ࡱ> y GbjbjEE -''pl l .$8Miv(  ###'''''''$n),((##0($$$##'$'$$:y','#^N!J' 'F(0v(' ,/$d,','(:8$S(($^v(,l u: BASIC NON-ESSENTIAL SERVICES IN GENERAL PRACTICE:- LOCAL ENHANCED SERVICES A discussion paper prepared by Norfolk LMC INTRODUCTION The old (red book) GMS contract did not adequately provide for the changing range of services which patients expect, which practices are capable of providing, and which PCTs may wish to commission in future. Instead, during the red book era, practices took on an increasing range of services which was only funded in an uneven, ad-hoc way, or often was not funded at all. This concept is not new; the GPC in its incarnation as the GMSC, published a comprehensive booklet in 1996 which defined Core Services as work which is remunerated through the intended average net remuneration, ie as determined by the Statement of Fees and Allowances, (the Red Book). The Global Sum and the MPIG are both direct replacements for the Red Book, and therefore the concept of Core Services is still applicable. The New GMS Contract (GMS2) has unequivocally redefined the parameters of services which GP Practices should make available to their registered patients on the NHS. Under GMS2, practices are only to be contracted to provide Essential Services, and Additional Services if these are opted-in. (Almost invariably, practices across Norfolk will all opt-in to Additional services). These Services are equivalent to the Core Services described above. Essential and Additional Services are, therefore Consulting and managing patients who present with illness or who believe themselves to be ill, from which recovery is generally expected, and for the duration of that illness General management of terminal illness Management of chronic disease in the manner determined by the practice Opportunistic health promotion and continuing care after acute referrals Cervical screening Contraceptive services Vaccinations and Immunisations (in relation to residency in the UK) Maternity services except intrapartum care Non-cutting / non-injecting types of minor surgery Additional non-discretionary Quality payments will permit practices also to opt-in to providing further organised recording and intervention in certain chronic conditions:- CHD, Stroke, Cancer, Hypothyroidism, Diabetes, Hypertension, Mental Health, Asthma, COPD & Epilepsy. The Global Sum and the Quality Framework will fund exclusively all of and only the above activities and services. The Global Sum is calculated irrespective of historical non-discretionary or discretionary funding, including staff reimbursements. Whilst the Global Sum does include a factor which recognises staff costs, this element is only in respect of the practice performing essential, additional and specified quality services set out above. ENHANCED SERVICES Every other activity or service which could be provided by practices, by definition, is an Enhanced Service. Every Enhanced service must be funded additionally to the Global Sum and Quality Scheme. The opportunities for Enhanced Services are potentially limitless, yet funding for NHS primary care is finite despite the projected increases over the next few years. Apart from the few Directed Enhanced Services, the commissioning of Enhanced Services is entirely at the discretion of a PCT, both in terms of whether the service is provided, and how it is provided. Whilst practices, therefore, may not automatically expect to be commissioned to provide them, the lack of any given Enhanced Service for a practices patients is not the responsibility of that practice, but that of the PCT. The DoH has introduced safeguards which are to ensure a minimum level of investment in Enhanced Services; at national level the Gross Investment Guarantee, and at PCT level, the Fixed Pricing of National Enhanced Services, and a minimum floor for expenditure on all Enhanced Services. RATIONALISING AND DEFINING ENHANCED SERVICES ACROSS NORFOLK Norfolk LMC has a policy of constructive dialogue with all 6 PCTs, and in relation to Enhanced Services seeks agreement on five fundamental areas:- The definition of services that would constitute Enhanced Services. Which services will be commissioned by PCTs The procedures for reconciling patients expectations of Enhanced Services which are not commissioned The pricing and contractual details of each separate Enhanced Service The process for annual review of all aspects of Enhanced Services With a view pursuant to this agreement, the LMC surveyed all practices in Norfolk during October 2003, and asked them to provide examples and details of activities which they were currently providing and which would not be incorporated or resourced in Essential, Additional and Quality Framework services. From the 75 responses the LMC produced an unsorted list of these examples. During late November and early December, the LMC hosted open meetings for GPs and practice managers in each PCT area, and the combined attendance was over 200. The LMC received further information and discussed the issues fully with those present. This paper has adopted the information gathered, and the endorsement received, and presents the outcome of the survey and roadshow meetings and has suggested examples of services currently perceived as non-core, and categorises them into a series of potential local enhanced services for PCTs to consider commissioning. A PROPOSED CATALOGUE OF ENHANCED SERVICES APPLICABLE TO NORFOLK GP PRACTICES This list is comprehensive but not exhaustive. The vast majority of examples are currently being carried out by most practices, whilst a few have been mentioned by as few as one practice. This is academic, however, because these are all services which are, in some way or other, available to patients. It is the PCTs individual and collective responsibilities to ensure that they consider each example, and outline both whether the service is to be available to their patients and whether it should be in primary care. (A) Services arising from surgical or other specialist procedures performed in secondary care Rationale The commissioning of secondary care procedures for patients must include the total package of care which arises from the instigation on a waiting list by the secondary provider to the successful outcome of the procedure. Historically, but since the introduction of the Red Book, much more of this work was provided by secondary care, in terms of pre-operative assessment, shorter waiting lists, longer in-patient stays, and earlier, more frequent and more prolonged out-patient management. The drift of services into primary care has been absorbed and largely carried out by practice nurses and at practices own expense. Examples Pre-operative services principally clinical assessment of patients prior to undertaking surgery and anaesthesia. GPs essential responsibilities are to refer when appropriate and not also to undertake assessment on behalf of secondary care when the responsibility for that element of care is commissioned from secondary care ( eg pre-op blood tests, lung function and ECGs) Post-operative services on identical principles, the responsibility for provision of care directly following surgery is that of the commissioned party and not the GP (eg dressing changes, stitch removal, wound examination) Provision of consumables arising therefrom (dressings, lotions, tape, instruments etc) We also wish PCTs to accept that there is an element of less quantifiable additional work incumbent on GPs as a result of delays awaiting surgery following placement on waiting lists, and as a result of early discharge. (eg clinical complications arising from either circumstance) Priority - HIGH - Practices have become increasingly bogged down with this unfunded work, and it is clearly not included in Essential or National Enhanced services. The slimming-down of the extent of services provided by the secondary sector was principally to generate efficiency savings, and this must be recognised as having had an equivalent resource burden on primary care. Proposed SLA On commissioning surgical services, PCTs must commission the whole package and not just outpatient and peri-operative services. The range and variation of the remainder of the work, currently performed free of charge in practices is too indeterminate at present, and thus a set payment per practice, based on list size, and reviewed annually seems sensible. Consumables should be reimbursed additionally, if not already provided. Practices could be selected at random throughout year 1 in sample months to document the level of activity in this area, which will inform renegotiation in year 2. A basis for negotiating the cost would logically appear to be similar to those determined in the Directed Enhanced Service (DES) pricing for minor surgery or the NES pricing for minor injuries. (B) Community or secondary services performed in the practice setting Rationale Much work which has been historically associated with specialist or secondary care and managed in the community has drifted into primary care without attached funding. This particularly relates to ambulant patients attending surgeries for community-based care. The greatest workload is dressings to varicose ulcers, but there are others. Once again, PCTs must commission whole patient pathways and not just at the level of interface with secondary care. Examples Treatment of Varicose and other skin ulcers - Stoma care and provision of consumables arising therefrom (dressings, lotions, tape etc) Priority - HIGH - Leg ulcer dressing must be afforded an integrated and properly resourced approach, and the fragmented, seemingly arbitrary provision by community nurses and practices has to be abolished. The costs are large but would be much greater if the work was referred back to the various outpatient clinics where it originated. Proposed SLA This service has similarities to pre and post-operative services (A, above) and could be commissioned together as one. Consumables should be funded additionally. (C) Secondary care or specialist clinical sampling, testing or examination procedures done in the practice setting Rationale Phlebotomy is the largest single area which would be included in this service, but it is difficult to separate it from the phlebotomy which should be needed in connection with essential services or in pursuit of quality points. The LMC believes that phlebotomy is an essential part of the management of patients who present as described in Essential Services, the timing and setting for the procedure being determined by the clinical presentation (eg urgency or mobility of the patient). It would, however, be perfectly appropriate for GPs, having identified the need for a blood test, to refer patients for blood sampling to departments of pathology. Historically, these factors have tended to result in a greater level of provision in practices at distances further from the nearest general hospital. The LMC would want to see PCTs commissioning phlebotomy to be performed in the setting most appropriate for the patient, but also to ensure that the funding for so doing was also provided in all settings. Similarly, practices have tended to take on other investigative procedures which would have been also available in secondary care, and these are listed below. Whilst GPs would be very likely to continue offering these, they are time-consuming and costly, and PCTs must urgently decide whether and where these take place. Examples Urine HCG (pregnancy) testing - Phlebotomy - Sigmoidoscopy - 12 lead ECGs Blood Testing (eg ESR) - Indirect laryngoscopy - Endometrial sampling - Audiometry - Routine neo-natal examination (new baby checks) Priority - HIGH - for part of this area of activity. Whilst the LMC accepts that phlebotomy and 12 lead ECGs are suitably performed within general practice, the PCTs must commission the services. The examples cited apart from blood sampling / testing and 12 lead ECG probably do not need commissioning at practice level, as patients requiring these can be safely and appropriately managed at locality or hospital level or, in the examples of neo-natal examination and pregnancy testing this can be largely abandoned unless there is a clinical reason for either. (The author of this paper a GP for 13 years cannot recall one single instance of a new baby check resulting in an alteration of management) Proposed SLA There is no accepted measure of current levels of phlebotomy across Norfolks practices; but we do know that the level of provision is extremely varied. The LMC proposes that there is written undertaking by PCTs that they accept that phlebotomy is Enhanced, and that detailed practice-level activity surveys are undertaken in year 1 to inform this. During year 1, the LMC proposes that PCTs suggest a one-off payment to cover the service and funds all phlebotomy consumables. On commissioning phlebotomy, PCTs must recognise that some phlebotomy initiated by GPs is carried out by District Nurses for housebound patients. Suggestions have been raised that if practices no longer carry out ulcer dressings, district nurses will no longer agree to perform phlebotomy. The LMC believes that this is an issue for PCTs to resolve, as PCTs will be commissioning phlebotomy to the whole of their patients. GP practices are not in a position to undertake phlebotomy without resourcing, irrespective of where the phlebotomy takes place. (D) Specialist Clinical Services Rationale This large and varied area has evolved due to the imprecise nature of the old Red Book contract, but has the common theme of not being included in the services funded by the raw Global Sum or quality payments. Practices currently do or do not offer them in a haphazard way, and many GPs unwittingly believe most of them to be core services. A few examples have had sporadic, although insufficient, funding (eg cardiac rehab, IOS for some Hep B vacs, vasectomy, health promotion and smoking cessation), but there are no clear indications that these will continue in GMS2, and none except health promotion appear in the mapping of Red Book payments to the Global Sum. In two examples, (writing prescriptions for malaria prophylaxis and for non-exempt erectile dysfunction), GPs are probably entitled to charge patients a private fee for those services. Examples Vaccination not covered in Additional services - solely for foreign travel, hepatitis B (when not covered by the Green Book) Advice and counselling on foreign travel in healthy travellers Prescribing malaria prophylaxis Genetic counselling Erectile Dysfunction including prescribing medication in non-excepted cases Conversion from tablet to insulin-dependency in DM Vasectomy Post-infarct cardiovascular rehabilitation Future shared care drug prescription and monitoring Benign positional vertigo manipulation Advice on fitness, sports participation and sports injuries, including letters to gyms Smoking cessation intervention (NRT etc) Occupational health advice Priority - MEDIUM Practices can safely discontinue these services without an immediately adverse impact on patients with the possible exception of travel advice and malaria prophylaxis. The LMC is aware that the GPC is actively pursuing these two areas at national level. Each PCT is at liberty to consider the remaining examples, and may well decide that these are best commissioned at locality or county level, or not at all if there is secondary care provision in place. Proposed SLA None needed, assuming that travel advice and malaria will be sorted nationally. For other areas, the LMC will strongly advise practices to cease provision and refer to secondary care, pending PCTs further deliberations. (E) Therapeutic invasive interventions, other than minor surgery Rationale The specific procedures and tariffs published under minor surgery Directed Enhanced Service greatly underestimates the range of therapeutic invasive procedures widely and frequently performed in practices, many of which have drifted from secondary care within the past 15-20 years. Most of this activity is subcutaneous injections of some sort or another, the commonest probably being maintenance treatment of prostate cancer, which is undeniably very suitably done in primary care. Examples Subcutaneous injections (eg assisted conception - growth hormone - domiciliary subcutaneous fluids - depot HRT - antipsychotics - erythropoietin - interferon - methotrexate) insertion of Mirena IUCD for non-contraceptive reasons - contraception implants - tear duct syringing - ear syringing - urethral catheterisation - management of catheters in Care Homes changing PEG feed tubes & suprapubic catheters - Intravenous cannulisation - draining body cavities (eg ascites and pleural effusions) - chemotherapy (eg intravesical infusion). Priority - HIGH to MEDIUM Specialist treatment by injection carried out in primary care is arguably appropriate, and the drift from secondary care may well be seen as advancement and changing profiles of common medical treatments. Practices would have difficulty in suggesting that B12 or steroid injections (for medical conditions) are not core services in the spirit of Essential Services. The fitting of Mirena IUCDs to treat menorrhagia is new specialist work, is not covered under the relevant National Enhanced Service, and is quite appropriately referred to secondary care. It is also very likely that it is a most cost-effective service to commission in primary care. Contraceptive implants are not covered in existing contraceptive services specifications and so are not read across to Additional services. Regarding the tradition of Ear Syringing, the LMC believes that patients presenting with ear wax as a cause of symptoms such as perceived impaired hearing are catered for under Essential Services, however we will advise practices that the routine requesting of ear syringing prior to attendance at ENT outpatients is not, and the PCTs should consider this as an Enhanced service. Proposed SLA PCTs should agree to commission, on an item of service basis, the fitting of Mirena IUCDs, and probably best as an add-on to the National Enhanced service of other IUCD fitting, and for insertion of contraception implants. The costs should be equivalent to a minor surgical procedure. That ENT clinics frequently write to practices requesting that referred patients have their ears syringed prior to attendance should be borne in mind by PCTs, when considering to commission this activity in practices. Otherwise all existing mainstream therapeutic injections should be carried out under Essential Services, but the PCT should consider funding consumables. The instances of non-mainstream injections, assisted fertility, growth hormone, depot HRT, methotrexate, erythropoietin, interferon and depot antipsychotics should be specified and funded as an Enhanced Service, and all new therapies arising should be considered carefully before assuming that practices will continue with them. (F) Complementary services Rationale Consistent with the spirit of the-one stop shop ethic, patient demand, and the modern acceptance that complementary techniques have important roles in the holistic management of illness, practices have introduced ranges of such services. The funding arrangements have been very varied; sometimes paid for by the practice, sometimes from discretionary GMS or other growth monies, and sometimes the practitioners have rented space and have treated patients independently, either by virtue of separate NHS funding or on a private basis. However, there is no funding for any of this under Essential or Additional Services, and the clinical areas involved will not affect the Quality payments. Examples Physiotherapy - Counselling - Homoeopathy - Dietician - Aromatherapy - Hypnotherapy Acupuncture - Stress Management Priority - HIGH Unless funding streams are specifically identified and provided by PCTs, practices could be in a very compromised position in terms of continuity of care, and liability as employers. However, the LMC does not want to see practices being treated differently on the basis of historic, and now redundant, discretionary payments. PCTs are urged to adopt a credible, realistic and above all, uniform strategy for the provision of complementary services. Proposed SLA Provided complementary services may be justified by evidence of efficacy, the LMC believes that they should be provided in a manner which makes them equitably accessible to all patients, but would not necessarily be provided in all practices. We propose that the current level of PCT expenditure should be preserved, at least, but that changed access and provision should be implemented so as to not discriminate between practices. (G) Supplementary Domiciliary or Care Home Visiting Rationale Domiciliary visits are frequently time-consuming and characteristically do not provide a clinical advantage to either the patient or the GP in comparison to the consultation occurring in the surgery. Many other similar countries manage perfectly well with a much lower visiting rate. Many patients who request visits are perfectly physically able to attend the surgery, and all GPs have experienced the same patients being quite happy to visit outpatient clinics, go shopping, attend lunch clubs and visit their relatives (please visit in the morning so I can go out in the afternoon). Visits are expensive in terms of relative time and compromise the achievement of access targets and access quality payments, and in terms of personal cost to the GP; motoring expenses are not reimbursed; merely tax deductible. The New Contract expressly states the criteria where (in-hour) home visits are necessary:- In the light of the patients medical condition, the doctor considers that such services are needed and would most appropriately be delivered by means of a home visit. PCTs should note that there is no mention of patient convenience, preference or availability of transport. PCTs should also note that by being resident in a Care Home does not mean that the patient is incapable of a journey to the surgery. GPs accept the responsibility to visit the frail, infirm and bed bound within Care Homes, but a significant proportion of residents are ambulant, witnessed by their ability to attend outpatients, visit relatives and go to lunch clubs and other outings. The LMC points out that the additional weighting of a global sum in respect of the prevalence of elderly patients in Care Homes merely reflects the more frequent consultation rate and does not presume that age is, in itself, a factor which informs assumptions about visiting rates. Priority - HIGH This has been a long-standing irritation for GPs, who are seeking the backing of PCTs to enable literal implementation of the new contract. The LMC proposes that a supplementary visit is defined as :- Any face-to-face consultation with an ambulant patient which occurs outside the practice premises and in which the GP perceives no clinical reason or advantage by so doing Proposed SLA No SLA is essential, as supplementary visits could be avoided entirely. The LMC will strongly advise GPs of the precise wording of para 2,26. Patients, their carers or relatives, or the management of Care Homes should take responsibility for transport and escort if needed. The PCTs should consider carefully para 2.27, and may decide to commission transport services for these purposes, or a separate home visiting service for requests outside the criteria, or commission GPs on an item-of-service basis to carry out such visits as a LES. If PCTs wish to commission Intermediate Services they must factor-in the total cost of GP involvement. (H) Enhanced Administration Services Rationale GPs and their staff are frequently caught up in administrative tasks or meetings arising from needs not catered for under Essential or Additional Services. A very disparate group of examples fall into this category but have one unifying theme - GPs (or practices) could quite legitimately decline to do them if unresourced, without being in breach of the New GMS Contract. Examples Completion of statutory sick notes for patients as a result of hospital treatment which should have been done by secondary care clinicians Letters and phone calls to hospitals arising from changed circumstances of, or pressure from, patients already on waiting lists Arranging hospital transport for patients Participating in Patient Choice initiatives (to commence next year) Providing copies of notes, letters and referrals to patients Attending child protection case conferences Attending mental health case conferences Completion of non-statutory forms not otherwise covered under collaborative arrangements Priority Essentially this is up to the PCTs - who should bear in mind that the LMC is quite prepared for a vigorous campaign to dissuade practices from undertaking this area of Services, as they would not be in breach of their contracts and patients would not be harmed, and that such requests will be referred to the PCT. In commissioning services for patients, the PCTs have to decide whether they wish to see this work performed, and thus how it should be provided. PMS and LOCAL ENHANCED SERVICES Various amounts of growth and quality were applied to PMS practices contacts as enhancements to their existing GMS contracts. However, as a generalisation, the LMC believes that these elements are comparable with, or equivalent to, areas of the new GMS contract which are provided under the Quality Framework and the Directed or National Enhanced Services. We do not believe that the move from (old) GMS to PMS altered the concept of non-core services, and were not factored in to PMS contracts. The essential proposals in this paper has been shared with the GPC during November, and Norfolk LMC asked the GPC negotiators about the concept of applying non core, local enhanced services to PMS practices, and we received this reply: On (this) issue you certainly have the GPCs support, but of course it will always be argued that, since these (PMS) contracts are local contracts it will be up to local discretion as to what happens. As I mentioned (in an earlier email), I believe that what happens in GMS will help those local arguments on the basis that the Minister has frequently said that PMS and GMS2 should be treated fairly SUMMARY This paper attempts to rationalise and prioritise areas of services and activities currently or potentially afforded to patients in general practice but which are not defined in the funding streams or contract specifications These services may be subdivided into the following categories:- 1 A) Pre and post surgical, together with B) community, services performed in GP practices 2 C) Secondary care testing and examinations performed in GP practices 3 D) Specialist clinical services 4 E) Invasive therapeutic interventions 5 F) Complementary services 6 G) Supplementary visiting 7 H) Supplementary administration Most of these categories need urgently to be addressed in time for the new contract. There is insufficient time to draft and test SLAs which accurately reflect the true activity and cost of each service during 2004-05 Urgent commissioning agreements are required in most categories because patient care will be affected adversely if not. The remaining areas need recognising, but are of less urgent priority to establish agreements by April 04 because either the services could carry on to some extent or their lack of provision would not harm patient care The LMC proposes: 1 Category A and B - should be commissioned in each practice, to carry on existing levels and funded by a flat rate adjusted for indicative practice list size. Widespread activity surveys to be conducted during 2004-05, with the aim of commitment to realistic pricing and funding in 2005-06. Additional full reimbursement of consumables not available on FP10 2 Category C - The principal element of this category is phlebotomy this should be recognised as such by the PCT with some good will funding and an undertaking to fund properly from 2005-6. Widespread activity surveys to be conducted during 2004-05. Additional full reimbursement of consumables 3 Category D With the exception of travel vaccines, travel advice and malaria prescribing (where national negotiation is under way), these activities can be ceased, with patients with genuine clinical need referred to secondary care. 4. Category E Significant areas are fitting Mirena IUCDs for non-contraceptive reasons and should be added on to fitting IUCDs under National Enhanced Services. Contraceptive implants should be commissioned additionally to Additional Services on an item of service basis. Ear syringing prior to attendance at ENT outpatients may be discontinued unless the PCT seeks to maintain it. Some specialist injections should be commissioned. Other areas should continue during 2004-5, with activity surveys to inform the following year. Consumables should be funded 5 Category F The current total level of spending (all sources) should be maintained and funded as Enhanced Services, but the services made available equitably to all patients. This should be reviewed at the end of 2004-05 6 Category G Practices should be supported to follow the letter of the contract in 2.26. Supplementary visiting or patient transport is an issue for PCTs to decide upon Category H These activities will cease, and the onus is on PCTs to resource them if they are to continue, meanwhile GPs will refer requests to undertake these services to PCTs Norfolk LMC December 2003 Appendix 1 Non-Core Services Identified in Core Services : Taking the Initiative (GMSC 1996) The following list is taken from the above document, less the examples cited in it which have now been covered in National Enhanced, Additional, Directed Enhanced and Quality Outcomes Framework Pre operative assessment Post operative care Phlebotomy Specimen transport Ordering or undertaking investigations for patients under hospital care Prescribing while hospital care continues Pre referral examination or investigation that does not influence referral decision Certification while patient is under hospital care Completion of forms not required by Terms of Service Removal of sutures Attention to dressings after a secondary care procedure Prescription / administration of interferon, cytotoxics, subfertility, hormone implants, Preparation of endometrium prior to hysteroscopy Mental health care for patients under supervision orders Sectioned patients temporarily in the community Acupuncture Hypnotherapy Endoscopy Sigmoidoscopy Vasectomy Physiotherapy Dietetics Chiropody Protocols which require specific GP activity prior to referral And Other Specific Tasks Norfolk LMC, December 2003 Appendix 2 The following other services were recorded by practices in the survey but have been discounted as they are covered elsewhere in the contract Cognitive Behavioral Therapy forms part of the National Enhanced Service specification in services to patients with depression. If none is commissioned, practices should cease providing this Removal of foreign bodies from eyes - forms part of the National Enhanced Service specification in minor injuries. If none is commissioned, practices should cease providing this and refer patients to the department of ophthalmology or A&E HIV testing forms part of the National Enhanced Service specification in Sexual Health services. If none is commissioned, practices should refer to the GUM clinic Pneumococcal vaccination is covered as an Additional service and prescribed in the Green Book Near patient testing of drugs not within the National Enhanced Schedule. We anticipate newer drugs such as leflunomide will be incorporated Zoladex injections for prostate cancer, we believe is an appropriate GP service under the management of chronic illness. The GP can claim the personally administered fee in addition Spirometry was suggested as an enhanced service; but we believe that the indications for spirometry are nearly all related to the clinical domains in the Quality and Outcomes framework, and thus, indirectly funded. This is not to say that other Q&O relevant investigations such as ECHO cardiography or CT scanning should also be provided by practices as these are clearly secondary sector services. (Spirometry specifically requested as a pre-operative assessment should be resourced) Norfolk LMC, December 2003  Core Services: Taking the Initiative, see Appendix 1 of this document  Paras 2.8 - 2.12, New GMS Contract 2003  Some Other Services published and circulated at local LMC roadshows  Mapping of Payments - New Contract, Supporting Documentation, Chapter 6  New Contract, Supporting Documentation, Chapter 2.4  New Contract Paragraphs 2.26 & 2.27  Dr Hamish Meldrum (Joint Deputy Chair of GPC), personal communication 03.12.03.      PAGE 1 6MNP{}o p  2:,R4!7B"%"'"="##%& &t''***,,N-V-b-..T//// 555ȼȳȳȳȨȨȟȳȼȟȟȨȳȳȨȨȟȨȨȨȟȨȨh0J5CJh0J56CJh0J6CJjh0JEHUh0JCJjhEHU h5CJ h6CJ hCJ hCJh h5CJ>6NOP{YY1$ Gp@ P !$`'0*-/2p5@8;=@:]:^a$. 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