Newsletter
Index
Newsletter March 2001Assuring the quality of medical practice BMA suggested fees for non-principals EditorialWe have recently seen signs of militancy from the Chairman of the GPC over the Review Body Award and the manpower crisis looming over general practice. However, the GPC did not see fit to send a copy of Dr Chisholm’s letter to all GPs, although they are available on the GPC website. I attach a copy of each for your information. We have also seen the Government make moves to placate general practitioners, firstly with the promise of extra money for young GPs to enter practices in deprived areas, and extra money to encourage GPs who are planning to retire to stay in practice, and more recently with promises to cut the amount of bureaucracy which we have to deal with. Although these may be moves in the right direction, they appear to be too little and too late. Money alone will not encourage GPs to postpone their retirement plans. The low morale of the profession needs addressing. I note that the day after the Government announced its plans to recruit and retain GPs, it announced that nicotine replacement patches are to be available on NHS prescription. No prizes for guessing whose workload that will increase! It is not the filling in of the occasional private form which brasses us off, but the unending and pointless requests for information from Health Authorities, PCG/Ts, Social Services, Councils, Benefits Agencies etc. Government must also learn that when it promises extra money to primary care it must be in a straightforward easily accessible way. We must not be continually made to jump through various convoluted hoops. The money must be traceable from the allocation to the Health Authority to the GP practice. Currently it is almost impossible to check that this “extra” money ends up in primary care. I suspect that the vast majority of it disappears on the way to make up for funding deficits elsewhere. LocumsGP locums will be able to enter the NHS Pension Scheme from 1 April 2001. In order to gain entry to the scheme, locums will need to be on a Supplementary List to be held by a Health Authority. However, legislation to introduce supplementary lists will not be in place until some months after 1 April 2001 (a precise date cannot be predicted). A mechanism has, therefore, been agreed with the Department of Health and the NHS Pensions Agency to enable retrospective NHS Pension Scheme membership back to 1 April 2001. From 1 April 2001, locums should record their work and income on forms which have been created for this purpose. Copies are available from the LMC Office. These forms are also available on the NHS Pensions Agency Website: www.nhspa.gov.uk and will be widely distributed in due course. The completed forms should be retained pending the setting up of the Supplementary List. At that time, a cheque will need to be sent to the Health Authority for the amount of the accumulated pension scheme contributions. The host Health Authority will probably be the one covering the area in which the locum resides/does most of their work. Could GPs please ensure that any locum working in their practice are informed of this item. Nursing HomesLast year the LMC successfully negotiated with the Health Authority the principle that GPs should receive an extra payment for services provided to patients in Nursing Homes in order to provide them with pro-active care rather than the reactive care which is provided under GMS. Unfortunately, and not surprisingly, this failed to secure funding in the 2001/02 spending round. This is disappointing after the large amount of work put into this issue in the last 3-4 years. Where is the commitment to invest in primary care and provide our elderly citizens with the care approach they deserve? Strategic Outline CaseThe Committee welcomes the announcement of the redevelopment of the North Staffordshire Hospital Centre to locate all services on one site. Successful progress of the project as far as primary care is concerned is dependent upon how services are to be configured around intermediate care and the secondary/primary care interface. It is planned that a Clinical Director, Primary and Intermediate Care, is appointed to oversee this aspect. The post will be for a minimum of three years and will be equivalent to a half-time post. It is envisaged that the post holder should be a practising North Staffordshire general practitioner who will liaise closely with the Local Medical Committee. Intermediate CareThe Committee is acutely concerned about the effects of intermediate care on general practice. This is yet another area of work which GPs will be expected to take on. The Committee is of the opinion that there should be adequate resource, training and quality. It has concerns regarding the workload, communications and revalidation. Colleagues taking on this work should be aware of the increased risk of complaints and are warned not to take on anything beyond their capabilities. Recognition of DeathIn April 1999, the GPC issued a document “Confirmation and Certification of death”. This guidance aimed to clarify the distinction between confirming and certifying death in relation to GP obligations. English Law does not require a doctor to “confirm” death. The West Midlands Regional Local Medical Committee spent a lot of time and effort in consulting with various interested parties and drawing up a regional framework for its implementation throughout the West Midlands. This would save a lot of resource for Police and Ambulance Services as well as GPs. Despite this extensive consultation which included the Police, Ambulance Service and Coroners, this document has met with opposition from the Police and Coroners in Staffordshire. The Committee, therefore, took the view that it was not worth pursuing at present, particularly in view of the impending review of procedures following the Shipman case. UltralaseThis private company has been circulating GPs in the area requesting information about their patients who have approached them about surgery. I wrote to this company last year pointing out that before information can be given, the patient'’ signed consent should be sought. This is their responsibility. I also pointed out that a fee should be payable for supplying the information they seek. I have not received a reply from them and it has been brought to my attention that they are still seeking information in the same way. I suggest that GPs should reply to them along the same lines. TonsillectomiesGPs have recently been circulated by the ENT Department and requested to hold back on referrals for tonsillectomy because of the Department of Health’s recommendation on the use of disposable instruments due to the theoretic risk of the transmission of New Variant CJD. This has caused some disquiet amongst colleagues. We have a duty to refer patients where their medical condition requires it. If we feel that a patient requires a tonsillectomy we should continue to refer to the ENT consultants for their opinion. They should be responsible for the decision on whether or not to operate. Any waiting list for the procedure due to lack of equipment is their responsibility. PEG FeedsThese are increasingly being used. The Committee has discussed its concerns that they are often inserted without reference to the GP who is aware of the previous circumstances of the patient. We are also concerned with the lack of back up advice when these patients are discharged to nursing homes. Dr Robert Jones of Trentham is interested to hear from anyone with problems. Registration of patientsThe Health Authority has noticed a significant increase in the number of patients who are turning to them for help with registration with a GP. These patients now include many who have simply moved home. This no doubt reflects the high workload and low morale of GPs in general. The Health Authority is now finding that they have to allocate approximately 300 patients per year which is a very time consuming process. Considerable effort is made to achieve a voluntary acceptance in order to ensure that patients do not get stigmatised as “difficult” because they are allocated. The process is also conducted fairly to ensure practices do not receive more than their fair share of allocations. The Health Authority also reports that their staff are receiving an unjustified level of verbal abuse from practices when attempting to find a GP for a patient. Whilst appreciating that GPs have the right to object to allocation, please do not abuse the Health Authority staff who are trying their best in difficult circumstances. The Health Authority does have an appeal mechanism in place for a GP to appeal against an allocation he/she considers unfair. It has been brought to my attention that at least one GP practice was under the impression that they were not responsible for the care of patients until their records have arrived from the Health Authority. Practices are reminded that they are responsible for the care of patients from the date they are first registered. It is not good practice to hold registration until patients attend for a new patient screening examination as this can effectively leave patients in limbo for a period of time. ConstitutionThe Constitution of the Local Medical Committee has now been amended to recognise its wider role in representing the interests of PMS doctors and non-principals as well as those of GMS doctors. GPC Items
BNF is now on line.
The British National Formulary (BNF) is now available to Internet users with the launch of a new website – BNF.org – at the BMA Annual Representative Meeting last month. BNF.org is a unique extension of the familiar paper BNF – a joint publication of the British Medical Association and Royal Pharmaceutical Society of Great Britain. BNF.org provides up to date free access to the most relevant prescribing advice and information needed for the day to day activities of health professionals. Not only does the site provide unrestricted access to the entire content of the current edition of the BNF, it also includes additional complementary sections. For instance, BNF Extra includes information on paracetamol poisoning and a cardiac risk assessment calculator while About the BNF includes answers to frequently asked questions about the BNF and its advice. Healthcare professionals in all settings will now be able to rely on BNF.org to keep themselves up to date on the best treatment options for their patients. Access to GP ServicesThe Health Department issued a Press Release promising more money for quicker appointments. A copy of the Press Release and the GPC’s reply is available on the Health Department and GPCs websites. Discussing these documents, the committee considered whether the Government’s targets were achievable, given that the extra resourcing equated to £144 per week per practice. If the Government’s targets were to be realised, it would have to consider many other factors such as demand management, patient education and patients not attending. The committee was particularly concerned about the implications for single handed GPs, quality issues and shy the Government was concentrating on 48 hour access in primary care when waiting lists in hospitals ran into months or years in some cases. Assuring the quality of medical practiceThe committee expressed disappointment with the Health Department’s publication “Assuring the Quality of Medical Practice: ;Implementing Supporting doctors Protecting Patients”. Whilst there was a cautious welcome for the aims of the proposals in the report, which incorporates some of the GPCs criticisms on the previous consultation document, there remain a number of concerns, including: · The introduction of a civil burden of proof in GMC procedures. This is totally unacceptable · The report links appraisal with continuing professional development. This is wholly inappropriate · GP returners are not recognised · It is not clear how the commitment to protected time can be reconciled with improved access to GP services by patients · Clarification is required on the constitution of the National Clinical Assessment Authority · The document makes no reference to the resources required to effect the proposals · It assumes that there exists reliable local structures on which proposed mechanisms for a resolution of poor performance can be based. This is not necessarily the case. The GPC have protested strongly to Government on each of these issues and will continue robust representations to ensure more equitable procedures. The document is available on the Department of Health’s website at http://www.doh.gov.uk/assuring quality/index.htm. NHS Net Post Connection packThis introduces the facilities available once an NHSnet connection is in place, and there is particular emphasis on how these new tools can be integrated into practice business. Some of the information is general in nature, while other parts refer to local circumstances. The pack should assist those unfamiliar with desktop computers and on-line working, as well as to more experienced users. It also contains useful reference material to support training and development being undertaken by local Health Authorities. The pack can be found on the NHSnet at: http://nww.gpnet.nhsia.nhs.uk/gpnetwow/post NHS net connection.rtf It is also available on the internet at: http://www.gpnet.nhsia.nhs.uk/gpnetwow/post NHSnet connection.rtf BMA suggested fees for non-principalsAs last year, the BMA will not be able to produce suggested fees for non-principals, due to the Office of Fair Trading still considering their views on compliance with legislation. The suggested fees are normally uprated in April to take account of the DDRB award. The marketplace for doctors with these qualifications has hardened considerably, and principals should note that alternative sources of work in the NHS have received a pay award in excess of the headline figure for GPs. To attract suitable applicants, principals employing other GPs should have regard for difficulties in supply of doctors and current levels of remuneration. Recruitment and RetentionThe GPC has debated the recent announcement of an additional £135m over three years, half of it for GP recruitment and retention in England. That announcement had stemmed directly from the pressure the GPC negotiators have been putting on the Government, but the negotiators had already made it clear that this additional money is simply not enough to tackle the serious problems the profession faces. The Government did not negotiate, nor consult, with the GPC before announcing the additional funding and its proposed allocation, and the precise detail of the proposed package has still to be revealed. The lack of consultation is unfortunate, because there are many other measures which the GPC believes would have had a more significant impact on GP recruitment and retention than the introduction of so-called “golden hellos” and “golden handcuffs”. Addressing the GPC, Chairman Dr John Chisholm called for even more positive action from the Government, action aimed at securing tangible improvements for all GPs. The meeting went on to carry unanimously a motion describing the Government’s announcement as completely failing to address the fundamental issues of GP workload, morale and pay. Drug Monitoringa.
Warfarin.
Due to the increase in workload the Cardiology outpatient
monitoring clinic is currently over-subscribed.
The Cardiology Directorate has instructed its doctors that patients
who require anticoagulation are referred to the clinic who will then put
them on a waiting list. Unfortunately, there have been instances where patients have been directed back to their GP practice for the instigation of anticoagulation and in some cases large initial doses of Warfarin have been advised. GPs should not be taking on this work unless they have both the resources and necessary skills. Any problems due to this should be referred back to the Cardiology Department. b.
Lithium. We have been informed that the Lithium Monitoring Clinic run
by Combined Healthcare has been discontinued and that the Trust wish to
move these patients back to GP care.
This is not acceptable to the committee on the grounds of both
safety and workload implications. Drug Dosage CassettesDrug dosage cassettes are becoming increasingly popular among elderly patients and community care workers will not take responsibility for the administration of medication unless these systems are used. Some pharmacies are demanding that GPs issue weekly scripts to help cover the cost of these systems. Pharmacies are not reimbursed by the NHS for dispensing in Monitored Dosage Systems. They are expensive in material costs and labour and usually needs to be delivered. 28 days prescriptions dispensed in a MDS are supplied at a loss. Weekly scripts reduce that loss. To complicate matters, pharmacists are paid from a negotiated global sum which takes into account forecast volume increases. If all prescriptions were written for 7 days, four times the number of dispensing fees would be claimed and the “excess” would be clawed back, so from a national point of view it is not policy to encourage 7 day prescribing, but from an individual contractors point of view it may seem reasonable. There are no easy answers, however, if there is a need for MDS, it should not be funded by the pharmacist or by increased GP workload. Locally GPs may refer a patient to the pharmaceutical advisor at the Health Authority for a review of their medication needs. Funds are then available if an MDS is felt to be appropriate. DR PAUL GOLIK Secretary
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