HEALTH INSURANCE (AMENDMENT No.14) (JERSEY) LAW 201-
REPORT
The Health Insurance (Amendment No.14) (Jersey) Law 201- introduces new arrangements which will support the development and implementation of a well-regulated primary healthcare system, with stronger governance arrangements for practising General Practitioners (GPs) combined with the ability to provide funding for specified medical services in agreed areas.
Background
It has previously been acknowledged that primary medical care in Jersey has, in some ways, been lagging behind developments seen in other parts of the world. In response to this, Proposition 36/2010 set out the first steps towards a better primary care service for the people of Jersey. In particular, P36/2010 highlighted the need for Jersey GPs to be licensed with the U.K. General Medical Council (GMC).
To practise medicine in the UK all doctors are now required by law to hold a licence to practise. Licences will require periodic renewal and revalidation starting from 2012. Revalidation will require doctors to demonstrate to the GMC that they are practising in accordance with specified generic standards.
The GMC has made it clear that, in order for GPs working in Jersey to fully meet the new expectations of revalidation, the accountability of GPs to the States of Jersey needs to be strengthened. A system of self-regulation is not acceptable. The first step in this process has already been taken with the recently agreed changes to the Medical Practitioners (Registration) Law, which creates a live register of all doctors practising in Jersey and allows the Minister for Health and Social Services to create arrangements to evaluate specific groups of doctors. The amendments to the Health Insurance Law covered by this proposition build on these changes and set out a mechanism (known as a performers’ list) to evaluate the performance of GPs.
The proposals set out in this amendment have been developed in close collaboration with the Primary Care Body (PCB), which represents practising GPs in the Island, and the Health and Social Services Department.
Changes to Health Insurance Law
Following on from the Assembly’s agreement of P36/2010, these amendments to the Health Insurance Law set up a legal framework for :
- Contracts for primary care services
- Funding for a Primary Care Governance Team
This report accompanies the primary legislation which amends the Health insurance Law. The amendments presented are an enabling framework which will be supported by Regulations and Orders to be brought forward at a later date. Further details of the amendments to primary legislation are provided below.
- GP Performers List established by the Health and Social Services Minister for the purposes of strengthening local governance, managing poor performance and providing assurance regarding the quality and safety of local GP services
Article 8 of the amendment, amending article 26 of the main law
Article 9 of this amendment, inserting new articles 27A and 27B in the main law
The proposed Jersey GP Performers List will be the primary mechanism for achieving the required greater accountability of GPs to the States of Jersey.
Once a doctor has satisfied the local registration requirements for practising medicine in Jersey, then they will be eligible to apply for inclusion on the Jersey GP Performers List, which will be managed on behalf of the Health and Social Services Minister by a Primary Care Governance Team.
The purpose of a GP Performers List is to provide a framework within which action can be taken if a medical practitioner’s personal and/or professional conduct, competence or performance gives cause for concern. Protection of patients will be the overriding consideration when considering whether:
- a medical practitioner should be admitted to the list,
- a medical practitioner should be suspended from the list,
- restrictions should be placed on a medical practitioner’s position on the list,
- a medical practitioner should be excluded from the list (disqualification).
GPs currently practising in Jersey will be included on the list by default once it is established. After establishment, all new GPs will need to satisfy the inclusion criteria before being accepted onto the list. Inclusion on the list will be a requirement for becoming an ‘approved medical practitioner’ with regards to medical benefit paid out of the Health Insurance Fund.
Draft details of the application, approval and removal of GPs to the Performers List are set out in Appendix 1. These details will be finalised by Orders made under Article 27A by the Minister for Health and Social Services.
Under the current Health Insurance Law, there is no provision for a GP to be suspended. In future, this will be achieved using the Performers List. To ensure that patients still have access to GP services during any suspension, the Minister will negotiate a standard contract with the PCB which will allow for payments to be made to the relevant GP practice for a period of no more than four weeks, to cover the cost of replacing the services that would otherwise be provided by the suspended GP.
2. The ability of the Social Security Minister to enter into contracts for securing agreed standards of quality and/or additional medical services provided in a primary care setting:
Article 5 of the amendment amends article 10 of the main law.
Article 6 of the Amendment inserts a new part 3A into the main law.
In future, the Minister for Social Security will be able to fund contracts for medical services from the Health Insurance Fund. This is a major step forward, which will help to guarantee quality standards and allow the development of modern primary care provision in Jersey over the next few years. It is intended that the first contract will be the £1.5m Quality Contract as described in the report accompanying P36/2010.
The contract will be based on the Quality and Outcomes Framework implemented in the UK as part of their GP contract, but amended to reflect local circumstances. The Jersey Quality Improvement Framework (QIF) is a set of performance and quality related indicators that will be used to assess and monitor the standard of routine medical services in Jersey.
The Health Insurance Fund medical benefit was increased from £15 to £19 in May 2010 in order to fund the preparatory work that GP Practices needed to undertake in order to ready themselves for the new contractual framework. However, once the QIF Contract is established the medical benefit will be reduced to its previous level (plus any increase for inflation) and the £1.5m QIF Contract will be available to GP practices based on their achievement of the agreed standards.
The Jersey QIF will promote and incentivise consistency of primary care for a number of common medical conditions that otherwise have the potential to cause significant ill-health, hospital admissions or early death, such as heart disease, diabetes, stroke, asthma and chronic lung disease. The QIF will also include indicators to provide assurance concerning the organisational governance of general practice. Areas that the QIF are likely to cover are set out in Appendix 2. As part of the contract, general practices will be able to include services provided by nurses and other healthcare professionals.
The amendment will also allow the Minister for Social Security to enter into contracts with local pharmacists for the provision of services. Pharmacists are trained to deliver a wide range of primary care services but these services are not generally available in Jersey as there is currently no public funding in this area. This is an area which could, in time, yield substantial benefits to the general public through the provision of additional primary care services through local pharmacies.
The structure of the amendment also allows the Minister for Social Security to return to the States in the future to seek approval to widen the contract making powers to include other types of health care professional.
3. Ability for the Social Security Minister to introduce patient registration requirements in order to both support the introduction of new contracts and to ensure that maximum benefit is achieved from the implementation of a centralised patient data base.
Article 4 of the amendment, inserting a new article 9A into the main law
The implementation of the QIF contract will require the current arrangements for patient registration to be updated. At present there are no rules in respect of patient registration and an individual can choose to access GP services at one or more practices. Without a mechanism for identifying an accurate ‘practice list’ it will not be possible to accurately assess progress or to benchmark performance between GP practices in Jersey or with other parts of the UK. For example, the majority of clinical indicators assume practices can identify a disease register for conditions such as diabetes, which then allows practices to demonstrate the progress they are making in providing appropriate interventions and care for patients on that register.
There is a presumption that primary care in Jersey is generally good, but currently it is difficult to demonstrate this objectively. In addition, there is a lack of robust primary health care information, which means that patterns of illness and the extent to which good quality care is delivered by GPs in Jersey, are unknown. Without this information, strategies to prevent disease and improve health services are hampered. Once available, information from the QIF will help address this shortfall.
The amendment gives the Minister the power to restrict the payment of medical benefit to individuals who have formally registered with a single general medical practice. Although it will be a requirement to be registered with a single medical practice, the amendment also specifically upholds the right of a member of the general public to receive GP services from any approved GP on the Island and to be able to claim the medical benefit.
4. Provision to establish funding for a Primary Care Governance Team, which will administer the new governance regime and contractual frameworks established under these amendments to the Health Insurance Law.
Article 7 of the amendment amends article 21 of the main law.
The report accompanying P36/2010 highlighted that the establishment of a Primary Care Governance Team would cost in the region of £200,000 per annum. This team will be under the control of the Minister for Health and Social Services but, subject to the ongoing agreement of the two ministers, the cost of the primary care governance team will be met from the Health Insurance Fund.
A staffing structure has been developed and agreed between Health and Social Services and Social Security, which also includes external specialist support from two national bodies; NHS Primary Care Commissioning, and the National Clinical Assessment Service.
Financial and Manpower considerations
As a set out in P. 36/2010, the cost of the Primary Care Governance Team is estimated to be up to £200,000 per annum. This cost will be borne by the Health Insurance Fund.
The cost of the initial QIF contract is limited at a maximum of £1.5 million but at the time that the contract is introduced the value of the medical benefit will be reduced by a compensating amount.
The development costs associated with setting up the primary care governance framework, including a new patient database are estimated at £1 million. This cost will be borne by the Health Insurance Fund, as approved by the States in P.125/2010.
There are no additional costs associated specifically with this proposition.
The Primary Care Governance Team is estimated at 4 FTE, which will be accommodated from within the Health and Social Services Department overall manpower total.
Appendix 1
Application for inclusion in the Performers List
Applications for inclusion to the Performers List will need to be made in writing to Health and Social Services and requirements are likely to include:
- Medical qualifications, professional registration number; date of first registration; where they were obtained (with evidence);
- Professional experience separated into experience in general practice, hospital appointments and “other”. This must include full supporting particulars including chronological details of professional experience (including the starting and finishing dates of each appointment together with an explanation of any gaps between appointments), and an explanation of why they were dismissed from any post;
- Names and addresses of two referees, who are willing to provide clinical references relating to two recent posts (which may include any current post) as a performer which lasted at least three months without a significant break, and, where this is not possible, a full explanation and the names and addresses of alternative referees;
- Details of any list or equivalent list from which they have been removed or contingently removed, or to which they have been refused admission or in which they have been conditionally included, with an explanation as to why; (including any application relating to a body corporate);
- Information about criminal convictions; current or pending criminal investigations;
- Consent to a request being made by Health and Social Services to any current or former employer (including partnerships), licensing, regulatory or other body in the United Kingdom or elsewhere, for information relating to a current investigation, or an investigation where the outcome was adverse, to them or a body corporate;
- If Health and Social Services finds that the information, references or documentation supplied are not sufficient for it to decide the application such further information, references or documentation as may reasonably be required in order to make a decision;
Undertakings required by doctors on the Performers List
GPs will also be required to give a series of undertakings to Health and Social Services when applying to join the list. Failure to adhere to these undertakings may lead to removal from the list. The main undertakings may include:
- To notify Health and Social Services within 7 days of any material changes to the information provided (i.e. that above) in the application until the application is finally determined and, if included in the performers list, at any time when their name is included in that list;
- To notify Health and Social Services if they are included, or apply to be included, in any other list held by a PCT or equivalent body;
- To participate in the required appraisal system;
- To co-operate with an assessment by the National Clinical Assessment Service (NCAS), when requested to do so by Health and Social Services;
Decisions concerning an application for inclusion on the Performers List
There are certain circumstances in which Health and Social Services will as a matter of course refuse an application. In other circumstances Health and Social Services may refuse admission, defer a decision or accept the applicant onto the list with conditions.
Reasons for an applications being refused may include:
- There is no satisfactory evidence of an intention to perform primary medical services in Jersey (does not apply in the case of an armed forces GP);
- Health and Social Services is not satisfied they have the necessary knowledge of English;
- The applicant has been convicted of murder;
- The applicant has been convicted of a criminal offence and has been sentenced to a term of imprisonment of over six months.
- The applicant has been subject to a national disqualification;
- The applicant is unwilling to accept conditions imposed after an appeal against their imposition.
Health and Social Services will also have discretion to refuse applications, for example if:
- Having considered the application and any other information or documents in its possession relating to them, it considers that they are unsuitable to be included in its performers list;
- It is not satisfied with the references;
- Having considered information and any other facts in its possession relating to fraud involving or relating to them, it considers these justify refusal;
- Having considers information relating to past or current investigations or proceedings involving or related to the performer, and, having considered these and any other facts in its possession involving or relating to the performer, it considers these justify refusal;
- There are any grounds for considering that admitting them to its performers list would be prejudicial to the efficiency of primary medical services;
- Their registration in the register of medical practitioners is subject to conditions or an order by the GMC or its committees;
- The applicant is included in the medical performers list of a PCT in the UK, unless notice has been given to that PCT that they wish to withdraw from that list.
Health and Social Services may also defer an application when:
- Information is not available or investigations or criminal proceedings are in progress. When reconsidering a deferred application Health and Social Services will require the doctor to provide updated information. There is no right of appeal against a decision to defer an application.
Removal from the Performers List
Health and Social Services will remove a medical practitioner from its performers list where it becomes aware that s/he-
- Has been convicted of murder;
- Has been convicted of a criminal offence and has been sentenced to a term of imprisonment of over six months;
- Is subject to a national disqualification;
- Has died or is no longer a member of the relevant health care profession.
Health and Social Services will use its discretion to remove medical practitioners from its performers list where:
- Their continued inclusion in the performers list would be prejudicial to the efficiency of primary medical services ("an efficiency case"). ‘The Department of Health guidance[1] defines this as ‘issues of competence and quality of performance. They may relate to everyday work, inadequate capability, poor clinical performance, bad practice, repeated wasteful use of resources that local mechanisms have been unable to address, or actions or activities that have added significantly to the burdens of others in the NHS (including other doctors)’;
- They are involved in a fraud case in relation to any health scheme; or
- They are unsuitable to be included in the performers list ("an unsuitability case"). The Department of Health guidance1 states that ‘suitability as a ground for action could be relied on where it is a consequence of a decision taken by others (for example, by a court, by a professional body, or the contents of a reference) or where ‘there is a lack of tangible evidence of a doctor’s ability to undertake the performer role (for example, satisfactory qualifications and experience, essential qualities)’.
- Where performers cannot demonstrate that they have performed primary medical services within Jersey during the preceding twelve months. (Excludes a period of suspension from the list or certain armed forces, or equivalent service.)
If Health and Social Services is considering removing a medical practitioner from its performers list it will give:
- Notice of any allegation against them;
- Notice of what action it is considering and on what grounds;
- The opportunity to make written representations to it within 28 days;
- The opportunity to put their case at an oral hearing before it, if they so request, within the 28 day period;
As an alternative to a removal Health and Social Services may impose conditions on the doctor’s continued inclusion in the list; this is known as Contingent Removal. Breach of the conditions may lead to actual removal. Such conditions might include additional educational or training requirements or restrictions on treating certain categories of patient.
Appeals
An appeal mechanism will also be put in place as part of the detailed procedural arrangements and this will be included in the Orders.
Appendix 2
The QIF assessment process for the current indicators will be in two stages. At the end of Dec 2011 all practices will be assessed against the organisational domain of the QIF, which is likely to include indicators covering:
- Professional Standards
- Clinical Governance
- Child Protection
- Information Governance
- Significant Event Review
- Practice Management & Employment
- Prescribing
- Access
- Patient Information
- Investigations
- Continuity of Care
At the end of Dec 2012 all practices will be assessed against the clinical domain of the QIF, which is likely to include indicators covering:
- Secondary prevention of Coronary Heart Disease
- Cardiovascular disease – primary prevention
- Heart failure
- Stroke and Transient Ischaemic Attack (TIA)
- Hypertension
- Diabetes mellitus
- Chronic Obstructive Pulmonary Disease
- Hypothyroid
- Cancer
- Asthma
- Dementia
- Depression
- Chronic kidney disease
- Atrial fibrillation
- Obesity
- Learning disability
- Smoking
- Suicide
The assessment of the clinical domain takes place later than the organisational domain as it is first necessary to complete the implementation of the GP Central Server before progress against the indicators across all practices can be assessed. The GP Central Server is currently due to be implemented in the early part of 2012.
Once the second stage has been completed, the overall assessment scores will be used to calculate the QIF Payment that practices will receive as a replacement for the additional £4 Health Insurance Fund payment. The exact assessment criteria are likely to closely mirror the arrangements in the UK where practices are awarded for achieving for certain thresholds. It is likely that some practices will make more progress and achieve a higher assessment score than other practices and will, as such, receive a correspondingly larger share of the QIF Fund.
After each assessment stage it is intended that a Primary Care Annual Report will also be prepared in order to provide feedback to all stakeholders on the progress being made. This will be prepared by the Primary Care Governance Team once it is established.
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