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Theresa May accused of failing to tackle growing NHS crisis

30 May 17

Credit: This story was first seen on The Independent

Theresa May has been accused of failing to tackle the growing crisis in the NHS and social care, with a ‘smoke and mirrors’ manifesto that has left future funding in doubt, The Independent reports.

Experts and campaign groups turned their fire on the prime minister as her promise to “get to grips with the great challenges of our time” if she returns to Downing Street drew scorn.

A flagship pledge to confront the social-care time bomb was attacked by the author of a previous review of policy for the Conservatives, who said older people would be “helpless” to plan their futures.

The Tories had also failed to offer hope to the 1.2 million people not receiving the care they need, with no commitment to bail out cash-starved local councils, the King’s Fund and Age UK warned.

And the British Medical Association (BMA) attacked a pledge to put an extra £8bn into the NHS, because it included money already promised. The Independent has learned this could be as much as £3bn.

Related story: -

“The extra £8bn touted in this manifesto for the NHS is smoke and mirrors,” said Dr Mark Porter, the chairman of the BMA council. “Rather than extra money, this essentially extends the funding already promised in the 2015 spending review for another two years and falls far short of what is needed. The NHS is already at breaking point.”

The criticism came after Ms May – in Labour-held Halifax – published an 84-page manifesto that marked a stark attempt to put clear water between her and past Conservative leaders.

“We do not believe in untrammelled free markets. We reject the cult of selfish individualism,” it stated, reflecting the prime minister’s belief that government should intervene to improve people’s lives.

Rejecting laissez-faire conservatism, Ms May said: “While it is never true that government has all the answers, government – put squarely at the service of ordinary working people – can and should be a force for good.”

But she denied a new philosophy, declaring: “There is no Mayism. There is good, solid conservatism that puts the interests of the country and the interests of ordinary working people at the heart of everything we do in government.”

The manifesto was also criticised by the Confederation of British Industry after including another crackdown on immigration, which remained the Conservatives’ “Achilles heel”, the business group said.

“In a global race for talent and innovation, UK firms risk being left in the starting blocks because of a blunt approach to immigration,” said Carolyn Fairbairn, the CBI’s director general.

GPs ‘planning to quit’ over low morale and workload pressure

30 May 17

Credit: This story was first seen on Sky News

Nearly 40% of GPs in southwest England say they are highly likely to quit the profession because of low morale and overwhelming workloads, a survey published in BMJ Open suggests.

The poll of more than 2,200 general practitioners found that 70% intend on reducing their contact with patients in some way over the next five years – through permanently leaving, taking a career break, or by cutting their hours, Sky News reports.

More than half of those polled by the University of Exeter reported low morale – and the professor behind the research has warned that similar figures across other British regions would necessitate robust action “swiftly and urgently” to prevent a staffing crisis.

Professor John Campbell has urged the government to move away from “sticking plaster solutions” and to tackle the workload pressures that GPs face – with younger doctors reluctant to take on a practice because of the financial risks and responsibilities involved.

He said the number of GPs who said they were thinking of quitting was bleaker than expected – not least because the South West is often considered a “desirable” place to work.

Related story: - 

“If the GPs we surveyed fulfil their intentions to leave or cut back their patient contact, and no action is taken to address the issue, the southwest of England will experience a severe shortfall of GPs in the next five years,” Professor Campbell warned.

He also claimed the looming shortage was exacerbated by how the country’s current workforce of GPs is aging – as 30% of them are over 50 years old.

According to Professor Campbell, GPs and their staff are responsible for 90% of patient contacts with the health service, yet receive 7p in every £1 of NHS spending.

Doctors in the region believe the situation is likely to get worse as demand increases because of fewer beds in community hospitals.

Research finds locum pay rates continue to rise

30 May 17

 

Credit: This story was first seen on On Medica

On Medica reports that hourly pay rates for locum staff have continued to rise, despite attempts to cap them, research by NHS workforce management consultancy Liaison shows.

Locum pay rates during the third quarter of 2016/17 were the highest since price caps were introduced by NHS Improvement. Of the hours worked by temporary staff in the third quarter, 80% exceeded NHS Improvement’s capped rates, compared with 64% in the second quarter.

The findings are published in the quarterly Taking the Temperature update produced by Liaison, which benchmarks the last quarter with the previous quarter. The report analyses pay and commission by grade and specialty across the 60 trusts and boards that Liaison supports with its workforce management services, and compares results by size, type, region and agency.

 

 

The findings shows that average hourly pay rates for locums increased from £63.30 to £64.17 (1.4%) in quarter three due to average consultant and ST3 rates rising by 1.8% and 2.4% respectively. The average pay for ST3 locums is more than double the core wage cap and the maximum rate of £120 paid this quarter was more than four and a half times the agreed cap.

Average hourly pay rates increased in eight of nine specialties, although rates decreased in radiology which still remains the highest-paid specialty for consultants. Maximum rates paid were greatest in general medicine at £187.50 per hour, almost two and a half times the core price cap.

Related story: - Treating patients closer to home

Vacancies continue to be the biggest reason for booking locums, accounting for 85.9% of all bookings.

However, while the overall average hourly pay rates for locums increased, the average commission rate paid for all grades of staff fell. Commission rates fell by 0.9% to £6.90 overall and for the four main grades of staff, most notably for FY2 locums, where rates fell by 2.9%. Commission as a percentage of the total bill (pay and commission) fell from 9.90% to 9.71% in the third quarter.

Treating patients closer to home

26 May 17

A new paramedic practitioner service is helping patients stay out of hospital by treating them at home.

The programme sees teams of paramedics and paramedic practitioners undertaking some of the GP home visits on behalf of surgeries while also being responsible for most of the 999 emergency calls in the area.

GPs will determine which patients are suitable for a paramedic visit, allowing the patient to receive a quicker response and GPs to focus on seeing patients in their surgeries.

Whitstable Paramedic Practitioner Steve Hulks said: “Working alongside our GP and community service teams in this way, you feel part of a whole team working together for the benefit of the patient.

“A really good example of this approach working well was when we received a 999 call involving an elderly man who had suffered a fall.  As I had already seen him previously on a GP home visit, I was fully aware of the patient’s previous medical history, which we have access to, and was then able to make an informed decision. This meant the patient could be kept at home and referred back to the GP the following day.”

Transforming care

Dr John Ribchester said the scheme was a good example of transforming care locally. He said: “The figures have been impressive and we expect it will prove very successful.

“In our first week we referred 32 patients to be assessed and 20 of them were dealt with by the paramedic practitioners, 10 were dealt with at home in liaison with the doctor and only two needed to be referred on for admission.

“The team also dealt with the referred 999 calls in the area and the transfer to A&E was also down so it has been an excellent start.”

Related article: How one practice tackled waiting times

Chris Stamp, Regional Operations Manager from South East Coast Ambulance Service NHS Foundation Trust (SECAmb), said: “We’re really pleased with the early stages of this new way of working which ensures better levels of care for our patients and means that where possible more patients are treated in their own homes without the need for hospital treatment.

“We’re looking forward to the further roll out of the scheme across our region as SECAmb is committed to innovation to improve care and experience for our patients and to increase local ties with GPs and other local community services.”

Similar models are already being trialled in other areas of Kent. Plans are being developed to roll these out across the whole region.

Changes to IR35 for GP Practices

26 May 17

Original post by Derek Charter who is a consultant for Network Locum

Limited Company V's Sole Trader 

On the 6th of April, a legislative change came into force that effects GP practices who use Locum GPs contracting through their own limited companies.

Many practices are unsure how this change will affect them, but we’re here to help. In this blog post I will explain what practices need to consider to help remain compliant after April, and what Network Locum is doing to help practices manage under the new legislation.

For more background on IR35 you can read my previous blog here:

http://blog.networklocum.com/2017/02/22/ir35-changes-for-gp-locums-with-ltd-companies/

Determining IR35 Scope

For practices, the first step is to determine if the engagement falls within the IR35 rules. These rules were implemented in 2000 to ensure that where limited company contractors work under conditions that are essentially the same as those of their employed counterparts, they also pay the same in taxes. Prior to this legislation workers and companies could avoid certain taxes by simply changing their employment status without any actual change to their working conditions.

Until now it has been the locum’s responsibility to determine the IR35 status  and apply the rules accordingly. However after April this responsibility will fall to the practice.

This is an important step as HMRC have said any unpaid tax due to an incorrect application of the rules, or a failure to apply the test can be reclaimed from the practice, along with any interest or penalties.

In order to help identify which contracts should be subject to the IR35, HMRC have developed an online tool, knowns as the Employment Status Service (https://www.gov.uk/guidance/check-employment-status-for-tax). Use of the tool is optional but HMRC will honor whatever result the practice arrives at from the tool. so long as the answers provided are accurate.

In order to interpret the questions correctly, and provide accurate answers, it’s helpful to consider the essential spirit of the IR35 rules; to differentiate between contractors who are genuinely independent and those who more closely resemble employees.      

Contract is “in scope” and locum is paid directly by the practice

If the practice engages a GP via the GP’s limited company on a contract that is subject to IR35 rules, the locum will need to be taxed as if they were an employee of the practice. The practice will need to run PAYE for the locum, and pay the locums fees after first deducting both income tax and primary NIC and paying this over to HMRC. The practice will also need to report this via the RTI system as for salaried employees.

In addition, the practice will need to pay a further 13.8% of the fee in Employers NIC and will have to include payments to limited company locums in the apprenticeship levy calculations.

Although the locum is treated as an employee of the practice for tax purposes they are not actually employees so are not auto-enrolled for pension and don’t receive statutory employment provisions such as sick or holiday pay from the practice.

Income Tax calculation

The locum is primarily employed by their limited company and the locum work is considered as “secondary employment” for PAYE. This means the practice will require the locum to make declaration C on the New Starter Checklist and report the locum on the HMRC Full Payment Summary (FPS).

Unless the locum has a P45 with an updated tax code for the existing year, tax will be calculated at the base rate (20% flat rate).

From the hourly rate the practice will need to determine what is known as the “deemed payment” and it’s that will be used to apply the tax rate. The deemed payment is essentially that portion of the fee that would be deemed the salary and upon which tax would be paid. This is the total fee minus any deductible expenses incurred by the locum that would be a reimbursable expense met by the practice if the locum was an employee of the practice.  

Employers NIC

Prior to April, the hourly rate paid to limited company locums is loaded to account for various taxed the locum and the locums limited company should be paying. For contracts where IR35 applies, the locums limited company is liable for 13.8% employes NIC, as the locum’s employer. After April, the locums limited company no longer has to pay this and the practice is now the employer for tax purposes.  Therefore the hourly rate should be reduced to reflect that the locum no longer has to pay employer NIC and the practice pays this directly.

Apprenticeship Levy

Employers with a total annual wage bill over £3mil are obliged to make apprenticeship levy payments of 0.5% of on amounts over that amount. This is separate legislation but is relevant because after April any fees paid to limited company locums are counted as part of the practice pay bill and so are to be included when calculating the apprenticeship levy.

Contract is in scope and paid via Network Locum

Network Locum is committed to helping practices manage under the new legislation. If the practice determines the locum contract to be in scope but the locum is paid via Network locum, Network Locum will perform the tax calculations, run payroll for the locum, deduct correct taxes, report and remit the taxes to HMRC.

The practice’s only obligation remains the initial determination of IR35 scope. Thereafter all other responsibilities fall to the Network Locum. This is a significant advantage to practices who still want access to limited company locums but without the significant administration and risk if the taxes are not paid correctly. The Network Locum platform will make communicating IR35 status simple and straightforward and thereafter the practice simply has to pay the invoice to Network locum and we will take care of the rest.

 

Related news: Implementation of Paramedics in a GP Setting

Urgent care needs to undergo a channel shift

26 May 17

How to transform urgent and emergency care will be one of the most challenging questions faced by Sustainability and Transformation Plan (STP) footprints.

Against a backdrop of stretched capacity and a system under intense pressure, STPs will want to understand how they can prioritise their local investment to maximise return in terms of activity, system efficiency and the potential for financial savings that can be reinvested in services.

Providers and commissioners will come together with a shared goal of addressing complex challenges and will need the best information to support their decision making.

As part of its Urgent and Emergency Care Review, NHS England aims to connect all UEC services together so the overall system becomes more than just the sum of its parts. This means we need to offer alternatives to A&E that provide access to a clinician closer to people’s homes, whilst making sure that skilled resource in hospitals is focused on the sickest patients.

The current reality is that much UEC activity is not taking place in the setting that is right for the patient and most efficient for the NHS. The interventions the UEC review has set out are intended, when taken collectively, to help shift care to the most appropriate setting.

This is known as channel shift.  There is an expectation that channel shift will always improve quality and, in most cases, that it will be more efficient.  In some cases, channel shift will also result in savings.

To support this, we have described a range of interventions that STPs should consider prioritising within their plans, such as:

  • Supporting local systems to deliver 24/7, clinician-led Integrated Urgent Care Services, accessed through NHS 111;
  • Introducing new ways of working for ambulance services that treat more patients in the community so safely reduce conveyance to A&E;
  • Introducing or increasing ambulatory emergency care services that manage emergency adult patients safely and effectively on the same day, avoiding admission; and
  • Providing education and support for staff in care homes to better respond to events and illnesses.

STP Footprints may have many questions about how to tackle their local pressures, including:

  • How will the interventions set out in the UEC review impact in our locality?
  • What will be the combined effect of multiple interventions?
  • What evidence do we have to support decision making?
  • How can we use local data to reach a collective informed decision of whether shifting activity between different providers / services can deliver savings?

To address these issues NHS England developed a stakeholder group comprising local and national organisations including NHS Improvement and led by Professor Keith Willett, NHS England’s Medical Director for Acute Care.

The group commissioned Capita and the North of England Commissioning Support Unit (NECS) to work with us to develop a “Consolidated Channel Shift Model (CCSM)” that will help commissioners and providers to:

  • understand the system effects of individual UEC interventions on activity;
  • secondly to understand the consolidated system effects of combining different UEC interventions;
  • and thirdly to appreciate the financial implications of system activity shift and the thresholds of activity redirection that deliver benefit.

Working with our UEC Vanguards, models were developed, drawing on the existing evidence base to understand the anticipated financial and activity impact using local information. The models were developed with two vanguard sites before validation with two further sites, to ensure the broadest appreciation of the channel shift impact. Each of the fifteen interventions is then brought together as part of an overarching model which calculates the combined effect of introducing the interventions.

The project team engaged with Professor Gwyn Bevan, an expert in health policy and commissioning at the London School of Economics to provide further, external, confidence on the appropriateness of the modelling.

What is particularly innovative in this work is the way it deals with two key concepts, “thresholds” and “local ambition”.  The threshold sets the level at which some of the semi-fixed cost can be addressed; local ambition describes how confident local managers are that they will be able to extract savings. The use of these approaches allows STPs and health systems to develop a shared approach to understand the costing and activity challenges of change in the next five years.

The channel shift model is now available to be populated by local footprints using their local data, supported by a comprehensive user guide. We will continue to build the model as we develop the evidence base, whether from international best practice, evaluation of our vanguards or wider evaluation of UEC interventions nationally.

Feedback from those who use the tool will be invaluable – we will collectively learn as commissioners and providers work together to plan strategically and facilitate service design.

Get in touch with us on england.uecchannelshift@nhs.net and tell us how you have found using the model  – what you’ve learned,  what  challenges you’ve faced, what you disagree with, any surprises and what you’re going to do locally as a result. We look forward to hearing from you.

Ciaran Sundstrem

Ciaran Sundstrem

Ciaran Sundstrem is the Care Model Lead for the Urgent and Emergency Care Vanguards, and Programme Lead for Urgent and Emergency Care within NHS England.

He has worked in a range of roles within the NHS since starting on the NHS Graduate Management Training Scheme in 2002, with particular experience in urgent and emergency care, health protection, health and justice, and substance misuse.

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