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March 2000 Bulletin
Contents:
New office - new members
On 16th February the LMC office moved from its old address in
Southgate Street to its new address at:
59 Tower Street Winchester Hants SO23 8TA
the telephone numbers, fax numbers and e-mail address remain unchanged.
The previous cramped conditions did not enable us to organise the
office in as efficient a way as we would have liked. We hope in future to be able to offer you a much better service. The new offices also
have facilities for a meeting room and economies may be available by having meetings of the Executive Committees at the LMC office,
rather than locally. We have car parking associated with this office which will mean that one of the great restrictions to people visiting the office has now been removed.
Associated with this change we have increased our area of responsibility. The IOW is very strongly tipped to join a mainland
Health Authority and because of this the LMCs have decided to work much more co-operatively together. As a result the Hampshire LMC
office is presently servicing the Committee meetings for the Isle of Wight and a certain amount of cross representation is occurring. As
and when detailed arrangements for any union are made public I will let you know.
A slightly more official notification is now possible with regard to the
relationship Hampshire is going to have with Wiltshire. The LMCs of Hampshire and Wiltshire have decided to federate. This will mean
that the office will now equally serve doctors in Wiltshire and Hampshire with effect from 1st April, 2000. Obviously with such a
large influx of doctors we shall need extra staff to cope with the load, but we hope that many of the things which we already provide for
Hampshire doctors can now be rolled out with minimal extra effort to all those doctors who are going to be equally represented but who practice in Wiltshire.
This change is effective from 1st April, 2000.
Change of Name
As a result of this it was felt inappropriate by the Secretariat to remain
known as the Hampshire LMCs Secretariat, and so the decision has been taken to change the name officially to the Secretariat of Wessex
LMCs. The website will similarly be re-named wessexlmcs.com
There is talk of even more federation in the future with the possibility
within a year or two of Dorset seeking to become part of this grouping and accordingly the name Wessex LMCs seemed even more appropriate
. With the increased responsibilities extra staff will be needed to
provide more time. One of the essentials considered by the Secretariat before the decision to federate was made was that there
should be no diminution or dilution of the attention I am able to give doctors. My idea is to have extra staff available who will be able to
deal with some of the more routine queries and do some of the practice visiting if felt appropriate, but my availability to any doctor in
the area of Wiltshire or Hampshire would be equal. I particularly wish to maintain my contacts with you with regard to partnership problems,
pastoral matters and complaints work, as well as the Committee meetings, although there may be the inevitable conflict when I just cannot physically be in two places at once.
I will certainly do my very best to ensure that the change does not
result in any diminution of service whatsoever and in fact I hope that people will be able to say this was a step forward in the provision of
the professional service which GPs increasingly demand and deserve from the local medical committees.
Enclosure: Recruitment letter for TA
Please note Upper age limit for medical specialists enlisting as officers in TA is "50"
Carers Notification
There has been a suggestion recently in Health Authorities that there should be some sort of record of carers in their areas.
Although this is a matter in which GPs may well feel they wish to
co-operate there is no statutory requirement on GPs to maintain any sort of register of the employment of their patients.
They may well do this for their own purposes, although this information
is confidential and any disclosure of names and responsibilities would have to be with the informed consent of the patient.
New Appointments
Joining us as we start our extended role will be 2 experienced people.
Alice Harding known to many of you as ex Chief Executive of
Hampshire FHSA will be providing us with an extra line of expertise on Regulations and documentation as well as being available to
advise practices. Alice will be joining us in early June.
Christine Dewbury who is presently a Medical Adviser at Portsmouth HA is joining us part time with special accent on pastoral
work with practices and doctors and utilising her communication skills to develop the website and bulletin. Her past experience in the media
world will be to our advantage. Christine starts 1st April.
We look forward to working with them both.
Access to Health Records
A local firm of Solicitors has drawn attention to the fact the Data
Protection Act comes into force in respect to Health Records from 1st March 2000. This does not mean however that the Access to Health
Records Act 1990 has been repealed. Slight amendments have been made to some of the wording in that Act, but effectively that Act remains extant.
The Solicitor who contacted one of the local practices sought to give the impression that the cut off date of November 1st 1991 had been
removed. This is not the case when application under the Access to the Health Records Act is made. Should however they make
application under the Data Protection Act, then it might be possible for them to have access to records made before that time.
One of the key points is however that the Data Protection Act
does not allow them to have copies sent to them.
I am sure that there is an element of hoping to get something for which
they know full well they are not entitled by the application that has been made.
I would suggest that where applications are made prior to the 1st
March they are to be considered to be made under the Access to Health Records Act.
Where applications are made under the Data Protection Act it needs
to be clearly ascertained by you under which Act the solicitor or client are making their application. Access is certainly available under the
Data Protection Act, but only providing they attend at your surgery and review the notes in your presence. I see nothing which indicates they
are entitled to have a photocopy. Should they bring their own photocopier with them and use it themselves under your supervision,
then I can see that being possible under the Act. However they have no rights to demand that you use your photocopier, or your paper or anything else in order to produce the copy.
There is in particular a misleading statement being made that the
maximum charge allowable under the Data Protection Act now is related to a £50 charge for up to 500 pages of copying. The schedule
of the Act that refers to this is in respect of educational records and not in respect of health records.
I feel for the moment that until we get the guidance, which I think is
imminent from the GPC, that any queries you have must be referred to the office and I will attempt to deal with them as and when they arise.
Heating Certificates!
I have recently had a couple of enquiries from GPs relating to the
request being made by tenants to support their applications for heating changes in council houses. Doctors may if they wish give
such a certificate. However, I would point out that there is nothing in the medical degree training that requires you to be the expert who
provides this information. I would suggest that a heating engineer would be perfectly able to determine the average temperatures to be
produced and it would be more appropriate for doctors only to be asked to indicate whether there was an overriding need for a
temperature band to be maintained in order that the health of the person may not be severely affected.
I would suggest Councils could use their Occupational Health
Departments to do an assessment and then liaise directly with the GP and have available sufficient information to gain any further clarification they require.
Disposal of dangerous drugs
I have had several queries recently about what GPs should do with regard to disposing of drugs, often drugs with addiction potential
which may have been prescribed for patients who subsequently die.
If the drugs are in the possession of the relative then that relative can
take the responsibility for disposing of the drugs, often in association with a pharmacist.
Doctors who wish to dispose of drugs which they hold which were not
originally held as part of their emergency supplies should liaise with a pharmacist about destruction arrangements. It is not sufficient to
merely flush tablets down the toilet. It requires proper consideration of the possible toxic metabolites which may result and accordingly in
some cases it is necessary to dispose of the drugs via a specialised route. Advice from the Pharmaceutical Advisers in the respective
Health Authorities I am sure will always be available.
It will be valuable at this point to remind doctors about the statutory
requirements in connection with a supply of dangerous drugs which may be held by them. All the drugs held by the doctor for the medical
care of his patients which are covered by the Misuse of Drugs Act must be recorded in a bound volume which is not in any way loose leaved.
In this bound volume each separate drug must have a separate page relating to either its strength or its presentation e.g. tablet/ampoule.
Every drug which is obtained from the pharmacists must be entered,
including the following details: name of drug, type of drug, strength of drug, number issued, date and a signature, ideally from the
pharmacist. When a drug is used by the doctor it must similarly be recorded so that disposal of that drug is incontrovertibly proved. In
particular the doctor must enter the name of the patient for whom the drug was administered and their address and the time of
administration and the amount. They must also have some method of indicating how much stock remains in their possession, as well as
signing the entry. When, as not uncommonly happens, ampoules of drugs become broken it is necessary for the doctor to record this fact
in the bound book and adjust the number remaining in his personal stock.
Where drugs of this nature become out of date, then disposal
is ideally made in conjunction with the pharmacist who can certify that the drug was removed from the doctor's stock and adequately disposed of.
Details of the more particular elements of the management of these
drugs, may always be obtained by speaking to the Pharmaceutical Advisers of the Health Authorities, or of course by contacting the LMC office.
Contact local Pharmaceutical Adviser or LMC office for more advice.
When I was in practice we had the system whereby the practice nurse
was responsible for maintaining a check on the state of the drugs which we kept and any which were coming up to the end of their
natural life, were often swapped for longer dated ones by an arrangement with the local pharmacist. I am not suggesting this is
something they have to in any way provide as a service, but many pharmacists have close relationships with GPs and are only too
willing to assist them in rotating their stock. This will ensure that there is never a risk of the doctor being faced with an out of date drug at the
time when a need arises for an emergency administration.
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Netting off
I return to this old chestnut to remind people of how important it is in
order that the DDRB awards should fully take into account their expenses, that all payments made by the practice are recorded in the
expenditure column of the accounts. All reimbursements received from the HA must be recorded in the income side of the accounts.
It is very tempting for people to believe that since these two will often
balance exactly there is no need to record either because it will have no net effect on the accounts. The key point here is that when the
DDRB are estimating expenses elements which affect the income of all GPs in the country they only look at the expenditure side of a
practice's accounts i.e. their expenses. Should a figure not be recorded for any reason then the value of that expenditure will be lost to the profession as a whole.
I am particularly worried about the payments in respect of Co-ops and
receipts of OOH development funding. With regard to Co-ops it is often not considered by the doctors to be necessary to enter these.
However, in the event of that not happening, in 3 years time when the DDRB figures from that year are produced, it will result in a lower than
equitable amount being put aside for GP expenses. May I encourage you to make sure your accounts, and your finance management staff,
do indeed avoid this "netting off" procedure and record fully all expenditure made by the practice, regardless of whether it is associated for reimbursement or not.
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Non Principals
The LMC in Southampton have been approached by the representative of Non-principals in Hampshire pointing out that some
practices are less than speedy about settling their accounts with locums they employ. The vast majority of practices have the view that
the correct way of settling this matter is for the locum doctor to be paid as they finish their last service for the practice. However the LMC
is concerned that often there is delay of more than a month before any money is forthcoming. The LMC has therefore decided that its
recommendation should be that settlement of payment for any locum who provides work for a practice must be no later than the last day of
the calendar month. In some cases this will involve a delay of some 3 weeks, but there never should be any greater delay. The LMC would
still wish to encourage practices to settle as quickly as possible even if it is before the end of the month.
The LMC intends to keep a note of any problems which locums run
across with practices who are persistently bad or late payers. This information would then be available to locums or non principals who
wish to check with the LMC, should they have any concerns expressed to them about the efficiency of the practice in terms of
paying them. This will then enable them to make such arrangements as they feel appropriate for payment so as to ensure that their cash flow is maintained.
In the event of a practice being so notified to the LMC office, then I
would contact the practice to determine the facts for myself. There is no question of the LMC accepting either one side or the other as
being entirely accurate without checking. However if the LMC were indeed satisfied that there was an unreasonable delay, it would take note of it.
Complementary Therapists
I have had many queries recently about the relationship between GPs and complementary therapists.
This is of course a decision for the GP personally concerned, but it is
often the case that a medical report is requested by the complementary therapist. It is important that the doctor should realise
that he has to ensure that he is dealing with someone who has sufficient qualifications for the doctor not to be accused of
co-operating with unqualified people, which would be contrary to the ethical guidelines of the GMC. Providing that the doctor is satisfied
with this, any information transmitted must be with the full informed consent of the patient. It is not a decision for the doctor alone.
Any information transmitted by the GP will be for the use of the
complementary therapist in conjunction with their relationship with the GP's patient. There should never be an intimation that the GP
approves, recommends or supports any particular treatment which is not given directly under their supervision. This is particularly important
in respect of any drugs that might be given which might conflict with treatment administered by the general practitioner.
It is also to be noted that in some circumstances employers will
accept the certification of complementary practitioners, particularly osteopaths and chiropractors which will obviate the need for GPs to
write certificates of incapacity for their patients.
A further point is that there should be no question of the doctor
indicating the patient's "fitness" for any treatment which is proposed by a complementary therapist, just as it is totally inappropriate for
doctors to give any other sort of quasi medical approval to matters which are outside their direct knowledge and skills e.g. whether or not
a child may wear goggles while swimming etc. etc.
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Nurses and minor surgery
It is quite clear from the Regulations that it is not appropriate for
practice nurses, however well trained to perform minor surgery under the Regulations for payment associated with the Red Book.
This is a payment only to be received by doctors who have achieved membership of the relevant supplementary list of the Health Authority,
clearly indicating that they have extra expertise in minor surgery.
It is of course entirely accepted that many nurses are not only as good,
but often better than some doctors at performing some of the simple surgical procedures. There is nothing to prevent these nurses
performing these tasks with the responsibility held by the doctor.
However, what cannot follow is a claim for payment under the minor
surgery system. Anyone whose practice nurse performs such a role might find it useful to discuss with me at the office the particular points
of detail which need to be covered.
Methadone Update
There has been recent publicity indicating the medico legal risk for
doctors prescribing methadone substitution. The LMC formally advises doctors not to prescribe methadone for abusers unless they are either:
• Separately contracted to provide this service
• Have received special training to handle all the problems.
Doctors must not allow themselves to be blackmailed into actions
which can have severe legal consequences and threaten their whole future careers. Anyone needing assistance with this, please contact me at the LMC office.
Prescription Information
We were always as medical students brought up to understand the
necessity for giving clear and unambiguous instructions associated with prescribing. It is increasingly the case, however, that we give
drugs on a "prn" or "as directed" basis.
There are problems with this sometimes, especially in regard to
nursing and residential homes, where the determination of the necessity for administration is not directly made by the patient and it
is not possible for the doctor to expect an instant understanding of their intentions by the care assistants or even the nurses.
In order to prevent any confusion or any tragedies due to wrong
administration, it is strongly recommended that doctors who issue prescriptions especially in regard to nursing homes and residential
homes should minimise their usage of the abbreviations "prn" or "as required". Clear and unambiguous instructions detailing the amount of
drug to be provided, how often to be administered and any other particular detail to be associated with the drug, should where possible
be recorded on the initial prescription. It is understood by everyone concerned that occasionally a prescription should be on an "as
required" basis but even then, it is possible to give some sort of indication as to the amount of the requirement which is anticipated.
Then in the event of a greater demand than this coming to pass, the doctor could be re-contacted in order to clarify their intentions in that
new situation. It is hoped that GPs will find this advice acceptable.
Mental Health Act responsibilities
Recently the BMA has felt it appropriate (November 99) to issue a guidance document on The Mental Health Act 1983 and GP
responsibilities. Anyone who wishes a copy of this, if they contact the office I will arrange for it to be sent to them.
There is also a guidance document written by the LMC in East
Sussex which is I believe extremely helpful particularly on need or otherwise for Section 12 doctors to give approval. I would point out
that although the fees payable to a doctor with special experience and on a Section 12 list are higher, nevertheless there are still fees
payable to any doctor who assists Social Services with the completion of Section documentation in respect of compulsory admission under the Mental Health Act.
It is very important indeed that all doctors are fully aware of their
responsibilities and the degree to which they are required to perform certain functions and also the degree to which any co-operation by them is entirely voluntary.
I would particularly point out that there is no requirement for a GP to
respond to a summons from a hospital or social worker to complete "Section" examinations in respect of a patient who is already resident
in the hospital unless the GP so wishes. In the event of them doing so they may attend if they wish at their convenience and may charge an
appropriate fee for both the time taken and the travel costs involved. Should the GP not wish to involve themselves at all in such
certification, it is entirely within their remit to decline the opportunity to participate.
Anyone who has any particular problems with this system, please let
me know at the office and I will do my best to assist.
Private Practice
There are a couple of problems which have come up recently which
are be worth drawing to your attention in respect of private treatment of patients.
Any patient may request an onward transmission to a Specialist or
even another GP who might provide a specialist service on a private basis, and their NHS GP is required to provide this without charge. It
is no part of the registered GP's role to seek payment from patients for providing what is part of their GMS service; i.e. referring for specialist opinion.
Recently there have been a couple of areas which have started
private GP services often in association with medical insurance agencies. These are perfectly legal providing certain criteria are observed.
• All patients who accept private care from the general practitioner
must be de-registered from that general practitioner or the list of any of their partners for NHS services
• It is certainly advisable, if not mandatory, that no contact with that patient should occur as part of any other NHS associated activity e.g. a co-operative
• All prescriptions for patients who are privately registered with the practice must be given privately and they may not have access to NHS drugs via an FP10 from their private GP
• If a private GP refers back to the GP with whom the patient is now registered and requests a prescription on the National Health Service
it will be the decision of the registered GP who is providing NHS treatment as to whether or not they accede to that request. There is no
difference here from the situation when a Consultant, private or otherwise asks a GP to prescribe a particular drug. The decision
remains with the doctor who accepts the responsibility of issuing any prescription.
There is no doubt that especially in areas such as ours, which have a
large commuter population, there are times when patients will wish to avail themselves of treatments from the point of view of their own
convenience which are not available under the National Health Service. This is certainly something which patients should be entitled
to expect. However, it is very important from the GP's point of view that they make sure there is no conflict at all with their often predominantly NHS activities in the area.
DIRECT Medical Services
I have recently been made aware of an organisation which has a base in Southampton which offers a locum service to those who wish to
avail themselves of it.
I would draw GPs' attention again to the fact that it is entirely the
responsibility of the GP who is to be the employer to ensure that any locum that is employed by their practice is indeed properly registered
and trained. It is not enough to accept the recommendation or approval of an agency such as this as a complete guarantee of the
standards to be applied. I would be grateful to hear from any GPs in the area who have had dealings with this firm so that their experience
can be passed on to any enquirers to this office.
I would ask you once more to indicate to me the ways in which you
think this Bulletin could be of most use to you. Especially in view of the fact that Wiltshire is now about to join us, I would be interested to hear
what their particular preferences would be. At present the office is only managing to produce a Bulletin once a quarter. It may in the
future be possible to increase the frequency of this. Alternatively, a much smaller mailing could be sent out monthly which would be
produced much more simply. I would be very interested to hear of your preferences.
Bulletin
Another point is that so many more practices nowadays are accepting
e-mail transmission of information or communication and this certainly facilitates prompt and cheap dissemination as far as the office is
concerned. With now over 1300 doctors to support, it is obviously very much more expensive for the office to duplicate in a paper form a
mailing such as this Bulletin. It is significantly cheaper if we can do this via the internet and in the event of practices wishing to receive it
in this way, it would be possible to adapt the arrangements. Obviously it would depend upon whether or not the vast majority of doctors
preferred this before it would be possible to amend the present distribution arrangements.
I am always willing to receive items for the Bulletin and these can be
distributed on area wide basis, rather than across the whole of the Secretariat coverage if this is the preference. Attached to this Bulletin
depending on your area are; in the case of Portsmouth and Southampton details about dental services and in the case of Winchester and
North & Mid Hampshire details of the Community Council's statement on homeopathy.
Should you be in Winchester and wish to call in at the office and see
the new arrangements you would be more than welcome. Obviously a telephone call beforehand would be very helpful, but if "push comes to
shove" - you can always just park in the car park and ring at the back door!
NHS Direct
As a result of the expansion of NHS Direct a new appointment has been made of a Medical Director who will work initially for 4 days a
week. This will be Dr Mike Sadler who will be known to some of you since he is presently Deputy Director of Public Health in Portsmouth
Health Authority. He is an ex-GP from Eastleigh with many years experience as well as his recent experience as a very skilled Public
Health physician. We feel this will be a positive advantage to both NHS Direct and to general practitioners in the area of Hampshire,
since his approach to innovation will be much more practically based than might otherwise have been the case.
We wish Mike well as he takes up his new post towards the end of April.
Chief Executive - Dr R I Button
Contact address:
59 Tower Street
Winchester
Hants SO23 8TA
Tel: 01962 867793
Fax: 01962 841867
E-mailmail: wessexlmcs@tcp.co.uk
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