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NHS GP Stats
nGMS PMS APMS
Outcome of the 2012/13 GP contract negotiations @ NeLM Nov 2011
Funding in GP
Dr Andy Withers Grange Practice Allerton
Essential
Additional
DES
NES
LES
QOF
Mandatory
Normally expected of all practices but opt-out possible
No one practice has to do Obligatory for each PCO Nationally specified
NES OPT-IN national terms and conditions
PCT commissioned service in response to specific local requirements. Local terms, conditions and standards. Possibly, innovative services for piloting and evaluation
6.3%
2.8
2.8
1.7
6.8
Management of patients ill or believing themselves to be ill for the duration of that illness where recovery is to be expected including health promotion and referral as appropriate and involving patient choice
cytology
CHS
Maternity
Contraception
Services to violent patients
Childhood vaccs
Minor Surgery
Flu Vaccs
Access
IMT
CandB
(PBC)
Heart Failure Osteoporosis LD Ethnicity Alcohol
Anticoagulant monitoring IUCD Sexual health MS Drug and alcohol misuse Terminally ill Depression Learning disabilities Intra partum care Minor injuries Near-patient testing Homeless Imm ediate/first response care
General management of the terminally ill
CDM
Paid as Global Sum in PMS or MPIG in GMS practices (MPIG = GS +correction factor)
PBC
Practice Based Commissioning
Voluntary
Devolved budgets to all practices
Virtual Money – you can’t take it home
For:
Prescribing
Secondary care, acute and elective
Community Staff
Can spend (up to) 70% of Freed up resources (FURs note not
savings) on patient care. Pct takes rest.
Only get FURs you predict (no serendipitous FUR)
Idea is to provide innovations in services to produce FUR
Usually done through commissioning alliances
Other Income
Teaching and Training Amount NHS
Pension?
GPR £7.5k Y
FY2 £10k Y
Medical Students £15-20k N
NHS related work GPwSI c £10k/ session Y
PCT
LMC
DH
Getting Paid 2 (This is real money)
Typical Middle sized practice (approx 5500 patients)
Total amount £875k
Less running expenses (36%) £315k
Less Staff costs (including salaried GPs and GPRs) £260k
Profit (34%) £300k
Divided between partners = income £100k
Need to pay 20% superannuation £80k
Need to pay Income tax
Premesis
Lift
PFI variants
DIY
Guaranteed income stream from PCT
Practice Finance
A brief look at the history:
GPs ‘independent contractors since 1948’
1990 contract existing framework PMS introduced from 1998 onwards
Increasing workload, diminishing numbers, bureaucratic overload, threat of ‘mass resignation’
Feeling in the profession that ‘something had to change!’
Carr-Hill formula
Primarycare Funding Carr Hill dh.gov.uk
Practice accounts
Understanding Practice Accounts Pulse Jan 08
Gross Practice Income
NHS
GP
Other (GPwSI, PEC, training etc)
Private
Medicals & reports
Other employment (e.g. Occ Health, DWP)
Practice Expenses
trends
Personal Income?
What goes into the practice?
What can I keep? (cremations, OOH sessions)
Personal or Practice Expenses
Professional subscriptions/defence society
Journals & Books
Telephone
Car
Home office & computing
Premises
Cost Rent
PFI
PCT rental
Capital
Buying in
Financing
Goodwill
Dispensing
Private Fees
Premises
Ownership
Buildings
Capital Costs
LIFT
Running Costs
Cost Rent
Improvement Grants
Branch Surgeries
Staff Reimbursements
Taxation expenses superannuation
GP personal Expense Claims GP Online Mar 2010
GP earnings and expenses 2009-10 NHS Information Centre
Partnership agreements
GP Partnerships @ Medical Interviews
GP NHS pensions
All NHS income pensionable
GMS / PMS work
locum work
board, advisory and other work for NHS bodies
education
statutory certification
work for GP cooperatives that are NHS bodies
BMA
GPC
General Practitioners Committee
LMCs
LMCs Local Medical Committees
Statutorily recognised representative bodies for all GPs (not just Independant Contractors or BMA members) within their geographical areas.
Not Trad Unions.
Funded mainly by a compulsory levy on all GP practices included in Global Sum, and an additional voluntary levy.
Annual practice reports
Annual Practice Reports
Practice leaflets
Practice Leaflets
Patient participation
Getting the most from your GP practice RCGP Aug 2011
see also QOF etc
Practice boundaries
Practice Boundaries and Registration
Practice lists
List Size Practice Size Personal and Shared Lists
Removing patients
MPS Factsheet Removing patients from the practice list
OOH
OOH Arrangements
Home visits
Home Visits
Access
National Primary Care Development Team
Understand demand
Shape demand
Match capacity to demand
Contingency plans
pulsetoday.co.uk How we increased our appointment capacity by 50%
Access to primary care: Advanced … or smart? BJGP Aug 2007
Employment law
Equal Opportunities Commission
Bullying and Harassment: ACAS as above
IHM Healthcare Management Code at www.ihm.org.uk
IHM Diversity Group recommendations for Recruitment and Selection
Sickness Absence: ACAS as above, including their booklet entitled Absence and Labour Turnover
BMA guidance on managing absence at www.bma.org.uk
Health and Safety
Business continuity plans
Practice Protocols
First Practice Management
Salford & Trafford LMC Advice in times of RIOT Aug 2011
Additional Precautions for Practices during times of Social Unrest
In line with advice being given out nationally we hope that all our practices have business continuity plans in place already. The recent social unrest in London, Liverpool & Birmingham could be a timely reminder to revisit them. Please be aware that unrest can start in one area, and then spread. Let’s hope that none of this advice should prove necessary, but please ensure that you and your staff would know what to do in such circumstances.
Should social unrest spread, attacks on surgery premises and individuals are possible (we have already seen attacks on pharmacies). Practices have a duty of care to colleagues and staff and we know you would wish to ensure that any such attack produces as little effect on delivery of services as possible. Bearing this in mind you may find the following guiding points helpful:
Protect Colleagues and Staff:
Make sure you discuss and record arrangements for access and exiting the premises, and have a clear means of communicating with colleagues and staff. Establish a named practice contact with a nominated mobile number and email address. Agree with staff and colleagues to share contact numbers, and have a simple codeword that identifies if they are in trouble, and report such cases to the police, or 999 if in immediate danger.
Note that colleagues and staff living locally may be intimidated, or feel subject to intimidation, and may not be able to attend the premises
Inform patients:
Using reasonable commonsense means make patients aware that normal services may be disrupted; house calls may not be possible and routine requests subject to delay. It may be necessary to increase the availability of telephone consultations.
Secure Records:
Ensure that manual records are out of sight and in locked storage
Ensure that computer back tapes are in a fireproof safe; consider a second back up to be kept temporarily off the premises, but be aware of data protection requirements. The tapes may need to be encrypted, or stored on alternative licensed premises (PCT or neighbouring practice)
Secure Prescriptions/drugs:
Ensure “blue” (for DDA drugs) FP10s are secure or kept off the premises. Lock FP10 pads and computer prescription forms out of sight.
Consider a notice – prominently visible from the street – stating that ‘no powerful drugs are kept on the premises’, and ensure this is the case.
Remove Cash and Valuables, and Secure Equipment:
Consider a notice – prominently visible from the street – stating that ‘no cash or valuables are kept on the premises’, and ensure this is the case
PHCT
Primary Health Care Team
Practice meetings
Practice Meetings
Practice manager
Practice Manager
Practice nurses
Practice Nurses
ANPs
Advanced Nurse Practitioners
Non-medical prescribing
Non-medical prescribing PGDs and Nurse Prescribing
nmprescribing.co.uk
DOH Evaluation of Nurse and Pharmacist Prescribing May 2011
Cumberlege Report (Department of Health, 1986).
Crown Reports (Department of Health, 1989/1999)
Types of nurse prescribing
Supplementary
Independent
Extended
BNF Orderline DH Publications 0300 123 1002
Nurse Prescribers’ Formulary Royal Pharmaceutical Press
PGDS
Patient Group Directives PGDs
Patient Group Directives NPC 2009
District nurses
District Nurses and Community Services
Community services
Pharmacists
Health visitors
DH Health Visitor Plan 2011-15
Every family with children under five years, and every GP practice has a named health visitor.
School nurses
School Nurses
MDT Multi Agency Working AHPs
Doctors, nurses, physiotherapists, occupational therapists, speech and language therapists, psychotherapists, dieticians, social workers and some others like specialist nurses, psychiatrists, etc.
Meet at regular intervals to discuss patients, review progress, make decisions and formulate plans.
Occupational therapy
Occupational therapy (OT)
SALT
Speech and language therapy
SALTs assist children and adults with developmental or acquired speech, language or swallowing problems:
difficulty producing and using speech
difficulty understanding and/or using language
difficulty with feeding, chewing or swallowing
stammering voice problems
Health and Social Services
Care closer to home
intermediate care
transitional care
hospital care at home.
Respite care.
Long-term care
sheltered accommodation, warden-controlled accommodation or elderly people’s home
residential home
nursing home
EMI (elderly mentally ill) home.
Homecare (once a week – four times a day not overnight)
cleaning, washing, preparing foods, shopping, collecting pension and other ADL. There is usually no carer available overnight.
Social workers
British Association of Social Workers
Discharge from Hospital – source ?
Once an individual is referred to social services, he/she will be allocated a named social worker who will be responsible for assessing the needs of the person and making a care plan in partnership with the client, relatives and carers.
Under the current legislation, in the hospital setup, once a patient (after being declared medically fit by the medical team) is referred to the social services (section 2), a social worker is expected to sort out the social issues within 34 days (except weekends). However, if they fail to do so, the hospital can issue a section 5 notice. If the social services fail to respond within 24 hours of issuing a section 5, then the social services will be penalised. Social services will have to pay part of the cost for any extra day stay of the patient in the hospital (Delayed Discharge Act, DH)
Approved social worker (ASW)
Trained and approved under the Mental Health Act 1983 to assess need to be detained in hospital. After assessing the patient, the ASW can arrange necessary support or voluntary hospital admission. However,if it is not possible because of the poor mental state of the patient, the ASW will consult with the person’s GP and an approved psychiatrist and may arrange for detention in hospital for a period of assessment and/or treatments
Rehabilitation
Process of helping a person who has acquired an illness disability or addiction to restore to normal or near-normal life or to re-adapt to society or a new job with the help of retraining, therapy or vocational guidance.
Intermediate care
Keeping people out of hospital – effective discharge and follow-up Pulse CPD module Aug 2011
source – Medical Interviews Yuen?
Intermediate care is defined as the care and support services that meet all of the following criteria:
targeted at people who would otherwise face unnecessarily prolonged hospital stay or inappropriate admission to acute inpatient care, long-term residential
care or continuing NHS inpatient care provided on the basis of a comprehensive assessment, resulting in a structured individual care plan that involves active therapy, treatment or opportunity for recovery
have a planned outcome of maximising independence and typically enabling patients/users to resume living at home
are time- limited, normally no longer than six weeks and frequently as little as 12 weeks or less and involve cross-professional working, with a single assessment framework, single professional records and shared protocols.
This service is available for individuals who require a period of rehabilitation, after illness or injury, to regain control and independence in their lives and this period
can extend up to a maximum of six weeks. This service is usually provided in one of the designated wards in hospital or local residential or nursing home.
Service models
Rapid response – prevent avoidable acute admissions by providing rapid assessment/diagnosis for patients referred from the GPs, A&E,
NHS Direct or social services and if necessary rapid access on a 24 hour basis to short term treatment, therapy or necessary support and care in the patient’s own home.
Hospital at home an intensive support in the patient’s own home, including investigations and treatments. This can be used either as a means of avoiding an acute admission or to enable earlier discharge from hospital.
Residential rehabilitation a short-term programme of therapy and enablement in a residential setting, such as community hospital, rehabilitation centre, nursing home or residential care home, for people who are medically stable but need a period of rehabilitation to enable them to regain sufficient physical functioning and confidence to return safely to their own home.
Supported discharge involves a short-term period of nursing and/or therapeutic support in a patient’s home, typically with a contributory package of home- care and support services, to enable earlier transfer of their care from
acute hospital and complete their rehabilitation and recovery at home.
Day rehabilitation a short-term programme of therapeutic support, provided at a day hospital or day centre. It may be used in conjunction with other forms of intermediate care. Day hospitals can also provide a one-stop rapid response service with both specialist and multidisciplinary input.
Referral criteria
Criteria for referral to IC service are as follows: The patient must:
be over 16 years of age
be resident and registered with a GP within that PCT boundary
be a hospital inpatient at present or have attended A&E /required GP review at home within last 48 hours and a rehabilitation need identified
have a level of memory recall and motivation that allow active participation in a rehabilitation programme
have potential to improve physical functioning and/or regain independence
have been seen by a therapist and a rehabilitation need identified
give informed consent to receive the care.
Transitional care
Another component of ‘care closer to home’ services and is also provided in one of the designated local residential or nursing homes for a maximum period of up to six weeks.
The service facilitates:
appropriate and early discharge from hospital
reduction in number and length of delayed transfer of care
support of patients requiring a passive recovery period (convalescence), either prior to possible rehabilitation or commencement of longterm care package.
The person must meet the following criteria:
over the age of 55 years
be resident and registered with a GP within that PCT boundary
medically stable or declared fit to transfer
currently a hospital inpatient
has an identified aim, outcome and exit route at the point of referral.
Continuing care
Continuing Care Checklist DH 2009
Hospital at home
Hospital at home
Respite care
Respite care
Long-term care
http://hacking-medschool.com/long-term-care-2
May be NHS funded or privately funded.
Sheltered accommodation, warden-controlled accommodation, elderly people’s home care
persons who are fully self-caring, but need companionship to help their loneliness and supervision of a warden in case they need any help.
Residential
persons who mainly need help for their activities of daily living from a healthcare assistant/carer with minimal nursing needs. Assessed by a social worker and this care is funded by social services.
Nursing home care this is suitable for persons who are largely nursing need dependent (e.g. patients on tube feeding, tracheostomy tube, etc.) and are usually fully dependent for their ADL.
Nursing home-care need is assessed by a social worker along with a nursing advisor and this care is funded by the healthservices.
EMI home care patients who have significant psychiatric problems (e.g. psychosis, depression, dementia, etc.) need placement in homes with input from specially trained professionals (carers, nurses and psychiatrists) and these are known as EM! (elderly mentally ill) homes. EM! homes can be residential homes or nursing homes depending upon the need of the patient.