LMC Update June 2019
Date sent: Tuesday 11 June 2019
LMC Update June 2019
Over the last couple of weeks, I have spent a considerable amount of time in meetings supporting emerging Primary Care Networks (PCNs), discussing the challenges we face locally with the Chief Executives of our local hospitals, Community providers and with the Chief Executive of the NHS, Simon Stevens. In addition, I presented to the Westminster Health Forum about the outcome of the Partnership Review and talking to GPs, Practices Nurses and specialist Diabetes Teams about how I believe diabetes care should be delivered in the future.
A couple of weeks ago the LMC held the first of our annual Practice Manager Conferences in Bournemouth, the second one was held near Basingstoke last week. We had over 250 Practice Managers attending these two events. As GPs we know that our Practice Manager is critical to a successful practice and when the practice is run efficiently it will make our lives easier. Unfortunately, when we are busy and under pressure, we tend to forget our hard working and dedicated Practice Managers, just take a moment and think what they do for us because it is not only us who have a massive workload and are under pressure. I am reminded that next Sunday is Father’s Day, perhaps we should have Practice Managers Day!
All of the above simply reinforces my view that general practice is not only vital to the delivery of high-quality care now but is essential for the future of the NHS. It was therefore disappointing to read the recent press coverage about the number of GPs falling and therefore making the Government target of recruiting 5,000 more GPs even more difficult. When you look at the figures more closely in Wessex, we are doing better than most other areas as we have increased our GP numbers by 1% (not enough but better than the fall seen in other parts of the country).
We need to be positive about the future as there are many opportunities occurring and we need to take these and make general practice a great place to work again. There are many GPs and Practices who are seeing things slowly getting better. Some practices are not only recruiting salaried GPs but have been able to recruit new Partners.
Those Practices that have been able to recruit new GPs have done so by offering greater flexibility and opportunities. Over the last few weeks I have seen a number of practices that are not only surviving but are thriving and are looking at the future more positively. But I am all too well aware of those Practices who have not been so fortunate and are really struggling.
In Wessex we have a good balance of GP Partners, Salaried GPs and Locums and all play an important role in the sustainability of general practice and delivering a safe and effective service. I am already seeing PCNs creating a greater sense of community and collaborative working between local Practices.
I am very concerned that is some areas where recruitment and retention is the most challenging, Practices are struggling to deliver care with fewer GPs and rising demand. In these situations, the Locum workforce are an essential part of the support that a Practice needs.
1. Primary Care Networks
There is a risk that the NHS sees PCNs as the solution to every problem – but what is the real purpose? Also some information about the Social prescriber Link Worker.
2. General Practice Nursing
With all the focus on recruitment and retention of GPs and the new clinical roles being developed through Primary Care Networks (PCNs) we must not forget the crucial role of the Practice Nurse.
3. Cremation Forms – Cause of death
More guidance eon completing cremation forms.
4. EMIS move to Amazon Web Services (AWS)
An update from the GPC about this development.
5. Vaccine acceptance in England 2018
Some information from Public Health England responding to the concerns about the anti-vaccination publicity.
6. Flu vaccine data
Public Health England has published its flu vaccine data for 2018/9.
Some useful information about the education and training offer from Wessex LMCs.
1. Primary Care Networks
The majority of the PCNs in Wessex have now been identified and the Clinical Directors have been appointed, elected or selected.
The LMC has held a number of workshops for PCNs to try and address the legal and financial concerns.
The main concerns that have been raised relate to VAT, taxation, pensions, risk, funding, cost of new staff, legal structures, workload and expectation.
Due to popular demand the LMC has arrange a further workshop for those who have not been able to attend the original workshops. The event will take place on the morning of 20th June at the Holiday Inn, Winchester.
Booking link as follows: https://www.fishbase.co.uk/event/view/9247.
The LMC is not qualified to provide you with legal and financial advice and you should seek this from the suitably qualified professional.
It is important that each PCN is clear about the potential liability for VAT. Although the provision of healthcare has a special status and can be exempt of VAT, it will depend on the services that is delivered and who delivers this.
It can be a complex area and therefore it is important that you seek professional advice. You can mitigate the risk of incurring VAT costs, depending on how you structure and provide services within your PCN, but if VAT costs are incurred it is important that this does not adversely affect one practice. This is why your network agreement is important.
Purpose of PCNs
1. The Core Members of your PCN are the Practices and this is established and funded by the Directed Enhanced Contract DES. The aim of this is support and incentivize practices to work together for the benefit of their communities and also to provide additional resources to expand the workforce, help with workload and contribute to practice sustainability.
This is why practices should see the PCN as an extension of their practice and should take ownership to help drive this forward.
2. Members– these are partners within the PCN who will work with general practice for the benefit of that community. For example, a community nursing team will be required to be configured to the footprint of the PCN and this team will form part of the PCN workforce and will need to work collaboratively with the core network practices.
3. There will be other organisations who are based in the community and may want to work with you for example local schools or the Voluntary Sector.
4. Federations can be very helpful in terms of supporting practices and PCNs and may be sub-contracted to provide services but should not be seen as the PCN.
5. The NHS sees PCNs as an important building block to deliver services at scale or the evolving out of hospital model. To be able to transform services and deliver more within a PCN there must be additional resources either in terms funding or people.
Social prescribing link worker
Social prescribing is part of the NHS’s commitment to personalised care, which means people have choice and control over the way their care is planned and delivered, based on ‘what matters to me’.
There is much confusion in general practice about what this role involves.
Social prescribing can support a wide range of people, including (but not exclusively) people:
• with one or more long term conditions
• who need support with their mental health
• who are lonely or isolated
• who have complex social needs which affect their wellbeing.
Social prescribing enables all primary care staff and local agencies to refer people to a link worker and supports self-referral. Working under supervision of a GP, link workers give people time and focus on what matters to the person, as identified through shared decision making or personalised care and support planning.
They will manage and prioritise their own caseload in accordance with the health and wellbeing needs of their population, and where required discuss and/or refer people back to other health professionals and GPs in the PCN. They also connect people to community groups and agencies for practical and emotional support.
Link workers work within multi-disciplinary teams and collaborate with local partners to support community groups to be accessible and sustainable and help people to start new groups and activities.
It is important to recruit the right person with the skills to ensure this role not only helps your patients but also helps address your workload. One in five GP appointments focus on wider social needs, rather than acute medical issues.
Please see the attached document which provides far more detail.
2. General Practice Nursing
With all the focus on recruitment and retention of GPs and the new clinical roles being developed through Primary Care Networks (PCNs) we must forget the crucial role of the Practice Nurse.
The LMC is very fortunate to have Helen Irvine, an experienced Advanced Nurse Practitioner working for the LMC as our Nurse Advisor.
When we look at recruitment and retention of GPs, there are significant concerns about the premature loss of experienced GPs in the later part of their careers and the significant numbers who are aged 55+.
Helene recently conducted a survey of the Practice Nurses in Wessex. This showed that 56% of Practice Nurses were aged 50+, of which 99% are female and 76% work part time. Of those who responded to the survey 32% indicated they plan to retire in the next 5 years.
The vast majority of Practice Nurses (nearly 90%) would recommend their Practice as a place to work, stating that it is friendly, supportive with a good team, potential for development with good management and leadership. The main negative comments are at times communication can be poor, team changes due to mergers, increasing workload, no access to training, pay, not feeling valued or respected.
The recommendations that Helene has suggested includes:
General practice as a place to work should be promoted as a preferred choice for students and those considering a change in career. The funding tariff for student nurse placements should be in line with Allied Health Professionals.
Students should be exposed to general practice early and more frequently in their training and have a positive experience. Universities should be encouraged to equip those who choose this as a career choice with the skills necessary to undertake the GPN role.
There is currently a lack of standardisation in titles, roles, salary, terms and conditions with a disparity between primary and secondary care and this needs to be addressed if we are to retain staff and improve recruitment.
Nurses on the LMC database currently use 33 different tiles. There should be a clear link between title, competency and academic levels and this should be reflected in job descriptions.
Practices need to consider the elements that attract and retain nurses in general practice, namely: the culture, team working, support, feeling valued, clinical supervision, job satisfaction, variety and flexibility of the role.
A high number of experienced nurses with specialist skills retire within the next 5 years, [so] we need to be creative in how we retain this part of the workforce. Funding and time need to be made available to support existing nurses that want to undertake specialist roles.
Practices should develop a culture that focuses on the wellbeing of their staff to reduce stress and absenteeism, improve retention and provide them with a coping mechanism to manage the daily pressure they face in the workplace.
All nurses have an important role to play in the sustainably and future of PCNs. Practices and nurses themselves should be encouraged to look at how their skills can be utilised and to consider different ways of providing care e.g. integrated nursing teams, group consultations and healthy leg clubs.
We should create opportunities for nurses to work across boundaries.
Nurses in general practice are generalists with specialist skills: we need to demystify the belief that this is a place for less experienced nurses, and the ‘mature’ female workforce.
To attract more people into primary care – including men – we need to look at portfolio careers, and discussion should take place with community and acute trusts to develop a flexible working environment that crosses traditional boundaries.
The profile of nursing in general practice needs to be improved and celebrated.
To read the full article look at the June edition of Practice Nurse - www.practicenurse.co.ukwhich will be published shortly.
I would personally like to take this opportunity to thank Helene for all the excellent work she does for Wessex LMCs in terms of supporting general practice and specifically Practices Nursing. Wessex LMCs a national profiler in terms of Practice Nursing and this is largely due to the work that Helene has led.
3. Cremation Forms – Cause of death
I can remember being told as a junior doctor that you were not allowed to put the cause of death as old age or multi organ failure. It later became clear that the completion of a death certificate and that of a Cremation Form are subject to separate rules. The Ministry of Justice requirements concerning the use of Old Age as a cause of death on Cremation Forms differ from those regarding the use of Old Age as a cause of death on Death Certificates. The LMC issued some guidance in 2015 and, following some recent discussions with a local Medical Referee of a Crematorium, the LMC has updated our guidance to reflect the changing nature of general practice.
If the cremation certificate is being given by the usual doctor, or a medical colleague with full access to the deceased’s medical records, Old Age, Multiple Organ Failure or Frailty of Old Age, as sole causes of death in section 1, are acceptable without reference to the coroner if there are one or more specific contributory causes identified in section 2
4. EMIS move to Amazon Web Services (AWS)
EMIS has sent out a communication to practices which the GPC believes is potentially misleading.
In relation to the plan to move NHS records to AWS (Amazon Web Services), which the GPC supports, their communication states that practices “may wish to inform your patients”. This the GPC believes is incorrect.
It is a requirement under GDPR to be ‘transparent’. Practices must inform their patients of significant changes to the way their data is processed, and failure to do so will almost certainly be a breach of GDPR.
Given the potential sensitivity of moving NHS records to AWS this seems to be counterintuitive when GDPR expects openness, transparency and accountability. BMA guidance on GPs’ responsibilities under GDPR states that: ‘Practices must ensure they continue to provide updated information to patients about new data sharing arrangements’.
This involves updating practice privacy notices (PPNs) and where practices have the ability to provide electronic alerts to patients relatively easily then these methods should be used. In practical terms this means that where mobile numbers or email addresses are held the practice should use these to make patients aware that new arrangements for data sharing exist and invite them to read the updated PPN.
This is set out in the BMA guidance ‘GPs as data controllers’ (see bottom page 6, from ‘Ensuring ongoing transparency – keeping patients updated’ to the top of page 8).
The communication also states “and/or undertake a Data Protection Impact Assessment (DPIA)”, which the GPC believes is also incorrect. A DPIA is not an optional alternative to informing patients, it is a standalone mandatory standalone requirement under GDPR that must be carried out prior to any significant or new processing arrangement. If you don’t do a DPIA you are in breach.
However, EMIS have helpfully provided a link to a template DPIA that practices can use. It is acceptable under GDPR to “borrow” or share DPIAs where the changes apply equally to many parties.
5. Vaccine acceptance in England 2018
Public Health England has provided the following statement, after recent press interest which highlighted growing amounts of anti-vaccination messages on social media, to reassure general practice staff that most parents remain confident in the programme and trust the advice that they get from GPs and practice nurses.
Each year PHE undertakes a cross-sectional interview survey exploring parental attitudes to infant vaccination.
In 2018 a total of 1,674 interviews of parents of children aged 0-4 were held. Ninety- three percent of parents reported that they were confident in the immunisation programme with almost 80% believing that all immunisations were safer than the diseases they protect against.
The majority of parents perceive each of the infant immunisations to be either completely safe or just a slight risk. The MMR vaccine was the most likely to be deemed as a moderate or high risk – but this was reported by only 9% of parents.
Only 4% of parents had ever flatly refused an immunisation. Of those, the flu vaccine was the most refused (44% - 31 parents) followed by MMR (17% - 11 parents). Satisfaction with all aspects of the immunisation process and trust in immunisation information provided by health professionals and the NHS were all over 90%.
The NHS website has a range of useful information for parents and for those who have more detailed questions the Vaccine Knowledge Project run by Oxford University is excellent. PHE also produce a range of leaflets for parents of young children which can be ordered free of charge here.
6. Flu vaccine data
Public Health England has published its flu vaccine data which showed that in England, for the over 65s, there was a vaccine uptake of 72%, 48% for those aged 6 months to 65 years (in clinical risk groups), and 45.2% in pregnant women.
The figures also showed that more children were vaccinated this winter than ever before, with around 3 million being vaccinated (44.9%). The report also showed that the adjuvanted influenza vaccine, which was given to over 65s for the first time, provided about 60% effectiveness.
This is a remarkable achievement that despite the flu vaccine supply problems practices had to contend with last year, leading to practices having to put on extra clinics and appointments much later in the year than normal and often at short notice, practices were able to achieve vaccination coverage very similar to the levels in the previous year.
We should acknowledge that this was only possible through the hard work of Practices and our commitment to protect as many of our patients as possible from the ill effects of influenza.
7. Wessex Lead
We organise approximately 250 events per year for receptionists, HCAs, nurses, practice managers and GPs.
We strive to offer resources needed for the core of general practice – whilst also catering for the new initiatives. The events offered are a mixture of conferences, open courses and bespoke events for practices or localities. We work with Health Education England, NHS England, the Leadership Academies and the Primary Care Training Hubs to keep practical, accessible training available.
We currently have a group of 9 Practice Managers with whom we work.
They support our PMs when they are new, when they are stressed and when they just need someone to chat something through with. We continue to encourage practice managers to take part in a peer appraisal run by one of our Supporters and gave each delegate a ruler for their desk at the PM Conferences to remind them through the year of this support that is available. Over 100 of our PMs have taken part in this process since we launched and ran the project for NHSE in 2017. NHS England are currently funding coaching, mentoring and appraisals for our PMs,
Lunch and learn
Our Lunch & Learn Resources continue to be popular.
These consist of a PowerPoint presentation and a script to enable leaders in the practice to run sessions for their staff in their practice at a time to suit them.
Following a successful workshop run by our Directors at the PM Conferences, a resource on managing records will be added. This will complement all the queries on managing records for transgender patients and within safeguarding scenarios that come into the Wessex LMCs office.
Over 2200 Lunch and Learntraining packageshave been downloaded to date. The most popular have been:
Accessible Information Standard (294 downloads), Sepsis (272 downloads)
The resources have been downloaded all over the country as well as in Wessex – from Yorkshire to Kent, West Midlands, Gloucester and Cambridgeshire.
In the light of always trying to provide practical resources when are where they are needed, LEaD is working with one of our SafeguardingTrainers to put together a training package so that clinicians can more easily achieve the many hours of safeguarding training that they are required to do. We continue to develop new courses – for example ‘How to Respond to Patients with Unexplained Symptoms’.
LEaD is also working with commissioners to make sure that education & training providers include options for primary care – for example with the Nursing Degree Apprentice. We look forward to rolling out our Prepare forPartnershipcourse further and taking up CQC’s offer of how to work together to make inspections less stressful for practices.
Churchill House, 122-124 Hursley Road,
Chandler's Ford, Eastleigh,
Hampshire, SO53 1JB (registered office)
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Dr Nigel Watson
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
Hants. SO53 1JB (Registered Office)