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WESSEX LMCs Bulletin - Sept 2000
4) Absolute Beginners Guide to LMC LIVE 7) Hep B Infected Health Care Workers 8) Trainers Grant for Part Time Registrars 9) Locums 14) Missing/stolen prescriptions 15) Zyban and helping patients give up smoking 17) Staff Involvement NHS Taskforce 18) Data Protection Act; Update 19) Cautionary Tale The National Plan We have a government at present that may be summed up as "never mind the quality feel the width." Their latest proposals for extended surgery opening hours on top of an already full and intellectually demanding working day are unreasonable. The government is taking consumerism as its God and furthermore by its stress on getting more for less, demonstrating they know the cost of everything and the value of nothing. When you are away from the front line of General Practice, or even like politicians, have never been there, the job seems easy. Why they lay such stress on the need for training in General Practice when they seem to know how to do the job with no training whatsoever, underlines the hypocritical attitude we have come to expect of them. Their National Plan is largely a series of "wish lists" constructed to appeal to an electorate which they will shortly be approaching. If it is so easy to reorganise the Health Service to deliver better and faster care, why didn't they get on with it? Of course you must be careful not to disturb their prejudice with facts, that might make them realise it is not so simple. GPs are already acting professionally every day in their surgeries. They are professionals who practice primarily to the benefit of their patients. They are the intellectual elite of the country and could use their intelligence in many fields – the vast majority of which could earn them a great deal more money. Yet they feel a vocation for helping others and ask no more than a fair reward and the opportunity to practise their skills curing occasionally, relieving often, but comforting always. I am always amazed by the way in which the vast majority of GPs are willing to do more than could ever reasonably be asked of them. They accept unsociable hours, emotional pressure and from those in authority, unreasonable expectations and meddlesome interference. GPs who lie down and do an impersonation of a doormat should not complain I suppose when people wipe their feet on them. At present as a profession we are doing just that. Every extra demand placed on us by government whim is grumbled about – but achieved. We are content it seems to be merely reactive to other's stimulation. We trained as Doctors – a valued caring profession of great learning. – We should know better than faceless bureaucrats the needs of the patients in our surgeries. We are failing as a profession by not resisting dictated medicine. Our responsibility is to patients – not politicians and we must examine proposals from government to see whether they really are in doctors and patient's interests. If they are not we should not acquiesce. Even more important we should be telling government what is necessary – not waiting to be told. "Doctor" means teacher – if ever a government needed education it is this one! Bob Button
Wider Powers for The General Medical Council: The Medical Act 1983 (Amendment) Order 2000 The Government and the public has become increasingly concerned over the past few months about the ability of the GMC to act swiftly and effectively when a doctor's fitness to practise is called into question. The Government has introduced legislation enacted under SI 2000 No. 1803, the Medical Act 1983 (Amendment) Order 2000, effective from 3rd August 2000 to widen the powers of the GMC. The key new provisions are: -
This is the first step towards the need for wider and broader change which will be the subject of further discussion with the GMC. However, strengthening the GMC's powers in these important and significant ways conveys the Government's determination to apply the lessons of recent events so that patients get the protection the deserve.
May I just draw your attention to the fact that all Bulletins are put on the Web and may be accessed by the LMC "Live" site. If you haven't yet tried it you will find this is intended to be a very up to date area which we will stock with points which are current, judging by the number of telephone calls and queries we receive. You might like to check the LMC "Live" website (www.lmclive.co.uk) to see whether or not we have already dealt with what might be your query before you contact the office. Although of course you are still welcome to telephone us if you need a more detailed response. I am delighted that the Practice Managers find it extremely useful, but I would ask them please to circulate it widely, because the Bulletin is intended to have information of interest to the whole of the primary health care team, so please if necessary duplicate a copy and make it available to all partners.
Absolute Beginners Guide to LMC LIVE !! "Hot links" are available on LMC LIVE to many documents and references. If a word, reference or phrase appears in blue and underlined, just point and click on it to be taken directly there. These "hot links" allow you to easily navigate LMC LIVE and jump to other Web Sites with one simple click. For example, click on the following "hot link" to the Revisiting the Web section to try it out. Some "hot links" take you to documents stored on the Web; these documents are usually in "pdf format" (portable document format). To read these you need a "PDF Reader" which can be obtained FREE at www.adobe.com Just follow the simple instructions to "download" the reader; then double-click the newly downloaded file and follow the installation instructions. It really is very simple. (TIP: For ease in finding downloaded files, such as the PDF Reader, set up a separate "downloads" folder on your disk, and always download to that.) Finally, to allow for easy access to LMC LIVE, just add it to your "favorites" or "bookmarks"; or better still, make it your "Home Page". If you aren't sure how to do any of the above - or if you need any further guidance - drop me an e-mail at david@mackell.co.uk and I will try to help. This "web stuff" can be confusing, and a little guidance may prevent hours of frustration. More hints and tips in the next bulletin!
Footnote: This section has been written by our web designer, David Chapman of Mackell Productions, who has very kindly offerred his assistance with any user queries relating to LMC LIVE. I am very grateful to David for all his help in setting up LMC LIVE and re-designing the Wessex LMCs web site. Thanks to his efficiency we are able to ensure that both are updated regularly and reliably. Christine Dewbury
LMC LIVE (www.lmclive.co.uk) seems to have proved popular with local practices, with an increasing number of "hits" each week. For those of you who have not yet accessed it I hope this summary of the contents might tempt you to click on! I hope the web site is easy to navigate and that it will prove useful. The Recent Guidance section speaks for itself. At the moment it contains documents on the new Human Rights and Data Protection Acts, recent guidance on hepatitis B positive health care workers, advice on the current complaints procedures and guidance on the handling of drugs returned by patients. It also includes an article by Stewart Drage, Secretary of Middlesex LMCs, entitled the ABC of PCTs. Under Employment Contracts and Guidance we have a copy of the Wessex Contract of GP Registrar's Employment and also change of partner advice. Last month's Bulletin was produced on the web shortly after publication and this edition has been published simultaneously on LMC LIVE and in hard copy. Predictably you will find them on the web under Bulletins . In due course it would be good to e-mail your copy direct to your practice but we will first need to develop a database of practices wishing to access the bulletin in this way. Those of you who used the old Wessex site will recognise articles in the Medical Reports and Certificates section which have been transferred to LMC LIVE. Dr Button's report on the LMC Annual Conference 2000 has its own special section! Common Abbreviations is self-explanatory and I would be very grateful for additional contributions. Links to Recent Documents is intended to put useful documents just a click away. There are hot links to the National Plan and the Joint Press Release from the RCGP and the GPC and a number of other recent documents. More recently Setting the Boundaries; a review on reform of the law on sex offences and NHS executive advice on hospital treatment of overseas visitors have been added. Last, but not least, we have Useful Medical Links that connect you directly to other potentially useful web sites. This brings me on neatly to the most useful link of all, which is the link with the old Wessex LMCs site www.wessexlmcs.com that has not been abandoned. We decided it needed a revamp if it was to run in parallel with its smart new partner, LMC LIVE. It will be re-launched any day now having shed its waspish yellow and black image in favour of a new cool blue look! The intention is that this site will serve the more specific local needs of the Wessex LMC Secretariat and also the individual needs of each LMC. The two sites are linked and therefore just a click away from each other, which should be easy enough! We have included photographs of some of us at the LMC secretariat so that you will have a clearer idea of who you are talking to on the telephone in future! It would be nice if this was a two-way exchange with photographs of some of the key players around the Wessex region included on the individual LMC pages. Now that we serve such a widespread geographical area it is important that we ensure our communication systems are as effective as possible and that we retain a personal approach. Please contact me with suggestions and comments on both web sites so that we can incorporate your ideas as much as possible in the future. It is up to you to let me know how we can best serve your interests and we will oblige if we can. Christine Dewbury
(Based on Health Service Circular 2000/025) The UK has been signed up to the European Convention on Human Rights (ECHR) since 1951. The Human Rights Act comes into force on 2nd October 2000 and incorporates the ECHR into UK law. This does not confer any new rights but allows people to enforce the convention in UK courts rather than taking a case to the European Court in Strasbourg. It aims to "embed values of fairness, inclusiveness and respect for human dignity at the heart of public services" and to "develop a culture of respect for individuals rights and responsibilities." GPs, as independent contractors within the public services, will need to ensure that they comply with the Human Rights Act in addition to implementing the Working Time Regulations, Parental and Maternity Leave Regulations and Part-time Workers Regulations. All of this legislation must be linked to existing equality and race relations legislation. These considerations apply to the GP's role in the delivery of patient care and as employers. We will endeavour to keep you informed of any future developments. It is most important that we become aware of any potential pitfalls as early as possible so that we can give timely advice and alert other GPs to possible pitfalls. Please notify Wessex LMCS if you have any problems or queries in relation to the Human Rights Act or the Regulations relating to Working Time, Parental and Maternity Leave, or Part-time Workers Regulations. Summary of Health Service Circular 2000/025 with full text link available under recent documents on www.lmclive.co.uk (The COIN database of all the Health Service Circulars on the Internet can be found on the Useful Medical Links page on www.lmclive.co.uk)
Hepatitis B Infected Health Care Workers: Guidance on implementation of Health Service Circular 2000/020
The GMC's guidance in Good Medical Practice and Serious Communicable Diseases states that doctors who have a serious communicable disease and continue in practice must have appropriate medical supervision and should not rely upon their own assessment of the risks they pose to patients. The UKCC also emphasises the duty of care of health workers to safeguard the well being of their patients. Much has already been achieved in preventing the transmission of Hepatitis B infection to patients and the new guidance aims to reduce further the risk of transmission and supplements previous guidance. Hepatitis B infected health workers are those who are hepatitis B surface antigen (HBsAg) positive. It is now known that some individuals are infected with a strain of Hepatitis B virus that is unable to produce the e antigen but is still able to assemble infectious particles. Health workers infected with such a variant strain could therefore place patients at risk. e-antigen positive The restrictions are unchanged for these health care workers who must not perform exposure prone procedures. e-antigen negative
Two laboratories have been designated to carry out the viral load assays and full details of the testing procedures to be undertaken are outlined in the official guidance. Summary of Guidance www.lmclive.co.uk/hepbrep/ + full text link available www.lmclive.co.uk/recpub/
Trainer's Grant for Part Time Registrars A change took place on 1st April this year when the responsibility for the payments for Registrar training was transferred from the HA to the Educational Authorities. In future although the HA will remain the paying agent, they will work under the direction of the GP Education Authority. Registrars have therefore been removed from the Red Book. One of the effects of this has been that future Trainers who have the responsibility for a part time Registrar will now receive a full trainer's grant, rather than pro rata.
There is a new HSC (2000/019) which deals with the appointment procedures for hospital community medical and dental staff. The consequences of this since it is very important indeed that practices employing them ensure they have in their possession all the necessary documentation including GMC registration, and evidence of appropriate membership of an Indemnity Organisation and or Training certification. HAs should be able to assist doctors who want a copy of these Regulations.
I have developed a lot more sympathy with patients since I have been dealing with practices who have instituted automatic exchanges. I do notice that on many occasions faults develop in these systems whereby you get on to a "loop" such that you never get through to your requested choice. This would not be immediately apparent to the practice and it is unlikely that patients would particularly draw it to your attention, unless it were an emergency. I don't of course ever use the emergency access arrangements but would ask practices to find some way of checking that their systems are really working appropriately. It has become so soul destroying and time consuming for the LMC office to be "hanging on" to a long series of options before they can get through to a receptionist wanting to be put through to a doctor to answer a query, that in some cases it is quicker to send a fax! Have practices thought of having an administrative line which by-passes this exchange? If they have I would be most grateful if the office could have access to it, or that this could be communicated as the actual number to ring at the time a query is placed with the office.
I have had a query recently about what responsibilities doctors have with regard to paternity testing. Let me state that in my opinion this is no part of NHS GMS. I do not believe there is any requirement on GPs to co-operate with this unless they feel there is need to do so from the point of view of the health of their patients. It is also worthwhile pointing out that paternity testing is actually a matter which applies more to the putative father, than it does to the mother. You must have the informed consent of the individual man and the result must be communicated to them both. It is not something which can be performed simply on request of the female of the partnership alone. Obviously in some areas women are more likely to be unsure about which of their partners fathered the child than in others. Nevertheless this is primarily a legal matter and not part of the GP's Terms of Service.
Both the BMA and the LMC are more than willing to advise on Contract Terms for Staff and in fact have available sample Contracts which could be utilised. It is very important to stress that just because you had a Contract you picked up from somewhere a couple of years ago, you cannot automatically presume that the Employment Law has remained unchanged since then. We have had a couple of cases recently where the doctors concerned have been attempting to apply, in one case to a doctor and in another case to a member of staff, conditions which have been subsequently made inappropriate and illegal under changes in Employment Law. I strongly counsel practices, therefore not to imagine it is a simple matter of writing a simple Contract for themselves and would invite them to contact both the LMC office or their local BMA office, where the Industrial Relations Officer will have access to the appropriate legislative guidance. Industrial Tribunals are both time consuming and often extremely expensive. To try and save costs at the stage of writing the Contract is often a very poor economy. I strongly advise you not to merely attempt to use a possibly out of date Contract, but seek up to date advice on every occasion when you have a new member of staff, (doctor or lay) working for the practice.
Shot gun certification is something which can give a great deal of trouble to GPs. If GPs become involved in certification and the decision goes against the applicant, then it is highly likely that the applicant will feel personally aggrieved with the general practitioner. This has happened already in Hampshire and it was not felt to be comfortable. I also point out that this is no part of your GMS. If you wish to be involved in this of course that is your right. However any actions you take in respect of this are to be considered private and outside the NHS. It is therefore entirely appropriate for any medical opinion sought by the Constabulary to be paid for by the Constabulary and I would suggest that you should agree the rates of your charges before you agree to do any form of examination. I also point out that in the event of you giving a medical opinion, you must make sure you can defend that opinion by demonstrating that you have carried out adequate procedures to enable you to reach that opinion, including possibly a medical examination.
FP10s are a highly marketable commodity. It is extremely common for them to "go missing" because they have either been stolen, or mislaid or accidentally destroyed. One of the advantages of the indexing system is that is gives the practice the opportunity to keep some sort of track of these pads. One of the things I would recommend to you is that as soon as it is noticed that for any reason a pad which should be there is not – without carrying out an exhausting investigation to determine exactly why, it is a good idea to notify the HA. This will enable them to notify pharmacists and for them to be vigilant about any prescriptions which carry the relevant serial numbers. It is not necessary for you to have a serial number note of all your individual prescriptions, but it is important that you have some form of record of the numbers of the pads issued to the practice, so that you can identify prescriptions which have not been validly issued by you.
Zyban and Helping Patients Give Up Smoking
The health hazards of smoking are well established. It is the greatest single cause of illness and premature death in the UK, with more than 120,000 deaths of people aged over 35 years attributable to smoking. Analyses have consistently shown that smoking cessation interventions, such as nicotine replacement therapy (NRT), are a relatively cheap way of saving lives. The following recommendations were taken from Effectiveness Matters, NHS Centre for Reviews and Dissemination, University of York. Smoking cessation interventions are highly cost-effective, therefore:
The new anti-smoking aid Zyban (bupropion) has now been available on the NHS since 26th June. It is presumed to act on the neurochemical pathways that reinforce nicotine addiction. The evidence suggests that, in combination with motivational support, Zyban can help those committed to giving up smoking. Its potential role in the reduction of coronary artery disease and cancer could therefore be significant. The National Institute for Clinical Excellence will be asked to advise GPs on the most appropriate and cost effective prescribing regimes for Zyban and nicotine replacement therapy including duration and targeting. The responsibility for deciding what treatment is best for any patient of course rests with the doctor in consultation with the patient and in the light of the clinical history. Health authorities do not have powers to prevent a GP from prescribing Zyban on the NHS if the doctor feels that the patient is likely to benefit from it. Christine Dewbury Footnote (04/06/01): Zyban Warning Since this bulletin report was written there have been numerous reports relating to the safety profile of Zyban. It is therefore vital that all GPs fully acquaint themselves with all the potential side effects, drug interactions and contraindications if they are considering prescribing Zyban. Chief Medical Officer's Urgent Communication 30/05/01 www.doh.gov.uk/cmo/cmo01_07.htm
A lot of people are still confused about the arrangements for pensions in respect of NHS retained medical staff. Retainer doctors are effectively subsidised assistants. They will have a Contract of Employment with the practice and the practice will be their employer. As such they are counted as NHS Staff and therefore entitled to membership of the NHS Pension scheme if they so wish. The responsibilities for payments of employers' contributions rest entirely with the practice who is their employer. Since they are subsidised it is irrelevant to whether the person concerned wants to be in the pension scheme or does not. The same amount of money is payable to a practice as a subsidy regardless of any contractual arrangements which may be entered into. Accordingly, the Red Book is irrelevant for consideration of this subject. Retainer doctors are not ancillary staff and as such there is no direct reimbursement of any pension contributions made by thepractice. This is just part of the overall costs of employing that doctor and the subsidy received by the HA is not directly related to membership of otherwise of the pension fund.
Are you consulted? Do you feel involved? Do you know how decisions are made? NHS Taskforce on Staff Involvement What is this about? Two years ago Alan Milburn set up a Taskforce to look at how frontline staff could be more involved in improving services. After spending ten months visiting NHS workplaces and talking to staff they made a revolutionary report to Ministers - they told them that - 'The people best placed to make decisions about patient care were the front line staff who looked after them. ' Revolutionary indeed ! As we all know, for most people most of the time their NHS care is delivered entirely within primary care and, for the most part, within general medical and dental practice. The creation of PCGs/Ts is increasingly making primary care the main focus for service delivery. So, of course, the document has a lot to say about GPs and practice staff doesn't it ? You guessed it - No mention at all of general practice!! Of course, the document is about staff involvement and the majority of GPs and their employees are not technically NHS staff (did someone say 'thank heavens?) ; but this makes it more rather than less important that they are consulted and able to participate fully in decision making. We just ignore it then?
Yes -
GP Board Members and Aspiring Board Members: The document says the 'the ability to demonstrate a track record of '' involving '' and motivating others' is to be 'a core competence in selection criteria for appointments to NHS Boards' and training will be available. If you want the training start asking now. PCTs will be expected to demonstrate that they are involving staff and frontline clinicians and that patient care improves as a result. Although not NHS staff, the involvement of GPs will be of critical importance. Other GPs
A Copy of the document and self-assessment tool is available under Recent Documents on www.lmclive.co.uk
Since the last Bulletin was published we have received less enquiries about Data Protection. Most local solicitors now seem to accept the guidance we have posted on www.lmclive.co.uk One of the firms of solicitors that proved most awkward in interpreting this new law tell me that they now generally accept fees charged on the basis of our guidance. Many practices are finding it difficult to cover their costs within the £50 maximum fee. When extensive notes are involved a spirit of co-operation may well prove the best hope of limiting the notes copied to those relating to a specific condition or period of time! A widespread problem has been caused by the £50 limit in general practice and also in the acute trusts where, for example, copies of numerous x-rays may have to be provided within the £50 charge. Hopefully the maximum fee will not be reduced to £10 in October 2001. We will keep you informed of developments. * * * * * Just as we thought most of the questions had been answered, one of our practices has asked whether they should display a poster informing patients of their rights under the Act. There is in fact an obligation to inform patients, but the law has proved so problematical that no official patient guidance has yet been issued. Clearly another case of different time scales applying to doctors and government! The latest patient leaflets "Your records are safe with us" predate the current legislation but provide some guidance. Copies can be obtained from the NHS Response Line (0541 555 455.) Core information for patients is available as part of the manual for Caldicott Guardians. You will find a hot link to this information on www.lmclive.co.uk under recent documents. Christine Dewbury
A Cautionary Tale – Parker not so "Permanent"Quink This article was written by Andy Friend, from the West Yorkshire Non principals Group and has sufficient interest associated with it to merit inclusion in this Bulletin. I hope that those who are interested will take note. On a recent visit to Chapel Allerton Police Station I was shown a prescription that I had written using Parker permanent blue-black ink. It had "been in the wash" in the hand of a drug addict and all the writing, bar my signature, had disappeared. Thus I discovered that the Parker Quink that I have used for the past decade, despite being labelled "permanent" is actually relatively easy to remove I decided to test this myself, using the same ink on another prescription and on a cheque, and found that most of the ink washed away with water alone. A few crystals of a non-biological detergent were enough to remove the rest, whilst hardly fading the background printing on the paper. I wrote to Parker about this, and have had a reply stating that: "Parker inks are not designed to meet the specialist requirements laid down for inks intended for use in Official registers" … and state that they use the term "permanent" to indicate that the ink, "although water-based, contains dyes that have a great affinity with paper, cotton, wool or any absorbent material" and that "when subjected to water immersion the soluble dye is washed away, leaving a legible permanent trace". I have tested a number of other inks provided by the Pen Shop in Thornton Arcade, Leeds and have found the best results from Pelikan 4001 and Cross Inks. (I understand the latter are used by Lawyers) – both faded with the above treatment but were still clearly legible.
Both Alice Fisher, with her enormous administrative experience and Dr. Christine Dewbury as an ex GP are available at the office to deal with many of the queries that you send forward. Obviously I tend to be out and about with the practices in the area quite often and it is sometimes the case that I am not immediately available to answer a query. Where possible, would you consider speaking to either Christine or Alice if they are available, since it is highly likely that they can give you a quicker answer to your query than would otherwise be the case, if everything has to be referred through me. I hope you found this Bulletin interesting and if there any other points you would like me to deal with in a future Bulletin, please do not hesitate to let me know at the office.
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