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Forensic analysis of pension records puts GP’s retirement plans back on track

February 14, 2024

The client

A GP partner in the East of England submitted their retirement benefits claim form 10 months prior to their planned retirement date in August 2023. Despite submitting it in good time, a year-long delay in processing the form by Primary Care Support England (PCSE) led to financial distress for the partner and a complaint to PCSE, backed by the BMA.

The dilemma

A review of the partner’s NHS pension record and dynamised earnings for 2022 by AISMA accountancy firm Larking Gowen LLP showed there were missing pension records in the previous six years. During this time the doctor had moved around the health service in a variety of officer roles, salaried and partnered GP roles and working as a locum. This mix of work was the likely reason for the missing records.

“While the previous accountant had reviewed and advised on annual allowance tax charges, it seemed they had never requested the doctor’s NHS pension record and were therefore unaware of the omissions,” said Carl Boardman, senior manager at Larking Gowen.

Carl and his team also identified that the doctor had incorrectly paid locum pension contributions for sessions worked at the practice where they were a partner. “These should have been treated as GP partner earnings,” he added. “It meant the contributions needed to be re-funded and the pension certificates amended and re-submitted.”

Action required

Once the pension records were obtained, the Larking Gowen team was able to identify the years of service missing in the records. These related mainly to the doctor’s salaried GP earnings and also some locum work.

Despite completing pension certificates for the missing years, the doctor had not always kept copies. The Larking Gowen team therefore went back through the doctor’s payslips to complete and re-submit the certificates to PCSE. They also undertook the work required to amend and re-submit the certificates where locum contributions had been paid incorrectly.

What happened next?

After lengthy delays in response times from PCSE, the GP, fearing his retirement plans were in jeopardy, registered a complaint with PCSE. The BMA also raised a complaint on the doctor’s behalf.

As a result, a named case handler was assigned by PCSE who was given authority to liaise with Larking Gowen on the doctor’s behalf.

Through a series of online meetings between PCSE and Larking Gowen, constructive dialogue was achieved. “It was really helpful and much easier to get to the bottom of the issues than just constantly raising cases for each one,” said Carl Boardman.

In September 2023, having made some progress in resolving the problems, Larking Gowen asked PCSE to process the retirement benefits claim form submitted 10 months earlier. “The GP needed to draw his pension since he had reduced sessions at the practice and was in a precarious financial position,” explained Carl. “He had depleted his savings by paying a large annual allowance tax charge personally in expectation of the pension lump sum. He also needed to repay some borrowings to reduce his monthly outgoings.”

While the issues had not all been wrapped up at this point, Larking Gowen pushed for an interim payment, explaining that the remaining points could be dealt with subsequently and any adjustments to the pension could be back dated.

A month later PCSE paid the lump sum and pension arrears back dated to August 2023, based on estimated figures.

The conclusion

When the GP first asked Larking Gowen for assistance, he had no inkling of how complicated it would be to unravel all the problems. “Many doctors are unaware of the issues caused by incomplete pension records,” said Carl Boardman. “We had to look back at the history in detail as most years had two or three separate sources of income since the doctor had moved around so much in a variety of different roles.

“We are still dealing with some of the unresolved issues, notably the locum pension contributions which were paid incorrectly, including the question of who should refund them. However, the doctor is in a much more stable financial position now and is grateful for our assistance.”

GPs HIT WITH ‘HUGE’ BILLS FOR COMPULSORY PHONE CHANGES

February 12, 2024

GPs are seeing their phone bills rocketing by as much as three times as they make changes required by the GP contract.

Now doctors’ leaders are requesting they get more financial help to pay for the switchover.

The problem stems from the new framework for ‘cloud-based telephony’ systems, a requirement in the current GP contract designed to speed up booking GP appointments.

According to the BMA, which recognises that the new telephony system could help patients and practices in easing the pressure on surgery telephone systems and support patients to get the care they require, it is significantly driving up costs for practices.  

​​It has written to NHS England saying the procurement process of the Better Purchasing Framework (BPF) in GP practices across England is resulting in ‘huge cost increases.’

​​Over the last year, and during talks on the 2023-24 contract, negotiators voiced concerns about increased costs to practices moving from existing suppliers on NHSE’s BPF.

All practices are expected to cover the costs of the rollout.

​ Dr David Wrigley, deputy chair of the BMA GP England committee, said: ‘At a time of significant pressure on GP practices, particularly on a contractual issue mandated by the 2023-24 imposition, this issue is of huge concern to GPs and it is having a direct impact on surgeries struggling to manage the finances they receive from government to run their practices.

​​‘Our concerns have long been ignored, and instead we’ve been told in meetings that costs for practices when changing to these services would not increase. This could not be further from the truth for many GPs across the country.

‘Some are seeing rises of 300% to their current telephone system costs. We cannot expect GP practices across the country to cover these significant additional costs without much needed support to help them manage the transition.’

​​He said without more funding the new system will be a further blow to GP surgeries already struggling to cope. ‘We need an immediate pause on this new programme of work and then work to ensure this new system is in the best possible place, so we don’t create additional problems for GP surgeries across the country.’

12 FEBRUARY 2024

GP REFERENDUM ON FINAL CONTRACT OFFER

February 2, 2024

GPs in England are to be balloted in a referendum on a final contract offer on 1 March.

The poll will take place following a 1.9% baseline uplift offer which has caused consternation among GP leaders.

GPC England today (Thursday) unanimously instructed its leadership team to continue talks with the Government and NHS England to address its concerns.

They warned that patients will struggle to get the care they need from their GP practice unless the Government decides to invest in general practice, at a rate greater than the current offer.

And they warned if the 1.9% goes through then some practices will close.

GPC England said the 2024-25 GP contract would do little to bring hope, stability or safety to the profession. 

Details of the contract come following a BMA survey of 10% of practices in England which found 64% were concerned over short and long-term viability.

GPC England said: ‘More than half (57%) have experienced cashflow issues in the last 12 months. The BMA estimates that up to one in four GP surgeries will seriously consider reducing their staffing to remain open for patients. This was before this year’s derisory contract offer.’ 

Its chair, Dr Katie Bramall-Stainer, said: ‘After spending an hour with Minister Andrea Leadsom yesterday evening, I believe her when she said to me how much she values general practice, so I am glad that GPC England has mandated we keep these conversations open. 

‘We have seen over 1,000 practices close since 2015, and with them the exodus of thousands more GPs from NHS roles, whilst patient numbers have risen by over six million.

STAFF REDUNDANCIES

‘The current offer means that practices will not be able to break even and will face awful choices over staff redundancies and service delivery which is incredibly concerning for GPs and patients in England. It is unconscionable that we are even seeing GPs out of work, and practices laying off staff to keep their doors open.

“We know a significant majority of practices which are struggling. Costs have risen driven by soaring inflation. 1.9% may be what was set by Treasury in their operational planning guidance back in 2021, but such slavish adherence to budget lines from three years ago is not replicated elsewhere in the NHS. This regrettably falls far below what we realistically need to keep our heads above water, and what GPC England has reasonably called for.’  

She said GPC England proposed many cost neutral proposals and solutions, and still had suggestions around what could be achieved, recycled or protected to sustain GPs through the challenging year ahead, such as to employ GPs and nursing staff.

‘We have presented evidence and data which makes the unarguable economic case for investment in GP services. To ignore it risks saving pennies today in order to spend pounds tomorrow.

‘It risks a swathe of practices facing no choice but to hand their contracts back, fuelling unemployment for trained GPs willing and able to work, and for some practices to close for good. That would be a ridiculous waste of taxpayers’ money and puts the care of the million plus patients we see each and every day at risk.’

SURVEY RESULTS

GPC England’s snapshot survey assessed the current state of GP practice finances, running from 8 December – 16 January.  

Staffing spend is significantly outpacing core funding uplifts. There is widespread concern and uncertainty over future viability: 

  • Have you experienced any cashflow challenges that have affected your practice operationally over the past twelve months?

Yes – 323 (57%)

No – 244 (43%)​

  • Do you think the impact of inflation/rising costs could affect the short- or long-term financial stability of your practice?

Yes, short-term and long-term – 375 (64%)

Yes, short-term – 22 (4%)

Yes, long-term – 123 (21%)

No – 14 (2%)

Not sure yet – 54 (9%)​

  • How worried are you about the impact of inflation on your practice’s finances?

Not at all worried – 1 (0%)

A little worried – 30 (5%)

Moderately worried 142 (24%)

Very worried – 222 (38%)

Extremely worried – 191 (33%)

1 FEBRUARY 2024

GPs react to £350m GP funding cuts findings

January 22, 2024

GPs say the £350m real terms funding cuts since 2019 revealed today by the Liberal Democrats (see the story on this website) make ‘absolutely no sense’.

Prof Kamila Hawthorne, chair of the Royal College of GPs, said: ‘General practice is the bedrock of the NHS, and investing in it leads both to better health outcomes for patients and delivers amazing value to the NHS.

‘We now know that for every £1 invested in primary care, at least £14 is delivered in productivity across the working community – so it makes absolutely no sense that spending on general practice is falling in real terms.’

Significantly more investment in general practice services is a key policy in the RCGP manifesto.

The College says as more and more services are relocated to primary care settings; resources must follow patient care. And it warns that demand for general practice will only intensify in coming years.

Prof Hawthorne said: ‘We also know that funding cuts in primary care adversely impact communities with higher rates of deprivation, worsening the situation for some of our most vulnerable patients. Across the NHS, we have seen health inequalities worsen over the past decade, and this has been felt even more so in recent years due to the cost-of-living crisis – a College survey found that 73% of GPs have seen an increase in patients presenting with conditions linked to poverty.’

MORE INVESTMENT NEEDED IN 2024-25 GP CONTRACT

Ruth Rankine, director of primary care at the NHS Confederation, warned that any drop in funding going to GP practices was concerning while primary care services continued to face mounting demand for care.

‘GPs and their teams are being stretched to breaking point managing patients with more complex or multiple conditions in the face of tightening budgets and long waiting lists for specialist care.

‘General practice delivers the majority of NHS activity and with the right level of investment in workforce, technology and estates it will be able to transform services to do more to keep people well and out of hospital.

‘There are opportunities amid the ongoing pressures to do more at scale leaving general practice to focus on continuity of care which we know patients value, while utilising the new roles in primary care.

“Our members want to see more investment and greater flexibility in the 2024-25 contract so they can continue to design and deliver services to better meet the needs of their populations.’

22 JANUARY 2024 

HOPES OF PAY TALKS RESUMPTION AS STRIKES END

January 9, 2024

NHS leaders are urging doctors and the government to re-start pay negotiations following the end of the juniors’ six-day strike.

Matthew Taylor, chief executive of the NHS Confederation, said it was too early to say what the full impact of the longest strikes in NHS history had been and how many patients have had their vital appointments or operations postponed.

But potentially more worrying, he added, was that it was unknown how many patients avoided coming forward for care due to the strikes and what kind of backlog this could create for already overstretched services.

Mr Taylor said: ‘NHS leaders will be relieved that this round of industrial action is coming to a close, but their teams now face the mop-up challenge of rebooking the tens of thousands of patients whose planned care was displaced. These strikes came during one of the busiest weeks of the year for the health service, as seen in number of trusts having to declare critical incidents or calling for junior doctors to return to work.’

The Confederation fears a cold snap on the horizon could bring yet more pressure.

He warned: ‘Consultants who covered for their junior doctor colleagues could also be taking time off now, which may lead to a further drop in productivity.’

BMA junior doctors committee co-chairs Dr Robert Laurenson and Dr Vivek Trivedi said: ‘Junior doctors are ready to settle this dispute once and for all. Victoria Atkins on Monday evening said she’s keen to deliver a ‘fair and reasonable’ outcome. We are ready to talk about that fair outcome at her earliest convenience. No strikes are currently scheduled and now is her moment to come forward with a credible offer that delivers the reasonable outcome of pay restoration.’

They claimed they had seen extraordinary public and patient support in the last week, despite reports that backing is ebbing.

Their mandate for strike action lasts until the end of February.

The pair added: ‘We know from both our own experience and the experience of other professionals that our Government only seems to listen when we have a mandate for strike action. We will prepare to extend that mandate in case we need to strike in the future. But the Government does not have to let it get to the point of more strikes being called.

‘Instead of passing the unhappy milestone of a year of strikes, we could this spring instead be celebrating a deal which will restore the value of our profession and bolster recruitment and retention. It is up to them.’

9 JANUARY 2024

PAY STRIKES: BMA SEES RED OVER ‘ASTONISHING’ TRUSTS’ ACTION

January 5, 2024

The BMA has requested NHS England’s chief executive to urgently intervene to ensure the derogations process is used as intended during the pay strikes.

It should be a last resort when alternative staffing strategies have failed to provide emergency cover during strike action.

But in a letter from the Association’s council chair Prof Philip Banfield to Ms Amanda Pritchard, he cites numerous examples of alleged unfair play including where Trusts have tried to call on the derogations process to undermine the junior doctors’ action.

He says consultants in some departments have been surprised that derogation was called for when they in fact had enough staffing.

And he blasts Trusts for failing to give information to back-up their actions.

He writes:

‘At the beginning of this dispute the BMA jointly agreed with NHS England a voluntary system to provide derogations which would allow for junior doctors to return to work in the event of safety concerns arising from “unexpected and extreme circumstances” unrelated to industrial action. We believe that this is a safety critical process.

‘As derogation undermines strike action, it is, and must remain, a last resort. As part of the agreed process, Trusts are asked for evidence that all other sources of staffing have been exhausted, including, for example, cancellation of elective activity, incentivisation of alternative staffing, and rearrangement of urgent cases to days around or outside strike action.

‘It is, therefore, astonishing that during this current round of industrial action, NHS England and some Trusts have refused to evidence any efforts to source alternative staffing or demonstrate rearrangements or cancellation of less urgent work. This refusal to provide the information necessary to take well informed decisions is fundamentally undermining the derogation process as we are being asked to take decisions about our members’ right to strike without the requisite information.

‘NHS England, it feels, is wilfully placing the BMA in an impossible situation. Derogation requests received so far in this action include incomplete and inaccurate information such as:

‘*Unevidenced assertion that no consultants, SAS doctors, or Advanced Practitioners are working at all in some specialties

*Unevidenced assertion that no additional consultants or SAS doctors are available to provide cover for junior doctors, in stark contrast to previous rounds of action

*Refusal to demonstrate they have sought alternative staffing from consultants or SAS doctors

*Refusal to provide information on whether elective activity is ongoing, with staff available to redeploy

*Refusal to detail any efforts to encourage alternative staff to assist, such as incentive rates or time off in-lieu, including in cases where we are aware there is no enhanced rate of pay

*Requests to derogate staff to levels beyond a normal weekend day

*Requests to derogate to enable provision of “P2” activity, which has a 28-day deadline and could be provided outside of strike action

*Refusal to confirm that requests have been viewed and approved by Incident Directors.

‘We are also in receipt of multiple requests that are dated Friday 29th December, demonstrating that little to no effort has gone into seeking an alternative solution. A number of local negotiating committee chairs have told us that their employers have made a decision to apply for a derogation well in advance of strike action and before alternative solutions could be pursued.

‘In addition, consultants on the frontline in several of the departments we have received requests from, have expressed surprise that a derogation request has been submitted, telling us that they are staffed well enough.

‘We are increasingly drawing the conclusion that NHS England’s change in attitude towards the process is not due to concerns around patient safety but due to political pressure to maintain a higher level of service, undermine our strike action and push the BMA into refusing an increasing number of requests; requests, we believe, would not have been put to us during previous rounds of strike action.

‘The change in approach also appears to be politicisation and weaponisation of a safety critical process to justify the Minimum Service Level regulations. It is an operational matter for the NHS if hospitals choose to prioritise less urgent cases over life and limb care.

‘We request your urgent intervention to ensure the derogations process is used as intended: as a last resort when alternative staffing strategies have failed to provide emergency cover during strike action, and that Trusts and NHS England fully cooperate with us to enable good and safe decision making in a process that we can have confidence in.’

2,290: THE AVERAGE NUMBER OF PATIENTS PER GP IN ENGLAND

January 5, 2024

New figures today show GPs and their teams are working harder than ever, according to the Royal College of GPs.

Chair Prof Kamila Hawthorne said NHS data clearly showed that need for our GPs’ services continued to spiral – but there were still fewer qualified, full-time equivalent GPs than before the pandemic.

She called for practical action to address this.

‘GPs and our teams had their busiest November on record last year, delivering more than 31m appointments – a 30% increase on 2019, yet with 646 fewer fully qualified, full-time equivalent GPs.

‘Almost 43% of these were delivered on the day they were booked, and almost 70% were conducted in person. The average number of patients per GP in England is now an eye watering 2,290, meaning each GP is responsible for 147 more patients than in December 2019.’

Prof Hawthorne said without significant investment in general practice and efforts ramped up to increase the GP workforce, especially into retaining GPs for longer, meeting the increasing demand for care would be ‘an incredible challenge.’

The College’s manifesto outlines seven ‘solutions’ – including’ appropriate resource allocation’ for recruitment and retention.

4 JANUARY 2024

FUNDING FOR GPs IN POORER AREAS IS ‘SKEWED’

December 18, 2023

GPs in poorer area PCNs are missing out on funding and additional primary care staff because the greater health needs of their populations are not adequately taken into account by current funding arrangements.

According to the Health Foundation, the skewed funding is particularly concerning as PCNs are tasked with reducing health inequalities.  

With new funding contracts for PCNs and GPs currently being negotiated, the organisation is urging NHS England to reform its funding formulas to ensure PCNs in areas of high deprivation receive the funding they need.  

The Health Foundation, a charity, says: ‘General practices in the most deprived areas of England, where people experience worse health on average, could collectively benefit from an additional £18.6m a year to improve the health of patients if the funding available to them better accounted for deprivation.’

Its new research also found that, when increased need is accounted for, there were significantly fewer additional primary care staff, such as pharmacists, physiotherapists and care coordinators, recruited to networks in the most deprived areas compared with the least deprived areas – six fewer per 100,000 needs-adjusted patient.

Dr Rebecca Fisher, a GP and a senior policy fellow at the Health Foundation, said: ‘General practice in the poorest areas, where people have the greatest health needs, is missing out on much needed funding and additional staff. Without this, the health of people in more deprived areas risks falling even further behind other parts of the country.

‘People in poorer areas need to have better access to GPs and other primary care professionals. Renegotiation of primary care contracts, currently being led by NHS England, is an opportunity to address this issue.’

15 DECEMBER 2023

Call for continuity of care to be in GP Contract

November 30, 2023

Making continuity of care an ‘essential requirement’ for GP practices could reduce the risk of a delay in diagnosing serious health conditions and ease significant pressure on GPs’ workload and welfare, according to a Health Services Safety Investigations Body’s (HSSIB) report out today.

It is worried there is no specific requirement in the GP contract to ensure GP practices provide continuity of care.

They can do so voluntarily but the HSSIB said there is no standard framework to help to deliver this, resulting in variation across England.

The report states it is ‘well documented’ that continuity of care has many benefits for patients and that it is important in recognising patterns of symptoms to aid timely diagnosis or referrals to other services.

It said: ‘During our investigation we spoke to a sample of patients and GPs from surgeries that did operate systems of continuity of care (as well as those surgeries that do not). They reiterated the positive benefits of having that system. For example, patients said they had a relationship with their GP which allowed them to know them and their health and personal circumstances. They could see the same person and not have to explain their long-term condition each time.

‘All GPs that we spoke to are aware of the benefits of continuity of care, but some did not believe it was possible to deliver that system of care in their practice. They cited many challenges from the complex social conditions of their geographical area to staff stability and availability.

‘In relation to essential requirements coming from the GP contract, practices told us that this creates competing priorities and that if there is no explicit requirement to adopt a system of continuity of care, it will ‘slip down’ the priority list when there are other challenges coming to the fore.’

Many GPs told the HSSIB that IT systems do not present information in a way that enables them to quickly see if a patient is returning with ‘unresolved symptoms.’ There is no requirement for GP IT systems to consider continuity of care or to ‘surface’ information to GPs.

GP Welfare

Investigators noted that they saw a visible difference in the demeanour between staff in practices that operate continuity of care and those that did not. The investigation observed first-hand the personal impact, as many became visibly upset when speaking about their workload and work environment.

Some of the examples shared by GPs included:

  • not having time to process technically difficult consultations resulting in cognitive fatigue, making decision making harder as the day progressed
  • feeling unable to do all the tasks required during a consultation
  • taking work home and into days off and weekends.

GP Contract recommendations

The HSSIB recommends the Department of Health and Social Care ensures the GP contract explicitly includes and supports the need for GP practices to deliver continuity of care. This is to improve patient safety by building clinician–patient relationships as well as providing continuity of information.

It also recommends NHS England updates the GP IT standards to ensure patient continuity of care is maintained, including the identification and prioritisation of information to health and care professionals, when patients visit GP practices multiple times with unresolving symptoms.

RCGP Response

Dr Victoria Tzortziou-Brown, vice chair of the Royal College of GPs, said: ‘Continuity of care is highly valued by GPs and patients alike – particularly those patients with complex health needs. It allows us to build trusting relationships with our patients, and this study highlights it has benefits for patients and the wider NHS.

‘But delivering continuity of care is becoming increasingly difficult as GPs and our teams struggle with intense workforce pressures and patient need growing in both volume and complexity.’

She added: ‘Making continuity of care a ‘requirement’ is not straightforward, as it may mean different things to different practices and patients, and some patients may value it and benefit from it more than others. As with any targets, there are also risks associated with taking an inflexible approach that could lead to unintended consequences.

‘Ultimately, given current pressures, it’s hard to see how such a requirement would be feasible for many practices. What we do need to see is more resources for general practice and thousands more GPs and other members of the team, so that practices can ensure their patient populations can get the appropriate care they need.’

30 NOVEMBER 2023

RCGP LOBBIES CHANCELLOR OVER GENERAL PRACTICE FUNDING

November 21, 2023

The Royal College of GPs is urging Chancellor Jeremy Hunt to be mindful of the need for general practice infrastructure funding when he delivers his Autumn Statement tomorrow.

A £2bn general practice infrastructure investment is one of seven steps it set out in its manifesto recently to save general practice and safeguard the NHS.

The College’s infrastructure concerns are based on a recent survey of 2,649 general practice staff, predominantly GPs, that found two in five considered their premises not fit for purpose, with 88% of them citing an insufficient number of consulting rooms.

Staff also raised concerns about the suitability of access to practices for patients with disabilities (32%), the condition of old buildings and equipment, and structural problems such as water leaks, mould, mildew and drafty windows (25%).

The survey found that of those who reported that their premises were not fit for purpose, one in three said that this is because the space for patients is inadequate.

RCGP chair Prof Kamila Hawthorne said: ‘Many GPs are dealing with inadequate buildings which in some instances, frankly, are unsafe. We’ve heard stories from GPs of temporary portacabin extensions now in their 18th year of use with rotten walls and cramped consultations rooms.

‘Our members have told us of leaky rooves and draughty windows. These are conditions which you would not associate with 21st century healthcare, but they’re the reality for a substantial number of practices in the UK and make neither for a safe or healthy environment in which to work or deliver care to poorly people.’

She described the Autumn Statement as a final chance for the Chancellor to address healthcare funding.

Prof Hawthorne added: ‘There has been little recognition from the government for the risks posed by underfunding general practice – not only to the profession but also to patients. General practice missed out on funding in the government’s Winter Relief Plan despite the fact we’ve seen a dramatic increase in demand that is simply unsustainable – in September 2023 we delivered 5m more appointments than in September 2019, but with 827 less fully qualified GPs. If we’re simply unable to meet the demand for care, many patients will be forced to seek help in more costly secondary care.

‘Similarly, a crucial asset to the NHS last winter was the introduction of Acute Respiratory Infection (ARI) hubs which will not see enough funding to operate in all areas of the country this winter – even though the NHS estimated that last winter, where they were implemented, they prevented 360,000 extra A&E admissions and 360,000 GP appointments, saving the NHS over £4 for every £1 spent.’ 

21 NOVEMBER 2023

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