Strain on A&E...

Just heard Hunt on Today program, trying very hard to back-pedal and say that it isn't actually GPs' fault that A&E can't cope with the extra 4 million visits per year but the previous governement for allowing us to opt out. And to put that 4 million extra consultations into context, UK GP see 300 million consulations per year. Yes, 2 whole orders of magnitude more...

Well, for one thing, my "part-time" week (read the comments on the Telegraph website) is already 47.5 hours, and that's without the extra I put in. For another, the reason I am tapping away on the computer is two-fold: most important is I'm keeping records so I can remember what happened to you years ago; but the way GP is resourced (NOT how I get paid but how the services in YOUR surgery are funded) means that if I don't tick an increasing number of boxes (many of which will do nothing to improve either your health or well-being), the resources don't come in to pay for the nurses, reception staff, equipment etc.

So rather than blame ME for poor OOH provision, fund the bloody service properly in the first place, rather than engage in a race to the bottom with cheapest wins the tender, set proper standards that must be adhered to. How about a national strategy, given it's the National Health Service? Rather than arms-length "oh that's the fault of local commissioners", who you haven't given the resources to in the first place. And make sure that A&E departments are empowered to tell people to go to the appropriate place rather than have to see and sort them (inadequately, which is not incidentally their fault).

It isn't bloody rocket science.

GPC report 18 April 2013

GPC Report

For East and West Sussex LMCs

Dr Russell Brown

 

18 April 2013

 

The GPC held its meeting on 18 March.

 

This months report will be brief as, for a change, much of the discussion was confidential.

 

Equitable funding, locum superannuation and PMS practices news

Discussions are ongoing. A letter to the profession has been sent by Laurence Buckman on 17 April and its contents are about all I can divulge on how the plans for equitable funding are likely to impact on PMS practices. Discussions about the new obligation on practices to pay locum superannuation are still ongoing but are no further forward at this time.

 

Additionally, there have been discussions about arrangements for collaborative fees and occupational health services for practice staff. But no news.

 

Communications

There will be an announcement shortly on a policy that is to be implemented very soon. You will have to wait for the announcement but expect some of previously aired concerns by LMC members to be addressed. It should also be noted that it will be an ongoing and developing piece of work, with involvement from the profession and patients being encouraged.

 

Premises

Work is continuing on nailing down the details for leases and the like. Legal advice is being taken by both sides in an effort to get an agreed and sensible model. However, it will still be necessary for practices to instruct their own advisors to ensure they will be well served by any lease arrangements.

 

NHS111

I was asked to give an interview to BBC South East Today about NHS111 during this months meeting. Fortunately, I managed to get back to the meeting without missing much about NHS111. In brief, it is still a mess, the tendering process has demonstrably failed, response times are still unacceptable. What we need is a reintegration on the triage service with the face-to-face service. Will it happen? As we already know, there is a political imperative on this. I just hope no one gets hurt.

 

Commissioning update

There was an update on the recently published conflicts of interest guidance from NHS England, the Monitor document on fair playing fields and an oral update on engagement with the process the Labour Party is going through to try and determine its health policies.

 

A motion was proposed and passed in all parts. I reproduce it below:

 

That GPC believes that compulsory practice membership of CCGs with statutory duties as defined by the Health and Social Care Act:

 

1. risks placing GP partners in a position of untenable conflict between their professional obligations to their patients and the statutory obligations of their practices as CCG members;

2. fundamentally changes the role and nature of general practices, and, in view of recent regulatory changes, risks forcing them to be integral agents of state rationing, cost control and privatisation, seriously threatening the trust between GPs and their patients and therefore posing a risk to the very integrity of NHS general practice;

 

3. places significant obstacles in the way of GPs and practices acting in accordance with the recommendations of the Francis report as they will be under inevitable pressure to comply with their CCGs' statutory obligations to stay within budgets and to achieve financially and managerially-driven targets which conflict with the needs of their patients;

 

4. adds to competing pressures on general practice, particularly following the recent contract imposition, and GPC recognises that practices must and will prioritise providing safe essential services to their patients and are therefore very likely to consider limiting their engagement with their CCG and its activities to their contractual obligations;

 

5. leads it to call upon the BMA , local medical committees to robustly support doctors who are placing the interests of their patients as their first concern and who may be unable to comply with obligations placed upon them by the constitution of their CCG where there is evidence that patient safety may be compromised by the requirements of CCG policy.

 

Words mean what words say and I will not embellish them by attempting to interpret the beyond repeating them.

 

I understand there are similar motions going to the Conference of LMCs next month. The next GPC meeting is in June because of this. There will be a report from there as well though.

 

I hope you have found this helpful. As ever, feedback on my report is encouraged.

 

Dr Russell Brown

 

PS It is interesting to see how much more detail is contained in this month's GPC News, which will be on the BMA website soon at tinyurl.com/cuea2rg, as I was under the impression much of the conversation was confidential. Perhaps I should be less discrete...

 

Text of my GPC report 21 March 2013

GPC Report
For East and West Sussex LMCs
Dr Russell Brown
21 March 2013
The GPC held its meeting on 21 March. Much of the agenda and discussions were confidential,
unfortunately. We are now in the new world of CCGs and post-Francis, not that I expect either of
those to make any difference to the direction of travel.
Contract and QOF
Though I cannot report on discussions which took place, details of the imposition and DES
specifications are gradually becoming clearer. It is not pretty and I suspect that at least some
practices will consider carefully whether the new work is affordable. I suppose it may be that
some of the less attractive bits may be possible to do in collaboration with other practices.
Whether that is desirable is for practices to consider. There has already been much comment and
guidance on this so I will not add to it except by pointing to some of it: http://bma.org.uk/practical-support-at-work/contracts/gp-contract-survival-guideThis is a work in progress and will be added
to over time.
The Francis Report
This said nothing terribly unexpected. The BMA welcomed it in the main. I have some concerns
about how it may affect GPs. However, with the rollout of 111 steaming ahead in many places
despite concerns being expressed by many, it appears that HMG and DH are still considering how
to implement some of the suggestions made in the report.
The future of General Practice
Not a GPC piece of work, but a response to a request from the Labour Party to consider how
they should develop their policies on this matter in the future. I can see arguments about being
inside a tent, but I am uncomfortable with this. I am generally cynical about the motives of
politicians.
Commissioning matters
An oral report from the negotiating team generated much discussion and, unusually, a motion
which was passed: "that GPC opposes and calls for the withdrawal of Statutory Instrument
2013/500." This referred to the competition concerns expressed elsewhere. Despite governmental
assurances, I suspect that CCGs will in effect have no choice but to tender services. If we can help
them see how and where they might avoid doing so I am sure they might be inclined to maintain
dialogue.
Premises
Work on premises cost directions is almost complete and there will be a common single set of
documents. The regulations themselves have been signed in to force in the last week. For the first
time there will be a uniform set of guidance notes, available by the end of April. One outstanding
area is the issue of waste of various types but I understand this will be resolved soon. Leases are
coming but still a work in progress.
NHS111 & NHSCB (now NHS England) Single Operating Model
Unfortunately I had to leave the meeting early so Julius will update us on theses items.
The next meeting is on 18 April. As ever, feedback on my report is encouraged.
Dr Russell Brown

GPC report 17 Jan 2013

GPC Report
For East and West Sussex LMCs
Dr Russell Brown

17 January 2013

The GPC held its meeting on 17 January. The day was in two parts, the morning being GPC-proper, the afternoon being devoted to a strategy session with thought-provoking (no, really) external speakers held under Chatham House rules. I expect to be able to share some of the issues raised in the afternoon with you in the months to come but as it is still a work in progress, now is not the time.

Contract negotiations update:
All of the details that can be shared can be found on the BMA website at
BMA.org.uk/working-for-change/negotiating-for-the-profession/general-practitioners-committee/contract-negotiations The BMA are running a survey until 13 February to gauge opinion from the profession. It can be found at http://www.demographix.com/surveys/6VQM-4EGE/72LVTJPV/
I urge you all to complete it before the deadline though it may be sensible to wait until you have attended the Negotiators Roadshow if you are unsure about the extent of the damage that is about to be inflicted on us. This is also true for our constituents and I would ask that you remind them about the survey repeatedly. The negotiators roadshow on Thursday, 31 January has been confirmed. This will be held in the Aurora hotel in Crawley though I am unsure which negotiator is attending. Julius maybe able to advise. This meeting technically covers Surrey and Sussex. As last month, I would encourage all of you to attend and I would ask that you encourage as many of our non-politically minded colleagues to attend as well. For those unable to attend, I understand that the intention is to webcast the Avon meeting which I believe is on 7 February. Either the LMC office or I will forward details of that when we have confirmation.

Public Sector Pensions update:
A useful presentation from Andy Blake, the head of the BMA Pensions department, updated the committee on where we are. The Bill is currently at the Lords Committee stage, about a month ahead of schedule. This implies a degree of "rush". The Government has conceded that the so-called "Henry VIII" clauses, allowing retrospective changes to Primary legislation using Secondary legislation, are inappropriate and has removed them from the Bill. This is good news though of course in a context of a dire inevitability.

GP workforce issues:
A paper was presented for discussion, to advise and inform strategy for dealing with and helping other bodies involved in issues such as workforce planning, a contradiction in terms as no one knows what the NHS will look like in five years, never mind fifteen to twenty. A learning point for me was that the UK has the lowest number of GPs per head of population of any European country. I already knew about the recent report showing we were also the most efficient in Europe. One can't help thinking those two facts must mean something significant.

The next GPC meeting is on Thursday, 21 February and I will be absent as I am on leave that day. Any feedback or questions are welcomed. I have also started publishing these reports at a blog I used to keep at www.thebrownstuff.blogspot.com so that people can get to it easily. I am not using the blog for anything else these days.

Dr Russell Brown.
GPC Rep East and West Sussex

GPC report 20 Dec 2012

GPC Report

For East and West Sussex LMCs

Dr Russell Brown

 

20 December 2012

 

The GPC held its meeting on 20 December. As is often the case there is much that I cannot share with you. However the image below should give you some idea of how I feel the meeting preceded at times.

 

 

 

Contract negotiations update:

You will all have seen the letters sent to the BMA as they have been circulated by Laurence Buckman. Analysis of the imposition documentation is taking place at the tools for modelling the effect on practices is being developed. This should be with us shortly. It is anticipated that there will be another letter in the next couple of weeks from GPC. After this there will be a survey of GPs to gather views on the proposals. This will not be a ballot. I will not repeat the details of the imposition. All of these details can be found on the BMA website at

BMA.org.uk/working-for-change/negotiating-for-the-profession/general-practitioners-committee/contract-negotiations

Given that we are technically in the midst of a consultation about these changes I would encourage all of you to respond to the consultation both individually and through the LMC office. This will enable the BMA to show how much strong feeling there is about this matter. There will be a negotiators roadshow on Thursday, 31 January. This will be held in the Aurora hotel in Crawley. I would encourage all of you to attend and I would ask that you encourage as many of our non-politically minded colleagues to attend as well.

 

 

 

Locum superannuation:

Separately to the contract negotiations the government is suggesting that superannuation payments for locums, which are currently paid by PCOs, will be moved into global sum. This has significant implications the both practices and locums. The BMA will be responding to this consultation in due course.

 

 

Data sharing agreement template for risk stratification:

A template has been developed by the BMA. This will hopefully help practices to ensure that local arrangements for datasharing between practices and third parties adhere to appropriate standards of confidentiality. This template will be sent out in due course.

 

Deprivation:

There was much discussion around the subject of deprivation and workload together with the impact of resource allocation formulae. A motion was passed to the effect that GPC will work with the Department of Health to introduce either a deprivation allowance or other recognition of increased workload in deprived areas. However it should be noted that much of the discussion was around the fact that many health problems may be dealt with by improving resources in other areas such as social services rather than directly in health.

 

CQC registration fees consultation:

The BMA has now responded to the CQCs recent consultation and the response can be found on the CQC section of the BMA website.

 

There was also a session of breakout groups to discuss how best to implement the separation of the positions of Chair and Lead Negotiator within GPC. This is a matter of LMC Conference policy. I started the afternoon thinking that the whole idea is madness. I'm delighted to report that by the end of it I was less convinced it was madness but I'm still unconvinced that it can be made to work. More news when I have it.

 

The next GPC meeting is on Thursday, 17 January.

 

May I wish you all a peaceful and restful Christmas and New Year.

 

Dr Russell Brown.

GPC Rep East and West Sussex

 

GPC report November 2012

I have just come back from a few days leave and was about to write my GPC report when I realised that actually, I have nothing to say this month.  Much of the meeting 10 days ago was either of no interest to grassroots GPs (being matters of process within GPC) or is confidential. 

I was hoping to have more info on the proposed imposition but have none as yet.  It does not, however, look good.

NHS 111 is still a mess and looks to be likely to cost around £2.2million per year more than the current system.

The NHS Mandate/online access business will need to be worked on and Jeremy Hunt already seems to be willing to talk about what is possible and more importantly from our point of view, what is not.

And that's it really.

So there will be no written report this month.

GPC report October 2012

GPC Report

For East and West Sussex LMCs

Dr Russell Brown



18 October 2012



This month was a meeting in two parts. The morning was spent in various subcommittees. I am a member of the Commissioning and Services Development Committee, which has a very wide brief.



Discussion was mainly about the ethically rather dubious incentive schemes being published in a variety of places, Harrow being a particularly harrowing example. These schemes aim to directly financially reward GPs for reducing referrals. This has obvious (I hope) implications. The GMC, when asked for comment, were not terribly helpful. I suspect any GP signing up will be on their own if anything untoward happens as a result of schemes like this. The BMA is intending on making it clear what it considers ethically appropriate. It is conceivable this will exceed what the GMC suggests is acceptable. I must confess to some confusion as to why the GMC is not being more clear in its position.



The other main topic under discussion was performance management of primary care (for which read general practice). The relevant team from the DH have been meeting with a small group of LMC secretaries to discuss how this may work. It should be noted that these are not negotiations, more of a feeling the way forward. The LMC secretaries concerned are being robust in their feedback. Eventually, these meetings may pave the way for negotiations about how to might work in a useful way. In the mean time, I recommend that GPs get in the habit of practicing the following mantra, so it can be recited at appropriate junctures, making any appropriate deletions: "My professional registration is with the GMC. My GMS/PMS contract is with the PCT/LAT. I have a contractual obligation to be a member of a CCG. And that's it. Further queries should be discussed with the LMC." We seem to have very good liaison with local emerging CCGs, so hopefully you will never need to use it. I will let you know if anything changes on that front.



There was a brief discussion on the commissioning of Local Enhanced Services. To reaffirm, unless a single contract is going to exceed £100,000 there is no need to go to tender. There is also no requirement on CCGs to use either the AQP route or competitive tendering. In e context of a LES, the contract size depends on the size of the practice, not on the size of the budget. So a budget of £250,000 does not require tendering if all practices will be taking part in a LES, as the individual contract with each practice will be under the limit.



The afternoon session was the full GPC meeting.



The need for confidentiality was repeated, forcefully.



The GP IT Subcommittee reported that work is ongoing to try and make the transition of GP IT support services as painless as possible. Many of the problems arise from the fact that the amount of funding in many areas is uncertain, so many PCOs are unable to tell the NHSCB with any certainty how much money it needs to budget for these services.



I will now report on other matters, including the current state of negotiations for GMS/QOF for 2013/14, as far as I am able to:

This space is left intentionally blank.

I hope this report is useful. Please feed back any comments if you would like me to present it differently. Additionally, if you have any matters you wish to discuss or that you would like me to raise at GPC, please contact me by email at my email address, which I'm not posting on blogger :)



Dr Russell Brown

GPC and Chair East Sussex LMC

GPC report September 2012

GPC Report

For East and West Sussex LMCs

Dr Russell Brown

 

20 September 2012

 

This month's meeting took place in BMA House in London again, as the Olympic season is over. The day started with a rather uninteresting 10 minute GPDF AGM and I will not subject you to further information on that.

 

There was discussion around the recent Dispatches program which effectively blew the whistle on the way DWP assessments are being undertaken by ATOS. A letter will be sent to the DWP asking what they are going to do about. Additionally, a meeting between Laurence Buckman, Mark Porter and the Minister has been organised for October to discuss the matter.

 

The matter of NHS Pledge cards was discussed briefly. I understand this will be considered by BMA Council next week. The intention of the cards, as I understand it, is to enable GPs to reassure patients that they are supporting the NHS by only referring them to NHS hospitals. Personally I am uncertain that this is something that is sensible for the BMA to commit to given the huge local variations in service availability and quality. I would be reluctant to commit to a scheme of this nature if I knew a local private or AQP provider would be a better choice for the patient sat in front of me for example. GPC's position is that we are neutral on the matter until we have more details to consider.

 

Pension matters have been quiet over the summer. I understand however they are to be discussed at BMA Council next week. The Public Service Pensions Bill was published on 13 September and as you know it's purpose is to address the claimed unsustainability of Public Sector Pensions. The BMA strongly believes that the scope of these changes is unfair and will adversely impact staff in the NHS Pension Scheme for reasons we have discussed before. The BMA is working on several strands of work. Firstly, the BMA is involved with the Working Longer Review, looking at the impact on health workers; secondly work with the other health unions to look at the principles of the relative contributions; lastly using the publishing of the Bill as an opportunity to lobby Parliamentarians and make them aware of our concerns.

 

Reports from various of the subcommittees were received. There seems to be an issue in the Kent, Surrey and Sussex Deanery area where GP Trainees who require further training are only being offered part time positions, apparently so as to avoid the prospect of a waiting list (and no work). Funding seems to be the issue. Many of the individual doctors concerned are vulnerable for one reason or another and seem to be unrepresented by anyone but GPC so far. The GP Trainee subcommittee is watching the situation. Of interest to some practices in the federation will be the fact that CSC, the provider of iSoft Synergy and Premier GP IT systems will not be supporting them after October 2013, necessitating a change of system for those practices. This will be managed carefully to avoid problems with QOF data degradation.

 

In better news, there has been movement on Revalidation: GP remediation will be funded in certain circumstances by NHSCBA from central funds, namely where the training needs to take place away from the normal place of work. However, I heard nothing about locums and am concerned that most GPs in need of remedial training will have it in their practices and so am unclear how this will be funded. Criteria for deciding on eligibility for this will be discussed and decided with the BMA in due course, but I have no idea how long that will take or what will happen in the mean time. Some colleagues may have seen stories in the press about the BMA agreeing that Revalidation can go ahead. That isn't quite right but the BMA has agreed that its seven principles have been met sufficiently to allow the process to move forward, though there are still many outstanding issues which need to be addressed.

 

The authorisation process for CCGs moves on in unstoppable fashion. We are fortunate locally that there is LMC involvement in developing our Constitutions. In some areas there are reports of CCG Boards behaving quite irresponsibly which doesn't bode well for their longevity I would think.

 

Finally, the juggernaut of NHS 111 similarly moves on. There are still many problems which the project board seems to find difficult to comprehend. Many of these are manifestly patient safety issues. The dispositions need much work. Pilot areas are feeding information back to GPC. The ScHARR report into the performance of the pilot schemes is inexplicably still unpublished, having been in the hands of the Ministry for some time.

 

I hope this report is useful. Please feed back any comments if you would like me to present it differently.

 

Dr Russell Brown

GPC and Chair East Sussex LMC

 

GPC report July 2012

GPC Report

For East and West Sussex LMCs

Dr Russell Brown

20 July 2012

The first meeting of this session of GPC took place, unusually, in Edinburgh, due to the Olympics dominating hotels and BMA House this month.  The city is lovely to visit, though I didn’t get to see much of it due to a pre-meeting meeting of the Commissioning and Services Development Sub-committee.  Although if I’m honest, that last was my own fault, as it was I who suggested meeting beforehand rather than after, as I had a plane to catch.

The first thing to report is the election of the GPC negotiating team: five candidates stood for four positions.  As has been widely reported in the medical comics, those elected were Richard Vautrey, Peter Holden, Chaand Nagpaul and Dean Marshal.  Beth McCarron-Nash was not.  This caused some consternation amongst some of those attending the meeting.  I suspect the result is at least in part down to the vagaries of the single transferrable vote system used.  However, the end result is that the negotiating team is perhaps less demographically representative than GPC as a whole, which is less demographically representative than the profession as a whole.  Richard Vautrey was also made Deputy Chair.

After the elections were held, discussion moved to the progress of negotiations with NHS Employers .  Unfortunately much that was discussed is confidential and I am under threat of death by suffocation if I reveal any details of the debate.  Nevertheless, I am prepared to tell you that the proposed changes to LES arrangements are at the very pinnacle of the mountain of issues the negotiating team intend to address.  There are numerous issues around this which we can discuss in committee if you wish.  Additionally, Julius has already written to colleagues about the contractual status of CCG constitutions, or rather their lack, and a physical signing may not be necessary, nor may 100% uptake.  However, much is uncertain as there are currently no regulations or guidance to assist anyone.  The Health and Social Care Bill (HSCB) of course mandates in clause 28 that all practices in England must be a member of a CCG from April 2013.  With regard to NHS 111, problems continue to be raised with the project board and the official report on the pilots will apparently be published later this month.

We had an opportunity to be addressed by our new Chairman of Council, Dr Mark Porter, an anaesthetist, though this should not be held against him. As you may be able to imagine, his main topic was that of pensions and industrial action.  I am sure you are aware that BMA Council decided, narrowly, to not pursue further industrial action.  He made several points about this, most of which has already been reported in the press but which can be summarised briefly as:

• No other unions will be taking further action and Labour will apparently not be opposing the Public Sector Pensions Bill;
• The only escalation which could be reasonably planned would be a full strike and it is unlikely the majority of members would engage with that;
• The DH and in particular the Treasury are determined not to make any concessions.  However, we took IA to get them to talk to us.  We have now been offered the chance to be involved in the review of the impacts the changes may have, the “Working longer” Review, and other Trades Unions are keen to have us there.   So we are talking.  Just not negotiating.  We could not be a member of that group if we were to take further IA. Being part of it allows at least the potential for influence and mitigation.

Dr Porter made the point that this is not the end.  There will be a campaign to make it clear to all what our position is.  It is perhaps arguable that we should have done that already.  However, regardless of how one feels about the IA taken already, a further escalation is likely to divide the profession and perhaps damage both the profession and our Trade Union permanently.  Having said that, it was obvious, reading between the lines, that there are many differing view points, both on and off Council.  But I probably didn’t need to tell you that.

There was some discussion about how to deal with Premises issues especially how to achieve improvement in funding arrangements.  I note this to advise that this is the case, but this is one of the issues I may not currently discuss in detail.  I can report that the Northern Ireland model is of considerable interest.

Revalidation was discussed again.  There are still many issues unresolved, especially how remediation is to be funded and how certain groups of colleagues such as freelance locums will be able to engage with the process.  However, I am not certain that much will be resolved before the Secretary of State for Health signs the process off as ready and fit for purpose.  The situation on the ground does not seem to be the same as that which is being discussed in the meetings reported to us at GPC.  No doubt it will all come out in the wash.  I just hope the rinse cycle doesn’t damage any of us in the process.

Finally there was further discussion about the non-Commissioning bits of the HSCB.  There is actually little to report.  A summary of most of it could be “meetings are continuing”.  There are some IT developments, in that the DH hopes, by 2015, to have achieved four things, that patients will be able to book GP appointments and request repeat prescriptions, which is achievable, given that many practices already offer this; access to patient records may not be as it is fraught with governance difficulties; e-consultations will for most patients not be their main method of communication with their GP I suspect, but it appears the focus groups the DH uses think it is a good idea.   Who knows, for some, patients and doctors, it may even be workable and secure.

I hope this report is useful.  Given it is my first, any feedback offered will be considered carefully.

Dr Russell Brown

GPC and Chair East Sussex LMC

Yet another phoenix (or possibly not)

I have just been elected to GPC, this time to the regional seat of East and West Sussex.  Given blogging seems to have deserted me (!), I shall, perhaps use this blog to provide reports for my constituents from now on, roughly monthly.

As my 3 year term begins in July, it may well be from then that reports appear.

PFI - we did tell you at the time.

http://www.parliament.uk/business/committees/committees-a-z/commons-select/treasury-committee/news/pfi-report/ 

The Treasury Select Committee has published the report of its inquiry into PFI, available. Many of the Committee's concerns echo those raised in the BMA's written evidence to the inquiry, particularly around the inflexibility and lack of value for money of PFI projects. A summary of the key points is below, prepared by the BMA's HPERU unit.

• Analysis undertaken by the Committee’s Specialist Adviser suggests that, all else being equal, paying off a PFI debt of £1bn may cost the same as paying off government debt of £1.7bn. This would mean that a 70 percent increase in investment could be achieved for the same long term cost if government funding were used instead of private finance.
• Allocating risk to the private sector is only worthwhile if it is better able to manage the risk and can pass on any subsequent savings to the client. The main benefit highlighted by PFI providers was the transfer of construction risk. However a PFI contract which lasts for 30 years is not necessary to transfer this risk.
• In the area of design innovation and building quality there is some evidence to suggest that PFI performs less well than traditionally procured buildings.
• The fixed nature of PFI contracts means they are likely to provide more certainty regarding price and time. However there is no convincing evidence to suggest that PFI projects are delivered more quickly and at a lower out-turn cost than projects using conventional procurement methods. On the contrary, the lengthy procurement process makes it likely that a PFI building will take longer to deliver, if the length of the whole process is considered.
• PFI contracts are inherently inflexible. There is little evidence of the benefits of PFI arrangements, but much evidence about the drawbacks, especially for NHS projects. The inflexibility of PFI means that any emergent problems or new demands on an asset cannot be efficiently resolved.
• The Value for Money appraisal system is biased to favour PFI. Assuming that there will always be significant cost over-runs within the non-PFI option is one example of this bias. There is an incentive for both HM Treasury and public bodies to present PFI as the best value for money option as it is often the only avenue for investment in the face of limited departmental capital budgets
• For too long PFI has been the ‘only game in town’ in some sectors which have not been provided with adequate capital budgets for their investment needs. This problem is likely to get worse in the future with capital budgets cut significantly at the Spending Review. If PFI is the only option for necessary capital expenditure then it will be used even if it is not value for money. A much–needed reappraisal of PFI needs to be accompanied by a similar reassessment of its effects on overall capital spending in the public sector
• The price of finance is significantly higher with a PFI. The financial cost of repaying the capital investment of PFI investors is therefore considerably greater than the equivalent repayment of direct government investment. The Committee has not seen evidence to suggest that this inefficient method of financing has been offset by the perceived benefits of PFI from increased risk transfer. On the contrary there is evidence of the opposite. The Committee does not believe that PFI can be relied upon to provide good value for money without substantial reform.
• Owing to the current high cost of project finance and other problems related to PFI, there are serious doubts about such widespread use of PFI. There are certain circumstances where PFI is likely to be particularly unsuitable, for example, where the future demand and usage of an asset is very uncertain and where it would be inefficient to transfer the related risks to the private sector.

Central servers

Is it just me? I fell distinctly uncomfortable with the prospect of universal, centrally held servers.

Oh, I can see the advantages, sharing info between practices, easy transfer of records etc.

However, as the data controller, how can I guarantee control when I don't physically have access to the server? I am less than reassured by the presence of robust audit trails etc, as that sort of thing is very useful after a breach has occured but useless to prevent such a breach occuring in the first place.

http://www.ehiprimarycare.com/news/6054/inps_wants_vision_360_to_be_gp_system

That is the article that has got me thinking (again) about this. I understand that EMIS Web will be the only EMIS product with accreditation for EPR2. That is a shame, as many practices will not wish to change just for that, and EPR2 is one part of the CfH schema that may actually be of use and benefit to practices. It appears that INPS will be keen to see a move to their new system, though of course Vision 3 will remain compliant.

There is a part of me that hopes that IT spend will be part of the devolved budget that comes through with the commissioning changes. GPs could once again then start driving the process of development rather than reacting to it.

Another example of where control needs to be wrested from the PCOs.

Practice Boundaries: a proposal

Text of a press release follows:

BMA sets out its proposal for how to reform general practice boundaries


The BMA today (Tuesday 26 January 2010) sets out its solution for how to reform GP practice boundaries* and make it easier for patients to see a GP in a place and at a time that is more convenient.

The government wants to abolish practice boundaries by October 2010 and the Conservatives have said they want patients to be able to register with the practice that best suits them (near their home or work). A government consultation on practice boundaries is to start shortly.

The BMA paper, Reforming General Practice Boundaries, explores the possible consequences of completely abolishing practice boundaries and suggests a solution which, while not a total abolition, would significantly improve choice and access for patients without the huge cost, upheaval and unintended consequences that completely free registration would cause.

Dr Laurence Buckman, Chairman of the BMA’s GPs Committee, said:

“Complete free choice of registration is a good idea in principle and we want patients to be able to choose the GP surgery that is right for them. However, we don’t want it to come at the expense of continuity of care or for it to lead to increased risks for vulnerable patients and a widening of health inequalities.”

The BMA believes that total abolition of practice boundaries could have a number of unintended consequences. Examples of issues that would need to be addressed in advance of completely free registration include:

* How to reform the home visiting system so continuity of care for patients, who are registered with practices far from their home, isn’t affected
* Current IT projects, such as the electronic patient record transfer project, would need to be accelerated so GPs could have access to full patient records in order to make safe clinical decisions
* How to avoid widening health inequalities – this could happen if frail people or those without access to private or affordable public transport are not able to access practices further from their home, while others can
* Systems would need to be put in place to protect and track ‘at risk’ patients who could be vulnerable if they are regularly re-registered at practices not within their social services boundary
* Funding arrangements for GP practices would need to be reformed to ensure that, with increased movement and changing patient demographics, funding for all practices is fair and equitable
* Popular practices that had reached the limit of physical capacity would need to be helped to improve their premises in order to match patient demand
* Primary Care Trust (PCT) funding would need to be completely changed in a way that would take into account the impact on hospitals and social services. This would be extremely complex if the patient lived in one trust but registered in another.

The General Practitioners Committee’s solution is to combine a series of local improvements with a national change in the current “temporary resident” arrangements. Local solutions should include permitting the widening of the boundaries of all practices in an urban area so patients have greater choice, the introduction of videophone and webcam consultations, as well as formally allowing patients who move outside a practice boundary the option of staying with their GP. The change in the temporary resident arrangements would mean unregistered patients could be treated by a distant practice on an ‘ad hoc’ basis whenever necessary, while their normal GP practice would still oversee their care. It would have the added benefit of encouraging patients, who might otherwise inappropriately attend A&E, to go to the nearest GP surgery instead.

Dr Buckman added:

“Getting rid of practice boundaries altogether is fraught with difficulties. Having worked through various alternatives, we believe this solution is the best option for the health service at this point in time. Not only will it be the most cost effective solution, it will also serve patients far better. They will get more choice and are less likely to be adversely affected by the new set of problems that total abolition would create.”

An explanation

Hello, been a while.

Someone noted that I haven't blogged for a while. I thought I should explain.

I have been busy. I am now very much part of the establishment, being Chair of East Sussex Local Medical Committe. Additionally, in June of last year, I was elected to the General Practitioners Committee of the BMA for a year. I am not sure whether I will get re-elected this year, time will tell.

As a result, given I do not (and have never) blogged anonymously, I partly have no wish to cause our negotiators difficulty by commenting publically on matters political, but mostly I have less time to post and comment.

Consequently, my blog has fallen by the wayside almost entirely. I spend sufficient time discussing medico-politics during the day, one way or the other!

On which note, I'm hoping to start using my camera more as a means of relaxation, so you might get some photos on here, interspersed perhaps with the odd bit of politics.

(By the way JD, it was nice to be missed. Thank you. That also to the few dozen people (or at least aggregators) who have persisted in checking my blog every week.)

Flickr

This is a test post from , a fancy photo sharing thing.

Darkness at the Heart of the Labour Party

I don't normally re-blog what others have, but this one is illuminating.

A greek chap I read pointed me to the blog of Frank Field MP.

"Harold Wilson asserted that the Labour party was a moral crusade or it was nothing. The McBride affair has left Labour members looking at nothing. That is the reality check that McBride has wrought on the party.

The whole of the government's energy should be spent on governing now and building a programme from which, within and year, we will be seeking permission to rule for another five years.

Far from helping sketch out a new roadmap, the McBride activities shine a searchlight on the paucity of the government's programme."

Please, go and read the rest.

How to work out your increase in funding

This one is for GMS GP readers (and possibly practice managers, I've no idea if any of those read my blog).

What does the DDRB recommendation mean for your practice? I was rather confused initially, so after working it out (with some help including an illustration by Dr David Shaw on DNUK) I wrote a very short paper to share with others.

So here it is. A quick guide. Except that I wrote it in Word to start with and discovered that copying and pasting from Word into HTML is an interesting experience, one that I will try and avoid in future. Anyway, I retyped it here.

How to work out your GMS funding

There are 4 components to it:

1. Global Sum (GS) increases by 2.4%
   
2. Global Sum Equivalent (GSE) which equals the GS plus your correction factor (if you are an MPIG Practice). This increases by 0.7%
3. QOF points increase by 1.7%
4. Enhanced services (ES) funding increases by 1.7%

For non-MPIG practices, your GS goes up by 2.4%, QOF and ES go up by 1.7%. Simple.

For MPIG practices, it is slightly more complex. Obviously the QOF and ES bits are the same, increasing by 1.7%. But for the rest of it, keep reading:

• Calculate both your new GS and your new GSE.
• If the uplifted GS exceeds the uplifted GSE, you move off MPIG (congratulations).
• If not, the GS component of GSE is uplifted by 2.4% and the CF is likely to drop to give an overall increase in GSE of 0.7%.
  

What this actually means in practice is that your Practice Manager will be able to see if Primary Care Support Services are paying you what they should each month.

Obviously your QOF and Enhanced Services monies will vary from practice to practice, but you should (at least) be able to work out how much each QOF point is worth to you practice. Ask your LMC rep if your PCT is uplifting the Enhanced Services Floor by 1.7%. They should be.

A couple of worked examples to illustrate differing magnitudes of CF:

Practice 1

• GSE £101,000, made up of GS £100,000 and CF £1,000
• GSE increases by 0.7% to £101,707
• But GS uplift gives £102,400
• This is bigger the GSE, so you no longer have a CF and you move off MPIG.

Practice 2

• GSE £110,000, made up of GS £100,000 and CF of £10,000
• GSE increases by 0.7% to £110,770
• GS uplift is also £102,400
• CF=GSE-GS, so =£8370
• So the net effect is an increase of 0.7% with a decrease in reliance on MPIG with a reduced CF (goes down by £1630)

Addendum: the CF is recycled into the GS, so as more Practices move off MPIG, there is no loss of money from the overall pot.

A decade

I really haven't been very good at keeping up with this blogging lark.

Part of the problem is my decision at the outset NOT to be anonymous. Consequently, much of the material others publish is not possible here as I have no wish to identify anyone, even if inadvertently, that I have seen in surgery.

Nevertheless, this week marks my tenth year at Manor Park. I think that deserves a mention.

I initially wrote a long piece about my time at the practice so far but frankly it was boring. However, the fact is that it can be summarised quite briefly: The patients keep coming because they need us, we are seeing more and more people all the time, I am still enjoying the clinical side of things greatly. The admin side of things gets increasingly onerous as time goes by. The "light-touch, high-trust" contract which was brought in in 2004 has proven to be anything but, though we are much luckier in our relationships with our PCT than many.

I have seen many changes in the last 10 years, some of which have happened to me and some of which I have been instrumental in.

The gradual adoption of our computer system's facilities has been a very significant change, one which I initially led. We now have a website as well, where patients can pre-book appointments and request repeat prescritions.

The new contract in 2004 was an eye-opener. Initially I can confidently say it improved matters in Primary Care. However, as is the nature of these things, the consequences (intended or otherwise) are playing havoc with General Practice, not helped by a predatory and antagonistic Government who seem to feel the need to grind us into submission when all we want to do is do our job. This despite our patients constantly supporting us in whichever survey you care to mention.

I have also been an active member of the East Sussex Local Medical Committee since 2000. I suppose this makes me a politician. I try my best to contribute in a meaningful way, though it is for others to say if I am successful. Whether any of those others read this blog, though, I have no idea. I can't see the pointing in whinging about things if you're not prepared to do somethig about it. So I try to.

I've also changed in the last decade. My experience base has grown. My practice has, too. I've been divorced, remarried and made a father again. I swear (a bit) less, laugh as much as I ever did (quite a bit) and I think I am both more considered by more adamant in my viewpoint and espousals. I guess I've grown up some more.

Anyway, I'm starting to ramble.

I will try and post more frequently...

Self confidence

"I'm a Normandy veteran you know. Yeah, I won the war.

Well, me and another bloke, but he was rubbish."

I love these old veterans.

Darzi and coffee

Honestly, he really has no idea, does he.

(With thanks to Hairy Aerosol for the image)