NEWSLETTER OCTOBER 2005
Diabetic Retinopathy Screening
Reconfiguration of the Health Service
Briefing note on Allergies for GP IT Systems
Influenza immunisation programme
Proposed changes to the Misuse of Drugs Act
Staffordshire Support Scheme
This scheme has been in existence for a number of years to give support to doctors and dentists in Staffordshire. We have secured funding for the scheme to continue for the time being and you will have recently received more details of the scheme. The Scheme is accessible to any GP (principal or non-principal), GP registrar or dentist working or living in North Staffordshire. As well as psychologists, psychotherapists, counsellors and GPs working in Staffordshire we have several psychiatrists, a careers counsellor, and helper GPs from outside the area which means that colleagues have an opportunity to seek help or support from further a field if they wish. Details of the scheme can be found here.
Diabetic Retinopathy Screening
The requirements for eye screening for diabetic patients have changed as a result of recommendations by the National Screening Committee. The 8 PCTs in Staffordshire have put together a community programme. Screening will now be undertaken by digital fundus photography performed by accredited optometrists at one of 58 sites throughout the county. The paper reports which we currently receive will be replaced. Screening reports will be sent electronically to a central management system which will generate reports for the patient's GP. The new system is currently being tested using 5 pilot sites and should be rolled out county wide in the next few months so that it is fully functional by the end of November.
Reconfiguration of the Health Service
The government has announced in a paper entitled "Commissioning a Patient Led NHS" published on 28th July, a review of the management structure of the health service with a view to reducing the number of Trusts. This has implications for the STA, Ambulance Service and PCTs.
Strategic Health Authority
It is suggested that the Shropshire and Staffordshire Strategic Health Authority should merge with the STAs of Birmingham and the Black Country and West Midlands South to form a West Midlands Strategic Health Authority. They already have a joint Chief Executive but three separate boards. A merger would provide significant cost savings and align the structure with the West Midlands Health Protection Agency.
Ambulance Service
The reform of the Ambulance Service described in "Taking Health Care to the Patient" proposes a strengthening of ambulance services with an associated reduction of at least 50% in the number of trusts and the broadening of the services they provide. In the West Midlands, it is suggested that the current four ambulance services could be replaced by one ambulance service covering the West Midlands. As well as allowing for cost savings its is claimed that this reorganisation would also allow for a broader range of managements skills to be brought in to develop a range of new services and services divested from PCTs. The need to maintain several call centres and locality "footprints" are also considered important.
Primary Care Trusts
The general principle contained in "Creating a Patient Led NHS" and reinforced in "Commissioning a Patient Led NHS" was that PCTs should have clear relationships with Local Authority Social Service boundaries. In considering arrangements for the current Shropshire and Staffordshire STA, discussions have taken place with the local NHS. A number of options were produced.
- The current two PCTs of North and South Stoke to merge to form one PCT covering the Stoke City council area. The current six PCTs of Cannock Chase, South Western Staffordshire, Newcastle-under-Lyme, East Staffordshire, Burntwood, Lichfield & Tamworth and Staffordshire Moorlands could form one PCT covering Staffordshire County local authority area.
- All the PCTs in Staffordshire could merge to form one PCT covering Staffordshire
- The current two PCTs of North and South Stoke to merge to form one PCT covering the Stoke City council area. The current four PCTs of Cannock Chase, South Western Staffordshire, East Staffordshire and Burntwood, Lichfield & Tamworth could form one PCT and the current two PCTs of Newcastle-under-Lyme and Staffordshire Moorlands could form one PCT.
The formation of one PCT for North Staffordshire covering Newcastle, Stoke and Staffordshire Moorlands was not an option considered. The STA is to make its recommendations to the DoH by 15th October and later in the year the DoH will undertake a formal three month consultation. The deadline for PCT reconfiguration to be complete is October 2006.
The first option is the one to be submitted by the STA and any consultation is likely to just be an academic exercise. Whatever the outcome the changes do have implications for the LMC. The LMC is a statutory committee whose boundaries have to be coterminous with one or more PCTs. Thus the LMC will also have to reconfigure to reflect the changes unless option three is adopted.
Mirena Coils
There has been some concern among colleagues about the UHNS referring patients back to GPs for the fitting of mirena coils. This has been discussed by the Clinical Interface Group who report that the hospital will still fit Mirena coils, but recognises that some GPs are willing to fit these coils in primary care. It has been suggested that GPs should inform the gynaecologist on referral, if he/she is willing to fit a mirena coil if the consultant feels this is appropriate. The GP should not be asked to prescribe a coil for fitting by secondary care.
Nurse Verification of Death
Emma Sutton has sent the following to practices.
"As you will be aware, both paramedics and district nurses are attending deceased patients in order to verify death. In the out of hours period this applies to all deaths, whilst in-hours district nurses who have undertaken additional training are attending to verify expected deaths.
As GP’s we have a legal obligation to complete certification of death i.e. the issuing of a death certificate stating the cause of death, unless the death is referred to the coroner. As part of this process we complete a section relating to whether the patient has been seen after death. The options given are a. seen after death by me; b. seen after death by another medical practitioner but not me or c. not seen after death.
In order to clarify how the death certificate should be completed we have sought guidance from the registrar generals’ office. They have confirmed that in the situation where a paramedic or district nurse has verified death, the correct response would be c. (not seen after death). This needs no additional annotation or information."
PCT Drug Budgets
As part of their plan for financial recovery, a number of PCTs in the country are requesting that GP change patients to less expensive medications. The savings in doing so do not take into account the expense of GP's time in identifying patients, notifying patients of such changes, explaining the changes, dealing with their enquires, changing repeat prescriptions and carrying out necessary follow up and laboratory investigations after the change. Any medico legal consequences of such a change will also be borne by the prescriber. GPs have a responsibility to be cost effective in prescribing and this takes into account the full picture rather than the single issue of drug cost. A number of PCTs have targeted the cost of statins and PPIs as a priority. With increasing evidence that lower cholesterol levels produce more benefit to patients and the likelihood that the target levels in the QOF will change, one wonders about the wisdom of changing patients to the cheapest drug available.
Waiting List Validations
GP colleagues may have received requests to validate and express an opinion as to whether some patients who are on secondary care waiting lists still require an investigation/procedure. Patients should only be removed from waiting lists after a full assessment of their clinical need and their consent. This process should only be performed by a clinician. In most cases the investigation in question was ordered by consultant colleagues. Any GP who "cancels" such a request must take into account the potential medico-legal consequences. This process can be time consuming and is not part of the GMS contract and thus such requests can be refused.
Freedom of Information Act
The GPC has issued revised guidance on the FOI act. The main changes are to questions 15, 17, 18, 19 and the flowchart. The revised guidance can be found here.
Hepatitis B for Employees
The GPC has issued updated guidance on the immunisation of employees for Hepatitis B. This guidance can be found here.
Incapacity Payments
There is currently a 5 month delay in cases of prolonged incapacity being considered by the Benefits Agency, therefore when GPs has provided a Med 4, the patient and the information provided are not assessed until 5 months later. This means the information is way out of date and also the GP is approached for another med 3, despite having issued a Med 4 unless the Med 4 was for a longer period of time. It may be worth GPs issuing Med 4 "until further notice", although I don't think this necessarily stops a request for a further Med 3.
Prospective Medical Students
We wrote to Keele University earlier this year about their request that GPs obtain the immunisation status of prospective medical students and arrange for Hepatitis B immunisations. They have replied stating that they will be changing their procedures for next year. Their Occupational Health Department will carry out all relevant blood tests on admission.
GPC Items
GMS contract review
Negotiations between the GPC and NHS Employers on the GMS contract review are progressing. The review will take place in two stages, with some changes to the QOF being implemented from April 2006. The work on the allocation formula review group will continue and it will produce a report for consultation during 06/07. However no actual changes to the formula will take place until April 07. The two sides have also been discussing how to release funding to practices for initiatives such as practice-based commissioning and patient choice.
Briefing note on Allergies for GP IT Systems
Arguably one of the most important aspects of patient records that should be accessible to all that provide care are their known allergies and sensitivities. For historic reasons the different GP clinical systems handle the recording of allergies in several different ways. Some have specific parts of the patient record database designed solely for that purpose. This presents problems when electronically transferring GP records. System “A” may hold the knowledge of an allergy to penicillin in a form that cannot be recognised by system “B” and vice versa. These differences can only be overcome by the application of complex translation tables and mapping rules, these are potentially unsafe.
However there is an opportunity to resolve this problem through the adoption of a QOF like approach to the recording of allergies. All GP systems have the full range of Read Codes available to them and the Read Code system has a wide range of specific codes that deal with allergies. Any Read coded data will be transferred with 100% accuracy between GP systems using the GP2GP transfer process. It is self evident that using a QOF like approach to the recording of allergies will be safer than system specific approaches. It will obviate the need for translation tables or mapping systems.
The GPC would, therefore, recommend to all GPs and surgeries that they begin recording allergies and sensitivities as Read Coded entries. Known and confirmed allergies are relatively rare and the numbers of patients involved is likely to be small. Some practices might consider doing searches of their existing records and adding Read Coded entries to supplement any system specific entries that may exist.
Medical records
It has come to the attention of the Joint GP IT Committee (JGPITC) that some practices are sending incomplete medical records on to the next practice when a patient transfers. This usually means that practices don’t print and forward letters and other reports that are often scanned and “attached” to the GP electronic patient record (EPR).
Sometimes the incompleteness is highlighted by a note advertising that the records are ‘available on request’, but other times the gaps in the record are only obvious when the records are under review (e.g. for a medical report). The JGPITC would like to remind practices that they are required to forward the complete medical record when requested to do so by their PCO. However, fully summarised “paper-light” records will generally be sufficient, providing they have been carefully examined to ensure that no important patient details have been omitted. Practices are reminded that it is their duty to ensure that all scanned letters and supporting documentation are explicitly linked in the appropriate place within the patient’s records, to ensure that vital information is transferred safely and efficiently and that context is maintained.
Influenza immunisation programme
On 25 July 2005 the Department of Health in England issued a letter stating that two additional groups have been added to those recommended to receive flu immunisation, namely people with chronic liver disease (CLD) and people who are the main carer for an elderly or disabled person whose welfare may be at risk if the carer falls ill. The same letter was issued in Scotland and discussions are ongoing in Northern Ireland.
The GPC was not consulted about these changes and the Department has not offered any additional funding for the DES that is currently used to fund and provide immunisations, leaving it to PCTs to consider if a separate LES is needed. The GPC is concerned that this will reduce the enhanced services funding available for other services within the PCO area, and feels that the new arrangements go against the GMS contract principle that new work will always attract new funding. It should be noted that in Wales agreement has been reached that the new groups receiving flu immunisation will be paid for in exactly the same way as for all other groups.
The GPC has written to the Department to voice its concerns and will seek to resolve this issue as part of the contract negotiations.
Proposed changes to the Misuse of Drugs Act
The GPC discussed a draft response from the BMA to a Home Office consultation on changes to the Misuse of Drugs Act. This follows on from the Department of Health's publication 'Safer Management of Controlled Drugs' written in response to the fourth report of the Shipman Inquiry. The GPC felt able to support many of the recommended changes and Dr John Grenville was thanked for his work in attending the Department of Health workshops that fed into these proposed changes. The tightening up of all procedures relating to the supply, prescribing and administration of controlled drugs was considered proportionate and reasonable in the circumstances.