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March 1997 Bulletin
Contents:
Health Centre Rents
You will remember that I wrote to all Health Centre doctors last
year inviting them to encourage the valuation of their premises for the purposes of the new rent arrangements which it was hoped
would result from agreement between the NHS Executive and the GMSC on a model lease. Unfortunately full agreement has still not
been obtained. The NHSE are holding back on a couple of vital points. As a result, if you receive any indication from Trusts they
wish you to sign a lease or to agree to change the rental arrangements, please do nothing without consulting the office.
The valuations which have been reached so far, since they have
not been agreed, cannot be considered binding. The Health Authorities concerned will have to arrange their own valuations
before any variation in the notional rent reimbursement payments can be agreed. The District Valuer is the arbiter of these rent
figures. However, the Red Book insists that the Health Authority obtain their own valuations and are bound to not exceed these
figures in reimbursement of notional rents. The system is not as simple as it might seem and, if there are problems, please don't hesitate to contact me for advice.
Health Education Authority Aims for Healthy Workplaces in Primary Care
The Health Education Authority (HEA) is about to undertake a
study of workplace health in General Practice. This is part of a larger initiative "Health at Work in the NHS" which the HEA
manages on behalf of the NHS Executive. The aim is to encourage employers working within the NHS to develop healthy workplaces.
So far, the initiative has targeted staff in Trusts and Health Authorities; now the plan is to move the focus to GPs and their practice staff.
An Advisory Group has been set up by the HEA and includes Ruth
Chambers the RCGP's GP Stress Fellow, Eric Rose from the GMSC, Rosey Foster from the Association of Managers in General Practice, Ken Prudhoe a GP in the North East and
representative of the RCGP, and others from occupational health medicine and nursing. Ruth Chambers is well fitted to manage the
study with her experience in the area of doctors' health, many research studies, her running of a support scheme for Staffordshire GPs, and her work with the RCGP's GP Stress Fellowship.
Five hundred practices from across England will be randomly
selected and practice managers (where they exist) will be invited to be interviewed by phone. A GP in each practice, will be sent a
postal questionnaire. The enquiry will cover workplace health issues such as personal safety, sickness absence, who GPs turn
to when they are ill, Health and Safety, risk assessment and stress management in the practice. Eric Rose, and others from the
Advisory Group have all commented on the questionnaires and helped to shape the questions. They will be involved in advising
the HEA where to go next once the answers come in.
They hope that any GPs and practice managers who are
approached will respond to the survey. They'll disseminate the results when the survey is completed by publishing a paper describing the findings, with reports of the HEA's plans and
activities in the medical press.
Victoria George from the HEA will be pleased to answer any
questions about the project as a whole on 0171-413-1881
Complaints of Sexual Abuse
As part of your Practice Complaints Procedure, you should have
in place an appropriate method of responding to complaints which may have sexual connotations. This may apply either to children or
to adults but concerning people who work in the Surgery, either partners or staff.
A necessary part of this complaints process should be:
- To ensure extra confidentiality
- That, in the case of any child sexual abuse, due regard is paid to protecting the child's interests
- All investigated complaints which may appear to show a
prima facie evidence of abuse would need consideration for early referral to the police for investigation
Although complaints of this nature should be considered in just the
same general way as any other matter, it is particularly important that staff feel confident that they are able to report any problems or
suspicions without any risk of being criticised or victimised.
It is very important in this regard to have a clearly nominated
person in the practice to whom complaints are referred as in the normal system. It may be considered appropriate for a person of
the opposite sex to also be available as an option in order to make any complaints process more user friendly.
- Counselling support from outside the practice structure may
be considered appropriate at an early stage in respect of a complainant who has concerns about the practice's partners or staff. This is by no means mandatory but may be
considered a wise action to be considered during any investigation which may proceed.
Chaperonage and adequate explanation of the actions taken by
all staff, including doctors, is often the way to prevent misunderstandings. These could result in complaints which are totally without foundation but merely the result of bad
communication.
As usual, I recommend that anyone who has concerns about the
process to be followed in dealing with a complaint, should contact the LMC Office at an early stage.
Specialist Drugs
Health Authorities are finding themselves under increasing
financial pressure with regard to all their expenditure. GPs who until now have been able to consider themselves on a non cash
limited basis for drug expenditure are beginning to enter the time when things will have to be re-thought. As you will know even Non
Fundholders this year received an allocation for their drug expenditure which has been expressed in cash terms. This means
that it is shown as the amount that it exactly costs the government to fund the dispensing of those drugs i.e. it is the net ingredient
costs (NIC) less the discount which is negotiated for the bulk dispensing arrangements.
I believe this is the first step along the line of cash limiting the
funding for drugs available in general practice. The net effect of this is going to be that while the politicians will be able to continue
to indicate that in their opinion the doctor is provided with all the necessary funding to supply all the clinically necessary drugs, it will
effectively be able to limit this amount via the Health Authorities. What they probably will do is pass down the funding for the drug
allocations in the form of part of the Health Authority's cash limit. The Health Authority, who in the event of GPs finding themselves
exceeding the budget allocated to them; will have to make economies from other expenditures e.g. hospital and community health service funding.
This will obviously mean that the very expensive drugs which
Consultants have sought in the past to have prescribed in general practice in order to avoid exceeding the hospital cash limited
budgets, will now become equally unaffordable in general practice.
It would appear to be the correct course that any new drug which
the Consultant or Specialist feels is a valuable addition to the therapeutic aramentarium, should be submitted to an authorised
body e.g. a Drug and Therapeutics Committee, as a fully developed business case in order to demonstrate its cost
effectiveness as an addition to pharmacopoeia available locally. In the event of that business case not succeeding, then it would be
up to the Trust concerned to decide whether or not extra funding would be made available or not from the allocations they already receive from the Health Authority.
Everyone will acknowledge that it is not possible to continually
expand the resources available to cover every single medical advance. Instead we will have to consider the relative benefits of
one form of treatment over another and if both cannot be afforded then sooner or later some degree of prioritisation will have to occur.
GPs who feel themselves under pressure to prescribe new drugs
of which they know nothing are strongly advised to contact the LMC office where support and advice will be available. In the
event of the GPs being asked to prescribe specialist drugs which are completely new to the market, I would strongly advise that this
could well be inappropriate, since it would be unusual for the GP to have the adequate expertise. Medico-legally the risks would be enormous.
Prescribing of Methylphenidate (Ritalin)
This drug is a stimulant related to amphetamine and is indicated
as part of a comprehensive treatment for attention deficit hyperactivity disorder (ADHD) in children. A number of GPs have
been asked to prescribe this drug, but in general have been unhappy to do so because experience with this drug is still limited
and the product licence specifies that treatment must be under the supervision of a specialist in childhood behaviour disorders.
In view of these difficulties a joint protocol has been agreed
between Portsmouth Health Care Trust Child Psychiatrists and Portsmouth and South East Hants GPs relating to the Shared
Care of children and adolescents receiving methylphenidate This protocol suggests responsibilities for both parties and recognises
that the Psychiatrists will be responsible for prescribing and monitoring the effects of methylphenidate.
The Portsmouth Drug & Therapeutics Committee has endorsed
this policy and methylphenidate will now be classified as a 'Red Drug' i.e. one which should only be prescribed by the appropriate
specialist. This policy will be reviewed after 12 months.
The same principles should be applicable in all authority areas
and the LMC will be recommending this course to be followed throughout Hampshire. GPs are invited to discuss the matter of
prescribing Ritalin with the Secretary if they are approached by specialists to accept prescribing responsibility.
"Named Patient" Drugs
There seems to be a lack of familiarity with the procedures to be
followed and what is involved in issuing drugs under the heading of "Named Patient " basis.
Effectively any doctor may prescribe any substance which they
consider the patient may need without recourse to virtually any legislation. However, when a doctor prescribes an item which is
outside its product licence use they intrinsically take on board the medico-legal responsibility for any ill effects.
Unlicensed drugs which have not yet reached the stage of having
a product licence granted, may be obtained by ordering them either through a pharmacist, or directly from the manufacturer.
These must be ordered with the intention of a particular patient receiving them. This is what is meant by "Named Patient". It is a
fallacy to believe that the patient's name must be divulged to anyone at all. Certainly in the United Kingdom a doctor only has to
have in mind the use of the drug in a particular patient.
It is very important in this circumstance however that the patient
gives their "informed" consent, since if untoward effects occur it is important the doctor can demonstrate clearly the patient was fully
appraised of the possible risks. The GMC would take a grave view indeed if the drug were given where this "informed" consent had not been obtained in advance.
Although this procedure is a fairly rare occurrence in most
people's practice, the very fact of its rarity means that if faced with it, a lot of GPs are unaware of what responsibilities they have. A
further discussion of the use of unlicensed medicines is to be found in the December 1992 edition of Drug & Therapeutics
Bulletin. The authority to give these drugs is vested in S.I. No. 3144 issued in 1994, but since most GPs won't have a copy of
this to hand there is one in the office and if anyone is interested in seeing it, please contact me.
Practice Staff Pensions
We are slowly getting information filtering through from the NHS
Executive about the new arrangements for pensions. The latest information we have is this will apply to all staff who are presently
employed by general practitioners in connection with
their GMS activities. It is not clear whether this would include the
fundholding staff members of the practice.
The NHSE is issuing a booklet in the near future with a question
and answer section which hopefully will deal with a lot of the commoner questions. As soon as it is available it will be brought to your attention.
It has been agreed locally that once full details are available there
will have to be a guillotine period in which applications can be lodged to join the superannuation scheme, because this funding
will come from the GMS cash limited account. In the event of there being a long delay in application the result would be GMS funding
would be underspent for the year which would be very unfortunate. Once it is known exactly what commitment will be made against
this funding, it will be possible to release some of the funding for other purposes in this financial year. May I suggest that you watch
this space and as soon as there is any definite information, I will get it out to you.
WUN532
This refers to a new form which seems to be making its
appearance with regard to special schools, which GPs are being asked to sign.
WUN532 concerns the administration of drugs to patients outside
their home environment. I draw your attention once more to the advice I gave in a previous bulletin which is that your terms of
service are fully complied with provided you issue any orders for drugs on the authorised form i.e. the FP10. There is no need for
you to sign other drug sheets whether they be in residential homes or special schools. This is a private matter. If the home or school
wish this to be done, then it will be something which requires them to enter into a private contract with you.
I have had this drawn to my attention primarily with relation to
Portsmouth Healthcare Trust, but should it happen in any other areas of Hampshire, I would give the same advice i.e. you do not need to sign this form.
Claims for Night Visits
Unfortunately my attention has been drawn to a habit which seems
to have grown up locally which does not appear to be in keeping with the regulations. In the event of a night visit being performed by
a principal on the list the principal is entitled to claim a fee for providing the visit as long as the person is that GP's registered patient or that of a partner.
With the advent of co-ops it is becoming increasingly common for one doctor to do a visit on behalf of another and sometimes those doctors are applying for
the night visit fee for the patient concerned with a claim over their own name. Unfortunately this is not in keeping with regulations and
auditors are likely to throw it out and require repayment. May I suggest that some degree of administrative cross-over is
necessary whereby if a visit is done for another doctor's patients, that doctor claim the fee in his own right and that any subsequent
payment to the doctor actually performing the visit should be done other than through the NHS claiming system.
I am sure people will feel this is an unnecessary administrative
extra burden, however, in order to avoid difficult financial problems after the accounts are audited, it would be wise to make sure the regulations are complied with.
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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