CEO Email Update - December 2013
Date sent: Thursday 19 December 2013
On behalf of the LMC, I would like to wish you and your family a very happy Christmas and a prosperous New Year.
As another year draws to a close it is a time when we look forward with hope to a New Year and reflect on the year that is about to end. This has never been more appropriate than it is now. I am sure you will all agree that the last 12 months have been challenging - but what can we expect next year?
We need to make general practice a great place in which to work once again, not only for our sakes but also to attract the future generation of doctors. I deliberately say “we” rather than someone else because I strongly believe that we are the only people who can achieve this – we will need support from others but we must be in control of change.
It would be very easy to get depressed reading the constant negative media stories about general practice, but of all the practices named and shamed in the last couple of weeks none have been local practices. On one level I believe we should simply ignore the stories because the national press are only interested in printing those that are sensationalised and negative. Having discussed the cases with other LMCs, few of them are accurate and most have already addressed the issues raised at the CQC inspections.
I have repeatedly said that the population of Wessex is very fortunate that they enjoy well-organised practices, which provide a quality of service that is good or excellent, and have GPs who are dedicated and committed. Practice Managers should not be forgotten as they are often overlooked, and are as dedicated and committed as GPs. But more about them later.
Having said all that, we must not become complacent. We always need to be honest with ourselves and ensure our practices are up to date and providing the best service possible.
The LMC has had some success in getting letters and news stories published in our local newspapers. Last week a number of local newspapers published my response to the national story about how rubbish GPs were at detecting cancer and how every problem in the NHS was therefore clearly the fault of GPs. (See below about cancer and also local newspapers).
Contents and Summary
1. Practice Managers and workload
This article is a response to the significant increase the LMC has witnessed over the last year in terms of Practice Managers seeking help from the LMC.
2. Revalidation and Appraisal – again!
Many GPs still remain confused about the requirements for revalidation and annual appraisals. The LMC has been working to resolve the outstanding confusion and has produced some new guidance for GPs.
Are you aware your nurses will be required to be revalidated in the future? This will be the responsibility of the Nursing and Midwifery Council.
3. Delay in the diagnosis of cancer
The media has picked up on a report about the use of fast track referrals for suspected cancer and have made a number of incorrect assumptions, including the belief that unless all cancer patients are diagnosed via a fast track the GP has failed their patients.
There are lots of positive aspects to the diagnosis and management of cancer within general practice and some challenges we need to meet.
4. Provider companies, tendering and procurement
GPs and PMs are discussing the future and looking at a number of issues including mergers, working in larger groups and even setting up a provider company. All this is necessary but where do you get the information to enable your practice to make the decision to take the next step?
5. LMC Conference 2013
Were you there, did you miss it? The conference was videoed and this will tell you how to view the presentations.
6. Care Quality Commission
Following the publication last week of the report from CQC about the first 1,000 practices inspected, general practice has been unfairly criticised and the failings of a few have been assumed to be the norm for many. The 9 practices that were named and shamed as being the ones who have caused most concerns are not in our area.
Below is some advice that I hope will enable you to have a successful inspection when your turn comes!
7. Practice Surveys
The latest figures are published this week. These can be seen at practice, locality, CCG and national level.
How well did your practice do compared to your neighbours?
8. Some interesting information for the elderly
This is some information about various topics from a telephone service that carries out a hearing screen, to services for carers, advice about where help is available for your patients.
9. Local Media Contacts
We write to local newspapers on a regular basis, is your local paper on our list? If not less us know.
1. Practice Managers and Workload
As GPs we do not have the monopoly of believing we work harder than everyone else or that we are under greater stress. Just pause for a minute and think about your Practice Manager.
The workload PMs are currently experiencing is unprecedented. Some GPs are aware of this and supportive of their PM, but sadly some PMs do not feel supported or appreciated by their partners.
The LMC has experienced a significant increase in the number of calls it has received from PMs and the numbers taking sick leave or even resigning. The lack of support and sense of isolation can even mean that PMs feel unable to attend PM groups and other meetings where assistance for some of these problems can be found: one example being collaborative working to achieve CQC inspection requirements.
Why reinvent the wheel?
Other examples of good practice are appointing deputy PMs and appointing an executive partner with protected time to work with the manager.
But, none of this applies to your practice...or does it?
Stress in PMs appears invisible to some partners.
Support is available through the LMC office and via the PM supporter scheme but mutual support at an early stage is much more important. The LMC asks partners - when did you last sit down with your PM (perhaps having first made time to make her/him a cup of tea) and, rather than talking about how stressed and busy you are, asked how things are for them?
The survival of your practice may depend upon it.
We will continue to advise and support GPs, Practices and Practice Managers whilst also trying to reduce the burdens placed on you all by the Area Teams, Public Health and CCG's where appropriate.
2. Revalidation and Appraisal
Since April 2013 approximately 10% of the profession have had their “Licence to Practice” renewed and have therefore been revalidated.
The LMC has produced guidance on both appraisals and revalidation, which has been well received and felt to be helpful.
The recent Wessex LMCs Locum Appraisal Toolkit has now gained national support and is being used by a number of LMCs. The Toolkit may be of use to all GPs not just locums. Web link – Wessex LMC Appraisal Toolkit
The LMC has been contacted by GPs who remain concerned about the apparently conflicting advice they have been given. To try and be helpful the LMC has been in discussion with the appraisal service and those responsible for revalidation in your Area Team and has produced new guidance that is attached to this email.
It is expected that nurse appraisal and revalidation will largely follow the model that we have in general practice.
Do your practice nurses have an annual appraisal? Does it reflect the sort of appraisal GPs experience or is it more of a performance review?
The LMC is working with a number of partners to develop nurse appraisals that will be fit for purpose in terms of revalidation.
The presentation from the nurse revalidation event we ran in November with Health Education Wessex.
Web link - Wessex LMCs Nurse Appraisal
Also on the link is an application form for any nurses who would like to be appraisers and an application form for those who are willing to be appraised. This is all part of the pilot project for us to get our nursing teams ready for revalidation in Wessex.
3. Delay in the diagnosis of cancer
I am sure many of you will have been frustrated with the headlines last week about the apparent failing of GPs in terms of timely referrals for those suspected of having cancer.
The Daily Telegraph headlines “Half of GPs don't refer cancer patients urgently, first league tables show”.
The overall cancer survival rate in the UK has improved significantly over the last 10 years, with more than 50% of patients presenting with cancer surviving more than 5 years.
The evidence suggests that the UK does not perform as well as many other Western countries in terms of survival. Simplistic reasoning is given for this delay in diagnosis and the blame is laid at the door of general practice. The reality is a little more complex. It has been estimated that if the UK performed as well as the European average, on average over 5,000 lives could be saved in the UK per year.
1. Survival rates are calculated on data available in each country, and often the quality of data is better in the UK than other countries and therefore the comparisons are not always fair.
2. There is a significant delay to investigations in some areas. This is being addressed with the introduction of 7 day working for hospitals but needs to take into account the need for GP access.
3. In many countries that do not have strong primary care, patients present directly to consultants. This has been cited as a reason for earlier diagnosis in those countries and has led to criticism of general practice in the UK being the gatekeeper. It inevitably adds to the negative way in which general practice is viewed.
The data used by the media looks at the use of fast-track referrals and the percentage that lead to a diagnosis of cancer. Even if a practice were perfect, there would still be patients presenting with acute and new presentations of cancer.
Some good news:
- 1 in 1000 GP consultations will be a new presentation of cancer
- 1 in 8 fast track referrals are proven to have cancer
- 75% of cancer referrals are made after 1 or 2 GP consultations
What can your practice do to improve the diagnosis and survival for cancer?
1. There is a vast difference between practices in terms of the use of fast track. It would therefore be helpful if practices looked at the cancer data that is available at practice level to ensure they are not an outlier.
2. For all new cases of cancers part of the cancer care review should be to have an honest look at the events leading to the diagnosis and reflect on this to see if, with the benefit of hindsight, the diagnosis could have been made earlier. If this is the case, discuss at a practice significant event meeting and use this in your appraisal as a quality improvement activity.
3. Screening is important – we now have cervical, breast and bowel screening. Look at how your practice performs against the national average. Practice support for these programmes is vital.
The bowel screening uptake is about 50 – 60 %, this can be increased significantly if a follow up letter is sent from the practice and even better if it comes from the patient’s GP. The Wessex Cancer Network is also working specifically on trying to increase the uptake of bowel screening.
- For some inexplicable reason, some patients for whom you have a high degree of suspicion of serious pathology and arrange an urgent investigation DNA.
Have you got a system in place to pick these patients up?
We all develop our own methods but these are some that GPs use:
- Add a Read Code – “patient awaiting investigation” and then run the report every 2 - 4 weeks to ensure the patient has had their investigations. We arrange too many tests for this to be done on all patients but it works if used for those you are concerned about.
- Some requests for urgent tests never arrive at their intended destination. Tell your patients (if they have not had an appointment within an agreed timescale) to contact you, and record this advice.
- Some GPs have a book and record the patient’s name and the date the request was made. They will then follow this up if a result is not received in an acceptable time frame.
Another aspect of cancer care and detection is matching up a result with clinical symptoms. A negative result does not mean there is no pathology.
I am sure you all remember your time as a medical student - being ”robustly” challenged about history, examination and special investigation. Then being told to treat the patient and not simply manage their investigation while ignoring the person!
Approximately 65% of successful medico-legal claims are due to delayed diagnosis.
In February 2013 the LMC organised a conference looking at the early diagnosis of cancer, this focused on primary care but also looked at some common cancers seen by GPs.
The new practice profiles will be released on 20/12/13.
See Appendix 1 – this is a letter I sent to local newspapers, several of which have published it.
4. Provider companies, tendering and procurement
This has been the subject of much discussion for a couple of years. At the recent LMC conference we talked about what practices could do to protect themselves for the future - possibly merging into larger practices, or groups of practices working together. So much for the theory but what about practical help?
The LMC is working with the specialist medical accountants and lawyers to arrange a number of meetings in the New Year to offer a number of workshops for GPs and PMs.
More details will be published shortly.
5. LMC Conference 2013
We have been asked by a number of GPs and PMs who were not able to attend the recent LMC conference for a copy of the presentations so they could keep up to date with developments.
This year we can go one better, on the LMC website a video of each presentation is available for you to watch.
6. Care Quality Commission
This was the second opportunity during last week for the media to blame GPs for all that is wrong with the NHS.
The report looked at the first 1,000 practices inspected. Many had been selected because they had self declared non-compliance or were identified as likely to be non compliant, but many were simply selected at random.
Of the 1,000 practices over 660 passed the inspection and were found to be fully compliant. Of the remaining 340 most only had minor compliance issues that were deemed to be easy to rectify. So this is good news for patients and general practice. However, unfortunately the whole report focuses on 9 practices (less than 1%) that were deemed to have serious failings.
None of the 9 practices identified are in Wessex and when I have discussed these practices with other LMCs it would appear the reports are not completely accurate and one or two practices are considering legal action.
As I am sure you are aware the LMC has been working closely with CQC, in fact many of the pilots were conducted in our region.
Practice Managers have been working hard to ensure practices are compliant and this responsibility needs to be shared with GP partners. All people who work in general practice have a responsibility to ensure their practice is compliant.
A key issue which has been common to many early inspections has been cleaning, infection control and safeguarding.
I am sure it is safe to assume that your practice building is cleaned regularly.
Have you got an agreed schedule for frequency of cleaning required in clinical, as opposed to non-clinical, areas? Can you justify this? Do you check that the cleaning is effective?
Some inspectors will look at your treatment areas and check for dust etc.
2. Infection control
You should have a policy that covers the usual eventualities.
The LMC has run a number of very successful events for practice nurses relating to infection control.
If you have a need for Infection Control training please contact Louise Greenwood: Louise.Greenwood@wessexlmcs.org.uk
At most inspection visits CQC are looking at staffing.
They are looking at 2 or 3 personnel folders to check for CV’s/application forms, references, DBS check or risk assessment, GMC/NMC numbers and renewal dates etc.
At your practice inspection they will ask about safeguarding children and adults. It is important you have a practice policy and everyone knows it exists, what is in it and, if appropriate, where to seek additional help.
Everyone should receive the appropriate level of training.
All of your non-clinical staff should have regular training and for safeguarding children must be able to demonstrate competency at level one, as defined by the 2010 Intercollegiate Safeguarding Competencies produced by the Royal College of Paediatricians and supported by the RCGP and other Royal Colleges.
Essentially competence at this level is about individuals knowing what to look for which may indicate possible harm and knowing who to contact and seek advice from if they have concerns.
It comprises of:
• Recognising potential indicators of child maltreatment – physical, emotional, and sexual abuse, and neglect
• Recognising the potential impact of a parent/carers physical and mental health on the well-being of a child or young person
• Taking appropriate action if they have concerns, including appropriately reporting concerns and seeking advice
Competences should be reviewed annually as part of staff appraisal in conjunction with individual learning and development plans.
Criteria for assessment:
• Demonstrates an awareness and understanding of child maltreatment
• Demonstrates an understanding of appropriate referral mechanisms and information sharing i.e. knows who to contact, where to access advice and how to report
The LMC has developed a Safeguarding lunch and learn package which is aimed at practices to use as a training tool with all members of staff in the practice, clinical and non-clinical, and is now available on the myLMC website.
This Lunch & Learn training resource has been written by an independent trainer in safeguarding and a designated nurse consultant for children.
It uniquely combines safeguarding issues for both adults and children and if presented to a group of multi-disciplinary practice staff will encourage better safeguarding awareness and practice procedures in safeguarding for the whole surgery.
This meets the requirements required for level 1 training.
7. Practice Survey 2013
The results of the latest surveys for every practice in the country have been published in the last couple of weeks. This allows you to compare your practice with other local practices, against your CCG and finally against the national average.
8. Some interesting information about services for the elderly
Do patients present to your surgery asking for a hearing test because they think they have a problem? Many practices will offer some sort of screening test, but were you aware that a test is availabe to your patients over the phone?
A hearing test is available from Action on Hearing Loss on 0844 800 3838 (local rate call), this is just an initial screening test and should be not be seen a substitute for a full hearing test.
This might be worth promoting to your patients and may even save you some work.
Web link – hearing problems
Care at home / help from social services
Help can be provided at home through paid workers employed by the local authority to assist with nursing care at home and intermediate care.
Financial support can be provided and more information can be found: web link – Finacial support for caring
Equipment can also be provided and help people to be more independent this can be accessed via Social Services: web link - community care assessment.
Directgov website can provide advice about assessments: web link – Needs Assessments and social services
Services available include:
- help in the home or in a care home
- community support and activities
- access to day centers
- help for people with disabilities
- financial support
- information and advisory services
NHS Choices has helpful tips to keep you & your home warm in the winter weather, how to travel safely in wintery conditions and links to the met office weather forecast.
Age UK has a guide for keeping warm and healthy during the winter months. The guide covers preparing for winter, staying healthy, keeping your home warm and what extra money people could be eligible for. It also covers a list of helpful organisations.
Carers Trust website
Carers Trust is a charity that provides breaks for carers, local schemes can offer local services to allow carers to take a break and know the person they look after is being cared for. Referrals can be made by carers, families of carers, your social services department, health workers and voluntary organisations.
A care manager from Carers Trust will discuss with you:
- the kind of help you need,
- how often you would like them to visit,
- how long you would like them to visit for, and
- a suitable time for visits to take place.
Respite services available include:
- extended care,
- hospice at home
- overnight services,
- palliative care,
- rapid response team, and
- traditional respite.
Care Watch is a private organisation that can help provide home care support in the community with domestic tasks, personal care and support for stroke or dementia rehabilitation. All of which can be provided in the persons home and is an alternative option to residential care and nursing homes.
Safety recommendations include;
- Have a cordless phone /mobile on the person at all times
- Make sure any external stairs have a hand rail fitted
- Ensure rugs and mats are slip resistant and are stuck down to prevent trips or falls
- Secure any hazardous wires and remove clutter from walkways
- Make sure adequate lighting is installed
- Dressing or mobility aids, and trolleys may help people to move around more easily
- Check fire & carbon monoxide alarms are installed and working correctly. The fire brigade may be able to fit and check free fire alarms.
New boilers and home insulation are being offered to certain people on pension credit, which will save money on electricity bills. The links below offer more information.
9. Local Newspapers
The LMC frequently writes to local newspapers. Currently we have the following on our database; if your local paper is not on this list please let us know:
- Alton Herald
- Basingstoke Observer
- Basingstoke Gazette
- Blackmore Vale Magazine
- Bordon Herald
- Bridport News
- Bournemouth Daily Echo
- Devizes Gazette and Herald
- Dorset Echo
- Farnham Herald
- Hampshire Chronicle
- Isle of Wight County Press
- Liphook Herald
- New Milton Advertiser and Lymington Times
- Petersfield Herald
- Portsmouth News
- Purbeck Gazette
- Romsey Advertiser
- Salisbury Journal
- Southern Daily Echo
- Swanage Wareham Advertiser
- Swindon Advertiser
- Wiltshire Gazette and Herald
Dr Nigel Watson