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Wessex LMCs Bulletin - December 2003
CONTENTS
1) Editorial - A New Hope
2) NHS Charges for Overseas Visitors
3) Who is responsible for the results of blood tests or investigations?
4) Metered dose systems
5) Food Handlers
6) Boarding Out Medicals for Children in Care
7) Probation Officers and Reports
8) Nursing Home Reports
9) Occupational Health
10) Copying letters to Patients
11) Registration of Patients with complex medical problems
12) IT issues
13) Dental Surgeons and Reports
14) Dental Prescribing
15) Christmas Opening Hours
Appendices:
Appendix 1) Guidance for the safe use of Multi-compartment Compliance Systems
Appendix 2) - Registration of new patients with complex medical problems
Appendix 3) - Pro-forma for use when Dental Surgeons approach GP's for
medical advice
1) Editorial - A New Hope
Although income levels are important they are not the only things that contribute to quality of life. Most of the queries we are getting at the
office are about the increased money that is likely to flow into GP bank accounts. I believe that this contract offers GPs something which in the long term will be much more valuable than short term financial
increase.
Practices will have to adapt to deliver the new contract. This will mean a decreased dependence on income from reactive response to illness
identified by the patient, and instead a greater practice priority to the delivery of more proactive preventive activity.
GPs will still need to do what they always do with respect to acute illness so will need to direct much of the proactive work to other
appropriately trained personnel. This will probably not to be solely to nurses.
The new contract will challenge practices to rethink their raison d'etre and require them to adapt it to the market in which they function. It is
a market, and failure to acknowledge this will result in a very unsatisfactory practice. Doctors who believe the contract represents just a way of earning more money have not understood it. It is a radical
change intended to get GPs doing what they are best at doing, and are trained for, rather than being responsible for everything.
It is intended to reduce the need for as many GPs as the present system requires, since it acknowledges that there are just not enough GPs at
present available and unless something is done there may not be sufficient numbers in the future.
GPs are going to have to adapt and understand that in a market economy the provider must provide that which the market requires. One can
draw a comparison between the present new contract and the changes in the approach of the acute trusts when fundholding began. It has been said that before fundholding, trusts offered what they had to offer and
we were grateful for it. After fundholding they noted what the practices wanted them to provide and offered to provide it. This is exactly the same as I think will happen under the new contract. The GP, in order to
run the practice effectively and profitably will have to offer what the Government is willing to pay for, rather than solely what do the GP has in the past felt most appropriate.
The role of the GP has got to be made more intellectually attractive and so once more to be an attractive career option. At the moment there is
often an enormous amount of work to be done that is often not particularly intellectually taxing. It is also the case that merely putting in a lot of hours does not equate with giving a good service.
Doctors are skilled individuals who need time and space in which to effectively use their lateral thinking abilities, in particular with regard
to the area of diagnostics. If the doctor continues to try and work from seven in the morning to seven the evening and do on call activities at
night they will become intellectually so stale that they will often fail to react to the triggers which patients offer in consultations. These are
often pointers to important health issues, but if the GP is already very tired then there will always be the temptation to fail to follow up these matters.
Accordingly doctors must now start adapting to the idea that they have sessions of consultation that are limited, and follow this with a rest
period for either external activity or alternatively doing something of a more leisurely nature which is not as intellectually demanding.
A change is as good as a rest!
The essence of the new contract is that it acknowledges this need and for the first time allows the realistic possibility of GPs adjusting the load
they carry to make it more manageable.
The macho approach of most doctors is going to make them resistant to this idea since they all believe that failing to work every hour available
means they are not pulling their weight. It is the old adage of "never mind the quality feel the width". This government without doubt has a
preference for a large volume and is not as devoted to what general practitioners will always call quality service, when this conflicts with their desire to meet as many political targets as possible.
I believe that this contract will enable a practice to deliver what the government believes is quality, i.e. more proactive and preventive
work, and yet still allow GPs to provide the essential services for which they are trained, namely and predominantly the diagnosis and treatment
of acute illness and the resolution of patient problems, in a way which will allow the GP to function for many years without the risk of burn-out.
Burn-out is something we see unfortunately much too regularly among GPs, and it would be great change for me were practices to be filled
with GPs who are keen to go to work every morning looking forward the challenges, rather than as they so often are at present, dragging themselves out of the bed so exhausted before they begin that they are
disinclined to delve into patients consultation triggers for fear of what it might release.
There is no conflict in these concepts with the PCTs since they also want to see a healthy workforce. Without it they will be unable to deliver
their responsibilities for the health of their populations. The LMC therefore is trying to work with PCTs to gain the benefits of the contract for both parties since we believe this is in the long-term
interest of both.
At this time of goodwill to all we at the LMC wish all readers "The Compliments of the Season"
Bob Button
2) NHS Charges for Overseas Visitors
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 (http://www.doh.gov.uk/overseasvisitors/nhschargesconsult.pdf)
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.
The current regulations are still in force and 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 2 - British State Pensioners living 6 months in
the UK and 6 months in EEA - is at odds with the current primary care rules that state that any person who goes to live outside the UK for 3 months or more should be removed from their GP's list.
We have now been informed that the powers of the charging regulations only apply to services provided by NHS hospitals, not services provided
by primary care providers.
The government is aware that the new proposals are at odds with current primary care rules and is discussing these issues with primary care representatives.
It is therefore probable that the proposed amendments to the regulations will not affect primary care services.
Further information on Overseas visitors - eligibility to receive free primary care is available on our web site www.lmclive.co.uk and can be accessed by searching on "overseas visitors".
CED
3) Who is responsible for the results of blood tests or investigations?
Many investigations are carried out by hospitals with copies of the results being sent to the patient's GP. Questions have been raised about
whose responsibility it is to follow up abnormal results.
The LMC has a clear view that it is primarilythe responsibility of the doctor initiating the investigation.
It is not acceptable for a doctor to initiate any investigation with the expectation that someone else will take responsibility in the event of
action being necessary, without the agreement of that person to accept the transfer of responsibility.
Frequently however a patient will return after an OPD appt and the GP will receive a copy of a result. GPs cannot just ignore any test results
carried out by the hospital because as GPs they have a duty of care to their patients. If a GP therefore receives an abnormal result; which they believe may result in harm to the patient if appropriate action is not
taken; they have a duty to act upon this.
This does not mean every test carried out by the hospital needs to be followed up by the GP, common sense must prevail, however the GP has
the responsibility to ensure that appropriate action is taken to ensure that the patient's interests are safeguarded.
4) Metered dose systems
GPs are irritated by being asked for seven-day prescriptions in respect of systems filled by pharmacists. This request is made to offset the cost
the pharmacist has for their time. The pharmacist is fully entitled to charge patients directly for the service and so the LMC advises that it should only be the most exceptional circumstances and when medical
need dictates that GPs are willing to offer a seven-day prescription.
As a result of the problems associated the systems the LMC and LPC together with the local pharmaceutical advisers in Hampshire endorse
the report that is attached to this bulletin as Annex One.
5) Food Handlers
A recent communication from the IOW closely followed a complaint I had received from a GP in Hampshire with regard to the examination
requirements for food handlers. It appears that a European Regulation if interpreted strictly seems to indicate that a general practitioner should be approached for a medical certificate relating to fitness for food
handling duties prior to employment of an individual. If a fee were payable it is something that some GPs feel perfectly happy to do. Nevertheless it is not a requirement under any part of the GMS
provisions and accordingly, if GPs feel that they do not wish to undertake this task, they may refuse. If under European Law a particular examination check for prospective food handlers is required then an
Occupational Health Department, or their own Medical Advisers can perform this examination and there is no requirement whatsoever for GPs to automatically co-operate.
6) Boarding Out Medicals for Children in Care
Somerset LMC has prepared some useful advice relating to the care or otherwise for boarding out medicals. This is a greater problem in
Somerset than in the Wessex area but might be of interest to those doctors who have concerns.
I am grateful to Somerset for allowing us to reproduce their advice.
"Boarding out Medicals" for Children in Care
Are not part of your GMS/PMS Commitment
The LMC was surprised to learn from the local office of the body that now regulates all care homes, the National Care Standards Commission
(NCSC), that there are over 100 small children's homes in Somerset. Some of these are set up to care for just one child, using staff working rotating shifts over 24 hours with as many as three carers on duty at any
one time. Little surprise, then that the cost may be over 4000 per week.
We have mentioned before our concern that young people with such high levels of need can place a considerable burden on already thinly
stretched specialist services, and other agencies have a similar view. However, a number of GPs have recently raised with us the specific matter of the "Boarding Out" medical examinations that are required by
the placing Social Services Department. Most children in these homes are placed by hard pressed local authorities in and around London or the midland cities. Under the 1989 Children Act young people in care should
really be placed within 50 miles of home, so one can but wonder why so many are ending up in Somerset. Part of the requirement laid on the relevant authority is that they should arrange for the children to be
medically examined annually and this is where the problem lies. So far as the care provider is concerned, this is just another chore, and the young people concerned for the most part want nothing to do with it - so
appointments are made and not attended, which is another half hour of GP time wasted. And just to rub salt into the wound, some Social Services Departments are notoriously slow payers, so even after the
examination has been done the fee can take many months to arrive.
To complicate matters, most of these young people can be considered "Gillick competent", and are therefore able to decide whether or not
to consent to the examination at all. We therefore suggest that when you are asked to book an appointment for a Boarding Out medical you send the following letter to the named senior officer for the home:
We understand that you have asked that .............................who is in your care should have a Boarding Out medical for the social services
department of the placing local authority.
This service is not part of the NHS services provided by GPs, and we are only able to undertake it on the following conditions:
1.The appointment will not be booked until we have received from you the relevant forms from the placing authority.
2.We need confirmation in writing from a senior officer at the home that the young person in question has consented to attend for the examination.
3.If the appointment is missed or cancelled at the last moment we will not offer another one.You will have to make other arrangements for
the examination to be carried out.
Please also note that Somerset Local Medical Committee, which represents GP practices in the county, has asked us to inform them of
any care home or organisation that regularly books appointments that are not attended so that this information can be passed on to the NCSC.
Finally, if like one GP you have been waiting 18 months to be paid by a local authority, we would be happy to advise on how to take the case to
the Small Claims Court.
7) Probation Officers and Reports
GPs are occasionally approached by probation officers, for reports in connection with proceedings at court. Such a report is not one that the
GP is required to provide under their terms of service. If the GP therefore agrees to provide one they do so as a private matter between them and the probation service.
Should the GPs be approached by a person subject to a community service order or probation report for some form of certification
indicating their inability to comply with the terms of the probation or community service, the GP must be very careful not to certify any matters about which they do not have personal knowledge. These
certificates are again a private matter and are not required as part of your Terms of Service.
8) Nursing Home Reports
Recently GPs have increasingly been approached by he seeking their opinion of the standards of care provided by nursing homes and in some
cases residential homes. These requests do not form part of the GP's Terms of Service and accordingly should the GP wish to provide such a report they are at liberty to charge a fee.
Many GPs do not wish to become involved in such reports and they are free in these circumstances to not render a report. This system is
however quite useful and on the occasions where a if GP has legitimate concerns to bring to the attention of the organisation investigating this may well be found then to be something the GP would be willing to
provide without necessarily asking for a fee.
9) Occupational Health
All PCTs should now have in place a comprehensive Occupational Health Service which may be used by GPs and their staff.
This service should include
- general occupational health advice,
- pre-employment questionnaires
- medicals if required
- specific help with issues relating to individuals who have work related health needs.
If you or your practice, wish to use this service for occupational health advice then please contact your PCT to find out how you access this.
In the unlikely event of you not being able to access any help please contact the LMC.
10) Copying letters to Patients
In response to a recent enquiry, the DOH has informed one of our local practices that GPs will be obliged to copy all referral letters to the
patient, starting in April 2004.
We are not aware of any new legal requirement to copy letters routinely.
We have asked for urgent official clarification and guidance.
The NHS Plan contained the original proposal that all letters between clinicians about an individual patient's care should 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 asked that the full cost should be calculated and met.
- The BMA expressed the preference that copies of letters should only be made available to patients on request and not as a matter of routine.
- There have been a few pilot schemes, but we are not aware of any official evaluation of the workforce implications.
- We are not aware of any evaluation of the cost to practices.
- We have no knowledge of any funding arrangements.
- Practices have received no practical information or guidance on achieving this objective.
Wessex LMCs would be very concerned if this proposal were to be implemented at exactly the same time as the new GMS contract in
view of the considerable additional demands upon staff.
We will provide full information on our web site as soon as it is available to us.
CED
11) Registration of Patients with complex medical problems
Many GPs have recently expressed concern over Social Services placing patients with complex needs in nursing homes. Frequently, information
necessary for good medical care is not made available to GPs.
It is also the case that discharge summaries from hospitals can be gravely deficient, with a long delay occurring before vital information is provided.
Annex Two contains some suggestions for GPs to help them deal with this difficult situation.
12) IT issues
Read Codes required for the nGMS Contract
To deliver the Quality and Outcomes framework it is essential that correct Read Codes are used. A number of new Read Codes are now
available including exemption codes.
A full listing of codes are available at:
http://www.bma.org.uk/ap.nsf/Content/newreadcodes
IT funding has caused significant problems during the year and a significant amount of frustration. Below is an update.
Maintenance
Maintenance is defined as the routine support that is normally provided under annual contracts by the GP clinical system suppliers or third parties.
PCTs have been given additional funding to meet this commitment to practices. Invoices that have not yet been reimbursed for computer
maintenance need to be submitted to the PCT in the near future.
Minor upgrades
Minor upgrades are defined as those required to ensure that existing practice 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.
It has been agreed with the Department of Health that these will be funded 100% this financial year.
Legacy systems
This refers to all practice based clinical systems that are not RFA 99 compliant. This means practice clinical systems that are no longer being
developed or supported e.g. Torex system 5. If you are unsure if yours is a Legacy System ask you software supplier.
All practices with Legacy Systems should be aware that these would no longer be supported and maintained next year. Practices should
therefore be upgrading to a compliant clinical system. This upgrade needs to take place with the agreement of the PCT and this will be funded 100% by the PCT.
Major practice upgrades
Practices need to develop a plan for IT development, which will include upgrading PCs, printers and software. There would appear to be little
funding available this year but negotiations are progressing at a national level to secure this for next year.
Education and training
PCTs are now responsible for funding 100% of education and training when related to IT. Work is on going to clarify where the funding is
coming from and how practices access this.
Choice
Some GPs have expressed concern that their choice of clinical software may be restricted in the future and that PCTs will be able to dictate
what software they use.
Computing in general practice has become expensive, a major upgrade could cost a practice 50-60,000. It is therefore no longer acceptable to
have between 25-50% funded through GMS and the rest to be funded by the practice with the vague hope that some of this will be reflected in the expense element of the annual pay award.
The GPC has secured agreement for 100% funding for all computer development. They have also secured the principal of choice. PCTs are
not and will not be able to tell you what system to use.
The funding for IT come from the PCT unified budgets, and therefore this will be a cost pressure for the PCTs as will many others things.
Practices will have to justify major expense in the future in a way that was often not carried out before.
Any difficulties in this area, practices should seek the help of the LMC.
Central or remote servers
Many practices have a clinical server in their practice. This gives them control over upgrades, back-ups and access to information. The draw
back is the work involved in maintaining the server.
A choice practices are being given is to have a server place with a third party, who maintain this perform back-ups and upgrade any software as
required. Benefits are obvious but some control is lost by the practice.
In the past the LMC has had major reservations about central or remote servers especially if the are hosted within a PCT.
Many of the concerns have been resolved. The LMC would support practice who wished to explore this but would suggest that they read the following guidance first:
http://www.bma.org.uk/ap.nsf/Content/remotelyheldrecords
If the PCT is host the server there needs to be strict agreements about access to information.
Other useful documents:
Consulting in the modern world
Good practice guidelines for paperless practices
13) Dental Surgeons and Reports
Dental Surgeons sometimes find themselves facing medical conditions which may influence the treatment they are proposing to give. In this
event they will approach the GPs for medical advice. There must be a commonsense limit between a complete medical report and a telephone conversation which is nowhere recorded. It is not feasible for doctors to
provide the former, since it is time-consuming and very largely unnecessary, and it is probably not reasonable to expect the GDP to rely on a brief telephone conversation as sufficient support or advice.
Accordingly, in North East Hampshire a pro-forma has been produced which the LMC has approved which is recommended for use when GDPs
approach GPs for medical advice concerning a patient. A copy is attached as Annex Three to this Bulletin.
14) Dental Prescribing
There has been some confusion recently when GPs have been asked by dental practitioners to prescribe drugs for patients who present with a
dental condition. There is a clear dental formulary which specifies drugs which are prescribable by dental surgeons and on occasions the dentist may find indications that suggest that an alternative remedy would be
more appropriate, but which they haven't the knowledge to personally prescribe. In this case they should refer the patient to the GP for the necessary prescription. A list of those medications which can be
prescribed by dentists is to be found on page 519 of the Drug Tariff and GPs are invited to take note of these when approached by dental surgeons for prescriptions.
Should the medication be on the list that GDPs can prescribe the matter should be dealt with by them. However, if the drug requested is not on
this list GPs are invited to consider prescribing it, on the recommendation of the GPD.
15) Christmas Opening Hours
The office will close at midday on Christmas Eve and will reopen on Monday 29th December. We will also be closed on New Years Day and Friday 2nd January.
All the staff at the LMC would like to take this opportunity to wish you a Merry Christmas and a Happy New Year.
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