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Q & A - Practice Matters 4 (Nov '03 - Mar '04)
Index
PRA118 - Patient participation groups
PRA117 - Fees for pharmaceutical company representative calls
PRA116 - Care home staff fitness documentation
PRA115 - Immunisation records of agency nurses
PRA114 - Scanning correspondence and reports into the medical record
PRA113 - Charge for practice brochure
PRA112 - NCSC registration for private consultations
PRA111 - Funding of premises under GMS 2
PRA110 - Exception codes
PRA109 - Overseas patients
PRA108 - Access to Medical Reports Act
PRA107 - Printer replacement and funding
PRA106 - Copying patient letters
PRA105 - Patients living abroad for extended periods
PRA104 - 'Emergency or immediately necessary' treatment
PRA103 - Registration and proof of eligibility or identity
PRA102 - Records of deceased patient
PRA101 - Patient experience
PRA100 - Administration fee
Q PRA118 - Patient participation groups - We are considering setting up a patient participation group (PPG) but are unsure how to set about
it. Can you advise please? New 10/03
Answer - Many practices have already set up a patient participation group and find it is a
useful way to gain constructive and relevant feedback on the services they provide. The National Association for
Patient Participation would be a useful source of information and advice on setting up and running such a group. Your local PCT would
probably be able to help and if other local practices have established a group they may also be able to share valuable experience.
Some practices find a PPG a useful way of raising money for additional practice equipment. This can, however, create significant ethical problems and some years
ago the BMA issued guidance on Fundraising for GP practices, which is still relevant today. This advises GPs on how to
manage this situation in an ethically correct manner. For example it suggests that individual GPs must not benefit from the funds raised and should not become directly involved in the money raising. It makes the
point that there must be no direct or indirect pressure on patients to contribute to any fund raising activity. It suggests creating a charitable trust and suggests that a simple statement in the surgery that such a
trust exists is the only acceptable "advertising".
Schedule 6, part 9, of the new GMS2 regulations (para 124) sets out the new regulations relating to the treatment of gifts under the new contract. This includes a
requirement to keep a register of gifts.
CED
Q PRA117 - Fees for pharmaceutical company representative calls - Can we charge pharmaceutical company representatives for GP
appointments? We were thinking of charging a fee that could be used to buy practice equipment. New 23/02
Answer - The ABPI code of practice strictly regulates the interface between doctors and the pharmaceutical industry and is quite clear on this issue.
Paragraph 15.3 states that; Representatives must not employ any inducement or subterfuge to gain an interview. No fee should be paid
or offered for the grant of an interview.
Paragraph 18.1 states that; Any donation to a charity must not constitute a payment that would otherwise be unacceptable under the
Code. For example, it would not be acceptable for a representative to pay into a practice equipment fund set up as a charity as this would be a financial inducement prohibited under Clause 18.1. Donations to
charities in return for representatives gaining interviews are also prohibited under Clause 15.3 of the Code.
The ABPI Code of Practice suggests that; A useful criterion in determining whether the arrangements for any meeting are acceptable
is to apply the question "would you and your company be willing to have these arrangements generally known?" The impression that is created by the arrangements for any meeting must always be kept in mind.
The General Medical Council is also quite clear when it states in relation to this issue and states that; you must not ask for or accept any
inducement, gift or hospitality which may affect or be seen to affect your judgement.
For all of these reasons it extremely unlikely that any reputable pharmaceutical company would agree to paying GPs for time granted to
company representatives, however wisely the payments would be used to benefit patients!
CED
Q PRA116 - Care home staff fitness documentation - A local care home is insisting that I must countersign the declaration of fitness
provided by one of their staff members. Am I obliged to do so?
New 18/02
Answer - The short answer is "Not unless you choose to do so, in which
case you may charge a fee."
This subject comes up time and time again and we have now reviewed all of the relevant documentation. We have also double-checked with
the regional office of the National Care Standards Commission (NCSC ) as well as one of the lead inspectors at the local inspectorate of the NCSC. They have agreed with our assessment of the situation.
The Care Standards 2000 sets out that
"2) Regulations may-
(a) make provision as to the persons who are fit to carry on or manage an establishment or agency;
(b) make provision as to the persons who are fit to work at an establishment or for the purposes of an agency;"
The
Care Homes for Older People: National Minimum Standards lists the documentation that is required for care home staff, which includes
evidence of checks with the police and with Protection of Children and Vulnerable Adults registers. GP documentation of fitness is not specified.
The
Care Homes Regulations 2001 Statutory Instrument 2001 No. 3965 sets out in regulation 19 the evidence required of the fitness of
workers. This states;
"Evidence that the person is physically and mentally fit for the purposes of the work which he is to perform at the care home or,
where it is impracticable for the person to obtain such evidence, a declaration signed by the person that he is so fit."
It seems quite clear, therefore, that a medical certificate is not required. In the event that the employee's declaration indicates a past
or present medical condition, which raises doubts as to their fitness, an occupational health opinion may be required. This should be funded by the employer, who is responsible for ensuring that members of staff are
fit for the work.
The GP may be prepared to provide this assessment, but alternatively the care home should make a private arrangement with an occupational
health physician or use an occupational health service such as NHS Plus. (This is a network of NHS occupational health departments across England that supplies quality services to non-NHS employers.)
We have seen sample staff declaration forms that require the member of staff to divulge confidential details of their medical history to an
employer. This is very bad occupational health practice. Best practice would indicate that the employer should engage an occupational health adviser to give an opinion on fitness for a specific job, whilst keeping
personal medical details confidential.
Countersigning such a form would in effect validate all of the information given, which you may well not be able to check without a
full medical consultation and examination.
Further information may be obtained from;
CSCI or CHAI
Commission for Social care inspection CSCI
Healthcare Commission
CSCI - National minimum standards
Healthcare Commission - standards
CED
Q PRA115 - Immunisation records of agency nurses - We have been asked to validate the immunisation record of an agency nurse. Are
we obliged to provide this service? New 18/02
Answer - This is not a prescribed certificate so you are not obliged to
provide this service under either the old or the new GMS contract. However, the agency is obliged under the Nurses Agencies Regulations 2002 - S I 2002 No. 3212 to ensure that no nurse is supplied by the
agency unless she is physically and mentally fit for that work.
Schedule 3 Regulation 12 set out the information required in respect of nurses to be supplied by an agency. This includes details of the health
record, including immunisation status.
Whilst this does not specify that the information must be validated by a doctor, in practice many patients are unaware of their exact
immunisation status. In view of the potential risks to the nurse and the indirect risk to patients, it is important that immunisation data is accurate. You may charge for providing this service.
If you refuse to validate the immunisation details on the form, the nurse would be entitled to a copy of the relevant part of her medical records
under the Data Protection Act. Maximum charges of £10 for a copy of electronic data and £50 for manual or mixed records would then apply.
Any patient may obtain a copy of their medical records under the Data Protection Act for the maximum sums mentioned above. If the agency
required documentary evidence of the nurse's medical or psychological fitness for the work. the nurse could request data relating to a particular
time period or condition or could ask for a copy of her entire medical record.
Before releasing any confidential data to the agency the nurse should seek an assurance that the agency complies in full with the Data
Protection Act and that the data will be held in strict confidence. Before a doctor releases any medical information direct to an agency he should
of course ensure that he has the valid legal consent of the nurse to do so.
CED
Q PRA114 - Scanning correspondence and reports into the medical record - Our computer system enables us to keep medical reports,
solicitors' letters and complaints documentation as a separate attachment to the clinical records. We do not normally forward these documents to a new GP. Is this correct?
We often find that when new patient notes are sent to us they contain copies of medical reports, letters of complaint etc. Should we return these documents to the previous practice? New 12/02
Answer - A reasonable working definition of medical records would be "Any record which consists of information relating to the physical or
mental health or condition of an individual, and has been made by or on behalf of a health professional in connection with the care of that individual."
Medical reports would probably be included in this category and, whilst it would be permissible to keep them attached to the record
electronically, many practice systems would be unable to cope with this. These medical reports should generally be forwarded when transferring patients' records.
Solicitors' letters and documentation of complaints procedures are not directly related to the medical care and it would seem reasonable
therefore to store these separately from the medical records. This would also make it easier to omit third party and legally privileged data from copies of the 'medical records' supplied under the Data Protection
Act.
Solicitors' letters and documentation relating to a complaint or litigation against you should normally be retained if you believe this may be
necessary for your own protection. Documentation that you do not require may be sent on to the new practice if you believe that the patient and/or the new GP will require it to handle an ongoing situation.
If the patient believes that you have retained documentation that they require they may seek access to copies under the Data Protection Act.
If you believe that the complaint or legal issue has been finally and satisfactorily resolved, with no chance of being revisited, then the
documentation should probably be destroyed under the provisions of the Data Protection Act that limit holding data for longer than necessary.
Unfortunately these decisions can only be made on an individual basis and the criteria and timescales cannot be precisely defined. A pragmatic
decision must be made in each case and if in doubt - don't!
There may be some argument for including a brief reference in the medical notes to a resolved complaint or legal issue as this may be
pertinent to the medical care of the patient in the future. For example a patient who has complained about an intimate examination is likely to require especially sensitive clinical management for problems that may
require further intimate examinations. A badly managed or misdiagnosed medical problem in the past may also create additional anxieties that would help inform future medical management. These decisions are a
matter of professional judgement.
It is not necessary to return superfluous data to a previous practice since that practice clearly did not wish to retain the documentation and is
presumably happy for you to hold it as part of the patient's medical records. You should handle this data subsequently in the same way that you would handle similar data for your existing patients.
Further information in Copies of scanned documents
CED
Q PRA113 - Charge for practice brochure - We would like to produce a new and improved glossy practice brochure. Since this will be
more expensive than our current leaflet, are we allowed to charge the patients to help defray the cost? New 05/02
Answer - You are required to produce a practice leaflet to inform
patients of the services you offer. This requirement remains under the new contractual arrangements. (The details are set out in schedule 3 page 229.) There is no suggestion that you may make a charge for this
service.
Part 18 (page 177) of the draft contract sets out the fees and charges that are permitted under GMS2 and again no mention is made of charging
for the practice leaflet.
The model publication scheme for GPs approved under the Freedom of Information Act clearly states in Class 7 information that;
b) Leaflets and brochures-free of charge for leaflets or booklets on,
for example, services we offer to the public.
It does also refer to;
c) "Glossy" or other bound paper copies, or in some cases a CD Rom,
video or other mediums, are for charge as in our publication lists available from.......................
However, this is undoubtedly intended to cover those publications that
are produced over and above the contractually required documentation and it is very unlikely to include the practice leaflet, however glossy and expensive!
CED
Q PRA112 - NCSC registration for private consultations - I am a GMS GP, but I also see a small number of private patients in a consulting
room at my home. I have recently been told that I am obliged to register with the National Care Standards Commission (NCSC). The cost of registration would reduce my private income to a point
where it was no longer worthwhile. One of our ex-partners who took early retirement also continues seeing some private patients at his home. Is it really necessary for either or both of us to register?
New 05/01
Answer - The Regulations apply to
- private walk-in medical centres, where services are provided by a medical practitioner;
- exclusively private medical practitioners (ie those who do no NHS work at all); and
- agencies that provide medical practitioners to private patients, for example in the patients own home, hotel or workplace.
The term "walk-in medical centre" is defined as a place "in which one or more medical practitioners provide services of a kind which, if
provided in pursuance of the NHS Act, would be provided as general medical services under Part II of that Act." You may, therefore, both be obliged to register on that basis alone.
It would appear from the wording of the regulations above that neither of you would need to register on the basis of providing exclusively
private services. However, we contacted the NCSC to clarify this particular issue and were advised that regulation 4b specifies "a surgery or consulting room in which a medical practitioner who provides no
services in pursuance of the NHS Act provides medical services of any kind (including psychiatric treatment) otherwise than under arrangements made on behalf of the patients by their employer or
another person."
It seem likely therefore that both of you would probably be obliged to register as you are offering exclusively private services from your
homes, even though you are also offering services to NHS patients from separate NHS practice premises.
We were advised that if you are providing prescriptions, even if you not carrying out any other clinical procedures, this ruling would probably
apply. If you are offering purely diagnostic services then you may not be obliged to register.
The regulations also specify that "Where two or more medical practitioners use different parts of the same premises as a surgery or
consulting room, or use the same surgery or consulting room at different times, each of the medical practitioners shall be regarded as carrying on a separate independent clinic unless they are in practice together." This would seem to rule out any economic advantage of using
the same private premises as your colleague, unless you choose to form a joint private practice.
There is an exception to this need to register if private services are provided "solely under arrangements made on behalf of the patients
by their employer or another person."
The NCSC regulations are currently being revised and you should contact your local Care Standards Commission to check their interpretation of
your specific current position.
Further information may be found in
Independent Health Care; National Minimum Standards Regulations
(See in particular section 15, page 176, and regulations 4 and 5, page 210)
CED
Q PRA111 - Funding of premises under GMS 2 - We have been advised by our PCT that the flexibilities set out in the new contract relating
to the funding of new premises will NOT be implemented because money is not going to be passed to them for this purpose, in particular this means:
Legal Fees relating to our new premises will not be met
Full reimbursement of leased equipment - in particular a
telephone system for our new surgery - will not be provided
Is the LMC aware of this? (29/12/03)
Answer - We are aware that there are unresolved problems relating to
the funding of premises under the new contract and that many PCTs have provided a similar response. This was not the intention of the contract and has occurred because of the lack of clarity on these issues.
With your permission, if you provide the LMC with the details of your situation, we will bring the matter once again to the attention of the
GPC and the Department of Health.
NW
Q PRA110 - Exception codes - If a patient is unsuitable or provides informed dissent does this need to be added annually or only once?
(29/12/03)
Answer- The current agreement is that exception codes should be
recorded annually. The only data items that will apply in perpetuity (i.e. they only need to be recorded once ever) are true drug allergies and adverse reactions.
'Never smoked' is also treated as a lifelong record, with one proviso; it must be recorded subsequent to the relevant diagnosis. Hence a
non-smoking patient with angina newly diagnosed on 2nd December 2003 would have to record a 'never smoked' on or after 2nd December 2003 to qualify for the CHS smoking records indicator.
The GPC have developed some Read code FAQs which will be published on the BMA website shortly which should help to clarify a number of
Read code and exception reporting issues.
NW
Q PRA109 - Overseas patients - Our PCT has given written guidance on overseas visitors' eligibility to NHS treatment. I am not at all
certain that it is entirely correct, but the clear implication is that I must adhere to this guidance and refuse to provide care to some patients from overseas. The document states clearly that "anyone
who has lived in the UK for the last 12 months is entitled to free treatment", but surely if a patient has been here as an illegal immigrant that does not apply! Please can you advise? (18/12/03)
Answer - It is essential to refer to the official documentation and to
decide each case on an individual basis, taking into account all the many variable factors. Our LMC guidance contains the relevant references and
a simple flow chart that you may find useful. You will also find a number of Q&As relating to specific circumstances. (Try searching on "overseas".)
You are correct in believing that illegal immigrants do not qualify for full NHS treatment since being "ordinarily resident" implies that the person
is living here legally.
However, all GPs under their NHS Terms of Service and under their professional obligations must provide any emergency or immediately
necessary treatment free under the NHS to any patient for a period of up to 14 days. Failing to do so could easily result in a disciplinary procedure or professional investigation by the GMC.
The decision as to what may constitute immediately necessary treatment is not at all clear-cut in every case, but DOH guidance indicates that it
may be considered to include "any treatment that is required as a result of a pre-existing condition that has become exacerbated during the period of the overseas visitor's stay in this country". EC regulations
require that such treatment is provided for EC nationals and this specifically includes oxygen therapy and renal dialysis.
There is some concern that GPs could fall foul of anti-discrimination legislation when questioning patients to assess eligibility to NHS care. All
patients must therefore be questioned sensitively and on an entirely equitable basis, regardless of race, religion, sex, colour or creed, in order to comply with the law.
It is always a matter for the GP's discretion whether or not to accept an overseas patient on his or her list as either a temporary or a permanent
patient. The official guidance stresses this fact and seems merely to "suggest" that NHS treatment should apply only to those people judged
to be ordinarily resident, and does not in fact direct the GP's decision. The DOH documentation also indicates that a GP who does not wish to
accept an overseas visitor onto his or her list may treat that patient on a private basis and in fact advises GPs to do so!
However, the emphasis is on the voluntary and discretionary basis for all decisions. This must be absolutely right since any misinterpretation of
the situation could easily result in serious legal or professional consequences for the GP. Wessex LMCs would not wish to see GPs running the additional risk of being penalised by the PCT/DOH for
making what is always a very sophisticated judgement based upon a whole raft of complex circumstances, in what may be a difficult clinical situation.
It is likely that in future we will all be required to carry identity cards which will be coded with information relating to our NHS eligibility
status. Until then it appears that the situation will remain a quagmire of poorly defined criteria that we will all struggle to interpret to the best of our ability!
CED
Q PRA108 - Access to Medical Reports Act - When does the 21 day period start in which the patient may see a report before it is sent off?
(10/12/03)
Answer - The Access to Medical Reports Act is quite specific on this.
(2) Where a medical practitioner is notified by the applicant under subsection (1) above that the individual in question wishes to have
access to the report before it is supplied, the practitioner shall not supply the report unless -
(a) he has given the individual access to it and any requirements of
section 5 below have been complied with, or
(b) the period of 21 days beginning with the date of the making of the application has elapsed without his having received any communication
from the individual concerning arrangements for the individual to have access to it.
If the patient wishes to see the report, the GP may not send it off until the patient has seen it and gives consent for the GP to do so. If the
patient sees the report and wishes it to be amended, the GP must do this before sending it off. If the GP is not prepared to change the report, the patient must be permitted to append a statement to be sent
with the report containing the amendments that he believed should have been made.
Further Information:
Medical information and insurance - Joint guidelines from the British
Medical Association and the Association of British Insurers
CED
Q PRA107 - Printer replacement and funding - We must replace all of our old tractor feed printers by the beginning of 2004. Our PCT is
refusing to reimburse the full cost of this. I thought all PCTs had to pay for 100% of minor upgrades. Can you please clarify?
(08/12/03)
Answer - This cost should be met fully by the PCT. The Department of
Health recently wrote to all PCTs saying:
'Minor upgrades are defined as those required to ensure that existing clinical systems continue to perform efficiently. For example; servers,
memory or hard disk upgrade, replacement of broken or defective items such as printers, screens or back-up devices'.
The letter from the Department to PCTs clearly states that any appeals process should not delay funding reaching practices and has confirmed
that the terms of the contract will be honoured in full.
PCTs that do not have sufficient funding can apply through their StHA.
CED
Q PRA106 - Copying patient letters - The PCT has told us that from April 2004 we will be obliged to copy all our referral letters to the
patient. The Department of Health have also confirmed this. I doubt we will be able implement the service in time for the deadline and even if we can, who will pay for it? (03/12/03)
Answer - The NHS Plan originally contained the proposal that letters
between clinicians about an individual patient's care would be copied to the patient. The RCGP/GPC prepared a joint response to that proposal,
highlighting the need for a full evaluation of the workforce implications before implementation. The BMA also asked that the full cost should be calculated and met. The BMA's expressed preference was for copies of
letters to be made available to patients only on request.
As far as we are aware there have been a few pilot schemes, but still no official evaluation of the workforce implications, or the cost and funding
arrangements, for GPs across the country. Practices have received no practical information or guidance on achieving this objective and have been given no information regarding funding.
We are not aware of any new legal requirement to copy letters as a matter of routine and have asked for urgent official clarification and
guidance. We will provide full information as soon as it is available to us.
We would be very concerned if this proposal were to be implemented simultaneously with the new GMS contract, in view of the considerable
additional and excessive demands upon staff at this time.
The DOH is aware that some GPs will find this task too onerous to undertake by the April deadline and has confirmed that there is indeed
no legal requirement to copy letters to patients.
It is, however, generally recognised as good practice to copy letters for patients who wish for a copy and may not prove to be too arduous or
expensive in practice.
One of our GPs has written to say;
"For more than 10 years it has been my practice to dictate any referral letters in the presence of the patient.
This has a number of practical advantages, and would seem to meet the spirit of openness required by the DOH, whilst at the same time not adding to costs, or to unnecessary paper.
It is really quite rare, probably no more than once or twice a year that referral letters shouldn't be shared with the patient.
There is a hidden bonus in that the patient can often correct errors
during the dictation process, and I often find that I am prompted to ask for additional information, which results ultimately in a better letter being produced.
I hope that other will find this suggestion helpful."
The GPC tried unsuccessfully to negotiate inclusion of this initiative as an organisational marker in the Quality and Outcomes Framework of GMS2.
However, if patients value the service, it could prove helpful in the Patient Experience section.
Further Information;
Copying letters to patients
Patient empowerment and public participation; One of a series of documents in response to the NHS Plan for England ;
Short report: copying referral letters to patients
CED
Q PRA105 - Patients living abroad for extended periods - We have a patient who lives abroad for most of the year. He returns from time
to time to a house that he owns locally and insists that he is eligible to the full range of free NHS care, including long term prescriptions. Is this so? (01/12/03)
Answer - Patients that leave the country for three months or more are
no longer entitled to remain on their GPs list. See Q PRA44 - Patients
travelling abroad for extended periods
They would only qualify to re-register with your practice if they were "living lawfully in the United Kingdom voluntarily and for settled
purposes as part of the regular order of their life for the time being. Whether they have an identifiable purpose for their residence here and whether that purpose has a sufficient degree of continuity to be
properly described as 'settled'."
In terms of eligibility for NHS care, the only thing that is relevant is residence and this cannot be judged from external appearance, name,
language, nationality, past or present payment of taxes, or whether they are registered with a GP and have been given a NHS number. This is what is meant by being "ordinarily resident".
The government is planning to tighten the rules for charging overseas visitors for NHS treatment.The proposed changes are set out in a new Consultation paper; Proposed Amendments to the National Health
Service (Charges to Overseas Visitors) Regulations 1989
The changes 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.
Under the current regulations GPs still have an obligation to treat any patient who presents in need of emergency or immediately necessary treatment.
In the LMC response to the consultation, we pointed out that the proposed new exemption for British State Pensioners living 6 months in
the UK and 6 months in EEA is at odds with the current need to de-register patients living outside the UK for 3 months or more.
The government is aware that the new proposals are at odds with current primary care rules and is discussing these issues with primary care representatives.
We have now been informed that the changed regulations on charges will only apply to services provided by NHS hospitals, and not by primary
care providers. It is therefore probable that the proposed amendments will not affect primary care services.
With regard to long-term prescriptions, you should never prescribe for long term periods unless you believe that it is entirely safe to do so. You
would be held to be professionally responsible in the event of any problems arising as a result of unsupervised treatment while the patient was abroad. Further prescribing information is available in LMC Guidance on Patients travelling abroad for extended periods.
Further information:
Overseas visitors' eligibility to receive free primary care
Department of Health Guidance to Hospital Trusts regarding Charges
for NHS Treatment
CED
Q PRA104 - 'Emergency or immediately necessary' treatment - We are updating our practice protocols on overseas visitors and are
struggling to come up with a policy on what is 'emergency or immediately necessary'. Could you advise us please and perhaps comment on the following examples?
- Acute crushing chest pain
- Severe abdominal pain for 2 days in RIF
- Chest infection for 2 days
- D & V for 1 week
- Weight loss for 6 weeks
- Dyspepsia for 1 year
- Needs repeat medication for pre-existing chronic disease
- Wants second opinion while in this country (01/12/03)
Answer - You have a professional duty and a Terms of Service obligation
to provide immediately necessary or emergency treatment. Specific guidance for GPs seems to be unavailable. However, there is
Department of Health Guidance to Hospital Trusts regarding Charges for NHS Treatment that may give some clarification and definition.
Life threatening illness - You would be obliged to treat this. It would
include crushing chest pain or an acute abdomen. (1&2 above.) Trusts are advised that treatment should be limited to that which is clinically necessary to enable the patient to return to their own country and
should not normally include routine treatment. The guidance states that "the decision to provide treatment in these circumstances is a
clinical one and the responsible health professional's reasons should be recorded in the patient's clinical notes."
Maternity services - The secondary care guidance indicates that maternity services are not exempt from charges. However, because of
the severe health risks associated with conditions such as eclampsia and pre-eclampsia, maternity services should not be withheld if the woman is unable to pay in advance. The GP would similarly be required to treat
serious acute problems associated with pregnancy.
Treatment given in accident and emergency departments is exempt from charges - If in doubt you could probably refer the patient to A&E,
unless the need for treatment is more urgent than that, in which case you must provide any immediate treatment that you are able to provide.
Treatment the need for which arose during the visit - this applies to
treatment needed where the diagnosis of a condition is made when first symptoms arise during a visit to the UK or where treatment is needed quickly to prevent a pre-existing condition increasing in severity. This is
of course the difficult grey area and entitlement to free treatment does not seem to have been clarified in this situation.
An acute psychosis might fall into this category, either as a new diagnosis or an exacerbation of an existing condition. In either case
there would be a clear need for you to provide immediately necessary treatment.
A chest infection or diarrhoea and vomiting for 2 days (2&3 above) could be trivial and self-limiting illnesses, but could indicate more serious
acute pathology leading to severe complications in a vulnerable patient. It would be difficult to criticise a decision to treat if you believed it treatment was 'immediately necessary'. However, failure to treat an
apparently simple condition could prove indefensible if the patient suffered serious complications as a result.
Also in the grey area is the need for repeat medication for pre-existing chronic disease (7 above), particularly if the condition is likely to
deteriorate substantially if you fail to prescribe. You could charge for this and issue a private prescription if the patient is not registered with your practice.
If the patient had experienced serious new symptoms that could indicate a need for additional medications or a change in the existing treatment,
this could be a case where immediately necessary diagnosis and treatment would be required.
It would be unlikely that weight loss for 6 weeks or dyspepsia for 1 year necessitate immediately necessary treatment in this country. In either
case the patient should return home for further investigation and treatment.
A patient that wants a second opinion (8 above) could not be classed as immediately necessary treatment.
In these grey areas the decision is a matter of finely tuned professional experience and judgement, which is almost impossible to express in a
fixed definitive list.
Wessex LMCS would be very interested in any definitive guidelines that you (or any other practice) manage to produce, particularly if
you would be prepared to share them on our web site!
Some NHS secondary care is always free including:
a) treatment in an A&E, but if admitted there may be a charge.
b) family planning services
c) treatment of diseases necessary for public health eg. polio, malaria, encephalitis, meningitis, tuberculosis, hepatitis, and food poisoning,
d) treatment given in, or as the result of a referral from, a Sexually Transmitted Diseases clinic except for HIV treatment.
e) treatment given to people detained under the provisions of the Mental Health Act 1983;
f) treatment given for mental health problems as part of a court probation order.
CED
Q PRA103 - Registration and proof of eligibility or identity - Can you give any advice about what paperwork patients must provide when
registering at a practice? Do they need to provide photo ID or proof of address? This is clearly very difficult for asylum seekers who have just been given leave to remain. I didn't think they had to provide
anything apart form a completed registration form, but a colleague tells me I am wrong.
(01/12/03)
Answer - You are absolutely correct in assuming that the GP is not required
to seek any specific verification of identity or eligibility. Indeed to do so purely on the basis of race or sex would be against the current UK laws on sexual or racial discrimination.
Article 14 of the European Convention on Human Rights prohibits discrimination against a person in the exercise of their rights under the
Convention, on any ground such as: sex, race, colour, language, religion, political or other opinion, national or social origin, association with a national minority, property, birth or other status.
In terms of eligibility for NHS care, the only thing that is relevant is residence and this cannot be judged from external appearance, or name,
or language, or nationality, or past or present payment of taxes, or whether they are registered with a GP and have been given a NHS number.
You may, however, ask all patients wishing to register where they have lived for the 12 months immediately preceding treatment.
To check eligibility to the full range of free NHS care you may ascertain whether prospective patients are "living lawfully in the United
Kingdom voluntarily and for settled purposes as part of the regular order of their life for the time being. Whether they have an identifiable purpose for their residence here and whether that
purpose has a sufficient degree of continuity to be properly described as 'settled'."
The Department of Health Guidance to Hospital Trusts regarding Charges for NHS Treatment suggests that if possible you should allow
the patient to provide "whatever evidence he or she thinks is appropriate to support their claim" and advises against automatically asking to see passports as a matter of routine.
The hospital guidance advises against questions relating to immigration status, unless it is strictly relevant. The DOH however admits that "there
will be times when a passport can provide useful evidence, in which case asking to see one would not be unreasonable."
The guidance also states that "Providing the trust can demonstrate, if need be, that it has acted reasonably in all cases it is unlikely to
encounter criticism."
GPs have been criticised for permitting illegal immigrants access to full NHS care without first checking their eligibility. This sounds like a 'Catch
22' situation for the GP. However, provided evidence of eligibility to NHS care is sought from all patients on an equitable basis, this is quite permissible.
A similar problem arises with those patients who attempt to register at multiple practices, usually to acquire controlled drugs, on the basis of a
false identity or address. Again you may request proof of identity or eligibility, provided it is applied equitably to all patients and is not discriminatory.
You may have a notice in your surgery stating that you reserve the right to request proof of identity or eligibility from any patient wishing to register.
If you accept a patient who fills in an NHS registration number on form GMS 1, the patient services administrator will cross check this against a
National database. If the patient is who he or she claims to be, and does indeed have an NHS number, then there should be no problem and the registration will proceed in the normal way with the notes being
transferred to the new doctor.
If the details provided on GMS 1 do not 'marry up' on the computer the matter is referred to a central tracing unit. This unit will contact the
patient to obtain further details regarding their identity. If the tracing unit does not receive an adequate response, the matter is referred back for investigation by the local fraud investigation unit.
There are often common identifiers in those registrations referred back for investigation indicating multiple applications by a single individual.
The fraud investigation unit will follow these up appropriately, sometimes by sending out an 'alert' to local practices, and/or by taking legal proceedings against the patient for obtaining services and supplies
by deception.
If a patient is newly arrived in this country and does not have an NHS number, as far as we have been able to ascertain, a new NHS number
will be issued as a matter of routine, since a GP has already accepted the patient for registration!
In other words, it appears that GPs are the only check on the eligibility of foreign patients to NHS primary care.
In fact, since most asylum seekers in our area are allocated, the GP is obliged to accept them on to the list!
If any patient is referred by the registered GP for secondary care, the hospital may check for eligibility and free care may be refused at that
stage. The NHS Number does not guarantee entiltlement!
The Terms of Service and your professional obligations require you to provide free care to anyone presenting for immediately necessary treatment.
See also
illegal immigrants and eligibility for routine NHS treatment
CED
Q PRA102 - Records of deceased patient - One of our young patients was killed in a road traffic accident three years ago. His mother has
asked if she can have his medical records as a keepsake as they are no longer of use to the NHS and may help her resolve her grief. Is this permissible? (27/11/03)
Answer - You would not be permitted to provide the original medical
records to the mother since they are officially the property of the NHS.
You are not obliged to do so, but it is probably permissible to provide the mother with a copy of all his notes, provided there are no specific
concerns about revealing data that he would not have wished to be disclosed and provided no third party data would be disclosed in the process. You should then return the original notes to the PPSA in the
usual manner.
DOH guidelines specify that records relating to children and young people (including paediatric, vaccination and community child health
service records) should be retained either until the patient's 25th birthday, (or 26th if an entry was made when the young person was 17,) or 10 years after death of the patient if that occurs sooner.
During this period of time it is very unlikely that the PPSA would allow the mother to hold the records herself. The mother could ask the PPSA
if she may have the records at such a time when they no longer have to be kept by the PPSA, rather than allowing them to be destroyed.
There could of course be evidence of a problem/negligence that may or may not yet have come to light. In this case the mother would almost
certainly have a right to a copy of the notes dating from 1991 under the Access to Health Records Act.
CED
Q PRA101 - Patient experience - Where can we get more information about patient experience questionnaire and how much do they cost?
(17/11/03)
Answer - Further information on patient experience is available in the New GMS contract - Supporting documentation in the section dealing with
Quality and Outcomes - Patient experience
There are two currently approved questionnaires, GPAQ and IPQ. Further details, including the conditions that apply to their use, can be found by
clicking on the following links;
The GPAQ was developed at the National Primary Care Research and
Development Centre in Manchester (NPCRDC) and is protected by copyright. It is free for practices who wish to photocopy questionnaires to run their own survey, but there is a charge of 10p per questionnaire if
it is printed or used at PCT level, both of which require prior permission. There is currently no charge if you use GPAQ in a non-paper form, e.g. web based, or on a computer in surgery waiting room.
The NPCRDC advises that you can add your own questions to the GPAQ, but you should not alter the main questions as only approved
questionnaires qualify under GMS2. It also asks practices to e-mail them their GPAQ data so that it can be added to the national benchmark. The NPCRDC guarantees that this data will not be used in an identifiable
form.
The IPQ is owned and administered by Client-Focused Evaluations
Programme (CFEP), an independent organisation that provides GP practices with systematic patient feedback.
IPQ costs are £60 +VAT per clinician undertaking the activity. If results are required only at Practice level, with no individual clinician results,
the cost is reduced and ranges from £60 +VAT for 50 questionnaires in a 1 doctor practice to £260 +VAT for 300 questionnaires, in a practice of 8 or
more doctors. These costs include all materials and prompt return of the results.
CED
Q PRA100 - Administration fee - We find the subject of immunisation
fees very confusing. Can you clarify some difficult points please?
- Can we charge patients an administration fee for travel immunisations where no IOS fee is claimable?
- Can we charge for advice given to patients travelling abroad or for attendance at a travel clinic?
- Can we charge a private prescription fee for issuing a private script for anti-malarial prophylaxis?
- For patients travelling abroad we do not charge for vaccinations that carry an IOS fee eg. Tetanus (Td), Polio,
Typhoid, 1st Dose Hepatitis. Can we recoup the cost of the vaccine (SFA Para 44.2/44.5) and the dispensing fee (unless the drug was centrally supplied eg polio)?
- For patients travelling abroad we charge the patient a £15 private administration fee for vaccinations that do not carry an
IOS fee. We also claim reimbursement for the vaccine (SFA Para 44.2/44.5) and a dispensing fee. Is this correct? (12/11/03)
Answer - To answer to your specific questions in turn;
- You may charge an administration fee.
- You may not charge for advice that would normally be given as part of GMS.
- You may charge for malaria prophylaxis.
- You may claim the IOS fee and recoup the cost of the vaccine and the dispensing fee under the SFA.
- You may charge privately for administering the vaccine, as well as claiming reimbursement for the vaccine and dispensing as set out in the SFA.
In relation to 4&5 above it is important to note that reimbursement of the cost of a vaccine is not a fee therefore does not conflict with IOS
payments. You may claim it as you describe under Para 44.2/44.5 or issue an FP10 to be dispensed by a pharmacy contractor, in which case the
patient will pay the prescription charge, unless he or she is exempt)
RIB
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