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Q & A - Practice Matters
Index
PR528 - Patient forum inspection visit
PR527 – Chaperones
PR526 - Hazardous Waste Regulations
PR525 - Locum reference
PR524 – NHS investigations for private patients
PR523 - Travel vaccines
PR522 - Conflict resolution training
PR521 – Hospital issue of med 3s
PR520 - Temporary patients
PR519 – QOF Fraud check
PR518 – Pre-registration clinical checks
PR517 - Visitor from a country with bilateral healthcare agreement
PR516 - Partners liability in employment disputes
PR515 - Patient demanding inappropriate prescriptions
PR514 - Jury service
PR513 - Child health record
PR512 - 087 and 084 telephone numbers
PR511 - CRB checks abroad
PR510 – Hepatitis A
PR509 – Hepatitis B immunisation
PR508 - Consent forms
PR507 - Practice based commissioning
PR506 - Housing letters
PR505 - Citizen Card
PR504 - Agenda for change
PR503 - Practice letterheads
PR502 - Full booking
PR501 - Practice Turnover
Q PR528 - Patient forum inspection visit – Our PCT has informed us that the Patients Forum intends to carry out an inspection visit at our
practice in the next two weeks. This is not very convenient to us. Are we obliged to permit this and if so can we choose a more convenient time? They wish to ask patients questions during their visit. Is this
permissible?
New 16/11
Answer - The GMS Regulations were amended in 2003 to make it a contractual requirement for GPs
to comply with the Patients' Forum regulations. PPI Forums may now enter GP premises as long as neither patients' safety, privacy, dignity or the effective operation of the health services are compromised. See Patient and Public Involvement
The NHS regulations Part 5 regulation 90
sets out the details regarding Entry and inspection by members of Patients' Forums as follows;
90. The
contractor shall allow members of a Patients' Forum authorised by or under regulation 3 of the Patients' Forums (Functions) Regulations 2003[103] to enter and inspect the practice premises for the purpose of any of
the Forum's functions in accordance with the requirements of that regulation.
The Patients' Forums (Functions) Regulations
sets out the relevant regulations regarding the entry and inspection of premises by Patient Forums in detail. Basically you must comply
with this request to enter and inspect your premises unless you believe it would compromise the effective provision of health services or patients' safety, privacy or dignity. You are of course not obliged to
grant entry to any residential quarters that form part of your surgery premises.
Each person authorised by a Patients' Forum must have written evidence of his or her authority which you may ask to view before permitting entry.
Provided the necessary patient consent is in place, the Patient Forum is allowed to seek patient information from your practice. There would seem to be no
reason, therefore, why the members of the forum may not ask your patient’s questions, provided the patients consent willingly to do so and it does not is does not compromise patient service provision.
CED
Q PR527 – Chaperones - At a practice meeting we discussed our policy regarding chaperones and felt we should have a formal written
policy and procedure to help protect patients and staff. Can you suggest a suitable policy?
New 11/08
Answer - The LMC does not have a policy but would recommend the NHS
clinical governance support team’s
Guidance on the Role and Effective Use of Chaperones in Primary and Community Care settings
This clear, common sense guidance includes a sample chaperone policy and a patient notification that can be displayed in your surgery. The
guidance can easily be adapted to your practice needs.
Further information;
Use of chaperone
Refusal of chaperone by vexatious patient
CED
Q PR526 - Hazardous Waste Regulations - I have heard a lot about the hazardous waste regulations. What are the implications for a GP
surgery?
New 12/07
Answer - New Hazardous Waste Regulations were introduced in England
and Wales on 16th July 2005. Most practices are likely to exceed the limit permitted for non-registered practices and will therefore be required to register with the Environment Agency before 16th July.
All hazardous waste must be transported in a licensed vehicle. (Prescription drugs are not classified as hazardous waste.)
The
NHS GMS Premises Cost (England) Directions 2004 sets out in Section 46 b (iii) that PCTs must consider that application and, in
appropriate cases (having regard, amongst other matters, to the budgetary targets it has set for itself), grant that application. Practices should contact their PCT to seek reimbursement for waste disposal which
includes the new registration costs.
The registration fee may already be included in the service contracts for some health centre practices or those with a PFI arrangement. If not
you may register on line which costs £18, by phone on 08708 502858 which costs £23 and by post from the Environment Agency, PO Box 544, RotherhamS60 1BY which costs £28.
Some waste disposal companies are offering a registration service. This is neither necessary nor desirable and will cost more money!
Footnote;
Another LMC has been advised by the Environment Agency that PCTs
would be able to register all their GP practices en bloc if the practices consent to this.
Details can be found on the Environment Agency’s registration page.
Since registration is an annual requirement this could be very helpful.
See also:
Q&A CL502 - Disposal of Sharps
CED
Q PR525 - Locum reference – We are trying to devise a reference proforma for a locum we wish to engage. Can you advise us please?
New 12/07
Answer – It is a legal requirement for GPs to obtain references from
prospective locums before employing them and you may find a
Structured Reference Form helpful.
In addition you may find other useful information on providing and obtaining references in STA08 - References and
NCO20 - References for locums
It is most important in these times of increasing medical mobility and increasing diversity of service provision that references are always
correctly provided and followed up in order to ensure that professional standards are maintained.
The importance of these issues has been highlighted by Dame Janet Smith’s recommendations following the Shipman enquiry. Her enquiry
and the Neale-Ayling enquiry both highlighted a doctor’s GMC obligation to alert the relevant authority if there are concerns that a doctor’s performance is putting patients at risk.
Employed staff may fear retaliation for drawing attention to their concerns but are in fact well protected by the Public Interest Disclosure
Act 1998 and current employment legislation. Further information on the is subject is to be found in PRA87 - Whistle-blowing protection
If you are concerned about the performance of any doctor and are unsure how to proceed please contact Wessex LMCs for advice on the correct
procedures that should be adopted. This will help ensure that an effective procedure is followed that takes into account all current legislation.
Wessex LMCS is currently revising the poorly performing doctor procedures in association with our local PCTs and SHAs to try to achieve a
uniform approach throughout the Wessex LMC region. This will take into account the new NCAS (formerly NCAA) guidelines due out at the end of the summer.
We all need confidence that the system is fair and effective, as set out as long ago as 1999 in the consultation paper Supporting doctors, protecting patients. Doctors must be confident that concerns will not turn into a witch hunt but will provide much needed support to cope
with a very difficult and demanding job. Detecting problems at an early stage is in the very best interest of patients and doctors.
CED
Q PR524 – NHS investigations for private patients – I recently referred
a patient for NHS X-rays and asked for the results to be forwarded to a private consultant who would be seeing the patient. On another occasion I referred a patient for NHS laboratory tests. She was
already receiving private care and I asked for the results to be copied to her consultant. On each occasion I was informed that this was an abuse of NHS services. I can see no moral or ethical reason why I
cannot refer patients for investigations to whoever I and they choose. Am I right?
New 07/07
Answer - You may refer patients within the NHS or private sector as you
and they choose and patients are entitled to opt in and out of the NHS as they choose.
However, the BMA guidance in the Consultant handbook, May 2005 - Private and independent practice advises that the guidance set out in
the DoH’s Green Book ‘helped to clarify the position where the general rule is that private patients should remain private throughout the whole treatment episode, although they do have the right to change
their status between an NHS and private patient at any stage of their treatment.’
The BMA ethics guidance on the
Interface between NHS and private treatment Guidance from the Ethics Department - February 2004 sets out the fact that ‘consultants may not use NHS staff for the provision of
private services without the agreement of their NHS employer.’
Many consultants offering very efficient NHS diagnostic services resent being used to investigate patients who feel obliged to bypass less
efficient NHS services in the private sector. Many GPs also resent being asked to carry out NHS tests on behalf of private consultants. Many NHS
hospitals object to their staff and diagnostic services being used to provide NHS backup for private patients at the hospital’s expense.
It is not at all unreasonable for GPs to use NHS services to support the NHS services that they are providing, but it is probably better to stick to
either private or NHS care for the ongoing management of a particular medical condition where it is reasonable to do so. There will be some situations where a mix is the most appropriate and where your GMC
obligation is to act in your patient's best interests. There is no regulation that prohibits you from doing so and it is the patient's right to demand
that any necessary tests are carried out in the NHS if they so wish.
It is not permitted for patients to jump the NHS queue for investigations or treatment as a result of accessing private care.
There is a professional obligation and a legal duty of care to share data between both the private and NHS sectors to ensure proper patient care
where the patient is accessing private and NHS services. GMC’s guidance also states that doctors must ‘keep colleagues well informed when sharing the care of patients’ even when the care is shared between the
NHS and private sector.
CED
Q PR523 - Travel vaccines – Can you advise if we are obliged to
provide travel vaccinations? Can we charge for travel advice? There is also some confusion around the use of revaxis and polio vaccine for travel. Can you help please? New 07/07
Answer – There has been considerable confusion and we hope that the
following will help clarify these issues.
- There are some travel vaccinations, given for public health reasons, namely smallpox, typhoid, cholera, polio and infectious hepatitis,
for which NHS GPs are paid by the NHS. (These are the vaccines given by the doctors under the old contract with an item of service A or B fee.) The funding is included in the global sum (in GMS
contract) or the baseline funding in PMS.
- A doctor may only refuse to give these public health immunisations if they opt out of the vaccination and immunisations additional
service in which case their global sum is reduced by 2%.
- The personal administration system will continue under the new contract and is detailed in the Statement of Financial Entitlements (SFE) in paragraphs 18.2 &18.3.
- Inactivated polio vaccine is no longer regarded as a childhood vaccine and patients must take an FP10 to the pharmacy for
dispensing and take the vaccine to the practice for administration. The SFE excludes an administration payment for oral polio or inactivated polio and the SFE has not been changed to permit reimbursement.
- Revaxis was centrally supplied and originally was only for children. Since April 1st this has changed and claims may now be submitted to
the PPA for reimbursement until the situation is clarified. However, there is currently a supply problem and revaxis cannot be supplied for adults or for travel.
- Schedule 5 allows the contractor to charge a fee for treatment consisting of a travel immunisation for which no remuneration is
paid by the PCT. It also allows a fee for prescribing or providing drugs, medicines or appliances (including a collection of such drugs,
medicines or appliances in the form of a travel kit) which may be necessary while travelling outside the UK but which were not required when prescribed
- You may not charge for travel advice.
- The new GMS contract regulations provide further information about vaccinations and immunisations. If you choose to give
vaccinations and immunisation you must adhere to the Regulations Schedule 2 relating to additional services.
CED
Q PR522 - Conflict resolution training - I have been told that under government guidelines GP staff are meant to be trained in conflict
resolution. Is this correct?
New 06/06
Answer - Conflict resolution training arose out of the strategy document
A Professional Approach to Managing Security in the NHS.
In April 2004 the largest ever training programme in the NHS was initiated for the benefit of all frontline NHS staff directly involved with patients in
order that more potentially violent situations could be defused. You can find out more about this training programme in Conflict resolution - implementing the national syllabus
Some health bodies have organised mandatory conflict resolution training for all staff, some have only made it available to staff if it was requested
and some have provided no training at all.
It is not a mandatory requirement for practices to provide training for their staff, but it may be a sensible risk management strategy to offer
access to the training. This would help to protect the practice from any accusation that, by not offering training that had been made widely
available to other frontline NHS staff, the practice had failed in its duty of care to its staff. This would of course be particularly important in the
event that a member of staff was harmed as a result of a violent attack and claimed that the practice had failed to provide training that might have prevented such an attack.
If staff had been offered training but had refused to take it up then the practice would probably be protected to some extent.
Different PCTs have made training available in different ways and you should approach your PCT with regard to the availability of training for
your staff and the possibility of special funding.
CED
Q PR521 – Hospital issue of med 3s – I still have patients requesting an urgent appointment following discharge from Hospital in order to
obtain a Med 3 certificate. I know that the hospital is supposed to issue these. Do you have a specimen letter we can send to the
hospital?
New 17/05
Answer – We have over the years produced a number of such letters and
have also written numerous letters ourselves to inform the hospital staff of the correct procedures. Whenever you are faced with this situation
we would suggest that you write to the hospital by modifying our suggested letter as appropriate.
CED
Q PR520 - Temporary patients – Under the new contract the payment
for temporary patients has been subsumed into the global sum. Is there any point filling in a temporary resident form since there is no extra money for providing this service? New 17/05
Answer – Payment for temporary patients was included into the global
sum on the basis of historic payments to your practice over the last five years. The temporary patient forms you fill in now will inform the
current level of services provided to temporary residents and will help to determine any necessary adjustments to global sum payments in the future. The blue book Investing in General Practice - 2.28 sets out that where the treatment of temporary residents is insufficiently accounted
for within the global sum this may be resourced either by a variation to the global sum or as a local enhanced service where, for example, a new
holiday park has opened close to the practice resulting in a large influx of temporary residents. It is important therefore to record all
non-registered patients who are treated, including those requiring emergency or immediately necessary treatment.
CED
Q PR519 – QOF Fraud check - We have been picked for a QOF fraud
check. Why were we selected and what is involved? Have the LMC been involved in the process? New 09/05
Answer - Practices in our region were subjected to a sophisticated and
fair random selection procedure for these fraud checks ie the practices were drawn out of a hat in an LMC approved process!
We helped to draw up and approve the following QOF random check protocol
with one of our PCTs. This should give you a clear idea of
what is involved. If your PCT has not used the LMC approved model and you are concerned by any significant variations you should contact your LMC to seek specific advice.
CED
Q PR518 – Pre-registration clinical checks – We always insist on a pre-registration clinical check with the practice nurse before
registering any new patient. One of the partners believes that we should not do so. Are we correct or is he? New 05/05
Answer – The GPC has given the view that this is procedurally incorrect
and a practice would be breaching its obligations to insist on this check, but the profession seems to be divided in their views of the contractual probity of these pre-registration checks.
Under the new contract you must invite all newly registered patients to attend a clinical consultation within 6 months of being registered. Under
the old contract many practices adopted a strategy of pre-registration checks because so many patients chose not to attend the new patient check.
Many doctors believe it is critical to the provision of good clinical care to establish an initial medical baseline to inform subsequent care. If this is
your view then you must be extremely careful to ensure that no element of discrimination creeps into this procedure if you subsequently choose not to register an applicant for any reason.
You are not obliged to accept every patient that applies to register, but must not discriminate on the basis of race, gender, social class, age,
religion, sexual orientation, appearance, disability or medical condition. You may refuse any applicant that lives outside the practice area. You
may also refuse to register a patient if your list is closed or temporarily full.
It would be sensible to have a list of non-discriminatory criteria that are always applied in making any decision not to register a patient. You
must notify a patient in writing within 14 days of a refusal to register them, stating clearly the reason for your decision. You must keep a written record of any refusals for PCT possible inspection.
If a patient who had recently moved to the area attended your surgery for emergency or immediately necessary treatment you would be obliged
to provide this. You could provide the treatment on a temporary patient basis, if you have non-discriminatory and valid reasons for refusing to register the patient.
CED
Q PR517 - Visitor from a country with bilateral healthcare agreement – We had a visitor from Australia come to the practice for routine
healthcare. We told him that he would have to pay to make a private appointment. Is this correct? New 04/05
Answer – Australia is one of the countries that has a
bilateral healthcare agreement with the UK so the visitor is free to ask any GP practice for
treatment. However, practices are free to decide which patients they accept on to their list of NHS patients and this includes vsitors from these
countries. If you do not wish to accept him on to your list you may offer him treatment as a temporary NHS patient, but equally you may offer to treat him as a private patient.
You are of course obliged to provide any emergency or immediately necessary treatment free of charge, regardless of whether you choose to
register the patient with your practice.
Further information
Overseas visitors; current entitlement to primary care services -
9/08/04
Are you visiting the United Kingdom from a country with a bilateral
healthcare agreement?
CED
Q PR516 - Partners liability in employment disputes – One of our partners recently criticised the performance of one of our practice
nurses who was very distressed as a result. One of the other partners was able to placate her and to reassure her that the other partners did not share this critical attitude. He persuaded her that we all
wanted her to continue working with us. If she had walked out I believe she could have claimed constructive dismissal. Would we have been responsible if our partner’s criticism had resulted in such a
claim? New 04/05
Answer – If she had good grounds to successfully claim constructive
dismissal then the other partners would probably share ‘joint and several liability’ for his actions. If an employee, such as a practice manager, had
caused the problem, then the partners would generally share the liability, unless there had been a very clear breach of procedure.
There are very clear statutory procedures for dealing with grievance, discipline and dismissal in the workplace and to act precipitately without
following the correct procedures could prove extremely expensive for the practice! It is therefore of critical importance that your practice has
very clear written policies that staff and partners must always follow in handling all employment issues. All partners and employees must be made aware of their responsibilities in this respect.
Strict adherence to proper procedure will usually help minimise the risk. In the case of an employee who ignores correct procedures the
partnership liability may be reduced. In the case of a partner, the partnership deed may cover failure to follow correct procedures.
Practices may seek insurance cover for the legal costs resulting from an employment claim, but this rarely covers any financial award made to the
employee, which may be substantial. If problems do arise it is wise to seek early advice from a lawyer with special experience in employment law to try to limit the damage!
CED
Q PR515 - Patient demanding inappropriate prescriptions – One of our patients keeps demanding prescriptions. Can we remove him from
the list? Should we remove the rest of the family even though they are not causing any problems?
New 28/04
Answer - If you believe that the doctor/patient relationship has
irretrievably broken down then you may ask for his removal. The GPC has recently published new guidance Removal of patients from GP lists and you would be well advised to read this carefully before taking any precipitate action.
It would be preferable in this situation to draw the attention of the patient to the problem and seek to improve matters by negotiation.
Sometimes a different doctor may establish a better working relationship and sometimes a discussion of the problem will improve matters
sufficiently to retain the patient on the list. You should issue a written warning to the patient that they risk removal if things do not improve. Such a warning should be issued in the 12 months before
removal for such behaviour. This warning letter should be retained after the patient moves to another practice for possible inspection by the PCT.
Even if the patient is removed it may not be necessary to remove the family, unless you believe that it would be impossible to care for them in
the circumstances.
CED
Q PR514 - Jury service – A partner at a neighbouring practice was recently called for jury service and was surprised to learn that under
the new regulations he was not automatically excused. We are a small practice and would find it impossible to manage without a locum. Would the PCT be obliged to provide reimbursement for this?
New 26/04
Answer - Since April 2004 doctors have no longer been 'excusable as of
right' from jury service. (See Q&A ML 33 - Jury Service)
The practical and financial implications of this for any GP practice could be considerable and patient care could be impaired as a result.
The SFE does not direct payment for locum cover in these circumstances, but in 9.2 it states in relation to locum payments for maternity, paternity
and adoption leave that ‘if an employee or partner who takes any such leave is a performer under a GMS contract, the contractor may need to employ a locum to maintain the level of services that it normally
provides. Even if the PCT is not directed in this SFE to pay for such cover, it may do so as a matter of discretion.’
Since practices have a similar statutory obligation to allow a GP to be absent from the practice for jury service, the PCT may be prepared to
make a discretionary payment from PCT administered funds to help ensure the maintenance of patient services. However, in the current financial climate the level of any support is uncertain.
We know of some PCTs that have committed themselves to assisting in these circumstances and have contacted all our PCTs to clarify the position locally.
In view of the uncertainty practices may wish to review their partnership contracts and/or consider locum cover insurance to protect themselves in
the event of partners being absent for an extended period on jury service.
Footnote:
GPs should check their buildings insurance policy to see if this covers loss
of income as a result of jury service. One of our GPs has notified us that they have checked with the underwriters and their cover does include this.
CED
Q PR513 - Child health record - The new Personal Child Health Record has no specific consent form for immunisations within the record,
although there is a consent form covering sharing of information on a database. Our doctors and nurses are uneasy about immunising a child without specific written consent so we have downloaded the
parental consent form from the DoH website. This will not of course be an integral part of the record. Is this a necessary and/or adequate precaution? New 25/04
Answer - It does seem strange that an NHS official document should omit
the issue of consent to treatment, as required by the NHS policy on consent!
Your own proposal regarding consent would seem to be quite adequate as you will be using the 'official' form. The official consent forms and the guidance that accompanies them are very useful to ensure that you
practice legally and safely with regard to any necessary consent.
In fact you would probably not need written consent. By bringing the child and asking you to go ahead with the immunisation the parent would
be giving legally valid explicit consent, provided you had given full information about the proposed immunisation, which the parent had understood. The important thing is to ensure that all staff follow a
written practice protocol on all occasions, which ensures ensure adequate informed consent is always obtained.
CED
Q PR512 - 087 and 084 telephone numbers - We recently changed to a modern phone system using 087, numbers which have now been
banned by the Department of Health (DOH). We were assured that changing to an 084 number would be acceptable, but are concerned to read that the use of 084 numbers is now being reviewed! Can you
advise? New 25/04
Answer – We were unaware of any concern regarding 084 numbers until
we also read a similar article!
087 and 084 numbers are examples of fixed rate Number Translation Services (NTS) where the cost of calls funds the provision of services
wholly or in part. The current ban on 087 numbers was in response to numerous complaints from patients.
A number of measures have been proposed by Ofcom as part of a consultation exercise and an analysis of the results will be published in summer 2005.
Among the concerns are:
- NTS calls do not attract the same discounts as geographic calls
- difficulty working out the cost of calls until the bill arrives
- misleading advertising describing calls as ‘local’ or ‘national rate’
- operators and customers sharing revenue from NTS calls
- call centres possibly encouraging queues to make money
- increasing usage by public service providers, such as GP surgeries
We have no knowledge of the possible outcome of this review and would suggest that you try to clarify these issues with your service provider.
(This is of particular importance to any practice currently thinking of installing a new system!)
In the meantime Ofcom suggests that organisations using an 0845 number should;
- make sure patients are fully informed about the price of calls
- be able to provide accurate answers to questions about the cost of calls
- consider making a geographic number available alongside the 0845 number to give patients a choice.
Further Information:
087 Phone Numbers Banned
0870 and 0845 Numbers: FAQs
CED
Q PR511 - CRB checks abroad – Does the Criminal Records Bureau provide information on people previously living and working abroad?
New 25/04
Answer – CRB checks only apply to the UK, but the CRB has set up a ‘fax
back service’ providing information regarding the availability of criminal records information from overseas. The CRB is not responsible for the information provider or any delay in response.
To check on someone previously living or working abroad you must set your fax machine to ‘polling’ mode and dial the appropriate number from
the list below. The information should be faxed back more or less straight away.
0906 55 55000 Denmark
0906 55 55001 France
0906 55 55002 Germany
0906 55 55003 Irish Republic
0906 55 55004 Italy (excluding Vatican City)
0906 55 55005 Netherlands
0906 55 55006 Spain
0906 55 55007 Sweden
0906 55 55008 Poland
0906 55 55009 Canada
0906 55 55010 Jamaica
0906 55 55011 South Africa
0906 55 55012 Malaysia
0906 55 55013 Philippines
0906 55 55014 Australia
0906 55 55015 New Zealand
0906 55 55016 Finland
The information provided will be no more than 4 pages long and will generally be self explanatory, although it may need translation from a
foreign language first!
There is a national rate helpline for technical problems provided by the fax service provider, Itouch, on 0870 906 3434.
All Graduates of UK Medical Schools and all International Medical Graduates who take the PLAB test already undergo pre-registration
identity checks in order to obtain GMC registration. Since 1 April 2005 the GMC has also carried out identity checks on all EEA doctors and Swiss
nationals who are exercising an EC right to work as doctors in the UK. Any enquiries about these doctors should be directed to the GMC on 0845 357 0020.
CED
Q PR510 – Hepatitis A – I am very confused about charging for the second dose of Hepatitis A. I understand that items for which an Item
of Service (IOS) fee was paid in the SFA under GMS 1 are now included in the Global Sum. However, we always charged for the second injection. Can we, therefore, continue to charge for this
since we never received an IOS fee and it is not therefore included in our global sum? New 13/04
Answer – Everyone is unclear about this issue! The GPC Focus on… Vaccinations and Immunisations is the most authoritative and current documentation, but it is silent on the issue of the second Hepatitis A
injection. Clearer and more definitive guidance is desperately needed and the GPC are aiming to provide this at some stage.
When we queried the current dilemma with the GPC we were told that nothing had changed with the new contract, but they believed that the
two injections had always constituted a single immunisation and that the second should never have been charged as private service, unless it related to a second travel episode.
However, the GPC conceded that, if you charged for the second injection before, you could still charge for it now, since global sums have
been calculated on an historic basis. Many local practices used to charge for the second injection, and this is consistent with advice given in the
past by Wessex LMC. Our advice was backed up by the PPSA who sent the attached guidance in relation to Hepatitis A;
“Reinforcing payment ONLY in connection with subsequent travel 12-months after the 1st dose.
If before the 12 month period a practice can charge patient for both the vaccine and administration.”
In view of the official and unofficial confusion on the subject it would probably be acceptable to continue as in the past under GMS1 until such
time as we have absolutely clear and authoritative official guidance.
We are aware that alternative interpretations have been published recently, but we believe our advice to be accurate.
See also our new
Vaccine payment guidance
CED
Q PR509 – Hepatitis B immunisation - Please can you clarify the issues of charging for Hepatitis B immunisations? New 13/04
Answer - Hepatitis B immunisation is not routinely available free of charge.
Travel
GPs can charge patients privately for this vaccination if it is requested in
connection with travel abroad. If hepatitis B immunisation is combined with hepatitis A in a single injection, you may not charge a fee for the
hepatitis A component and you are, therefore, not permitted to charge for the Hepatitis B element either. You may refuse to provide any travel
immunisations and may refer the patient to a specialist travel clinic.
Occupational Health
Hepatitis B has always been a very contentious issue. Some GPs believed
that occupational hepatitis B could be given by the GP acting as an 'agent' for the employer. The GPC did not agree with this 'arrangement' and
believed it to be contrary to the regulations, as GPs were not supposed to charge the patient or anyone else on the patient's behalf for this
service. They received a legal opinion that supported this view. Most LMCs, including Wessex, are now of the view that this is correct.
You are not obliged to provide an occupational health service as part of your NHS duties. You could be at risk of negligence if a patient did not
receive appropriate accompanying advice on minimising the risk of Hep B and other blood borne viruses such as Hep C or HIV. You could also be at
risk if the occupational hazards were not assessed with a view to reducing the risk.
Hepatitis B immunisation should ideally be given only if shown to be necessary after a full COSSH assessment.
If the patient is at very obvious risk and has no access to an occupational health service it could perhaps be argued that it should be part of normal
NHS primary care to provide protection from a potentially very serious, or even fatal, infection. However, a private occupational health consultation and treatment with another doctor would probably still be
the most appropriate way forward to ensure that a full preventive occupational health service is provided.
If a GP is qualified to provide a full occupational health service it would be acceptable if the GP offered to provide an occupational health
service to a company for any or all of their company employees on a private basis, rather than providing individual services for specific NHS
registered patients. The GP would therefore be offering this private occupational health service to patients registered with any practice, which could include his or her own practice.
Global sum
If hepatitis B immunisation and advice is required for some other
non-occupational reason which places the patient at risk of infection, this should be provided as normal GP services which are included within the global sum.
Immunisation may be required on this basis for;
a) Babies born to mothers who are chronic carriers of hepatitis B virus or
to mothers who have had acute hepatitis B during pregnancy.
b) Parenteral drug misusers
c) Individuals who change sexual partners frequently
d) Close family contacts of a case or carrier
e) Families adopting children from countries with a high prevalence of hepatitis B
f) Haemophiliacs
g) Patients with chronic renal failure.
h) Those travelling to areas of high prevalence
i) Children born outside the UK and who have received a primary dose in their country of origin and who are now domiciled in the UK should
have their course of the vaccine completed under GMS.
Charging for Hepatitis B immunisations has been a very fuzzy area for many years and hopefully this clarifies our current understanding.
See the new guidance on
Vaccine payments
Footnote:
Important change of GPC legal opinion - re Hepatitis B immunisation fees
for occupational health purposes.
The GPC issued revised guidance in November 2005.
Please note that the previous LMC advice was that a practice was not able to charge an employer for giving Hepatitis B vaccination unless the
practice provided this to all in the organisation. This advice has now been changed and a practice can charge the employer for vaccination of an individual employee.
CED
Q PR508 - Consent forms - In the past we have recorded patient consent on our computer system on a template. We wish to move
across to a written consent form to comply with new regulations. Does the LMC have a patient consent form? If not where can I find a standard consent form? New 07/04
Answer - Wessex LMCS does not have any specific approved consent form, but the 'official' Consent Forms are available on the Department of Health Website.
If you are changing your system to comply with DOH advice on consent these would probably be the best ones to use in any case.
You may also find it helpful to know what's in the DOH patient information leaflet About the consent form
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Q PR507 - Practice based commissioning - Everybody is talking about practice based commissioning and I don’t know anything about it.
How can I find out more and should I get involved? What about Choose and Book? New 23/03
Answer – Wessex LMCS is currently encouraging practices to become
involved with Practice Based Commissioning, at least in terms of finding out more and keeping a watching brief to see how they might wish to take a more active role.
We have produced several briefings for GPs and are actively engaging with PCTs and practices to discuss these issues. The references below should provide you with a general working
background knowledge.
Practice based commissioning may take many forms and has been left deliberately vague to allow scope for innovation. There is still plenty of
time to become more actively involved if and when you feel comfortable with doing so.
There are now financial incentives available to encourage GPs to register an interest in Choose and Book and further incentives if and when you
become actively engaged. At the moment the systems available are still in the developmental stages and the potential problems have not yet
been ironed out. It seems likely that the ‘choose’ aspects of the system will be acceptable, but the ‘book’ service may well prove too
time-consuming to fit into a normal patient consultation. Expressing an interest will not commit you to following through if the systems prove to be impracticable.
Wessex LMCS will try to keep you informed of major developments through meetings, newsletters and this website.
Further information
Practice Based Commissioning Technical Guidance
;
Practice based commissioning: GPC guidance for GPs and local
medical committees - March 2005 ;
Choose and book financial incentives ;
NHS Alliance - Caveat Emptor payment by results and practice led commissioning - February 2005
;
Alternative Provider Medical Services (APMS)
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Q PR506 - Housing letters – We get a steady trickle of requests from patients for housing letters. I know that we are not obliged to
provide these. Has the LMC produced a standard and appropriate template letter to send to the housing department in response to such requests? New 01/03
Answer – You are quite correct that this is not a contractual or statutory
requirement. If you choose to supply a certificate then you may charge a fee for the service. Before agreeing to provide the report you should
establish the patient’s consent, the precise information that is required, any deadline and an undertaking to pay the fee. The following letter may be adapted to serve your purpose.
Letter to housing department
See also
Housing association certificates.
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Q PR505 - Citizen Card - I have received an application to fill in a Citizen Card for one of my patients which requires me to certify that
I know the patient and endorse a photo as a true likeness. I have never heard of the card. Should I undertake this task? New 01/02
Answer – Citizen Card is approved by the Home Office, police, trading
standard authority, retailers and airlines for domestic flights. If you wish to facilitate the application you may choose to fill in the form and charge
a fee for doing so. However, this is not a prescribed certificate, nor is it part of your contractual obligations. If you do not wish to complete the
application form you may refuse to do so. There are many other people who are accepted as signatories, including teachers, nurses, civil servants etc.
Further information on Citizen Card
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Q PR504 - Agenda for change – Our practice nurses are very keen for us to adopt the agenda for change but the cost implications of this
would be considerable. Are we obliged to adopt the agenda and if so how will it be funded? We have been told that it is already in the global sum. Is that correct?
New 12/01
Answer – GP practices are under no obligation to implement the Agenda
for Change (AfC) but market forces are likely to dictate that practices treat their staff fairly in comparison to staff directly employed by the
NHS. If you have competent and well qualified staff you would not wish to risk losing them to a practice that was implementing the AfC.
While some elements of the AfC were included in the global sum, the value of these was subsequently eroded. There will be a renegotiation of
the global sum for 2006 onwards when the GPC negotiators will argue that AfC has considerable cost implications that will undoubtedly increase practice costs in the future.
Some practices are already trying to improve staff pay and conditions to reflect improved practise performance in relation to the quality agenda.
This will provide useful evidence for the renegotiations.
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Q PR503 - Practice letterheads - I am a doctor working at a practice
under the flexible career scheme. Our practice manager insists that for 'legal reasons' my name must be removed from the practice letterhead. Is this true? New 11/01
Answer – Your practice manager probably believes that you could be
considered to be 'held out' as a partner if your name is included. This would make you liable in the same way as the partners.
There has been considerable debate on this issue. The GPC has advised us that under The Business Names Act 1985 a business is required to
include all the names of its partners on the letter heading if they are not included in the Business Name. All pf those partners carry joint liability in relation to their business.
The GPC advises that practices may include the names of other members of staff including salaried doctors salaried on their letter head.
However, it is important that they put a very clear qualifier by their name (e.g. assistant, staff GP) so as to distinguish them clearly from the
partners. Failure to do this so could leave these doctors/staff members open to carrying joint liability with the partners.
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Q PR502 - Full booking - What is full booking? New 11/01
Answer - A fully booked appointment or admission is defined as one
where the patient is given the choice of when to attend. For full booking the patient is given the opportunity to agree a date at the time
of, or within one working day of, the referral or decision to admit. The patient may choose to agree the date when initially offered, or defer their decision until later.
A partially booked appointment or admission is defined as one where the patient is given the choice of when to attend. For partial booking the
patient is advised of the total waiting time during the consultation between themselves and the health care provider/practitioner. The patient is able to choose and confirm their appointment or admission
approximately four to six weeks in advance of their appointment or admission date.
The responsibility for implementing booking systems rests with the Strategic Health Authorities who are now trying to move towards 100% full booking.
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Q PR501 - Practice Turnover - Do the Practice Turnover calculations include patients leaving the practice as well as newly registering
patients? New 09/01
Answer – No. The Practice List Turnover Index looks at the impact of
‘new-start’ patients, so only new registrations are taken into account (this attracts additional weighting) in the calculations.
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