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Q & A - New Contract (Apr '04 onwards)
Pre April 2004 New contract Q&A
Index
NCO32 - Bonus points for access
NCO31 - PMS agreements
NCO30 - Appraisal
NCO29 - Open, full and closed Lists - update
NCO28 - Prison medical services
NCO27 - Minor injuries unit
NCO26 - PGEA
NCO25 - GPAQ and IPQ patient experience surveys
NCO24 - Surgery opening hours
NCO23 - Flu & travel vaccines
NCO22 - Open, full and closed Lists
NCO21 - Seniority and superannuation
NCO20 - References for locums
NCO19 - Consent to treatment under the new contract
NCO18 - Child health surveillance checks
NCO17 - Medicines review
NCO16 - Contraceptive services to non-registered patients
NCO15 - Private patients after retirement
Q NCO32 - Bonus points for access – Our PCT is challenging our eligibility for the 50 bonus points for the DES for Access to GMS. We
have a range of appointment options, but most of our patients choose to arrive at the surgery between 0830-1030 and 1600-1800 and are given the next available appointment with the GP. They take a number when
they arrive and then wait their turn. The PCT have produced a document from NATPACT setting out the access requirements. We always fill out a monthly access form.
(24/11/04)
Answer - The DES for access to GMS was based upon the objective contained in the NHS Plan in
England that: "by 2004, all patients will be able to see a primary care professional within 24 hours and a GP within 48 hours". You appear to have achieved this objective.
Part 2 Para 5.26 of the SFE sets out details for the Calculation of points in relation to QOF Access Payment
relating to the access targets referred to in paragraph 6.1(a).
"Achievement in relation to these targets in the four months from December 2004 to March 2005 inclusive will enable contractors to score up
to 8 data points (4 in relation to access to GPs and 4 in relation to access to health care professionals) under the Primary Care Access Survey during that four month period. Practices scoring–
(a) 6, 7 or 8
data points in respect of achieving these access targets during that period;
(b) at least 3 data points in relation to access to GPs during that period; and
(c) at least 3 points in relation to access to
health care professionals during that period,
will be entitled to 50 points as the basis of a QOF Access Payment."
Para 6.1 of the SFE requires each PCT to establish an Improved Access Scheme which may comprise or include –
"(a) arrangements for ensuring that patients
requiring routine appointments will, on request, be able to see face-to-face, by the end of–
(i) the first normal working day after the day on which the request was made, a health care professional, and
(ii)
the second normal working day after the day on which the request was made, a general practitioner; "
It does not state specifically that the patient must be given an appointment, nor does it define 'appointment'. If you fulfil the criteria and achieve
the targets set out in 5.26 you should therefore be eligible for the bonus points.
The NATPACT documentation that the PCT has sent also states quite clearly that "the proportion of appointments that may be bookable has not been prescribed
centrally - this is something that needs to be addressed locally in the light of practice or provider capacity and organisation, and the needs and preferences of patients." It also states that PCTs
have 'discretion' in the matter.
You appear to offer what is effectively a 'block appointment' rapid access system and sufficient pre-booked appointments to satisfy the reasonable needs of those
people for whom a specific pre-booked appointment is essential to fit in with their other commitments. The fact that most of your patients tend to choose 'same day' slots with the GP of their choice, tends to
imply that they find this satisfactory. You would, therefore, appear to meet these NATPACT criteria.
The matter of access payments under the DES is determined by different and very clear criteria set out in paragraph 6 of the SFE and in the Supporting documentation
which sets out the process which must be agreed with the PCT.
The funding is divided into 50% for the implementation at the start of the year and 50% reward at the end of the year. Your practice does not appear to have
agreed with the PCT the basis for your funding in advance and they may cite this as a reason for withholding full payments this year.
It would, however, be worth negotiating with your PCT to see if any payment is possible for this year, based upon your achievements in improving patient access, as
demonstrated by your monthly access checks.
It is important to keep a watching brief to ensure that your patients remain satisfied with your booking arrangements and to make any necessary adjustments to meet
their needs and preferences. This is likely to be even more important to practices in the future with the increasing emphasis on patient choice and even possible competition to offer essential services if APMS
and PCTMS become a reality.
The Advanced Access model was a modernising initiative managed by the National Primary Care Development Team (NPDT) consisting of a framework of principles and ideas based upon
practical examples of managing access more efficiently in general practice. You may find their documentation helpful. Your PCT should be able to help you to establish an improved system if you feel that
this would be beneficial to you and your patients.
It is also important to consider Management Indicator 5, which relates to appointments, and Patient Experience Indicator 1, which sets out the criteria for the
length of consultations.
By aiming to satisfy as many as possible of the good practice criteria established in the new contract you should be best placed to maximise your service to
patients, your total practice income and your right to provide that service in the future in the face of any outside provider competition.
CED
Q NCO31 - PMS agreements - Am I right in thinking that the PCT cannot impose a particular PMS contract on our practice?
(27/10/04)
Answer - Absolutely. Wessex LMCS issued an Urgent PMS Agreement Alert in September to inform GPs of their rights in this respect.
Most practices have now resolved any problems with their PMS contract, so please contact the LMC if you have any ongoing problems.
CED
Q NCO30 - Appraisal - We are about to commence preparation for our second round of GP appraisal. Last year, before the new
contract we received a payment for preparation and for the appraisal itself. Is this payment now included in the global sum? If not has a figure for this year been agreed? (18/10/04)
Answer - Appraisal funding has been agreed nationally at 26p per patient
and this should be added to the Global Sum. Some PCTs have not yet made the adjustment to reflect this so you should check with your PCT that the money has in fact been included.
CED
Q NCO29 - Open, full and closed Lists - update - All three local practices are currently having difficulty physically accommodating
additional patients. Are we still entitled to refuse patients on the basis that our list is temporarily full, even though we do not wish to close it permanently? (04/10/04)
Answer - You are still entitled to refuse to accept a patient on a
non-discriminatory basis because your list is temporarily full. The situation is set out in Q&A NCO22 - Open, full and closed Lists.
We are aware that some local GPs are abusing their right to refuse patients because their list is currently 'full'. This creates problems for
neighbouring 'open' practices who may be finding it equally difficult to cope.
There is also a major problem for the PCT if all the practices in a particular area decide to regard their lists as 'full'. The PCT would then
be obliged to allocate all new patients to those practices, which would be an undesirable way to resolve any local crisis in healthcare provision on anything other than a short term temporary basis.
The best course of action would be for you to discuss the current situation with the PCT in order to try to find a more effective way
forward. You may even discover a more creative solution to the problem that could work to your advantage. This would be much better than the PCT being forced to devise their own solution, which may not
be in your best interests or the best interests of your patients or the public in general.
It is always better to try to negotiate a mutually beneficial, 'win-win' situation, than for either side to take an entrenched or defensive position!
Further Information;
LMC Advice to Practices
CED
Q NCO28 - Prison medical services - Our PCT intends to provide Prison Medical Services under the Enhanced Services budget. Is this
permissable ? (08/07/04)
Answer - The GPC has confirmed that this is not permissible since prison
services have always been funded separately from GMS.
CED
Q NCO27 - Minor injuries unit - There is a minor injuries community hospital unit in our area and the PCT has suggested that this will now
be funded from the enhanced services budget. Is this permissible?
(05/07/04)
Answer - No. The funding of this unit must not be taken from the
enhanced services budget as it is funded by an entirely different financial stream.
GPs who are providing a paid service for this community hospital unit are not providing an enhanced service and must not therefore be
included in the enhanced service budget.
If local GPs have a dedicated area within the unit in which they are providing an enhanced minor injuries service, they would be expected
to pay rent, however small, for use of that facility. Their service would of course then be funded fully as an enhanced service.
CED
Q NCO26 - PGEA - Are we entitled to PGEA payments for 2003-4?
(29/06/04)
Answer - This matter has still not been fully resolved. The money that
was previously paid for PGEA has now been included in the global sum. Monthly payments from the global sum include funding for continuing professional development.
The GPC is of the view that PGEA funding for postgraduate education undertaken in 2003-4 should be paid in addition to the new funding
included in the global sum. This interpretation has, however, not been universally accepted and the matter will probably not be resolved until a test case is brought to settle the matter.
Further information;
GPC Focus on postgraduate education after the postgraduate
education allowance - March 2004
The GPC has confirmed that GPs have 6 years in which to claim any backdated PGEA payments, so there is still plenty of time in which to
claim if the GPC view is accepted.
CED
Q NCO25 - GPAQ and IPQ patient experience surveys - Two of my partners work half time. Can we use half the recommended number
of surveys for each of them? Can we photocopy the patient experience survey forms from the Internet? (16/06/04)
Answer - GMS2 is a practice-based contract and it is irrelevant whether
each partner works full or part time for the purposes of this survey. For further information on patient numbers to be surveyed see Q NCO11 on GPAQ patient survey.
Unauthorised copying of the GPAQ or IPQ questionnaires is illegal. Practices must not therefore photocopy the questionnaires from the contract supporting documentation or from the BMA or NHS Confederation websites.
The GPC has just issued an Update on Patient experience section QOF and patient surveys - June 2004.
This makes it clear that the GPAQ and IPQ surveys are protected by copyright. The GPAQ copyright is waived in certain circumstances. For further information see the GPAQ website.
CED
Q NCO24 - Surgery opening hours - We have been told that we have an obligation to open the surgery for 45 hour a week. I am aware
that we have an obligation to provide cover during the "core hours" but have reviewed the contract and can find no mention of opening hours. Please could you advise? (03/06/04)
Answer - There is no requirement to open throughout the entire core
hour period, which is defined as 8am until 6.30pm Monday to Friday, with the exception of Good Friday, Christmas Day and other bank holidays.
Regulation 20 sets out that;
"A contract must contain a term which requires the contractor in core hours -
(a) to provide -
(i) essential services, and
(ii) additional services funded under the global sum,
at such times, within core hours, as are appropriate to meet the
reasonable needs of its patients; and
(b) to have in place arrangements for its patients to access such services throughout the core hours in case of emergency."
Provided you fulfil these requirements you would be fulfilling the terms of your contract and would not be in breach of the regulations.
CED
Q NCO23 - Flu & travel vaccines - Some practices appear to charge registered patients who are under the age of 65 a private fee for a
flu vaccine. Is this permitted under GMS 2? We have always given a private prescription and vaccinate free of charge.
Also, some practices appear to be charging for holiday advice. We allocate our Nurse for 20-30 minutes to give free advice on vaccines and only charge for those immunisations for which we cannot claim
under the NHS. Are we now permitted to charge for travel advice under GMS 2? (03/06/04)
Answer - The matter of private provision of 'flu immunisation to those
registered patients who are not in an NHS risk category, or specifically covered by an LES, is still not entirely clear. However, we believe your previous policy is the correct one and that the position is unchanged
under the new contract. You may give a free private prescription for the vaccine to your registered patients and administer it free, but may not charge for the prescription or the administration under the new
contract.
This is set out in Regulation 24 which states;
"(2) The contractor shall not, either itself or through any other person, demand or accept from any patient of its a fee or other
remuneration, for its own or another's benefit, for -
(a) the provision of any treatment whether under the contract or otherwise; or
(b) any prescription or repeatable prescription for any drug, medicine
or appliance,
except in the circumstances set out in Schedule 5."
In relation to vaccinations, schedule 5, 1g specifically states only that you may charge;
"for treatment consisting of an immunisation for which no
remuneration is payable by the Primary Care Trust and which is requested in connection with travel abroad;"
The issue of charging for travel advice is even less clear. However, we believe that you are not permitted to charge for advice. Where you are
allowed to charge for administering a travel vaccine it is, however, permissible to incorporate a fee for advice within a total composite charge for the immunisation. In this way you may legitimately cover the
cost of your travel advice.
In relation to prescriptions for those travelling abroad, Schedule 5, 2h sets out clearly that you may charge;
"for prescribing or providing drugs, medicines or appliances (including
a collection of such drugs, medicines or appliances in the form of a travel kit) which a patient requires to have in his possession solely in anticipation of the onset of an ailment or occurrence of an injury
while he is outside the United Kingdom but for which he is not requiring treatment when the medicine is prescribed;"
Your fee for providing this service may include a component to cover the advice given.
CED
Q NCO22 - Open, full and closed Lists - Can you clarify the position with regard to open, full and closed lists under GMS 2? (03/06/04)
Answer - John Chisholm has now made the view of the GPC, which is
endorsed by Wessex LMCS, perfectly clear. If your list is open you retain the right to accept or refuse to accept any patient on to your list, provided you do not discriminate in any way that is against the law.
For example, you must not discriminate on the basis of race, gender, sexual orientation, religion, social class , medical condition, disability,
or appearance. You are not obliged to accept patient who live outside your practice area.l
If for some reason you find that you are unable at any time to accept more patients without compromising the care of your existing registered
patients, then it is your right, and indeed probably your obligation, to refuse to accept additional patients until the situation improves.
If you expect this to be a permanent situation then you should inform the PCT that you wish to close your list formally and they will institute
the necessary procedures.
However, if the reason for the difficulty is a temporary situation that makes it impossible to accept new patients, for example a doctor is on
holiday, sick or maternity leave or there is a current epidemic, which is creating additional pressure of work, then it is not necessary to close your list formally
. You may seek support from the PCT if you are unable to cope and require some temporary assistance. Alternatively you may be able to cope on your own in the short term until the crisis has passed.
There are no longer set numbers above which your list is considered to be full, but it is your ability to cope with the current situation that is
critical. This may be a rapidly changing state which is outside your control. It is of course not always possible in these situations to predict accurately how long that temporary situation will last.
Whenever you believe your list to be full it would be helpful to have a very strict and non-discriminatory list of criteria as to which patients
you may admit. (This is analogous to the situation under the old contract when, for example, newborn babies or close family members of registered patients who will be living in the family home, or previously
registered patients who have moved back to the area, were accepted on to a closed list.)
Under GMS 2 you are obliged to provide every patient with a written reason for refusal to register them on your list within 14 days. A copy of
this must be retained for inspection by the PCT.
If your list remains formally open you are still obliged to accept allocated patients, as under the old contract. However, if your list is closed on a
formal basis then you are no longer obliged to accept allocated patients.
Further information, including a suggested letter for patients refused admission.
See also Regulations, Schedule 6 part 2, para 17
CED
Q NCO21 - Seniority and superannuation - I work part-time in a practice and do not pay pension contributions. Does this mean I am
not entitled to seniority payments? If I am entitled to seniority payments, am I entitled to them personally, or is this a practice payment? (05/05/04)
Answer - You are still entitled to seniority payments provided you have
enough years of service to qualify, even though you are not paying pension contributions.
The calculation of seniority entitlements requires calculation of your Superannuable Income Fraction, which must be at least two thirds to
qualify for full seniority payments. However, you do not have to be a member of the NHS Pensions Scheme.
Section 13 of the
SFE provides all the details relating to seniority payments.
The actual contractor Global Sum (or MPIG) payments, with the relevant adjustments, will not be agreed between practices and PCTs until the
end of May. The April and May payments were based on the indicative Contractor Global Sum (or MPIG) which did not factor in the extra 7% employer superannuation contributions for GPs and staff.
In June, practices should receive corrected payments (global sum/MPIG) plus any adjustments owed in respect of the April and May payments.
Most practices treat seniority payments as belonging specifically to the individual who qualifies for them. Paragraph 13.21 (d) of the SFE sets out that;
"a contractor who receives a Seniority Payment in respect of a GP provider must give that payment to that doctor -
(i) within one calendar month of it receiving that payment"
However, some practices regard seniority pay as a part of the general practice income and apportion the total income in accordance with the
provisions of the partnership agreement. This is also permissible.
CED
Q NCO20 - References for locums - When a doctor joins a Performers List, the checks made are very stringent. Our PCT insists that we are
still obliged to obtain references for any locums we employ. Is this correct under the new contract? (29/04/04)
Answer - This was a requirement in the old regulations and remains in the new The National Health Service (General Medical Services Contracts) Regulations 2004
Part 4 relates to Persons who perform services and paragraphs 57-60 relate to Conditions for employment and engagement.
This stipulates that the contractor shall not employ or engage a health care professional to perform medical services under the contract unless:
(a) that person has provided two clinical references, relating to two
recent posts (which may include any current post) as a health care professional which lasted for three months without a significant break, or where this is not possible, a full explanation and alternative
referees; and
(b) the contractor has checked and is satisfied with the references.
(2) Where the employment or engagement of a health care
professional is urgently needed and it is not possible to obtain and check the references in accordance with sub-paragraph (1)(b) before employing or engaging him, he may be employed or engaged on a
temporary basis for a single period of up to 14 days whilst his references are checked and considered, and for an additional single period of a further 7 days if the contractor believes the person
supplying those references is ill, on holiday or otherwise temporarily unavailable.
(3) Where the contractor employs or engages the same person on
more than one occasion within a period of three months, it may rely on the references provided on the first occasion, provided that those references are not more than twelve months old.
You are of course also obliged to check that the locum doctor has medical defence cover and is in fact on a Performers list.
CED
Q NCO19 - Consent to treatment under the new contract - I am very confused about the issue of patient consent to treatment. Am I
obliged to use the official NHS consent forms under the new contract? Do I have to get consent every time I examine a patient or measure the blood pressure or take blood? (29/04/04)
Answer - The new contract has no fresh impact on these issues. Sadly
there is not a simple 'one size fits all' answer in questions of consent. It is generally a process of risk management and pragmatism and being mindful of your common law duty to always act in the patient's best
interests.
For consent to be legally valid;
- Consent must, by definition, be based upon full information.
- The patient must be capable of understanding and assessing the information given
- The patient must be competent to make a decision based upon the information.
- Consent must always be given entirely voluntarily.
Legally valid consent to a medical examination or procedure may be;
- Implied consent - eg you ask a patient if you may take the BP to
see if the anti-hypertensive treatment is working and he does not retract his arm but permits you to measure the BP.
- Explicit or express consent - eg you explain to the patient that
you wish to give a specific treatment such as an injection and explain that it works in a particular way, which is generally very safe and effective, although occasionally people experience very
slight transient side effects. You ask the patient if he has understood and if it is acceptable. He says it is and puts out his arm for the injection.
- Explicit written consent - eg you are surgically well-trained and
have special dermatological experience. You are confident that a pigmented lesion is entirely innocent and that you are competent to perform the excision. Since there is a small chance that you may
be wrong, with potentially serious consequences for the patient, it is a matter of good risk management to explain the risks fully, and to ask the patient to sign to indicate consent. This consent may not
be valid, even if you have a signature, for example if;
- o If you are not a skilful surgeon and operate on the face without explaining that a scar will result and that a more
experienced surgeon would be likely to achieve a better result - because the patient has not been fully informed
- o The patient is poorly educated and has not understood what you have tried to explain in relation to malignancy or
scarring
- o The patient asked to be referred to a specialist and you exerted pressure on them to accept the treatment from you,
despite their reservations.
- Explicit formally documented consent - In cases where you judge
that the treatment is more likely to result in problems that would be unacceptable to the patient, and would therefore be more likely to lead to litigation or complaint, you would be well advised
to use the 'official' Department of Health procedures and forms. You are not legally obliged to follow these 'official' procedures, but would be foolish to use a protocol that was not sufficiently
robust to serve in your defence in the event of subsequent problems.
Special care must be exercised in relation to children and those who
are not mentally competent to consent personally and to note that;
- a child or young person who is 'Gillick' competent may be able to consent for themselves and is owed the same duty of confidentiality as an adult.
- only a person with parental responsibility may consent on behalf of a younger child.
- nobody may consent on behalf of a patient who is mentally incompetent. You must then be particularly conscious of your
common law duty to act in the patient's best interests at all times, while taking into account the views of a parent or carer with regard to what they believe the patient would have wished if
competent. You should seek legal advice before treatment if there is any doubt as to its legality.
In the past a medical defence would often rest upon the Bolam Test ie 'a doctor is not guilty of negligence if he has acted in accordance with a
practice accepted as proper by a responsible body of medical men skilled in that particular art'. Many doctors do not follow best practice
with regard to consent, but their failure to observe high standards would be unlikely to serve in your defence. It is much more likely that a doctor would now be judged against recognised best practice (eg NICE) or
other NHS guidelines. If you choose to ignore NHS procedures and guidelines you may be required to demonstrate that your practice procedures conform to recognised best practice in the event of a challenge.
Further information:
Consent to treatment - LMC guidance ;
Seeking patients' consent: the ethical considerations - GMC ;
Consent - Department of Health
CED
Q NCO18 - Child health surveillance checks - Could you clarify the subject of 8 month baby checks? The doctors in our practice are
under the impression that they no longer have to perform these checks, but the health visitor is insistent that it is "best practice".
(14/04/04)
Answer - The new GMS regulations (schedule 2, para 6, 2b) set out the
requirement to carry out;
(b) the examination of the child at a frequency that has been agreed with the Primary Care Trust in accordance with the nationally agreed
evidence based programme set out in the fourth edition of "Health for all Children".
In February this year, the Royal College of Paediatrics and Child Health (RCPCH) published the fourth edition of Health for All Children (Hall 4),
the report of its most recent review of child health surveillance and screening activity in the UK.
"Health for all Children" (Hall 4) is sadly not available on the web, although GPs may purchase a copy! The Scottish NHS publication Health for all children; Guidance on implementation in Scotland; a draft for consultation, however, provides very useful background information on the Hall report, including an executive summary and the Universal Core
Programme for Child Health Screening and Surveillance, which you may find useful. There is no specific mention of an 8 month check in this documentation.
Hall 4 moves away from a wholly medical model of screening for disorders towards a more holistic approach, with greater emphasis on
health promotion, primary prevention and active intervention for children and families at risk.
The whole subject of child health surveillance is currently under national consideration and the DoH is due to publish the NSF for Children in the
near future. This will include a section on Child Health Surveillance on which to base your future practice.
CED
Q NCO17 - Medicines review - In the contract documentation it stipulates that only a doctor, nurse prescriber or pharmacist may
conduct a medicines review. Our practice nurses usually see patients who require oral contraceptive medication. Does the doctor have to see these patients himself in future in order to review the medication?
(14/04/04)
Answer - The blue book of supporting documentation says quite clearly that the "review may not always necessarily be a face-to-face review. It
is possible to review the patient's repeat prescriptions in some circumstances without seeing the patient face to face eg by telephone review or a review of the records."
If the doctor is satisfied that the nurse is competent and has adequate training, he may delegate the nurse to provide a patient's contraceptive
care under an agreed protocol on his behalf. The doctor, nurse prescriber or pharmacist may then carry out the medicines review based upon the records of the nurse consultation.
CED
Q NCO16 - Contraceptive services to non-registered patients - Under the old contract we have over the years provided contraceptive
services to some patients who are not registered with us and we have been paid by the PCT for doing so. Some practices have also provided maternity services and child health surveillance on this basis in the past.
Clauses 59-61 in the standard contract set out a requirement to continue to offer these services, unless the practice chooses to opt out of that additional service, for all patients so that patients do not
have to change the practitioner who was providing these services just because of the change in the contract arrangements.
It appears that I have an open-ended obligation to non-registered
patients and will not be paid anything for providing the service. Is this correct? (01/04/04)
Answer - Paragraph 24 of The General Medical Services Transitional
and Consequential Provisions Order 2004 - Statutory Instrument 2004 No. 433 sets out in detail the
Services to patients not registered with the contractor in default contracts and general medical services contracts entered into on or before 31st March 2004. It specifies that
when the default or new GMS contract is signed it must require the contractor to provide those additional services to non-registered patients who had been receiving them.
This does not apply if the practice has already opted out of the provision of these additional services for registered patients and the
practice may subsequently choose to opt out of providing those additional services for all patients under regulation 17.
The contractor may also terminate this responsibility for a non-registered patient under paragraph 28 of Schedule 6 to the 2004
Regulations (or the equivalent term of a default contract).
Our understanding is that if the practice chooses to continue providing this service to non-registered patients the GP would have to make a
separate claim for payment. However, at present there are technical difficulties in doing so and some considerable uncertainty about exactly how the system will work. The GPC has, however, confirmed that GPs
should be paid for additional services to non-registered patients under the new contract.
CED
Q NCO15 - Private patients after retirement - I have been told that part 18 of the new contract will prevent me from seeing patients
privately when I retire next year. Is this correct? (01/04/04)
Answer - No, this is not correct and is based upon a misunderstanding of
the implications of Part 18 of the new contract. In the draft contract, paragraph 465 stated that "Part 18 shall survive the expiry or termination of the Contract".
However, in the final contract this was clarified in paragraph 487. It now makes it quite clear that after the expiry or termination of the contract,
you may not directly or indirectly demand or accept payment for the treatment of any patient, under the Contract or otherwise, or for a prescription or repeat prescription for any drug, medicine or appliance,
that was provided during the existence of the Contract.
In other words you cannot retire and subsequently demand payment for services or prescriptions provided whilst you were still bound by the contract.
It will remain permissible for you to see and prescribe for patients privately once you have retired.
CED
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