December 11th 2017 - LMC Update
Date sent: Tuesday 12 December 2017
It seems appropriate with the cold weather that there is a focus on what patients can do to help themselves and where they can seek help if needed. We need to ensure that the default for every problem is not see your GP or go to A/E.
Over the next week I have been asked to do a couple of interviews for the local media focusing on winter pressures. This will be aligned with NHS England's campaign where they are warning of an increased risk of stroke and heart attacks in the days following a "cold snap".
1. Winter pressures
It comes as no surprise that winter is here again and as a consequence our workload has increase but why does the medical focus only on hospital based demand?
2. GP representation
What is the difference between the RCGP and the BMA? What is the relationship between the GPC and LMCs? I hope to add some clarity to this confusion!
3. Anti-viral prophylaxis and care homes
For years there has been an ongoing discussion about who is responsible both for the commissioning and delivery of the mass prevention of influenza if there were a flu outbreak and how homes would be supplied with antivirals. Finally a conclusion has been reach with NHS England.
4. Measles Outbreak
My last emails described the increase in scarlet fever and now we are seeing an increase in the reported cases of measles.
5. TPP (SystmnOne) and data sharing
Following previous concerns about TPP and security a joint statement has been issued by the RCGP and GPC IT Committees.
6. QOF review practice group advert
Are you interesting in contributing to this review?
7. Medical Students and their experience of General Practice
If we are going to get more medical students to choose general practice as a career then they must have a good experience of general practice in their training but what do they say about their experience?
8. GP Consultant exchange
This is a project that the LMC has been involved in for some time - please read for more details.
1. Winter Pressures
It comes as no surprise that every year we experience a rise in demand as the winter sets it. Much of the media coverage focuses on the demand experienced in the hospital and particularly in A/E. There is little recognition of the pressure that this increase in demand has on general practice.
Over the next couple of weeks, we should expect a public facing campaign to inform patients about this. NHS England will be promoting the increased availability of GP appointments delivered via the additional investment of £6/pt for extended opening delivered at scale and the additional capacity delivered via the new investment in having GPs at the front door of A/E delivered through the A/E streaming project.
Over the next couple of weeks the LMC will use the opportunity of supporting the national campaign with local messages about winter pressure and the impact on general practice, promoting alternative sources of help and support for patients.
The LMC is working closely with CCGs, Federations and other providers to ensure the additional investment in extended opening delivered at scale supports local practices with the additional investment and to ensure the capacity is beneficial to practices.
We are told that CCGs have also been given resources to support the provision of additional urgent appointments over the Christmas and New Year period. Whilst additional investment is welcome, the real need is for long term funding and the LMC will be asking the CGGs what their plans are for winter pressures, how they are going to support general practices and where this additional investment is being placed.
2. GP representation
I am often asked about who represents GPs and what is the role of the LMC, the BMA, the GPC and the RCGP and what does each body do and how do they work at a national and local level?
The attached document was produced to help and support a debate item in the latest round of LMC Committee meetings. Several LMC Members thought that the document would be really helpful for GP Trainers and Trainees. So I have revised the document and added some information to make it more relevant to these parties and I hope that you will find it useful.
3. Agreement with NHS England about anti-viral prophylaxis
Following pressure by GPC England, NHS England has now published guidelines which set out the contractual position for primary care for the provision of anti-viral prophylaxis in situations of a flu outbreak. This is particularly the case in residential and care home settings.
NHS England makes clear that this is not a contractual responsibility for GP practices and additional arrangements should be commissioned. It is important that CCG to put in place arrangements for this as soon as possible.
To read the guidance letter sent to all CCGs, please click here .
The LMC will be seeking clarification from CCGs that they have plans in place in case there is an outbreak of flu and there is a requirement to implement the provision of antivirals to the residents of care homes.
4. Measles Outbreak
Approximately 70 confirmed measles cases across four separate areas have been reported since early November. In three areas - Leeds, Liverpool and Birmingham – the cases have all arisen from importations from Romania which have spread within the Romanian and other under-vaccinated communities locally. In addition small clusters of confirmed measles cases are also being investigated in Manchester and Surrey and Sussex. This spread is unsurprising given a huge outbreak in Romania (>5,000 cases and 30 deaths) itself, with smaller outbreaks in Italy and Germany.
At present I am unaware of this being a problem in Wessex but as you can see this is getting closer.
As is normal practice in measles cases, local public health teams will usually contact the GP and/or the patients themselves to get a history around each case or cluster and will attempt to limit any onward spread. Certain populations are under-vaccinated and certain individuals are at increased risk of serious consequences and/or cannot be vaccinated. Identifying the latter group is a priority for the local teams as they can potentially be offered post-exposure management to reduce the risk of infection. This management is standard and has been going on for many years, when numbers of cases were much higher – for example in 2013 we had 1800 cases and in 2016 there were over 500 cases, so the numbers involved this year are so far small in comparison.
Fairly commonly, measles cases are diagnosed late and may have spent time waiting in GP surgeries or hospitals, thus exposing a large number of vulnerable patients. When this occurs public health teams have been asking GPs or hospitals to identify these patients so that the HPT can undertake a risk assessment based on vaccine history, underlying condition etc. – it may include contacting a specialist to clarify the underlying condition. Based on this risk assessment they may then recommend that these patients are tested and/or offered immunoglobulin. Most exposed individuals will be assessed to be at low risk, either because they are already protected, or because they are healthy. Healthy contacts may be advised to catch-up on the MMR doses or simply be given a warn and inform message. A small number of contacts who are at serious risk of measles and it’s complications – mainly pregnant women and immunosuppressed people, may need to be tested and almost all will be found to be immune. Those that are not may require immunoglobulin. This management may be done by a specialist or by the GP depending on the underlying condition but is urgent.
PHE recommend that practices should continue to catch-up patients over the age of three years and four months who do not have two recorded doses of MMR vaccine remain eligible. There is no upper age limit to offering MMR vaccine. GPs should note that recent travel to countries with ongoing measles outbreaks like Romania, Italy and Germany increases the likelihood of a measles diagnosis. Isolation of suspected measles in cases attending surgeries will reduce the risk of other patients being exposed.
Catching up children aged 15 years or younger is covered under the additional services of global sum and an item of service fee can be claimed manually via the CQRS MMR programme (aged 16 and over) for each dose of MMR administered to patients aged 16 years or over. Local NHS England teams are mounting responses to the outbreaks in some areas which may include active call recall of unimmunised children in areas where measles is circulating and specific campaigns in high risk populations
5. TPP and data sharing
Some will remember some months ago that there was significant concern about TPP (SystmnOne) and the way that electronic patient records were shared between organisations. The dilemma here was that to deliver effective care in an integrated way that was safe and effective, the sharing of patient records becomes essential particularly when you implement a model whereby more and more services are delivered out of hospital at sc ale and more importantly are supportive of and embedded in general practice. At one point it seemed that the concern was such that the Information Commissioner's Office (ICO) would demand that practice turn of the sharing in and out functionality within TPP.
Fortunately, following much discussion and lobbying particularly from Wessex LMCs, common sense prevailed and the ICO and it was agreed that turning off the sharing was a greater risk to patient care than the concerns about the method of sharing. The caveat was that the GPC, RCGP and NHS England would work together and with TPP to implement a more secure solution, it would appear that this has now been achieved.
A statement has been produced from the Co-Chairs of the Joint GP IT Committee to provide LMCs with a brief update on the issue of GPs' ability, as data controllers, to comply with the Data Protection Act when using TPP’s SystmOne. This has been attached for your information.
6. QOF review practice group advert
NHS England and GPC England have agreed to undertake a review of the Quality and Outcomes Framework (QOF) as part of the 2017/18 contract negotiations.
As part of that work, practice reference groups are being created in Bristol, Leeds and London. The closing date for expressions of interest is 15 December 2017.
Opportunity to join the practice reference group for the review of the Quality and Outcomes Framework
- GPs, nurses and practice managers required for a practice reference group.
- Interest Area: Quality and Outcomes Framework review
- Closing date for expressions of interest: 15 December 2017.
NHS England and the British Medical Association agreed to undertake a review of the Quality and Outcomes Framework (QOF) as part of the 2017/18 contract negotiations.
They are setting up practice reference groups which will involve one or two face-to- face meetings and if required further virtual engagement either via WebEx or surveys.
The first round of meetings is planned for January 2018 as per below, with a further round likely to take place in Spring 2018:
? Bristol - 17 January
If you are interested in participating in one of these reference groups or would like further information please email Anisa Varsani on firstname.lastname@example.org or contact 07730 380 387.
7. Medical Students and their experience of General Practice
Recently the RCGP and the Medical Schools Council published a report entitled - "Destination GP - Medical Students' experience and perceptions of general practice". This makes very interesting reading. If you would like to read the whole report click here .
Some key messages from the report:
- 81% of students reported GPs on placement had most influenced their perceptions of general practice
- 35% of students indicated that their peers at medical school are one of the most influential groups on their views of general practice
- 71% of students say that GP tutors make them want to work in general practice more
- 91% believe their peers have negative views about general practice
- By their fifth year 76% of students have encountered negativity towards general practice from academics, clinicians or educational trainers
- 41% of students say their interaction with their GP Society has had a positive influence on their interest in general practice
As the demand for general practice increases and is greater that the demand for hospital based care the expansion of GP numbers by 5,000 by 2020 as detailed by the GP Forward View seems somewhat remote. Recent NHS figures showed a drop of 1,193 full-time equivalent (FTE) GPs in the year to September 2017. This compounded by an increase in activity of between 15 - 20% over the last 7 years. The total number of GPs last year fell from 41,865 to 41,324 - a drop of 541 (this reflects the number of GPs leaving the profession and also is less than the FTE because that also reflects that to survive many GPs are reducing the number of sessions they work.
Previous research has shown that many medical students experience negative messages about general practice during their training and this is particularly common from hospital specialists, although other specialities experience the negative comments, general practice is the worse affected.
There are 4 key recommendations in the report which need to be addressed but what else can be done to make general practice more attractive to medical students?
An expansion of the number of medical student places by 1,500 which will begin in April 2018, of this 500 additional places will be added to the existing medical school places and a further 1000 placed will be achieved by increasing the number of medical schools.
But how does that benefit general practice?
Despite the aim to increase the number of GPs, invest in general practice and community based services and create an put of hospital model embedded in general practice but delivered at scale we have seen over the last couple of years the increase in the numbers of hospital based consultants and a fall in the number of GPs.
The new medical school places are aimed at institutions that are more likely to train doctors who are going to become GPs. We need about 50% of newly qualified doctors to enter the speciality of general practice, yet some medical schools are currently not even achieving 20%.
Part of encouraging medical student is to provide them with a valuable experience of general practice during their training. The feedback we are getting is that medical students today are getting greater exposure to general practice and are having a better experience that my generation did and this will make a different but despite this students need to spend longer in general practice than they currently do, but how can this be achieved at a time where general practice is under such pressure? To recruit and retain GPs we need to make general practice a better place to work and part of that is enabling GPs to fell they have a greater degree of control ove their working day. Many GPs both enjoy and are good at teaching, we need time and adequate resources to undertake this work. Currently general practice placements attracts a lower payment than a hospital based placement - this cannot be right and there needs to be parity of esteem and resources.
The LMC is developing closer links with the local Medical School and will be promoting general practice and the valuable position we hold in the local health economy.
8. GP - Consultant exchange
I think many people would agree that one of the challenges we face is the fragmented care that patients receive as we all work in our silos whether that be general practice, primary care, or hospitals. Some would argue that years ago there was a far closer working relationship between GPs and Consultants and this relationship frequently helped in ensuring patients received the best possible care.
Over the past few years I have had the privilege of spending a day with a number of different consults in my local hospital, an Ophthalmologist, an Orthopaedic Surgeon and a Paediatric Intensive Care consultant, they then spent a day in my practice seeing how general practice works. These exchanges were really interesting and had great educational value. As a GP I have not worked in a hospital for many years, so my experience opened my eyes to a number of problems and also possible solutions and the Consultants were surprised how valuable they found it, some key observations:
- Most patients who I saw, I knew and could tell the consultants quite a bit about the person and their family but largely did not know why they were coming in to see me.
- In OPD the Consultant had a letter or notes so knew the problem but did not know the person.
- The Consultants we surprised by the range of patients we manage and the complexity.
- They all found general practice far more interesting than their memories of it as a student.
- They all commented on our IT and clinical records and how much better this was than hospital records.
- The educational component was great, I learned from them and they picked up quite a bit from me (which was a surprise to me!).
- It was a bit daunting when a person presented with an eye problem or a MSK complaint when you have a specialist with you - but is was clear that their way of managing was different and level of intervention was far greater than mine, not a criticism but reflected to fact that we filter out many patients before they see the specialist, and therefore we are essentially seeing a different cohort of patients, this was a bit of a revelation to them.
The LMC has been working with a number of hospitals to promote these exchanges. Portsmouth Hospitals ran a very successful exchange with about 50 GPs and 50 Consultants being involved, which concluded with an evening meeting with all participants who exchanged experiences and this was seen to be very successful. The LMC have also been involved in schemes with the Hampshire Hospitals (Basingstoke Hospital and Royal Hampshire County Hospital, Winchester) and Poole Hospital.
The LMC has also been working with University Hospital Southampton (UHS) and Southampton CCG to promote GP Consultant exchanges within the UHS catchment area. If you are interested please see the attached flyer.
Dr Nigel Watson
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
Hants. SO53 1JB (Registered Office)
Attached file: Clinician Statement on Progress 081117.docx
Attached file: Jan event flyer_.docx
Attached file: GP Representation document NW 11 12_.docx