LMC Update 2nd April 2017
Date sent: Sunday 2 April 2017
Email sent by Wessex LMCs to all GPs and Practice Managers
As we leave one financial year and start another, there is a sense of relief in my practice that we have completed the work for QoF and Admissions Avoidance to ensure we maximise the resources that are essential to the practice to continue to provide services to our patients.
I have taken some time to reflect on the last year, what we have achieved as a practice, the work I have been involved in within my MCP area (West New Forest), the wider MCP in Hampshire and most importantly what the LMC has done to support individual GPs and Practice Managers and also our profession of general practice.
So the questions I ask often myself are:
- Is general practice in a better place now than we were a year ago?
- What are the things that have helped?
- What more needs to be done?
- What can your LMC do for you and your practice?
Although we are still facing difficult times, I do believe that things are better now than they were a year ago and the future looks bright for general practice.
This will only happen if we understand and embrace the opportunities that present themselves and we maintain the pressure on CCGs, Hospitals and NHS England to value and support the work we do in general practice. I know some see that if only NHS England substantially increased the funding general practice currently receives that all our problems will be solved. It is important to understand the the sustainability of general practice is not going to come from direct funding but will come from additional resources that are being made available that will support practices and their locality. The additional resources available so far are only small and need to be expanded and made more widely available.
What are the factors that will help us now?
- The GP Forward View (GPFV) has started to deliver additional resources to practices. Resilience funding of up to £35,000 per practice has been invested in over 50 practices in need in Wessex. A separate email will be sent to you about the GPFV.
- The Vanguards in Hampshire and the IoW have been working to develop the out of hospital model and an important part of this is supporting practices. For example, all practices in the SW New Forest have a fully funded pharmacist based in their practice, in Gosport there is a Same Day Access Centre (SDAC) which covers a population of over 40,000 (4 Practices) delivering urgent care and helping reduce the pressure on the participating practice, a home visiting service covers the whole of Portsmouth City.
- Many areas are developing frailty services to help meet the demands of our aging patients. We have Paramedics doing home visits in parts of Wiltshire and Hampshire. The ambulance service is losing staff at an alarming rate, the good news is that they are coming to work in general practice. The ambulance service is now looking at some joint posts between general practice and their service.
- The work is not just occurring in the Vanguard areas as there is important development supporting general practice taking place in Dorset, Wiltshire and Southampton and Portsmouth.
- The GP contract changes increase core funding, remove the unpopular admission avoidance care plans, fund CQC, provide funding for indemnity increases and provide funding for sickness and maternity leave.
- The NHS England Forward view "refresh" makes general practice a priority and removes the focus on hospital based care at the expense of general practice.
- The local Sustainability and Transformation Plans (STPs) have all identified the sustainability as a priority and the LMC is involved in all 3 in our area and will work tirelessly to ensure general practice gets the priority it deserves as the most important building block of the NHS.
- The "New Models of Care" that we have been developing locally, which are clinically led with GPs partnering other organisations, with a high degree of clinical and practice engagement are being seen as the way forward and are being made more widely available.
So I approach the next year with great optimism but to achieve this we need to understand and engage with the agenda and more importantly expand our workforce.
The locum workforce has grown significantly over the last 5 years, this needs to shrink as we need more locums to join the permanent workforce in practices. If this trend is not reversed there will come a point where general practice will not be able to survive with too few GPs being based in a practice to deliver the services that our patients need and deserve.
What does this all mean to you and your practice?
General practice remains the service that delivers the vast majority of care within the NHS, so the registered list of patients remains vital to the health and wellbeing of the public. The future will be building on the registered list with the development of the out of hospital model based around populations of 30-50,000 with practices working together and integrating with community services. There are numerous opportunities for practices and localities and to survive and develop we need to embrace the opportunities.
The good news for Wessex is that we have more GPs in training than we have ever had before but the latest figures showed that as a profession in England we are still losing more GPs than we are gaining. A recent NHS publication showed that at September 2016 :
• There are 41,865 GPs working in general practices. This is a decrease of 12 (0.0%) since September 2015.
• This represents 34,495 FTE GPs, a decrease of 96 (0.3%) since September 2015.
GPs excluding Registrars (i.e. trainees), Retainers and Locums
• There are 34,836 headcount GPs excluding Registrars, Retainers and Locums.
• This represents 28,458 FTE GPs excluding Registrars, Retainers and Locums.
Contents of this email
1. The 2017/18 GMS Contract is now live - make sure you know how the changes affect you
2. Reimbursement of Business Improvement District (BID) levies
3. The Next Steps on the NHS Five Year Forward View
4. National Association of Primary Care (NAPC) - Primary Care Home Programme
5. DOLs and the Coroner - good news at last!
6. GP Induction and Refreshers Scheme
7. Ear Wax
7. My views on working in New Zealand - the grass is not always greener! A personal view from Samantha Powell -
1. The 2017/18 GMS Contract is now live - make sure you know how the changes affect you
This is taken from the recent BMA update but I thought it was worth adding this to my email to remind you of the changes that came into effect as of April 1st 2017.
Discontinuation of Avoiding Unplanned Admissions DES (AUA)
The AUA DES has now been discontinued. You no longer need to collect reporting data regarding care plans or submit claim forms. The corresponding £156.7m has been transferred to global sum, which will be reflected in your monthly G/PMS statements from April onwards.
From 1 July 2017 practices will use an appropriate tool to identify patients aged 65 and over who are living with moderate and severe frailty. For those patients identified as living with severe frailty, the practice will deliver a clinical review providing an annual medication review and where clinically appropriate discuss whether the patient has fallen in the last 12 months and provide any other clinically relevant interventions. In addition, where a patient does not already have an enriched Summary Care Record (SCR) the practice will promote this seeking informed patient consent to activate the enriched SCR.
There will be further guidance from GPC and NHS England available shortly regarding how to implement this requirement as of 1st July 2017
There will be full reimbursement of practices’ total CQC fees. A system of direct reimbursement will be introduced whereby practices will submit their paid invoices to NHS England or their CCG (under delegated commissioning) and will receive full reimbursement of their actual costs.
Once you have paid your CQC fees, proof of payment will need to be submitted to your local NHS England team or CCG in areas of delegated commissioning. Full details of the process will be provided to local areas shortly.
There will be an additional £30m to cover the rises this year in indemnity insurance costs. This has been based on figures received from medical indemnity organisations, to cover GMS work. This is being paid to practices on a non-weighted per patient basis (i.e. not subject to the Carr-Hill formula).
A figure of £0.516 per head should have been received by practices as part of the March G/PMS monthly payments – please check your statement. Practices are contractually required to ensure that principal and salaried GPs who are paying for part or all of their indemnity costs, are reimbursed, from the payment received, an appropriate proportion of the amount which the GP has paid for their cover. The reimbursement amount should be based on the proportion of GMS services which the GP is providing for the practice.
Locum GPs will need to ensure that their invoices/agreements with practices are uplifted appropriately to take account of this business expense if they have not already done so.
Sickness cover reimbursement for GPs
From 1 April 2017, sickness cover reimbursement will no longer be a discretionary payment, but a practice entitlement. The qualifying criteria based on list size has been removed. Restrictions of cover being provided by a locum has been removed - and cover can now be provided from an existing practice GP who is not working full time. Payments will be made after 2 weeks of a GP being absent from the practice due to sick leave. The maximum amount payable has been increased to £1734.18 per week. The GPC have also negotiated ending pro-rata payments - practices will be paid on their invoiced cover up to the maximum allowable.
Practices should notify NHS England of an absent GP due to sick leave, using relevant claim forms as presently. Practices may wish to review their locum insurance policies in light of these changes.
Maternity cover reimbursement
From 1 April 2017, maternity payments will no longer be subject to a pro-rata application. Practices will be paid the full invoiced amount up to the maximum payable.
Learning Disabilities DES
The Learning Disabilities DES health check will increase from £116 to £140. NHS England has also developed a voluntary template, which is available for practices to use should they choose to do so, but there is no obligation to use this.
The LMC is working with the CCGs in Hampshire to help increase the uptake of LD Medicals and help provide some useful training for GPs and Practice Nurses - more details shortly.
Expenses and pay uplift
There is an increase in expenses that should deliver a pay uplift of 1%, which will be added to global sum. There will also be an uplift of £3.8 million to recognise increased superannuation costs of 0.08% as a result of changes to the NHS pension scheme to take effect in April 2017.
Agreement has also been reached for eligible practices to be reimbursed for all costs relating to levies incurred as a result of being in a Business Improvement District (See below). The reimbursement is to be made via the Premises Costs Directions.
Payment for completion of workforce census
From 1 July 2017 completion of the workforce census will be a contractual requirement for every practice. This is something that most practices are already doing, and which was already a requirement on practices. We have however negotiated that £1.5 million will be added to global sum to recognise the workload involved.
From 1 July, all practices will need to ensure that they have added the necessary information for their practice to allow extraction of the Workforce Minimum Dataset.
Quality and Outcomes Framework (QOF)
There will be no changes to the indicators in QOF or the total number of points. The value of a QOF point will increase by £6.02 (3.6%) from £165.18 in 2016/17 to £171.20 in 2017/18.
Core opening hours and Extended Hours DES
The GPC have committed to working with NHS England to ensure locally responsive, safe and appropriate access to general practice for all patients in England during contracted hours, with a particular focus on the minority of practices which currently close for a half day on a weekly basis. Local Medical Committees should be integral partners in working with local commissioners in ensuring practices are fulfilling their contractual requirements.
New conditions will be introduced from October 2017 which will mean that practices who regularly close for a half day, on a weekly basis, will not ordinarily qualify to deliver the Extended Hours DES.
Further guidance will be provided shortly. Those practices which regularly close for a half day on a weekly basis, should start planning for October 2017, and consider whether they wish to to cease closing for a half day (and be eligible for extended hours DES payments) or to end participating in the extended hours DES.
Access to healthcare
The GPC have agreed with NHS Employers contractual changes that will help to identify patients with a non-UK issued EHIC (European Health Insurance Card or S1 form or who may be subject to the NHS (Charges to Overseas Visitors) Regulations 2015. New recurrent investment of £5 million will be added to the global sum to support any associated administrative workload.
Once available, practices will use a revised GMS1 form for new patient registrations. This will require patients to self-declare that they hold either a non-UK issued EHIC or a S1 form. Once a practice has manually recorded that the patient holds either a non-UK issued EHIC or a S1 form in the patient’s medical record, they will then need to send the form and supplementary questions to NHS Digital (for non-UK issued EHIC cards) or the Overseas Healthcare Team (for S1 forms) via email or post. Details will be provided shortly about how to do this.
The new GMS1 form and copies of the patient leaflet will be provided to practices by NHS England once available, and supporting guidance will be published.
National diabetes audit (NDA)
From 1 July 2017 all practices will be contractually required to allow collection of data relating to the NDA.
Most practices are already enabling the extraction of data for a selection of agreed indicators no longer in QOF (INLIQ) and retired ESs. From July 2017 this will become a contractual requirement for all practices. This data will not be used for performance management processes and practices should not be focusing on recording data on indicators that are not in QOF unless it is clinically appropriate to do so.
Registration of prisoners
From 1 July 2017 prisoners will be able to register with a practice before they leave prison. The intention is for the timely transfer of clinical information, with an emphasis on medication history and substance misuse management plans.
Vaccinations and Immunisations
The following vaccination and immunisation programme changes from 1 April 2017:
− Childhood seasonal influenza – the removal of four year olds from enhanced service patient cohort (transferring to schools programme) and the removal of the requirement to use Child Health Information Systems (CHIS).
− Seasonal influenza – the inclusion of morbidly obese patients as an at-risk cohort and a reminder for practices that it is a contractual requirement to record all influenza vaccinations on ImmForm. £6.2m has been added to the contract to cover this expansion of the target group.
− Pertussis or pregnant women – a reduction in the eligibility of patients for vaccination from 20 weeks to 16 weeks.
− MenACWY programmes– a reduction in the upper age limit from ‘up to 26th birthday’ to ‘up to 25th birthday’ (in line with the Green Book).
− Shingles (routine) – a change in patient eligibility to the date the patient turns 70 rather than on 1 September.
− Shingles (catch-up) – a change in patient eligibility to the date the patient turns 78 rather than on 1 September.
Practices will need to ensure that the above changes are reflected in their vaccinations and immunisations processes.
GP retention scheme
A new scheme has been agreed to replace the existing retention scheme. In 2016, under an interim scheme, the practice payment rose from £59.18 to £76.92 per session and this will continue in the 2017 scheme. The joint BMA, RCGP, HEE and NHS England guidance on the scheme will be published shortly.
Practices should make themselves aware of these changes and make use of this facility where appropriate.
Please do make sure that GPs and relevant staff in the practice are aware of the above changes, and take any necessary action to ensure that you are working appropriately and realising the benefits which have been negotiated through these contract changes. Please also check your G/PMS statements to ensure that you are receiving monies as specified above.
2. Reimbursement of Business Improvement District (BID) levies
For most this has not been an issue but the LMC has been trying to address this problem is some parts of Wessex. Below is a letter from the Director of Primary Care, NHS England, Dr David Geddes
I wanted to make sure you were aware that NHS England has agreed, as part of the General Medical Services (GMS) contract for 2017/18, to reimburse practices’ BID levy payments from 1 April onwards. You can see details of the overall agreement in a letter to the service here. The funding to cover these costs is included in baseline primary care commissioning allocations for 2017/18.
In case you are not familiar with them, Business Improvement Districts are business led partnerships created to deliver additional services to local businesses. To fund those services, local authorities charge a levy which is typically 1-1.5% of a business’s rateable value. There is more information here.
Where practices forward you their paid BID levy invoices, please reimburse that amount in their next regular payment. The 2013 Premises Costs Directions allow this reimbursement under Direction 6, financial assistance in circumstances not contemplated in these Directions. I understand when the Directions are updated there will be a specific provision.
Please let me know if you require any further information by contacting england.primarycareops@nhs.
3. The Next Steps on the NHS Five Year Forward View
This is an important document that was published last week and contains many things that make it a defining document in terms of the future of commissioning and providing, refocusing on four key areas (and not hospitals which is the usual thing). The four areas are:
- General Practice
- Emergency and urgent care
- Mental health
This is such an important document for general practice that it will be the subject of a separate email.
4. National Association of Primary Care (NAPC) - Primary Care Home Programme
Recently there was an excellent meeting held in Dorset where Prof Nick Harding, who is a GP and a Board member of Modality, which is a Super Partnership in the Midlands and Dr Nav Chana, a GP and Chair of NAPC gave excellent presentations about the transformation that was taking place in Birmingham and also in the Primary Care Homes across multiple sites in England.
It is very interesting when you look at the map of where the Primary Care Home Sites are and there are very few in Wessex. The Wessex Vanguards have been trying to develop natural communities of 30-50,000, Dorset has localities of a similar size and Wiltshire has the same. A number of GPs and PMs have asked me for more details. Below is an email that landed in my inbox recently that I thought might be of interest to some.
Email from NAPC
Thousands of patients benefit from NAPC’s Primary Care Home programme: new report shows drop in emergency hospital admissions and waiting times for GP appointments.The Primary Care Home (PCH) programme is delivering a range of benefits for patients, staff and the wider health system, according to a new report released recently.
Key findings from an early analysis of three rapid test sites show significant reductions in A&E attendances, emergency hospital admissions and GP referrals to hospital.
For GP practices and other providers involved, the benefits include reduced prescribing costs and a rise in staff satisfaction and retention. Patients have experienced a drop in the average waiting time to see their GPs and reduced stays in hospital.
Commissioned by the National Association of Primary Care, the report "Does the Primary Care Home Make a Difference?" looked at the impact of three primary care home rapid test sites, covering a population of more than 110,000, and assessed how PCH could support the delivery of the 44 Sustainability and Transformation Plans (STPs) across England.
The report by PA Consulting Group concludes that PCH can unlock a range of financial and non-financial benefits.
“Implementing the PCH ways of working can drive positive change in a relatively short period of time. This points to the fact that the defining characteristics, of the PCH make it a vehicle for change, and that it is a catalyst enabling faster progress to be made in addressing local primary care priorities.”
The report found the model could support the delivery of STPs and the triple aims of health and wellbeing, care and quality and financial efficiency as set out in the Five Year Forward View. With staff key to their success, it highlighted that PCH could engage them to own their futures, achieve a happier workforce with reduced sickness and increased retention, and foster a sense of partnership and collaboration.
“The launch of the PCH is timely. The morale across primary care is decreasing. What is required now is a scalable model that is easy to introduce, that unlocks the creativity and energy of staff with the aim of making rapid improvements in the way that primary care is delivered.”
NAPC Chair Dr Nav Chana said: “This report provides confidence that the PCH model is helping to make a real and much-needed difference to patients and staff as well as easing pressures on the wider health system. It shows that it is inspiring staff to embrace and own change at a time when it’s urgently needed”.
Developed by the NAPC, Primary Care Home offers an innovative approach to strengthening and redesigning primary care to support the delivery of the Five Year Forward View – the shared vision for the NHS.
Following the success of 15 rapid test sites, PCH has been rolled out to another 77 sites to develop and test the model (referred to as the community of practice, a learning network), bringing the total number to 92. More than 50 sites have applied to be part of the third wave, which would bring the number of patients covered by PCH to five to six million.
The new model brings together a range of health and social care professionals - from GP surgeries, community, mental health and acute trusts, social care and the voluntary sector - to focus on local health priorities and provide out of hospital care closer to patients’ homes.
Some benefits from the three rapid test sites are outlined below.
- The creation of an Acute Response Team at Thanet Health in Kent led to a sharp fall in A&E admissions. The team - made up a GP, nurses, health care assistants, physiotherapist, occupational therapist, voluntary care, care agency working closely with social services - provides a range of treatment and personal care support to keep people - particularly the frail elderly - out of hospital. They assess patients and put a package of care in place to enable them to remain at home or be discharged. Over a 10-week trial period in 2016/17, admissions fell by 155 compared to the same period last year, suggesting potential annual savings of almost £300,000.
- Larwood and Bawtry in Nottinghamshire cut prescribing costs by 5% following the appointment of a practice pharmacist who carried out medicine reviews for care home residents. Analysis over a seven-month period found a significant reduction in prescribing costs and projected £229,000 annual savings, as well as reducing the risk of side-effects for patients.
- The Beacon Medical Group in Plymouth cut the average waiting time to see a GP by six days by redesigning its Urgent Care Team and extending it to include another 7,000 patients. The team has an additional two nurse practitioners and paramedic as well as GPs and pharmacists. The group ensure people seeking an urgent appointment are seen quickly by one of their specialist staff, rather than having to wait to see a doctor. Over six months, the average waiting time for a GP appointment fell from 14 to eight days.
For more details, please contact Caroline Thomsett, NAPC Communications Lead, by email@example.com or by telephone 020 7636 7228
The PCH was launched at the NAPC’s annual conference in October 2015. Fifteen rapid test sites (RTS) were chosen in December 2015 from 70 expressions of interest involving networks of GPs, health and social care staff. A year later, the programme expanded to 92 sites - with another 77 areas joining a community of practice to develop and test the model. Applications are now being received for a third wave, more than 50 sites have so far applied.
There are four defining characteristics of the PCH:
- Provision of care to a defined, registered population of between 30,000 and 50,000
- An integrated workforce, with a strong focus on partnerships spanning primary, secondary and social care including patients and the voluntary sector
- A combined focus on personalisation of care with improvements in population health outcomes and
- Aligned clinical and financial drivers through a unified, whole population budget with appropriate shared risks and rewards.
5. DOLs and the Coroner - good news at last!
On the 16th November 2016 The Government accepted and supported an amendment to the Policing and Crime Bill proposed by Baroness Finlay (Chair of the National Mental Capacity Act Forum). Baroness Finlay proposed the removal of death while subject to an authorised deprivation of Liberty from the definition of “state detention” for purposes of the Coroners and Justice Act 2009. Assuming that the Bill ( as amended) is accepted by the House of Commons, and is enacted unchanged the mandatory requirement to refer these deaths to the Coroner would no longer exist because there would be no legal obligation to undertake an inquest.
Section 178 of the Policing and Crime Bill 2017 (coroners’ investigations into deaths: meaning of “state detention”) will be enacted on 3rd April 2017. This amendment to the Coroners and Justice Act 2009 removes DoLS from the definition of State detention for the purposes of an inquest.
Therefore with effect from 3rd April 2017 there will be no longer be a mandatory requirement to refer to the Coroner simply because a person has died whilst subject to a DoLS Authorisation.
Please see attached the hyperlink for information/confirmation of the enactment timetable - click here .
6. GP Induction and Refreshers Scheme
There are lots of reasons why you may have taken a break from working in NHS general practice. Sometimes it’s to take time out to raise a family, move or work abroad or to gain experience in a different profession or role.
Whatever the reason, there is a direct route for those that wish to return to a career in NHS general practice through the GP Induction and Refresher (I&R) Scheme.
Please see the attached document.
7. Ear Wax
I find it rather odd with all the information that I send you, and I hope you find this useful, that I am including information about ear wax. Yet this is a topic that is frequently raised with the LMC. So here we go ......
Does ear syringing form part of essential services or is it an enhanced service?
As I’m sure you are aware, ear syringing is not stipulated within the GMS contract. The GP and or qualified nurse has a duty under contract to assess the patient, undertake the appropriate examination and decide either to treat the patient or refer to an alternative service for this. Practices need to take into consideration their resources, competency of staff, training needs, safety and risk of litigation.
The recommendation from the RCN, The Rotherham NHS Foundation Trust, Medical Defence Organisations and the BMA is that the GP and or registered nurse remains responsible for any task such as ear irrigation delegated to an unregistered practitioner (HCA). The NMC (2015) requires that any registered nurse that delegates a task to another person is adequately supervised and has ongoing support and access to a clinician.
The role of an unregistered practitioner (HCA) is not to diagnose but to work within guidelines and protocols, it is therefore not appropriate for an HCA to make the initial assessment. Medical Protection Society would support ‘reasonable delegation’ within the field of the HCA’s expertise ensuring that they are fully trained, competent and follow a robust protocol. “The degree of risk must have been assessed because ultimately the patient has a right to the same standard of care, whoever delivers it “(CQC Mythbusters Health Care Assistants in General Practice. Oct 2015).
What practices can do, however, is encourage self-care for patients. There is evidence that oiling and self-irrigation can work well for a significant number of patients (approx. 50% reduction of nurse appointments). Many practices in attempting to reduce demand for appointments have produced a leaflet encouraging self-care, before accessing ear syringing with the nurse (never refusing appointments for those who have ear pain to be assessed) Patients should be encouraged to oil their ears for at least 10-14 days prior to having them re-assessed for ear irrigation. The person undertaking the task should ensure there are no contraindications prior to undertaking the procedure and this is documented in the patient’s notes.
We at the LMC have produced a leaflet based on advice and recommendations from The Rotherham Ear Care Centre and that produced by Twyford Surgery who have kindly agreed for us to share this information Click here to download the LMC Guide to Earwax.
7. My views on working in New Zealand - a personal view from Samantha Powell
The grass always looks greener!
Fed up with being a partner with an intolerable work load and endless patient complaints, I decided last year to check out whether the grass really is greener in New Zealand. Like everyone else, I'd heard how wonderful it was. There were stories of endless sunshine, great working environments, less stress and, best of all, actual time with patients. Everyone I spoke to was full of enthusiasm. I couldn’t find anyone who disliked New Zealand. I was seriously thinking about whether I would emigrate. I rang a company called NZ Locums and was welcomed with open arms. We worked together to find out what would suit me best.
There is a desperate need for GPs in NZ and every practice seems to be understaffed, so I had choices of where to go and what kind of practice I wanted. I followed in the footsteps of a friend who’d been for 6/12 and raved about his experience. I was full of excitement. There was an awful lot of paperwork, effort and money required upfront. Visas, certificates to prove everything I’d ever done and multiple forms to complete for both NZ Locums and Medical Council NZ.
Eventually, all done, my flights were booked. The excitement and trepidation built, until finally, the day arrived. About 50 hours later, I was trying to sleep in NZ, sadly freezing cold. That wasn't in the plan!! It was meant to be hot!! But Auckland in spring is like the UK in spring. It can be very chilly. In fact, the weather wasn't better than a normal summer in Britain the whole time I was there. I think it rained every day for a month when I first went to South Island. But at least I was there, having an experience and trying something new to stop me whining on about the old!
Induction was unfortunately extremely tedious to me. Long hours listening to how to drive in NZ, despite the fact I'd just driven 600km to the induction. Not enough time on the terrible computer system and far too long on a very badly taught BLS course, despite the fact I'd just done an ALS course in the UK. However, there were some positives.
I met 12 other GPs all in the same boat as me. Belgium, German, American, Australian and a few of us Brits. Some emigrating permanently, lured by the dream, others on sabbaticals, work breaks or post retirement. There were some useful parts to the course. For example, it was useful to learn about their compensation and benefits system and how they handle rationing. If you have an accident, your recovery pathway is paid for by the government to get you back into work ASAP. So, there is a desperate need to make everything possible an accident. For example, one man tried to persuade me that hurting his back whilst bending forward peeling a potato qualified as an accident. I felt that was rather stretching the definition of an accident, but the physio disagreed and felt it was. Drs (and physios) get paid more if an appointment is one of these accident appointments, and so there is a conflict of interest.
Then, there was the WINZ form, Work and Income, or benefits as we know them. For those not able to work, for example, due to depression or health problems, there were complicated forms to complete, every month. The patient must be seen, which they sometimes have to pay for, and the form completed, which took much longer than signing a med 3. And you couldn't just sign someone off permanently, the WINZ “police” would phone to make you change it to say they might possibly be able to work in the future, even if you felt that was highly unlikely.
Rationing was in force, both by restrictions on what you could prescribe and in referrals. Prescribing is enshrined by a committee who decides what is funded by the government. Those drugs are then pretty cheap to the patient, but if you want to prescribe an alternative, the Pt will pay the drug price. I spent many frustrated moments, fighting the computer to try and find a drug I could prescribe and then one that was paid for. There were no choices. I'm used to picking, say, a moisturiser for eczema based on what the patient has tried before and if something didn't work, changing it, but there, I couldn't seem to ever find moisturiser, let alone more than one option. I found it incredibly frustrating. Referring was also rationed with services just not adequately available in some cases. Letters would be sent back saying the patient wouldn't get an appointment. There might be advice on how to manage them but there may not be.
The computer seemed to be a daily issue, I couldn't believe how unsafe I felt the system was. It was put in place in the early days of computer technology and as far as I could tell, hasn’t been updated since. There is no interest in changing it, despite the risks I felt it put the pt at purely because I couldn’t easily see what I needed. There were about 6 windows open on the screen by the time you got into the patient’s notes and it wasn’t easy to see what had been happening to them without trawling back through by date. The coding was non-existent in some cases and it wasn’t easy to see their significant history, admissions, or outpatient letters. Prescribing seemed a high-risk activity, if you could find a drug you wanted to prescribe, as you couldn’t easily see an up to date repeat list or list of recent meds. Maybe I’m being unfair and I never thought I’d say that EMIS and Vision are great systems, but they are! Compared to Medtech. One example was a patient who needed repeat medications. He had no idea what he was on so I best guessed from the ones on his screen that seemed to have been done recently. 10mins later, the pharmacist wandered in with a hospital discharge letter showing the correct meds and we redid it between us. Can you imagine a system where the pharmacist has time to come in and correct mistakes and where the doctor has time to let them?
I spent 9 weeks working there, on both North and South Islands. The practices were completely different. One was small, almost single handed, rural though only an hour from Auckland. The other was much bigger and covered a larger rural area, mainly run by nurses. I had 15mins per patient but a couple of DNAs nearly every day, and up to 2 hour lunch breaks. If I'm honest, I was bored. I like a bit of a challenge and to feel that I'm being useful and doing some good.
I honestly didn't get that feeling in NZ but I do get it every day here. I'm not sure where the sick patients go there, maybe straight to hospital as it’s free. I certainly didn't feel I was seeing anyone ill, though I was still seeing hundreds of kids with sore throats. And people are people the world over. The patients were no different really from our patients here. Just with an accent, time to chat and maybe a more positive attitude. And acceptance of “no”. I enjoyed the close-knit team work with reception and nurses. Every patient was known, especially in the north island practice, though that is changing as the town grows with commuters to Auckland moving in. But the more time I spent there, the more I missed about home and the familiar way we work here. Yes, our system is broken, but for me at least, the grass wasn’t greener. It was just different grass. And, I discovered, to my family and friends great relief, I rather like my grass here!
Dr Nigel Watson
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
Hants. SO53 1JB (Registered Office)
Attached file: NHS_BROCHURE_0217 FINAL# reduced.pdf