Wednesday, November 26, 2014

GPC report from 20 November 2014

GPC Report
For East and West Sussex LMCs
Dr Russell Brown

20 November 2014

The GPC held its latest last week.   The latest official GPC news can be found at the BMA Communities web site and for constituents and LMC members is included with this report.  Unlike last month, though the actual conversations are confidential, I am able to be considerably less discrete than last month.  As a result, this report is almost diametrically opposite to last month’s in its length and, of course, its consequent interest value.  No, really.

CQC and “Intelligent Monitoring”

As I am sure you are aware, the CQC published a frighteningly misleading data set about all practices in England, and classified them into 6 bands of concern.  Band 6 practices are apparently least likely to be putting patients at risk, and band 1 practices most likely. Speaking as a partner in a Band 1 practice, which went through a CQC inspection less than 6 months ago where nothing of any meaningful significance was found and which will be going through another inspection in the next few weeks under the new regime, I was extremely angry that CQC had once again deliberately made statements which they must have known the press would leap upon with glee.  My partners and practice manager were understandably upset.  On the other hand, my patients were either totally disinterested in the CQC’s assessment or horrified that their practice was being pilloried in this way.  I have written to my local paper, the Eastbourne Herald, about the matter.  They haven’t published it yet, so it would appear the local press aren’t fussed either.  

The 38 indicators chosen do not seem to reflect on the quality of care provided by practices as well as being out of date.  GPC was consulted by CQC on the use of the indicators and opposed their use as overly simplistic,  but as is normal the genuinely constructive comments made were completely ignored.  CQC has once again proven itself unfit for purpose, even assuming that its purpose is definable, which I am doubtful of.  You will of course recall that fees are increasing by 9%, which is fascinating given the organisation is not providing value for money by any stretch of even the most fevered imagination.  The GPC chairman, Chaand Nagpaul, has written to both Prof Steve Field, that well-known friend to general practice, and the Jeremy Hunt, the Health Secretary, expressing our anger and dismay.   We are actually fortunate locally that the LMC office has managed to establish such a constructive relationship with the local CQC office, meaning that, to a degree, pragmatism and common sense is being applied.  If you are to be inspected, please notify the LMC office as soon as possible and feedback about your experiences.

NHS Five Year Forward View

The full report can be found here.  Interestingly, much of this document seems to suggest a move in a direction which GPs might consider to be right, as it often focusses on many of the areas that GPC has been working on in the last couple of years, particularly the “Your GP Cares” campaign which calls for long term sustained investment in General Practice.  This can be broadly categorised under funding, workforce and workload (where the document agrees we need to expand the workforce including nurses and other primary care staff) and empowering patients, moving towards more self care and support for carers.  Patient access to information is a strong theme and fits with the recently published long term NHS IT strategy and recently concluded contract negotiations, as well as local schemes such as ROCI and the enhanced Summary Care Record.

However, whilst the document recognises the pressure general practice is under as well as the unhelpful focus on hospital care that has existed for the last decade, it does not provide all the solutions, which is perhaps helpful as it recognises that a “one-size-fits-all” approach is inappropriate.  It is worth remembering that funding for hospitals has increased by over 40% in the last 10 years, whilst in general practice that figure is only about 10%, and that consultant numbers have increased at three times the rate of GPs.  The document talks about breaking down barriers between primary and secondary care, between mental health and health and social care.  Services need to be organised to support patients with multiple conditions, with locally delivered services, whilst recognising that specialist centres can produce better outcomes.  The plan recognises that list based general practice is the foundation of the NHS and this will continue. It also recognises the pressure that general practices is currently under and that there needs to be a “new deal” for GPs.  There is a commitment to invest more in primary care over the next 5 years whilst stabilising the core funding for general practice nationally over the next 2 years.

To this end, new models of care are proposed: 
Multispeciality Community Providers (MCP) will offer a new option for groups of GPs to combine with nurses, other community specialists and perhaps mental health and social care to create an integrated out of hospital care organisation. There are some early versions of this around the country but as yet they have not moved to the next stage of employing hospital consultants, having admitting rights to hospital beds, running community hospitals or taking on delegated control of NHS budgets.
Primary and Acute Care Systems (PACS) – this model of vertical integration combines general practice and hospital services, similar to an accountable care organisation now developing in other countries including the USA.  Many would question what would happen to a practice if their contract was held by a hospital. This option could provide a model for some that has something to offer but would need many safeguards to be put in place.  I suspect this may work in urban, under-doctored areas but is going to be of no use at all in the countryside.

Additionally, urgent and emergency care will be redesigned and integrated between A&E Departments, GP out-of-hours services, urgent care centres, NHS 111 and ambulance services.  There has been a great focus on the pressure A&E is under, with an additional £500m being given to hospitals over a 2 year period to help relieve the pressure,  yet A&E sees 21 million patients a year compared to the 340 million seen in general practice (increased from 240 million in 2004 but general practice has not received additional funding for this increased demand).  Urgent Care Centres refers I think to the emerging model of groups of practices working together in partnership with others such as community nurses, paramedics, social workers etc to cover a larger population than an individual practice.  The current model does not work and there are perverse incentives in the system:  if A&E is paid on the basis of each patient seen and critically ill patients are funded at the same level as minor injuries, what is the incentive for them to stop the minor injuries attending the hospital.  This is an important initiative to reducing the workload on general practice as well as A&E.

It is worth considering that many of our younger, often sessional, colleagues are perhaps ambivalent about our independent contractor status.  Succession planning is something that should be thought of early and frequently and the LMC office is happy to provide advice and support.

But change is coming.  Are you and your practice willing and able to embrace this change and move to a more interdependent model with colleagues in other practices as a means to maintain your independence?  I am also concerned that the persistent failure to change the focus of investment from hospitals to out-of-hospital settings will continue.  Without that nettle being grasped firmly, I do not see how this plan can succeed.


Co-commissioning

The NHS England report “Next steps towards primary care co-commissioning” was launched on 10th November 2014 and can be found here.  It outlines three models of co-commissioning, NHS England’s plans for resource allocations for CCGs, plans for developing and delivering a new framework on conflicts of interests and the timeline for approval and implementation.  The LMC is holding events on co-commissioning this week.  This idea should not be dismissed out of hand as, if resourced and used appropriately, co-commissioning may be a mechanism to deliver more resources into primary care.  Of course, the entire concept is only necessary because of a botched major reconfiguration of the NHS which is funded inadequately.  

The key features of the three models are described in the report in this table: 

























In my view, model C is a nightmare scenario for general practices.  CCGs are membership organisations of GP practices.  The conflicts of interest evident in model C are unbelievable, with a GP-led (apparently) organisation being responsible for the commissioning of general practice.  How can we hold the board of our respective CCGs to account if they are responsible for decisions on investments into our practices? How is this process going to do anything other than create a wide-ranging postcode lottery of service provision? And that in turn risks significant repetitional damage to GPs, who may well be perceived by the public and the press as commissioning with their own self-interests at the fore-front of their minds.  Disinvestment in and decommissioning of secondary care during service reconfigurations could inflame tensions between primary and secondary care, jeopardising service redesign and integration, with the perception of wide-ranging conflicts of interests paralysing the decision making processes and removing clinical input by devolving more and more decision making powers to lay members of boards.

In summary, I am not a fan and would urge you to consider extremely carefully the various options.  CCGs will, no doubt, be canvassing their member practices for views on a way forward.  It is vital that you engage with those processes.

The next GPC meeting is to be held on 18th December 2014.

I hope you have found this report helpful.  Please feedback so that I can ensure my reports are useful.  

Dr Russell Brown


Wednesday, October 22, 2014

GPC Report 16 October 2014

GPC Report
For East and West Sussex LMCs
Dr Russell Brown

16 October 2014

The GPC held its latest last week.   The latest official GPC news can be found at the BMA Communities web site.  The meeting this time was in two parts, with GPC proper held in the morning session and subcommittee meetings in the afternoon.  I was elected for a further year as Deputy Chairman of the Commissioning and Services Development Subcommittee.

Unfortunately, almost everything we discussed in the morning was confidential.  Consequently, I can’t say very much at all.

However, the new Dementia Identification Scheme was discussed.  I understand the BMA is unable to advise GPs not to do this work as this would be tantamount to inciting improperly formulated industrial action.  My personal viewpoint is that this is work which is verging on unethical in the way the scheme has been devised and that this money, which has been located from the back of a sofa somewhere in the otherwise allegedly financially moribund Department of Health, would have been much better used towards a properly negotiated and structured package of work which might actually made a difference to those families suffering from the effects of a member with dementia.  But that is politicians for you.  I fully expect many practices to sign up to this in an effort to get at least some funding through the door.  I am also fundamentally unsurprised at the press coverage on this, most of which seems focussed on the erroneous impression that a GP will be paid £55 just for making a diagnosis.  

The CSD meeting in the afternoon discussed networks and federations, co-commissioning and integration.  There is much work going on in many places in the country.  Again, much of this discussion is and was confidential.

I hope you have found this report helpful, though given it’s structure and the dearth of information in it this month..…  Please feedback so that I can ensure my reports are useful.  

Dr Russell Brown

Wednesday, October 01, 2014

GPC report 18 September 2014

GPC Report
For East and West Sussex LMCs
Dr Russell Brown

18 September 2014

The GPC held its latest meeting a couple of weeks ago.   The latest official GPC news can be found at the BMA Communities web site.  The meeting this time was in two parts, with GPC proper held in the morning session which predominantly involved the executive team presenting the details of the proposed contractual changes and breakout groups in the afternoon to discuss them in the afternoon.

This report is, as a result, rather shorter than usual.  Anyone audibly celebrating this fact will be looked at sternly.

As you will no doubt be aware, the negotiations for changes to GPs’ contracts have concluded and been announced.  Chaand Nagpaul has sent out one of his regular updates and the details can be found on the BMA website at http://bma.org.uk/gpcontract2015.  

I know this is usually trotted out, but I have such a grumpy reputation that I hope my reassurance that this is the best deal that could have been achieved is sufficient.  It would be fair to say that, this year, neither side came away from negotiations happy.  Perhaps this reflects a successful process.

However, this is barely the beginning of the work that is needed to protect General Practice and put it on a sound footing.  If you like, the contract negotiations are simply a box that needed to be ticked so we can get on with the more important work.  With this in mind, GPC is already engaging with the DH and has proactively suggested several ways forward.  Details can be found at http://tinyurl.com/mvry8yw but there are 8 suggestions which we hope to base urgent discussions upon.

The next meeting is to be held on 16 October 2014.  It would be very helpful to hear your feedback on the contractual changes before then, if you feel able to.

I hope you have found this report helpful.  Please feedback so that I can ensure my reports are useful.  


Dr Russell Brown

Tuesday, September 30, 2014

Dinner time

So my lovely wife is cooking my dinner. We usually do that together. Why am I not with her in the kitchen?
Because, Mr Cameron, after yet another 12 hour day, I am now at home sorting out paperwork, by remotely accessing the surgery computer system. Don't worry, it is all secure and conforms to the NHS Information Governance arrangements. I'm doing that from home so that I could actually see my kids before they went to bed.
If you think that people will be able to see their GP, or a GP (and incidentally I wish you'd make your mind up because you seem to say the first one when you start, then change tack in the middle of each sentence) from 8-8, 7 days a week, you are frankly deluded.
There are not enough GPs. So that means that patients will NOT be seeing GPs, but other health professionals, nurse, physicians assistants or whoever.
I can't see how you are going to train enough GPs, given that takes as an absolute minimum 5 years from graduation from medical school. There is a looming crisis, over and above the one already happening. Did you know that something like 40% of GPs are over 50? How long do you think they will hang around for? And that thousands of young doctors are emigrating rather than staying here to work in the NHS? Can you think why that may be?
340 MILLION consultations a year in General Practice. Compare that to 40 million in A&E and it kind of puts it in perspective. You want us to do more and more. Fine we can do it, or at least arrange for it to be done, but not without resourcing. The proportion of the NHS budget going into Primary Care has gone from about 10% to less than 8.5% in the last four years. That 1.5% reduction is the equivalent of about £1.5 BILLION quid, very roughly. So how are we to pay for all of this extra stuff? It is certainly doable. But it doesn't come cheap.
And what about premises? If you want us to do these things, provide a new model of out of hospital care, closer to peoples' homes, what are we going to do it in? There has been a de facto moratorium on the revenue needed to fund the extra space that General Practice needs, never mind all this extra stuff. So where are you going to fund that from?
And as for GPs now being in charge of the NHS, local groups making decisions for local health economies... Have you actually seen what is going on? There are so many financial constraints that there is very little flexibility in the system almost everywhere to allow for sensible redesign of systems and services. Yes, yes, I know there are places doing bits and pieces but, and I appreciate you are not of a scientific bent like me, anecdote does not make evidence.
The Commonwealth fund report this year showed we had not only the most efficient but THE BEST health service in the world. About the only thing we could do better is speed up access. Guess what? That requires resources.
Demand is going up and up, inexorably. You can't blame the patients, they expect what you promise them. The problem is, you keep talking about an NHS based on wants, but you then barely fund it enough to cater for the populations needs.
We need as a nation to decide what we want from the NHS. That may be the status quo, which is still going to need more resources given the ageing population etc. It may be that it provides less. Or it may need wholesale change of models of provision but that takes resources and is not without risk.
You need to start engaging with the issues honestly. Except I have no expectation that you or any of your political allies or enemies will do so, as there is an election in a few months and unless you are elected, your promises mean nothing at all.
My dinner is ready now. When I've eaten, I'm going to come back and finish off my paperwork.
Have a pleasant evening.
Russell Brown
GP, Polegate, East Sussex

Friday, June 20, 2014

GPC report 19 June 2014

GPC Report
For East and West Sussex LMCs
Dr Russell Brown

19 June 2014

The GPC held its latest meeting today.   The latest official GPC news can be found at the BMA Communities web site.  The meeting this time was in two parts, with GPC proper held in the morning session and subcommittee meetings in the afternoon.

Negotiation report
There is much going on in the background, developing and assisting idea formation within the DH.  As usual, much is confidential.  However, PMS reviews guidance and a checklist for LMCs has been published.  The LMC in our area has already had extensive experience in assisting practices during the review process.  I would recommend practices affected by reviews approach the LMC office at the earliest stages.  A letter has ben sent to once again ask what support the outlying practices affected by the phasing out of MPIG has yet to be replied to.  I am not aware of any outliers in our area but of more concern is those practices outside of the 98 identified by NHSE as outliers, as many other practices are going to find the situation uncomfortable if not ruinous.  Again, please contact the LMC office as early as you can if you have any concerns about your practice.  Care.data was not a big feature of the agenda today, a welcome break.  Pilots are however to be held later this year, involving 100-500 practices, to look at the mechanism for data extraction.  There is no date set for the national roll out of the scheme.  A GPC CCG involvement survey has taken place, the results of which will be published soon.  I hope it will make some CCGs around the country take note.  The local Somerset QOF replacement scheme was discussed at length.  It is causing much consternation and concern.  Though practices will not be performance managed, they will still need to do the work (and so will be collecting the data anyway).  I am concerned that this is a short term view which will have implications for a nationally negotiated contract in future.  NHSE has been clear that this is a one off pilot and we are pressing to ensure that a proper and full evaluation takes place, given the DH’s past definition of the word “pilot” in various other schemes.

Communications
The “Your GP cares” campaign was launched at LMC Conference.  Although separate, the RCGP have also launched a campaign and the two organisations are now, finally, collaborating on the development of both and planning to work much more closely in the future.  Given the different nuances of the two bodies, this can only be a good thing.  Practices should expect to receive patient materials from the comms team very soon.  I would encourage all practices to engage with the campaign.  As a part of the campaign, there is an e-petition at http://epetitions.direct.gov.uk/petitions/65093.  I urge you to read it and sign it and share it with your professional and personal networks such as patient groups and friends on Facebook or Twitter.  It has already drawn almost 5000 people to sign it in its first few weeks.  It’s closing date is next year, just before the General Election.  Additionally, an early day motion, sponsored by several past health ministers including Frank Dobson is being placed before the Commons.  Please consider emailing your GP, which can be done easily by clicking on the following link and following the prompts.  It takes about 2 minutes and could have a real impact.  The link is http://bma.org.uk/working-for-change/your-gp-cares/email-your-local-politician

Recruitment and the future
Figures soon to be published have revealed an absolutely dire situation in GP training, with many places north of London desperately short of candidate for training places.  Worse, HEE is shifting funding around and planning on spending money meant to train GPs on other projects, given they have been unable to fill places.  The only solution is to make General Practice a more attractive carer choice and that is in the gift of others, which of course is where the negotiations we go through each year come in.

The next meeting is to be held on 17 July 2014, but I will be on annual leave that week.  There will be an election for the negotiating Executive team taking place.  I will be voting by proxy,, an arrangement which allows a more democratic process.  Until recently, on those actually present at the relevant meeting could vote.  There is a hiatus in August so expect my next report in September.

I hope you have found this report helpful.  Please feedback so that I can ensure my reports are useful. 

Dr Russell Brown


Wednesday, April 23, 2014

GPC Report 17 April 2014

GPC Report
For East and West Sussex LMCs
Dr Russell Brown

17 April 2014

The GPC held its latest meeting today.   The latest official GPC news can be found at the BMA Communities web site.

Collaborative fees: In some areas of the country, there have been issues with getting these fees paid.  I am not aware of any particular issues in Sussex, but if there are any, please let the LMC office know.  It has been acknowledged this is an NHS responsibility and the system that existed for payments prior to the changes last year should still be functional.

Negotiation report
As ever, much of this is confidential, but as discretion is my watchword, I can reveal that we appear to have someone in a position of influence who wants to see lots of money come into primary care (which as you may recall includes general practice).  Treasury however is apparently concerned that hospital waiting times will go up, which demonstrates nicely the difficulties we have in perception of the problem and potential solutions to it within the NHS, as well as the apparent mismatch in viewpoints, not to mention priorities, in different places in Government..
Contract implementation
Admission avoidance DES read codes should be available by the end of April.  I am unclear which April but I assume the aim is this year.  Hopefully, there will very soon be some short and snappy GPC guidance on implementation to compliment the official joint guidance.
Transforming Primary Care, aka the £5 per head.  
A document sent out by NHS England has made it clear that this money should be used to support the work of practices.  Local plans are developing and I anticipate the usual proactive and productive discussions will take place between the LMC and CCGs in the two Sussexes.
Prime Minister’s Challenge Fund
The eagle-eyed amongst you will have seen that Brighton and Hove have bid successfully for some of this money.  I heard that all these schemes will be independently evaluated in due course.
QOF 13-14 payments
There was an error in calculating the achievement scores of some practices, who will have been contacted by HSCIC already.  It is not yet clear, however, whether PMS deductions have been similarly affected.
QOF 14-15
There is an issue affecting the value of the average QOF point as the average list size changes.  This is being actively addressed by the negotiating team as it has a small but significant effect on funding for General Practice and will continue to do so in future if not sorted.
PMS reviews
Guidance for LMCs will be issued shortly.  In my personal view, PMS practices might be sensible to ask the LMC for assistance at an early stage as there is unlikely to be anything other than a single model approach, perhaps even on a national basis, adopted for these locally negotiated contracts. GPC is prevented from negotiating directly on matters relating to PMS contracts.

Care.data
There was yet another presentation on this.  There is now an independent advisory group, which has an interesting combination of members.  I am not sure if the membership is currently in the public domain.  However, this is highly likely to be discussed at length at LMC Conference, where GPC policy on the matter will be set.

Communications
I may actually have news I can share on something which may actually be quite promising soon.  As things stand, I can’t/haven’t.

Recruitment and the future
An excellent paper was presented by some younger members of the committee, which is included as an attachment to this report.  Please, read it, forward it on, give feedback and encourage others to do so to, either to me or to the GPC secretariat.


The next meeting is to be held on 19 June 2014, as the annual Conference of Local Medical Committees, the annual “policy setting” conference, is taking place on 23/24 May in York.  I hope to be tweeting/updating from there as we go along (@drbrown1970), broadband and batteries allowing.  

I hope you have found this report helpful.  Please feedback so that I can ensure my reports are useful.  Feel free to email me if you would like to comment or ask me anything.  Comments can also be posted on my blog where this report will also be posted at www.thebrownstuff.blogspot.com

Dr Russell Brown

Friday, March 21, 2014

GPC report 20 March 2014

GPC Report
For East and West Sussex LMCs
Dr Russell Brown

20 March 2014

The GPC held its latest meeting today. 

Negotiation report
As usual, much of this part of the meeting was confidential.  
Contract 2014-15 Under sustained pressure from our negotiators, guidance on the contract changes for the next financial year should be out soon, after various last minute changes were rejected.  Likewise, guidance for the Unplanned Admission avoidance DES has been delayed as certain changes were proposed and rejected.  I understand the guidance will reflect the agreed position of some months ago. The GPC guidance documents have been ready for some time but need to be published after the "official" joint guidance documents that are published. Jeremy Hunt has said that there will be £5 per patient made available to further support the work around the Unplanned admissions DES.  However, it is likely that this money already resides within CCG budgets, albeit unbadged. LMCs will need to work with CCGs to ensure practices can access this money for their patients' benefit. Locally, I suspect there will be positive, proactive discussions.  Nationally, the picture is distinctly patchy. 
DDRB announcement We will be getting a 0.28% uplift, which is supposed to deliver a 1% rise in income for GPs. This figure has been arrived at because expenses have apparently fallen, a situation I do not recognise.  What this means is that the system for calculating expenses is flawed.  We are pressing for a review of the process to ensure the formulaic approach reflects reality in future.  The negotiating team are continuing to press hard on this.
MPIG/PMS reviews This is still chaotic, we continue to express dismay and anger that it is not sorted out.  There is a ready reckoner produced by NHS England to help practices get some idea how they will be affected.  I am not sure how accurate it is given the assumptions it makes.  However, my own non-MPIG practice would appear, on the face of it, to LOSE £6k per year, which seems odd.  NHS England persists with the fiction of local resolution of the PMS review process, given they are locally negotiated contracts, albeit with a de facto national "solution" to the differential funding “problem” between PMS and GMS practices.  Work is ongoing to ensure the £235M identified as NOT being mappable to additional work remains within General Practice.
Premises Work is ongoing, with discussions with health ministers.  They are aware their wishes for service changes will not work without some kind of premises strategy. Expect news at some point before the next general election...

Structure and function of GPC
Changes to nomenclature and processes were debated.  An attempt was mounted at the outset to have all the suggestions adopted en mass, facilitating an early lunch.  Sadly, my suggestion fell on deaf ears and lunch took place two hours later.

Care.data
After last month's discussion with Tim Kelsey, Tony Calland, the chair of the BMA's Ethics Committee, presented further information on care.data and it's implications.  There was a broad-ranging and lengthy debate.  The delay on extractions provides an opportunity to influence how this works.  It should be allowed to work, as it is potentially a valuable research tool.  Negotiations about potential changes are ongoing.

ICM perceptions survey
HPERU presented a summary of th results of a BMA perceptions survey, covering public perceptions of the NHS and GPs in particular,  As usual, we do well.

The latest edition of GPC news will be on the BMA website at https://communities.bma.org.uk/the_practice/default.aspx soon.  I suggest bookmarking the URL as in future GPC news will be published there, often on a more frequent basis than in the past.

The next meeting is to be held on 17 April 2014.  I hope you have found this report helpful.  Please feedback so that I can ensure my reports are useful.  Feel free to email me if you would like to comment or ask me anything.  Comments can also be posted on my blog where this report will also be posted at www.thebrownstuff.blogspot.com


Dr Russell Brown