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No.

317
Your Chairman writes ……..
March 2018 All Change at the LMC

Nothing lasts forever and the world of the LMC is no exception.


LMCs have been in existence for over 100 years in varied forms
serving General Practice throughout the four nations of the United
Kingdom. Our own LMC has been serving the GPs of Cornwall and
the Isles of Scilly for many decades and has been fortunate in
finding dedicated staff who have become stalwarts in the support
and defence of General Practice. Our current Executive Manager,
Dawn Molenkamp, is one such stalwart. All good things come to an
end and Dawn has recently announced that she plans to retire at
the beginning of June. Plans are underway to seek a suitable
Cornwall & Isles of Scilly

replacement and we will keep you informed of our progress.


Meanwhile, I feel it is appropriate at this juncture to thank Dawn for
her many years of dedicated service to our LMC and to the
community of General Practice in Cornwall. She has and continues
to be deeply committed to our organisation and I know many
managers and GPs will want to thank her personally for the support
that she has rendered to them in times of need. This work is
invisible to most of you but it is invaluable to colleagues. Finally I
want to thank Dawn for the help and support she has given to me
and cabinet colleagues over the years without which we could not
function.
Thank you Dawn.
LMC Newsletter

Inside this issue:

NHS services in institutions 2/3


and care homes Sessional GP Newsletter
International GPs. 4
Workload Control in General
Practice. Here is a link to the latest
GP Contracts Announcement.
National Flu imms. letter
Sessional GP newsletter
Learning from incidences in 5
Primary Care.

Responsibilities for prescribing 6


Contract changes 2018/19
Anyone for Cricket?

PM & Admin courses 2017/18 7 • Items for the Newsletter should be


New LMC Executive sent to the Editor, Dawn Molenkamp
at Victoria Beacon Place, Room
B314, Station Approach, Victoria,
Events 8/9 Roche, St Austell, PL26 8LG
Tel :01726 210141
Vacancies 10
• e-mail dawn@kernowlmc.co.uk
Dr Basil Bile 11
NHS primary care medical services in institutions and care
homes in the UK

NHS GP practices are increasingly being asked to provide primary care medical services to patients residing in
institutions or care homes where the types of services expected may not fall under their contractual obligations;
accordingly the BMA is receiving increased queries from practices and LMCs as to the requirements to register
and provide services to such patients.
This guidance outlines the responsibilities of practices in deciding whether they need to register such patients,
and if so, what services they are required to provide.
When GPs provide services to patients residing in institutions and care homes, there is often confusion over
who is clinically responsible for their care, which may present a risk to patient safety. GPs must not be forced to
accept clinical responsibility for aspects of the care of patients in secondary care institutions, nor for those in
any setting where the clinical needs of the patient fall outside the normal skills and contractual requirements of
GPs.

Care for patients in intermediate care can also present problems caused by a lack of clarity about the profes-
sional responsibility of GPs. This is important in the light of the trend to discharge relatively high-dependency
patients from hospitals to other institutions, with GPs increasingly being asked to provide care which is likely to
be beyond that which most GPs are trained, or contracted, to provide.
With this in mind, and following legal advice, this guidance outlines the responsibilities of practices in deciding
whether they need to register such patients, and if so, what services they are required to provide. References
to the CQC and NHS England should be read as including the relevant bodies in the four nations (e.g. Health
Inspectorate Wales, NHS Scotland etc.) and members should also ensure they refer to the relevant regulations
for their jurisdiction.

Guidance for GP practices


Registration of hospital inpatients
There are limited grounds by which a practice may refuse to register a patient who is a (temporary or perma-
nent) resident of an institution within the practice boundary, under Part 2 paragraph 21 of Schedule 3 of the
GMS regulations (2015).
Decisions need to be taken on a case by case basis, taking into consideration the needs of the patient,
the services provided by the institution and any other commissioned services that may be available to
the patient.
If a hospital is providing a full range of medical services e.g. acute care and is not a single speciality
(e.g. a psychiatric hospital), then it is very likely the practice will have reasonable grounds to refuse reg-
istration.
If adequate primary medical services are provided by the institution (as commissioned by the Commis-
sioner) or if alternative commissioned arrangements are available to the patient, then it may not be nec-
essary for a practice to register a patient who is resident in that institution, but again any decision needs
to be taken on a case by case basis.
However, where it is known to the practice (remembering that the assessment and decision rests with
the GP) that adequate primary medical services are not provided, current legal advice suggests there
are unlikely to be reasonable grounds for refusing to register such patients.
Provision of services
Regulation 17 (5) (b) of the Regulations provides contractors with discretion (which must be exercised reasona-
bly) to decide the scope of the treatment or investigations that are necessary or appropriate; but again a deci-
sion must be taken for each individual case. The fact that certain services may be provided within the institution
is a factor in deciding the extent of any supplemental services which it is necessary or appropriate for the GP to
provide.
The view of GPC, based on our legal advice, is that GPs are entitled to refuse to provide care of a kind
which the patient already receives or can receive from the institution where they reside; or that would
be beyond the scope of normal primary medical services as defined by the GMS contract.
Obligation to carry out a visit
If a GP is requested to carry out a visit to an institution to provide services to a registered patient, a clinical
decision should be taken on a case by case basis in the same way as any other registered patient
would be assessed for a home visit.

NO . 3 1 7 Page 2
NHS primary care medical services in institutions and care
homes in the UK (2)

Indicators of whether GPs are responsible for patient care


When assessing institutions to determine who is responsible for patients, it is appropriate to consider sever-
al points which will help indicate whether GPs should be providing services:
 is there a consultant or other non-primary care doctor with clinical responsibility for the patients or resi-
dents?
 does any consultant or other hospital doctor act for the patients/residents, and is this at the GP's sole invi-
tation?
 what are the historical care arrangements?
are there often instances where the level of care required is above that which would normally be pro-
vided by GPs?
GPs are likely to be responsible for patient care if:
 the residents fall into the practice's geographical area and
 the institution is registered as a care home by the Care Quality Commission (CQC) and is not registered as
providing hospital services (in England).
These characteristics indicate that GPs may be responsible but they need not all be present, nor is this an
exhaustive list. Moreover, even if these points apply, the GP may not be responsible if other factors out-
weigh these characteristics.
Even where GPs are required to take responsibility for residents or patients, there is no requirement to pro-
vide any services beyond those set out in the GP’s primary care contract and GPs should decline to
work outside their normal clinical remit.
GPs are reminded that the definition of essential services in the GMS/PMS regulations refers to services
being provided in a manner that is determined by the practice and are "necessary and appropriate". If a
GP is working outside their expertise and training they put patients at risk as well as their own registra-
tion.

GPs are unlikely to be responsible for patient care if:


 the institution is registered with the CQC as a hospital (in England)
 the institution provides a full range of medical services e.g. an acute hospitals setting, rather than being a
single specialty or psychiatric institution
GPs should not be responsible for clinical care for patients that is routinely provided by secondary care
professionals who are NOT:
 directly clinically responsible to the GP and
 directly managerially responsible to the GP and
 acting for the patient solely at the GP's invitation

Providing primary care services to patients in secondary care institutions


GPs need to be aware that some services simply do not fall within the normal competencies of the average
GP and should be provided only by a doctor with the appropriate specialist skills and training.
GPs who are being pressured into providing care in hospitals or are not clear whether an institution is a
secondary care establishment and are unclear in respect of their responsibilities for both patient regis-
tration and the provision of care should contact their LMC and their medical defence body for advice.
GPs should also raise concerns with the CQC (in England) over the care in any institution should they feel
that safe and appropriate medical arrangements are not being adequately commissioned or provided
and are putting patients at risk.

NO . 3 1 7 Page 3
Reminder for practices – Recruitment companies may contact
you with offers of International GP for work.

This is just a reminder that all doctors working in a practice are required to be included on the National
Performers List (PL) if they are delivering a GMS, PMS, and APMS contract.
There are a number of International recruitment companies which are contacting GP surgeries and other
NHS bodies who deliver primary care offering doctors to work in primary care.
Very often the companies will advise that these GPs are fully qualified and on the GMC register and that
their status as an EU doctor allows them to work in this country. These GPS are able to work but MUST
also be on the PL to work in practice delivering GMS/PMS/APMS contracts.
If you employ a doctor who is not on the PL then your indemnity will not cover their clinical activity leaving
you at risk of patient harm and potentially ruinous litigation costs.
If you are interested in employing an International GP then you can do so through the national IGPR
scheme which has engaged with approved recruitment companies.
For further information on the regulations please contact the performance team in the medical directorate
who are the experts in this matter england.southwestperformerslist@nhs.net .
If you are interested in the International GP recruitment scheme then you can email your interest to
liz.thomas2@nhs.net – South Lead for the IGPR.

Workload Control in General Practice

This useful and pertinent document is attached to this newsletter, and you are encouraged to read it.
If you prefer it can be accessed here

GP contracts (England) announcement

Please see below link for the information about the contract agreement.

Link: https://www.bma.org.uk/gpcontractengland

National flu immunisation programme letter for 2018/19

Here is the link to the national flu immunisation programme letter for 2018/19:

.It includes detail of extension of the childhood flu immunisation programme to include children in school
year 5.
Please note, further detail around vaccination of frontline health and social care workers will follow in a
second letter due to be released in late Spring.

NO . 3 1 7 Page 4
Learning from incidences in Primary Care
These are a result of incidences that have occurred in primary care and the learning has come from the Primary
Care Quality & Sustainability Hub Meetings.
Lost prescriptions in the post
6 loose prescriptions were delivered to a practice with the incoming mail which had apparently been found at the
Sorting Office. These prescriptions had been posted in an A5 envelope and taped at both ends. A postage label to
the Prescriptions Pricing Authority had been secured to the package.
The practice immediately identified that 39 prescriptions were unaccounted for. Royal Mail advised that 3 working
days should be left before contacting the recipient to check the outstanding items had been delivered.
Key learning points are:
1) That all prescriptions need to be sent recorded or special delivery as loss of prescriptions has both income and
information governance implications.
Medication error into a Monitored Dosage System (MDS)
Carer returned an unused MDS for a change in medication. The pharmacy team removed the Ramipril 2.5mg and
5mg Capsules and dispensed 10mg Capsules into the MDS but failed to identified that Ticagrelor was not present in
the MDS.
Key learning points are:
1) Ensure MDS is not accepted for alterations or re-dispensing. A new prescription should be requested and any
changes should be recorded on the MDS record card.
2) The content and the dispensing label on the MDS should always be checked against the MDS record card and
prescriptions as per Standard Operating Procedures.
Patients refusing to attend hospital
Recently a number of Serious Incidents and Significant Events in Primary Care have been identified with patients
refusing to attend hospital. NHS South, Central and West Commissioning Support Unit (SCW CSU) have investigat-
ed similar issues.
Key learning points are:
1) Informed consent needs to be accepted and understood by the patient. For consent to be truly informed, the infor-
mation given needs to be fully understood by the patient.
2) Healthcare Professionals must explain all reasonably and foreseeable risks of any patient decision. SCW CSU call
this ‘informed consent - explaining the risk’.
3) This conversation needs to be documented, including the risks discussed.
4) It should be noted that this applies not just to patients refusing to attend hospital, but particular treatments also.
SCW CSU also note that:
“If an adult has the capacity to make a voluntary and informed decision to consent to or refuse a particular treatment,
their decision must be respected.” – NHS Choices.’
EPS system does NOT allow urgent prescriptions to be highlighted to the receiving pharmacy when sent
from a GP system
A recent incident has occurred whereby, following a home visit from the GP, a patient was prescribed Amoxicillin
500mg capsules for a suspected chest infection. The GP issued this prescription electronically on their return to the
surgery via EPS, which was confirmed as received and downloaded at the patients chosen pharmacy.
The EPS token was sent to print@ the visual alert on the PMR which would indicate the patient required a delivery
was not seen by staff at the pharmacy. Additionally, there was no record of any verbal request from the GP, patient
or the patients family requesting the medication be delivered urgently. Consequently, the medication was neither
dispensed nor supplied.
The patient collapsed 5 days later and was admitted to hospital. Sadly the patient died 3 days later with the cause of
death noted as sepsis.
This incident highlights the importance of reiterating to General Practice teams that the EPS system does NOT allow
urgent prescriptions to be highlighted to the receiving pharmacy when sent from a GP system.
NHS Digital are currently reviewing the options available to support the identification of clinically urgent prescriptions
however, this is likely to take time in order to follow due process therefore unlikely to happen in the foreseeable fu-
ture.

NO . 3 1 7 Page 5
Guidance on Responsibilities for Prescribing between Primary
and Secondary/Tertiary Care
We have been alerted to this document from NHSE concerning prescribing at the primary and secondary/
tertiary care interface, and which is the result of a year’s work arising from the GPC’s Urgent Prescription for
General Practice

I would urge you to read it carefully, as its implementation will help with many of the problems that GPs will
have been reporting to you in recent years. Patients will also benefit by no longer being caught in the middle
with regard to obtaining the drugs that they need.

GMS contract changes for 2018/19

Please see below link for the information about the contract agreement.

Link: https://www.bma.org.uk/gpcontractengland

Contract changes - in summary


• Interim uplift of 1% for pay and in line with inflation for expenses, which would be increased further fol-
lowing any uplift secured through the DDRB process
• Increase in indemnity costs covered
• Uplift in line with inflation for those vaccinations and immunisations in the SFE
• Uplift to reimbursements of locum cover for sickness and maternity/paternity/adoption leave
• Fixed-term contracted salaried GPs for sickness/parental leave will be reimbursed (in line with locum
cover)
• Minor amendments to clinical aspects of vaccinations and immunisations
• Significant resources and support for implementation of the electronic referral service
• QOF point value to be uplifted to reflect population increase
• New regulations to support practices in the removal of violent patients
• New premises cost directions

INTERESTED IN A LITTLE SOCIAL CRICKET?

How about joining Methigion cricket club? A doctors team who have been together since 1989. We are a
mixture of Hospital doctors and GPs and are always keen for new players to come and join us. We play
evening 20.20 cricket throughout the summer. We play socially and don't take it too seriously .We have
Nets booked at the Truro cricket centre on the 11th April 7.30 - 9.00 , and a fun internal indoor six a side
at the same venue a week later on the 18th April, 7.---9.00 . Further outdoor nets on the 25th venue TBA,
all before the season starts in May. Any queries please get in touch - david.farrar2@nhs.net

NO . 3 1 7 Page 6
Practice Managers and Admin Courses Run
2017/18
I thought it would be quite nice to give you a summary of the courses we ran and the support we had from
them.
The courses ran throughout 2017 and into 2018 starting in May 2017 with the programme ending in March
2018. The maximum number of delegates we could have for each course was 20 delegates, but the ideal
number was actually 15. Due to demand we tried to put on the same course at different times of the year
which was reasonably successful, so here is a quick summary with delegate numbers.

Medical Terminology (May and Sept) – Total 31 delegates


Read Coding (May and Nov) – Total 27 delegates
Employment Law Seminars (June, Sept and Nov) – Total 41 delegates
Note Summarising (June and Nov) – Total 19 delegates
Handling Complaints (July) – Total 16 delegates
Exceptional Customer Service (Nov and Feb 18) – Total 27 delegates
Dealing with Difficult People (Dec) – Total 15 delegates
Snomed (5 in total) – Total 98 delegates
GDPR (3 in total) – Total 60 delegates
Managing Change in GP Practices (Feb 18) – Total 13 delegates
Appraisal Skills (Mar 18) – Total 13 delegates

So, Dawn and I would like to thank everybody that has supported us by attending the courses and I am
pleased to add that our programme for 2018/19 is already booking well.

If you have any suggestions for future courses, please do not hesitate to get in contact with us and we will
investigate them.

LMC Executive

I am pleased to announce that the new LMC Executive team has been elected unopposed and will
comprise of the following.

Chair Elect Dr Will Hynds.

Vice Chair Dr Nick Rogers.

Treasurer Dr Phil Trevail.

Dawn Molenkamp
Returning Officer

Page 7 C O R NWA LL & I S LE S O F S C I LL Y LM C NE WS LE T TE R


EVENTS

LMC Training Courses

Employment Law Seminar – Thursday 3rd May 2018.

Just to let you know the course title for the day will be “Legal Surgery” and the content will run as follows:

Legal Surgery
This seminar provides delegates with an opportunity to have their individual scenarios considered and, as
such, it is run with a great emphasis on the individual delegate. Very practical answers are given to direct con-
cerns and delegates learn not just from the tutor, but also from one another’s problems.

And of course, the course tutor will be the ever-popular Darius Ferrigno – early booking is recommended as the
maximum number for this day will be 16.

Accounts Update – Wednesday 11th July 2018

I now also have more details on the days content. This will be run by Lucy Mace and Joe Dowling from Francis
Clark with Luke Bennett introducing the day. Luke will also be on hand for the entire session.

Topics covered during the day will be:


Making Tax Digital (MTD)
Cloud Accounting and packages available
Francis Clark supporting GP’s through these changes
VAT - applicable to VAT registered practices

Employment Seminar – Thursday 20th September 2018

Again the course tutor will be Darius Ferrigno and the subject for the day will an “Employment Law Update”.
Booking forms for the above is attached to the back of this newsletter – please email to: ad-
min@kernowlmc.co.uk

NO . 3 1 7 Page 8
EVENTS

LARC UPDATE
LARC UPDATE – 2nd MAY 2018 – St Erme Community Centre
There are still spaces available for this study day.
It is structured as two separate 3-hour sessions which can be used towards DFSRH reaccreditation.
The morning session covering IUD provision (3 hours CPD). This will include the very latest changes to
guidance and product range. The afternoon session (3 hours CPD) will review contraceptive implants. It
will cover the theory base for this method and set the context for making a choice between the various
hormonal methods.
Details and a booking form are available on
http://www.crescetis.co.uk/womens-health-training-sexualhealth.html#lu_0205
Sarah Gray

Forth Coming Practice Manager and Admin Courses

Just to remind you we have the following courses coming up in the next couple of months:

Signposting Level 1 and Level 2 – Weds 18th April and Weds 15th May respectively – places available

Employment Seminar, entitled “Legal Surgery” with the ever-popular Darius Ferrigno – Thursday 3rd May
– places available

Keep your eyes on the courses coming up and we have an addition to the current list, that being
“Managing Pressure At Work” – an all day course and the date being Weds 10th Oct 2018.

Anybody that needs a schedule of courses please just email me – admin@kernowlmc.co.uk and I will
send you one with the booking forms.

Page 9 C O R NWA LL & I S LE S O F S C I LL Y LM C NE WS LE T TE R


Vacancies

Come and work for the LMC


Office Administrator

Office Administrator required 3 days a week (24hrs per week – Weds, Thurs & Fri) plus holiday and
sickness cover. This post is to work alongside the present administrator. The ability to run the office alone
for part of the week will be required.
Tasks to include covering Sage Payroll and Sage Accounts, Co-managing the LMC Web site, minute tak-
ing and all general office functions.
Generous pay and holiday, good working conditions.
For further information contact either Dawn or Nicky (01726 210140 or 01726 210141) or email either:
Dawn@kernowlmc.co.uk or Admin@kernowlmc.co.uk

Vacancies on the LMC website

For more details on these vacancies please see the LMC website

Salaried GP – The Rame Group Practice, Torpoint


Salaried GP – Frome Medical Practice, Somerset – CD 12th April 2018
Locum GP – Frome Medical Practice, Somerset
RMS Clinical Lead – CD 30th April 2018
Salaried GP or Partner – Tamar Valley Health, CD 30th April 2018
Practice Nurse & Trainee Advanced Nurse Practitioner – Newton Abbot
GP – Salaried or Partner – Phoenix Surgery, Camborne
GP Partners – Bodriggy Health Centre, Hayle

Page 10 C O R NWA LL & I S LE S O F S C I LL Y LM C NE WS LE T TE R


Dr Basil Bile

“GPs Too Soft On Back Pain.”


Belinda takes great pleasure in reading out newspaper headlines that she knows will distress me
at the breakfast table. Especially when she is well aware that I am busily engaged in trying to extricate the
free model submarine from an economy pack of Sugar Munchybits. This is a first-class example of pre-
ventative medicine being practiced by yours truly, for which I receive scant credit. If Belinda were to choke
to death on the Nautilus whilst ingesting her favourite breakfast cereal I would never hear the end of it.
“Bloody cheek!” I respond. “What evidence do they have for this ludicrous assertion?”
“They say family doctors sign patients off work too easily.”
“Who does?”
“The Lancet. They also condemned as ‘unconscionable’ the readiness of GPs to use therapies that
do not work.”
“If I knew what ‘unconscionable’ meant it might help. Typical of the stuck-up Lancet to use long
words lifted from a thesaurus that one of their journos found hidden down the back of the sofa. The BMJ
wouldn’t stoop to using such underhand tactics.”
Belinda was clearly enjoying herself and, ignoring my discomfiture, ploughed on regardless. “Most
chronic back pain cases respond only to exercise and psychological treatment, but research suggested
clinicians felt unable to deny their patients painkillers.”
“Well, there you are then.”
“Where exactly am I, Basil?”
“It said ‘clinicians’. I’m not a clinician. Perish the thought. I’m a GP.”
In spite of the wisdom of my argument she continued to bang on. “The cost to productivity of back
pain in Britain appears proportionately higher than several comparable nations, with a million years of
working days lost among a population of sixty-five million.”
“That must be a typo. Typical of the sloppy approach of The Lancet.”
“I don’t suppose your antipathy towards this particular medical journal has anything to do with their
turning down your article?”
“About the link between Athletes Foot and The Colour of Socks Worn? Their loss, not mine. Any-
way, their figures are preposterous.”
“They say it equates to more than five lost working days per person per year.”
“Well that proves they’re talking balderdash. Every person doesn’t get back pain every year.”
I grabbed the Daily Torygraph from my wife’s grasp. She was probably misreading it. Instead of
buying exorbitantly priced spectacles from Specsavers she should, like me, get her goggles from the local
Garden Centre. A fiver for off-the-shelf jobs.
I perused the offending article for myself. I’m afraid the old red cells began to heat up. Some Pro-
fessor from Southern Denmark had the absolute barefaced cheek to say that millions of people are getting
the wrong care. Fortunately, the delectably imperious Professor Helen Stokes-Lampoon waded in to the
defence of UK family docs.
“Family Doctors are mindful of clinical guidelines,” she said.
For one awful moment I thought she was going to blather on about ‘mindfulness’. But I should have
had more faith.
“For some patients there is a limit to how realistic a significant amount of exercise is.”
Quite right, old fruit. I’m going for a lie down. My back’s aching something dreadful after strug-
gling with that cereal packet. I think I’ll write myself a sick note…

Page 11 C O R NWA LL & I S LE S O F S C I LL Y LM C NE WS LE T TE R

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