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CCGs insisting anti-coagulation management 'is part of core contract'

GPs have been advised to stop taking responsibility for patients’ anticoagulation management after CCGs refused to commission and fund the service properly, and insisted it was part of GPs' core contract.

Local GP leaders have advised practices to give CCGs notice that they can no longer continue providing the care because it is not safe to do so, after one offered no payment at all and another offered a ‘pitiful’ fee.

The move follows a disagreement over how anticoagulation services are funded, with some CCGs arguing that the care comes under core GP work.

North and South Essex LMC has now written to GPs in the area to remind practices anticoagulation does not fall under essential services within the GMS/PMS contract.

The LMC is advising GPs who have not been properly commissioned through an enhanced service to serve notice to the CCGs – and is offering assistance to any practices if they come under pressure to continue.

In a letter to practices, seen by Pulse, the LMC explained that some CCGs ‘are now suggesting to practices that provision of anticoagulation is part of practices’ core contract’ and that ‘one CCG is offering a fee, at a pitiable level’ and that another ‘isn’t even suggesting a payment’.

The LMC advised: ‘If you are not commissioned properly to provide the service but have continued to do so, at your own expense, you have the right to serve notice to the CCG – it is for the CCG to make proper arrangements for provision of treatment to patients.’

It added that if practices receive ‘undue pressure from the CCG, please contact the LMC for assistance’.

LMC chief executive Dr Brian Balmer told Pulse the CCGs in question – NHS Basildon and Brentwood CCG and NHS Thurrock CCG – ‘basically don’t want to fund a safe system’.

Dr Balmer said: ‘To take on anticoagulation properly – which should involve testing, monitoring, checking results, adjusting doses – requires proper funding and resources.

‘I don’t want people doing it for free or shabbily because it’s not being funded properly, that’s dangerous.’

He said the GPs should ‘be more concerned about the CQC than the commissioner, because the CQC is going to come up and say, why are you doing this it is not safe?’

Dr Balmer added: ‘They should give them notice they are going to stop and get the commissioner to tell the patient where the service is now being provided – and if the commissioner doesn’t, personally I would send people straight to hospital.’

Dr Bob Morley, GPC policy lead on contracts and regulation, said it was ‘completely erroneous’ for CCGs to ‘state that anticoagulation services fall under GMS/PMS essential services’.

Dr Morley added: ‘My advice to the practices affected by their CCG neglecting their responsibilities to commission fit for purpose an adequately funded anticoagulation enhanced services would be to refer all patients requiring anticoagulation to a secondary care services – patient safety must be the priority.’

Rahul Chaudhari, head of primary care at NHS Thurrock CCG, said in a statement to Pulse that the CCG ‘is aware of the current issues with anticoagulation therapy management’ and that the ‘CCG’s medicines management and commissioning teams are working with our GP colleagues and Basildon Hospital to improve this pathway’.

NHS Basildon and Brentwood CCG declined to comment.

 

Readers' comments (15)

  • I have just had a patient in her 80s seen in the CDU for fast atrial fibrillation. She was discharged on a large dose of apixaban and clopidogrel continued , having spent an afternoon there. There was no follow up and I have no idea whether she was properly investigated and managed. It is expected that I will continue a prescription that i am unsure about. She has certainly not been adequately counselled.

    There is no way I am going to take responsibility for her inadequate management so I have referred her to cardiology myself. Not all GPs have done senior medical jobs, and I believe we should all know our limitations.

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  • Anticoagulation is NOT part of the core contract.
    Any GPs who work on the board of CCGs that claim this are quite frankly useless as well as dangerous (see Pev's article previously)

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  • Are we grouping Warfarin and NOAC together here? We are funded for warfarin initiating / monitoring but no such contract for NOAC. DO the LMC have a view on NOAC.

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  • It is often done by large pharmacy chains up here. I am sure they will more than happy to provide a free service.

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  • NOAC/Warfarin dioesnt matter - not core - in anycase how GPs manage is up to practice not ccg

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  • The idea above is pretty good - send every patient needed an INR to A+E.

    That will very quickly result in a service being commissioned.

    Option 2 is just start everyone on Apixaban/ rivaroxaban. If you ask nicely the drug companies will help fund time required for initiation and monitoring - I imagine 10000 patients accross a CCG paying the drug companies 800 pounds a year would garnish a lot of assistance from the drug companies.

    Finally option 3 is to prescribe every warfarin patient a self minor kit with 100 monitor strips. Tell them to take their INR tds. You will very quickly see the CCG come up with an alternative solution. I think the INR sticks are about £2 each.

    Any one of the above will result in the impasse being resolved. Just don't do nothing.

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  • Well done Brian and the LMC, keep up the good work

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  • Since starting / monitoring a NOAC is no more work than starting / monitoring a statin, I wouldn't expect to be paid extra for this. But warfarin management is definitely an "extra".

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  • It depends if you are starting and monitoring your NOACs correctly and in line with guidance.

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  • surely NOACs are secondary care initiation? Unless your CCG wants to invest in extra training and an LCS?

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