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Usually August is a quiet month but unfortunately that was not entirely the case this year. At the beginning of the month the PCT was informed by the Strategic Health Authority that they would not accept performance under the Worcestershire Extended Access LES. In other words GPs working under these terms would not count towards the PCTs 50% implementation target. This clearly leaves the PCT in some difficulty and there has been no way to resolve this. The DES has now been published and circulated and as you will see it offers no flexibilities whatsoever. The PCT has agreed to honour the LES until the 31^st March next year but we would assume once the more onerous terms of the DES come in many practices may well decline to continue to provide extended opening. Indeed some practices who were planning to start the LES in the autumn have felt it is not worth bothering just for a few months. 

 

The LMC is dismayed at this hard line approach by the Strategic Health Authority which has clearly come from the politicians in London. In particular we think it is outrageous that practices are not being allowed to offer coterminous working. In this day and age it is ridiculous to insist on GPs working on their own. Support staff should be there for both chaperoning and safety issues. It is also bizarre that the Department doesn’t want us to do the kind of work that many patients would want such as practice nurse clinics; smears or immunisations. One can only wonder that the Department does not want us to succeed. 

 

The PCT have been looking to see whether there are any ways that they could provide a LES to run alongside the DES which would encourage practices to open but as is typical with the Department, the PCTs now have been given the new DES’s to implement with no additional funding. This could cost as much as £500,000 for the county and so there is now no additional funding to support extended access. Documentation that we have received so far on the new DES’s has been circulated and we have spoken to the PCT about these. It is questionable whether the ethnicity DES is achievable but otherwise we would imagine most practices would find these fairly manageable. In the Learning Disabilities DES there is reference to training and the PCT has indicated that they will be exploring how this can be provided for practices across the county. 

 

Work has proceeded and a draft INR LES has been produced. The LMC is very supportive of this as it will be split into two sections. There will be LES for initiation of patients and then a maintenance LES. Broadly speaking we are happy with the funding but some of the recording requirements do seem a bit excessive. One can only wonder whether anybody at the other end is going to look at this stuff! 

 

The LMC was saddened to find out that Trevor Neatherway had not been successful in obtaining the substantive post as Head of Primary Care. In the short time that he has been in Worcestershire we had already built up what we felt was a good working relationship and have been jointly trying to deal with various issues around facing general practice. Trevor for the time being is staying on to look at Practice Based Commissioning where there is also a great deal of work to be done. The LMC has particularly raised with him the issue of LES’s. Currently the arrangements are a shambles. All sorts of people seem to be able to write LES’s and nobody is quite clear who should agree them or who should authorize them. The funding for LES’s is included in PBC budgets and one can imagine that PBC clusters may “legitimately feel they should have the last word”. We need to discuss this as a whole and tidy up the arrangements to allow various schemes to be taken forward.   Thankfully a Diabetes LES for type 2 patients on insulin has been produced and is being rolled forward. The LMC has some reservations about the proposed COPD LES and in particular the rather bizarre funding arrangements for this.

 

The LMC has been informed that the new Head of Primary Care is Linda Dando who has worked in South Gloucestershire; Cardiff and Herefordshire as Head of Primary Care. She starts work in October and we will be endeavouring to meet with her as soon as possible as there will be clearly a lot in her in-tray! Sadly the other vacancies in the Primary Care department at the PCT have yet to be filled.

 

As you will have no doubt seen already in communications from the PCT and the media the MMR catch up campaign has been launched. The way vaccination policy in this country is decided is always pretty bizarre and it seems nobody is ever consulted. We have the situation that the MMR catch up campaign; flu vaccination and HPV vaccination are all starting at exactly the same time in the autumn. With little or no advance notice about MMR and the PCT has been given limited funding to deal with this. What is not clear is how many patients who declined MMR in the first place will come forward. The LMC has agreed the outline for a LES to deal with this. Essentially patients under the age of 8 will be recalled in exactly the same system as happens now and over 8’s are to be contacted by practices. Child Healthcare will send lists to practices and there will be a template letter for us to be use to send for these patients. Under 8’s will be paid under the current system and over 8’s will be remunerated at the current rate of £7.51 per jab.

 

In regard to the HPV vaccine programme the details have also come out very late. Year 8’s will receive a letter via school and their injections will be provided by the school nurses and these will be staggered through the year to allow them to cope with the workload. If they miss vaccination they will be offered an alternative session or an opportunity to go to a GP. If patients prefer they can all be done by their GP. Year 13 (17-18 year olds) are to be vaccinated via their GPs. Only 30% of this age group are at school and there are approximately 3,600 girls in the county. Practices will have to identify these patients and send letters. Vaccines will be supplied direct to practices but unfortunately the PCT is the only organisation able to order them. There will be an arrangement for practices to have a small stock for ad-hoc vaccination and then they can do their regular ordering via the PCT. This system will mean there will be sometime between ordering and arrival of vaccines. We hope this system will work reasonably well. The national consent form will be provided for practice use and practices will have to inform Child Healthcare after each dose is given on a paper form. A £9 per dose has been agreed to cover the workload.

 

Recently there was a major problem with the NHS emails, particularly going to the old GP email sites. Everybody is encouraged to migrate to nhs.net emails as soon as possible. For the time being there is a mechanism for emails to be redirected from your old address to your new one for any practices and GPs who use the old addresses.

 

At the last LMC meeting Dr Schrieber informed us firstly that Dr Martin Wilkinson is now the substantive GP Education Director. Secondly he told us that funding has been received for the CPD payments but there is some confusion about them.  In the past they have had to claim the money from Dr Schrieber.  They should have received correspondence from him to send in their 2007/08 claim direct to him, but from 2008/09 this claim should be sent to the Deanery.  They may have received two lots of correspondence but to be clear this is for different claim years. If anyone is still confused they can ask Dr Schrieber.

 

The LMC has had discussion about the document ‘Pharmacy in England’ otherwise known as the ‘Pharmacy White Paper’. This has major implications for dispensing doctors particularly on the edges of urban areas or market towns. Similarly small pharmacies should be very concerned about this. The issue will be discussed formally at the next LMC meeting when we will be responding to the consultation exercise. Practices who are concerned about this may be interested to know that the LMC is looking to organise a joint meeting with colleagues in the other shire counties nearby where Dr Russell Walshaw who leads for dispensing matters on the GPC will come and talk to us about these issues. We hope to have a definite date and invitations out in the not so distant future. Practices are encouraged to write to their local members of parliament and to promote this to patients. We have already met with some of our local MPs and Peter Luff MP suggested that we encourage patients not to use the on-line consultation exercise but to write formally. There is a feeling that these letters carry more weight than simply the on-line tick box exercise. As always with these on-line consultation processes the questions tend to be stacked in favour of the policy. Your thoughts and comments will be very welcome before our next LMC meeting when this will be discussed. 

 

In addition the LMC had a useful meeting with the representatives with the Local Pharmaceutical Committee when we had a quite a wide ranging discussion over a number of issues. There are some issues that we can help to improve joint working and we will be looking at these in the coming weeks. Some of the other areas may be more appropriate for Practice Based Commissioning groups and we suggested this to our pharmacy colleagues. Clearly the Pharmacy White Paper is an issue for both our organisations.

 

This is an issue that has been exercising the LMC recently and the LMC sought clarification from the PCT. There do seem to be differing views about this around the country and the view is held elsewhere that the new pharmacy contract includes funding for DDA compliance and that pharmacies have an obligation to see if Nomad trays are required to meet the demands of the Act. It suggests that multiple scripts are not necessary. We have raised this with the PCT but Anne Kingham has reiterated to us that the revised vulnerable patient scheme for Worcestershire recommends the use of weekly prescriptions if a patient needs a multi dose compliance aid. From a scheme that existed in Redditch and Bromsgrove, the most common reason a patient needs a multi dose aid was because they were getting in a muddle with their medicines and it was felt appropriate to restrict the amount they had in their homes. If a patient is receiving some form of support other than a compliance aid then they will not require weekly prescriptions. In the three years that the Redditch and Bromsgrove scheme operated 350 patients were referred for assessment but only 50% of them required a multi dose aid.  The advice being given is that if someone other than a member of the pharmaceutical team requests 7 day prescriptions then the request should be refused and practices should discuss this with their PCT pharmacist or Mary Short. Requests from Social Services; care workers and other people should not be acted upon until this has been reviewed by the PCT pharmacist. Certainly it is the LMC’s belief that this is currently being overused.

 

As part of the Acute Trusts bid for Foundation status they have contacted the LMC offering us a seat on the Council of Governors. This body will have 34 representatives from local government; universities; the county councils; PCT and others. The committee will meet four times a year and will scrutinise the working of the Acute Trust Board. The LMC welcomes this opportunity to have a Stakeholder Representative as clearly it has been our long term desire to try and improve the working relationship between primary and secondary care. Interestingly my own practice recently had a visit from the Primary Care Liaison Officer of the University of Birmingham Healthcare who are years ahead of our own Trust in terms of liaison and working with GPs. We only hope we can make similar progress in Worcestershire.

 

Practices in Redditch and Bromsgrove received yet another silly form which was a standard referral form for Redditch Community Mental Health Team. The Secretary reminded this organisation that they cannot insist on GPs using such forms and the LMC received a letter stating that the letter and accompanying forms were sent out without approval and the knowledge of the appropriate manager and effectively to ignore it!

 

There seems to be ongoing concern about the wording of a letter from Daphne O’Connor about the implementation of the IM&T DES. The letter included a figure for quality standards which the LMC has not been able to find in any of the documentation. There has been ongoing correspondence and it appears that the PRIMIS IM&T Facilitators who have been looking at practices are happy with the work that is being done. We would be grateful if any practice would contact the LMC if it is decided that they do not meet the appropriate standard for remuneration of component 2 of the DES.  We hope this matter has now been resolved.

 

Many of you attended the all day session we organised a while ago on practice agreements and employment law. BMA Law have produced some more talks, this time there is one on procurement tendering and the rules and contractual law regarding negotiations and disputes with other organisations. This will be an afternoon session and we are in the process of organising this for November. We hope to send out invitations shortly.

 

Several GPs contacted the LMC very surprised that they had received an email from the PCT suggesting that in future 2 week cancer referrals had to be done with Choose & Book. The LMC advised the GPs and also the PCT that this is not an enforceable requirement. In view of the phenomenal problems that people have with using Choose and Book we felt this was in any way unworkable. It is totally inappropriate to have only an IT based referral system. We have asked the PCT to drop this policy.

 

The LMC had a presentation at the last meeting from Dr Kennedy, the Medical Director of TCN and Jan Thomas the Operating Manager. The Secretary had previously met Dr Kennedy and talked through a number of issues. There are essentially some concerns that the LMC has about the forthcoming arrangements. Essentially these resolve around the apparent lack of the support and encouragement by TCN to local doctors who may wish to continue to work in Out of Hours. They have reduced the rate of pay to £50 per hour which is less than daytime locum payments and clearly makes working Out of Hours not attractive to GPs. We hope to have further discussion with TCN about this and are concerned about the knock on effect to the availability of slots for GP Registrars. We have had their assurance at the meeting that they guarantee that all Worcestershire Registrars will be able to get appropriate training sessions. This is something we obviously have to watch with great interest. GP Registrars should be logging their interest in booking sessions with Catherine Wilkins at the booking team at TCN.

 

A second issue relates to the rota’s. The initial rota that was put out by TCN showed up to 30% decrease in the number of doctor shifts. Many of us felt this was unacceptable. TCN emailed the LMC a copy of the rota and to our surprise and their concern this rota was different to the one on their website. They have told us that this is a mistake and the one on the website used for booking shifts is wrong. Again the LMC will be watching very carefully to see that appropriate staffing levels are put in place. TCN gave us assurance that they would not employ EU doctors from other countries that do not speak good English. They assured us that all doctors would meet a certain requirement on spoken English, although apparently many shifts for the OOH are being booked via a London based locum agency. The LMC hopes to meet shortly with TCN again to try and see what can be done to incentivise local GPs to continue to work in the service. They go live on the 1^st October and practices should have been notified of the new patient access number which is 0300 123 3211.

 

If practices have concerns about OOH, operational issues should be addressed to Kathy Dale at Kathy.dale@worcspct.nhs.uk. Contractual performance issues on the management side go to Paul Newell at paul.newell@worcspct.nhs.uk.

 

 

The following guidance has been added to the LMC website during the last month:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Statement of Financial Entitlements (Amendment No. 4) Directions 2008