Newsletter December 2004 |
Welcome To our winter newsletter. It has been a busy 6 months for all of us both in practice and here in the office. The concept of the summer months as a “quiet time” for catching up is now a distant memory, as we struggle with the new contract and all the other developments that are inflicted upon us. In this edition we shall give you a further batch of questions and answers, nor only about the contract, but also about your other favourite topic, certificates. Many of you will by now have had your contract practice visits, and we hope they have gone smoothly. There has been some protest at the level of documentation that had to be submitted, but the national group has just come up with the instructions uncannily similar to the actions already being taken in Glasgow. We are therefore ahead of the game, and visits next year should be that much simpler as a result. Just to really confuse you, our new contracts state that there should be two annual visits, one a contract review and one specifically to look at Q.O.F. We think that practices would rather get this over with in one go – opinions welcome. We have had lots of specific questions, both at the recent open meetings and also by letter and e-mail, so here is a summary of the most frequently asked Your Questions Our Answers Q/ “If a service is not available in GGHB area, or the patient has been referred but not seen, how can we exception code them”? This refers mainly to spirometry for existing patients with COPD, for diagnosis purposes, regular FeV1 for these patients and retinal screening for diabetics. A/ The only code available is “patient unsuitable” and so unless we get a more specific code before March this is the one to use. Theoretically this exempts you from providing any services for these patients, but we hope that you will continue to monitor all aspects of their care until the matter is resolved. Doing this will not affect your prevalence. Q/ “We think the new Near Patient Testing service is too onerous and have opted out. We wonder if practices really understand what they have taken on”? A/ We agree that there may be aspects of all the enhanced services that many practices have not yet considered. However, we think it is perfectly possible to fulfil the conditions. But please do read them. Q/ “If new IHD patients have been seen by a specialist but didn’t get an ETT, how do we exception code them”? A/ You don’t have to. The Q.O.F. framework allows for ETT or specialist review. Q/ “Can we exception code all smear defaulters on the basis that they will all have had three letters of invitation”? A/ If your practice subscribes to the GGHB call/recall system, you can confidently state that all your patients have had three letters. The trouble is that the three letters may not have been in the year prior to March 31st 2005. We shall need to clarify the position here. If you run your own call/recall system you will know what you have done, but may be asked to demonstrate your system. Q/ “How do we deal with housebound patients? We don’t have the resources to visit them for routine chronic disease management, and it will affect our targets”. A/ You can exception report them if they are genuinely unsuitable e.g. very frail, terminally ill etc. You can also exception report if they have not attended after three letters. However, we appreciate that this isn’t satisfactory, and so the PCD is exploring the possibility of employing community based health care assistants who can take blood, BPs etc. and be a resource for everyone who needs these procedures done at home. But do remember that some of your patients are more mobile than you imagine. Q/ “Medical reviews seem incredibly onerous. What do you think is an acceptable standard”? A/ It depends on the patient, some can be done purely as a computer exam, some can be done over the phone and some might need a face to face encounter. Dr Jim Campbell has produced a piece of software that enables you to check any reviews outstanding. Q/ “If the podiatrist doesn’t turn up at our diabetic clinic, can we put in an exemption code for testing pulses and sensation (DM 9&10)”? A/ Unfortunately the blue book doesn’t specify that this has to be done by a chiropodist, and in the final analysis, it would be you or your practice nurse who might have to test for this. Superannuation Questions We have received a lot of enquiries, possibly from our more mature colleagues. Q/ “In the past the PSD had collected and paid on my behalf my added years contribution for superannuation. They are no longer able to do this and I am concerned that I may be breaking my added years agreement by not paying as before.”? A/ You will not break your agreement by not making payments as before. However, we would suggest that you put the money aside so that when your final contribution (including your added years) is calculated you are not facing a large bill. Q/ “If a GP retires for superannuation purposes, can he still claim seniority”? A/ Yes. Any income he earns in the NHS is potentially superannuable, whether he is currently paying into the scheme or not, and so seniority should continue. If he reduces his commitment drastically he may fall below the “one third of average earnings” rule, but as an existing practitioner he should still get his seniority payments under the “no detriment” clause. Q/ “If a GP retires for superannuation purposes, what happens to the funding that has been put into the practice to pay for his employer’s contribution”? A/ It remains as part of the practice funding, and it’s up to the practice what they do with it. However the converse is also true, an extra partner will not result in extra funding being put in for his employer’s superannuation. Q/ “What money is available in Scotland to fund 14% superannuation payments on profit for new work”? A/ Your guess is as good as ours. Some funding was made available in England to increase the global sum payments and this at least partially redressed the balance. This has not happened in Scotland. SEHD has finally admitted that it has not yet provided funding for this, but we are no further forward as to how it will be provided. Q/ “How should internal locums be handled for superannuation purposes”? A/ We had to ask the Chairman of the BMA Superannuation Committee (Andrew Dearden) about this. Previously GP Principals could not get locum payments superannuated. Now, they can. If you work for another practice this is simple. Fill in the superannuation form and send it to the health board. They will pay you employer’s superannuation for that session. If you are doing the locum for your own practice the situation is more tricky. Andrew Dearden is of the opinion that if you have a very clear and limited commitment to the practice, and you do the locum as a clear and defined extra session, it should be superannuated by sending the form to the health board. However, we don’t know if anyone has actually tested out this mechanism. If the internal locum is a bit more vague than that, we suggest the only thing you can do is alter the profit share. Q/ “Who is responsible for paying the locum employer superannuation costs? Is it the practice or the locum as they are self-employed. A/ This financial year (04/05) employer’s superannuation contributions are part of the PCO administered fund and the locum employer’s superannuation is met by the PCO. It has been suggested that, for 05/06, the department of health might take the funding for this out of the PCO administered funds and distribute it to practices. This distribution however would be on a very general basis, it is unlikely that it would reflect your actual usage of locums, so high users of locums would lose out. Nevertheless, in this circumstance the locum himself would be responsible for remitting the employer’s contribution to the appropriate authority – which would presumably result in higher locum fees. Other Queries Q/ “Do you know if periods spent locuming in General Practice and/or hospice work is counted towards seniority“? A/ Time spent as a GP Locum should count towards years of service for calculating seniority entitlement. PSD has recently written to all existing GPs to establish this. They have not asked for any proof, but possibly the Post Payment Verification Unit may be doing this in the future. So keep your locum receipts, or get some written confirmation from practices you previously worked for. New GP partners will also in future have previous locum service counted – so keep the paperwork! Q/ “Advice please re not accepting patients on list either permanently or temporarily. Usually, patients arrive at reception and ask to register. Our policy is that if they live outwith practice area or are already registered with a GP in the area, we do not take them on. This is all verbal - nothing in writing. As per the new contract, does it now mean that we need to take a note of the name and address of these patient and write with reasons for refusal? Do we have to have a list of names for inspection or just numbers of those refused registration“? A/ You have to write to the patients and explain the reason why you are not accepting them. You can keep a record of the patient’s name and address in a computer file which can be printed out for any inspection visits. We would also suggest a standard letter stating the reason they are not being accepted onto your list. You could incorporate your practice policy (which would also prove non discrimination) for example, as you stated earlier, “Our policy is that if a patient lives outwith the practice area or is already registered with a GP in the area, we decline to take them on”, could be included in the letter. In your computer file at the top of the document you could indicate that your standard letter was sent to the following patients with the date letter was sent. You could also keep a hard copy file with a copy of every letter sent. Either should suffice. Q/ “We had a call from a patient’s mother requesting a house call for the patient. We then discovered that the patient had moved several months ago to the other side of Glasgow and was now outwith our practice area. Do we still have to attend? A/ No. Under the new regulations you do not have to provide medical services to a patient who has moved outwith your practice area. You should advise the patient to seek any immediate necessary treatment from a practice within their new locality. Once the health board has been informed of a patient’s change of address and it is outwith your practice area, under the new standard general medical services contract (clause 213), the health board may inform them (and you) that the practice is no longer obliged to visit and treat the patient. They will advise the patient either to obtain the practice’s agreement to the continued inclusion of the patient on its list of patients or to apply for registration with another provider of “essential services” (or their equivalent). Q/ “Further to the circular regarding mumps immunisation and item of service claim – can we claim from 1st April 2004” A/ We have had a look at the circular and can see no reason why you should not claim from 1st April 2004. Q/ “Ex-smokers for nGMS - do we still have to give out smoking advice? A/ No, this is a mistake in the template. It would suggest the patient still smoking. Q/ “The local community addiction team has written requesting some health information on a patient. We have a consent form. Question is do we charge a fee or not? Is this a borderline situation?” A/ We think this would best be considered as a clinical communication. The form of information provided is not specified but might be the same as in a clinical referral. We do not think a fee is appropriate, the nGMS requirement to provide adequate data to alternative providers probably applies. And finally. We are still discussing future enhanced services funding with the PCD and we will let you know as soon as we have the basket of proposals. CHPs and the Disaggregation of the Primary Care Division The proposed reorganisation of the structure of the health board in Glasgow is proving very contentious. The formation of one huge acute division, with primary care divided into nine CHPs and no central primary care forum seems universally unpopular. We continue to lobby the health board for a strong and effective primary care voice – please let us know what you think. Zero Tolerance The Southern General’s Aggression Management Services Team run training courses for aggression management. Although these courses are primarily designed for ward staff there are two that would be suitable for practice staff. 1. Awareness Training. This is aimed at staff who have little contact with patients and consists of a half day course. It would be suitable staff working in reception. 2. Breakaway Techniques. This is for staff who require to evade and seek assistance during incidents of violence and aggression and would benefit clinical staff who deal with patients on a one to one basis especially if home visiting. This course lasts two days. For further details or to book a place on either of these courses please contact Aggression Management Services on 201 1976 or e-mail david.mccolvin@glacomen.scot.nhs.co.uk Can we also remind practices to obtain an incident number from the police (even if the practice do not wish to prosecute) in order to have a patient with challenging behaviour removed immediately from the practice list and transferred into the CBR practice. Dental Treatment for Patients Not Registered with a Dentist We have had a few enquiries from GPs about patients who were not registered with a dentist, but were coming to the practice with dental problems. Our advice would be to, where appropriate, give immediate necessary treatment and then refer such patients on to the dental hospital. There is a special clinic open from 10am to 6pm, Monday to Friday to treat patients who are not registered with a dentist. However, the service is not fully up and running as yet and can only offer ten appointments per day at the moment. We would also suggest noting in the patient’s record that the patient was advised to seek dental treatment. Telephone Enquiries For those practices in health centres where the telephone system has changed – just in case you do not already know, for telephone directory enquires the numbers to call are:- One enquiry - #699 Multiple enquiries - #698 International - #697 Central Stores A practice was billed for an order of request forms for haematology, biochemistry, chlamydia and danger of infection labels. If you receive such an invoice please do not pay. We have also heard of practices receiving invoices for blood and urine sample bottles. Again, please do not pay. Supplies to GP practices tend to be very inconsistent and ad hoc around the city. Practices in some areas are being charged for supplies that should be free and others not charged for items that should be paid for. An PCD exercise is now underway to review the list of GP supplies, with the aim of establishing equity throughout the city. The new list will be circulated to practices once it is agreed. However, be aware that this may be a slow process given the size of the task. Diabetic Pre-Clinic Bloods We are aware that some practices have been asked to do pre-clinic bloods for the diabetic clinic at Stobhill. We have written to the unit and told them that, at present, this is not part of our arrangements for diabetes care. Please refer back to the unit. Certificates, Reports, Certificates Six Monthly Healthcare Assessments for Residents in Care Homes We have written to social work services and explained to them that there is not the resource available in general practice to undertake six monthly assessments of the health needs of their service users. We have suggested that if social services wish such a service they contact the health board with a view to commissioning this as a local enhanced service. We have also advised that Glasgow GPs cannot currently provide this service within their current resources and therefore will decline to provide this service in the meantime. Blood Pressure Clinics – Shared Care for Hypertension A practice recently received a request from the blood pressure clinic at the Tennent Institute to complete a form and take some bloods for one of its patients. With the advent of nGMS we are unclear as to the continuing value of such clinics, but would leave it entirely to the individual GP as to whether they wished to do it or not. Council Tax Exemption/Discount for Severe Mental Impairment We have been made aware that Glasgow City Council financial services department have asked some GPs for additional information to clarify the condition and provide exact details of how an illness causes a permanent severe impairment of intelligence and social functioning of the patient applying for a council tax reduction. We have written to the Glasgow City finance department and explained that under a GP’s contract with the NHS we do provide a certificate to support a claim by or on behalf of a severely mentally impaired person for exemption from liability to pay the council tax or eligibility for a discount in respect of the amount of council tax payable. We do this in reference to the Local Government Finance Act 1992, schedule 1, paragraph 2(1)(b). We pointed out however, that having provided a certificate to this end, a GP would be considered to have fulfilled this responsibility and we do not see that there is any further need for GPs to provide additional reports beyond that. We would therefore advise our GP colleagues simply to provide one certificate stating that they consider the patient to have severe mental impairment or a severe mental impairment of intelligence and social functioning which appears to be permanent. Please do not supply any additional information if requested to do so. One GP was asked to provide information on Downs Syndrome and asked how long the patient had suffered from it! Council Tax – Disabled Persons Reduction All this requires is that the GP stamps and signs the application form. Under the circumstances we feel that, as these are likely to be few and far between, you should do without charging. Personal References Banks asking for a reference to confirm a patient’s address when they apply to open an account. If you decide to do it we would suggest a fee commensurate with the work involved. Application/Appeals for Disability Living Allowances (Again!) As we have said previously, unless there is a significant change to the patient’s condition that you think may have a bearing on their case, or you may believe that the patient has been treated unjustly, please do not undertake such reports/form filling for organisations such as the Citizen’s Advice Bureau or ‘Money Matters’ (who seem to think the patient can sue them if they do not ask for a GP report). Welfare Rights Officers have stated that statistically an additional GP report enhances the chance of a successful claim, this may well be the case if GPs only do such reports rarely as in the cases above. However, The Department of Works and Pensions do not want additional reports as it just ‘muddies’ the water. Their decisions are based on the patient self-report and reports from GPs or, if necessary, an independent medical assessment which then takes precedence over the GP report. The LMC is also considering producing a fact sheet for such groups similar to that for housing associations. Can we also remind our colleagues that from 1st October 2004 the fee for completing DLA reports was increased to £32 however, this is dependent on the GP meeting new turnaround targets (10 days). If for any reason the GP is unable to meet this target, for example the GP most familiar with the patient is on holiday, please inform the department of work and pensions of a delay. The reports are also to be made shorter and will ask for factual information rather than functional based questions. Housing Associations Please do not provide reports for housing associations unless you feel there are exceptional circumstances prevailing in the case of the applicant. Can we ask practices to forward the name and address of any housing officer or association who persistently ask for such reports, so that we may contact them directly on your behalf. Patients Working Beyond 65 A practice was asked to supply a private medial report for a patient who wants to work beyond 65 and was concerned about medico–legal issues should the patient have a problem following such an examination. Firstly, it is up to the GP to decide whether or not they wish to provide a report to an employer requesting a private medical report for a patient who is seeking to work beyond age 65. Secondly, in the absence of a structured request, the GP can decide the format of the report and charge accordingly (at the BMA recommended rate for private work per hour). Thirdly, a general medical report should not be a problem, however if the employer is asking for an opinion then the GP should either decline on the basis of not being an expert on occupational health or provide an opinion based on what the GP knows whilst reminding the employer that they have no expertise in occupational health. So long as the GP is giving an opinion from the position of being a general medical practitioner and does so honestly and based on factual knowledge, we would think any liability would be small but the Defence Union would be able to offer advice on this. Fitness to Travel The RAC insurance company recently wrote to a patient stating that their annual policy would cover all relevant medical conditions without the doctor‘s fitness to travel note being required by them. Instead they suggested that the patient ask their GP to just make a note in their record stating that the patient had been declared fit to travel. We have written to the company and pointed out that the NHS does not provide routine fitness to travel advice in this way. We advised that a GP will inform a patient if they think they are unfit to travel and that this would be recorded in the records as part of the patient’s medical care and that appointments should not be made simply to assess fitness to travel on a routine basis. We made it clear that we felt it was unfair to ask the patient to ensure that this was recorded in the medical notes as the GP may well refuse to do so. We also highlighted that a patient visiting the GP solely for the purpose of asking for this to be recorded would, in fact, legitimately be charged for this as a private service. They have indicated that they will be reviewing their procedures shortly and will take our comments on board. You do not have to comply with this request. Bright Grey Insurance Co The Bright Grey Insurance Company has been advising practices (again) that they are only obliged to pay £15.75 for a medical report. This is incorrect and if this company requests a report from you please inform them of your fee before completing their reports. Central Scotland Police Force A practice was informed that under Central Scotland Police Force’s attendance management policy, an officer had had his rights to self-certification removed. The officer was informed that he should attend his GP for a sick-line to cover the period of absence and the Force also advised that there might be a cost involved which the constable should pay. The GP concerned was unhappy about this and wondered whether statutorily the GP would have to comply with this request and the simple answer is no. Just because a company or institution states in their employment policy that the right to self-certify can be or is removed does not mean that GPs have to comply. On our webpage www.glasgow-lmc.co.uk, under the information section there is a leaflet that can be sent to companies issuing requests for less than seven day sickness certification.
Could we also remind colleagues that guidance on certification for statutory sick/maternity pay and incapacity benefit has been updated and information can be found on www.dwp.gov.uk/medical/guides_detailed.asp Pantomime Certificates It is that time of the year again (although shows/plays/TV appearances last the whole year through) and we have had some queries recently about certifying children fit to perform. Unfortunately, the law states that councils have to be given a certificate to allow children to take part in certain performances. They are unable to bypass this requirement. It seems that a statement has to be made that the child is fit to take part in performances for which a licence is requested and that his/her health will not suffer by reason of taking part in such a performance. We would like to remind our colleagues that provision of these certificates are not part of your GMS and that you do not have to provide them. We have suggested to various organisations that they may wish to employ a GP on a sessional basis to examine and provide certificates for the child performers in their companies. A few organisations have pointed out their charitable status. However, we have suggested in this case that perhaps one of their children may have a parent or guardian who is a GP and would be willing to provide this service for free. If you do wish to provide such a certificate we suggest you charge according to the level of service you give. A full private examination and report with certificate would take approximately 45 minutes we suspect. Alternatively, you may choose to offer a 10 minute appointment with a letter and certificate at the same level as the fitness to attend school examination, for a smaller fee. Shotgun Licences A GP recently had a request from the police for an opinion on the suitability of a patient to hold a shotgun licence. The GP wondered whether she had to do this as the patient was rarely at the practice and was not that well known to the GP. We suggested that the GP might like to reply stating that as she disagreed with the use of firearms and was opposed to anyone carrying them, she was therefore not in a position to offer an opinion.
LMC and GP Subcommittee Elections Following the elections earlier this year, the new committee line-up is as follows:- East Drs Richard Groden, Tollcross, Elaine McLellan and Gerry Lynas from Bridgeton, Robert McNeill, Stepps, Jim O’Neil, Carntyne, Paul Ryan, Royston and Andrew Townsley, Easterhouse. North Sector Drs Georgina Brown, Springburn, Norrie Gaw, Woodside, Ian Gordon, Bishopbriggs, Krystyna Gruszecka, Possilpark, Susan Langridge, Woodside, John McLauchlan, Kirkintilloch and David Sutherland Woodside/Anderston. South East Sector Drs Douglas Colville, Rutherglen, Stephen Goldberg, Pollokshaws, Gary Hamilton, Giffnock, Keith McIntyre, Cambuslang, Nigel Pexton, Clarkston, Iain Robertson, Cambuslang and Peter Wiggins, Castlemilk. South West Sector Drs Barry Adams-Strump, Cessnock, Donald Blackwood, Govan, Malcolm Brown, Pollokshaws, William Doak, Pollok, Ian Struthers, Cardonald and Sheila Thomson, Paisley Road West. West Sector Drs Jane Connelly, Drumchapel, David Gaffney, Partick, Andrew McCall, Scotstoun, Alan McDevitt, Clydebank, John Nugent, Drumchapel, Douglas Robertson, Knightswood, Alastair Taylor and Barbara West, Drumchapel. The Committee also includes representatives from the Area Medical Committee, GP Regional Adviser, GP Postgraduate Education, the prescribing adviser and co-opted members for the retainee, registrar and locum groups. The GP Subcommittee meets on the third Monday of every month (except for July and August when there is a summer recess). GP Awards Congratulations to Dr Richard Groden on his Scottish Health Doctor’s Award for his work reducing GP appointment waiting times in the East of Glasgow. Congratulations also to Dr Paul Newman on his Glasgow Health Council Award earlier this year. Agenda for Change The Whitley Council ceases at the end of 2004. However, it has been suggested that it would be unwise for practices to apply AfC in the first year until its impact on staff costs is known. It appears practice clerical staff would be most vulnerable as mapping exercises carried out on PCD staff had shown the AfC pay scale as being less than the current Whitley Council rates for many clerical posts. Also each practice would be required to map across all staff and this in itself would be a huge undertaking. Our advice is to hang fire for the time being. This has been discussed with the PCD and practice manager representatives, and it would seem sensible to wait until more work has been done for PCD staff – they will then be in a better position to advise you if you want to go down the AfC route. Remember that the basic uplift for GP staff of 3.225% has already been agreed for 2005/06. Counselling Services for GPs and their Families Can we remind colleagues that the Dovedale Counselling service is a free and confidential service available to GPs and their immediate families. Dovedale can be contacted on 0800 214 307 twenty-four hours a day, seven days a week. Usage of the service has been quite high this year – we wonder why! Visitors from Oversees There has been a significant interest in our suggestion to hold some workshops on visitors from oversees. Ian is currently working on arranging the workshops which we hope will start in mid-January (gives everyone a chance to recover after the festive break). The workshops will be run in conjunction with the PSD. If you have any particularly difficult scenario that you think you would like covered, can we ask you to e-mail Ian at ian@glasgow-lmc.co.uk with the details and he will try and accommodate it. Resignation and Retiral from Greater Glasgow Medical List Could we please ask GPs (especially those in a single-handed or small practice) who may be thinking of resigning or retiring from general practice in Glasgow to please contact the LMC Medical Secretaries for advice before they submit their resignations. Violence Against Doctors You may be aware that there is currently legislation going through the Scottish Parliament to protect emergency workers against violence. While this Bill protects doctors when they are attending to emergencies outwith hospitals, it fails to protect them when in their surgeries or when visiting patients at home (non emergency). SGPC are actively campaigning to amend this Bill to try and ensure greater protection for GPs. To this end, SGPC are trying to gather data on violence against doctors to illustrate their case. If you have had a violent or threatening experience with a patient and would not mind sharing it with SGPC, could we ask you e-mail to Mary at mary@glasgow-lmc.co.uk, with the details. Sterile Services at Ross Hall Hospital Ross Hall have a fully compliant purpose built sterilisation unit located within the Hillington Industrial Estate. The unit offers a complete sterilisation service to both large and small organisations but unfortunately we do not know how much the service will cost. However, more details can be obtained by contacting Mr Steven Buchan, BMI Sterile Services Manager (Scotland), 0141 810 3151. East Dumbartonshire Single Shared Assessment Forms Earlier this year it was agreed that GPs in the East Dumbartonshire area would continue (for a six week period only) to complete East Dumbartonshire social work department’s single shared assessment (SSA) form whilst the social work department moved to the more user friendly Carnap form. We have now been informed by practices that SSA’s are still in use and GPs are still being asked to complete them. If you are asked to complete the East Dumbartonshire form we suggest you send a computer summary of the patient’s problems – as accepted in other parts of the GGHB area. Christmas and New Year Holidays GEMS NHS will cover both the 27th and 28th December and the 3rd and 4th of January. Can we remind practices that if they intend to have any extended leave outwith these dates over the festive season, they must make their own additional cover arrangements. CanaRx Services Many of you have received a personalised letter from a Mr Tony Howard, President and C.E.O. of a company called CanaRx Services, inviting you to participate in a prescription service to North American patients. We have checked with the medicines management team and we both believe that this is one of the many web based companies who mail medicines. Our advice is to ignore this letter. Guidance on internet and telephone prescribing can be found on the GMC guidance page http://www.gmc-uk.org/standards/default.htm, in their FAQ's page. Patients with Communication Difficulties Deaf Connections, Capability Scotland and Visibility have asked if it would be possible to note in a referral letter if a patient has a communication difficulty. On electronic referrals we think this would be included automatically but if not it has been suggested that noting such difficulties in electronic or manual referral letters would be very helpful for the patient. Finally… A little joke to brighten the day. A surgeon is being sued by a patient for uttering a four letter word during their op. OOPS!
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