|
February 1997 Bulletin
Contents:
Drugs: Abuse not GMS
The government set out a consultation document in 1995 called
"Tackling Drugs Together" intended as a strategy for England for the following 3 years. At that time the profession made it
absolutely plain that the GP's obligation to a drug misuser is the same as to other patients, namely providing GMS. Any involvement GPs may undertake in the
specialistcare of drug misusers is outside the GMS contract and thus voluntary. This means that if it is undertaken it should be funded adequately and remunerated
separately. This has come into the limelight again recently with the increasing numbers of drug-users particularly in the Southampton
area. The Government has given extra resources to Health Authorities to deal with among other things drug abuse in their areas.
It is the wish of many Public Health Departments and the Health
Authorities with which they work, that GPs undertake the routine care of drug abusers from the point of view of prescribing the drugs of addiction as part of GMS.
This is entirely contrary to the policy of the GMSC and should be firmly resisted.
There are real dangers if routinely GPs become prescribers in
this way. It is not unknown for drug abusers to use several aliases and to be economical with the truth in stating they have lost
prescriptions; have left them at their Aunties etc. etc. The manipulation indulged in by drug abusers is very similar to that of
alcoholics and the more experience and greater skill you have in dealing with this, the better for all concerned.
The policy of the LMCs locally is that this should not be part of
routine GP activity. In the event of a patient who is an abuser of drugs requesting a prescription for cd.s they should be directed to
a Drug Misuse Clinic, at which an adequate number of GP prescribers should be available; either at the site of the Clinic or
elsewhere; in order to supply the necessary drugs. There is some dispute as to whether or not drug abuse should be treated by
reducing the drugs. I have seen this policy followed successfully in the London area. Nevertheless the management of drug abuse is
specialised and if it is the policy of the Drug Abuse Clinic locally not to do this, then they must be respected as specialists in their
field. Equally, however, if they wish to follow a policy of adequate free supplies of drugs in large quantities, they must also accept the prescribing responsibility.
Should you be approached by someone who wishes you take over
the prescribing responsibility for an addict, may I suggest you decline the invitation, unless you have a special interest. If you
need further advice, please contact the LMC Office.
Drugs: Clinical Responsibility
I return to another "old chestnut" which is: who is responsible for
prescribing drugs which are recommended by a Consultant in hospital?
When a patient is referred by a GP to a hospital for specialist
treatment, it is reasonable to expect that any specialist treatment being recommended would also be provided by the hospital
concerned. It is not sufficient for the specialist to indicate they do not consider it part of their role to prescribe. Many of these drugs
are indeed complicated and unless the GP concerned has the special experience necessary, they are running a medico- legal risk by agreeing to prescribe them.
It has been clearly laid down over the past few years by the NHS
Executive, Regional Health Authorities, and by the GMC and the GMSC that prescribing is part of the clinical responsibility when
you accept a patient. This means that the Consultant who takes a patient on specialist referral accepts at that time responsibility for
the prescribing. This does not mean that on every occasion that should be the case. However, when drug prescribing responsibility
is handed back to general practitioners it must be on the basis:
- that the GP feels competent in the drug management;
- has the right to discontinue the drug;
- to vary the dosage;
- to adopt other treatments if they consider it necessary
In many cases I find myself contacted by GPs who are being
asked by a Consultant to merely act as a remote signature on a prescription form in order to avoid financial resources being expended by the Trust.
It is very important that the GP is recognised as an individual and
the Consultants do not presume there is a "generic"GP in the community who is familiar with all specialist drugs used in
hospital. Some are, but many are not. GPs are not a cheap way of avoiding prescribing responsibility.
I have spent several years now dealing with this problem and am
very happy to advise GPs who find themselves being placed under pressure to prescribe a drug which they do not feel clinically confident to handle.
Drugs : Charging For
I get frequent requests for information regarding when and in what
circumstances a GP may charge for drugs. These are clearly laid down in paragraph 38 of the Terms of Service and as a general rule the acid test should be "
is the patient travelling abroad?"
If the patient is going abroad and requires immunisation in
connection with that travel then if there is no item of service fee payable, the doctor can charge for the service given. Similarly with
regard to prescribing vaccines, if an immunisation is one which can be issued on FP10 then it should be provided as such. If it is
not allowable for prescription in this way, then a charge may be made for a doctor to issue a private prescription, or the doctor may of course supply the drug personally.
A charge may also be made when drugs are requested by
patients travelling which they wish to use in the event of illness occurring when they are abroad but from which they are not presently suffering.
You may notcharge for a branded drug which is available on the NHS in a generic form (i.e. a black-listed drug).Since the patient is not travelling abroad this is part of general medical
services and no charge may be levied for it.
There are occasions, as every doctor knows, when a drug
prescribed on an FP10 would result in a cost to the patient greater than if the patient accepted a private prescription. In this event it is
perfectly reasonable for the doctor to suggest this point to the patient. The doctor must always offer the drug on an FP10. Should
the patient after being advised request the doctor to issue the prescription in a private form, then the doctor may do so, but again
since it is part of general medical services, he may not make a charge.
There are other queries and difficulties associated with charging
for travel advice and for drugs that I advise GPs to contact me at the office for detailed advice in particular circumstances.
Drugs : Monitored Dispensing Systems
Attached to this bulletin is a letter from the Hampshire LPCs
dealing with the use of monitored dosage systems and the fact that pharmacists are not being adequately reimbursed for the
costs involved. GPs are encouraged to read this letter and take such action as they feel is appropriate in the circumstances.
Complaints and the LMC
It is very important that whenever a complaint is made, early
consideration is given as to whether or not the LMC should be contacted. Obviously as the Secretary I could not possibly become
involved in every single complaint in every single practice. However, there are occasions when I would particularly wish to be involved at an early stage.
Where a Health Authority is invited by the patient to make the
initial contact with the practice, I believe it is very important that the LMC is able to advise the practice as to the way in which it should
proceed. In particular there are usually reasons why it would be better for the practice not to send a detailed letter rebutting the
complaint. Complaints by and large are most efficiently settled by the complainant and the doctor meeting face to face and being
able to exchange information to clarify the situation for both sides. The days of the old formal complaint are largely over, and doctors
providing detailed written explanations, as an initial response, is not now appropriate at first.
Another area which is proving a little bit tricky can sometimes be
where a GP in a co-op, as a result of activities undertaken while working for the co-op in respect of another GP's patient, has a
complaint made to the co-op against them. I would stress here that the person in contract with the Health Authority is the GP and not
the co-op. Accordingly, although the co-op may administer the system, it is the doctor who must be personally involved in ensuring
that the responses made are entirely adequate and present his side of the story effectively. Once again I would like to see the
person making the complaint meeting the GP concerned, rather than attempting to deal with this by long detailed letters.
It is not universally known that if a person who makes a complaint
subsequently indicates they are considering legal action, then the NHS complaint procedure is discontinued forthwith. Before 1st
April, 1996 the complaints system was used as a preliminary to a legal action being taken and this is something which the new system is seeking to avoid.
When conciliation is suggested by a Health Authority and the offer
of a conciliator is made, I would expect that conciliation to take place between :
- the person who is making the complaint,
- the doctor who is complained against,
- the conciliator
and no other persons being present.
I would include in this the CHC and the LMC. Both will become
involved if the matter proceeds further to an independent review. Accordingly, I don't think it is appropriate that they should interfere
in any way in the stage which seeks to prevent such a review being needed.
Pressure may be put on doctors to try and accept third parties
present at a conciliation process and although I have some sympathy with the idea of a person who is a relative, especially in
the cases of deaths, to assist and comfort the complainant, I do not think there is a place for any of the supporting organisations.
Similarly at conciliation meetings it is neither helpful nor wise to
allow formal notes to be taken. The point of conciliation is to attempt to improve communications between the two parties to
such a degree that the complaint is resolved. Should notes be taken this could be used at any later stage which is reached in a way which may not be advantageous to one or other side.
We have now had independent review procedures across the
county and the LMC has always been available to provide support and help. It is important to stress that the earlier the contact is
made with the office, the greater the assistance that can be offered.
There is absolutely no reason why practice managers, who often
are the complaints officers in practices, cannot contact me direct if they need advice about how to proceed. The same would of
course apply to administrators who are dealing with the complaints initially on behalf of a co-operative.
Changing Partners
Amendment 23/10/02
A lot of people are unaware of the manner in which new partners
may be recruited either to replace retiring partners or recruit additional partners. The right to approve the recruitment of GPs
partners is given solely by the Medical Practices Committee (MPC). This Committee is charged with ensuring an adequate and
even distribution of general practitioners across the country. So they jealously guard their right to determine whether or not an area is under or over doctored.
When a partner leaves a practice, it is not an automatic right for
the practice to be able to recruit another partner to replace them. MPC areas do not fit exactly the boundaries of individual
practices. Accordingly, it may be that other practices in the area have grown to such an extent that they have received approval for
extra doctors. This may mean that there are sufficient GPs in the area, and a replacement doctor in that particular practice would not be considered useful.
It is vital then that when a partner proposes to leave, the partners
who remain apply (through the HA) to the MPC for the right to be able to recruit a new partner to the same degree of whole time
equivalence as the old partner represented. This will normally be granted for a period of 12 months. At the end of that time, if the
vacancy has not been filled, a further application may be made. Good reason will have to be shown to the MPC as to why the vacancy has not been filled and they may seek evidence on what
actions the practice have taken. May I stress that there is not an automatic rightto an extension. Any help that is needed with
these letters is always forthcoming from the LMC office.
Normally the LMC is contacted by the HA for its opinion whenever
a new partner is applied for and always when a practice seeks to change the existing partnership structure. The LMC can advise
about the wording of any letter and draw attention to the points which will count in their favour with the MPC. It can also draw
attention to points which the MPC do not consider favourably. I would particularly refer to out-of practice activities. These,
although medical in nature, may contribute to general medical service provision, e.g. clinical assistantships. These are not
viewed by the MPC as supportive of the need for more people to provide the GMS which the clinical assistant might otherwise be
performing for themselves. May I suggest that any question of changing the balance of partners in a practice, whether seeking to
change a partner from a full time to half time, or to recruit an extra doctor on half, full or three-quarter time, merits early contact with
the LMC office to help the practice in achieving what they want.
TRs via the phones
A question has arisen recently as to whether or not a GP may
claim for advice given to a person who is temporarily resident in the area, which does not involve a face to face meeting. A
common example would be where a temporary resident with a child contacts a doctor out of hours and asks advice, particularly in
regard to what they need to do before they return to their home area and see their own GP. There is absolutely no reason why this
cannot be considered to be an item of service just as if the doctor saw the patient. When claiming a fee GPs must ensure that:
- the claim form is completed fully;
- there is sufficient evidence that a consultation has occurred;
- patients and the GP with whom they are registered are identified;
- their NHS numbers if known
This note should be included with the claim form and a copy retained in the practice.
Under the new PPV or post payment verification system, the
practice may be asked to show evidence that in fact the service indicated was provided. Practices should be prepared to meet any such queries with sufficient detail.
The doctor is of course, clinically and medico-legally liable for advice given. Accordingly it is vital
that adequate notes are kept of the conversation and any advice given over the telephone, in order to offer a complete answer in the event of any complaint or further
investigation being necessary.
Visiting Policy?
Recently you may have read in the GP newspapers of some
criteria suggested by Staffordshire LMC as a guideline to when patients should and should not be visited, particularly with regard to out of hours requests.
A questionnaire was sent to all general practitioners in the county
to see what their views were and by and large the doctors wanted the LMC to formulate a policy.
The solution is turning out to be very much more complicated when
you get down to detail, than it would appear at first sight. Julian Neal, the GMSC representative, is working on a possible policy. I
will report when we have any developments.
IVF Paperwork
A GP contacted me recently after being requested to complete a
BUPA form in connection with the provision of IVF. This form asked for a lot of details about things which the GP could not have
known and which might be considered pejorative to the patient concerned.
I would suggest that a GP, if they make the referral for private IVF
treatment would have included in that referral letter all the necessary clinical details which they had available to assist the
Consultant in making a determination on appropriateness. Should that have taken place and if the Consultant then sends a form, for
completion before the IVF can take place, then this would be a private matter between the Consultant and the GP and not
constitute part of general medical services provision. Accordingly, the GP should consider how long it takes to complete the form and
ask for an appropriate fee to be paid in respect of the actions taken.
I would however, counsel caution if the questionnaire is completed. Any opinion given by the GP makes him
medico-legally liable for it.
The office will always advise if GPs have comments about this aspect.
Net Profit %
At a recent practice managers' forum net profit % was discussed
as an easy way of getting a quick "snapshot" of practice efficiency. Essentially "net profit %" is an expression which
indicates as a percentage the actual profit you make compared with the turnover. It is calculated by dividing the profit by the gross income of the practice and multiplying by 100.
To give a worked example:
- the total income of the practice £100,000
- costs or expenses of the practice £40,000
- the profit would be £60,000.
60,000 % = 60% net profit
100,000
Anyone however, who is not achieving at least a net of profit of
50% should consider whether the expenses of their practice are severely curtailing their ability to make a realistic profit. Those who
are showing a net profit in excess of 60% however, could be investing inadequately in their practice. It must be stressed this is
only a "snapshot" and not a definitive analysis.
Leave for Study
Attached to this bulletin is information from the GMSC and the
RCGP offering advice if you are considering any long-term study leave.
If you have any particular subjects giving problems in your practice
on which you feel general advice would be useful then please let me know and I will try to include them in future editions.
All feedback is welcomed.
Chief Executive - Dr R I Button
12 Southgate Street
Winchester
Hants SO23 9EF
Tel: - 01962 867793
Fax: - 01962 841867
E-mail:
office@wessexlmcs.com
|
