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LMC Email update February 17th 2018
Date sent: Sunday 18 February 2018
This is always an interesting time of year, the winter seems to have gone on for ever, the evenings are getting lighter, you are starting to see the spring growth in the garden yet we are still facing the increased pressures with the usual winter infections and illnesses. Christmas and New Year seem a long time away and access to some warmer weather is needed.
This is also a busy time of year as the NHS still working is annual cycles of plans, investments and developments.
As yet we are still waiting for the outcomes of national negotiations for relatively minor changes to the contract and additional investment in general practice. We will need to wait for the publication of the DDRB recommendations and then see what NHS England's response to this is.
1. Message from the Chair of the GPC - Dr Richard Vautrey - looking at GP pay
2. NHS England's Planning guidance 2018/9
On the face of it these documents provide little detail but the contents do provide clarification on what will be seen as important for the following year.
3. Number of 'fit notes' from GPs soars
I am sure you do not need any evidence to tell you that our workload is increasing but if you need it here it is.
4. An update on the indemnity scheme
A dream is closer to becoming a reality.
5. GP Trainee pay reimbursements to practices
Wessex is one of the areas where the problem relating to pay reimbursement for GP Trainees has been slower to resolve than other areas where individual NHS Trusts hold the contract for GP trainees and pay them directly.
6. Prescribing
Some useful guidance produced by the GPC relating to end of life prescribing and excessive prescribing.
7. Sessional GPs
1. Message from the Chair of the GPC
After a decade of pay cuts, GPs deserve a pay rise.
"Since 2007 GPs have had pay cut after pay cut, with a 20% fall in real terms income overall. This has not only impacted GP morale but also GP recruitment and retention. It's one of the reasons GP workload is unsustainable.
In the last two years, GPC in England has negotiated directly with NHS Employers and secured an uplift to pay and expenses, but this has been limited to a 1% pay rise. It stopped the pay cuts but in reality, taking in to account inflation, this still eroded our pay in real terms.
We cannot accept a further real terms cut to GP pay, which is why this year rather than agreeing a separate deal on pay and expenses, the BMA is making a strong case to the Doctors and Dentists Review Body that doctors should be treated in line with the wider economy and should receive an uplift to pay in line with the Retail Price Index (RPI), plus £800 or 2 per cent (whichever is greater).
In addition, GP practice expenses have been steadily rising without sufficient funding to cover them. This also impacts GP partner pay, as they take the burden whilst trying to fund pay rises for their staff. Expenses must be properly funded if we are to sustain the partnership model of working, and we have outlined our case to the DDRB to do this" This includes:
Impact of sub-inflation pay awards and the decline on real terms doctors' pay.
Comparison to the wider economy
Vacancies, workforce planning and future supply
Impact of Brexit
Workload, morale and motivation
NHS finances and the need to increase investment.
This has just been published by NHS England.
Overall Goals for 2017-2019 (Primary Care)
Stabilise general practice today and support the transformation of primary care and for tomorrow, by delivering General Practice Forward View and Next Steps on the NHS Five Year Forward View.
LMC Comment: These are important words and are meaningless unless general practice starts to see the benefits as they are intended.
The £6/patient invested to deliver appointments on evenings and weekends, based on populations larger than individual practices (Extended access as opposed to extended opening) now covers over 50% of the country. This should be seen against the 2017/8 target of 40% coverage.
LMC Comment: These services are being developed and implemented across our area. Many initiatives are being delivered by GP Federations or GP Provider Companies. If they are going to have an impact and deliver greater sustainability of individual practices it is vital that they provide additional capacity and are not seen simply as a way of subsidising other services such as out of hours. Many areas are beginning to use these "Hubs" to deliver other services which are part of the agenda of out of hospital services delivered at scale. These services need to supportive of general practice and not simply to reduce pressures on hospitals.
Primary care workforce:
There are over 770 additional GP trainees started specialist training since 2015 baseline (3,157 in total in 2017/18);
LMC Comment: This is good news but needs to be seen in the context of an overall fall in GP WTE numbers last year. There are signs that some practices are finding it easier to recruit to both salaried posts and to partnerships but this is not a universal picture across Wessex. Future sustainability must be judged on making the workload manageable on a daily basis and making the future role of a GP something that both younger doctors and older ones want to do i.e. making general practice a better place to work.
The GP international recruitment has commenced, with the first 100 GPs being recruited;
LMC Comment: It is important to expand the workforce but this must be done with doctors who are trained to a high standard and are able to work effectively in a very challenging environment.
Deliverables for 2018/19
Progress against all Next Steps on the NHS Five Year Forward View and General Practice Forward View commitments. This includes all CCGs:
Providing extended access to GP services, including at evenings and weekends, for 100% of their population by 1 October 2018. This must include ensuring access is available during peak times of demand, including bank holidays and across the Easter, Christmas and New Year periods.
Delivering their contribution to the workforce commitment the key points from the guidance:
Launched the GP Retention Scheme;
Recruitment of an additional 505 clinical pharmacists, in addition to the 494 already in post.
LMC Comment: In Wessex we have a number of GPs who have benefited already from the GP Retention scheme and this will continue to prove popular. Pharmacists are proving to be a valued asset to workforce and work well in the GP setting, they can help practices to increase electronic prescribing, reduce the cost of prescribing, reduce hospital admission in those patients on multiple medications, improve the quality of life in those patients who take 7 or more drugs and may benefit from a reduction in the number of drugs they take. Many of the benefits will benefit the system rather than the individual practice therefore these posts should be fully funded from the GP Forward View rather than the costs being placed incrementally with practices.
Investment in general practice continues to increase on track to deliver the pledged additional £2.4 billion by 2021. CCGs investing in line with expectations set out in the 2017/18 NHS's Planning Guidance, for additional primary care transformation investment (£3/head) over two years.
Invested in upgrading primary care facilities, with 844 schemes completed and a further 868 schemes in development.
LMC Comment: The GP Forward View committed to invest an additional £2.4bn per year to support general practice by 2020/1. Yet many practices will say that they do not see this additional resource and if this is a real investment in the future of general practice it has to be seen by frontline services.
The primary care transformation fund (£3/pt) over two years in some areas is being invested in helping practices to work together in localities of 30-50,000. In other it has simply been "badged" against existing work.
We need to see more of the fund being invested recurrently in workforce that directly supports general practice.
General practice funding
The guidance states that the new £540 million being made available by the Department of Health and Social Care will help support core frontline services, including primary care – however there is little further detail in how this will happen. Elsewhere in the guidance, NHS England makes clear that it expects the funding commitments in the 2016 GP Forward View (which pledged to increase general practice funding by £2.4 billion by 2020/21) to be met.
LMC Comment: The additional funding will be welcomed but it needs to be invested in frontline care and until we know more details it is hard to make any meaningful comments.
There will be no additional funding will be provided for winter pressures in 2018/19.
LMC Comment: In the past winter pressure monies have been given to hospitals and community providers and very few practices have seen any additional funding. This year some national money was made available for general practice winter pressures but sadly the window for bids was very short so that most CCGs were unable to develop plans and so did not bid or they bid and rather that invest in practice based services used the fund to commission additional activity from the Extended Access providers.
CCGs and trusts will be expected to achieve financial balance over the course of 2018/19.
STPs (Sustainability and Transformation Partnerships) are expected to play a more prominent role in the planning and management of system-wide efforts to improve services and to meet financial targets.
ACSs (Accountable Care Systems) have been renamed ICSs (Integrated Care Systems) and the most advanced will receive additional freedoms and flexibilities.
It is anticipated that more ACSs/ICSs will be confirmed in 2018/19.
LMC Comment: There are 8 early adopter ACS sites in England, two of which are in Wessex, Dorset and the Frimley system (in NE Hants and Farnham). There have been a number of concerns expressed by GPs about ACSs and recently the LMC held a meeting in Dorset to better understand the concerns and help provide information.
If an ACS now called an ICS means that a population based approached required general practice to give up their independent contractor status and essential become an employee, then clearly there would be much to fear and this would be opposed by many GPs and could spell the end of what is considered the Jewel in the Crown of the NHS and the main reasons that we have one of the most cost effective healthcare systems in the world.
Looking at it another way, if general practice retained the partnership model, where it works well and is able to deliver high quality care, being a partner in an ICS would mean that general practice had a seat on the Board, was able to have influence and design services that supported practices then maybe this becomes less of a threat and more of an opportunity.
CCGs will be expected to actively encourage every GP practice to be part of a local primary care network by the end of 2018/19. These will be geographically contiguous, and therefore all areas of a CCG (and all practices) will be covered.
LMC Comment: What does this mean? I believe this is what the LMC has been describing for some time. The future of the NHS has to be built on the solid foundation of general practice and the concept of the registered list. You then need local services delivered at populations of 30-50,000 that not only support practices and that defined population but that practices work closely with and have a degree of influence and accountability over but do not need to directly employ.
Groups of practices or a super partnership cover a define geographical area and is supported by and integrates with community nursing and therapy, services such as Diabetes or respiratory care or frailty. The NHS has a number of specialist nurses in heart failure, stroke, diabetes, respiratory care etc, rather han work for the hospital and be based in the community more could be achieved if they we embedded in in these neighborhoods supporting practices and maintaining a relationship with the specialists who will also become part of the locality structure but probably covering a number of these communities.
Is this all pie in the sky? Well no, it is worth looking at the Primary Care Home model -
Primary care home is an innovative approach to strengthening and redesigning primary care.
Developed by the National Association of Primary Care (NAPC), the model brings together a range of health and social care professionals to work together to provide enhanced personalised and preventative care for their local community.
Staff come together as a complete care community – drawn from GP surgeries, community, mental health and acute trusts, social care and the voluntary sector – to focus on local population needs and provide care closer to patients' homes.
Primary care home shares some of the features of the multispecialty community provider (MCP) – its focus is on a smaller population enabling primary care transformation to happen at a fast pace, either on its own or as a foundation for larger models.
The Primary Care Home programme was launched in October 2015. Supported by the new care models programme, 15 rapid test sites were chosen in December 2015. The programme has since expanded to more than 220 sites across England, serving seven million patients, 20% of the population. The sites have come together as a community of practice to develop and test the model.
Four key characteristics make up the Primary Care Home:
An integrated workforce, with a strong focus on partnerships spanning primary, secondary and social care;
A combined focus on personalisation of care with improvements in population health outcomes;
Aligned clinical and financial drivers through a unified, capitated budget with appropriate shared risks and rewards;
Provision of care to a defined, registered population of between 30,000 and 50,000
Click here for more details about the Primary Care Home.
To look at the full planning guidance click here .
This planning guidance does not provide us with many details but it is worth looking at some of the key statements in more detail.
New NHS Digital figures have shown almost 1.4m fit notes were issued between July and September 2017, a nine per cent increase on the previous year.
This is yet another indicator of the workload pressures family doctors are facing.
Read what the Daily Mail has to say!
In my practice we are using online consultations via e-Consult formerly known as WebGP. We encourage patients who need a fit note and have been issued one before to use e-Consult to request this. This works well and saves time and appointments. The patient submits the request and provides you with the full details as to why they want the Fit Note the relevant dates and also provides other valuable information such as mobile number, email address and smoking and alcohol data for the practice.
The GPC are working with the Department of Health and Social Care on the details of a state-backed indemnity scheme.
To support their commitment to this they have issued the following update: "Following the Secretary of State's announcement on 12 October 2017 of a state-backed indemnity scheme for general practice in England, the Government has started work with GPs and their representatives to develop a more stable and more affordable indemnity scheme for general practice.
This will require significant complex work before it can be implemented, including further work with GP representatives and other parties to develop our plans.
We expect to announce further details of the scheme in May 2018, with the scheme going live from April 2019.
Until the scheme is in place, GPs should continue to ensure they have appropriate indemnity cover in line with GMC requirements to enable them to practice. We want to ensure that the scheme works best for general practice and their patients, and provides value for money for government. As part of this work, we are commissioning a survey so that we can draw on an informed and up to date view of the GP indemnity market as we design the scheme. The survey will commence shortly, and we want to encourage GPs who are contacted to take part, as well as other health professionals working in general practice, to respond."
There was a risk that GP trainee pay reimbursements in Wessex, Yorkshire and Thames Valley areas (where there are no single lead employer arrangements) were potentially going to be problematic again this month.
The GPC raised this urgently with NHS England who have since assured the GPC that they were able to work to resolve the problem so that it should not result in delays if the practices have submitted the relevant information .
If practices find themselves in a position where the payments did not come through, please do alert the LMC who will flag it with us. GP trainees should not be put in a position where they do not receive their salary at the end of the month.
GPC prescribing policy group have updated its Focus on documents:
Focus on anticipatory prescribing for end of life care - click here .
Focus on excessive prescribing - click here for detail.
For the latest newsletter - please click here .
Dr Nigel Watson
Wessex LMCs
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
Hants. SO53 1JB (Registered Office)
www.wessexlmcs.com
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Updated on 18 February 2018 866 views
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