National Updates 2018

September 2018

Fund General Practice:

Recently, LMC’s across England have received information from a GP regarding challenging the bar on charging patients on our registered lists for additional medical services that are not provided on the NHS.

If the challenge is successful it would potentially allow practices to open outside of core hours for private consultations to all patients, to offer longer appointments outside of core hours to all patients, to offer minor surgery for cosmetic problems that are not funded on the NHS for all patients, to offer private vaccinations such as chickenpox that our local NHS pharmacy are able to provide privately to our mutual patients, whilst GPs are not.

The GP is aiming to raise £5,000 for the initial steps of the challenge, to fund BMA Law Solicitors and barristers fees through a crowdfunding website.

Medicine Supply Issue Update

The BMA have released a Medicine Supply Issue update for Primary Care.

It includes new issues, ongoing issues and resolved issues.

Mental Health Therapists in GP Practices

NHS England have released new guidance to encourage GPs to place mental health therapists in their surgeries.

Taking and Using Visual and Audio Recordings of Patients

The BMA has recently updated its guidance on GPs taking and using video recordings. The Increasing use of technologies such as video and picture messaging has made it considerably easier to record, copy and transmit recordings of patients. Doctors may be interested in using new technologies to aid rapid diagnosis and consultation and therefore improve patient care. Doctors need to bear in mind that when used for clinical purposes such recordings form part of the patient's medical record and the same standards of confidentiality, and the same requirements for consent disclosure, apply.

A small number of expectations to these requirements are covered in this guidance. The guidance does not apply to CCTV recordings of public areas in hospitals and surgeries, which are the subject of separate advice from the Information Commissioner.

To read the full article and guidance, please click here.

BMA Update

Richard Vautrey has published his update for September.

This update includes the following topics:

Face to Face meeting with Matt Hancock
PCSE/Capita Service Update
Interim Seniority Factors 2018-19
Data Protection Officers in GP Practices
GPs Experiencing Mental Health Problems

Face to Face meeting with Matt Hancock, the Secretary of State for Health and Social Care:

In this meeting, wider issues facing GPs and their practices were outlined.

Discussion turned to how to tackle the workload pressures facing GPs, and the linked workforce crisis. Key elements to resolving some of these problems and making general practice a career that is more attractive to younger doctors as well as a role that older doctors want to remain in, is to address the unsustainable indemnity costs GPs have to bear. It was therefore good to hear the Secretary of State commit to continue with the work to implement a state backed indemnity scheme for GPs to be introduced by April 2019. The Health Secretary also supports the important partnership and premises reviews that are currently under way.

PCSE / Capita service update:

As previously shared with you, following the publication of the National Audit Office report into the procurement of PCSE earlier this year, I wrote to NHS England to again raise our serious concerns with the poor service delivery by Capita/PCSE to GP services and LMCs. NHS England has responded to us this week to update us on the progress that has been made to address the many issues we had highlighted. They have told us that following complete roll-out of the bar-code tracking system, 98.5% of records are now being delivered within 12 days of collection. In addition, Capita's management of the performers list is improving, with complaints having dropped by 72% from the peak in August 2017 and turnaround times for changes to the performers list completed in less than two weeks.

Interim Seniority Factors 2018-19:

The Interim Seniority Factors 2018-19 for England and Northern Ireland have now been published on NHS Digital's Website.

Data Protection Officers in GP Practices:

The BMA has published guidance on the requirement for Data Protection Officers in GP practices under GDPR. In particular, members should note details of the recently published Addendum to the GP IT Operating Model, Securing Excellence in the GP IT Services. The guidance is available on the GDPR page , in the FAQs about the role of the DPO section.

GPs Experiencing Mental Health Problems:

Mental health charity Mind found in their recent survey that 40% of family doctors are experiencing symptoms of depression , anxiety or post-traumatic stress disorder and feel unable to turn to their colleagues for support. This was covered by iNews highlighting that the vast majority (86 per cent) of GPs affected said that they were much more likely to look for help from family and friends or their own doctor. 48% said they would seek help from a colleague just a third said they would turn to their practice manager. Dr Krishna Kasaraneni, GPC England executive team member,was quoted as saying, “This report is extremely concerning and highlights the need for better support for GPs and their teams. The BMA is calling for a properly-funded universal occupational health service, so that GPs and the wider practice staff are able to access the support they need, and in turn are better equipped to care for their patients. After all, no one wants to be treated by a sick doctor, and strains on clinicians' mental health will only lead to more turning away from the profession."

Read the latest GP Newsletter here.

June 2018

Appraisal Preparation:

Recently, NHSE have released guidance on the changes of how much preparation needs to be done for annual appraisals. There have been numerous concerns expressed by Clinicians as preparation for appraisals can impact on work-life balance and patient care.

Summary of the Guidance follows:

Learning credits will need to be justifiable and display appropriate levels of CPD to demonstrate you are staying up to date and are fit to practice (no longer defined as mandatory 50 credits)
Provide a minimum of one piece of quality written reflection on key learning events against each of the GMC domains in Good Medical Practice (examples and guidance in the attached document);
Mandatory declarations on elements such as health, probity, Multi-Source Feedback (MSF for patient and colleague feedback per each revalidation cycle);
Shall cover all aspects of your full scope of work;
You will reflect within your appraisal meeting on the learning undertaken for that year, and we hope this shall result in a more supportive and developmental approach to appraisal, focussed on you as an individual, with active and targeted complaints remain unchanged.

To view the full guidance please click here.

BMA Sessional GP Pensions Guidance:

Since Capita took over the pensions contract in November 2015, it had been supported by a team from NHSE (NHS England) to help deliver the contract. NHSE made the decision to withdraw that support in January 2018.

The Guidance the BMA have provided aims to address the main questions sessional GPs have raised.

This includes questions on:

Bank details
Unallocated forms
Total Rewards Statement (TRS)
Contacting Capita

To view the guidance please click here.

Non-Prescription Medication for Care Homes:

Practices are increasingly receiving requests regarding signing a “Homely Remedies” form for patients in care homes. Considering this, the GPC’s Prescribing Policy Group’s advice is:

"We approve of patients in residential homes or other such environments self-caring or receiving over-the-counter (OTC) medicines as all other people do, although recognise that their frailty does being with it special problems. Many care homes are introducing these policies, sometimes with the approval of local medicines management schemes, and GPs are being asked to complete the paperwork as an alternative to receiving inappropriate prescription requests.

The main problem, however, is that there is no guarantee that the circumstances that were present when the form was signed still apply when the OTC medicine is to be used, and there is a real danger that these forms will not be updated when patients’ circumstances change.

Therefore, it is safest if OTC medicines are available to care home residents after the input of a community pharmacist, where possible from the same pharmacy that supplies the patient’s normal medication. This is an appropriate use of a pharmacist’s skills, within their competence, and in line with the low value medicines agenda."

Diamorphine Supply Issue:

The Department of Health and Social Care (DHSC) and NHS England have been made aware of a manufacturing

issue from one of their suppliers of Diamorphine 5mg and 10mg injection. There are currently two suppliers of Diamorphine injection in the UK; Accord and Wockhardt. Recently Accord’s plant in Germany has experienced quality issues and the DHSC is working closely with Accord, regulators, and others to resolve these issues.

Based on current usage and remaining stock, there is the potential for supplies of Diamorphine 5mg to be depleted week commencing 4 June and diamorphine 10mg injection week commencing 11 June. Further supplies are currently expected the week commencing 28 June.

The DHSC and NHS England have since been working with Accord and their supplier in Germany and the manufacture of diamorphine 5mg and 10mg injection will soon resume with an anticipated resupply date of beginning of September 2018. DHSC and NHSE have also been working with the remaining supplier, Wockhardt, to support the supply issue and they have been able to increase their production of diamorphine 5mg and 10mg but are unable to support the entire market in July and August. A management plan has been developed to manage the supply issue during July and August:

Management plan from 1^st July 2018:

Primary care and drug misuse centres will be able to continue to order diamorphine in line with historical demand.
Secondary care will have access to restricted supplies of diamorphine
The DHSC has been working with national clinical leads and specialists to discuss alternatives. The UKMi has published guidance to help support this supply issue, available here:
The recommended alternative is morphine injection; the DHSC are in discussions with all the manufacturers to ensure that any additional demand can be met.
Further information includes the Patient Safety Alert on high dose morphine and diamorphine available here.

Recommended Local Action- Primary care and drug misuse centres

Review and share UKMi clinical guidance and engage with clinical colleagues to review / amend clinical guidance accordingly.
Morphine 10mg injection will be available to cover the Diamorphine supply issue in June.
Please only order extra stock of Morphine as Diamorphine injection becomes unavailable locally and do not stock pile.
Please cascade this message to all relevant networks in primary care including GPs, pharmacies and palliative care networks.
DHSC and NHSE will continue to work with all stakeholders and provide further updates as available.
Although you will be able to access diamorphine as per historical demand, we would encourage prescribers to be aware of the supply issues and reduce prescribing where appropriate
Please order responsibly during this time, in line with historical demand and do not stock pile to avoid lengthening the stock out period.
In the case that diamorphine cannot be accessed, please refer to the clinical guidance issued by UKMI which provides more information on suggested alternatives to diamorphine: www.sps.nhs.uk/articles/shortage-of-diamorphine-5mg-10mg/. The first-choice is morphine which is given in detail in this link. If you require clinical guidance locally – please liaise with secondary care prescribing partners in substance misuse services or pain specialist services
Further information which you may wish to review include the Patient Safety Alert on high dose morphine and diamorphine www.nrls.npsa.nhs.uk/resources/?entryid45=59803

Distribution Arrangements (From 1^st July)

Diamorphine 5mg and 10mg will only be available to order from Alliance. No minimum surcharges will be levied
Morphine 10mg injection (Martindale) available to order from AAH only.
Diamorphine 30mg injection (Wockhardt), diamorphine 100mg (Accord) and diamorphine 500mg (Accord and Wockhardt) – usual wholesalers.

For further information on ordering processes please contact:

Alliance 0330 1000 448 / customerservice@alliance-healthcare.co.uk

AAH: 0344 561 8899

NHSE have also supplied a patient information sheet to support this medicine supply issue. To view this please click here.

Imms and Vaccs 2018/19 GMS Guidance:

The GMS immunisation guidance for 2018/19 is now available. The guidance is available to view on the NHS Employers Website and through the BMA Imms and Vaccs Page.

Low Value Medicine GPC Guidance:

Following two consultations on which items should not be routinely prescribed in primary care, and on conditions for which over the counter (OTC) items should not routinely be prescribed in primary care, NHS England published revised commissioning guidance for CCGs on reducing prescribing of OTC medicines for minor, short-term health concerns, as part of a drive to reduce prescribing of OTC medicines to save the NHS money.

The GPC responded to both consultations, supporting the efforts to educate patients about self-care of minor ailments, and encouraging the appropriate use of effective medicines that are available from community pharmacies or other retail outlets. However, without changes to the GMS regulations that govern GP prescribing, we highlighted that GPs will be at risk of

complaint from patients or criticism from their CCGs, and that the NHS England guidance cannot be used by CCGs to ban all such treatments.

GPs must continue to treat patients according to their individual circumstances and needs, and that includes issuing prescriptions where there are reasons why self-care is inappropriate.

The GPC has now published guidance on the contractual requirements for practices in prescribing OTC medicines for minor, short-term health concerns, which is available here.

The full low value medicine guidance can be viewed here.

Update from the BMA:

Richard Vautrey has published 2 updates to LMC’s. They key topics in his first update were as follows:

Changes to data sharing MoU: The Government has announced a fundamental change to the Memorandum of Understanding (MoU) between NHS Digital, the Home Office and the Department of Health and Social Care and will now be restricting NHS Digital’s data sharing with the Home Office to the tracing of an individual who is being considered for deportation action having been investigated for, or convicted of, a serious criminal offence, or where they present a risk to the public. The change in position aligns the MoU with existing legal and ethical standards of confidentiality which restrict disclosures ‘in the public interest’ for law enforcement purposes only when the crime under investigation is a ‘serious’ crime. It is estimated that the change to the MoU will exclude some 95% of current Home Office requests.

The BMA has strongly opposed to the MoU, because of the concerning impact it has on the confidential and trusting relationship between doctors and patients.

GDPR Privacy Notices: Template GDPR practice privacy notices (PPNs) have now been published on the GDPR hub page in the BMA resources section. The hub page also contains information on the regulation and hosts a suite of resources and blogs to help guide members, including a new GDPR webinar to help practices prepare.

GP Pension Records: GPC has been made aware of historic administrative issues with GP pension records and we have written to NHS England to seek further information. We understand that NHS England have commissioned further work on how to resolve the issues found. They will not, therefore, be in a position to advise individuals until this is done. We will provide further detail when we have clarity on this issue.

Included in Richard Vautrey’s update is a paper on supply issues from primary care from April/May. To view this paper please click here.

In addition to this, the update included the 2018 MenB PDG (Patient Direction Group). This paper will be reviewed in November 2019 and expire in April 2020. To view this paper please click here.

The key topics from his second update we are follows:

GPs struggle to offer routine appointments: A Pulse investigation suggests one in six GPs are under such pressure they have resorted to halting routine appointments or limiting appointments to ‘emergency only’ at some point in the last 12 months. The survey of 800 doctors found some practices are not able to offer appointments for a month, and will screen every patient who calls by telephone to assess if they need. In response to this, I commented: “This is further evidence of the pressures practices are under, with growing demands for appointments not being matched with an ability to provide them due to the continuing recruitment and retention crisis in general practice.” The news was also covered in the Independent, the Daily Telegraph, The Times and the Daily Mail. I also did interviews for BBC Radio Cumbria, Talk Radio, LBC and Radio Aire about this and related issues. In addition, I spoke to BBC South Today about the impact a practice closure would have on other practices in the area.

GPs and their vital role as gatekeepers for the NHS: To mark the NHS’ 70th anniversary, I was interviewed by the Guardian on the essential role that GPs play within the NHS. In it, the Guardian makes reference to GPs as being gatekeepers for the NHS and I said that the role of the GP “enables continuity of care and holistic, family medicine”. This article was only published in print, but is attached for information. BMA honorary vice president Dr Kailash Chand, and GPC member Dr Clare Gerada, were also interviewed on ITV lunch time news today about the future of general practice.

GDPR changes to SARS and fees from 25^th May: The General Data Protection Regulations and the Data Protection Act 2018 will replace the existing Data Protection Act 1998 from today (25 May) and will see widespread changes to UK data protection legislation. For GPs it will bring in a number of changes, specifically the charges that were in place for undertaking Subject Access Requests (SARs). In most cases, patients must be given access to their medical records free of charge, including when a patient authorises access by a third party such as a solicitor. A ‘reasonable fee’ can be charged if the request is manifestly unfounded or excessive. However, these circumstances are likely to be rare. If the request is for a medical report (rather than a SAR) then this falls under the Access to Medical Reports Act (AMRA) and should be handled in the usual way. The GDPR does not change the AMRA.

We are in the process of updating our guidance document ‘Access to Health records’ which will available shortly on the BMA website and will provide further details on this. For more general information on GDPR and how this may affect you please view our main GDPR guidance. We are keen to pursue how we can ensure doctors and their practices do not suffer under these changes and will be collating information post implementation to use in future discussions with Government.

The full update paper can be found here.

Included in the update, there were papers on BMA guidance on competition law for LMCs. To view this click here. As well as a paper on "Gatekeeping- General Practice" by the guardian. To view this please click here.

Leicester, Leicestershire & Rutland Local Medical Committee Ltd.