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Q & A - Practice Matters 3 (June '03 - Oct '03)
Index
PRA99 - Medical certificate for child actor
PRA98 - Report for National Care Standards Commission
PRA97 - "No resource to public funds" and eligibility for NHS treatment
PRA96 - Allocated patients
PRA95 - Safe haven faxes
PRA94 - Charge for copy of Health and Safety Policy
PRA93 - New HSE Accident book
PRA92 - EEA health care entitlement in the UK
PRA91 - Records management policy
PRA90 - Practice leaflet requirements
PRA89 - Data protection access survey
PRA88 - Residential home patient reports
PRA87 - Whistle-blowing protection
PRA86 - Patients right to change to female partner's list
PRA85 - Overseas visitors
PRA84 - Overseas Visitors
PRA83 - Pregnancy testing
PRA82 - Change of practice hours
PRA81 - 'Out of hours' information
PRA80 - NHS registration as proof of entitlement to benefits
PRA79 - Illegal immigrants and eligibility for routine NHS treatment
PRA78 - Microlight pilot's licence
PRA77 - Occupational health opinion
PRA76 - Medical students and viral screening
PRA75 - Copying referral letters to patients
Q PRA99 - Medical certificate for child actor - A child registered on my
list is to appear in a film and I have been told that I am obliged to provide a medical report. Can you confirm whether this is so?
(13/10/03)
Answer - A considerable number of complex legal restrictions and Local Education Authority
conditions are set out in relation to child performers in entertainment, professional sport or modelling. These restrictions apply to the granting of a licence and to the conditions that must be met when the child
is performing.
The Local Education Authority has the discretion to require a medical examination before any licence to perform is granted. Medical clearance is essential
for:
- film or television work
- performances lasting more than a week in which the child is to perform on six days during that week (five days for sound broadcasting)
- every month for runs lasting more than four weeks.
Medical clearance lasts for a period of six months.
A matron is responsible for the child's safety, health and welfare whilst performing and a doctor must be called if the child becomes ill or is injured and the
licence holder must inform the parent and Local Education Authority as soon as possible.
It is not part of your Terms of Service to provide medical clearance, and if you choose to issue a certificate of medical clearance you may therefore charge a fee.
It would be wise to use a form of words indicating that you know of no medical reason why the licence should not be granted, based on the recorded medical history and your knowledge of the child, the family and the
proposed performance rather than giving a medical opinion that the child is definitely fit to perform.
As the child's registered doctor you have a duty to act in the child's best interests at all times. Performing should be a pleasurable experience for the child and
if you believe that it would not be in the child's interests to perform you have a professional responsibility, and possibly a legal obligation, to indicate this.
For more detailed information, you may contact the Child Employment Office on 01483 517839.
Further information is to be found in Children in entertainment.
CED
Q PRA98 - Report for National Care Standards Commission - A local residential home has sent us a form to fill in as it is due an inspection
from the National Care Standards Commission and is seeking the doctor's comments on the care of service users in the home. May we charge a fee for this? The NCSC said they had not been asked for a
fee before, but the home is willing to pay. What should we do?
(09/10/03)
Answer - As a matter of routine this is not part of your Terms of Service
and therefore a fee would be appropriate if you wish to co-operate. The new care standards have placed all sorts of additional burdens on care homes, such as certifying staff as fit for their work. Some homes
are transferring these new responsibilities on to GPs where possible and where the GPs are prepared to co-operate.
If the home is prepared to pay there is no reason why you should not charge them.
If, however, you are concerned that patients are not being cared for properly, and are therefore at risk, you have an obligation as a doctor to
draw this matter to the attention of the regulatory authorities and may of course not charge a fee for this. Every doctor has such a duty with
regard to the proper care of patients and could be disciplined by the GMC if he or she failed to raise appropriate concerns.
Even doctors working in an entirely administrative capacity should be aware that they retain a professional responsibility in this regard and
that their registration is at risk if they fail in this obligation.
You may find our advice on GP services to nursing homes helpful.
CED
Q PRA97 - "No resource to public funds" and eligibility for NHS treatment - A foreign patient recently attended the practice for
medical care. His passport was stamped "no resource to public funds". Does this mean that we are not obliged to provide medical care? (29/09/03)
Answer - The Home Office has now clarified the position. The phrase
"no resource to public funds" means that he cannot apply for benefits and does not relate to the provision of NHS services. You must still provide medical care to this patient according to current guidance and
the Terms of Service.
Further information available in Overseas Visitors Eligibility to Receive Free Primary Care
CED
Q PRA96 - Allocated patients - I am a single handed practitioner with over 3,500 patients. The PCT is telling me that I may not accept any
new patients, but insists that they may still allocate patients if the need arises. Is this correct? (22/09/03)
Answer - It is possible for the PCT to allocate, even though you have
3500 patients and may not voluntarily accept any more patients, unless you employ an assistant.
Patients at present may be allocated to any principal, regardless of whether he or she works full or part time.
GMS Regulations Para 24 (2),(6),(9) and (11b) apply here. (11b is open to various interpretations!)
However, Para 4(4) of
SI 668 - 1998 - Choice of Medical Practitioner Regulations allows the Secretary of State to overrule Para 24 of the
GMS Regs and allocate patients to a practice, even though the list size would then exceed the maximum permitted under that paragraph.
RIB
Q PRA95 - Safe haven faxes - Our practice has a query with regard to the recent Wessex LMC guidance on Safe haven faxes and the reminder sent to practices that unauthorised staff such as cleaners and caretakers should not have access to fax machines during the
out of hours period. The company which supplies our cleaners currently obtains a confidentiality agreement from each of their staff before they are permitted on site. We could not realistically
exclude cleaners from any part of the building and many faxes are normally received out of hours from the PCTs, Out of Hours service providers, hospitals etc. Does this mean that we are failing to
comply with the guidance? (18/09/03)
Answer - This is obviously a cause for concern for many practices and
we have had a number of similar enquiries.
It is impossible to guarantee absolutely that staff will stick rigidly to their contractual duty of confidentiality and if you have totally
disregarded all the safe haven guidance and good practice in this area you could be found negligent.
In a perfect world we could avoid all risk, but sadly our world is far from perfect! It would seem reasonable to take a pragmatic approach in terms
of risk management if there is no reasonable and easy way to ensure cleaners would never ever be able to see faxes out of hours and you believe that switching off the fax machine during that period would
create insuperable difficulties in the receipt of essential data.
In order to demonstrate clearly that you have taken the guidance seriously you could notify those organisations that regularly send faxes
out of hours that particularly sensitive personal and identifiable data should only be transmitted by fax if absolutely necessary and should not be faxed out of hours unless the sender has checked that there is an
authorised recipient ready to receive and deal with the data safely and in complete confidence as soon as it arrives. In this way the onus of responsibility with regard to confidentiality would rest with the
organisation faxing the data and you would have made your own position perfectly clear. If this pragmatic solution is unacceptable it is for them to find an alternative solution to the problem.
Within a small GP team it is impossible to guarantee that sensitive data could never be seen by an unauthorised person. However, you must
always take confidentiality very seriously and limit the risk as much as possible. In practice you can only operate within the bounds of what is reasonable and practicable and then rely on a contractual duty of
confidentiality that is binding on all staff.
As an LMC we try to make practices aware of best practice guidelines but, our own experience as GPs makes us all too aware of the difficulties
in the real world in which you operate!
CED
Q PRA94 - Charge for copy of Health and Safety Policy - My partners want to charge £150 for a copy of our Health and Safety Policy. Is
there a limit to the charges that may be made for copies that are provided under the Freedom of Information Act? (01/09/03)
Answer - £150 seems somewhat excessive, but the LMC is not in a
position to give you any specific and directive advice since the Secretary of State has not yet published the regulations that will control the fees that may be charged.
The FOI Act allows that these regulations may provide
- that no fee is to be payable in prescribed cases,
- that any fee is not to exceed such maximum as may be specified in, or determined in accordance with, the regulations, and
- that any fee is to be calculated in such manner as may be prescribed by the regulations.
It seems unlikely that the fees permitted will be as high as £150 and will probably be more in line with Data Protection access charges, but we
will have to wait and see.
"It is proposed that the regulations governing fees will specify that up to 10% of the reasonable marginal costs of complying with the request
may be charged." This extract from Section 9 of the Explanatory Notes to Freedom of Information Act 2000 sounds rather ominous and
reminiscent of the debate that raged over Data Protection Act (DPA) access charges. The argument that the full cost of DPA copies should be covered by the charges was of course rejected at that time, despite
quite forceful campaigning. Hopefully the FOI Act will not generate the same volume of access demands, nor create the same problems, as the Data Protection Act.
The obligation to respond to access demands will not be fully implemented until January 2005, so it seems unlikely that you will be
obliged to respond to many requests before that time. In the meantime perhaps you could provide a single written copy of your Health and Safety Policy that could be viewed at the surgery. This should not be
too difficult or expensive. You could then consider charging patients who wish to copy particular sections of the policy.
CED
Q PRA93 - New HSE Accident book - I have been told that we must use the new Health and Safety Accident Book. Is this correct?
(01/09/03)
Answer - You are not obliged to use the HSE accident book. but you are
obliged to comply in full with all relevant Health and Safety legislation.
Most existing accident books allow personal details and information to be seen by anyone reading or making an entry in the book. The Information
Commissioner has therefore ruled that businesses must change their accident book to comply with the Data Protection Act by 31 December 2003. The Health and Safety Executive (HSE) has produced a new
Accident Book that has been approved by the Information Commissioner.
The new design allows for accidents to be recorded, while details of individual(s) can be stored separately in a secure location.
In addition to recording incidents, the new book also contains useful information on first aid and how to manage health and safety
information to help prevent accidents from happening in the first place.
Copies of The HSE Accident Book cost £4.75 plus VAT and are available from HSE Books, PO Box 1999, Sudbury, Suffolk, CO10 2WA.
( tel: 01787-881165 or fax: 01787-313995.)
CED
Q PRA92 - EEA health care entitlement in the UK- Can you please clarify the eligibility of EEA visitors to NHS treatment? (01/09/03)
Answer - Visitors from EEA member states carrying Form E 128 must be
treated free of charge because of EU obligations unless the purpose of the journey is to receive medical treatment abroad when no entitlement is established by the form.
It applies only to two groups of EEA nationals;
- workers posted temporarily to another member state and any members of their family who accompany them
- students temporarily in another member state to study and any accompanying members of their family.
These patients are entitled to receive full health care under the NHS on the same terms as UK residents.
Posted workers or students on holiday visits to the UK from their posting or state of study, who present a form E128 issued by a third country,
should be told the form is not valid in the UK. They are entitled only to immediately necessary treatment unless they produce Form E112.
This is generally intended to give cover under the NHS for specific treatment of a particular condition. The vast majority of referral
arrangements are made direct with hospitals on a consultant to consultant basis, and GPs do not generally get involved. The form specifically states the condition, operation or procedure for which it is intended.
Most EEA countries require overseas visitors from other EEA countries to present Form E111 when seeking emergency health care. This is not required in the UK.
Further infomation is available in;
Overseas Visitors Eligibility to Receive Free Primary Care
Getting Treatment in Countries in the European Economic Area
Health advice for travellers: form e128 - information
Health care entitlements for UK residents visiting an EEA country
CED
Q PRA91 - Records management policy - We have been told that we must have a formal records management policy in place in order to
comply with the Freedom of Information Act. Can you advise please?
(21/08/03)
Answer - We are not aware of any such requirement. The Records management policy appears to be aimed at Public Bodies such as Health
Authorities and Trusts, and not specifically at GPs, who were designated as Public Bodies for the purposes of the Freedom of Information Act only. It does not therefore seem to be an essential part of the
interpretation of the FOIA for GPs at this stage.
It does not feature in the model scheme, nor is it in the official guidance for GPs from the FOI project.
To add records management to the FOI obligations at a time when most practices are struggling to cope with a heavy workload, as well as the
implications of the new contract, seems unnecessary at this time.
CED
Q PRA90 - Practice leaflet requirements - What are the requirements for a practice leaflet and how does this differ from the publication
scheme required by the Freedom of Information Act? (21/08/03)
Answer - Paragraph 47 of the Terms of Service sets out the requirements for a practice leaflet. Schedule 12 in the regulations sets
out the data that must be included in a practice leaflet.
S.I.1996/702 added paragraphs 47A and 47B that relate to complaints management.
The leaflet must be reviewed and amended as necessary, at least once in every 12 months, and the most recent edition of the practice leaflet
must be made available to the Health Authority, to each patient on his list and to any other person who, in the doctor's opinion, reasonably requires one.
The requirements for a publication scheme are slightly different, and more comprehensive, detailing all the information that is published and
made routinely available to the public by the practice. Further information is available in the Freedom of Information Act.
Many practices in fact provide much more than the basic minimum information in their practice leaflet. If this is the case, the publication
scheme may be used to direct the public to the practice leaflet for the details required in some classes of information, rather than duplicating them in the publication scheme. The details may then be amended
regularly in the practice leaflet and the publication scheme will merely point the way automatically to this updated information. This applies particularly to Class 1 and Class 2 information.
CED
Q PRA89 - Data protection access survey - We have been asked to completed a questionnaire on this subject. Should we take part?
(21/08/03)
Answer - The Health Records and Data Protection Review Group was set
up in May 2002. The group will advise the Government on:
- charges levied by Doctors, under the Data Protection Act, for providing individuals with copies of their health records;
- whether and when Doctors need to screen a patient's health records before they can see them;
- how information in a patient's medical record about their family and family history should be handled in respect of the Data Protection Act 1998; and
- whether conditions need to be prescribed to govern the use of the new NHS Number, which is a unique number allocated to individuals.
The professional fees committee of the GPC has had input into this investigation which will help inform the Group in their deliberations. If
you are one of those practices that has found access requests under the Data Protection Act to be very costly in terms of workload, inconvenience and expense, completing the survey will allow you to
produce the evidence to support this view.
CED
Q PRA88 - Residential home patient reports - I have been asked to provide a medical report on a patient of mine who lives in a local
residential home. This is to assist the Trust with a review of funding subsequent to the Ombudsman's judgement on NHS funding of patients in homes. Am I correct in assuming that providing such a
report is not within our GMS Terms of Service and that I can therefore charge a private fee? (21/08/03)
Answer - You are absolutely right. I have been seeing a lot of these
lately for some reason. You are entitled to a fee if you choose to charge it.
RIB
Q PRA87 - Whistle-blowing protection - I am worried that if our practice reports a problem within the PCT we will be victimised.
What protection would we have if we reported something that we believed was in the public interest? (13/08/03)
Answer - GPs or other health care professionals are often scared to
report PCT problems for fear of the consequences. A report published by Unison in May 2003 would seem to indicate that there may be good reason to be scared! A third of NHS workers who have "blown the
whistle" on bad practice have faced reprisals, according to their report.
The 2,000 health workers surveyed were most afraid of raising concerns about staffing levels, government targets, waiting lists and bullying. 33%
of those surveyed said they had suffered some form of personal comeback when they had highlighted problems to managers.
NHS Trusts should have clear whistle-blowing policies that are open and easily accessible to everyone, yet half of all those surveyed did not
know if their Trust had such a policy! There would appear to be a substantial "reality gap" between Government initiatives and the real world.
Despite the problems, the survey found that 90 per cent of those surveyed were willing to blow the whistle when they had concerns
about patient safety.
Further information on the subject can be obtained from HSC 1999/198 The Public Interest Disclosure Act - Whistle-blowing in the NHS.
This sets out the background and the policies that every NHS Trust should have in place in relation to whistle-blowing. The Director of
Human Resources for the NHS has also recently written to all trusts and health authorities on the implementation of policies on Whistle-blowing in the NHS.
If you believe that there are problems that should be dealt with, but remain fearful of reporting them directly, you could seek advice from
the LMC. Doctors have a legal duty of care and also a professional obligation to take action if patients are at risk. If you have concerns, please contact the LMC to discuss the best course of action in your
specific circumstances. There are sometimes occasions when the LMC can raise the issue in confidence on your behalf, but if that is not possible or appropriate the LMC may be able to support you in an
alternative approach.
Further Information
The Public Interest Disclosure Act 1998
The Public Interest Disclosure Act 1998 HSC1999/198
Public concern at Work
Public Concern At Work (PCAW) Is whistle blowing working in the NHS? - The Evidence; May 2003
CED
Q PRA86 - Patients right to change to female partner's list - We have a patient who is requesting a change to one of our female doctors.
However, they both have full lists and I wrote to the patient explaining that this was not possible at this time and that if she insisted on having a female doctor she would need to change to
another practice. She is refusing to do this and insists that she has the right to see a female doctor. In practice we always allow patients registered with a male doctor to see one of the female
doctors for a specific problem, provided this is possible.
There are no real issues with her current doctor and he is happy to continue seeing her! Does this patient have the right to insist on an
internal practice transfer? (13/08/03)
Answer - No patient has the right to demand an internal transfer and if
this does not suit your practice staffing arrangements and individual list vacancies you are not obliged to comply with her request.
In fact the new contract will mean that patients will in future in any case be registered with the practice, and not with an individual GP.
If the practice can cope, and the patient and practice are happy to accept the arrangement, your current policy of allowing her to see a
female doctor on the occasions when she particularly wishes to do so would seem a reasonable compromise. However, she cannot now, or in the future, demand to see the doctor of her choice at any time, nor can
she require a particular doctor to visit. Indeed, in the future it is quite possible that part of the doctor's current caseload will be delegated to
an appropriately qualified and trained nurse/pharmacist/physiotherapist etc. so the requirement to see a doctor at all is likely to change.
CED
Q PRA85 - Overseas visitors - I gather that the government plans tightening the rules for charging overseas visitors for NHS treatment.
What are the changes? (30/07/03)
Answer - The proposed changes are set out in a new consultation paper and are intended to prevent abuses like:
- Failed asylum seekers and others with no legal right to be in the country receiving treatment free of charge
- Dependants of someone who is exempt from charges visiting the country briefly just to obtain free treatment
- Business travellers and their dependants receiving free treatment if they fall ill or are injured on a trip to the UK
Other proposals include:
- changes to the rules on charging for treatment of UK citizens who have been working abroad for more than five years.
- new charge exemptions for pensioners who share their time between this country and another European Economic Area country,
- new charge exemptions for foreign students resident in this country.
The current regulations still apply.
Further information is available on this web site in Overseas Visitors Eligibility to Receive Free Primary Care and in
Practice Matters Q&As numbers 79, 80 & 84
GPs will still have an obligation to treat any patient who presents in need ofemergency or immediately necessary treatment.
If you have strong views on this subject you should respond to the government consultation.
CED
Footnote 24/11/03
In response to the consultation on changes we pointed out that the proposed new Exemption 2 - British State Pensioners living 6 months in
the UK and 6 months in EEA - are at odds with the current primary care rules that state that any person who goes to live out of the UK for 3 months or more should be removed from their GP's list.
We have now been informed that the powers of the charging regulations only apply to services provided by NHS hospitals, not services provided
by primary care providers. The government is aware that the new proposals are at odds with current primary care rules and is currently discussing those issues.
The proposed amendments to the regulations will probably not effect primary care services.
The government has been advised that it would be impractical to charge foreigners for GP care until 2007, when the government is planning to
introduce identity cards. It is estimated that a maximum of £15 million would be raised, which would be reduced substantially by payments to GPs for policing the exercise and other unavoidable administrative costs.
CED
Q PRA84 - Overseas Visitors - I need to clarify the situation for an overseas visitor that has just arrived from South Africa, to stay with
a family member for around nine months. He presented with cardiac problems and wants to be referred to hospital for treatment. We believe his health problems are long-standing rather than new problems. (03/07/03)
Answer - All patients from abroad are entitled to NHS emergency care,
including emergency care that has arisen as a result of a pre-existing condition.
However, it appears that this patient has come on an extended holiday which would indicate that he was not 'ordinarily resident' and therefore
not entitled to non-emergency treatment under the NHS.
You might like to refer him to the circular Treatment of Overseas Visitors; Patients' Guide. Nowhere in this does it indicate that he
would be entitled to free care for a pre-existing, non-emergency condition.
The following extract is from HSC 1999/018
Overseas visitors' eligibility to receive free primary care
3. The courts have decided that a person is regarded as 'ordinarily
resident' in the UK if he or she is lawfully living in the UK voluntarily and for a settled purpose as part of the regular order of his or her life
for the time being. A person must have an identifiable purpose for his or her residence here and that purpose must have a sufficient degree of continuity to be properly described as settled. It is unlikely that
anyone coming to live in the UK, intending to stay for less than 6 months, will fulfil these criteria.
4. 'Overseas visitor' describes a person who is not ordinarily resident
in the UK. It is essentially a short-term position until the person either returns abroad or becomes ordinarily resident here. If a GP chooses to accept such a person as an NHS patient, the terms of service provide
that the GP cannot charge (with certain exceptions set out in paragraph 5 below). If the GP decides instead to accept the person as a private patient, the GP is free to charge.
If his condition is pre-existing then one might be concerned that the main purpose of his visit was 'NHS tourism', with the objective of
obtaining treatment free of charge under the NHS.
In order to qualify for non-emergency NHS treatment he would have to prove that his visit was for a 'settled purpose', in which case he could
be considered 'ordinarily resident'. He might be able to demonstrate this for example by trying to find a permanent job or a house to live in long-term or by undertaking an extended period of study.
If you are prepared to treat this patient you could accept him on your NHS list and provide care under the NHS. However, in view of the
excessive demands on the NHS at the present time, you should probably provide care only on a private basis. You should also make it clear that any non-emergency hospital treatment would almost certainly also only
be offered on a private basis.
CED
Q PRA83 - Pregnancy testing - We have just been informed that our local hospital will no longer carry out pregnancy testing. The cost to
the practice of performing a pregnancy test ourselves is £7-£8. This is not reimbursed and we are not prepared to fund this service ourselves. What is the legal and ethical position? (02/07/03)
Answer - If this service is no longer provided under the NHS it would be
quite unreasonable for you to have to fund it on a personal or practice basis.
In the case of routine pregnancy tests requested by a patient as a matter of interest, there would be no legal or ethical requirement to perform
the test. It would not be unreasonable to ask the patient to carry out the test at home using a test kit bought from the chemist.
In the event of a test being required for clinical reasons eg to diagnose a suspected ectopic pregnancy, to check before inserting an intrauterine
contraceptive device or to check before prescribing treatment that could have a harmful effect on a foetus, there is likely to be a professional, if not a legal, requirement to carry out a pregnancy test.
We raised this issue with the general manager of the pathology laboratory who informed us that the decision was based on inadequate funds.
However, we have now learned that the urine test that used to be performed for GP patients would be insufficiently accurate if required
for important clinical reasons and that 95% of those tests were performed out of interest only. The test only becomes positive at about 4-6 weeks, whilst home testing kits become positive at about the time
of the first missed period.
We contacted the clinical director of pathology services at the hospital who informed us that primary care referrals are increasing the
microbiology workload by 8-10% a year and the introduction of infection control surveillance last year increased this burden by a further 20%.
He has reassured us that GPs will still have access to blood estimation of hCG from the biochemistry department for the small number of patients
where there are strong clinical grounds for an accurate and sensitive test or a strong social need for a patient who cannot afford to buy a home test.
Similar cuts are apparently occurring throughout the country and hopefully will be resolved in a similar satisfactory manner. If there are
continuing problems in the Wessex region please contact the LMC.
CED
Q PRA82 - Change of practice hours - The neighbouring 4 partner practice that shares our practice premises has reduced their surgery
hours with PCT consent and will not be available in the afternoons in future. We are in a fairly deprived practice area and we are concerned that we will be asked to look after the patients of the
other practice in the afternoons. Of added concern is the fear that we will receive an unfair proportion of future allocations because of our greater convenience with 9 afternoon surgeries. Was the LMC
consulted on this? Can we do anything about it? (26/06/03)
Answer - There would be no obligation to provide routine care for their
patients as this clearly remains the responsibility of the other practice. Allocations must always be made on a fair and equitable basis. You should therefore have nothing to fear as a result.
The LMC was not consulted on this matter but for a 4 partner practice the new hours would not seem to be convenient and satisfactory for the patients.
You should check with the PCT as to why they did not involve the LMC in discussions and also check whether they involved the CHC in their
decision, as they were obliged to do. Perhaps they would be prepared to reconsider their decision in the light of appropriate discussions.
Presumably the PCT considers the revised hours are still adequate for the provision of patient care so would support your practice in the
event of any serious workload implications for your practice. In any case please consult us again if you experience any problems.
CED
Q PRA81 - 'Out of hours' information - Now that the new contract has been accepted where can I access information on the new Out
of Hours arrangements? (23/06/03)
Answer - There is a new web site http://www.out-of-hours.info/ that
should provide all the information on this topic as it becomes available. Rest assured that Wessex LMCS will be involved in ensuring that GPs are
able to delegate their 'out of hours' responsibilities as soon as possible!
CED
Q PRA80 - NHS registration as proof of entitlement to benefits - I read that 73 million people from Eastern and Southern Europe will be
entitled to full UK social security benefits, council housing, treatment on the NHS and schooling when their countries join the EU in May 2004. What concerned me was a statement that EU citizens
could claim full benefits as long as they demonstrated their intention to stay in the UK by registering with a GP, finding accommodation or enrolling their children in school. Should I check patients'
documentation before they register? (19/06/03)
Answer - You are entitled to check that all patients are eligible for NHS
treatment before registration, provided verification is required equitably regardless of nationality, skin colour, income, sex, disability etc. If registration with a GP is to be used as proof of entitlement to all
other state benefits this becomes particularly important.
Related Q&A
PRA79 - Illegal immigrants and eligibility for routine NHS treatment
CED
Q PRA79 - Illegal immigrants and eligibility for routine NHS treatment - We recently had several patients trying to register who all gave the
same address and date of birth and spoke very little English. We were concerned that they were illegal immigrants but were afraid to ask for evidence of their eligibility to NHS treatment for fear of being
accused of racial discrimination. The PPSA directed us to the information provided on the Refugee Council web site but we would
like the Wessex LMCS view on how we should deal with this kind of situation? Are we permitted to breach confidentiality by seeking
specific advice from outside the practice? (18/06/03)
Answer - There is guidance on treating oversees visitor and asylum
seekers on this web site under Overseas Visitors Eligibility to Receive Free Primary Care and Asylum seekers - Access to NHS treatment
In these you will find links to the relevant official guidance on entitlement to NHS care.
Everyone is entitled to emergency medical treatment under the NHS, but the full range of NHS services is not necessarily available to everyone
who seeks registration at a GP's surgery.
The following extract is taken from the refugee council web site.
Registering with a GP
Asylum applicants are not required to show official documentation
when they register with a general practice. General practice staff have no right to demand to see an asylum seeker's passport or any other identity documentation. They can get the patient's address from a
Home Office letter, bill or similar document addressed to the asylum applicant.
If an asylum applicant is unable to register with a GP after a third
attempt, they should be advised to contact their local Primary Care Trust, which can allocate a GP to them.
Wessex LMCS believes that a GP may, and probably should, ask ANY patient to demonstrate eligibility to NHS treatment before registering,
PROVIDED this is applied equitably to ALL patients. What is not permissible under racial discrimination legislation is to apply this criterion for registration selectively to applicants on the basis of colour
or nationality.
The information on the Refugee Council website is very helpful, but applies to genuine refugees and asylum seekers who are entitled to free
access to all NHS services. At no point does it state that recently arrived illegal immigrants are entitled to what would effectively be free access
to the full range of NHS care. This is a privilege that does not even apply to long-standing, tax-paying British nationals, resident in the UK who must pay for the privilege through their taxes!
The criteria for NHS care are clearly set out in the government documentation and it is not unreasonable that every patient is asked to
demonstrate their entitlement by providing an item from a possible selection of official documents to prove their eligibility.
The official guidance sets out that a member of staff in secondary care is permitted to ask three questions to establish eligibility for treatment.
- Have you been living in the UK for the past 12 months?
- On what date did you arrive in the UK?
- What is the basis of your stay in the UK?
If further confirmation is required, asylum applicants and those with refugee status or ELR/ELE (Exceptional Leave to Remain / Enter) can show hospital staff their Home Office letter, which either confirms an asylum application has been lodged or refugee status or ELR/ELE been
granted. Asylum seekers can also show them their Application Registration Card (ARC).
It seems entirely reasonable that primary care staff should be able to establish a prospective patient's eligibility to NHS Services in the same way.
There is in any case no obligation on a GP to accept any patient on their NHS list, unless the PCT has allocated that patient. Again the GP must not
discriminate on racial grounds, but must have clear criteria to establish why a patient may or may not be accepted eg patients living outside the
practice area will not be accepted, or the list is officially closed so that only previously registered patients and the children and close relatives of existing patients will be accepted. See Q&A on closed lists for the
locally agreed code of practice drawn up by the PPSA and LMC.
It is very important that GPs avoid any accusation of racial discrimination. However, there has been considerable adverse publicity
and criticism in the national media recently regarding GPs who do not check the entitlement of foreign visitors to NHS care. To deny a genuine asylum seeker care under the NHS is not acceptable, but equally to
provide care to illegal immigrants and 'NHS tourists' reduces the scarce resources that are available to all those genuinely entitled to NHS treatment, including genuine asylum seekers and refugees!
If you wish to seek advice from an outside source you should generally obtain the prospective patients' valid informed consent before
disclosing any confidential data. However, if you believe it is overwhelmingly in the public interest and/or that it is necessary for the pursuit of a serious legal matter, you may disclose data without consent,
if obtaining that consent is not practicable. The data disclosed must be kept to the bare minimum necessary to serve the intended purpose and your disclosure could be challenged by the GMC or the courts. If you are
uncertain in a specific situation you should seek legal advice from your medical defence organisation before disclosure.
It would be advisable to have a prominent poster in your surgery stating that all patients wishing to register with the practice MAY be required to
provide proof of eligibility to NHS services in order to safeguard the valuable resources of the NHS.
Most patients, including genuine refugees and asylum seekers, would probably appreciate your efforts to stop illegal abuse of the system and
would be only too happy to comply.
The most important thing to keep in mind is that you must always apply any system of proof equitably across all applicants and must not
discriminate against patients on any grounds including age, sex, social class, income, disability, likely demands on the system or nationality.
CED
Q PRA78 - Microlight pilot's licence - One of my patients requires a certificate of medical fitness to fly a microlight plane. He insists that
I am obliged to provide a countersignature for validation purposes. I am not happy to do so. What is your advice? (12/06/03)
Answer - GPs should not sign any routine paperwork unless it is a
requirement under the NHS Terms of Service. This is in line with the current government policy to reduce GP paperwork. You have absolutely no contractual obligation to complete this form and unless you wish to
complete it as a private service you should refuse to do so.
However, reviewing the information on the
Civil Aviation Authority web site indicates that completing this certificate is not a routine piece
of paperwork requiring a simple countersignature, as represented to the GP by the patient!
The GP would be obliged to read through all the relevant CAA documentation and to possess a detailed knowledge of the medical
requirements for a private (DVLA1) or professional (DVLA2) driving licence. The CAA documentation also states, quite correctly, that a driver would usually have the ability to pull to the side of the road in
the event of a medical emergency, unlike a pilot. The CAA site states that, as a consequence of this, the DVLA Group1 standards would need to be more restrictive for pilots!
Countersigning the pilot's declaration would therefore carry the legal responsibility to assess these matters correctly and to form a medical
opinion as to the patient's medical fitness to fly. Many GPs are unhappy to accept professional liability for providing an opinion on a patient's
fitness for a pass-time that they, perhaps incorrectly, assess as being high risk. It is entirely the prerogative of the GP to refuse to take this risk.
Absence of any relevant past history is the best predictor of fitness to fly and the GP would be in the best position to certify this, which would
carry little medico-legal risk. However, in cases where there was potentially relevant past history it would be impossible for the GP to 'un-know' that the certificate was in fact for flying, and not for driving,
and this would probably increase the medico-legal risk, despite CAA assurances.
Many prospective pilots currently fail to understand the potential for litigation that a GP faces when signing such documentation in a professional capacity.
Wessex LMCS has written to the CAA asking them to make these facts clear to prospective pilots, along with the details of how to contact
alternative doctors that would be willing to provide the necessary certification. The current lack of clarity often results in unnecessary ill feeling between GPs and their patients which is definitely not in the
best interests of good doctor patient relationships and ongoing patient care.
In response to our correspondence, the CAA has kindly agreed to modify their website to indicate clearly that the GP has no contractual
obligation to countersign a certificate for flying, and to provide a list of authorised examiners next to this information.
You should advise your patient to contact an authorised medical examiner (AME) using the search facility on the CAA web site. You would
of course be required to provide copies of the relevant parts of your patient's medical records under the Data Protection Act to enable this doctor to provide the necessary certification.
Latest CAA documentation revised in response to Wessex LMCS concerns
Medical Declaration
Notes for the Pilot
Notes for the GP
Additional Information for GPs
CED
Q PRA77 - Occupational health opinion - We are receiving increasing requests for occupational health reports on patients relating to
sickness absence from work. The company generally seeks an opinion on the employee's fitness for the job, any limitations that should apply and possible adverse effects of continuing in the job. I
am not qualified in occupational health and do not feel happy giving such opinions. However, several of the companies have implied that my duties as a GMC registered doctor oblige me to do so in order to
act in my patient's best interests. What is your advice? (02/06/03)
Answer - If you do not feel competent to give what is effectively an
expert opinion you should not do so, however much pressure is exerted. There is nothing in the Terms of Service that require you to provide an Occupational Health Service for your patients, and it may be contrary to
your patient's best interests to do so! The GMC is specific in the advice contained in
The duties of a doctor registered with the General Medical Council
It states quite categorically that you must recognise the limits of your professional competence and that you should work with colleagues in
the ways that best serve patients' interests.
The company should provide a proper Occupational Health Service by employing a trained Occupational Health Physician, by using the private
services of a GP with the appropriate interest and expertise in occupational health or by using a company specialising in the provision of occupational health services.
If you wish to provide a report based upon facts, rather than an opinion, you may do so with your patient's fully informed and valid consent. You
may alternatively provide the patient with a copy of the relevant clinical notes. The patient may then choose whether or not to provide this data for her employer. Employees should generally refuse to
provide confidential medical information to anyone except another doctor trained to assess it's relevance to the patient's employment.
Once you offer a subjective opinion on the patient's fitness to work in a specific job you are placing yourself at risk of subsequent legal action if
your opinion has an adverse effect on the patient's employment prospects.
CED
Q PRA76 - Medical students and viral screening - Some medical schools refer prospective students for an intensive schedule of viral
screening and immunisation to ensure the student is fit and fully immunised at the start of training. We are required to
- test for Hep s antigen to exclude carrier status.
- If s antigen +ve, but e antigen -ve, seek advice on viral load testing from the PHLS.
- If s antigen -ve start immunisation immediately, with 2nd dose after 1 month and 3rd dose after 6 months.
- 6 weeks after vaccination test for surface antibodies to ensure sero-conversion.
- screen for Hep C, Rubella, Chickenpox and Measles antibodies.
- provide all relevant medical information with full details of immunisation
history, including 1st, 2nd, 3rd and booster doses of polio, tetanus, diphtheria, BCG/Heaf test, Hep B, Rubella, Meningitis, Varicella, Measles and MMR.
The patient is allegedly aware that they may be responsible for any charge but am I permitted to charge an NHS patient for this service?
(02/06/03)
Answer - It is the responsibility of the medical school, not the GP, to
ensure students are fit to start training and have been properly screened and immunised before starting clinical attachments that could place them or their patients at risk. However, this is an Occupational Health
issue and Universities/Trusts should undertake to provide and fund this service themselves.
Under the Terms of Service a GP cannot charge patients for providing medical treatment that a GP would normally be expected to provide.
However, GPs are not required by the Terms of Service to provide an Occupational Health service and it is unreasonable for medical schools to
transfer their responsibilities to GPs who are already struggling to cope.
Preventing the transmission of disease, especially potentially fatal blood borne infections, is an extremely serious occupational health issue that
requires far more than a series of tests and immunisations. It is unreasonable to allow newly enrolled students to have such close clinical contact as to create a significant possibility of transmitting infection.
Relying on screening and immunisation carried out by a third party could well create a false sense of security with increased risk of transmitting
potentially lethal infections, including those for which immunisation is not yet available.
Some medical schools accept students who have not been screened or immunised and organise comprehensive screening, immunisation
together with thorough training in infection control before allowing close clinical contact. This seems an eminently sensible approach.
It is incumbent upon medical schools to develop proper policies for implementing and funding an effective occupational health programme.
This could be based upon a private occupational health service, perhaps provided by those doctors with the relevant interest and expertise to participate. Until then Wessex LMCS would advise all GPs to resist the
pressure to provide a free occupational health service for medical schools.
CED
Q PRA75 - Copying referral letters to patients - Our PCT is taking part in a pilot project to copy referral letters to patients. There is
considerable amount of work to be done before we will be able to copy all letters to patients routinely. One of the major problems will be to ensure that all letters are written in such a way that the
patients can readily understand them. Is there a set date when the full DOH recommendations will become mandatory? (02/06/03)
Answer - Full details of this new Government intitiative can be found in Copying letters to Patients; A report to the Department of Health and
draft good practice guidelines for consultation.
The following extract appears to answer your question.
Phasing the implementation
76 The Department of Health has set April 2004 as the date for full
implementation, although many services may have systems in place in advance of the implementation date. Different ways of introducing the policy could include:
- requiring different types of letters to be copied from an earlier date, starting for example, with inpatient discharge letters, then letters following outpatient consultations or GP referral letters
- requiring some services or professionals to implement the policy from an earlier date than others.
77 On balance the Working Group supports an implementation
programme which recognises other pressures for providers and health professionals, but which requires progress to be made. In some cases it may make sense to introduce the copying letters policy at the same
time as new IT systems. It would be wasteful to set up a system based on technology that will be soon replaced.
Funding for this initiative has not been established and Wessex LMCS currently takes the view that this is yet another initiative that creates
even more pressure on already overburdened practices that is neither desirable nor affordable. It is also questionable whether providing paper copies of correspondence makes sense at a time when more and
more practices are becoming paperless.
CED
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