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Wessex LMCs Bulletin - May 2004
CONTENTS
1) Editorial - LMCs "The Future"
2) LMC LIVE
3) Scam
4) Clinical Decision Making
5) Charges for NHS care for overseas visitors
6) Advice on completion of cremation forms
7) European Working Time Directive
8) The future of general practice IT
9) Violent Patients
10) Charges for Use of Rooms in practices by PCT Staff
11) Hepatitis 'B'
12) Surgery Opening Hours
13) Wessex Small Practices Association (WESPA)
14) Child protection
15) E-Mail Addresses
Attachment:
Attachment 1) - Summary of Lord Laming's recommendations for healthcare
1) Editorial - LMCs "The Future"
As I told you in a recent letter, Dr Nigel Watson from Southampton has now become Joint Chief Executive with me. This pairing will I hope
enable the LMC to be able to move from strength to strength, since I must admit of recent years my strength has been noticeably waning!
We have done nothing it seems in the last few months but concentrate on the New Contract and I do not expect this to change very much in
the immediate future. To say we are busy is an understatement. One of the things we have to remember however is that GPs are now only part of the system of primary care and their integral monopoly position has
been eroded for ever.
What therefore will be the LMC be doing? Well, under the New Contract arrangements, the words 'Local Medical Committee' occur quite
frequently. Essentially it is legally 'recognised' under the Act, and as such still represents general practice and the views of general practice.
It is also laid down that the LMC must be consulted and be part of an assessment panel whenever a practice is appealing against closure of list,
or indeed wishes to opt out of any of its activities. It must be consulted when there is any question of excessive prescribing raised by a PCT, either directly or through its advisers. It must be consulted about the
appraisal system to be put in place by the PCT and also with regard to the selection and identity of those people who are proposed by the PCT
as appraisers of their colleagues. I note this is not always the case at the present time with PCTs and we shall be drawing their attention to it so
that they can comply with the Contract which is now in place.
The LMC is frequently referred to in the Contract sections on OOH, particularly with regard to the organisations that may be approved as
OOH providers. PCTs are specifically unable to refuse to grant approval to these without first consulting the LMC for the area. They may not withdraw approval from an OOH provider, unless they first consult the
LMC. We hear an awful lot about the way in which all these things are going to be managed without the involvement of GPs, but in practical terms PCTs are finding, as the government has already acknowledged,
that to run a medical service without GPs is like 'going to sea without a boat'. You can certainly do it, but 'drowning' is very likely after only a
short time! This is the reason that the LMC has its integral position in the provision of OOH care, since it alone can reflect the GPs' opinion as to
whether or not a successor system to that which they have operated almost alone for many years, is likely to be safe and successful.
At the Annual Review visit the LMC may, at the request of either the PCT or the Contractor, be present during the Review procedures. It is
also allowable for the LMC to nominate someone to act for them in this respect. This is a very important point, since it will give the opportunity for active GPs to comment sensibly about the criteria that are being
applied during the Annual Review. The LMC traditionally had a role in practice inspection and in verifying whether or not a particular surgery premises was suitable for its role. This is still the case under the New
Contract, and the GP will once more be protected by the presence of an LMC officer at any inspection which may consider removing the premises from the rent and rates reimbursement arrangements.
Contract disputes, which are almost inevitable, are going to be areas that could lead to an awful lot of bad feeling. Since both the practice
concerned and the PCT are likely to carry on in the area for a long while, it is very important that these disputes are settled as amicably and as quickly as possible. To this extent the LMC can provide an active
and assisting role. The PCT is not allowed to end a Contract or impose contract sanctions on any GP, unless the LMC has been first involved. The intention of this is to try and get compromise and conciliation in
place as soon as possible and to avoid the tendency that managers sometimes have, to suspend neurosurgeons over a 'bowl of soup'. My experience of difficulties between PCTs and practices has been, like all
the other problems the LMC gets involved in, that communication is 99% of the problem. If the LMC can facilitate this communication to the benefit of both sides, it will indeed be providing a very useful service
to all.
In the Regulations, Paragraph 27 very clearly lays down a Complaints Mediation Role for the LMC as the LMC can formally consider complaints
by any doctor about any other doctor. The LMC still retains its right, previously enshrined in Regulation 25 of the old GMS Regulations, now under Regulation Paragraph 27 to arrange medicals at the request of
either a Contractor practice or the PCT, to determine whether or not the individual doctor is fit to carry out the role of a general practitioner. The interesting thing here is that the LMC's role is
extended to cover more than just partners in the practice and now deals with what used to be known as 'Non- Principals' as well. Now that everyone has become a 'Performer' it is important that all doctors are
treated equally.
So what will the LMC's role be in the future? Well I think the local importance of the LMC will be unchanged. It is an organisation that has
increasingly found itself adapting to both the GPs and management structures, and supplies a source of expertise when guidance is needed. It is obvious from this Contract and from the government's strategic
intention, that local implementation is vital and local negotiation is part of this. The LMC is increasingly finding itself placed in a position of negotiating on behalf of the GPs, whether for a locally enhanced
service, or to modify an approach with regard to premises or improvement grants etc. I see this role becoming more important in the future as practices come to realise that the expertise the LMC has could
be brought to bear on their behalf.
One of the most satisfying parts of the LMC's role in the past has been the area of pastoral care and I see this as being more not less important
in the future. Not only am I anticipating more disputes between partners by virtue of the manner in which the New Contract allows the victimisation of one partner by another. Also we must remember that
the stress of following a target ridden method of practising medicine is likely to result in ill-health becoming even more marked in GPs than we have seen in the past. One of the roles the LMC has been to provide a
listening ear as what one might term a 'doctors doctor', and to perform this role in as confidential a way as it is possible. The LMC has also been
integral in arranging the medical care for doctors in such a way that the doctor concerned is offered the same degree of confidentiality and consideration as any other patient. This usually means that they are
referred out of area to a consultant with whom they do not have professional relations normally, and often under a pseudonym so that track back is not possible, as to the details of their illness.
There is no doubt that partnership problems, whether in the share of profit, the way in which decisions are taken, the time to parity or the
general social intercourse between them, will form a large and increasing part of the LMC's activities. I do not therefore see the LMC in any way as an antediluvian or dinosaur organisation, but rather as I have
said in a lecture I have frequently given, we are a 'phoenix rising from the ashes of the last NHS re-organisation' and we continue to provide the 'memory' of the NHS by supporting the GP in their prime position as
the lynchpin of healthcare provision in this country.
Bob Button
2) LMC LIVE
LMC LIVE was introduced in 2000 and has grown like Topsy!
We now register around 10,000 'hits' a month.
Calls to the office can often be answered by reference to the web site & calls prefaced by "We couldn't find anything on the web site"
generally trigger a new inclusion for future reference!
We don't need to remind any of you how much general practice is changing!
In the absence of a dedicated web team we can't hope to change the website at that pace.
However, all items on LMC LIVE are dated.
If you are not sure whether they are still relevant please contact us for further information.
If you find an item that's out of data and confusing let us know.
To reflect recent changes, without losing old data that is still useful, we are introducing
NEW PINK PAGES & PINK LINKS.
After April 2004 all Guidance, Q&As and Bulletins will appear on the new pink pages.
They will be linked from the existing blue pages by new pink links.
Old and new pages will still work together seamlessly!
You will still be able to search the entire web site!
If it's new, it won't be blue, it will be 'in the pink'!
Let's hope this applies to you too!
CED
3) Scam
Don't be a Mug; The DTI consumer's guide to scams and rip-offs.
http://www.dti.gov.uk/ccp/scams/page1.htm
Warning signs
Make money in your spare time - Earn thousands per week - Guaranteed income
Sign up now or the price will increase.
Claim your prize by sending....
- Requests for identification details
Card numbers (beware the 3 security numbers) bank account details, mother's maiden name...
Beware, especially in spam mail or websites that offer 'free access' if you provide a credit card number as proof of age! (This is NOT proof of age!)
Beware internet auctions and sending money before receiving the product - this is the most common reported internet fraud - always use an escrow service.
The Trading Standards and the DTI have together produced;
Rip-off Tip-off
http://www.ripofftipoff.net/
They want to know about:
- unscrupulous doorstep traders
- cowboy builders
- counterfeit product sellers/manufacturers
- loan sharks
- bogus homeworking schemes
- bogus competitions
- e-cons
"If it sounds too good to be true, it probably is."
CED
4) Clinical Decision Making
There is an unstoppable vogue for clinical advisory frameworks and guidelines that set down on 'tablets of stone' the precise basis for clinical decisions.
If these are based on sound evidence and established best practice most clinicians are happy to take them into account.
However, many give conflicting advice and are not always legally, ethically or clinically sound and serve only to constrain and direct medical decisions.
Wessex LMCS was particularly concerned to see the following phrase included in one local framework;
"The committee will not enter into any direct patient correspondence."
So a patient aggrieved by a 'clinical decision', conveyed but not decided by you, is permitted to blame you, and vent their frustration
and anger on you directly, but the committee can hide behind the terms of the protocol!
The patient is forbidden direct recourse to the real decision makers.
This is not in accord with the policy to encourage patient involvement and participation that is so actively promoted and encouraged by government and PCTs.
If a committee has the right to control and direct the clinical decisions of doctors, that committee must accept the full and direct responsibility
for the consequences of that decision and must facilitate, not prohibit, the patient's right to respond directly.
Medicine is becoming increasingly protocol-driven, but;
- nobody considers the cost of producing and implementing these protocols
- nobody accepts responsibility when they fail to satisfy a clinical problem
- nobody provides a cost benefit analysis that reflects the bureaucratic realities
Doctors have particular experience and expertise in clinical decision making, based upon a full and sophisticated understanding of the medical
condition, the individual patient and the effect of that particular problem on that particular patient - and this is all part of a normal consultation. It's impossible to convert all of that into 'tablets of stone',
but it doesn't stop faceless bureaucrats from trying!
If they get it wrong, it's their problem - not yours!
Footnote; We have of course made our views known to the PCT in
question. You are entitled to make patients aware of any constraints imposed on your clinical decisions and of their right to address their views direct to the 'real' decision makers if they choose.
CED
5) Charges for NHS care for overseas visitors
The regulations relating to charges for the NHS care of overseas visitors were changed on April 1st and have some bearing on two regularly
recurring questions.
Department of Health guidance sets out quite clearly that when an asylum application fails and all the appeal processes have been exhausted, the asylum seeker
becomes ineligible for routine NHS primary care treatment and that GPs should charge the patient for any treatment provided. Emergency or immediately necessary treatment
must be provided free and there are also limited exemptions from charges for treating some infectious diseases and mental health problems.
The regulations relating to secondary care are rather more complex and have recently been amended. These are a matter for the hospital trust
to determine. Basically when an asylum application fails and all appeal processes have been exhausted, the applicant will become chargeable for any hospital treatment from the date their asylum claim failed -
unless they have been in the UK legally for more than 12 months.
As a resultof the new regulations NHS care is now freefor any overseas visitor who:
- 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.
Further information can be found on: www.lmclive.co.uk
CED
6) Advice on completion of cremation forms
Dame Janet Smith recently published her third report of the Shipman Inquiry and recommended a complete reform of the system of
certification of deaths, burials and cremations. These reforms will occur but as yet have not been fully agreed.
As an interim measure the Home Office has recently published advice to doctors on completing cremation forms. (www.homeoffice.gov.uk/docs3/compcrembc.html)
From the 1st April new requirements regarding the completion of cremation forms were implemented. Medical Referees at Crematoriums
are recommended not to accept cremation forms where doctors completing form C have not made enquiries of a relevant 3rd party (i.e. that one of the questions 5-8 should be answered in the affirmative).
Question 5 - 8 are as follows:
- (a) Have you seen and questioned any other medical practitioner who attended the deceased?
(b) (give names and addresses of persons seen and say whether you saw them alone)
- (a) Have you seen and questioned any person who nursed the deceased during his or her last illness, or who was present at death?
(b) (give names and addresses of persons seen and say whether you saw them alone)
- (a) Have you seen and questioned any of the relatives of the deceased?
(b) (give names and addresses of persons seen and say whether you saw them alone)
- (a) Have you seen and questioned any other person?
(b) (give names and addresses of persons seen and say whether you saw them alone)
These recommendations regarding the completion of cremation forms have occurred as a direct result of the Shipman Inquiry.
The doctor filling in part 1 of the cremation form, should obtain relevant telephone numbers to enable the doctor to complete part 2 and
answer one of question 5 - 8 in affirmative.
The LMC is concerned that this recommendation not only puts additional pressure on doctors, but it also can cause distress to recently bereaved
relatives with little or no benefit.
The LMC's advice:
- Speak to another doctor in the practice of the doctor who completed part 1 if possible.
- If the person died in a Rest or Nursing Home speak to a member of staff who looked after the deceased.
- Only telephone relatives if you are suspicious of the mode of death, need clarification, or if there is no other alternative
If you have any problems please contact the LMC.
NW
7) European Working Time Directive
The European WTD relates to the individual, and not to a particular job, and the onus of responsibility for compliance lies with the employer.
This would therefore include those doctors who work on a self-employed basis, but carry out additional work on an employed basis.
The employer must take reasonable steps to ascertain the total number of hours that an employee works in his employ, as well as in any other
capacity. He must then allow compensatory rest periods as required by the regulations.
A recent judgement in the European Court of Justice, has established that a doctor on call at their place of work is considered to be working
throughout the whole period, even if sleeping undisturbed! A doctor who is on call from home is not considered to be working, except for
periods when he or she is actually called out. In either situation a doctor may occasionally exceed the hours permitted by the WTD and the employer must try to allow an appropriate rest period as soon as
possible.
Doctors who work on an exclusively self-employed basis are not subject to the WTD and doctors in training will not be subject to the
regulations until August 2004.
The regulations are intended to protect employees from exploitation by an employer. If an employee chooses voluntarily to exceed the hours
stipulated in the WTD, he or she may sign an opt-out waiver.
However, if as a result of working while over-tired a doctor harms a patient, he or she may well bear both professional and legal liability for
failing in their duty of care to the patient. The WTD could well provide an objective measure of 'excessive' working hours in this context.
An employer that permits an employed doctor to work excessive hours, even if a waiver has been signed, could also be deemed to have failed
in their duty of care to patients. An employer that had effectively forced a doctor to waive their rights under the WTD would almost certainly share in that responsibility!
Further details with links to reference documentation is available in the Q&A section of LMC LIVE at: http://myweb.tiscali.co.uk/lmclive/qaindex/qastaff/qastaff.html#q14
CED
8) The future of general practice IT
The National Programme for IT also known as NPfIT.
The National Programme for IT in the NHS is one of the largest IT projects undertaken in the world. It has a budget of over £2 billion and
aims to focus on the key developments expected to make a significant difference to improving the patient experience and the delivery of care and services.
The four key areas are:
- electronic appointment booking
The LMC approves the concept of improved access and choice for patients to hospital based clinics.
This project appears to be continuing to focus on GPs. During a 10 minute appointment the GP is to, suggest to a patient a referral to
hospital is required, give the patient the choice of 4 or 5 providers, access the hospital information about clinics and book an appointment
that is convenient to the patient. Oh nearly forgot, this is all to be done within existing resources, i.e. money spent on IT and savings from improved DNA rates and booking within the hospital, but no additional
resources given to practice. This system will not work and the Department of Health have been told this repeatedly.
A system by which the patient can go home armed with information, then make contact with a booking service who offers a choice of time
and access, would work and have minimal impact on practices.
- an electronic care records service, was called integrated care records system (ICRS)
This is a clinical record management system for England that will support clinicians in their delivery of patient-centred care. The individual NHS
Care Record for patients will hold some nationally available information about their treatment and be supplemented at a local level by relevant information e.g. digital images.
This ultimately is the electronic patient record. There are huge issues to be resolved in terms of patient confidentiality, access to information etc.
- electronic transmission of prescriptions
This programme will deliver a service allowing prescriptions to be generated by GPs (and other primary care prescribers) and then
transferred electronically between prescriber, community pharmacist and the Prescription Pricing Authority. The electronic prescription and supply data generated by the system will form a critical part of each
individual's care record.
- an underpinning IT infrastructure with sufficient connectivity and broadband capacity to support the critical national applications and local systems.
This will deliver greater bandwidth for faster transmission of data and an improved electronic mail system with a comprehensive national directory.
England has been divided into 5 areas as far as IT is concerned. Wessex falls within the Southern Cluster, i.e. the South of England. Recently
Fujitsu was appointed as the Local Service Provider (LSP) for this area.
As you may have read, there have been difficulties with EMIS (who have 55% of the market share) declaring they will take no further part in the
NPfIT, as they were not one of the primary care partners in any of the 5 clusters. This has caused great concern to practices as well as PCTs locally, who were planning developments in their clinical systems. These
difficulties have now been resolved and EMIS is now playing an active part in the NPfIT.
The Fujitsu Alliance long term proposal appear to be that it wishes to have its Primary Care system to be based on some American Software
called IDX, which has yet to be developed, and as an interim would be IPS (formerly VAMP). It would therefore appear that no other system (EMIS, TOREX, or MICROTEST) would have a long term future in the south
of England.
These proposals have not taken into account the cost of conversion of 80% of practices to a new system, the data conversion issues, the cost of
training and probably most importantly the loss of goodwill within practices. We hope that common sense will prevail in this matter and pressure be brought to bear to modify this position.
Make sure your practice makes maximum use of your clinical system, and the LMC believes ultimately there will remain a choice of clinical
systems above the current 2 which are proposed.
NW
9) Violent Patients
We have now at last got the government to put some pressure on PCTs to ensure that there is a Violent Patient Scheme present in every area.
Regretfully, despite the fact that it was originally promulgated in a January 2000 HSC, many PCTs have been unable to do anything about until now.
One of the problems is the PCTs indicate that there are not that many violent patients in their area and there is not really any need for a
scheme at all. This has arisen because the definition of a violent patient is when a patient has been referred to the Police and a Police Number has been affixed to their case. Unfortunately, a lot of practices have
been dealing with the often isolated violent incidents and passed the patient on, and not going through the rigmarole of notifying the Police.
As a result of this there has arisen the impression in PCTs that there only a very few violent patients around and therefore, it is not worth setting up a special scheme to deal with them.
I think the lessons we need to draw from this are:
1. It is essential that on every occasion that any violent incident occurs you must notify the Police
2. That you should make sure you get a Police number in respect of every single case
3. That you notify this number to the PCT and make sure it is recorded by an individual whose name you take
The LMC has succeeded in most PCTs in getting a Violent Patient Scheme initiated. The continuation of these schemes must be subject to
adequate funding being available and this will not be forthcoming unless the PCTs have a much better idea of the number of patients who may need to be covered by the Violent Patient arrangements.
RIB
10) Charges for Use of Rooms in practices by PCT Staff
Increasingly PCT staff of various types, including Health Visitors and other directly employed PCT staff are performing their services, at or in
a surgery. There is no compunction upon GPs to charge the PCT for such usage. However, it is unreasonable to expect the GPs to provide this 'free good' and not even cover their expenses.
In most cases it is perfectly legitimate to ask for a sum of money from the PCT in respect of the usage by the staff of the premises, providing
this can be justified in terms of the service usage. It is not possible to charge a rent for these premises, unless that room is available permanently to the PCT, which is an undesirable state of affairs.
The use to which the room is put and the equipment which is made available to the PCT staff member by the practice, will vary and the
decision on how much is necessary to ask for the use of the room and equipment will depend on these details.
It is also important that the practices discern whether or not the individual will have access to the practice computer system and
whether matters of confidentiality have been fully addressed. It is also important that if it is decided that this is not the case, that if computer
provision is made for these staff members, it is done entirely at the expense of the PCT.
If there are any queries about individual cases, these are best dealt with by referring them to the office, initially through Jenny Steiner, the
General Manager.
RIB
11) Hepatitis 'B'
There is still confusion about exactly what the situation is with Hepatitis 'B' immunisations.
It is certainly the case that anyone requiring Hepatitis 'B' for travel abroad may be charged privately for the administration and the cost of
vaccines may be re-charged through the NHS under the personal administration scheme.
Where a person in this country requires Hepatitis 'B' immunisation because of their employment it is normally the employer's responsibility
to pay for this. The employer should be doing a 'COSHH' examination and when that determines that the individual concerned requires immunisation, the employer can approach the GP to act as their agent in
providing it. It can then be charged for by the individual GP. This is irrespective of whether the person involved is a patient of the practice, or not.
It is not possible however, in other circumstances, for an individual who is a patient of the practice to be charged directly for the administration
of Hepatitis 'B' immunisation, nor for the resulting tests which are necessary to assess seroconversion.
RIB
12) Surgery Opening Hours
There has been some confusion recently concerning the number of hours which a practice must be open to the public. The situation is that the
practice has to be willing to provide a service under the New Contract between 8 a.m. and 6.30 p.m. Monday to Friday, excluding Bank Holidays. This does not mean the practice needs to be open for all these
45 hours per week. It is perfectly legitimate for them to close the surgery premises, but still remain available for providing their patients' needs.
Where a practice does remain open fully between the hours of 8 a.m. and 6.30 p.m. those 45 hours would be used to count for an extra quality
point under the Quality and Outcome Framework.
Some PCTs have mistaken this arrangement and inferred that practices must be open to the public for the whole 45 hours in the week. This is
not the case and if any PCTs are suggesting this, please refer them to the LMC, when we will be delighted to clarify matters.
RIB
13) Wessex Small Practices Association (WESPA)
The Inaugural Meeting of the Wessex SPA was held at Taw Hill Surgery in Swindon on 17th March, with an excellent talk by Dr Andrew Dearden on
the benefits of the new contract for small practice and how to get the best out of it. One of the better ideas was to give his staff a week's
wages for reaching 700 quality points and up to 4 weeks wages if the 900 point target was hit.
Dr Peter Swinyard is the SPA Council Member for Wessex and would love to hear from small practices as to how they would like the WESPA to
develop. He is happy to hear suggestions for meetings, educational, political or social - or, in best SPA tradition, a mixture of the three, or to answer any questions on the SPA.
Contact him on p.swinyard@ntlworld.com or phone 01793 600440
14) Child protection
The Joint Chief Inspectors' (JCI) report on safeguarding children in 2002 identified "widespread concern that GPs did not attend initial child
protection conferences or multi-agency training, and made little contribution to the whole safeguarding agenda".
In addition the Data Protection Act, Human Rights Act, common law on confidence and the doctor's professional obligation of confidentiality,
have combined to create uncertainty and confusion regarding data sharing for the purpose of child protection.
The Information Commissioner's "Make Data Protection Simpler" and "Helping organisations to get it right" campaigns will hopefully address
some of these issues.
Doctors have an obligation to protect data and patient confidentiality, but have an over-riding professional and legal duty to
protect a vulnerable child at risk.
If you believe a child is being abused this must be your paramount consideration.
Lord Laming in his report on the Victoria Climbie Inquiry identified three specific issues requiring attention, based on the limited contact that
Victoria had with GPs;
- The way new child patients are registered with general practitioners
- The information to be gathered during registration and how it should be shared
- Training in child protection and knowledge of local policies and procedures.
He recognised that GPs do not have the time or training to act as social workers. They do have a major role in distributing information vital to
determine if a child needs protection and skills and experience that are essential to protect children.
The Laming Report can be accessed in full at;
http://www.victoria-climbie-inquiry.org.uk/finreport/downloadreport. htm
The recommendations for healthcare start on page 378 of the report.
A summary of his recommendations is set out as an attachment to this Bulletin. (Attachment 1)
Further information on child protection is available on
www.lmclive.co.uk in the Child Protection Section of Guidance.
CED
15) E-Mail Addresses
Key to Contributors: + current e-mail addresses
RIB Dr R I Button Joint Chief Executive
bob.button@wessexlmcs.org.uk
NW Dr Nigel Watson Joint Chief Executive
nigel.watson@wessexlmcs.org.uk
CED Dr Christine Dewbury Medical Secretary
christine.dewbury@wessexlmcs.org.uk
Telephone number: 01962 867793
Fax number: 01962 841867
Remember the old BT click e-mail address no longer exists.
To e-mail anyone here in the office simply use:
First name (dot) surname followed by @wessexlmcs.org.uk
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