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Name: Shaun Firth
Date: 06 Jul 2000
Time: 11:59:42
GPC INSIGHT News from your GPC Representative Issue: 18 June 2000
Dr.Shaun Firth
CONTENTS (1) Harrogate and beyond (2) Out-of-Hours Fund
(3) Government Review of Out-of-Hours Care (4) The £660 million funding for the NHS
(5) Influenza Vaccination (6) Practice Nurses’ Pay
(7) Primary Care Trusts (8) Tackling Violence
(9) Staff Budgets (10) Complaints and Poor Performance
(1) Harrogate and beyond
There was no GPC INSIGHT from me in May, because the April meeting of the GPC was taken up with workshop discussions about the issues raised at the Conference, which I covered in my April issue. In many ways, the GPC workshop meeting was much more useful than the Conference itself because it gave ordinary members the chance to share views and explore new ideas for the future of general practice.
We also discussed our response to the Government’s promise of improved funding for the NHS in order to try to ensure that decisions are made which will truly support the improvement and development of primary care in the coming years. The Government has set up a number of national advisory groups which will report back over a very short timescale. The GPC is represented on these groups so now is the time for us all to make our views known.
It is vital that the debate started by the Harrogate Conference continues within the whole profession and I hope all LMCs will respond to the request from the GPC chairman to arrange opportunities for grass roots GPs to express their views and influence the development of GPC policy. I am delighted that we are responding to this challenge in Essex and I would urge you to encourage your colleagues to take part in this process.
We seem to have a real window of opportunity to influence the future development of primary care and to help shape the changing role of the general practitioner. The commitment of extra funding by the Government and their apparent willingness to consult and listen gives us the chance to be heard. It is vital in my view that the Government does not just hear the opinions of the great and good but rather those of those working at the front-line of the NHS.
(2) Out-of Hours Fund
The GPC was justifiably angry to learn about the sudden change of Government policy announced on 13 April. The very important extra funding ring fenced for geographically isolated doctors provided last year was withdrawn and the £2 million sum involved is to be distributed to all GPs irrespective of location.
The Essex LMCs have been concerned for some time that colleagues who practice in isolated geographical areas, which are not easy to cover by GP co-operatives or deputising services, have had very little help from the Out-of Hours fund because of the stringent Red Book rules. The Government’s recognition of this problem last year was very welcome and it is beyond belief that this policy reversal has taken place without consultation. The GPC negotiators are seeking an urgent meeting with the Minister of State at the Health Department about this issue.
(3) Government Review of Out-of-Hours Care
Again without any prior consultation, the Government has recently set up a national review of all arrangements for out-of-hours care. The remit of the Review Team is to look at all aspects of the provision of out-of-hours care including commercial deputising services, GP co-operatives, GP rotas, etc. The remit also includes making recommendations about the future distribution of the out-of-hours development fund. It is also thought that the Review will cover the inter-relationship between all GP out-of-hours cover arrangements, Walk-in Centres and NHS Direct.
The GPC received no prior notification about this Review and is not represented on the Review Team. The Out-of-Hours Development Fund has had a major influence in relieving the load on GPs and has also resulted in a significant improvement in out-of-hours care. We will have to be very vigilant on this issue in case any recommendations damage these improvements by reducing funding for GP services in order to fund the politically correct Walk-in Centres and NHS Direct. (4) The £660 Million funding for the NHS
The Government’s announcement of new funding for the NHS in the last Budget was of course very welcome but it will be vital for us to fight to ensure that a significant proportion of this reaches primary care to help us meet both our existing workload and the future challenges made by the Government for improvements.
This is particularly vital in areas like Essex where it would be very easy for this new money to be swallowed up in the black hole of existing debt. The track record is not very encouraging with primary care development over recent years at an all time low because of the funding requirements of secondary care.
Although much of the initial £660 million tranche of funding will be directed at the secondary care sector, further announcements are expected soon with regard to further additional funding which will be made available for primary and intermediate care.
It has become a fact of life in the new NHS that deadlines for new initiatives to secure extra funding are very tight. In anticipation of this new finance, GPs should be working now to ensure that detailed primary care investment plans are prepared. Carefully thought out schemes will attract funding more readily and we must not be left behind in attracting this money to improve primary care.
Around £60 million of the extra money is being held back to provide what the Government calls “performance bonuses”. As yet we have not seen any details of how this bonus scheme will work in practice and the GPC is making representations to the Department to be consulted at an early stage.
(5) Influenza Vaccination
You will have seen media coverage of the proposals for extending the influenza vaccination campaign this autumn. The Government wants to provide flu immunisation routinely for patients aged from 65 onwards as well as the high risk groups. They also want to achieve a much greater uptake level.
So far, there has been no discussion about how this goal can be achieved although the GPC has been approached to discuss this. The Department seems to recognize that a flu immunisation programme of this sort would need to be funded with new incentive payments for GPs to help deliver an improved take up rate. The GPC is insisting that any such incentive scheme would need to be funded by new money outside the current remuneration pool.
(6) Practice Nurses’ Pay
Many practices in the last two years or so have been unable to fully fund practice nurses’ pay increases because of restrictions on staff budgets. It is unfair that our nursing colleagues in primary care who take on such a vital role within our practices should lose out on the national pay negotiations for nurses.
The GPC has been asked by the Government to encourage GPs to honour pay increases for practice nurses but we have made quite clear that the Department must ensure that health authorities also increase practice staff budgets in order to cover the full cost of any increase.
The Department has now agreed to write to the GPC to explain how they intend to do this. Watch this space! This is of course particularly relevant when staff funds are being adjusted by PCG schemes to meet the requirements of formula-based budgets.
(7) Primary Care Trusts
Once again Essex was the subject of discussion at the May GPC meeting when we heard about the outcome of our actions to raise our concerns with the Government about the South Essex Health Authority’s decision to ignore the result of the GP ballot in Southend.
The GPC obtained very detailed legal advice on the regulations determining the requirements for the establishing of Primary Care Trusts. Although the Health Act 1999 lays down very specific requirements for consultation before a PCT can be established, the wording is vague about the duty of the Secretary of State to give weight to the results of consultation before making a decision.
The Government issued a Health Service Circular in August 1999 which said that consultation should demonstrate broad local support from “relevant Primary Care Groups and their constituent GPs”. The wording is not specific on how this should be achieved or whether the Secretary of State needs to heed GPs’ views!
The lawyers felt that legal action would not be successful but wrote on behalf of the GPC to the Minister drawing our concern to his notice. As you will have seen, this issue received considerable coverage in the medical press and the GPC’s concern about the Southend situation was supported by the RCGP, the NHS Alliance and the National Association of Primary Care.
The Minister expressed his concern about the situation in Southend but could not commit himself to a change in the wording of the regulations: we did not expect to achieve this! We have since heard on the grapevine that NHS Executive staff at regional offices have been told that the Minister will expect to see evidence of significant support from local GPs before approving PCT applications.
Members of the GPC were grateful to the South Essex LMC for bringing this issue to the attention of the Committee. (8) Tackling Violence Towards GPs and their Staff
The GPC welcomed the Government’s recognition of the problem of violence towards GPs and staff in primary care. A Health Service Circular issued in December 1999 was an important step forward in dealing with this issue.
By law, health authorities are now no longer required to provide general medical services with the most local GP practice for patients with a history of violence or abusive behaviour. They can now be seen in a location which provides a secure environment for GPs and NHS staff. GPs can no longer be forced to take on the care of violent patients and extra funding has been provided under Section 36 Local Development Schemes to develop suitable local provisions staffed by GPs who have volunteered to provide this service and are paid appropriately..
It is now up to health authorities to make the necessary arrangements in each area. I understand that negotiations in South Essex to meet the requirements of this policy are well-advanced but that progress in North Essex has been much slower. The GPC asked to be kept informed about local developments (or the lack of them) so that the implementation of this Government policy can be monitored and any problems taken up with the Department.
(9) Staff Budgets
Many of the quality improvements expected by the Government will depend on being able to deliver the new agenda at practice level.
Extended opening hours, new services, better skill mix and the greater responsibilities for practice nurses will all require adequate resources.
Up and down the country, and Essex is no exception, staff budgets are being threatened by financial constraints. After considerable concern expressed by the LMC, all PCGs are now progressing to a formula-based calculation of staff budgets and I am very concerned that these budgets will be too tight to allow the new initiatives which will be necessary.
There is some protection given by the Red Book regulations and, where GPs are dissatisfied with any PCG/HA decision concerning staff reimbursement, there is a right of appeal to the Secretary of State within two months of the final HA decision.
The Red Book makes it a requirement for HAs to give practices one year’s notice where it is intended to reduce staff reimbursement and Alan Milburn made it clear in 1998 that any downward assessment of practice staff funding by PCGs requires an additional year’s notice.
It is also important that any staff budget takes into account the costs of holidays, sick leave and study leave and GPs should not assume that they have no option other than to fund any shortfall in HA reimbursement out of their own pockets: they may need to review service provision instead and make it quite clear to their patients why services have been cut.
Staff budgets are cash-limited under the Health and Medicines Act 1998 and are “intended for staff to assist with the delivery of general medical services.”
The time has perhaps now come to look again at the funding of other professionals out of a cash-limited fund intended for reception, secretarial, nursing, dispensing and administrative staff. With new money available, other staff ( phlebotomists, counsellors, physiotherapists, etc) should perhaps now be funded from the correct community, secondary care budget or local development scheme and fully funded without a GP contribution. (10) Complaints and Poorly Performing Doctors
I am becoming increasingly concerned about the multiplicity of processes which are emerging to deal with GPs who are performing below standard. We have the NHS Complaints Procedure itself with local resolution, the Independent Review Panels and ultimately the Health Service Commissioner; the GMC’s plans for revalidation; the Chief Medical Officer’s proposals for annual appraisal and “retraining” centres; the proposed powers for health authorities to suspend GPs without recourse to the NHS Tribunal; the GMC performance procedures; Clinical Governance measures at PCG/T level; local procedures for dealing with poor performance and of course the legal system.
There is an urgent need for some agreement on how these various processes are to fit together and how we can ensure fairness and equity for GPs. In North Essex, we have established the Primary Care Support Group as a result of the recommendations of the ScHARR report which aims to help and support GPs whose performance gives rise to concern. The Health Authority is developing parallel procedures at PCG/T level and in some areas the Clinical Governance system is being used to implement the recommendations of Independent Review Panels. It is vital that we develop some joined up thinking on these issues which will achieve the aim of managing poor performance in a way which is open and fair to all of us.
( I am anxious to reflect your views and concerns on the GPC : Please contact me as follows:
Dr Shaun Firth, Nuffield House, The Stow, Harlow, Essex, CM20 3AX
Phone: 01279 425661 (work) Fax: 01279 427116 (work)
Phone: 01279 731396 (home) Mobile: 07957 207442 Email: shaun.firth@lineone.net
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