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The New GP Contract 4.24 GPs are currently considering the proposals for a new General Medical Services (GMS) contract which was published on 26 February 2003 following negotiation by the NHS Confederation (on behalf of all UK Health Ministers) and the British Medical Association (BMA). The principles of the new contract are to reward family doctors with significant additional income where they deliver better quality and a wider range of services, and allocate resources more fairly on the basis of patient need, not doctor numbers.
4.25 If the contract is accepted, GP Practices will provide a range of essential and additional services, and have the opportunity to further increase their income through opting in to provision of a wider range of enhanced services commissioned by the local PCT. Local enhanced services will include those services which are a response to specific local requirements, such as the care of asylum seekers. PCTs will be free and able to commission whatever enhanced services they consider appropriate to meet local health need above a guaranteed minimum level of investment.
Personal Medical Services (PMS) 4.27 The NHS (Primary Care) Act 1997 allowed for the introduction of ‘PMS pilots’. PMS refers to the same type of services as General Medical Services, but it differentiates the services as being delivered under a pilot scheme. PMS pilot schemes are voluntary and are intended to give PCTs, Strategic Health Authorities and providers – particularly GPs and nurses – the flexibility and opportunity to innovate by offering different options for addressing primary care needs.
4.28 Doctors, nurses and PCTs that become PMS pilots, are able to negotiate directly with their commissioner to provide the services patients want, for example, varying surgery times to meet the needs of the local population, including addressing the needs of particular groups. Potential PMS providers should enter into discussions with their PCT, as PMS will be a continuing contractual option in primary care. More detailed information on the future of PMS will be available after the results of the current ballot on the new GMS contract.
4.29 This flexibility has meant that many PMS pilots have been set up to provide primary care for
asylum seekers. PMS pilots can offer flexibilities such as:
• provision of longer consultations on behalf of many GPs in an area;
• use of nurse led health teams to identify and address healthcare needs;
• satellite GPs working from several centres when asylum seekers are dispersed over a wide area;
• use of specialist health visitors to work with asylum seekers by providing immediate interventions on arrival in a dispersal area.
Three PMS pilots – in Huddersfield, Suffolk and Sunderland – are profiled on the following pages.
Caring for Dispersed Asylum Seekers The Whitehouse Centre (Huddersfield) Ms Rachel Haigh, PMS Pilot to Asylum Seekers, The Whitehouse Centre, 23a New North Parade, Huddersfield, Yorkshire HD1 5JU. Tel. 01484 301 911, Fax. 01484 301 941 Staffing • 1.5 full time equivalent salaried GP.
• 1 full time equivalent Health Advisor with special responsibility for the homeless/asylum seekers.
• Two Primary Care nurses – both prescribing.
• Post vacant for a named Social Worker.
• 3 sessions shared care per week.
• 2 sessions with a CPN per week.
• 2 Peer Health Educators.
Process This scheme addresses the need for longer consultations with asylum seekers as it guarantees 30 minutes with the GP to explore in a holistic way what the patient’s real needs are. The GP has the time to communicate to a patient through an interpreter, can tackle the root cause as well as the acute problem and is more likely to pick up on underlying issues such as somatic expression of mental distress. The extra time allotted also allows them to look at patients social care needs such as housing as well as their medical needs.
The scheme has developed more of a social model of consultation, more time consuming in the short term but addresses the issues in the long term.
The GP is able to give patients more time as the surgery does not offer home visits. The scheme operates on a principle that an in-depth consultation significantly reduces the need for a home visit. Service is open from 9 a.m. to 5 p.m. on weekdays. Outside the surgery hours patients are referred to A&E department in cases of emergency, the out-of-hours GP co-operative, or to NHS Direct. Benefits of longer consultations and improved inter-agency links far outweigh the loss of a guaranteed home visit.
Suffolk Community Refugee Team PMS Pilot Suffolk Suffolk Community Refugee Team, 70 –74 St Helens St, Ipswich, Suffolk, IP4 2LA Tel: 01473 340190 Fax: 01473 286525 Email email@example.com Background The project grew out of an initial initiative to relieve pressure on local Primary Care services by appointing a health visitor to assist asylum seekers with access to services. It quickly became clear that one person could not address all the difficulties asylum seekers experienced in accessing services and all the issues faced by service providers when working with this client group.
The project’s overall aim is to provide a “bridging service” to assist integration of asylum seekers and refugees into local communities and services. It is not the aim of the project to create separate tier of service provision to asylum seekers over and above anything provided for the local community or to relieve the need for local services to develop their provision to work effectively with this client group. Asylum seekers simply highlight Caring for Dispersed Asylum Seekers needs and gaps in service provision faced by other minority ethnic groups and by local communities as a whole.
Aims • To provide a ‘bridge’ for integration of clients into general mainstream services.
• To provide support to general mainstream services – education/information.
• To provide specialist services to asylum seekers and refugees.
• To provide a package of holistic care for unaccompanied minors.
• To explore ways of extending aspects of this service to all minority ethnic groups.
Funding PMS Greenfield Pilot (4th Wave – commenced April 2002) Ipswich PCT hosted service for all of Suffolk.
Original PCT top sliced funding for project Co-ordinator.
Existing Social Services funding for Asylum Support Team.
Staffing Co-ordinator (in post) Salaried GP (part-time) Nurse Practitioner (part time) Mental Health Worker (in post) Bilingual community link workers (recruiting) Community Development Worker Administrator (recruiting) Clerical support (in post) Social Worker (in post) 2 Family Support Workers (in post) Physicians Assistants (Refugee Doctors) Management Project management – Operational Steering Group – key members of partnership agencies with strategic responsibilities. Line management and clinical supervision through links with key professionals in PCT and Social Care.
Partnerships for specific initiatives Counselling services, Local Mental Health agencies, Volunteer Project Refugee Council, Suffolk Refugee Support Forum.
Translation and Interpreting Project, Community Dental Service, and Accommodation providers.
Evaluation Ongoing monitoring by PCT.
Reporting to Strategic Health Authority.
Health and Social Care needs identified.
East of England Consortium for Asylum Seekers Services.
PMS Sunderland Pegasi Practice, Hendon Health Centre, Meaburn Terrace, Sunderland SR1 2RL Tel: 0191 510 1865 Aims • To provide a holistic, multi-disciplinary approach to asylum-seeker and refugee health care.
• To integrate asylum-seeker and refugee health care into mainstream health services in the community.
Work The team is in close contact with the landlords of the accommodation in which refugees are placed, and are kept informed of new arrivals. The accommodation providers will register asylum seekers with the Pegasi practice, those beyond the catchment area are allocated a GP. After notification of new arrival is received a translated appointment letter is sent out to the asylum seeker.
Refugee Clinic is held three times a week with the practice nurse and GP in attendance. The team has also been instrumental in initiating research into the health needs of asylum-seekers and refugees in Sunderland and North Tyneside.
Training sessions have been held on culture, mental health issues, post dispersal factors, and refugee experience. The team is working with the voluntary sector to develop support groups for asylum seekers.
Funding The team is mainly funded by the local PMS Pilot, and by Sunderland Teaching PCTs.
Evaluation The proposal for the service included a recommendation that it be linked with Sunderland University for audit and evaluation. This will be done when the service is fully established.
Language support 4.30 For asylum seekers who do not speak English, interpreting is a crucial issue and one of the most important factors in relation to accessible health care. However, the diversity of language and culture among asylum seekers has made forward planning challenging in some areas. PCTs and Local Councils are responsible for ensuring adequate access to interpreters for asylum seekers within their own area. It is often beneficial for language resources to be shared across sectors.
4.31 For some languages there may be very few interpreters in the whole country. Telephone based interpreting offers an alternative which can help deal with the diversity of languages needed in a co-ordinated way. The limitations of telephone interpreting should be considered before use,
however. These include:
• inability to assess non-verbal communication;
• interpreters may not be familiar with medical terminology/background and may vary in quality;
• patients do not get any additional information or support once the consultation is over.
4.32 Providing an appropriate interpreting service can be challenging and expensive. This is recognised by the Department of Health and as such, work is underway to assess provision.
Caring for Dispersed Asylum Seekers
4.33 Here are some basic guidelines for service planners and frontline staff on interpreting services:
Service planners • An agreed framework, standards and guidelines for the use of interpreting services should ideally be developed at PCT/Local Council level.
• Where possible, interpreters should be trained, supervised and supported as integral members of the team.
• Continuity of care is an important factor particularly for sensitive consultations such as rape, torture or mental health problems. Some PCTs allow GPs, dentists, health visitors and others access to the same interpreters for continuity. Westminster PCT use language stickers on GP referral letters to hospitals to alert service providers of interpreting and language need.
• Links should ideally be developed with refugee community groups to establish what particular needs each community has.
languages other than English is in development. This protocol will enable frontline staff to develop resources online, leading to a bank of downloadable information available to all. To initiate this, a set of key leaflets will be developed, via the protocol, in over 30 languages.
NHS Direct 4.37 NHS Direct is a valuable tool for all people living in Britain, including Asylum Seekers and Refugees. The service has access to Language Line and has produced information sheets in 25 different languages. Please see www.nhsdirect.nhs.uk for further details.
City & Hackney Primary Care Trust Advocacy Services (CHAS) Basement B Block, St Leonard’s, Nuttall Street, London N1 5LZ, Tel: 020 7301 3024/3026 Provides advocacy and interpreting service to users of primary and community services in the City and Hackney area, and Homerton University Hospital. Service operates 9.30 – 17.15 Monday to Friday. An out of hours telephone interpreting service is provided to GPs by Newham Language Shop funded by the PCT.
Staff 18 permanent health advocates (12 core languages) and 15 sessional advocates (11 languages). A manager, two co-ordinators, refugee link worker and two administrators. Health Advocates are provided with training on the NHS, and many have completed accredited qualifications in advocacy of interpreting.
Work The service operates an open referral system, including self-referrals. Appointments can be requested with a completed referral form by telephone or fax and an advocate allocated within 72 hours for non-emergency cases. A twenty-minute slot is allocated unless agreed otherwise, with a maximum two hours in any one booking. Multiple bookings can be made. Bookings are confirmed by fax or by telephone, and unallocated cases are informed within 48 hours. Genuine emergencies are catered for through telephone interpreting sessions.
Advocacy is any action an interpreter takes on behalf of the patient outside the bounds of an interpreted interview. The advocate is concerned with quality of care in addition to quality of communication.
Advocates can give information to the health care provider about cultural and religious practices relevant to the patient’s health. They are involved in the training of health care workers about the different cultural norms and practices.
An operational policy document and an information pack are in place. They contain information for professional staff and self-referred users to clarify services available and how to access them. The information for the latter group has been translated into 6 languages. The service is widely publicised using a variety of mechanisms such as open days, posters, and adverts in the local community press for example.
Funding The project is core-funded by the City and Hackney PCT. CHAS can also generate income by providing a sessional advocacy service to other services who are charged an hourly rate inclusive of all costs including management and administrative costs.