What does the LMC do?

The LMC is the only elected, representative body of local GP opinion. It has certain statutory duties and must be consulted on certain issues. It exists to represent, advise and support GPs and General Practice.

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Locum Agency Fees Charged When Appointing a Partner

Question

I have been employing locums through a locum agency while I look for another partner.   One of the locums was very good and successfully applied for the vacant partnership post.   I informed the agency that I would no longer need their services and that one of the locums provided by them had now accepted a partnership with me.  They demanded a substantial Transfer Fee representing 25% of the locums expected earnings in the first 12 months.  There has been some negotiation as to the exact level of compensation that they will require, but it is quite clear that this will prove very expensive.  Is this a usual arrangement?

Answer

In the small print of the contract with the agency there will undoubtedly be a reference to just such an eventuality.  It may be possible to avoid payment if the clause can be legally challenged, but it seems very likely that you have been caught unawares by what is commonly one of the terms and conditions attached to the contract with the agency.  

CED     29/04/09

Hepatitis B - incomplete vaccinations in infants returning from abroad

A British couple have recently moved back to the UK from Hong Kong.  Their baby was started on routine immunisation against Hepatitis B in Hong Kong and the mother wishes for us to complete the immunisation schedule.  This is not in the normal UK childhood immunisations.  What should we do?

Answer

Where good healthcare exists in countries with a very high prevalence of Hepatitis B, such as Hong Kong, immunisation is usually given routinely in infancy.

Opinions on the correct course of action in this situation are divided. 

Hepatitis B immunisation is not offered routinely to infants in the UK despite the World Health Organization recommendation in 1992 that all countries should introduce universal hepatitis B vaccination into their immunisation schedules by December 1997.  

The local Health Protection Unit has advised that only those immunisations included in the UK's routine infant immunisation schedule should be given at public expense.  They argue that a baby that has received any routine immunisations would have a greater degree of immunity than most British babies. If you subscribe to this view then the baby should be referred to a private practitioner for immunisation. You may not charge the patient yourself for providing this service.

You may, however, choose to complete the immunisations under the NHS if you believe this is in the best interests of your patient.

Before refusing to complete the schedule it is essential to check that the immunisation was, in fact, purely routine and was not given to the baby because the mother or another close family member was infected with Hepatitis B.  If this is the case then it is essential that the baby completes the course of immunisation.

UK guidelines recommend that all pregnant women should be offered screening for hepatitis B infection during each pregnancy and all babies born to infective mothers should receive a complete course of vaccine.

If mothers are chronically infected with Hep B or have had an acute hepatitis B infection during pregnancy the infection can be transmitted to their babies at or around the time of birth.  These babies have a high risk of becoming chronically infected with the virus and this can be prevented in over 90% of cases by appropriate vaccination, starting at birth.

Most Asian countries have a very high prevalence of Hepatitis B infection and travellers to areas of high or intermediate prevalence may be at increased risk.  This will include children who may require medical care while travelling to visit families or relatives in high or moderate-endemicity countries.  If such travel is likely to occur, completion of the baby's immunisation schedule is a sensible precaution.

Usual schedule for hepatitis B immunisation in infancy

• The first dose is given with 2 days of birth
• A second dose is given at 1 month old
• A third dose is given at 2 months old
• A booster dose and blood test are given at 12 months old

The evidence suggests that the immunity acquired after vaccination lasts for life.

These immunisations are all included within the global sum and the cost of the vaccine to complete the immunisation may be charged to the PPA on FP 34D.

Further information on Hepatitis B Immunisation may be found on the Green Book which is available at www.dh.gov.uk/greenbook

Footnote

World wide prevalence

The prevalence of HBV infection varies markedly but overall approximately 45% of the global population live in areas of high chronic HBV prevalence.

In sub-Saharan Africa, the Pacific, and particularly Asia, HBV infection is endemic, with the majority of individuals becoming infected during childhood.

Outside of the endemic areas, regions with high rates of chronic HBV infection include the southern parts of Eastern and Central Europe, the Amazon basin, the Middle East, and the Indian subcontinent.

In western and northern European countries and North America, HBV infection is relatively rare and acquired primarily in adulthood.

CED     09/04/09

Health Screening Companies and General Practice

Question

We have been approached by a Private Medical Screening Company who offer screening for vascular, ovarian and bone density risks? Can we do business with them?

Answer

Yes, you may but there are some issues you must be aware of and consider.

You must make a judgement about whether you think this is a useful service that is likely to be of benefit. (e.g. you would probably judge Ht, wt, BP , aortic diameter as being useful vascular risk factors but analysis of hair samples for allergies to be invalid and misleading.)

You must not give them your practice list. If you write to your patients to advertise this service you could be in breach of the Data Protection Act.

The best way forward is a local advertising or a non-list based mail shot to the local people.

We would recommend that you rent space to the company at a commercial rate rather than earn a "per patient" commission thus removing yourself from having a vested interest in "selling" to your patients.

FS jan 09

I am really confused about HPV vaccination. Can you help?

There has been much national and local confusion. More info here.

Patients taking extended breaks abroad and medication requests

Question

I have a patient who is moving abroad who intends to return briefly every 3 months. He insists that he is entitled to full NHS care during the visit and to NHS prescriptions to cover the 3 month period that he is living abroad. 

Answer  

Entitlement to NHS services is dependent upon being 'ordinarily resident' ie; "living lawfully in the United Kingdom voluntarily and for settled purposes as part of the regular order of their life for the time being. Whether they have an identifiable purpose for their residence here and whether that purpose has a sufficient degree of continuity to be properly described as 'settled'."  

If your patient is moving abroad and only returning briefly every 3 months this does not qualify as ordinary residence.  Entitlement does not hinge upon having paid taxes or national insurance in the UK. 

The entitlement of overseas visitors to NHS primary care is an entirely discretionary matter, but being registered with a GP does not necessarily entitle that patient to secondary care.

If the patient is now living in an EU country he would be entitled under the NHS to 'all necessary care' while visiting the UK.  If he is living outside the EU he would be entitled to all 'urgent and immediately necessary care' but any further NHS entitlement would vary depending on the country in which he is now living. 

If you prescribe for him while he is visiting in the UK, then you must only prescribe for a safe interval and the patient must be informed of the need to obtain appropriate follow up care and further medications when he returns to his home abroad.

Once a patient leaves the country for 13 weeks he or she would normally be obliged to deregister. However some UK state pensioners that live abroad for long periods may be exempt from this regulation and remain eligible to full NHS entitlement.  This includes

• Pensioners who remain ordinarily resident in the UK, but take long holidays abroad
• Pensioners receiving UK retirement pension who live in the UK for at least 6 months and in another EEA member State for less than 6 months each year, and who are not registered as a resident of another member State.

CED   15/10/08

Police seeking confidential information

Question

The police have called at our surgery today asking for all new patient registration details as they are trying to track down a young woman who has disappeared with a very newborn baby.  They are concerned that the mother's lifestyle may be putting the baby at risk.

Answer  

If there is genuine concern for the welfare of the baby there is no question that the safety and well being of the child is paramount and you would be permitted to breach the mother's confidentiality in such a situation.  You would not of course be permitted to release details of any other new patient registrations but only the details of the patient in question.  

CED  15/10/08 

Stalking / Harassment

Question

One of our doctors is concerned that she is being stalked by a patient and is concerned for her own safety and for the safety of her young children.  What is the best course of action?

Answer

The Protection from Harassment Act 1997 (http://www.opsi.gov.uk/acts/acts1997/ukpga_19970040_en_1) makes it a criminal offence to pursue a course of conduct, which amounts to harassment of a person. The Act makes it possible to obtain a civil court injunction to stop harassment occurring and to claim damages where appropriate. The courts could issue an arrest warrant for breach of that injunction

Harassment is not defined in the Act and so it will be a matter for assessment based on each case. However, there must be a course of conduct in order to bring a claim. This means that there must be at least two incidents representing harassment. The fewer the incidents and the longer the period of time between them the less likely they are to be considered as harassment. In addition the person who is carrying out the harassment must know, or ought to know, that it would amount to harassment. 

However, people with psychiatric illnesses will not be excluded from the effect of the Act merely because they did not think that their behaviour would amount to harassment. The test is whether a reasonable person would think that the course of conduct amounted to harassment.

You could contact the police confirming that you consider that you are suffering from harassment under the terms of the Act and seek their assistance. Very often police involvement is enough to make the patient refrain from being a nuisance. If the police are called on a number of occasions they could then initiate criminal proceedings. Alternatively you could start civil proceedings. If a number of doctors have had a similar experience with the same patient this might help establish a course of conduct.

Harassment is a criminal offence that could lead to imprisonment for up to exceeding 6 months or a fine of up to £2000.

CED  20/10/08

Can I charge interest on late payments from debtors?

The short answer is yes, under certain circumstances.  It would be wise to take individual legal advice in most cases.

http://www.opsi.gov.uk/acts/acts1998/ukpga_19980020_en_1

Copies of records after death

Question

The wife of one of our patients who recently died has asked for copies of her husband's medical records. However, a few months before he died he wrote to us saying that his wife was not to have access to his medical records. May we release them to her now that he is dead?  
                                                                                  

Answer

Your legal and professional duty of confidentiality to a patient extends beyond death.  In view of the husband's explicit dissent to disclosure of his medical records to his wife you must maintain his confidentiality. If she needs a copy of the notes to settle a claim arising out of her husband's death the notes may need to be made available. The wife should seek legal assistance and if necessary a court order may be obtained to require disclosure.  In the absence of a court order you should not release the notes without first seeking specific legal advice from you medical defence organisation. 

CED 

05/05/05  

Confidentiality and public health information

Question

We have recently received several calls form the public health department asking for confidential patient information. We have refused because they could not provide patient consent. Are we correct to do so?   
 

Answer                                                                             

If this is a routine matter where it would be practicable to obtain consent, then you would be right. However, very often the Public Health Department is carrying out their statutory duty to protect the public form a serious health risk.  In this situation consent may well not be practicable within a tight enough time frame.   In those circumstances if disclosure without consent is essential to prevent death or harm to the patient or any other person, or if it  is judged to be overwhelmingly in the public interest, it is almost certainly permissible to disclose sufficient data to serve this statutory function, without consent if necessary.  

One of local Public Health Departments wrote this:

In the course of our work we frequently call GPs' surgeries to check the data we hold or to request additional information. This may be specifically medical, such as patients' vaccination status, or more administrative - checking the right address or asking for a telephone number. Particularly we often need 'phone numbers so that we, or our Environmental Health Officer colleagues, can liaise directly with patients to try to determine the source of infection and - equally important - the possible risks of further transmission (especially from those involved in food handling, patient care etc.).

Wessex LMCS would ask practices to cooperate with public health doctors in such circumstances and to seek advice from their own defence organisation or the LMC if they are unsure.

 CED       (24/03/05) 

Purchasing Land From a Neighbour

Question

I am looking for some guidance regarding the purchase of an adjacent plot to our existing surgery:

The current owner is a patient who, a number of years ago, said that we could have first refusal on his property when he wanted to sell. Yesterday, he approached his GP to say that he has decided to sell in order to move to a warden controlled flat locally. He stated that he wanted to move fairly quickly and he wanted to get a fair price. He has told his family that he wants to sell to us. How should we proceed?

Answer

• you must get an independent valuation
• involve a solicitor for fuller advice to the practice
• encourage the patient to seek legal advice 
• involvement of the patient and (if possible) his family in the decision to sell
• seek involvement of the PCT at an early stage should it be likely that the practice might be seeking reimbursement for rent at a future stage
  
  

2008