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Wessex LMCs Bulletin - June 2002
CONTENTS
1) Editorial
2) GP Appraisals
3) Electronic Records in Primary Care
4) Locum Checks
5) Annual Leave when away sick
6) NHSnet, Global Crossing and modems
7) Web News
8) Data Sharing; the future
9) Data Sharing; checklist
Attachments:
10) Letter to Headteachers
11) Examination Certificates
12) Premises Advice to GPs
13) Private Works Certificates of Fitness
14) Supplementary Lists
1) Editorial
Much has been written already about this contract and every doctor should have received a copy of the GPC report.
This consists of:
- an executive summary followed by what may be termed the GPC's interpretation of what the contract could mean
- details of the letter by Mike Farrar who led the NHS Confederation negotiating team indicating what he believes has been agreed.
I would ask GPs to read this document extremely carefully, particularly the Mike Farrar summary of contract decisions. There are possible
differences of interpretation in the actual wording which Mike Farrar refers to, which may not accord completely with the GPC's hopes for what these words could mean. The vital point is that, as has been
frequently said in BMA circles, "words mean, what words say".
It is vital that any contract negotiated should be clearly understood and not liable to misapprehensions by either side. At the moment I am not
satisfied that both sides are firmly convinced that the words are being used sufficiently exactly to allow no possible misinterpretations.
This document is going to be further discussed at meetings around the country where the negotiators are offering themselves to GPs as
sacrificial lambs to be interrogated on the detail. It is wise to remember though that their interpretations are just that - their interpretations.
After that, the profession is to be offered the opportunity to vote on whether the principles of this new contract have achieved sufficient of
the profession's aspirations to merit going forward for pricing.
A lot of discussion took place on whether the pricing should have been before the initial ballot or, as is the plan, a separate ballot be held to
approve the pricing if the initial contract proposals are acceptable.
There is a grave risk that in the event of the profession agreeing the principles of the contract and then rejecting the contract because it is
not priced at a level they consider acceptable, that the press and the spin doctors will get to work indicating that doctors have no interest in
their patients but only care about their wallets. Kenneth Clarke lives!
We must not forget that although this contract will be operated by people who are voting on it now, it is going to have a great effect on
those people who form the next generation of GPs in this country and will therefore, be the ones most affected. To some extent they do not have a voice in this process and this is unfortunate but unavoidable.
We, as the existing profession are aware of all the "weasel ways" in which the government can seek to obtain as much as possible for as
little as possible, and must try very hard to get the contract as clearly expressed as we can so as to protect our interests.
The great lack I see in this contract is that there is no real attempt to manage demand. We all know day to day just how demanding patients
can be, egged on by a government which seems to consider imposing yet another task on general practice to be as routine as taking in the morning milk. The best we could obtain at the national meeting where
the contract negotiations were launched (from Simon Fradd) was a suggestion that increased education in schools would lead to the public asking less of its GPs. I was not impressed by this response!
There are positive things from this document which must not be overlooked. They include:
- reflecting the quality of general practice more appropriately, in terms of remuneration.
- doctors utilising their skills in a way which is not demeaning,
- the possibility of many of the tasks which presently lie at the feet of general practice being removed and done by people with a less
intensive training who are perfectly capable of providing the routine monitoring services which are an essential part of prevention nowadays.
It is unfortunate the document says nothing whatsoever about 2º care however. Nor does it give the priority which the public at large want to
treatment for illnesses when they occur. This government, like many others, has chosen to misinterpret the saying "prevention is better than cure".
When a person is suffering from an acute illness which could be life threatening the last thing in their minds is prevention. Although
prevention has a place we must fight hard to maintain the prime function of general practice which must be to treat patients who are ill, in as efficient a way as possible, and with as much humanity as we can.
Only by doing this will we retain the respect of the public at large.
The GP should on every occasion speak up on the need for enhancement of the treatment services. Since general practice is so dependent upon
the 2º care sector to provide expert therapies it is a matter of regret there is no mention of the interaction between 1º and 2º care in this document.
The only concession to this is the proposal of a "GP with special interests". It is difficult to see however; with demand not being
managed or reduced directly; how a GP is going to find that extra time for performing these specialised functions.
One of the great achievements held out for this proposed new contract is the possibility of avoiding an OOH commitment. It has long been the
case that people in other professions such as airline pilots are required to have adequate time for rest and recuperation in order to perform at
their best. Why this is not considered the case for GPs has long amazed me.
A concept of the PCOs being responsible for OOH care is one which appeals to me enormously. I am hoping it will have the effect of
persuading patients that the care they have OOH will be severely restricted and that they should limit their calls on GP's time to emergencies only.
This will not be achieved by an inadequate number of doctors being available to treat every patient who wishes advice during the night or
weekends. This advice will have to be provided by people who are not medically qualified, e.g. through NHS Direct advice services and perhaps even walk-in centres. This is the real revolution, and the only point at
which the contract addresses the question of demand. The patient must realise that medical care from GPs is basically utilising a very scarce and
very skilled resource and that to use it at any time of the day or night is inevitably going to devalue the services that can be provided.
I see in my job GPs who are finding the whole situation too much of a burden to bear any longer. They are leaving the profession, often long
before their professional career needs to be over. The net effect of this is that more strain and stress is put upon the GPs who do remain and the system is rapidly getting to the meltdown stage. I am yet to be
convinced the government has fully understood the severity of the crisis in general practice, and I can only hope that the contract proposed will go some way towards re-enthusing doctors about remaining in the
profession and serving their patients to the best of their ability.
The contract proposal is not perfect, there are many points in which it fails to meet the profession's aspirations. Nevertheless, it is at present
the only offer on the table. If the profession rejects these proposals then it is vital that negotiators feel that this is not be a personal rejection of them but rather an indication that they have not yet
finished a job which they have at least tried hard to begin.
It is vital the profession considers very carefully, in detail what the proposals are and how they would affect them and then cast their vote.
The worst possible outcome would be an unrepresentative vote which didn't give a clear indication of the profession's wishes.
RB
2) GP Appraisals
There has been wide publicity about the change to the Terms of Service which has now been enacted which requires all GPs to participate in a
regular appraisal process.
Unfortunately the amount of money available to support this process and meet the government's agreement with the negotiators that it should be
at no cost to the doctor concerned, and also take place during protected time with adequate time for preparation, as well as development funding, has not yet been achieved.
The indication was given in the allocations issued to Health Authorities under an HSC in late 2001 HSC(2001/024) that they would be expected
to find from their unified budget the funding necessary to support doctors who are undergoing appraisal, including full locum costs. It also specified that money should be available from the PCTs to support any
development needs which are identified.
This is a very "weasel" way of approaching it by the government. The PCTs have by and large been given less than adequate funding to provide
all the services which the government seems to expect and often during the year the government even adds to the services. The net effect is that the PCTs have been placed in the unenviable position of
determining whether or not to provide the funding to allow GPs to comply with their Terms of Service or to provide funding for the active clinical care of patients in urgent need of it.
A lot of PCTs have taken the view that their priorities must lie with the patient and accordingly have not made money available to support the
appraisal process.
It is quite clear from our negotiators that the government has undertaken that no action will be taken against doctors for breach of Terms of
Service with regard to failing to complete an appraisal, unless adequate funding has been made available by the PCTs.
It is open to the individual doctor to determine whether or not they wish to have a locum supplied by the PCT, or whether they wish to
have money to provide their own locums. What is not arguable is whether or not such support must be forthcoming, either in the form of the locum, or in the form of the finance.
A new Statutory Instrument has been published now, which indicates that the PCTs may employ practitioners to act as locums for GPs and in
doing this they could therefore provide the support needed for individual practitioners to undergo appraisal.
Appraisal is an educational process which can be beneficial both to the Health Service and to the individual GP. Unfortunately, trying to do it on
the cheap, and trying to hurry through it will actually result in the devaluation of the whole process. It is strongly to be recommended that GPs make sure they get adequate support from their PCTs before they
agree to undergo the government procedures on appraisal.
In Dorset a pragmatic solution has been arrived at whereby doctors who wish to continue to involve themselves in the basically voluntary
appraisal process existing in that area, will be supported to some degree by the PCTs in financial terms. Should the doctor concerned feel that the amount of money is not sufficient, then it will be up to them to
renegotiate with the PCT, or indicate clearly what their needs are, before they undergo the process.
The Dorset LMC will be discussing this matter and will reach a final decision before their next main meeting in July.
RB
3) Electronic Records in Primary Care
This is a reminder to everyone that although it is now possible to keep your records entirely in electronic form on a computer, that many
practices who are doing this appear not to have obtained the necessary approval from the Health Authority.
The dispensation in the Regulations allowing you to keep electronic records is dependent upon you meeting certain quality criteria. These
have been agreed between the HAs and the LMC and must be adhered to in order for you to discontinue the necessity for keeping records on paper as well.
It is worth noting here that once a patient leaves your list, the records you have must be passed on in full to the HA for onward transmission to
the new GP. This means that it has to be done in paper form, and regretfully a printout will have to be produced to send to the new GP.
It is to be hoped that the full benefits of electronic record keeping will be attained soon which would result in the ability to transfer records
electronically between practices.
RB
4) Locum Checks
The effects of the changes in the Law are now in operation. This means that all people who offer services in support of general practice who are
not themselves principals and this includes GP Registrars, locums, assistants, retainers and medical staff providing on call services for commercial agencies, must all now be on a Supplementary Health
Authority List.
Unfortunately, it appears that some of these people have not taken advantage of the three month's grace to get themselves on a list and are therefore from the 1st June going to be
acting illegally should they offer to provide medical services in support of general practitioners.
My real concern is that GPs may not realise that they will be employing unqualified personnel for the provision of NHS services. I think it could
well call into question the degree to which they are indemnified by the defence societies against the actions that these people may take.
I would strongly advise practices, at least for the next six months, to check on every occasion they use a locum, that this person is indeed
on a relevant Supplementary List of either their own Health Authority, or a neighbouring one.
I cannot stress too greatly the importance of GPs only using doctors as locums or assistants who are on a Supplementary List.
For those in Hampshire the correct check would be initially made via Coitbury House and in Dorset via the Health Authority Headquarters and
in Wiltshire for the moment at least I believe enquiries should be directed to the old Health Authority in Devizes.
Should doctors discover there are locums who are offering their services, who are not on a Supplementary List, I should be grateful if
the LMC office could be informed.
RB
5) Annual Leave when away sick
It has been held in a recent test case that employees continue to accrue entitlement to paid holiday whilst on long term sick leave. Thus even
when their contractual sick pay and SSP entitlements have run out, they will be entitled at least to 4 weeks paid holiday per annum during any long term sick leave.
This decision means that it may no longer be practical for employers to keep employees on long term sickness absence without pay, since they
will be liable to pay 4 weeks holiday salary a year whilst the workers remain as employees.
A bigger problem for GPs is that most practice agreements have a clause indicating the partners who are absent for a period of 12 months are
required to relinquish their partnership.
What is not always present is an indication that the leave entitlement which accrues during that 12 months is to be included as part of that 12
months. This means that if a doctor completes 12 months sickness absence and resigns from the partnership, they would still be entitled to their 6 weeks of paid annual leave, in addition to the 12 months sickness
absence. It is strongly advised that this matter is dealt with in the practice agreement and if you have any problems with it, then it would be best to contact either the LMC office, or alternatively a BMA
member, the BMA office for detailed advice about how it should be dealt with.
RB
6) NHSnet, Global Crossing and modems
Once practices have established that all their links, i.e. Registration, IOS Pathology, have moved to NHSnet, they will have no further need for
their Global Crossing (GC) mailbox.
When a practice's clinical system supplier assures them, preferably in writing, that their dial-in software support has been transferred to
NHSnet, practices should disconnect their modems from the telephone system, as required under the Code of Connection for NHSnet. The telephone line can then be used for other purposes or its costs saved by
the practices.
GMS reimbursement will cease three months after the need for the GC mailbox ceases.
Three months notice is required to terminate the contract with Global Crossing. The necessary form should have been sent to all practices.
Practices are advised NOT to rely upon giving this notice by email.
It has been reported that GC is proving resistant to receiving these notices and this is being monitored nationally.
Practices are therefore advised to keep detailed records of the notice given and the relevant dates, with photocopies of all documentation.
CD
7) Web News
www.lmclive.co.uk
2000 hits a week
220 web pages - a total of 330,000 words - 15 megabytes of disk space
LMC LIVE is fast becoming a major source of information for all primary
care staff.
New Q&A section
Even the most experienced doctors come up against non-clinical questions that they can't answer.
Adding these to a Q&A section on the web means that we are building a useful database of answers that are readily accessible when we are not
available to answer your questions personally or when the office is closed.
Newly added Q & As are published in NEW ITEMS under NEW Q & As, as
well as being included in the Q & A section under various index category links.
The Q & A section can be searched independently, but may also be searched together with the entire web site.
We hope you will find this a useful addition to the web site.
Please let us know if you have any questions and please let us know if
we get any of the answers wrong!
CD
And a further word from me on the subject!
In particular I would draw your attention to the fact that all the Bulletins, which have been sent out in paper form, have also been
recorded in a separate section on the website and can be easily searched for any particular item on which advice is sought by using the search engine dedicated to it.
I know that the Bulletin is popular and is often stored and filed for the purposes of future reference, but with the best will in the world
occasionally copies go astray. This gives you an opportunity to check up on any back-issue without the necessity of keeping a paper copy.
As always we are willing to listen to any comments regarding the LMC website and improvements are constantly being made.
RB
8) Data Sharing; the Future
The legality of current data sharing practice in primary care is very complex. Current practice is governed by the Data Protection Act,
Human Rights Act, the Common Law on Confidentiality, the Freedom of Information Act, the Caldicott regulations, professional ethics etc.
The Health and Social Care Act paved the way for the Secretary of State to introduce new legislation requiring the disclosure of confidential data,
without consent if necessary.
A Draft Statutory Instrument,
The Health Service (Control of Patient information) Regulations 2002 was published in April 2002. The
government hopes to implement this by June 2002.
The consultation document Privacy and data-sharing: the way forward for public services
was also published in April and sets out the extended government vision for the future of data-sharing in the public services.
In many ways these documents are welcome;
- they clarify the current legal situation and signpost future developments.
- they establish a basis for proper protocols to allow improved data flows and enhanced security, now and in the future.
- they will facilitate the proper functioning of the Cancer Registries and the PHLS and allow for proper medical research to continue in a controlled way.
- they allow PCTs to manage primary care more effectively
- they are clearly essential for implementation of the government's modernising agenda for the NHS and indeed all public services
- they allow for improved monitoring of quality standards in primary and are probably essential if the New Primary Care Contract is to be implemented.
So why the silence?
The silence surrounding the publication of these important documents was deafening!
A few doctors and patients have been alerted through occasional news items in the national press such as;
"New Snooper's charter sparks privacy outcry" - Times 12.04/02
"Milburn demands patients' case notes from doctors" - Sunday Times 5/5/02.
But, there has been no serious attempt to inform the public or the medical profession about these far-reaching changes.
The government's attitude to informed consent, transparency and openness seems to have been abandoned.
Did the government try to bury these documents in the New Contract and the Budget announcement of increased NHS funding?
The future of the doctor/patient relationship and medical confidentiality in the NHS is changing.
- informed consent will no longer apply to many aspects of data sharing
- the strict confidentiality of the medical consultation will disappear
- some people may be afraid to consult an NHS doctor in the future for fear of intrusion into their privacy.
- will a patient be obliged to pay to see a doctor outside the NHS to guarantee the right to privacy?
- if patients withhold information to preserve confidentiality this will impair patient-care.
Public and professional information and engagement in an informed debate are minimal requirements before these changes are implemented.
A number of important questions must be addressed with regard to the changes;
- What is the objective?
- What are the benefits?
- What kind of data-sharing is proposed and what are the alternatives?
- What are the costs and risks of data-sharing?
- How large are the benefits in relation to the risks?
- What is being done to maximise the benefits and minimise the costs and risks?
Let us know what you think.
More important, respond to the public consultation on Privacy and data-sharing: the way forward for the public services by 12th July 2002 to:
Paul Henery, Freedom of Information & Data Protection Division,
Lord Chancellor's Department, Room 912,
50 Queen Anne's Gate, LONDON SW1H 9AT.
Fax: 020 7273 2684
E-mail: foiu@homeoffice.gsi.gov.uk
Your views matter
CD
9) Data Sharing; Checklist
Data sharing arrangements are set to change in the very near future. However, for the present all primary care staff should be aware of the
legal and ethical framework that is currently in place. Information on all aspects of data protection, consent and confidentiality issues is regularly updated on www.lmclive.co.uk. Sharing data may place you at risk of
breaching the law and/or your professional code of conduct.
We hope that the attached checklist will prove a useful reminder.
Legal obligation
- Is there a legal obligation to share this data without consent and if so have I limited it to the minimum data possible to serve the purpose?
Patient information
- Would my patients be aware how their data may be processed?
- Would my patients know who is processing their data?
- Would my patients know why their data is being processed?
- Have I made a reasonable attempt to inform my patients of the ways in which their data will be held and processed?
- Have I provided the name of the data controller who can provide more information if they wish to know more?
- Have I given them an opportunity to raise any objections?
- Have I explained their right to access and correct the data?
Duty of confidentiality
- Are all individuals who have access to identifiable medical data bound by a strict professional and contractual duty of confidentiality?
- If non-professionals have access to medical data are they bound by a strict contractual duty of confidentiality?
Anonymisation
- Has the data been anonymised, or anonymised and aggregated, wherever possible?
Harm
- Is disclosure likely to cause serious harm to the patient's health or well-being?
- Am I breaching a third party confidence (excluding a medical professional caring for the patient)?
Consent (with very few exceptions consent is always required)
- Have I sought consent wherever possible?
- Has the patient expressed an objection to sharing this data? (Any objection must be respected, even after death.)
- If consent is not possible is it essential to share patient-identifiable data in the best interests of the patient's health and well being?
- If consent is not possible is it overwhelmingly in the public interest to share patient-identifiable data?
- If consent is not possible have I informed or do I intend to inform the patient as soon as possible if I have disclosed identifiable data?
Damage limitation (to be applied to all disclosures)
- Have I restricted the data I intend to disclose to the minimum that would serve the intended purpose?
- Is the data to be disclosed for a clearly identified and limited purpose?
- Is the data to be disclosed to a clearly identified individual(s)
Staff awareness
- Are all members of staff who handle this data aware of the need to ensure that data sharing is always checked before disclosure?
Personal considerations
- Would I object to my own most personal medical data being shared in this way?
- Would I be prepared to defend this disclosure in a court of law or with the GMC?
If in doubt seek advice from your LMC and/or defence organisation before disclosure
CD
10) Letter to Headteachers
Attached to this Bulletin (Attachment No. 1) is a copy of a letter which has been produced under the letterhead of the Secretariat which may be duplicated and used by individual practitioners if they wish to
indicate the fact that they are not required to issue certification to schools for pupils' absences.
While appreciating that teachers sometimes benefit very greatly from the opinion of the doctor regarding the validity of the child's absence
due to illness, nevertheless it is not part of the GP's Terms of Service and in some cases the requests are being made in a way which significantly increases GP's workloads. They may well wish to apply their
own judgement as to whether in a particular circumstance it is appropriate to give any indication of the medical reasons for absence from school, or whether it should be a matter for the parents to
indicate to the school the reason for the child's absence.
I would particularly draw your attention to the fact that no doctor under any circumstances is in a position to certify anything retrospectively,
unless they have been in attendance during the illness and are satisfied that they can personally certify the facts which they are noting. The only exception to this is where they are in possession of a document
produced by another doctor who was in that situation and whose opinion they can accept and onwardly certify.
11) Examination Certificates Attachment No. 2
I recently had occasion to write to headteachers concerning the frequent requests made of GPs to provide sickness certification in
respect of pupils who for medical reasons are unable to sit a particular examination. The intention of these certificates is for them to be passed to the relevant Board, who may make due allowance in the marks
allocated to the given candidate.
In a helpful reply I received from one headmaster, he pointed out that such certification was not of any use whatsoever unless the pupil had at
least completed some 35% of the examination. Unless that minimum had been reached no amount of certification was going to affect the Board and the pupil will not be given an examination mark.
It is vital that before doctors waste their time certifying that they do make sure that there is clear undertaking given by someone who is in a
position to know, that the pupil is within this parameter and therefore will be able to benefit from any certification the doctor feels appropriate to issue. Perhaps the teacher could issue a certificate to
this effect.
I draw your attention again to the point I have made in the paragraph above, that retrospective certification is only possible where the doctor
is personally in possession of the information which he/she certifies.
RB
12) Premises Advice to GP's
This guidance paper (Attachment No. 3) has been written by Alice Fisher and highlights some of the main points you may need to consider when thinking of surgery improvements or changes.
AF
13) Private Works Certificates of Fitness
I am grateful to Drs Corbin and Partners of Havant Hampshire for their agreement to let us duplicate a letter on fitness certification which they
have written for use in their area. I have their permission to provide this as a template which can be used by other practices, if they find such a handout to be relevant in their practice. (Attachment No. 4)
14) Supplementary Lists
Attached to this Bulletin (Attachment No. 5) is a form which may be of use to practices who are seeking references for people who are due to be employed by them as locums.
You will be aware that all people who are offering locum services now have to be on a Supplementary List maintained by the Health Authority.
As part of this process Dr Carole Linnard of Dorset produced a document which covers a lot of the points which need to be checked by a GP, before employing a locum. This has been adopted by the Health
Authority in that area as a routine reference form to be utilised when people are applying for Supplementary Lists. The LMC is fully supportive of this.
Dr Linnard has given permission for this form to be adapted for use in Wessex and I encourage doctors to bear in mind that unless they are
already aware of the clinical abilities of any doctor to be employed as a locum, or unless there has been a recent reference to which they have access, it is always wise to seek references in their own interests to
ensure that the person concerned is capable of the functions of a GP locum and is clinically reliable. All the actions taken by the locum will be
the responsibility of the prinicpal who employs them and it is wise to be sure that the person you are putting in this very responsible position, is worthy of that trust.
This form has also been produced and published on the website from which it may be downloaded as a "pdf" file if required.
Key to Contributors
RB = Dr Bob Button, Chief Executive
CD = Dr Christine Dewbury, Medical Secretary
AF = Alice Fisher, Executive Manager
JS = Jenny Steiner, General Manager
Bulletin - 01/06/02
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