Newsletter June 2006 | ||
Welcome to the first newsletter of our new expanded Glasgow & Clyde LMC. On 1st April, Argyll & Clyde Health Board was formally dissolved and divided between GGHB and Highland Health Board. We are therefore joined by colleagues from Dumbarton, Paisley, Renfrew and Inverclyde. This makes us the biggest Health Board in Scotland, covering 25% of the population. The LMC will now serve:- We have now successfully integrated our two Committees and the membership is as follows:-
Chairman: Vice-Chair: Treasurer: Medical Secretaries: Executive Members: Main Committee:
This makes for large but very lively meetings. We hope to support and represent all our constituents and welcome your queries and comments. Contact Details: Email: bw@glasgow-lmc.co.uk amcdev@glasgow-lmc.co.uk john@glasgow-lmc.co.uk murray@glasgow-lmc.co.uk Tel no: 0141 332 8081 May we remind new Clyde members that you need to sign a new voluntary levy mandate, if you have not already done so. The work of the Committee will be particularly challenging this year, and we need all the support we can get. NES Drug Misuse Following our negotiations about GP participation in methadone substitution and care of drug misusers, we now believe we have a better relationship with the drug misuse service. An LMC representative now attends the management group and we’ve also had two educational events which were open to practitioners working in the CAT teams and in General Practice. As you know practices can now take on new patients to replace patients who have left without requiring specific permission. This enables practices to maintain a stable number of patients and to be able to plan appropriately. There has been a large expansion of the CAT teams last year. They now appear to be pretty much at capacity and we hope that in the future stable patients can be repatriated to general practice care to enable the CATS to take on the more difficult and chaotic users. Please let us know if you are encountering any problems or if you have any suggestions for the development of the service which our representatives can take forward to the management group. We have asked whether the Drug Misuse NES which is currently operating in Clyde will be integrated into the Glasgow model but, at the moment, we understand there is to be parallel running. The New Mental Health Act Since our last newsletter a fee of £173.37p has been agreed for the second signature on the CTO (Compulsory Treatment Order). We are still awaiting the paperwork whereby you can claim these fees and we understand the hold up is because we need an agreement about annual cost of living uplift to these fees. However if you have signed any CTOs you should be keeping a note of the details and payments will be backdated for all claims to 1st October 2005. We have also clarified that the general practitioner will in every circumstance be invited to attend the tribunal but attendance is voluntary. The tribunal does have the power to compel you to attend but this will only be done in very rare circumstances if they feel the GP has a particular point of view or particular expertise that they need to hear. Such a compulsory attendance would be funded. Other interested parties e.g. the patient himself or the mental health officer can ask you to attend but no-one had the authority to compel you to attend except the tribunal. This has been a very long and tedious negotiation and we sincerely hope that by the time of our next newsletter we can finally put the matter to rest. 24 Hour Retirement for Superannuation Purposes There have been recent changes to the rules around retiring, collecting your NHS pension and then returning to clinical work. For the last few years a GP had to do no clinical work at all for a month following his retirement date. This meant that in a group practice you had to be confident that your partners would actually want you back after the month was up. For a single-handed GP it was impossible. We now have guidance that makes the whole process much easier. A GP can retire for superannuation purposes and must do no clinical work for 24 hours. This can be over the weekend. He can then return to work but must do no more than 16 hours per week for the first month. He does not at anytime have to come off the performer’s list and, if a single-handed practitioner, his contract with the health board will not be terminated. He can therefore provide a locum to make up the shortfall in hours for that month and then go back to his normal pattern of working if he so wishes. Please remember that Out of Hours work counts towards the 16 hours so unfortunately the lost income cannot be recouped via GEMS or REMS. However we do think that these new rules make the situation much fairer, especially for our single-handed colleagues. Working with Suppliers of Clinical Products For the last year a small group has been writing a protocol for use in Greater Glasgow to regulate the way in which clinicians interact with drug companies and other companies who provide supplies of various sorts. This document is in its final round of consultation and will shortly be issued across the city. Its use is mandatory for NHS employees. For independent contractors, the terms of the protocol can be viewed as good practice and guidance however, if you are employed in any capacity by the Board e.g. a prescribing lead or if you sit on any Board committee that deals with prescribing issues you will require to adhere to this policy and in particular you must declare any personal interests that you have regarding drug firms. Labels The topic of specimen and request form labels has been generating a lot of heat and not too much light over the last few months. The initial concern regarding labels was that they should all have the CHI number on them , as use of the CHI is now very important in secondary as well as primary care. This subsequently led to a lot of discussion as to what else should be on the various labels as there was a lack of consistency across the city. The labels now have the patients’ name; address and telephone number on them. This was asked for by GEMS who were often rung up on a Saturday morning with a seriously abnormal result that had been processed in the lab that morning and GEMS did not have any method of communicating with the patient, short of a house visit. Of course the telephone number is only as good as the information on your system but we hope this will help patient care. Another main bone of contention was whether there should be a pre-printed date and time on the specimen and request label. We believe that there should be as the way we work in practice is generally to provide labels in real time with the patient sitting in front of you and anything that saves writing on those pesky little bottles is to be commended. However, the labs weren’t happy with this. They thought that people would pre-print masses and masses of labels for future use and the date and time would clearly be wrong. In the end a compromise. You will see that there are two request labels; one with a date and time and one without. Use the label without the date and time if the sample is going to be taken at a later date e.g. by a district nurse or handed in by the patient himself. That person must then write the correct date and time on the form. As regards the specimen label; one half of it has date and time the other half doesn’t. So again if this is for a future sample get rid of the dated part and ask the patient or nurse to scribble on the bottle. We know this is nit-picking to the umpteenth degree but you can’t imagine how many person hours have been spent on discussing this topic. Perhaps we can also remind you to use the CHI number in any communication about a patient. It has to be stressed that general practice is much, much better at doing this (via the aforementioned labels and electronic referrals) than the hospitals are. One of the many targets that the health board has to meet is so called ‘CHI compliance’ and again endless groups and committees are working away to try and achieve this. VAT There has been a long running dispute between the BMA and her Majesty’s Revenue and Customs as to whether staff employed and provided by the Health Board to practices (who then reimburse the salary) are deemed to be a VATable supply. This dispute is ongoing. Meanwhile, we know that some of our colleagues in Clyde have been sent bills for VAT, whereas this has not yet happened in the Greater Glasgow Health area. If at the end of the day the provision of such staff is deemed to be VAT exempt then any payments would have to be refunded to you. However if the final decision is that VAT is liable then this poses a problem for practices with such provided staff. You will in effect be paying a 17.5% levy for very little discernible benefit. The number of staff that work under these arrangements are steadily declining but it certainly poses a problem in some health centres. If you are in this situation and wish further advice please discuss this with one of the secretaries. More VAT From April 2007 doctors will be liable to pay VAT on services that are not immediately related to patient care. This in the main includes the provision of medical reports. You only have to register for VAT if your earnings in this respect are over the VAT limit of £61,000. For small practices this is unlikely to be a problem but for larger ones you may well approach this limit. If you feel you are in this category we suggest that you speak urgently to your accountant. You really do not want to be caught unawares on the 31st March! There have been some suggestions that practices could divide up into smaller entities or that doctors could do this work on a personal basis. We believe that the various loopholes suggested are fraught with difficulty and could not recommend such courses of action. Please speak to your accountant now if you think you might be going to breach the limit. IT Systems Change Please remember that the Glasgow ‘Beauty Parade’ will be held at Hampden National Stadium on 7th and 8th June. If you have not yet replied to the invitation to attend this event please contact the office urgently. You will have the opportunity to view all five accredited systems in the course of a morning or an afternoon and places are limited.Paperlite and Docman New Funding has been announced for practices to implement Docman in Greater Glasgow and Clyde.If practices in the Clyde region are interested in going paperlite, could you please speak to your local IM&T team in the first instance as they will help guide you through the process of applying. Glasgow practices should contact the IT Mentoring Team.
Waiting Lists Initiatives We had a letter before Christmas about a patient who had an operative procedure at the Nuffield as part of the waiting list initiative. Instead of the Nuffield arranging rehabilitation care directly they asked the GP to do this, completely inappropriately. We are happy to say that a considered and robust response from the practice concerned caused the Nuffield to investigate this problem and assure them that it would never happen again. When a patient has a procedure done in the private sector there must always be appropriate arrangements for ongoing care organised by the hospital concerned. Direct Service for Young People Direct Access Service for Young People is a city wide service for young people aged 12 - 17 years inclusive, with early-stage mild to moderate mental health difficulties. The team consists of Clinical Psychologists (3.5 wte), Nurse Therapists (2.0 wte) and Liaison Teachers (3.0 wte). The services offers brief (6 - 10 sessions) focussed psychological interventions across a range of settings, including clinics and schools. They also work jointly with other agencies on specific projects such as therapeutic groups and offer consultation to other professionals on mental health issues for young people. As part of the NHS Greater Glasgow Primary Care Division Adolescent Directorate, they work closely with other mental health services for young people including the Adolescent Psychiatry teams. The service accept referrals from all professionals working directly with young people. To process a referral they require information regarding the duration of the mental health concerns and the impact on the young person's functioning as well as confirmation that the young person has agreed to attend. If you would like to discuss the service further or make a referral, please contact them at: Direct Access Service for Young People
Certificates, Reports, Certificates Glasgow City Council Request for medical report about ability to complete and understand forms. This is yet a another form of request from the Glasgow City Council and our advice is that this is entirely private work and you should agree a fee in advance for provision of such information to the council. Obviously there should always be adequate patient consent before providing any of this information to the council. Some practices felt they were being pressurised to provide this information for no payment under the threat of a citation to appear in court. If the court cited you to attend it is likely that this would have to be as an expert witness and would be remunerated. South Lanarkshire Council Our thanks to Dr Keith McIntyre whose dogged determination has led to the following response from South Lanarkshire Council‘s Housing and Technical Resources Department. “...The Council is currently reviewing the way in which it assesses medical information provided by an applicant requesting council services on medical grounds. It is anticipated that the Council will shortly be entering into a service level agreement with a contractor who will undertake independent medical assessments on behalf of the council across a range of service delivery areas where there is a requirement to have a medical condition in order to be awarded priority. This will therefore remove the need for applicants to contact their GP in this respect“. Fitness to Exercise A number of practices have been in touch regarding requests for ’medical referrals’ for patients who have joined local gyms. We advise against doctors doing such medical referrals as we are usually not performing an adequate assessment to decide whether a patient is fit to undertake exercise particularly without knowing exactly what they are going to do. There is a formal exercise referral programme within Glasgow which simply asks the doctor to note significant medical problems and to refer patients to an exercise counsellor who makes further assessments. Outwith this arrangement we have, we would discourage doctors from signing any other medical referral forms for exercise. In most instances it is quite appropriate for all members of the public to undertake exercise appropriate to their level of fitness and ability. We appreciate that there may be issues with regard to insurance for organisations offering exercise facilities. However it is inappropriate to ask doctors to give reassurance as regards fitness as there is always a risk of exercise which cannot be excluded by a medical opinion letter. We obviously encourage patients to undertake exercise but we consider this should be gauged under normal life activities and patients should use their own judgement as to what is appropriate for them. Most gyms nowadays also encourage new clients by advertising that they have trained exercise counsellors who are able to offer clients appropriate advice. Referrals for Private Healthcare Can we please remind practices that you cannot charge a fee to write a referral letter for a patient to access private healthcare. You can however, charge a fee for completion of the insurance form to allow them to claim the cost of their treatment. Enhanced Services Update Access DES The access criteria are now provided under a DES as opposed to part of the QoF. As a result this is therefore paid quarterly rather than at yearend. As a result practices have to claim on a quarterly basis that they are meeting the targets for access and have to be able to provide evidence to back it up. Should your practice chose to undertake the voluntary stock-take on IT and provide this information to the Board this is more than adequate to meet the access standards. The new software should also warn you before you send your results to the board if your practice is not meeting the stock-take standard. Should this happen you should also provide a claim which shows which of the access standards you are meeting . These other standards are at a lower level than the voluntary stock-take. Clyde Practices are not yet involved in this stock-take and will have separate arrangements similar to the statement on access levels for last year’s QoF. Local Enhanced Services The vast majority of Glasgow practices have opted into the LESs for 2006/07. With only 4 opting out of Diabetes, 3 out of CHD and 5 opting out of Stroke. It is possible that new local enhanced services for Epilepsy, Rheumatoid Arthritis, COPD, Hypertension and Heart Failure could be proposed within the next couple of years and we will let you know when more details are available. Clyde Funded Enhanced Services The Health Board are currently carrying out a pricing exercise to determine the cost of opening up Glasgow’s enhanced services to Clyde and vice a versa. However, we have made it clear that there should be equity of provision for patients and also equity amongst the GPs of Greater Glasgow and Clyde.
Finally can we ask practices to let us know of blood tests or monitoring you have been asked to carry out by secondary care colleagues that is not part of the local enhanced services. Diabetes, CHD & Stroke LES Payments 2005/06 Under the agreement for 2005/06 a small number of practices had a 20% deduction made for poor data quality. The vast majority of practices received 100% of their payments for this year. Please note that the payment arrangement for 2006/07 are much more specific and are paid on achievement and adequate data entry. Minocycline Phlebotomy LES This LES allows GPs to provide phlebotomy only for patients receiving Minocycline from specialist Rheumatology Services. It is necessary for the blood result to go back to the specialist who requires it as the prescriber. At present we have not been able to come up with an IT solution to this and the hospital clinic should provide the practice with a list of labels which can be applied to blood forms so that the result goes back directly to the correct clinician. This may be a little messy in practice and hopefully we will have an IT solution in the future.
MS Information The multiple sclerosis workers collect a lot of information when they do an annual review of a patient. We have been trying to decide how much of this information practices would wish to receive. At present the suggestion is that we would either be able to access this information on a website or receive a letter of actions taken by the MS worker in response to problems that particular patient has. There are now 2.3 whole time equivalent MS workers across the city and this should mean that most MS patients should receive a review this year. Most of the South-side of Glasgow has not yet had MS reviews carried out on their patients. Near Patient Testing At present Hydroxycarbamide and Adalimumab are not part of this and practices who are requested to carry out monitoring should inform the hospital that this is not currently part of Near Patient Testing. Should they wish it to be part of the NPT they should pass it to the Rheumatology Committee for discussion at the Enhanced Services and Quality Outcome Group, chaired by Dr John Nugent. Spironolactone and Eplerenone have not yet been added to the NPT and are still the subject of significant discussion. QoF Update Read Codes The new GPASS read codes for the QoF apparently should be installed and available from the 29th May which would allow practices to be recording the new QoF information. Obviously this delay has complicated us beginning work on these QoF points. Depression 1&2 The view of the Enhanced Services and Quality and Outcomes Committee was that for patients with diabetes or coronary heart disease who have completed a HADS questionnaire as part of the LES, then it would not be necessary for the health professional to ask the 2 screening questions. However, if the patient did not complete the HADS score then the health professional should apply the 2 standard screening questions. We have yet to see if this is going to be possible to record and therefore you will require further information before this can be confirmed. It has been suggested that there should be a third question which is “and do you wish to do anything about that”. Obviously patients should be asked if they wished to do anything about detected low mood or depression. For depression 2 you have to decide which questionnaire you wish to apply for diagnoses of all new depressions. Clearly if you have diagnosed depression in a patient with CHD or Diabetes through the HADS questionnaire then this has already been met. The Board is happy to continue to supply the HADS questionnaires and indeed the scoring sheets which are available from Tom Clackson. However you are absolutely at liberty to use any of the other scoring sheets detailed in the new blue book. eGFR By now all parts of the city should be receiving the eGFR as some practices receiving the results from Southern General had not been getting this up to now. eGFR should only lead to a coding of chronic kidney disease where it is sustained for over 3 months. Obviously it is possible for a patient to have a result below 60 initially and later to be above 60, which mean that they do not have to be recorded as CKD. Some software programmes are being prepared which will hopefully make this much easier to work. What we are not yet sure of is whether recording a code as greater than 60 would negate earlier results which are specifically less than 60 as is reported in Glasgow. Mental Health Some of the new wording in mental health is far from clear. Particularly with MH7 where patients are to be followed up within 14 days of non attendance. A pragmatic view of the Enhanced Services and Quality and Outcomes Group was that sending three invitations for a review with a fourth follow-up contact within a couple of weeks of the third letter should meet this requirement. It was unlikely that the fourteen day timing could be strictly enforced in view of the difficulty defining when the time period starts. Should a national view be reached on this we will let you know.Medicines 11 & 12 Medicines review now requires at least a level 2 medication review where the review is carried out by a health professional with full access to the medical record. By definition any medicines review by the GP with the patient present at a consultation would constitute a level 3 review which is above the minimum required. However practitioners should be clear that when they mark a medication review as having been carried out, they would be challenged if the medication record showed obviously inappropriate content for example duplicate items or items clearly not being used which should be used regularly. We are compiling a more exhaustive list of differences between the old and new QoF and will provide further information as soon as possible. A useful summary of changes can be found at www.bma.org.uk/ap.nsf/Content/qof06 Chaperones in Consultations /p>The GMC and BMA both advise that chaperones should be offered to patients for any intimate examinations, including breast; genital and rectal examinations. If a patient chooses not to have a chaperone present, the doctor may choose to continue with the examination if it is necessary, but it is advisable to record that a chaperone was offered and declined.Chaperones could be other professionals (e.g. nurses), a patient relative, or a member of the non-clinical practice staff. The role of the chaperone should be to look after the interests of the patient, and it would normally be expected that they should be present in the room, not behind closed curtains. The patient could of course choose to have the chaperone behind the curtains but this might not allow the same level of protection for either patient or doctor. A nurse might reasonably be asked to assist the doctor in carrying out an examination, but it would probably not be acceptable to expect a receptionist or relative to assist e.g. in handling instruments. Some organisations run training courses in chaperoning, however the MDDUS do not feel this is necessary, and that a policy agreed by a practice using common sense should be acceptable. Good record keeping of the consultation, including whether a chaperone was offered and/or present is of course vital. Ian@Glasgow-lmc.co.uk Civil Partnership Act 2004 In the last LMC Newsletter we wrote about how the above act will alter the rights of the non British half of a same sex couple, married legally abroad, to access to Health Services in this country. In short they will have dependent rights to NHS treatment. There is another implication of the Act that may affect Practices. Same sex partners, of an employee of the Practice, either legally married abroad, or in a Civil Partnership in this country, from the 5th December 2005, will be entitled to the same rights to employment benefits as the spouses of employees currently have. In the terms of the Act a Civil Partnership involves two same sex partners, both over the age of sixteen, not related in a forbidden degree, not married or in a Civil Partnership with another, capable of understanding the nature of civil partnership, and validly consenting to its formation, signing the civil partnership schedule in the presence of; each other, two witnesses over the age of 16, and the authorised registrar. There is more to it than this, but it is as legally binding as marriage, with the same requirements, and rights. You will need to complete an audit of all the benefits that you offer to your married employees or their spouses. These could include; benefits from the NHS Pension Scheme, extra time off to get married, provision of a wedding gift, etc. Having audited the benefits you then need to ensure that the benefits you offer to married employees and their spouses are now also made available to Civil Partners. Staff Handbooks/Contracts of Employment will also have to be amended to show that spouse benefits are now available to Civil Partners. You should not wait for an employee to come and ask for the benefit, they should be given it as a right, and although you may not currently have an employee in this position, that could change. You do not need to backdate the rights to benefits; you are only obliged to make them available from the 5th of December 2005. Bear in mind that many homosexual employees prefer their sexual orientation to be kept private. If an employee tells you that they have entered into a Civil Partnership, ask them whether they want the information to be kept confidential. And finally from the Latest Scheme News on the NHS Superannuation Scheme page on the SPPA Website: -Civil Partnerships (Reviewed 22/12/2005) Changes to the main public service schemes in Scotland came into effect on 5th December 2005 to implement the survivor pension provision of the Civil Partnership Act 2004. The overall effect will be that civil partners are treated for the purposes of survivor pensions in the same way as married spouses for service after 6th April 1988. For information on any deadlines imposed in respect of buy-back arrangements for pre-1988 service, please follow the links below to access the relevant circulars relating to these changes. Please visit the page and click on the links below this item to access two documents relating to the Act and issued at the end of last year: - 1. Letter to Employers / Annex A – issued October 2005 2. Circular 2005/9 – issued 14 December 2005 Agenda for Change A lot of practices still ask about this. Agenda for Change does not apply to GP practice staff. A practice can use it and advice and training are available from the Board should you wish to do so. However, if it increases your staff costs, there is no additional finance to cover this. Initial feedback also suggests that some practice staff may come out of the job matching process worse off. There is an arrangement for Board employed staff to protect income but this would not exist for practice staff (unless you agree it). Practices can set their own pay rates although you should ensure that you treat staff according to the contract you have with them. Whitley Council rates will not be re-issued but you can continue to refer to the last set and give any further increases you decide are appropriate. If you have issues around employment you can ASK BMA by phoning 0870 60 60 828. District Nurse Referral Forms We have had queries from around the city about the ‘District Nurse Referral Form’ which practices have been told they have to complete. This form is more to audit the referrals to the nurse and to collect consistent data than as a method of communication between the district nurse and the practice. It is a tool for the district nurses themselves. If you normally use a form, and find this helpful, carry on. If you correspond effectively by phone, personal contact, or a diary method, keep doing that. All practices should have received a letter to this effect from Ellen Hudson (formally the Assistant Director of Nursing) prior to her move to the Acute Sector. The LMC will be happy to discuss this further with lead nurses if they wish to contact us. 24 Hour Checks on New Born Babies At a recent GP Subcommittee meeting we discussed GPs being asked to carry out 24 hour checks on new born babies. This examination is specifically excluded from the requirement of providing maternity medical services. We have made it clear that we expect the Health Board to organise this examination for babies who are discharged before the hospital paediatrician can see them. Performing Rights Society and Licences (PRS) We have received a large number of calls from practices about the PRS and the need for PRS music licences if you play music through television, radio or CD player, in the waiting room. Unfortunately for practices if you do use (or relay) television, radio or CDs in areas where members of the public can hear it then a licence is required. The licence is renewable on an annual basis and there are different tariffs dependent on the number of seats you have in your waiting area. Practices should also note there is a separate tariff for playing music (not musak) to callers ‘on hold’. More information can be found on www.prs.co.uk/health Blood Tests and Screening for Private IVF Treatment Practices are still being asked inappropriately to carry out a range of blood tests and screening for patients undergoing IVF treatment in private clinics. Our advice is not to carry out such tests and would ask our colleagues to write to the clinics concerned and ask them to either contact the LMC or Dr John Nugent, Chairman Quality and Enhanced Services Committee with a view to setting up an LES for this. Practices should be aware that laboratories will charge the practice for these tests. Any qualifying patient undergoing NHS IVF treatment will have all the necessary prescribing and screening done in secondary care. There is also now no requirement for GPs to be asked routinely for medical or social information about these prospective parents. This information will now be collected from the patients themselves. Hep B Vaccination and Serology Checking for Drug Misuse Patient A practice was asked to undertake Hep B vaccination and serology checks for a patient who attended their local addiction team. The practice wondered if this should be the responsibility of the CAT team and not the practice. Our advice is that if you provide a drug misuse enhanced service for the patient then we consider that it would be part of this service for you to provide Hep B vaccination and serology checking for that patient. If you do not provide the drug misuse enhanced service for the patient then you do not have to provide Hep B vaccination and serology and this should be the responsibility of the CAT team. Changes to Cytology Result Pads GRI We had a query about cytology results from colposcopy clinics at the GRI. We understand practices used to get a copy of the result but that this has now ceased. We discussed this with the consultant and it seems that the printer at the lab in the Royal used to churn out results on a dot matrix printer which used carbon copy type paper. Both of these were sent to the colposcopy clinic and one copy of it was sent on to the GP (which doesn’t actually happen in other cytology labs as far as we are aware). The printer has now been replaced with a more modern machine which only produces single sheets. It is apparently now technically difficult to produce and send duplicate copies. However practices should get a letter from the colposcopy clinic when the patient attends stating what treatment they have had; whether they have had a further smear and what the outcome is. Practices should look at the letter from the colposcopy clinic and code the smear results from the letter. The whole system of notification of smear results from whatever source is due to be radically changed within the next year with the advent of SCCRS and that will be a much bigger change for practice than anything we have yet seen. Read the Small Print Can we remind practices to read the small print in maintenance agreements, especially with regard to cancellation periods of notice. The majority of these contracts use a standard 90 day cancellation clause and we have been told of another practice who were obliged to pay a year’s maintenance because they did not cancel the contract in time when they changed suppliers. And Finally………. Have a great summer. Barbara, Alan, John, Murray, Mary, Ian and Elaine |