months we have been constructing a new website which will be launched very shortly. The ‘new look’ website will be visually more appealing, easy to access and navigate, updated regularly and contain information which is helpful, supported by a powerful new search function.
I will let you know once it is up and functioning so please have a look and any feedback about the appearance, contents or missing areas would be appreciated.
6. PSA is it a good screening test?
What should we do if asked to undertake this in an asymptomatic man?
We know prostate cancer is common. It is the second most common cause of cancer deaths in men in the UK. About 35,000 men are diagnosed with prostate cancer every year and about 10,000 die from it. It is less common under the age of 50 with the average age of diagnosis being between 70 and 74.
The cancers can be slow growing or progress rapidly. Slow growing cancers are common and may not cause symptoms or shorten life.
The specificity and sensitivity of the PSA test means that it is a poor test for population screening. It is useful when undertaken in conjunction with a person’s history and having examined the patient.
I have been told that some practices are adopting a policy of refusing to undertake a PSA on a patient that requests the test unless they have significant symptoms. This is a very dangerous route to go down.
The general advice if a patient requests this test is to take a history examine them (if appropriate) and then advised them of the potential advantages and disadvantages of the test.
I am sure we have all had patients who have requested a test; they have no symptoms but have a friend who has been diagnosed and told them they should be checked out. What do you do then? I have had two patients in the last 3 months, both of whom I gave them the general advice about the test not being a good screening test and both accepted this but still asked for the test to be undertaken. Both had high PSAs and both went on to have a biopsy and were found to have prostate cancer. If I have declined the test when these men subsequently were diagnosed it might have been difficult to defend my earlier position.
There remains a question about early diagnosis and the best treatment, if any and also that the test does not differentiate between the slow and rapidly progressive cancer. At this stage there is not a consensus to refuse this test to asymptomatic men.
7. Revised guidance on the unplanned admissions enhanced service is now available
Following pressure from GPC, the revised guidance clarifies that:
- Care plans for patients initially added to the case management register have to be in place by the end of September 2014, not June 2014 as was originally specified.
- Patients initially added to the case management register have to be informed of their named accountable GP and care co-ordinator by the end of July 2014, not June 2014 as was originally specified. The July deadline for the named accountable GP applies only to patients added to the register who are under the age of 75, as patients aged 75 and over will have been informed of their named GP by the end of June (existing patients) or within 21 days of registration (new patients), as per the requirements of the GMS and PMS regulations.
The changes are made on pages 7 and 15 of the guidance.
Dr Nigel Watson