LMC Email update July 2015
Date sent: Sunday 19 July 2015
Email sent by Wessex LMCs sent to all GPs and Practice Managers on Sunday 19th July 2015
This week I have spent much of my time thinking and talking about the future of general practice and the work that is being undertaken to improve the situation.
It will come as no surprise to you that this is the single most important topic that is being discussed at LMC Committee meetings, discussions with the CCG, the Area Team and the Local Education and Training Board (LETB) and the Clinical Senate.
On Thursday the General Practitioners Committee of the BMA spent some time considering the "New Models of Care" - these are the 29 Vanguard sites around the country. There were two presentations to the Committee, one by Dr Sam Everington (Knighted in the Queen's Birthday Honours List) a GP in Tower Hamlets, Chair of their CCG, and a Primary Care Advisor to the New Model of Care team and one by myself, describing what is taking place in Wessex.
You might think that Tower Hamlets, one of the most deprived boroughs in London with a very high % of Bangladeshi residents which is probably as culturally and demographic different from where I work as a GP in the New Forest and therefore has nothing in common. What I found really interesting was how much we had in common rather than any significant differences.
Some key messages that came out of the presentations and subsequent discussion were:
1. Leadership and relationships
Delivering change and improvements especially when it is needed across organisations will have a far great chance of success where there is strong clinical leadership and good relationships exists (these don't happen without the investment of time and effort).
2. Have you heard of Social Prescribing?
Before you throw your hands up in horror and ask why is he asking us to take on more work and responsibility, would you read on if I said this could save your time and reduce your workload!!
This has been well developed in Tower Hamlets. The GPs have a single referral form on their computer system, from which they prescribe services such as health training, debt or legal advice, or a direct referral to a social prescribing coordinator who will either make an onward referral to an appropriate service, or meet the patient to get a better understanding of their needs. The service has access to 1,100 voluntary sector organisations in the borough to which it can refer.
In some areas the £5 per patient transformation funding for the over 75s has been invested in Care Navigators who are essentially “Social Prescribing Coordinators” .
The GPs in Tower Hamlets can refer, prescribe a medication or do a social prescription – very easy print off – write on what is needed and the patient then engages with the Social Prescribing Coordinator who then will sign post to the voluntary sector – evidence it is good for the patients, helps GPs saves the health service money.
3. Common Health Record
To work more closely with the community teams and to achieve a single team through integration requires a common health record with read write capability. This is a common theme in the Southern Hampshire Vanguard and also in Tower Hamlets.
4. Choose and Book or e-Referral
There is a desire to reconnect GPs and Consultants and to establish a much closer and mutually supportive relationship. There is quite a lot of work ongoing in the Hampshire Vanguard to achieve this as there is in Tower Hamlets. One question is whether C&B enhances this relationship or is a barrier to it.
5. Consultants and general practice
In the SW New Forest Vanguard we are building on the move to ensure a more holistic approach to the care of patients by consultants. All the Medical Consultants that are employed by Lymington Hospital provide general medical expertise and also have an area of specialist interest (for example care of the elderly, GI, Cardiology etc).
Three new Consultants have been appointed recently and within their job plans they has a session a week allocated to general practice. This gives the opportunity for the lead GPs in the Vanguard to work with the Medical Director and new Consultants to use this time in the most effective way by "thinking outside the box" and doing something that is radically different from the current ways of working without being inhibited by the current contracting and payment mechanisms.
Any ideas greatfully received.
Tower Hamlets has now produced some of the best data in the country in terms of control of HBA1c, cholesterol and blood pressure and as a result they have seen a reduction the complication and achieved better outcomes.
How have they done this?
They developed a community based diabetic team that worked closely with practices. There was a clinical lead with great enthusiasm who visited practices regularly.
In addition practices were funding to provide enhanced care for their patients on the basis of 70% of funding the service and 30% based on achieving "stretch targets" that were achievable.
With the NHS spending over £10 billion on Diabetes, most spent on managing the complications. It seems blindingly obvious that more resources is needed to "upstream" in the community and primary care to prevent this tsunami that is facing us in the future.
In Southern Hampshire there is strong and enthusiastic diabetic leadership based in the community, we need to build on this replicate these impressive outcomes.
Launch of new joint GMC/NMC guidance on the professional duty of candour
The General Medical Council and the Nursing & Midwifery Council have produced guidance for doctors, nurses and midwives on the professional duty of candour. It aims to provide a framework and give confidence to individuals working with patients to respond openly and honestly when things go wrong. Page 5 of 7 The guidance is available to read and download via the
ACUTE KIDNEY INJURY - for Wessex GPs
Within the field of acute renal medicine there has in recent years been a significant shift in the approach of acute deterioration of renal function.
AKI definition: historically called 'acute renal failure', however this was poorly classified, difficult to research and needed to be redefined. Acute Kidney Injury (AKI) is now defined as:
1. i) An increase of serum creatinine by 1.5-1.9 times baseline (stage 1),
ii) 2-3 times baseline (stage 2) or
iii) more than 3 times baseline (stage 3).
2. A rise of 26 micromol/l or more in less than 48 hours (stage 1) or above 354 micromol/l (stage 3).
Current problem: Nationally 100,000 deaths per year are associated with AKI. Up to 18% of hospital admissions have AKI having a mortality rate of 30%.
Up to a third of these deaths could be avoided. Even mild AKI episodes are associated with poorer clinical outcomes. AKI quadruples mortality risk, is associated with prolonged hospital stay; with increased risk of chronic kidney disease and future AKI events; with recurrent admissions and increased need for residential care.
Locally 68% of AKI hospital emergency admissions are acquired in the community, these tend to be more severe and often related to sepsis.
Solution: The initiation of a national NHS-wide effort involving primary care and secondary care including biochemistry laboratories, hospital clinicians across specialties and pharmacists.
A national implementation of biochemistry AKI e-alerts across secondary care has been underway since April 2015 and will follow across primary care by April 2016.
In some areas it has not been possible to dissociate the primary care AKI e-alert from the hospital based system. For now these primary care e-alerts are commented on as 'not applicable'. In addition a national CQUIN is being implemented to include the reporting of an AKI diagnosis in hospital discharge letters.
The Wessex AKI clinical forum has supported implementation of the above changes across the region including the provision of educational sessions and guidelines.
We wish to share with all GPs the Wessex Adult Acute Kidney Injury Care Pathway for Primary Care together with the Acute Kidney Injury Primary Care Top Ten Tips. We hope this will raise awareness of AKI, assist GPs in their care for patients with AKI and support the implementation of the electronic alerts in the next 6 months.
To illustrate the significance and impact of AKI the Think Kidneys website provides a range of clinical primary care scenarios.
If you have any further queries please contact to Alastair Bateman, GP-lead Wessex AKI forum, via firstname.lastname@example.org or Caroline Cross, Quality Improvement Lead at Wessex Strategic Clinical Network via email@example.com
Key message from LMC
We have been involved in these discussion for about a year.
Acute Kidney Injury developing in general practice is not something most GPs are aware of - we should be and please take some time to read the links and potentially hold a clinical meeting in your practice and consider developing a practice plan for the prevention, identification and management of AKI.
All practices should code AKI and ensure it is prominent in the clinical records.
Action we should all consider:
- Review the need for nephrotoxic medication and consider safer alternatives.
- Educate patients and carers about the risk of dehydration during an acute illness.
- Educate patients to seek help/advice early in the event of an acute illness.
During an acute illness:
- Review medicaion that could be adjusted or temporalily stopped if clinically appropriate e.g. diuretics, ACE inhibitors, NSAIDs etc
- Check hydration and consider serum creatinine and electrolytes
- Monitor for dehydration
Beware septsis and intervene early in at risk patients
The patients GPs should be particularly focused on are:
- Known CKD
- History of AKI
- Vascular disease
- Heart/liver disease
A good practical tip is to remember to consider stop the DAMN drugs in at risk patients during periods of acute inter-current illness
Diuretics, Angiotensin drugs, Metformin and NSAIDs.
The LMC will continue to work with the Wessex Strategic Network an update you about information and tools that may be of use to you and your patients.
Quality Improvement Ideas
- Consider running a report of the at risk groups and ensuring they have a baseline creatinine.
- If a discharge summary suggests that the patient was admitted with an AKI, discuss at a significant event meeting and see if the admission and the AKI could have been prevented.
Subject Access Reports under the Data Protection Act
After many years of lobbying and negotiation by LMCs and the GPC we have now been informed by the ICO that use of the Data Protection Act to obtain access to medical records is an abuse of subject access rights.
The ICO has written to the Association of British Insurers who regulate the insurance industry outlining the ICO review and judgement in full but culminating in the following summary:
'The right of subject access is a key element of the fundamental right to protection of personal data provided for under Article 8 of the EU charter of Fundamental Rights which is conferred upon individuals. It is not designed to underpin the commercial processes of the life insurance industry. The Commissioner takes the view that the use of subject access rights to access medical records in this way is an abuse of those rights.
If the specific statutory mechanism provided by legislators for obtaining medical information for insurance purposes is failing to provide the information within the timescales the industry needs, then those affected should seek to review that mechanism and have this subjected to proper parliamentary scrutiny with a view to changing it. Using individuals' own data protection rights to side step the current statutory arrangements designed to meet the insurance industry's needs and including important safeguards for individuals, is not the appropriate approach.'
This means that practices are no longer obliged to accept subject access requests nor comply with the timescales and fees laid down in the Data Protection Act. The LMC would not wish to see patients suffer because of this judgement and practices are urged to agree an appropriate fee and timescale for the work involved with insurance companies prior to providing the reports or copies of medical records requested.
If you have any questions about this please email: firstname.lastname@example.org
GPC guidance notes – update
The following guidance notes have been issued by the GPC, in recent months, and are available on the BMA website:
- CQC guidance on registration and inspection
- Co-commissioning guidance – information for GP providers
- Co-commissioning guidance – conflicts of interest
- Discussion paper on new models of care
- Focus on Fitness to Work guidance
- Focus on new deal for general practice
- Focus on PMS reviews
- Focus on rent reimbursement
- Focus on the global sum allocation formula
- Guidance and FAQs on out of areas registrations
- Guidance on applying for premises transformation funds
- Guiding principle for GP networks
- How to declare GP earnings guidance paper
- How to deliver new contract IT requirements
- How to set up a network
- Induction and refresher scheme
- Legal framework for practice networks
- Quality first: Managing workload to deliver safe patient care
- More detailed and practical how-to guidance to help practices prepare for CQC visits etc
- New care models – Vanguard sites
- New GP contract guidance
- Sessional GP Appraisal and Revalidation Survey and Guidance
- Supporting pupils at school
- Updated guidance on migrant access
I hope this information is of help to you
Dr Nigel Watson
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
Hants. SO53 1JB (Registered Office)