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Q & A - Practice Matters 5 (Apr '04 - Jul '04)
Index
PRA143 - NHS Direct Feedback form
PRA142 - Maternity pay for salaried GPs
PRA141 - Safety Alert Broadcast System (SABS)
PRA140 - Refusal of chaperone by vexatious patient
PRA139 - Private fees for malaria prophylaxis and yellow fever immunisation
PRA138 - Travel immunisations
PRA137 - Capitation count
PRA136 - Hepatitis risk
PRA135 - New patient records
PRA134 - Details in medical records
PRA133 - Use of chaperone
PRA132 - Overseas visitors' entitlement to primary care registration
PRA131 - 48 hour target
PRA130 - Recurrent short term sickness and certification
PRA129 - Overseas visitor and humanitarian dispensation
PRA128 - Collection of Household Waste certificate
PRA127 - Specific advice on overseas visitors
PRA126 - Overseas visitors' eligibility for NHS services
PRA125 - Replacing existing computer systems
PRA124 - Employees from EU accession states
PRA123 - Change of name
PRA122 - Refusing to register patients from neighbouring practice
PRA121 - EU accession states and entitlement to NHS care
PRA120 - Failed asylum seekers
PRA119 - Pensioners and NHS care
Q PRA143 - NHS Direct Feedback form - Where can I obtain an on-line copy of the NHS Direct Feedback form? (15/07/04)
Answer - Some months ago we also were unable to obtain a feedback form online and managed to
obtain a copy from the National Office of NHS Direct. This is available on this website at NHS Direct feedback
Alternatively, if you use the search facility on this website and enter "NHS direct feedback" it will also bring up the link to this document.
CED
Q PRA142 - Maternity pay for salaried GPs - We are about to employ a female salaried doctor. The model contract quotes the 'General
Whitley Council Handbook' as a reference for maternity terms and conditions. However, in General Practice we do not use this document and we don't even have a copy. Are there any clear
guidelines for salaried GP's employed in General Practice, especially with regards to Maternity leave and pay. What financial responsibility do if any does the PCT have in meeting our costs? (12/07/04)
Answer - The following links will take you to authoritative and
comprehensive guidance on the subject of the employment of salaried GPs;
Supporting documentation
Focus on Salaried GPs - June 2004
Guidance & contracts for salaried GPs
Non principals
The right to full pay while absent on maternity leave should be included in the GP's contract and must conform, at the very least, to the current
statutory entitlements.
(There are particular problems with regard to maternity pay for GP Registrars. See Q&A STA 18 on Maternity pay)
If maternity leave and pay entitlement is covered in the contract of employment, then the PCT will be obliged either to help pay for a
locum to assist the practice or to provide a doctor to assist. (See
Part 4 of the SFE.)
You should not be too concerned by the current Whitley council arrangements as GP practices are not obliged to adopt these pay scales,
which apply to staff employed directly by the NHS. In fact the Agenda for change will replace the Whitley Council Handbook by the end of 2004.
At that time there will be three pay spines or series of pay bands for directly employed NHS staff. These will be:
- Staff within the remit of the Doctors and Dentists Review Body.
- Staff within the extended remit of the Pay Review Body for nurses and other health professions.
- Other directly employed NHS staff, with the exception of senior executives.
Two new bodies, rather than the Whitley Council, will make national decisions on pay and terms and conditions of service for directly employed NHS staff. These are;
- The NHS Staff Council which will oversee the operation of the new pay system and have responsibility for NHS-wide terms and conditions of service.
- The Pay Negotiating Council which will negotiate pay for staff on the third pay spine.
The remit of the Review Body for Nurses, Midwives, Health Visitors and the Professions Allied to Medicine (the NPRB) will be expanded to
include a wider number of qualified health professionals and their support staff.
The New NHS/HPSS Pay System - An Overview describes the arrangements for staff on the second and third of these pay spines.
Whilst practices will probably not be obliged to comply with the pay scales and conditions established by these new arrangements, market
forces may well determine that staff will be reluctant to accept less favourable pay and conditions.
Implementation of the new system may well be delayed as several of the 'early implementer' schemes have encountered problems, not least the
fact that some staff would be paid less under the new scales of pay!
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Q PRA141 - Safety Alert Broadcast System (SABS) - Are we obliged to provide a return to the SHA to let them know that we have received
an SABS message and to provide them with details of what action we have taken in order to comply? (08/07/04)
Answer - The Safety Alert Broadcast System (SABS) was launched
towards the end of 2003. Safety and device alerts are now e-mailed to nominated leads in NHS Trusts and PCTs for dissemination. Initially the SABS will only issue alerts from the Medicines and Healthcare products
Regulatory Agency (MHRA) relating to Medical Devices and alerts from the National Patient Safety Agency (NPSA) and NHS Estates. If SABS is successful it will later include drug alerts issued by the MHRA.
The SABS alerts introduced the additional responsibility of completing a short feedback form to confirm that action has indeed been taken by
the PCT and/or Strategic Health Authority. There is currently no legal requirement for GPs to complete these, unless a local contract with the PCT specifies that they should.
GPs must, however, take heed of any action that may be required to ensure patient safety as part of their normal practice risk management strategy.
The SABS safety alerts will form part of the new NHS standards an, as such, will be accessible to the Healthcare Commission when it carries
out routine inspections. Practices would be expected to have taken any necessary action highlighted by the alert.
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Q PRA140 - Refusal of chaperone by vexatious patient - I am a young male GP and one of our female patients has alleged that various
previous doctors have performed inappropriate intimate examinations on her. She frequently comes to me with minor gynaecological problems which require a pelvic examination. I
suggested that our practice nurse should act as a chaperone, but she refused to allow this. She is adamant that she will not have any other person present as a chaperone on any occasion. What should I do?
(08/07/04)
Answer - You would be very unwise to examine this patient without a
chaperone. It is also important that the chaperone has nothing to gain from misrepresenting the situation so that her presence would provide protection for both you and the patient. However, you may not force
any patient to have a chaperone present and if you try to force her to agree then her consent would not be legally valid.
Your practice policy should require all partners to make appropriate use of a chaperone for intimate clinical examinations and you should inform
the patient of this. If she refuses to accept a chaperone you should inform her that you would be unable to continue treating her. You could quite reasonably claim in these circumstances that the professional
relationship between you had broken down and you could ask her to find a new GP. She should contact the PCT for assistance if she is unable to
find a new GP who is prepared to register her as a patient. You may ask the PCT to remove her from your list if this becomes necessary.
If you believe it is clinically vital that she is examined, there may be less risk if a female partner examines her. If this is not possible then you
should seek the specific advice of your medical defence organisation before carrying out the examination yourself without a chaperone. It would be very important to record the circumstances in which you
performed the examination and any specific advice you had received. It would be wise to have one of your practice staff available outside the examination room in case the patient wishes to call for assistance at any
point.
See PRA133 - Use of chaperone
Further information;
Guidance on the Role and Effective Use of Chaperones in Primary
and Community Care settings ;
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Q PRA139 - Private fees for malaria prophylaxis and yellow fever immunisation - In relation to travel abroad, for what services can we
charge the patient a private fee? I am particularly uncertain about malaria prophylaxis and yellow fever immunisations. (05/07/04)
Answer - The GPC Focus on Private Practice sets out the detailed
circumstances in which a private fee may be charged and was amended specifically to ensure that it permitted a fee for the provision of malaria prophylaxis.
It states very clearly that;
"The contractor may demand or accept a fee or other remuneration...
(g) for treatment consisting of an immunisation for which no remuneration is payable by the Primary Care Trust and which is requested in connection with travel abroad;
(h) for prescribing or providing drugs, medicines or appliances (including a collection of such drugs, medicines or appliances in the form of a travel kit) which a patient requires to have in his possession
solely in anticipation of the onset of an ailment or occurrence of an injury while he is outside the United Kingdom but for which he is not requiring treatment when the medicine is prescribed;
(l) for prescribing or providing drugs or medicines for malaria chemoprophylaxis."
Yellow fever immunisation should not be given on the NHS and GPs may charge their own patients for it.
See also GPC Focus on Vaccinations and Immunisations
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Q PRA138 - Travel immunisations - I am fed up with providing immunisations for foreign travel. Am I obliged to provide this service?
(05/07/04)
Answer - A GP's contractual responsibility in relation to foreign travel is
limited to advising patients on health matter. Referring a patient to a private clinic is usually sufficient in this respect. You are entitled to opt
out of all of the additional vaccinations and immunisations, but this would cost you a reduction of 2% of your global sum.
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Q PRA137 - Capitation count - At the start of each academic year we always have a very large influx of students wishing to register with
our practice. If they are to be included in our capitation count for the quarter starting in October these new patients must all be included on our computer system within the last few days of
September. Obviously we do not wish to miss out on a quarter's increase in budget because we are unable to meet the deadline. It would suit us very much better if our capitation count could be
delayed until the middle of October, January, April and July. The PPSA insists that this is not possible. Do you agree? (05/07/04)
Answer - A GP is responsible for each of his or her patients from the
day of acceptance, but the census of practice list sizes (capitation count) throughout the country is always taken on the first day of each quarter. This helps to ensure that patients nationally are only counted
once for payment purposes. Submissions are acceptable up to 48 hours from the end of the 1st day of the quarter and late submissions are subject to payment adjustments in subsequent quarters.
To be included in a quarter's capitation count the patient must submit his or her medical card (or form GMS1) and this must be signed by the
GP and passed to the PPSA on or before the first day of the quarter.
These arrangements have been in place since the commencement of the NHS and still apply under GMS2. Although it might suit one or two
practices to change the date, it would be unworkable on a national basis if the date was not fixed. This would almost certainly not be acceptable to the auditors.
On this occasion, therefore, we believe that the PPSA is correct.
Paragraph 21.18 in Part 6 of the Supplementary Provisions of the SFE
sets out the details for the Adjustment of Contractor Registered Populations.
CED
Q PRA136 - Hepatitis risk - I read recently that a GP who is not immunised against hepatitis risks litigation. Is this true? (05/07/04)
Answer - This has been reported to be the view of at least one of the
defence organisations!
In a recent study only 57% of GPs had been effectively immunised against Hepatitis B. Only 56% of practice nurses filled in a blood exposure
incident form after a needle-stick injury. Part of the problem was attributed to the very limited availability of Occupational Health Services for GPs and their practice staff. However, this is unlikely to be
an effective defence in the courts or in a GMC hearing!
All GPs are advised to check the immune status of themselves and their practice staff and to review their practice protocols for managing and
minimising the risk of serious blood-borne infections.
A GP or practice nurse is placing themselves and others at risk of serious and potentially fatal blood-borne disease unless they have protective
levels of antibodies and follow adequate risk reduction procedures.
The practice has a duty of care to staff and to patients and there are very likely to be legal implications if either a member of staff or a
patient becomes infected as a result of a failure to adopt sufficiently robust policies.
The GMC provides guidance to doctors on
Serious Communicable Diseases - which states that;
"You should always take appropriate measures to protect yourself and
others from infection. You must make sure that any staff for whom you are responsible are also appropriately informed and co-operate with measures designed to prevent transmission of infection to other patients.
You must protect patients from unnecessary exposure to infection by following safe working practices and implementing appropriate infection control measures. This includes following the Control of
Substances Hazardous to Health Regulations 1994 and other health and safety at work legislation. These regulations may require you to inform your employer, or the person responsible for health and safety in your
organisation, if there are any deficiencies in protection measures in your work place. Failure to do so may amount to a criminal offence.
You must always take action to protect patients when you have good
reason to suspect that your own health, or that of a colleague, is a risk to them."
Any failure to operate an adequate policy with respect to serious communicable diseases would place the practice at risk of legal
proceedings and the GP at risk of legal, professional and/or disciplinary action.
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Q PRA135 - New patient records - Computer printouts as well as the paper records for new patients from computerised practices are
often incomplete. What should we do about this? (30/06/04)
Answer - Schedule 6, Part 5 of the regulations relating to Records, information, notifications and rights of entry requires a GP to send the complete records relating to a patient to the PCT if the patient dies
or if a patient is no longer registered with the practice. The medical records may be in the form of the manual record or a printed copy of the full computerised record. (If the PCT approves, the record may be
transmitted in other forms.)
If the copy of the electronic record relating to a new patient is incomplete there are two possible reasons;
- The previous practice has not kept adequate records as required by the regulations and for the purpose of clinical governance and
for medico-legal reasons. (see Q&A PRA134)
- Different computer systems provide the option of a full print-out, as well as various abbreviated printouts. It may well be that you
have been sent an abbreviated version of the full record.
You should ask for a complete printed record as soon as possible to ensure that your records are complete and if this proves impossible you
should seek further specific advice from the SHA and/or the LMC.
If a patient is no longer registered with your practice you should always remember to send a copy of the complete medical record as required by
the regulations. This is important for medico-legal reasons and may be critical for the continuing care of living patients.
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Q PRA134 - Details in medical records - Is it enough for a doctor that sees a patient to enter only 'surgery attendance' and the date in the
computer or the manual record? (30/06/04)
Answer - No. Schedule 6, Part 5 of the regulations relating to Records, information, notifications and rights of entry requires that a GP "shall keep adequate records of its attendance on and treatment of its patients" using the official forms and/or a computerised record. The GP
must also include clinical reports from any other health care professional who has cared for the patient.
Omitting details in the way you describe would be an important medico-legal and clinical governance issue.
Wessex LMCs are not aware that inadequate recording of consultations is a problem in our area and would be very concerned if this were to be
the case.
All GPs should check that their practice is in fact keeping a full record on the computer system and/or in the manual records.
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Q PRA133 - Use of chaperone - There has been a lot of publicity recently regarding the use of a chaperone when examining patients.
What advice would the LMC give? (24/06/04)
Answer - Some patients are very embarrassed by any physical
examination. This may apply particularly to very young or to elderly patients or to female patients from certain religious or ethnic groups. If the patient, or if you, feel uncomfortable about any examination it is
always wise to consider the use of a chaperone. This is particularly important when an intimate examination of breasts, genitalia or rectum, are necessary.
Before undertaking any examination it is basic good manners, and also a legal necessity, to ask permission. The level of consent required to take
the radial pulse is obviously less than that required to carry out a cervical smear!
For any intrusive or intimate examination you should explain why it is necessary, what is involved and give the patient an opportunity to ask
questions, to request a chaperone or to refuse the examination, if they so wish. Consent may be withdrawn at any stage of the examination and you must respect any subsequent objection to continuing with an
examination.
This is not an arduous matter and hopefully most GPs already show such common courtesy and common sense when examining patients! There is
usually no need to have written consent unless the examination is accompanied by a clinical procedure, such as insertion of an IUCD, which may carry an element of risk.
If you are training staff or teaching students you must obtain valid consent to their presence or participation in the examination.
It makes good sense to allow the patient privacy to undress and dress and to provide some covering to preserve the patient's dignity. You
should keep any discussion relevant to the examination and avoid any unnecessary personal or humorous comments.
Occasionally you may believe that there is an element of risk involved, for example if a patient has previously shown inappropriate behaviour in
your presence or is psychologically disturbed or has made a previous complaint about a physical examination. Common sense is essential here and a chaperone would always make very good sense!
If you think it wise to offer a chaperone you must seek the patient's consent and should record the presence of the chaperone, or make a
note if the offer is declined. You may alternatively suggest that the patient asks a relative or friend to be present. The chaperone should only be present during the examination and most of the consultation
should take place in their absence, for reasons of privacy and confidentiality, unless the patient specifically requests otherwise. The patient should be reassured that any practice staff acting as chaperones
are bound by a strict duty of confidentiality.
It is important to remember that complaints are not limited to male doctors examining female patients. This is an issue that may create
problems for any doctor with any patient, regardless of their sex!
Further information;
Guidance on the Role and Effective Use of Chaperones in Primary
and Community Care settings ;
GMC guidance on Intimate Examinations ;
Reference guide to consent for treatment or examination
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Q PRA132 - Overseas visitors' entitlement to primary care registration - We have recently had two requests for registration and
been unsure whether we were obliged to accept the patients on our list. Please can you clarify the situation for;
- a German man who intends working here for only 3 months?
- a man from Iraq working here legally on a highly skilled migrant workers programme. His papers state that he is legally entitled
to stay here for one year only, but are stamped with the words 'no recourse to public funds'? (16/06/04)
Answer - We have clarified the situation with the Department of Health
who confirm that acceptance of any patient by a GP practice is a discretionary matter which hinges on the concept of 'ordinary residence'. This may be defined as "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 the absence of any clearer definition, the practice may apply a reasonable interpretation. Many people would consider a six month
period of work in this country as indicating a settled purpose, but this is not a fixed concept.
EEA citizens are not obliged to have any of the official European forms of healthcare entitlement, such as an E111 or E128.
The practice has an obligation to provide any immediately necessary or emergency treatment to any patient that presents, regardless of the
concept of ordinary residence.
- The German patient may legitimately be registered as a permanent or temporary resident, since he is staying here to work for only
three months. You may, however, refuse to accept him as an NHS patient if you do not consider him to be 'ordinarily resident'. In that case you may provide treatment for him privately.
- The Iraqi patient may be accepted on your list if you consider him to be 'ordinarily resident'. The fact that his papers are marked as
being no recourse to public funds does not apply to NHS entitlement, but only to social security benefits. If, however, you do not regard this patient as being 'ordinarily resident', since he is
planning to return to Iraq when his current one year visa runs out, you may legitimately refuse to accept him on your NHS list as a permanent resident. You would then be entitled to treat him privately.
Under GMS 2 you must provide any patient with a written reason for your refusal to register him and you must keep a record of this for the PCT.
You may not refuse to accept either patient on the basis of their racial origin alone, nor must you use any other discriminatory basis for your
refusal. You should make it absolutely clear that you have refused acceptance only on the basis of your practice view that they are not 'ordinarily resident' and therefore not entitled to NHS care.
If either patient applies to the PCT, and is in the view of the PCT ordinarily resident, the patient may then be allocated to your list, unless
your list has been formally closed.
The consultation document
Proposals to Exclude Overseas Visitors from Eligibility to Free NHS Primary Medical Services sets out the
government's proposals for change and also sets out the details of the current regulations.
CED
Q PRA131 - 48 hour target - Please could you clarify whether we have to offer normal routine appointments of a specific length in
order to meet the advanced access requirements? Do emergency appointments on the same day count? Our PCT has told us that we must offer a routine 10 minute appointment within 48 hours in order
to meet the advanced access target. (14/06/04)
Answer - We believe that your PCT managers are wrong.
The Blue book of 'Supporting documentation' in the section on Access to general medical services; Specification for a Directed Enhanced Service April 2003
in relation to 'Improved access' does not stipulate that access to a routine appointment of a specified length must be provided on a 48 hour basis in order to qualify. Emergency 24 hour
appointments with a health professional would certainly count towards the advanced access target.
The Department of Health documentation on 48 hour access indicates
that all patients should be seen by a GP within two working days, or by another primary care professional within one working day, if they wish to do so.
Patients may choose to be seen outside the 48 hour target if that suits them better. This could include waiting longer for a normal appointment
with their preferred GP at a time which is more convenient both for the patient and for the doctor. Appointment systems should allow for this.
Section 4 of the Q&O framework provides the details relating to length
of appointments in relation to patient experience. If you offer too many 'routine' appointments on a '48 hour' basis that do not conform to the
Q&O recommendations on consultation length, then your Q&O targets in this area may be more difficult to achieve.
CED
Q PRA130 - Recurrent short term sickness and certification - A police office recently tried to insist on a short term sickness
certificate for a 5 day illness. He claimed that his employer insisted on this as part of their policy on recurrent sickness absence. Was I right to refuse? (10/06/04)
Answer - There is no contractual or legal obligation to provide short
term certification. This is reinforced by the government's cutting paperwork initiative and is strongly supported by the LMC.
We are aware that some police forces, in an effort to cut excessive sickness-attributed absence from work, are seeking such short term
certification from any employee with frequent recurrent short term sickness absence. These patients are very often suffering from problems induced or exacerbated by a high stress working environment. This is a
predominantly a human resources and occupational health service problem for the police force and should not be allowed to create an additional and unnecessary burden for GPs.
If the patient attends your surgery for treatment, then you may choose to provide a private certificate for an appropriate fee if you wish.
Employees are frequently asked to pay any fees charged, which are then reimbursed by the employer.
It is inappropriate for a patient who does not require medical treatment to attend the surgery to obtain short term certification just to suit the
purposes of the employer.
Sadly many employers feel it is their right to demand that GPs help them monitor what is frequently an organisational problem without funding an
adequately funded occupational health programme or addressing the underlying problems. This puts both patients and GPs in a difficult position in which the GP may feel obliged to collude with the request
for short term certification in order to avoid straining the doctor patient relationship. This may, however, be counter productive in the long term for all employees and we would generally advise against it.
Referring employers to the guidance in
Managing Short term sickness may be helpful. It is particularly relevant to note that the Association of
Chief Police Officers was one of the organisations to endorse this guidance, which states quite clearly that;
"The most common causes of sickness absence are minor complaints
such as colds or headaches, which can be treated most effectively with self-medication. GPs are not obliged to provide their patients with sick certification for illnesses of seven days or less.The use of GPs
services to manage short-term sickness absence is a waste of NHS resources, problematic for employees and may have cost and efficiency implications for employers."
Footnote 22/02/05
The Association of Chief Police Officers collaborated in the production
of a very helpful leaflet on Managing Short term Sickness
This states clearly that 'The use of GPs services to manage short-term sickness absence is a waste of NHS resources, problematic for
employees and may have cost and efficiency implications for employers.'
Further useful information on managing short term sickness may be found at Managing Sickness Absence - A comprehensive guide for employers.
In the event of further problems regarding short term sickness absence it would be helpful to direct employers to this information.
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Q PRA129 - Overseas visitor and humanitarian dispensation - A young couple from overseas recently registered with my practice. They are
not working or studying here and intend to return home to be with the rest of their family in the near future. They have valid visitors' visas. It is now apparent that their young child who is staying here
with them requires ongoing medical treatment. This is not urgent or immediately necessary but requires hospital investigations which could be costly. Are they entitled to free NHS secondary care?
(20/05/04)
Answer - Since they have not been living legally in the UK for 12 months
or more, and neither the father nor mother is working or studying here, and they are not intending to stay in the UK, they could not be regarded
as 'ordinarily resident'. Since they are not seeking asylum they do not have an entitlement on that basis either.
If their visas were granted on the specific basis that the couple were seeking treatment for their child, the Secretary of State may, on very
rare occasions, authorise exemption from NHS charges on the basis of "exceptional humanitarian reasons" as set out in paragraph 7 of The National Health Service (Charges to Overseas Visitors) (Amendment) Regulations 2004, SI 2004 no 614. We are led to believe from our
conversations with the Department of Health Overseas Policy Unit that this would be very unlikely in this situation.
The couple may wish to check this for themselves with the Overseas Policy Unit on 0113 254 5819.
CED
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Q PRA128 - Collection of Household Waste certificate - One of our patients has just received the following request from the local
council recycling department and has attended the surgery for the requisite confirmation!
I refer to the telephone enquiry on Wednesday 5 May 2004 from
xxxxxxxxxxxx occupational therapy assistant, requesting assistance with the weekly removal of refuse from your address.
This service is for persons who are physically unable to carry out
their black sack to the front of their property and there is no able person resident to assist them. I require written confirmation from your G.P. and I have enclosed a sample letter for your G.P. to
complete and sign. You will need to check with your G.P. when making a request, as some doctors do charge a fee but the Council does not pay for this.
Please ask your G.P. to return the completed letter to me so that we can make the necessary arrangements to issue you with your 'D' card. If you require further information please contact xxxxxxxxxx
on the direct dial number shown above.
Yours sincerely
Director
Borough Council Recycling Department
(19/05/04)
Answer - We are very grateful to one of our local practices who
recently received a similar request and suggested that other practices may wish to adapt their response letter to the local council. Wessex LMCS would endorse this approach to a request that would not generally justify medical input.
CED
Q PRA127 - Specific advice on overseas visitors - Where can I get authoritative advice on specific questions relating to the entitlement
of overseas visitors to NHS care?
(19/05/04)
Answer - The best source of specific advice in particular situations is
from the various departments dealing with these issues on an everyday basis.
The direct telephone numbers are;
Asylum seekers - 0113 2546605.
Primary care- 0113 254 5256
Secondary care-0113 254 5819
See also DOH Guidance on Overseas Visitors
CED
Q PRA126 - Overseas visitors' eligibility for NHS services - I am thoroughly confused by the eligibility of overseas visitors to access
NHS services. I am not sure when I must and when I may not treat an overseas visitor under the NHS and when I am permitted to provide care on a private basis. I understand that this is the subject of a new
consultation,which leaves me even more confused. Can you clarify the position or point me to some authoritative guidance?
(17/05/04)
Answer - Everyone is confused and we are currently receiving numerous
enquiries on this subject. Even the Department of Health has been unable to answer a number of recent queries we have put to them!
The new consultation document
Proposals to Exclude Overseas Visitors from Eligibility to Free NHS Primary Medical Services, outlines the
current criteria in Annex A as well as setting out the proposals for change.
At the present the regulations allow a practice the discretion to offer NHS treatment to UK residents, as well as visitors from any other
country, either on a temporary or permanent basis. This does not automatically entitle an individual to receive other NHS services free of charge.
The GP practice may alternatively provide care on a private basis and in the past the Department of Health has positively encouraged this
approach to 'NHS Tourists'.
Under the new GMS contract or PMS agreement, a practice is required to offer free NHS treatment if it is 'immediately necessary'. This is defined
as essential treatment, which cannot be delayed or avoided, and is necessary to treat a new or a pre-existing condition while the person is in the UK. Any drugs and dressings that are required are prescribed and
supplied in the same way as for UK residents.
Practices must offer free emergency or immediately necessary treatment to anyone refused acceptance as a temporary or permanent patient until
the patient has been able to register elsewhere or for up to 14 days after the refusal.
A practice is also obliged to provide immediately necessary treatment for up to 24 hours if a patient is staying in the area for less than 24 hours.
Visitors from EEA member states or Switzerland are entitled to 'all necessary' care, including for pre-existing chronic conditions, and are not required
to carry any EU form of entitlement except a passport or a document such as a national ID card.
Visitors from non-EEA countries that have a bilateral health agreement with the UK are entitled to immediately necessary treatment on
production of a passport or residence document.
Further information is available on the Department of Health's Overseas Visitors Home page
In the event that you are still not clear about a particular patient's eligibility to treatment we would suggest that you telephone the
Overseas Visitors' Policy Unit on 01132-545819.
The situation is still far from clear. If you wish to influence future arrangements you are strongly advised to make your views known in the
current consultation.
CED
Q PRA125 - Replacing existing computer systems - We have been advised that our computer system should be replaced as soon as
possible as it does not conform to the requirements of the NHS National Programme for IT. What advice can you give us?
(06/05/04)
Answer - Essentially if your system is RFA99+ accredited, and you are
quite happy with it, there is no urgency to transfer to another supplier provided that the supplier has confirmed their intention to make the system NPfIT compliant. It is understood that most systems currently in
use will be made compliant.
If your system is not RFA accredited, or you are otherwise unhappy with it, then you should seek further advice on the way forward from your PCT.
The GPC has recently produced guidance on The NHS programme for IT which should be helpful to you.
The PHCSG Primary Health Care Specialist Group of the British Computer Society has also produced helpful information in The National
Programme and Primary Care Informatics.
Update 22/02/05
It has been reported that health minister John Hutton told MPs that GPs'
existing computer systems will ultimately be replaced by software being created under the National Programme for IT whether practices want it
or not. The two 'core systems' are Lorenzo and Carecast. We have been unable to confirm this information.
GPC
Guidance for GP practices on system choice from the GPC and RCGP has not been updated since September 2004.
Update 23/03/05
It has just been announced that GPs will in fact get a choice between all
the accredited systems offered by any of the four local service providers within the NHS programme for IT (NPfIT). The accredited systems, provided by iSOFT, In Practice Sytems, The Phoenix
Partnership, and EMIS, will all be paid for by the national programme.
Practices to get choice of any LSP primary care system - 23 Mar 2005
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Q PRA124 - Employees from EU accession states - I have been asked if I would be prepared to employ the sister of a Polish doctor to
work as a secretary in our practice after May 1st. She speaks fluent English and has a university degree.
(29/04/04)
Answer - From May 1st 2004 nationals from the ten new European Union
accession states and their immediate family members can enter and work in the UK without any restrictions. However, they are required to register with the Home Office for monitoring purposes, unless they are
specifically exempt.
It is a criminal offence under Section 8 of the Asylum and Immigration Act 1996 to employ someone, aged 16 or over, who has no right to
work in the United Kingdom or no right to do the work that you are offering.
You must ask for proof of the prospective employee's nationality, preferably a national passport, national identity card or a residence
permit issued by the Home Office, confirming the right to reside and work here.
You must, however, ensure that you do not discriminate on racial grounds. This presumably means you must from May 1st apply similar
identification procedures to all applicants, including UK citizens.
You must satisfy yourself that the potential employee is in fact the rightful holder of any identifying documents by checking the employee's
appearance against any photographs and against the date of birth. You must check that expiry dates have not been passed and must also check for any UK Government stamps or endorsements to see if the employee
is permitted to do the type of work you are offering.
In the absence of the identifying documents mentioned above you should consult the official documentation for the secondary list of acceptable
combinations of identifying documents.
You must scan or photocopy all documentation, including the front cover and all the individual pages which give personal details, photograph and
signature, plus any page containing a UK Government stamp or endorsement permitting the type of employment you are offering.
You should keep a record of these documents as your legal defence against employing someone to work illegally, for which the penalty is
currently £5,000 per employee.
The following documents will no longer provide a defence against employing someone not entitled to work in the UK;
- Home Office Standard Acknowledgement Letter or Immigration Service Letter (IS96W) stating that an asylum seeker can work in the UK.
- Home office letter stating that the holder is a British citizen
- passport describing the holder as a British Dependent Territories Citizen, stating that the holder has a connection with Gibraltar
- a short birth certificate issued in the UK which does not have details of one of the holder's parents
- an Inland revenue card or certificate issued under the Construction Industry Scheme.
- a temporary National Insurance Number beginning with TN, or any number which ends with the letters from E to Z inclusive
- a driving licence issued by the Driver and Vehicle Licensing Agency
- a bill issued by a financial institution or a utility company.
Further advice;
Changes to the law on preventing illegal working: short guidance for
United Kingdom employers
Employers' Helpline on
0845 010 6677
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Q PRA123 - Change of name - A mother recently came to the surgery and asked us to change her child's name on its medical records. Is
this permissible? If a woman marries we change the name if we have seen a copy of the marriage certificate. What happens if an adult wishes to change their name for any other reason? (28/04/04)
Answer - It is perfectly legal for anyone over the age of 16 to use any
name they choose, provided there is no intent to defraud anyone by using that new name. There is no formal legal process that has to be adopted.
The name on a birth certificate, marriage certificate or decree absolute cannot generally be changed.
To obtain official documents, like a passport or driving licence, or to amend current documents into the new name, will probably need legal
evidence of the change. This may include:-
- a letter from a responsible person
- a public announcement
- a statutory declaration
- a deed poll.
It is, however, not strictly essential to see the marriage certificate before changing the name on the medical records and the new name
should simply be notified to the PPSA who will amend the records appropriately.
In the case of a name change for a child the situation is more complicated, unless the child has sufficient legal understanding to apply
to the Court personally for permission to change his or her name. It is essential that a child between the ages of 16 and 18 signs a change of name deed as evidence of consent.
When a child is born;
- Married parents usually register their child's name on the birth certificate using the father's surname, unless both agree to a different surname.
- Unmarried fathers are not obliged to register their children and have no independent right to have their name entered on the register.
- Unmarried mothers can only enter the father's name if they both agree and sign the register; they must each produce a sworn
statement, unless they have an appropriate court order.
This registered name may be changed only if the Courts decide it is in the child's best interests, which normally depends on the written consent of everyone with parental responsibility*. (This may include
the birth parents, adoptive parents, step parents or grandparents.)
Any person with parental responsibility may subsequently issue a Specific Issue Order, stating that the child's name may not be changed, although
a court may over-rule this.
Unless a change of name has been authorised, the name on the birth certificate should generally be used for all formal documentation, even
where children have been known by other names.
The medical records are identified by the NHS number. This remains unchanged throughout life, except in cases of adoption, gender
reassignment and witness protection. It allows electronic access to patient details via secure online access, which is viewed as an important key to improving data quality and improving medical care and removes
the need to rely on the name alone.
If a mother wishes to change the name on her child's medical records she should provide the surgery with proof that the name change has
been approved by the court. If this is the case the change of name should be notified to the PPSA who will amend the records appropriately.
Occasionally a person with parental responsibility will inform the practice or the PPSA of a legal objection to a change of name. In this
situation it is essential to take legal advice before making any changes.
*Parental responsibility
Someone with parental responsibility has "all the rights, duties, powers, responsibilities and authority which by law a parent has in relation to
the child and his property".
The following may have parental responsibility;
- 1. the mother of a child born in the UK
- 2. the father of a child who was married to the mother at the time of the birth,
- 3. the father of a child who subsequently marries the mother
- 4. an unmarried father who has registered the birth with the mother since 1/12/03
- 5. an unmarried father with a parental responsibility order issued by the court
- 6. an unmarried father who has registered a formal agreement with the mother.
- 7. an unmarried father who is appointed a guardian
- 8. an unmarried father who has a residency order
- 9. a step parent, if a parent with a residence order has the order varied to include the step-parent.
- 10. a grandparent who has been granted a residence order
- 11. a guardian appointed to care for a child if the parent dies.
- 12. a local authority
- 13. an adoptive parent
A natural parent's parental responsibility is generally not lost, unless the child is adopted.
A step child is considered a 'child of the family' which gives the step parent responsibility for the welfare of the child, but does not
automatically provide parental responsibility.
Further Information: (with Thanks to Malcolm Darch)
Name Change Flow Chart
Name Change Permission Slip
Related Q&A's :
DPA 56 - Changing medical records for adopted patients
DPA 77 - National Strategic Tracing Service
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Q PRA122 - Refusing to register patients from neighbouring practice - Our experience tells us that patients who are locally registered and
request to join our list without moving address are difficult to look after. Are we allowed to refuse registration on the grounds that they are already registered? At present we meet these patients before we
register them and discuss the problems they are having. If we feel that we cannot fulfil their needs we refuse to register them. Is this interview fair? (26/04/04)
Answer - Schedule 6, paragraph 17, of the new regulations sets out the
rules regarding refusal to accept new patients.
You are not obliged to accept any patient, unless the PCT has allocated them to your practice. However you must have reasonable grounds for refusal
, such as the patient living outside your practice area. You are not permitted to discriminate in the selection of patients that you are willing to accept on the basis of race, gender, social class, appearance,
disability, religion sexual orientation, medical condition or disability. Any patient that you decide to refuse must be given a written reason for
the refusal and you must keep a copy of this for inspection by the PCT should they wish to see it.
It is questionable whether the fact that they were previously registered with another practice, and therefore likely to be troublesome, would
constitute reasonable grounds for refusal. In your interview process there is also a very real possibility that you will introduce some other element of discrimination which would not be permissible.
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Q PRA121 - EU accession states and entitlement to NHS care - One of our patients has been living here legally for many years. Her mother,
who is a pensioner, lives in Slovakia and now wishes to come and live here in the UK with her daughter, as soon as possible. Sadly the mother is very ill and will require immediate access to full NHS
healthcare. Will she be entitled to this? (22/04/04)
Answer - All persons legally working in the United Kingdom, and their
family members, are entitled to immediate access to NHS services on the same terms as any other person 'ordinarily resident' in the UK. From
1 May 2004, this will apply equally to persons from the European Union accession states, Cyprus, the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Malta, Poland, Slovakia and Slovenia, who will have free
access to the UK labour market subject to a registration system.
Accession state citizens 'ordinarily resident' in the United Kingdom will be entitled to E111s or E112s for medical treatment while temporarily
visiting other member states on the same terms as any other UK resident.
Your patient's mother will be perfectly entitled to come here to live from May 1st. However, regulations (EEC) 1408/71 and 574/72 relate
specifically to NHS treatment of pensioners. It is unclear from these whether a pensioner moving to the UK would be considered ordinarily resident, and therefore entitled to full NHS care at UK expense, or
whether NHS costs would have to be paid by the person's home state.
Unfortunately 'ordinarily resident' is not clearly defined, but the Department of Health refers to a person who is "lawfully living in the
UK for a settled purpose as part of the regular order of his or her life for the time being. Anyone coming to live in this country would qualify as ordinarily resident." This does not specify employment status and
would in fact seem to include pensioners.
A dependant moving to live permanently and legally with a close relative in the UK, who was entitled to full NHS care, may be eligible for full NHS
care on that basis alone. However, this entitlement may well be restricted to the spouse or dependent children only.
Reciprocal health rules will apply to the accession states from 1st May and temporary visitors from these states will be able to access
immediately necessary treatment, under the E111 arrangements, but their home state will have to pay the bill. There will be no automatic entitlement to free treatment for pre-existing conditions unless the
home country authorises and pays for that care under the E112 arrangements.
A dependant of someone entitled to full NHS care who visits the country briefly for the purpose of obtaining free treatment would generally be
unlikely to qualify for treatment for a pre-existing medical condition, unless their home country had agreed to meet the cost. The Department of Health encourages GPs and hospitals to charge for treatment of
'health tourists'.
In view of the complexity of these issues, and the lack of clarity, we are seeking advice from the Overseas Visitors Policy Unit which deals with
issues around NHS hospital charges to overseas visitors to the UK.
Your patient would be well advised to seek written confirmation of entitlement from the Department of Heath and/or your local trust before
her mother moves to the UK as the cost of care could prove exorbitant otherwise. The Overseas Visitors Policy Unit may be contacted by telephone on 01132-545819 (secondary care) and 0113 254 5256 (primary care).
Nationals of the accession states (other than Cyprus and Malta) will be eligible for income-related benefits only if they have worked lawfully in
the UK for a continuous period of 12 months. This restriction will apply for two years and may be extended. (Those in work on a low income will be entitled to the normal work-related benefits.) This may be of
importance to your patient's mother. Your patient should also check whether her mother would receive a retirement pension in this country.
Footnote 26/04/04
The Department of Health has confirmed that a decision as to whether to provide secondary care would be up to the Trust concerned. The
definition of 'ordinarily resident' given above has been accepted by the House of Lords and does not include any reference to employment status or duration of stay.
The Department of Health has confirmed that, if an EU citizen is in receipt of incapacity benefit or a retirement pension, then his health
expenses could be covered by his home state under the E106 or E121 arrangements if he takes up residence here.
We are seeking further clarification.
Footnote 20/05/04
The DoH has confirmed that your patient's father is now legally entitled to come to live here permanently with his daughter. If he chooses to do
so he would be regarded as ordinarily resident on arrival, whether or not he is working, and would be entitled to full healthcare under the NHS.
CED
Q PRA120 - Failed asylum seekers - Is a failed asylum seeker entitled to free NHS care? (14/04/04)
Answer - Caring for dispersed asylum seekers - a Resource pack
(June 2003) sets out quite clearly that;
Primary Care
1.19 When an asylum seeker fails their claim to asylum and all appeal
processes have been exhausted, from the date their asylum claim failed, they become ineligible for routine NHS primary care treatment and GPs, PMS providers or NHS Walk In Centres should
charge the individual concerned for any such treatment provided. However, there are exceptions for emergencies or for treatment which is immediately necessary. When any person requires such treatment,
this must be provided free of charge by an NHS provider.
Hospital Treatment
1.20 When an asylum seeker fails in their claim for asylum, and all
appeal processes have been exhausted, they will become chargeable for any hospital treatment from the date their asylum claim failed, unless they have been in the UK for more than 12 months.
Immediately necessary life saving treatment should be given to failed asylum seekers who have been in the country for less than 12 months if required, even if they are unable to pay. However the charge will still
apply. If the failed asylum seeker has been in the UK for more than 12 months then, at present, the 12 months residency exemption will come into effect.
Paragraph 4 of
National Health Service (Charges to Overseas Visitors) Regulations 1989 - SI 1989 no 306 sets out the categories of patients
who are exempt from charges for specific, mainly secondary, health care services. This includes an overseas visitor, or the spouse or child of a person
(b) who has resided in the United Kingdom for the period of not less than one year immediately preceding the time when the services are provided
A number of amendments to the 1989 regulations were proposed last year and were the subject of a consultation. A Summary of outcome
in response to these proposals was published in December 2003.
One of the abuses that the proposals set out to end was free hospital care for failed asylum seekers and others with no legal right to be in the
country.
One of the questions asked in the consultation was "Should this regulation be amended to exclude any person who is in the UK without
proper authority, even if they have been resident for over 12 months?" The majority of respondent supported this proposal, although there was strong opposition from many organisations supporting
vulnerable patients. There was apparently no intention to terminate free treatment that had already been initiated, or to deny patients free treatment for communicable diseases, such as TB. The proposal was
aimed at applying charges for hospital treatment.
The National Health Service (Charges to Overseas Visitors)
(Amendment) Regulations 2004 - SI 2004 no 614 came into force on
April 1st 2004 and have amended paragraph 4 to read;
(b) who has resided lawfully in the United Kingdom for a period of not less than one year immediately preceding the time when the services
are provided unless this period of residence followed the grant of leave to enter the United Kingdom for the purpose of undergoing private medical treatment or a determination under regulation 6A.
In summary, it would seem clear that, in relation to primary care, failed asylum seekers or illegal immigrants are eligible to receive only
emergency or immediately necessary treatment. The situation in secondary care is rather more complex and is a matter for the hospital trust to determine.
If you are unsure about a patient's eligibility for care you are advised to telephone the Asylum Seeker Team at the Department of Health on 0113 2546605.
Further information:
Asylum seekers and refugees ;
Department of Health - Asylum Seekers Entitlement table Version 2 April 8th 2004 NB The information contained in this table is subject to
change, and it is the individual reader's responsibility to check that this is the most up-to-date document.
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Q PRA119 - Pensioners and NHS care - Have the regulations- regarding free NHS care of pensioners living abroad for part of the
year been changed? (14/04/04)
Answer - The National Health Service (Charges to Overseas Visitors)
(Amendment) Regulations 2004 - SI 2004 no 614 has changed the
regulations relating to charges for NHS care during long term visits by United Kingdom pensioners.
As a result there is no charge for any overseas visitor who receives health service care while resident in the UK who fulfils the following three conditions:
- is in receipt of a UK retirement pension
- resides in the UK for at least six months and in another member State for less than six months each year; and
- is not registered as a resident of another member State;
This exemption also applies to the spouse or child who lives on a permanent basis with the overseas visitor during the period of residence in the United Kingdom.
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