LMC Email update
Date sent: Saturday 9 May 2015
Email sent by Wessex LMCs, on 9th May 2015
Did the outcome of the election have a major impact on the NHS and would it have been different if another political party was elected? Probably not as the same challenges remain.
It was clear that throughout the campaign the NHS is an important issue that voters have expressed concern about.
In my view the NHS is far too important to be used as a political football.
- An honest debate with the general public about what the NHS can do within the existing resources and what it cannot do.
- If we want to retain a world class NHS it will need to be funded at the same level as other comparable counties – we spend less/head of population than many other countries.
- Competition and choice can be helpful when used appropriately but when applied in a blanket way can prove costly and does not always result in higher quality at a lower cost. Rationalisation of the role of choice and competition need to be undertaken.
- General practice has been described as the “Jewel in the Crown” of the NHS – if this fails the rest of the NHS will not be able to cope. The current problems need to be addressed as a matter of urgency.
Most people have now got the message that general practice is suffering from a recruitment and retention crisis. One of the major challenges is that younger doctors have clearly got the message and the result has been a significant drop in the numbers applying for GP training places.
We need to reverse the trend and make general practice a great place to work once again.
I believe CCGs, NHS England and even the Politicians want to find solutions but are not clear what can be achieved especially in the current climate.
We need to give them solutions to our problems and this needs to be divided into the short, medium and long term. It also needs to address issues such as workload, financial risk associated with premises, the cost of medical indemnity, and solutions to the rising workload associated with the ageing population and explosion in the numbers with one or more long term conditions.
Put yourself in the position of the Chief Executive of the NHS what would you do to rescue general practice. What would you do to solve the problems?
If you have any great ideas please let me know.
- Future of general practice survey
- LMC annual conference – the big debate – a salaried service
- New Models of Care – Vanguard, MCPs or PACs – what is it all about?
- Legislative changes to electronic prescribing of Schedules 2 and 3 controlled drug
- List closure
- New National Induction and Refresher (I&R) Scheme
- Practice Nurse Revalidation
1. Future of general practice survey
The future of general practice survey conducted by the BMA received an overwhelming response with 15,560 GPs responding, making a 45% response rate.
The survey results are being released in three separate tranches, with the two sections of results released so far available on the BMA website:
Some of the main results released so far are:
- Only 8% of GPs feel that the standard 10 minute consultation is adequate
- On opening hours, 51% of GPs feel that all practices should offer at least one extended hours session in a week,
- 94% of GPs do not feel that practices should offer seven day opening in their own practices and 21% of GPs feel that practices should work in networks to offer seven day opening from shared sites.
- Continuity of care (mentioned by 80% of GPs), trust and confidentiality between GP and patient (61%) and holistic care (51%) are the three factors that GPs feel are most essential to general practice.
- When GPs were asked to rank the main factors that could help them better deliver these essentials, the top three most mentioned answers were: increased core general practice funding (76%), an increase in the number of GPs (74%) and longer consultation times (70%).
- 34% of respondents are considering retirement in the next five years
- 9% of all GPs and 19% of GP trainees hope to work abroad in the next five years
- 93% of GPs feel their workload is impacting negatively on patient care
- 68% of GPs are experiencing a significant, manageable amount of work related stress, while 16% of GPs are experiencing a significant and unmanageable amount of work-related stress.
The main factors detracting from GPs’ commitment to general practice are:
- workload (71%),
- unresourced work being moved to general practice (54%) and
- GPs not having enough time with patients (43%).
These results are important and hopefully will provide clarity about the many issues that need to be addressed.
2. LMC annual conference – the big debate – a salaried service
Each year in May there is a national conference of LMCs which taken place over a 2 day period and runs in a very similar way to Party Political Conferences. There are 500+ LMC representatives who will debate a number of motions that are relevant (some not so relevant) to general practice. The outcome of these debates form the basis of the GPC’s policy in that area.
Last year there was a very controversial debate about should the NHS be charging patients. This year I suspect one of the major issues will be a salaried service.
When I talk to GPs about the partnership models, a salaried service and the independent contractor status the response often is very different depending on the age of the GP. Many are very protective, and rightly so, of the independent contractor status as it has served this country well for over 60 years and should not be discarded without a great deal of thought but other models are emerging and are worth consideration.
Rather than a salaried model, perhaps we should consider employed vs self employed.
Currently general practice is facing the rather toxic mixture of rising expenses, income not keeping pace with expenses, property ownership (with large mortgages) or leaseholder status, financial responsibility of employing staff and for some practices the salaried GPs are earning more than the partners.
If there was an option for a different structure where within a practice GPs could be “Consultants in Primary Care” and employed on the same basis as hospital or community consultants could this be an attractive alternative for some? I suppose the answer is, it would depend.
A Consultant in Primary Care would have the similar accountability and responsibility that a GP partner does but the risk and responsibility for premises and staff could be removed, also salaries would not fall because profits are being squeezed.
This is not a solution for all practices but is an attractive proposition for some.
More details in the New Models of Care section.
3. New Models of Care – Vanguard, MCP or PACs
The NHS was established in July 1948 and the cost of the NHS in 1949 was about £11 billion. Over the last 60 years the spend on the NHS has increase 10 fold, and now is in excess of £120 billion. Over the same timescale GDP and total public expenditure has increased by a factor of 4.8. This means that the growth in funding of the NHS has outstripped inflation significantly. But in the period 2007-2015 following the global financial crisis the NHS has received below inflation uplifts each year.
Over the last 10 years, significant additional resource has been invested in hospital based care. Between 2004 and 2014 there was a 43% increase in the number of Full Time Equivalent (FTE) Consultants over the same time period the number of FTE GPs increased by 15%. What this does not take into account is the significant number of sessions currently unfilled in general practice – reflecting the current recruitment and retention problems.
Compare this 15% increase in number of GPs to the rise in workload where the number of annual consultations has increase from 260,000,000 per year in 2004 to over 340,000,000 in 2014 (24% increase) compounding this is the increase in complexity of each and every consultation.
What is clear to all is that the current growth in hospital-based care is not sustainable and all western nations have come to the same conclusion. There needs to be a strong out of hospital service that has the ability to operate at scale and manage patients effectively in their own homes. You could argue that this has traditionally the function of the community services. These services have been based in community trusts, PCTs, Community FTs or even in Hospital FTs, yet they are not been effective in preventing the growth in hospital based care, why?
The answer is simple, about 90% of patient contacts with the NHS occur in general practice. You cannot create an out of hospital care model that will be effective without having general practice at the core.
The Vanguard pilots are expected to deliver new ways of providing care. The aim is to break down organisational barriers. Change the current system of payment by activity to one where the needs of a population is looked at and investments are made on the basis of need rather than activity. This is called "Place Based Commissioning".
The Multi Specialty Community Provider Model (MCP) is looking at providing an out of hospital model by combining the strengths of general practice with a community provider and working with acute trusts, social care and the voluntary sector.
The pilots are being asked to be radical, remove existing barriers and essentially gain clinical engagement.
We have three pilots in Wessex – 2 PACs (Primary and Acute Care System) and one MCP.
The MPC is based in Southern Hampshire, with three localities – SW New Forest, Gosport and East Hants. I am leading the SW New Forest MCP.
Why is the LMC involved in the MCP?
I believe the LMC is in a strong place to lead and innovate. This is because of our broad based knowledge, understanding of national and local drivers and also the strong support we have from GPs, Practice Managers and Practices.
I am involved because I want to see general practice taking its rightful place at the centre of out of hospital care. By being involved there are many opportunities to influence and lead positive change and this will have benefits that go far wider than just the pilot sites.
If you want to keep informed about what is going on in the SW New Forest MCP – follow my blog on the Wessex LMC website
What are we doing in the SW New Forest?
We have a population of 70,000 served by 7 practices (all training practices) with a small local hospital that offered excellent diagnostics, in-patient medical beds, elective surgery and a minor injury unit.
The MCP has a local delivery group which is GP led and includes two GPs, a Practice Manager, a Director of our GP provider company, the Medical Director of the hospital and a Nursing lead from the community provider and the local General Manager. This group includes the CCG and will work closely with the local authority and patient groups.
What are we trying to achieve?
- Sustainable general practice
- Make workload manageable
- Improved out of hospital model
- Develop services at Lymington Hospital
- Better services for patients and improved access
- Break down organisational barriers
To gain and maintain practice engagement and involvement we are establishing a clinical reference group who can hold the local delivery group to account.
What are we doing now?
- Building on existing work – bringing together organisations and workstreams.
- Creating a new provider partnership.
- Ensuring we are clinically led but strong management support.
- Starting to change culture and behaviour.
- Gaining engagement with clinicians and beyond.
- Creating a common vision
- “Just do it” – a new attitude with support from senior managers and clinicians
What change is envisaged?
- Urgent care
- Improved access
- General practice sustainability
- Care of the elderly
- Long term conditions
- End of life care
- Community based training
- Integrated community teams
This is defined as care which is needed in the next 24 hours as defined by a clinician or the patient. It is an all-encompassing term that includes emergency care.
Over the years general practice has struggled with access as the workload rises and varying initiatives demand 48 hour access, same day, extended opening etc.
Locally we recognised that the demands of urgent care have a significant impact on a practices workload and associated stress. This is compounded by the age profile locally with a high elderly population. There has been a focus on A/E attendance but it is clear the issues start before this point.
There is an argument to separate urgent care from the on going care of patients with complex care needs or those with long term conditions.
The benefits of providing care based on a registered list are widely acknowledged and the value of continuity of care must not be forgotten. But for a person with an acute problem such as a chest infection or acute presentation of appendicitis these problems could be dealt with by a competent clinicians. This could be enhanced by providing that clinician with full access to the patient’s clinical records and that clinician records their findings on the primary record.
So what have we achieved so far?
We were successful in our bid for funding via the Prime Minister’s Challenge Fund 2. We are establishing a Primary Care Access Centre (PCAC), based in Lymington Hospital, which will provide services from 8am – 8pm seven days a week. It will be staffed by GPs, Physiotherapists, Clinical Pharmacists and Nurses. It will be located next to the minor injury unit and ultimately it is envisaged that these will merge.
The 7 practices are moving to a common internet based telephone system which will allow the practices to collaborate more closely and also transfer calls from the practice to the PCAC. There PCAC will have both EMIS web and SystmnOne and provide the ability to directly access the patients clinical record to add clinical entries from the PCAC.
Practices or patients will be able to directly book appointments in the PCAC.
Our aim is to provide better access over 7 days for urgent and routine problems, to do this in a way that adds capacity but is integrated with practices and not a separate and isolated service.
Although this is being led by our GP provider company it is being supported by the CCG and our community provider who also are responsible for Lymington hospital.
I see this very much as a starting point but see huge potential to provide services at scale.
Is this not just a Walk in Centre, many of which are being closed?
No I don’t think it is. This will be run by our GP provider company, with accountability to general practice and working in a complementary way to general practice, rather than an independent alternative.
This is a constant demand, particularly from the politicians.
The new Government has committed to providing access to general practice 8am - 8pm seven days a week by 2020. If we provide better access on the same day or within 48 hours then something else has got to be sacrificed unless more capacity is put into the system. I have not met may practices lately who believe they have spare capacity and this is particularly relevant when we all have to increase capacity over the winter months. We were fortunate this surge was less this year than in previous years.
The PCAC will add additional capacity and improve access and deliver 8am - 8pm access to general practice.
Care of the elderly
Locally we are probably about 10 years ahead of other parts of the country as we already have about 30% of the population who are aged 65 or more. We also have a far greater % of patients aged 85 or more compared to other areas.
We have historically had a community geriatrician who is focused on care out of hospital and works closely with the community nursing and therapy team.
The £5 per patient funding for the over 75s is about to fund practice based Care Navigators and additional GPs to focus on the patients who are either house bound or are resident in care homes.
The Frail Elder Persons strategy nationally focuses on looking at the needs of this vulnerable group and looks to stratify them into mild, moderate and severe – the mild need self care, the severe we are probably already involved with their care but in put at the moderate stage has been shown to have great benefit to the individual and the future health economy.
Admission avoidance DES has focused on people with complex needs and this is particularly relevant to the elderly population.
Practices are seeing significant increases in workload in this age group as a result of increased numbers and also complex needs.
The CCG is developing a strategy for the elderly – but what does this mean for local services?
Lots of potential here but a real risk that these services duplicate or work in silos.
Our aim would be to align all these initiatives to gain the maximum benefit for patients and also help with general practice sustainability.
Consideration will be given to developing an alternative service for the frail older person esp. for those with health and social care needs – so rather than the GP being the first point of contact – this service could be available – but this would only work if there was full access to the primary clinical record, and the service covered a larger population than a single practice.
Long term conditions
The number of people with a single long term currently stands at 15m and is going to rise to 18m by 2018. The number with multiple LTCs stands at 1.8m and will increase to 2.8m by 2020.
This means that despite the move from GP based opportunistic care to a more nurse led model with greater focus on a structured care model the workload cannot be met by the current model of care – we need help!
We may not be able to take money out of hospitals but we need some of the resources to manage these patients more effectively and cope with the rising workload.
The start is to look at diabetes. The annual costs to the NHS is estimated at £14 billion per year. The major problem is that this is largely spent on dealing with the complications and hospital based care. The amount invested in general practice and the community is relatively small, especially when about 80% of the care is provided by general practice.
Our aim is to have the Consultant Community Diabetologist and Specialist Nurse undertaking clinics with GPs and Practice Nurses. As more specialists need community based experience and training, some of this time could be based in general practice providing this additional capacity and expertise. Recording the care on the primary record with the ability to produce care plans for individual patients.
The expected advantage of this model is that it will add capacity to the practice team, enhance the expertise and provide a transference of skills.
Other potential advantages would be getting practices to work together and potentially share practice nurses with additional knowledge of diabetes.
The GP is the specialist generalist and is the expert and coordinating and delivering holistic care.
The provision of care to the individual LTC needs to be considered on a condition by condition basis.
End of life care
This is an area that is a very rewarding part of general practice, but sometimes the care provided by a hospice, the community team and general practice is isolated and poorly coordinated. How many times is the individual or family asked where the preferred place of death is etc? How often is this information shared?
Our MCP is looking to get better co-ordination and teamwork and this can be assisted by having a common health record with the effective sharing of information and the ability to see each others information.
General practice sustainability
The current model of general practice is not sustainable.
The partnership model will survive but we are going to have to play a major part in an out of hospital model that is provided at scale. So I want to see services provided to patients that support general practice and are wrapped around patients.
We are not going to get 10,000 additional GPs in the timescale that they are needed. So what are the alternatives?
We need to have additional resources in terms of people to help with the workload. So considerations needs to be given to whether community mental health workers, physiotherapists, community pharmacists etc could become a part of the practice team and add capacity and expertise.
Our MCP has already started to evaluate the use of physiotherapists as the first point of contact for MSK problems presenting to general practice.
Is there an alternative model to a partnership for general practice?
The partnership model is not as attractive to the younger generation of doctors as it was to my generation.
The term a “salaried model” has the connotation of loss of autonomy, being management led with loss of clinical freedom – none of this would be very appealing to most GPs. But the current issues we face have made GPs think about other models.
Most consultants I know, do not talk about being salaried consultants, they have a fair degree of clinical freedom and have as much autonomy as we have as GPs.
We are therefore exploring what a model of general practice might look like – if a practice lost the responsibility for owning the premises or being the leaseholder, the HR and employment responsibilities of staff were no longer your responsibility.
If GPs were given the same terms and conditions as hospital consultants and retaining the same autonomy and responsibility, would this be an attractive alternative?
This model needs to be worked up and evaluated to see if it is a viable alternative.
Integrated community teams
The MCP has to find a way of integrating community based nursing and therapy teams with general practice. The integration that has taken place has largely been achieved within the community services and has singly failed to integrate with general practice.
We have to find solutions and achieve an integrated team that may not be achievable at practice level but will be at a small locality of 20-30,000.
One major step forward would be to create a common health record that would improve care but the effective sharing of information, improve communication and provide the basis to create a more effective model. The next stage would be to remove the barriers between practices and community services. These solutions may be different for different areas. We should consider "seconding" the community team in a given area to the local practices, who would then have the responsibility to deliver on a number of pre defined outcomes. They could achieve this by integrating the community services with their practices. Working in this new way would need to resourced and would need investment in time and resources for leadership development and to develop effective teams.
This is just a starting point – we need to establish a new way of delivering out of hospital care at scale and this is an opportunity for Practices, GP Provider companies and the community provider to establish much more than a working relationship to become a provider unit with a legal entity.
4. Legislative changes to electronic prescribing of Schedules 2 and 3 controlled drugs
As a result of the public consultation and advice from the Advisory Committee on Misuse of Drugs (ACMD), legislative amendments have been made to enable the electronic prescribing of Schedules 2 and 3 controlled drugs for NHS and private prescribers.
Prescriptions will be signed with an advanced electronic signature and sent via the electronic prescription service (EPS), with its additional security features.
The amendments require the total quantity of Schedules 2 and 3 CDs dispensed to be recorded in words and figures within the electronic prescription, as is the case for paper prescriptions for these drugs.
The public consultation response document and a letter containing advice from the ACMD have both been published on GOV.UK. They can be accessed via the following links:
Three statutory instruments underpin this change:
NHS http://www.legislation.gov.uk/uksi/2015/915/contents/made. This comes into effect from 1 July 2015 and enables:
- those providing GMS and PMS to issue electronic prescriptions (including instalment prescriptions) for Schedules 2 and 3 CDs via EPS
- those providing GMS and PMS to issue electronic prescriptions via the EPS for prescriptions written as part of a private arrangement but within an NHS consultation, when the medicine required cannot be prescribed at NHS expense. Where the electronic prescription contains Schedules 2 or 3 CDs, the EPS is the only electronic system which can be used.
- providers of pharmaceutical services and local pharmaceutical services to dispense electronic prescriptions for drugs listed in Schedule 2 or 3 of the Misuse of Drugs 2001Regulations (MDR) when they are sent via the EPS.
Human Medicines http://www.legislation.gov.uk/uksi/2015/903/contents/made. This comes into effect from 1 July 2015 and:
- enables prescriptions for Schedules 2 and 3 CDs to be signed with an Advanced Electronic Signature (AES) - this will be limited to the EP
- corrects a transposition error which arose during the consolidation of the Medicines Act into the Human Medicines Regulations 2012 (HMR) – see below for background.
Home Office- SI 2015/891 - The Misuse of Drugs (Amendment) (No. 2) (England, Wales and Scotland) Regulations 2015. This comes into effect from 1 June 2015 and contains provisions which enable:
- electronic prescription forms to be sent via the EPS for Schedules 2 and 3 CDs.
5. List closures
This has been a subject of much debate for some time and the GPC has recently issued new guidance to LMCs.
GPC is aware of concerns about the approach taken by some Area Teams to informal list closures. Our guidance is contained ‘Quality first: Managing workload to deliver safe patient care’, available on the BMA website.
GPC has been in contact with NHS England and has received the following statement regarding list closures:
“Patient safety is the top most priority. Both for commissioner and provider, commissioning services need to always reflect that and the contract is a means by which we can ensure that a practice is continuing to offer safe and high quality services to patients.
For a practice to formally close its list, we require it to consult with patients and other key local stakeholders. Clearly, NHS England has a responsibility to ensure that services are available to patients. There are different issues raised if an urban practice closes its list compared to one that supports a very rural and large practice area, so all cases will be considered on a case by case basis.
If a practice is experiencing severe disruption, then of course it may be necessary to take immediate action, so that the practice can maintain safe services. However, a provider should be communicating with the commissioner as soon as practical in order to establish a plan of action to address the issue.
If the issues are not imminently likely to be rectified, then in order to fully assess the impact of a closed list on local services for patients, a formal request to close a list should be made, so that the views of patients as well as local GP and community pharmacy services can be taken into account. In most circumstances, we find that patient groups and local health services are very understanding of a practice difficulties, however practices don’t exist in isolation, and we need to ensure that a closed list does not adversely affect the pressures being experienced elsewhere, in another practice.
Because of our need to ensure we engage with the local community regarding the services we commission, we do not accept that a practice can close its list without going through a formal process of engagement.
However, we do appreciate that there are times when urgent action needs to be taken. If there is a sudden impact on a practice’s ability to provide patient services, we accept that a temporary halt to new patient registration is appropriate, but this should be followed quickly by a discussion with the commissioner to identify an action plan to address the issues. Where it is evident that the issues can be resolved within a short time scale, then we would look to support a practice address these issues without requiring formal list closure.
If progress was not being made, we would advise that consideration be given formally to close the list.
Where a practice is opting to restrict patient registration without discussing the implications and appropriate actions with NHS England, we would consider whether contractual action ought to be taken.”
In addition to the above, the Central Midlands Sub-Regional Team of NHS England has provided the following:
“From a local perspective, we would always urge a GP practice experiencing difficulties to contact their local NHS England Contract Manager at an early stage. GP practices experiencing difficulties often consider working more closely with neighbouring practices, including exploring options for mergers and federations. At a local level, NHS England can support these discussions and encourage practices to fully engage with their CCG, which may also be able to offer support.
Unmanaged list closures have the potential to be problematic for patients and other local practices; for example, in rural areas where only one or two practices may cover a given location, patient access to a GP could become unduly restricted. The formal list closure process allows local commissioners scope to engage with neighbouring practices and to assess the impact that a closed list may have on other practices in a locality.”
NHS England has agreed to work with GPC on producing further guidance to Area Teams to clarify the above position. In the meantime the guidance in ‘Quality First’ remains current.
6. The new national Induction and Refresher (I&R) Scheme
This was launched in England on Wednesday 25 March. This was agreed by Health Education England, NHS England, the GPC and the RCGP and is one of the objectives of the 10 point GP workforce plan. The plan is a four party agreement to work together to tackle the current GP workforce crisis. For further details and to read the plan, please visit the BMA website.
Kickstarter funding has been invested in the new I&R scheme over a three year period and it is hoped GPs who have been out of the UK general practice workforce, eg on a career break / maternity leave or working overseas, will return to work. Scheme members will receive a monthly bursary of £2,300 per month pro rata and reimbursement for first assessment attempt costs, eg multiple choice questionnaire (MCQ), simulated surgery etc, on completion of the scheme. Practices will receive a supervision fee of £8,000 pro rata over a whole year.
GPs will be able to apply to the scheme via the National Recruitment Office (NRO). The NRO will direct applications to the most appropriate area team and Local Education and Training Board (LETB) and scheme entrants will receive expert advice and support in returning to work. Each area team will have a designated responsible officer for scheme members too.
Further details about the scheme and how to apply can be found on the BMA website.
7. Practice Nurse Revalidation
It looks as if the first nurses to be revalidated will now be in April 2016. There are lots of resources on the NMC website including a good powerpoint presentation that you might want to talk through with your nursing team http://www.nmc.org.uk/standards/revalidation/revalidation-guidance-and-resources/ . There is a concern nationally that nurses may be frightened off by this process and we really cannot afford to lose any of this valuable workforce.
It expected that the senior nurse within the organisation will be the confirmer ie confirm that the nurse is fit to practice. It is hoped that training will be made available to nurses who are to act in this role. We are involved in how to set up a process to enable practice nurses to revalidate in a positive way that is not too onerous on the practice nor on the nurse.
Do contact Louise Greenwood if you have any queries about this at all on firstname.lastname@example.org.
We are holding an information afternoon on revalidation on 1st July to which all our nurses and managers are welcome. ( click here to book ).
QOF guidance 2015-16 - England
The QOF guidance for 2015-16, applicable from 1 April 2015, has now been published on the NHS Employers website.
A link to the guidance has also been published on the BMA website QOF guidance pages.
Dr Nigel Watson
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
Hants. SO53 1JB (Registered Office)