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June 1998 Bulletin
Contents:
The White Paper & PCGs
Attached to this Bulletin you will find details of the outcome of the GMSC
negotiations with Mr. Alan Milburn, the Minister for Health. It also
shows clearly the pathway of certain of the funding which is very important to GPs continued existence.
In Summary:
We must accept that PCGs will happen. No government with a
majority of 180 will fail to get its proposals through. The correct course of action, was therefore, for the GMSC to negotiate the
terms which would best protect GP interests. I believe they have done this. It may not be "Peace in our Time", but it could possibly
mean that there will be no outright war between the profession and the government. Time will tell. In particular at the LMC Conference,
which is due to take place a week ahead of when I am writing this Bulletin.
New Prescription Forms
The concept of having Prescription Forms numbered has obvious
advantages from the point of view of preventing misuse of prescriptions and in the case of their loss. This is the logic behind
having the numbered Prescription Forms which are now being issued to GP's surgeries.
It is reasonable for GPs, or their staff, to certify that they are in fact
receiving the numbered forms which the HA purport to be giving them. This will enable a check to be kept on any pads which go missing from that consecutive set.
Misunderstandings occurred however about the degree to which
practices have to account for odd prescriptions which have either been miswritten or somehow rendered inappropriate for transmission through the dispensing system.
There is no requirement for the practice to keep extensive
records of individual prescriptions which are wasted.
The sole point of keeping a record is to ensure that when the
prescription leaves the doctor's surgery it is in such a form that it is appropriate for dispensing and that any theft of prescriptions is
ascertainable from the overall total which the doctor has received. The bureaucratic effort which would be involved in noting every
occasion on which a prescription is not in some way properly completed would result in a huge amount of unnecessary work,
which would serve no useful purpose i.e. entirely against the principle of "Patients not Paper".
Practices therefore need not feel guilty about not recording
individual prescriptions which are destroyed, providing they are satisfied they have been adequately destroyed.
Any audit which may be carried out by the PPA would be a matter
of negotiation with the profession and there is no statutory requirement whatsoever for practices to be unnecessarily bureaucratic about the management of their FP10 prescription
stocks.
Valuation of Surgery Premises
Notional Rent repayment for premises
not held under cost rent are made by submission of the Prem. 1
form. This is rendered in triplicate every 3 years. This is then sent to the District Valuer who is required to value the property at the
current market rent for what is effectively "office" premises in that area. This then forms the figure upon which the offer of
reimbursement of rent is made to the practice.
It is important that practices do not presume that because the
District Valuer has given a value there is no Appeal procedure.
Some times there is discrepancy between what the District Valuer
assesses as the market value, and the value the practice feels should be placed on the surgery. In that event it is open to the
practice to appeal the rent. If practices require assistance in doing this, the LMC does have recommendations on Surveyors who are
skilled in this work and accordingly could give a reliable opinion.
This is an essential first step in any Appeal procedure against the
valuation placed by the District Valuer, since without the opinion of an expert behind you, it will not be possible to negotiate from
strength to increase the value of the surgery premises for rent purposes.
Anyone having any doubts about it is invited to contact me at the office and I will assist them in any way I can.
Nursing Homes Death Certification & Undertakers
It is unfortunately becoming increasingly common for both Nursing
and Residential Homes and on occasion, undertakers to ask a doctor to attend to establish the fact of death OOH. This is something which may well be, and often is, linked with the
production by the doctor of a Certificate of Death, but the two are quite separate activities.
Establishment of the fact of death is acceptable by any lay person, providing they are satisfied and can
perform the necessary simple tests to demonstrate death has occurred.
Accordingly, one would expect nurses in Nursing Homes and in
fact in some circumstances, care assistants to be in a position to establish the fact that death has occurred. It should also, in view of
their great experience, be possible for undertakers to carry out a check to ensure that there has been no error.
No one is suggesting that doctors will not be called in most cases
in order to provide a Certificate and at the same time establish the fact of death. However, it must be understood that there is no need
for a doctor to be called in the middle of the night to attest the fact of death before a person may be removed from a Nursing or
Residential Home to an undertaker at their rooms of repose, especially if the death is fully expected.
Doctors have been expressing concern recently that Nursing
Homes do not seem to realise that death, once it occurs, it not an immediate medical emergency. It is perfectly reasonable for the
doctor to indicate that they will attend if they think it appropriate the next day, or even certify without the necessity of seeing the body if
they are happy that the death was entirely expected. I must stress that it is the GP's responsibility to make these decisions, not that of the Nursing Home proprietor.
It would be even more helpful if the Nursing Homes forbore from
ringing doctors in the middle of the night in order to even discuss this matter, since doctors already have quite enough to do with the
medical emergencies in the living, without attending to unnecessary calls at night for matters which could very well be left to the next morning.
Should doctors find themselves troubled in this way, I invite them
to let me know at the LMC Office and I will see what I can do about speaking directly to the Homes concerned.
GOS 18
This form is used by Ophthalmic Medical Practitioners and
sometimes optometrists to refer patients back to their GP where they have been found to have possible eye disease.
The essence of the form is to allow the GP to contribute details of
the systemic medical condition before onward transmission to the Specialist of the GP's choice. On occasions, however, the GP will
decide that it is not appropriate for the patient to be referred immediately and the matter is held in abeyance. An example of
this might be a very early cataract, correctly referred back by the OMP, but felt by the GP not to merit Out Patient referral, until it becomes more mature.
It appears that quite a lot of these forms are being despatched by
OMPs, but then disappearing into some sort of limbo. The patients are not always appearing at the Specialists and formal
notification is not being made to the OMP that a decision has been taken by the GP not to refer the patient for any Specialist opinion.
Obviously if the patient's welfare is being adequately dealt with
there is no intrinsic problem, but there is a worry that perhaps patients are "slipping through the net" and even that referrals may
not be being made, which are appropriate.
In Portsmouth area they are proposing to do an Audit of GOS18
forms to see what is happening to them and how far the system can be improved. Should you be in any way involved in this, it is
hoped you will give your full co-operation so that what it is intrinsically a good system, can be re-examined to ensure that the
best parts are retained and any unnecessary bureaucracy is excluded.
In the meanwhile practices may wish to:
- review their present policy (if any) on GOS18 action
- try to ensure that the OMP is always aware of GP decisions
- let the LMC know of any amendments to the system that they feel would be helpful
Patients' Own Medicines
Portsmouth LMC recently had a discussion with Dr Ann Dowd the
Consultant Geriatrician in the Portsmouth HealthCare Trust. She has developed a system whereby patients' medications brought
with them to hospital, instead of being destroyed, were used for that patient where possible and then returned with the patient when they were discharged home.
There had been problems originally when schemes like this were
suggested in that pharmacists were pointing out the lack of detailed knowledge of the actual state of those medicines, such
that they could not be put into any sort of ward stock. Accordingly, it became the habit for all medicines on entry to be destroyed. The
level of waste is quite obvious and the savings which have resulted from the initial workings of this scheme, which has only
been run for a short time, is upwards of £33,000 per year.
The scheme may be further developed and used as a test of the
ability of the elderly person to manage their own medication and the observation of how accurate they are about their medication,
would be a useful source of information for GPs. It is also thought that this might be possibly applicable to the Acute Wards of the
hospital, though the stays there tend to be shorter and savings may be commensurately less.
It is hoped that this good idea could be rolled out to other areas of
Hampshire and people who wish to have more information on this, or would like to raise it with their own hospital units, please get in
touch with the Office and I will be able to give you further details.
Violent Patients
GPs know that if a patient is violent or threatens violence to the
doctor or staff their name may be removed from the registered list immediately. The only requirement on the GP would be to provide
immediately necessary treatment and even then only in circumstances which guaranteed the safety of the GP & staff.
What is not widely known is that a temporary resident effectively
becomes one of the doctor's registered patients and in the event of a temporary resident behaving in a way which gives similar
cause for concern, they may also be removed under the same regulation.
The important thing here is that if the temporary resident patient is
removed in this way, their name will be entered on the list of violent patients, and some record kept of their movements and activity.
I know that in Winchester particularly there are problems with
itinerants who can plague the surgeries, and at the moment we have not got a clear understanding of who these people are. If you
do have such a temporary resident, please do notify the HA so that we may better find ways of controlling what is a totally unacceptable situation.
Partial Post Natal Care Fees
This vexed question continues to rumble on. One thing which
would be useful is for midwives who carry out visits on GP patients to keep some sort of clear record, and perhaps even for this to be
recorded in the notes of the patient, so that a check may be made of when exactly visits are performed.
The LMC is still working hard to clarify this whole situation, but do
not in any way wish to disturb the increasingly common arrangement of team working between midwives and GPs.
Benefits Agency Doctors
Any doctors who do work for the Benefits Agency and are invited
to sign the new contract which has been provided by SEMA, are advised to contact the LMC for further advice.
The BMA at present is advising against signing this contract since
there are very serious concerns about these contracts which do not appear to provide proper professional Terms of Service. The
BMA is actively negotiating on this matter at present and up to date information can be obtained from the office.
Nomad Prescribing
This system of controlled dispensing, which is often utilized with
patients who need assistance in coping with often large numbers of medications taken at different times, is giving problems.
When it was originally introduced, largely on the initiative of the
Pharmacists, it was done without any form of remuneration being payable to the Pharmacists for the extra dispensing work involved.
This has now reached the stage where the systems are becoming
so common that the Pharmacists are finding this to be a significant drain upon their dispensing time.
The only recourse that has been considered at the present time is
increased frequency of prescribing to offer in the form of dispensing fees extra remuneration to Pharmacists for the extra work involved.
Unfortunately this has meant that on some occasions doctors were
being approached and asked to prescribe as frequently as every week. This is obviously unacceptable, since the surgery system
would break down, were this to be followed universally.
A reasonable compromise should be negotiated wherever
possible. Subject to the overriding consideration that prescribing should be for sufficient medication and for a time which is felt by
the doctor to be clinically appropriate for that particular condition. It is not a matter of a Pharmacist indicating that they expect
prescribing for a particular period to suit the convenience of Nomad prescribing. It is also the case that the doctor must understand that the Pharmacist is providing this service very
largely for no fee and that if it is possible to reach a compromise arrangement with your individual pharmacist, this is by far the best course of action.
As in all these things, although the rights and duties of each side
are clearly laid down, progress is usually best made by negotiation and reasoned discussion about what could be helpful
to both professions and yet safeguard and improve the interest of the patient.
If the LMC office can be of assistance in facilitating any such
information exchange, we will be glad to do so.
Voting arrangements in LMC organised elections
There has been some concern expressed in one area when
doctors who were invited to vote in an election were asked to use a ballot paper on which their name is recorded and to countersign
with their own signature once the vote had been cast. This is standard practice for LMCs in order to ensure that only eligible
voters have in fact completed the form. Perish the thought, but it has been known for one partner in the practice, who may well be
oldest to take it upon themselves to enter votes on behalf of partners without individually consulting them. As a result the LMC insists on clear authentication of every vote.
Confidentiality in Parliamentary voting is not absolute and I am
sure that everyone is aware that it is perfectly simple for the Returning Officer to identify from a voting slip issued, exactly who
voted in what way. Obviously, the LMC system would make it even easier to tie up an individual vote with an individual voter, but the
advantages of ensuring that the voter's real preferences are recorded, is felt to be absolutely vital.
The votes, when they are received at the LMC office are dealt with
entirely by the Returning Officer, Mr. Nigel Richardson, the Administrator. He keeps these records totally confidentially and he
does not even normally share them with the LMC Secretary. Only in the event of there being some dispute as to whether the vote is
indeed a valid one and whether it should be disallowed and not count in the final result, would the LMC Secretary become
involved. If that were the case it may even be that clarification is sought from the voter who is identified on the form to ascertain their true intentions.
After the election is completed and the results have been formally
agreed, these ballot papers are destroyed in a confidential way and no list or record is kept of the voting pattern which may have occurred.
I think it would be extremely dangerous to move away from a
system which allowed authentication of the individual voter's signature, since often elections are decided by a small number of
votes and any uncertainties as to whether the true intentions of the voter have been adequately represented, would call into question
the whole democratic structure under which the voting took place.
Should any GPs have ideas which might provide equal security
and avoid the necessity for the individual identification, I would be very interested to hear about them, but the LMCs at present do not
intend to change the system unless there is clear reason for doing so and an equal degree of security can be guaranteed.
There has been a change in the Officers of the LMC in
Portsmouth. Dr Jim Warner has now retired as Chairman and elected in his place is Steve McKenning. The new Vice Chairman for Portsmouth is David Melville.
Both Southampton & Portsmouth have under their new
Committees agreed to invite to the Open Meetings the Chief Officer of their CHC. It is important that the CHC is felt to be
contributing to patient care and in this new area of co-operative NHS working, it is hoped that such contacts will facilitate closer
working in future for the benefit of patients. Attached to this Bulletin is an article by Mick Rolfe.
The LMCs in Hampshire have discussed among other things recently:
- The development of a new formula for the allocation of computer reimbursements from HAs.
- The inappropriateness of the prescribing of Methotrexate
and its 1 - M administration in general practice in most cases.
- The necessity for Ritalin to be considered a Specialist Drug provided only in secondary care.
- The withdrawal of Methadone prescribing from general
medical services and the encouragement of its provision as a specialist service, either with specialist GPs, or through a Drug Advisory Service.
- A Virement project to allow funding for secondary care
expensive drugs to be top sliced from prescribing allocations and the responsibility firmly placed with the specialist secondary care.
- The monitoring standards for OOH care for Co-ops and commercial deputising services.
- All LMCs keep a watching brief on GMS cash limit usage and negotiate with HAs.
- White Paper and PCG activity which varies in its intensity and detail across all the areas.
- Motions for the LMC Conference to take place 25th/26th June 1998.
- The question of Study Leave for Trainers and whether this
should be an extra week automatically for everybody.
- In Portsmouth co-operative working with the CHC on analysis of Mental Health Services.
- Others matters which are often individual to the LMCs concerned, dealing with problems which individual
constituents have brought to the attention of the Committee.
Should you wish to discuss any of these matters or find out what
your LMC has done in more detail, then you are invited to contact your constituency representative.
Chief Executive - Dr R I Button
12 Southgate Street
Winchester
Hants SO23 9EF
Tel: - 01962 867793
Fax: - 01962 841867
E-mail:
office@wessexlmcs.com
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