Joint
letter from John Hutton and John Chisholm
This letter
is issued jointly by John Hutton, Minister for Health and John
Chisholm, Chairman of the General Practitioners Committee of the
BMA.
Following
talks between representatives of the GPC and the NHS Confederation,
the framework agreement setting out the key approaches for the
new GP contract was published on 19 April 2002.
This agreement
emphasises the need to ensure that GPs continue to receive financial
support towards costs they incur as owner-occupiers or leaseholders
of premises used to provide NHS general practice services.
The agreement
also sets out a package of measures which are designed to address
the obstacles which in some cases inhibit GPs from moving to new
premises. It is intended that the package of measures on offer
demonstrates the continuing commitment by Government to supporting
GPs in providing practice premises. Full details of the package
are summarised at Annex A.
We are also
aware of particular concerns being expressed by GPs who are considering
leasing modern practice premises from third party developers.
The concerns centre around whether GPs will continue to be supported
towards practice premises’ costs under the new GP contract. In
addition, GPs who have or will sign leases are concerned that
they will be trapped in premises when they need to move elsewhere
or retire but another practitioner is not available to accept
an assignment of the lease. The Government is acting to address
these concerns too and Annex B provides advice on these and other
related GP premises issues. Further guidance will follow concerning
the implementation of these proposals.
The measures
we have set out in this letter allow for practical solutions to
be found locally to deal with concerns that have been raised on
landlord-tenant leasehold matters. This letter also demonstrates
to third party developers and their funders the strength of support
and safeguards that are available to GPs who enter into leasehold
arrangements.
We therefore
look forward to GPs working closely with their PCTs and others
to seize the opportunities which are now being offered by traditional
investment routes, third party developers and NHS LIFT to modernise
the premises from which primary care services are provided.
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John
Hutton
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John
Chisholm
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Annex
A
Infrastructure
premises
1. The provision
of modern practice premises requires that GPs incur significant
cost liabilities that require specific funding scheme arrangements
to support their availability. The private sector is increasingly
playing the role of provider of capital to build the premises
and acting as landlord to its GP tenants through binding legal
agreements. It is important therefore that explicit funding scheme
arrangements are available to provide robust, national arrangements
to support GPs on a similarly favourable basis as those for third
party developers, in terms of revenue stream, overall return on
projects and risk. This will provide stability for GPs as well
as giving assurances to funders and landlords that premises’ costs
will attract consistency of support under the new GP contract.
2. Areas with
poor returns on capital have historically attracted low levels
of investment in primary care infrastructure. A first tranche
of premises flexibilities has already been introduced to address
barriers to investment. A second tranche has now been developed
to extend the first, together with other changes to maintain GP
choice in investment routes and to provide parity in access to
funding. As with earlier flexibilities, these will come with inbuilt
controls and checks to ensure they are used by PCOs in the interests
of the service and deliver value for money.
3. The second
tranche of flexibilities, which the BMA has agreed will shortly
be implemented in England, includes:
- the possibility
of payment of a grant to meet mortgage deficit costs, to enable
GPs to sell their existing premises and move to appropriate
alternative premises
- the possibility
of payment of a grant to meet mortgage redemption costs
- the possibility
of allowing PCOs to take an option on land
- allowing
PCOs to continue cost rent payments to GPs who buy premises
from a single handed/two partner practice
- allowing
PCOs to review cost rent payments when GPs re-mortgage to lower
interest rates
- reimbursement
of legal and other professional fees for GPs in new premises
developed by public-private partnership
- revised
arrangements to pay notional rent in addition to cost rent when
premises are modernised or extended
- abatement
of notional rentto pay full notional rent on GP capital invested
in premises and abated notional rent for NHS capital equivalent
to additional costs for heating, lighting, maintenance etc.
- payment
of notional rent to leaseholder GPs who improve their premises
- extension
of the timescale to repay improvement grants and PMS equivalents
to 10 years for owner occupiers and for renting GPs to re-negotiate
the terms of their lease to 15 years
- allowing
PCOs to reimburse service charges directly
- introducing
periodic (potentially quarterly) reviews of building cost location
factors
- introducing
index-linked leases (e.g. RPI-based) to support capital invested
in primary care premises better
- a revised
premises schedule
- a revised
commentary
- issuing
a letter on safeguards and security for GPs signing leases with
third party developers with the intention that PCOs will be
able to have a lease assigned to them temporarily if the departing
GP is unable to assign it.
4. Additional
investment in primary care facilities is needed to ensure delivery
of many of the national targets and standards. Decisions about
the funding for premises will draw on the PCO’s 3-5 year service
development and delivery plans. This will ensure that funds are
targeted at those areas where premises are most in need of improvement.
5. Allocations
to PCOs will include funds to support the capital and revenue
consequences of developing and maintaining the primary and community
care estate. There will be an ability to reimburse practices directly
for the costs of large pieces of capital equipment. PCOs will
be required to develop collaborative arrangements that ensure
the investment which is needed to support delivery of high quality
primary care services is in place.
6. Customised
arrangements for implementation of the above process will need
to be developed for Scotland, Wales and Northern Ireland.
Annex
B
Future
funding of GP premises
In providing
premises from which to see patients, GPs incur liabilities to
meet mortgage or leasehold costs for extended periods of time.
In return, successive governments have supported GPs towards those
costs and the framework agreement sets out a range of mechanisms
to assist GPs in overcoming barriers to the provision of modern
premises from which to see their patients.
Leasehold
issues
There is a
perception that having signed a lease, GPs will be locked into
premises until the lease expires. The concern is that GPs will
be unable to retire or practise elsewhere, or if able to move,
that they will continue to be liable for future rental costs.
These concerns are addressed below.
Normally,
a successor GP will be able to accept an assignment of the lease
and responsibility for associated rental costs which, in turn,
will be reimbursed. However, occasions can arise where such an
assignment is not possible because for example, any remaining
GPs are unable to increase their leasehold interest in the premises
because they practise part time, or a successor practitioner has
yet to be appointed.
In the interest
of service continuity, PCTs should accept an assignment of the
departing practitioner’s interest in the lease, effectively as
a ‘sleeping partner’, for a temporary period of time until alternative
arrangements involving a successor practitioner (or PMS provider)
are made. In this way, GPs would be free to retire, move elsewhere
to practise etc. with no ongoing liabilities.
In the same
way, successor GPs, particularly those new to general practice,
can be assured that they would be able to accept a lease assignment
in the knowledge that they will be unencumbered should they need
to move at some point in the future. It should be noted that leases
should allow assignments between PCTs and practitioners and vice
versa and that they should not contain authorised guaranteed agreements
(AGAs). Where an existing lease allows for an AGA, the above arrangements
provide sufficient safeguards such that it would be unnecessary
for the landlord to call upon the AGA.
The above
arrangements will be equally available to support GMS GPs and
PMS pilot providers in leasehold agreements where the practitioners
are non-salaried contractors. Where practitioners are salaried,
it will be for PCTs or other pilot PMS providers to enter into
lease agreements on behalf of their employees.
PCT
Headleases
We are also
aware that PCTs are being encouraged to take headleases to sublet
practice premises to GPs or nurse practitioners. Reasons given
for entering into such arrangements include providing certainty
that practitioners will be able to make career moves, retire etc,
unhindered, and additionally that from their commercial standpoints
some third party developers and funders view PCT headleases as
providing better covenants and stability.
However, as
explained above, there are no plans to discontinue support to
GPs in meeting premises’ costs. That commitment means that a lease
held by a GP is a strong covenant in itself. This covenant is
strengthened by the fact that should a GP need to move from existing
premises, PCTs will be able to take an assignment on a temporary
basis until alternative arrangements are made. There is therefore
no need for PCTs to take a head lease for areas of premises to
be occupied by non-salaried GPs/nurse practitioners.
Nevertheless,
there are limited circumstances where a PCT headlease will be
appropriate. In the main, this will be to bring together disparate
GPs to share new premises. It is recognised that this new group
will need time to settle before taking responsibility themselves
for the lease.
In such circumstances,
it is recognised that, in the interests of the service, PCTs may
take a headlease for the new premises and sublet space to the
GMS GP practice or PMS pilot provider. This will maximise flexibility
to deal with future changes in circumstances. Again, however,
this should be planned to be a temporary arrangement with an agreed
policy to assign the lease to the practitioners when their business
arrangements allow this to happen.
Capital
charges
Where PCTs
need to take a temporary lease interest (for example, as set out
in the previous paragraphs) they may incur a liability to pay
capital charges. The potential to incur this additional cost has
deterred some PCTs from taking a lease interest, which in the
past has prevented necessary developments going ahead.
However, it
should be noted that in July or August each year a review is undertaken
to determine total PCT capital charge liabilities; these estimates
will inform the resources allocation process. Higher than planned
capital charges will represent a cost pressure and PCTs will wish
to discuss resource limit cover with their sponsor HA. Trusts
and SHAs can therefore forward-plan to accommodate additional
capital charges that will arise at a future point in time. Capital
charge liabilities that arise unexpectedly can initially be met
from existing unified allocations and capital charge adjustments
discussed with SHAs at the earliest opportunity.
NHS
LIFT
The NHS Plan
for England set a target to have up to £1billion invested in the
primary care infrastructure. A major new initiative to help achieve
this will be new public, private partnership equity stake companies
– NHS LIFTs – in areas where primary care services are in most
need of expansion. Eighteen LIFTs have already been announced,
with around another 24 to be announced later this year. This new
approach to public, private funding will enable modernprimary
care facilities to be provided across local health economies where
previously there have been low levels of investment.
However, it
is recognised that LIFTs will not operate in all parts of the
country but will concentrate on areas with greatest need. In addition,
it will take time for all LIFTs to become fully functional. Where
premises need to be developed now, PCTs and GPs should not wait
to see if their needs might be covered by the LIFT initiative.
Rather, the premises should be developed using traditional cost/notional
rent and third party developer arrangements. In this way, practitioners
and the wider primary care team will be able to occupy modern
facilities and provide better patient access to local services.
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UK
healthcare for diplomatic and Crown servants serving overseas
Crown servants
are in a unique position, being UK citizens and Crown servants
who pay UK taxes and National Insurance but – for extended periods
– live overseas. None the less, their home country remains responsible
for their healthcare. That means that Crown servants who live
abroad should be able to access healthcare in the UK as if they
were ordinarily resident here.
To deliver
this Crown servants and their families should be afforded temporary
registration as a matter of course. This would not include occupational
health or other services outside of normal medical services. Patients
who fall into this category should be treated as any other temporary
resident.
The Foreign
and Commonwealth Office (FCO) report that since January 2001 it
has received complaints from staff who have been charged a fee
as an overseas visitor when they sought medical help from a GP
when last in the UK.
The complaints
have been few given that the FCO alone has about 2,500 staff serving
overseas and the overwhelming majority appear to have no problems
accessing GP services as a temporary resident when on leave in
the UK.
Even so it
is not acceptable for UK citizens to be denied access to NHS services
and the FCO, and other government departments have asked us to
ensure that all its staff are able to access NHS primary care
services when they return to the UK on leave. It would be helpful
therefore if all GP practices and PMS pilots follow the approach
described here.
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New
guidance on commissioning freedoms of primary care trusts
The Department
of Health has just issued a Health Service Circular (HSC 2002/007
– Securing Service Delivery: Commissioning Freedoms of Primary
Care Trusts). It reinforces the discretion that PCTs have in securing
the provision of services from a variety of providers, across
primary, community, social or hospital care, from a local NHS
provider or another NHS provider and from the public, private
or voluntary sectors.
The HSC makes
explicit that PCTs should aim to deliver the best possible healthcare
by the most effective means and should feel free to commission
from wherever they can obtain the best services for patients.
To ensure that services are designed around the needs of patients
and their experience of care, the expectation is that commissioning
decisions will increasingly be informed by the choices patients
make for themselves.
The discretion
PCTs have in reshaping local service delivery should focus on
reducing waiting times, increasing responsiveness and improving
clinical outcomes. The HSC re-emphasises that all commissioning
decisions should be made on the basis of the healthcare needs
of the local community and be judged against the twin tests of
high clinical standards and good value for money. To support stability
for the NHS and as part of the process of empowering frontline
professionals, PCTs will receive their allocations for the next
three financial years in Autumn 2002.
Overseas treatment
within the European economic area is one of the options open to
PCTs seeking to increase the number of patients treated and reduce
waiting times. The Department of Health will be issuing guidance
on overseas treatment this summer. The Departmental policy contact
on overseas treatment is Tim Baxter: 020 7210 5740, email tim.baxter@doh.gsi.gov.uk
Any other
queries about PCT commissioning freedoms and obligations should
be directed to Paul Rice (PCT Commissioning, Department of Health)
on 0113 254 5069, email: paul.rice@doh.gsi.gov.uk
Copies of
HSC 2002/007 are available from http://www.doh.gov.uk/coinh.html
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Implementing
a scheme for GPs with special interest (GpwSI)
The NHS Plan
set out clear targets for improving access to and convenience
of primary care services, by reducing waiting times in primary
care and extending the range of services available in primary
and secondary care settings. Recruiting a GPwSI is one of a range
of options available to PCTs to help achieve these aims.
From 2004,
primary care trusts (PCTs) will be responsible for all the funds
for local NHS, including all hospital services, and are therefore
key to the development of integrated services for patients. GPs
with special interests can in some instances be a key component
of such integrated services. They are able to provide a bridge
between primary care and hospital services through redesigned
patient pathways, for example.
A framework
on implementing a scheme for GPs with special interests is now
available on the DH website. The framework has been jointly developed
by the RCGP and Department of Health to offer the public, the
health service and health professionals’ information on the issues
to be considered when setting up a GP with a special interest
scheme. It contains information on:
- what
are GPs with special interests
- how such
a scheme will operate nationally and locally
- contractual
arrangements between the PCT and GP
- guidelines
for different specialties and roles
The introduction
of GPs with special interests will be a locally driven initiative,
based on service needs in individual PCTs. Local schemes will
reflect broad service standards agreed at national level. It is
envisaged that PCTs will assess local needs and the advantages
and disadvantages of recruiting GPs to such a scheme as part of
the local healthcare teams delivering patient care.
There are
two broad categories of activities that may be undertaken by GPs
with special clinical interests:
- delivering
a clinical service
- undertaking
of procedures
Guidelines
covering a wide range of services within these two broad categories
are being developed by the RCGP, in consultation with other key
stakeholders. Both the guidelines and other supporting documentation
(contractual models, job descriptions etc) will be added to the
DH website as they become available. The framework and first sets
of guidelines can be found at:
www.doh.gov.uk/pricare/gp-specialinterests/index.htm
However, PCTs
do not need to wait for the publications of the guidelines. If
a PCT wishes to appoint before guidelines are developed for a
specific service, or outside any guidelines from the National
Development Group, they can choose to do so, subject to the normal
performance management processes. PCTs are also advised to review
their procedures in light of national guidelines as they become
available.
Contact the
Department of Health’s GPwSI National Development Group Secretariat
with any queries at: gpwsi@doh.gsi.uk
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Achieving
the primary care access targets
The NHS Plan
sets a target that by 2004, patients will be able to see a primary
care professional within 24 hours, and a GP within 48 hours if
they so choose. Since September 2001 all PCTs have been undertaking
quarterly telephone surveys of their GMS practices and PMS providers
to take a snapshot of when the next routine appointments with
a GP and a health professional are available. As part of the NHS
performance management arrangements for 2001/02, an interim milestone
was set that by March 2002 60% of practices should be able to
offer patients a GP appointment within two working days and an
appointment with another health professional within one working
day.
The March
survey results are encouraging. They show that the milestone was
achieved for access to a GP and that it was nearly achieved for
access to a primary healthcare professional – a shortfall of less
than 1%. This outcome suggests that the milestone was realistic
and confirms it was challenging, especially for access to a primary
healthcare professional. Embedding a culture whereby the NHS offers
fast, responsive access to the appropriate service is a key Government
priority for all of the NHS. For 2002/03 the primary care access
milestone of 90% of patients being offered appointments within
one or two working days reflects this.
This is more
challenging than the 2001/02 milestone. But PCTs do have available
the £83.5m earmarked increase in the primary care access fund
to help them support practices in achieving this. In addition,
the Primary Care Collaborative continues to show impressive results
and is now rolling out its work on advanced access through its
11 new local centres.
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GP
appraisal CD-ROM
The Department
of Health has been working to produce an educational CD-ROM on
GP appraisal, which will provide helpful information about the
appraisal process. The Chief Medical Officer gives an introduction,
and David Haslam, Chair of the Royal College of General Practitioners,
provides a commentary.
The CD demonstrates
the right and wrong ways to conduct an appraisal and is aimed
at both the GP being appraised and the appraiser. It also includes
copies of the Department’s guidance on appraisal and the documentation
to be used in the process.
The CD-ROM
is currently in the final stages of production and will be available
shortly. Each practice will receive a copy.
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GP
out-of-hours
PCTs have
now completed a stock-take of their existing out-of-hours services,
together with an initial plan for the way in which they will integrate
GP out-of-hours services with NHS Direct and the wider emergency/urgent
care network by 2004. The data included in these plans allows
us to establish for the very first time a detailed, comprehensive
database of the character of existing services – a firm foundation
on which to plan for the future.
At the same
time, the roll-out of exemplar sites (integrating GP out-of-hours
services with NHS Direct) continues and, by the end of this month,
a total of 34 exemplars will be in operation, providing the new
integrated service to some 10 million patients nationwide.
The purpose
of the exemplar programme is to enable further, additional learning
about how this integration could most effectively be achieved,
and all those participating in the exemplar programme have been
invited to a one day workshop at the end of May. That event will
bring together representatives of all out-of-hours providers and
NHS Direct sites involved in the programme, ensuring that early
lessons are quickly learned.
All of the
new knowledge will be incorporated into a toolkit which will be
made available later in the year, providing important additional
advice and support for those who are yet to establish an integrated
out-of-hours service in their locality.
For further
details, please email Catherine Davies at: catherine.davies@doh.gsi.gov.uk
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Developing
GP services for mentally disordered offenders – Conference of
the International Institute on Special Needs Offenders (IISNO),
London, June 28 2002
The International
Institute on Special Needs Offenders is a unique international
organisation. Its work addresses the needs of adult and adolescent
mentally disordered and special needs offenders who require the
intervention of education, health, housing, social care and criminal
justice agencies.
The IISNO
assists agencies throughout the world to improve the care and
treatment of mentally disordered and special needs offenders,
by collaborating in the design of culturally sensitive processes
enabling care to be delivered in the least restrictive and most
enlightened manner possible. Its focus is humane, equal care and
treatment for all regardless of ethnicity, gender or religious
beliefs and justice for both victims and perpetrators of crimes.
This year’s
IISNO conference will focus exclusively on the issues and concerns
of GPs and will be chaired by IISNO board member John Bowis, MEP
and Rapporteur on Health within the European Parliament.
The morning
sessions will be dedicated to up-to-the-minute contributions on
best practice and new developments in GP services, with time set
aside for questions and debate.
Speakers include:
- Professor
Antony Sheehan, Joint Branch Head – NHS Mental Health Branch
and Chief Executive, National Institute for Mental Health, England
- Ailsa Claire,
Chief Executive Barnsley PCT
- Paul Tarbuck,
Service Director Specialist Services Bolton, Trafford, and Salford
Mental Health Partnership
- Dr Jonathan
Adams
- Anne Williams,
Drugs Implementation Adviser to the National Probation Service
- John Boyington,
Head of the Prison Task Force
The afternoon
will be structured as an open forum. Delegates will have the opportunity
to work in small-facilitated groups to give their views on the
key themes and issues raised at the conference. Feedback will
be collected for inclusion in a conference report to be presented
to the President of the Royal College of GPs, the President of
the Royal College of Psychiatrists and the Minister for Health
in July 2002.
Conference
details:
Date: 28 June
Venue: Hamilton
House, Mabledon Place, Euston, London WC1 9BD
Timing:
09.00 – 16.45 (registration from 08.30)
Conference
fees: £99 – including buffet lunch and refreshments
To reserve
a place, please contact Liz Waide on 01296 713754 or by email:
liz.waide@talk21.com
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MDA
safety information
Safety
notices
SN2002 (10)
– Baxter Colleague 1 and 3 volumetric infusion pumps: unwanted
"power on" or "power off" due to fluid ingress
SN2002
(11) – Benchtop vacuum steam sterilizers – the "prion cycle"
SN2002
(12) – DR-70 General cancer test
Device
bulletins
DB2002 (02)
– Management of In Vitro Diagnostic Medical Devices
DB2002
(03) – Management and Use of IVD Point of care Test Devices
DB2002
(04) – Update of MDA Warning Notices Issued in 1996
DB2002
(05) – Guidance on the Purchase, Operation and Maintenance of
Vacuum Benchtop Steam Sterilizers
Relevance
of safety warnings
During customer
research undertaken recently to check the effectiveness of safety
warning distribution, some general practices commented that they
frequently received notices for medical devices they did not use
and questioned whether safety information could be better targeted.
When a safety
related concern arises, MDA’s priority is to alert all potential
users of that device, so it targets all the sectors in which the
device may be in use. In the interests of device users and patient
safety it is vital that each notice received is checked and acted
upon as a necessary.
Ensuring that
everyone who needs to know receives the advice means that on occasions
users will receive information of no direct relevance to them.
However, we endeavour to keep these instances to the minimum.
Thank you for your co-operation when this happens.
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