Local Medical Committee Meeting6 December 2016

Local Medical Committee Meeting 6 December 2016

MINUTES OF THE COUNTY DURHAM AND DARLINGTON LOCAL MEDICAL COMMITTEE HELD ON TUESDAY 6 DECEMBER 2016 IN THE BOARD ROOM AT APPLETON HOUSE

Present:

Tanya Johnston Chair David Robertson Secretary

James McMichael CLS Caren Purvis Derwentside – Practice Manager Niamh Telford Durham Gopal Chealikani Easington Rushi Mudalagiri Easington Kamal Sidhu Easington Heather Prestwich Sessional

Claire Elder LMC

Invited:

James Carlton DDES CCG Neil O’Brien ND CCG

Number Item L16/110 Apologies for Absence

Francis Whalley (Durham) Andrea Jones (Darlington CCG) Norbert Dielehner (Sedgefield)

L16/111 Minutes of the Meeting held on 1 November 2016 – were agreed as an accurate record.

L16/112 Matters Arising

Firearms

The Committee discussed the on-going problems surrounding applications for Firearms Licences. The Secretary had produced the following report as advice for Practices:-

County Durham & Darlington Local Medical Committee Briefing Paper – Firearms Licencing Process December 2016

There has been a significant shift in BMA guidance on how to respond to requests from the police for information about applicants for firearm licences (see attached for current version).

This has arisen because of several factors, including legal advice to the GPC/BMA.

A special group has been set up by GPC to clarify the situation as soon as possible.

Private and Confidential

Ref: CNE/MINUTES/AGENDAS/LMC/Minutes 2016/LMC Minutes 6 DECEMBER 2016 Local Medical Committee Meeting 6 December 2016

Does the current situation provide GPC/LMCs an opportunity to draw up a national policy, standard response and set a fee for this work without consultation with outside bodies but consistent with current legal advice, contractual requirements, and conference policy?

To decide if an applicant is suitable to be granted a firearm licence the licensing authority should have access to relevant social, criminal and health information.

Health information should include an independent factual statement of:

 Long term conditions  Significant current diagnoses  Past mental health diagnoses  Recorded alcohol intake  Current medication  Last 12 (?24) months consultations in general practice

This information is only obtainable from the applicant’s registered GP a fee can be charged for providing this information and because this is a registered list based service then the BMA can and should set a fee for providing it.

Therefore, the standard reply to the police letter should be:

Dear XXX

Thank you for your letter of xx-xx-xx. I do have concerns this patient being granted a licence without you having access to a factual independent medical report giving details of:  Long term conditions  Significant current diagnoses  Past mental health diagnoses  Recorded alcohol intake  Current medication  Last 12 (?24) months consultations in general practice

I am prepared to provide a report with this information but I am entitled to payment for doing so. Please arrange payment of £XX to XXXX. When I have received payment then I will send a report.

Please acknowledge that you have received this letter.

What should advice about enduring marker be?

After much discussion the Committee agreed that the letter was the best way forward in the interim until further information could be made available from the BMA.

DAR would meet with the local Constabulary to discuss this matter further before issuing substantive guidance.

L16/113 Clinical Commissioning Groups

North Durham CCG – Neil O’Brien DDES CCG – James Carlton

Financial Position North Durham - Neil informed the Committee that North Durham was in a reasonably good position at present, they have a 1½% surplus (Business rules dictate they must have 1%) but the additional ½% may have be drawn upon.

The CCGs in the northern region are looking to make savings with the cessation of prescriptions for:-

Gluten Free Products Lactose Free Milk

Over the counter medication ie Paracetamol.

Neil pointed out that this would only work in reduction of costs if all GPs were on board and restricted their prescribing.

Members wondered on the legal position of this – Neil pointed out that whilst GPs could not be made to not prescribe what was available in the BNF but it didn’t mean they had to. Members felt that if this was going to happen then there would have to be regional communications so that everyone (doctors and patients alike) were aware. Members pointed out that Derbyshire were already doing something similar with some success.

Other services to be looked at were:-

 Hearing Aids;  Podiatory.

Diabetes Model – will go live in North Durham from April 2007.

Christmas Opening – Neil confirmed that the CCGs (DDES, North Durham & Darlington) were informed by Tim Rideout of NHS England that they must provide bookable GP appointments on Christmas Day (Sunday this year) even though Urgent Care,111 and A&E would all be open on a Sunday for care as usual. The cost of commissioning this service was significant.

Members wondered if it was worth the LMC writing to NHS England – that in this time of monetary constraints it seemed a waste of resources and money to open on a Sunday when Urgent Care was already paid to cover this time period. It was also felt by members that this was not the best use of a clinicians time and if there was need to reduce Christmas pressures then a doctor(s) could have been placed in A&E to help with triage or increase cover within Urgent Care.

It was pointed out that funding for Christmas opening had been halved from last year’s funding.

Referral management – Local MPs are very vocal about this at present. Outcomes of this scheme will not be known until February 2017 but in addition to a number of referral being re-directed to alternative services, soft intelligence suggests that there has also been a significant reduction in referrals since the scheme was introduced. Clinical support is coming from CSI Guidance.

Members pointed out that the scheme did involve some increased work within Practice. Neil informed the Committee that this scheme would be running for at least the next 12-24 months.

Costings for CSI are approximately £10 per letter (DDES use Mastrix at approx. £12) but the CCG anticipated that overall the scheme would be cost-effective.

Members wondered why Optometrists needed medical history for referral and why referrals couldn’t be done at source and the Consultant request a Private and Confidential

medical summary from practices, saving time and need for the GP Practice to be involved until necessary. Newcastle and Gateshead are presently looking at Ophthalmology and DDES was waiting to learn from their scheme. JC recognised that the burden on administration was not insubstantial.

VBCC / IFR – Update from Secretary

DAR informed the Committee that he had contacted the Plastics Department which were causing issues with IFR returns. There has been a mis-interpretation of the rules – Chris Gray and Ian Davidson have had a meeting with the surgical team and there should be an improvement in paperwork shortly.

Value Based Commissioning – DDES

New round to come in line with contracting. James Carlton would be overseeing for DDES and Ian Davidson for North Durham. When this has all gone through Governance JC will share the information with the Committee.

IFR - DDES

This continued to need appropriate IT support and DDES was trying to work on a similar system to ND CCG.

Provision of General Practice

Presently provision of general practice is on the CCGs’ risk register. In the event of CCGs not meeting their financial targets then “Turn Around Teams” might remove any discretionary money that CCGs intended to invest in primary care and further risk provision of GP services.

DAR had produced the following document:-

CDDLMC is concerned that the sustainable provision of general practice is at risk and this should be recognised by adding it to the “Risk Register” of local CCGs.

Supporting Statement

There has been a lack of investment in general practice over the last decade and now only about 8% of the NHS budget is given to practices. Over the same time there has been a huge increase in general practice workload and costs:

 Demand for more appointments  Dealing with more complex problems  Unresourced shifts of work from secondary to primary care  Increasing regulations, such as CQC and appraisals  Increases in costs: staff, indemnity, and premises never completely recognised by DDRB  Withdrawal of support framework for practices  Dogmatic and often misguided central directions

There are also significant problems with recruiting and retaining staff – not just GPs but also practice nurses.

As a result general practice is in crisis and CDDLMC is concerned that the sustainable provision of general practice is at risk. A recent survey showed that more than eight out of 10 of GPs believe that they cannot provide quality and safe care to patients owing to either unmanageable (57%) or excessive (27%) workload pressures. Locally we know that an increasing number of practices are applying to close

their lists to new registrations of patients.

General practices have no spare capacity to deal with any additional workload and are vulnerable to unexpected events such as staff absences or significant increases in demand such as during an outbreak of flu or the closure of a neighbouring practice.

It remains to be seen how much additional investment will arise from the implementation of the GP forward view. PMS practices will experience a real terms reduction in funding because of the withdrawal of the “PMS Premium” over the next few years.

Recommendation

CDDLMC recommends that the CCG adds the provision of primary care to its risk register and considers what steps it can take as a co-commissioner of primary care to address the problems facing general practice.

Secondary Care – PBR contracts would be signed on 23 December 2016. Members wondered why block contracts would not be used – the Trust were not willing to take any risk with a block contract.

The Trusts cost improvement plans are on track.

Members wanted once again to point out that there was no slack left in Primary Care. Neil confirmed ND CCGs absolute commitment to support Primary Care and members thanked him and appreciated the support that local CCGs were providing to practices.

L16/114 Local Authority

Fees for safeguarding work

Still awaiting responses from the CCGs.

L16/115 Secondary Care

Standard NHS Contract Policy for Outpatient Treatment Recommendations

DAR shared the following proposal:-

County Durham & Darlington Local Medical Committee Policy for Outpatient Treatment Recommendations

Preamble

As outlined in the GP Forward View, the new NHS standard contract for secondary care trusts came into force on 1 April 2016. The NHS standard contract for secondary care trusts has placed new requirements on hospitals to reduce inappropriate bureaucratic workload shift onto GP practices. Many of those changes to the standard contract have been brought about as a result of ongoing negotiations between GPC and NHS England to get them to understand how important it is that the bureaucratic burden that all GPs are under is reduced.

The new standard contract includes the requirement that after a hospital outpatient attendance GPs should receive a timely clinic letter, no later than 14 days after the appointment.

Hospital trusts have been required to provide any “urgent” medication at the time of the outpatient appointment.

In County Durham the outpatient treatment recommendation form did not specify a time frame for provision of a prescription but in neighbouring CCGs it is made clear that acting on the form might take up to two weeks.

Since a reasonable time frame for responding to an outpatient treatment recommendation form is now

the same as the contractual requirement for a timely clinic letter then the former is redundant and merely adds to the administrative burden in general practice.

Consequently, CDDLMC policy is that GPs should no longer receive or respond to outpatient treatment recommendations forms.

If a prescription is required sooner than 14 days from the date of the outpatient appointment then it should be provided by the hospital trust by providing the patient with an FP10 (HNC) for a supply of medication to last at least 14 days. Faxing or emailing an outpatient letter does not remove this responsibility.

Hospital prescribers should prescribe from the CDDFT formulary and if they choose to prescribe outside this then a reason should be provided in the clinic letter. If the reason is not clear or clinically justified, then they may be invited to suggest an alternative.

Policy

1. GPs should no longer receive or respond to outpatient treatment recommendations forms.

1. If a prescription is required sooner than 14 days after the outpatient appointment, # then it should be arranged by the hospital trust by providing the patient with an FP10 (HNC) for a supply of medication to last at least 14 days. Faxing or emailing an outpatient letter does not remove this responsibility.

2. Hospital prescribers should prescribe from the CDDFT formulary and if they choose to prescribe outside this then a reason should be provided in the clinic letter. If the reason is not clear or not clinically justified, then they may be invited to suggest an alternative.

Access Policy

DAR shared the following proposal:-

If patients fail to keep their hospital appointment, then typically their GP receives a letter as follows:

Unfortunately your patient failed to keep their recent outpatient appointment with DR X XXXX on Day Date Month Year. As per County Durham and Darlington Foundation Trust's Access Policy we will not be sending a further appointment and return this patient to your care.

To help us reduce our DNA rates, you may wish to discuss with your patient their reason for not attending.

Yours sincerely

Appointments Co-ordinator on behalf of the Patient Booking Manager

A new hospital standard contract came into force on 1 April 2016, with new requirements to reduce inappropriate bureaucratic workload shift onto GP practices and these new contractual requirements include:

Stopping hospitals adopting blanket policies under which patients who do not attend an outpatient clinic appointment are automatically discharged back to their GP for re- referral (this wastes an estimated 15 million GP appointments per year).

Current CCDFT Access Policy Does Not Attend and Outpatient Appointment

1) If a patient fails to attend an outpatient appointment, the patient’s notes will be reviewed by the clinician who will decide whether to discharge the patient back to the GP or to re-appoint. 2) If the patient is discharged both the patient and GP will be informed. 3) When a review patient DNAs their GP will be given a 20 day window to reinstate the appointment rather than re-refer as a new patient. 4) Exceptions to this will be cancer, diabetic ophthalmology and paediatrics who will always be given a second.

Proposed Amendment Does Not Attend and Outpatient Appointment

1) If a patient fails to attend an outpatient appointment, the patient’s notes will be reviewed by the clinician who will decide whether to discharge the patient back to the GP or to re-appoint. 2) If the patient is discharged the patient will be informed by letter with a copy to the GP. The letter will include instructions on how a further appointment can be arranged by contacting CDDFT directly within 20 days. 3) If the patient fails to attend, then they will be notified of this with a copy to the GP. The letter will include instructions on how a further appointment can be arranged by contacting CDDFT directly within 20 days. 4) When a review patient DNAs they will be notified of this with a copy to the GP. The letter will include instructions on how a further appointment can be arranged by contacting CDDFT directly within 20 days. 5) Exceptions to this will be cancer, diabetic ophthalmology and paediatrics who will always be given a second appointment. The committee supported these approaches. DAR agreed to take this up with the CDDFT.

Two Week Rule

Members expressed concern that Consultants were not referring in house when patients had been diagnosed with cancer and that should have been referred to another consultant colleague. Members were receiving letters (one letter to a member was received 2 months after the initial hospital diagnosis) to re-refer back to the Trust to the relevant department. It was felt time to relaunch quality first from the BMA.

Reception Training

Members gave examples of how practice staff were being trained to reduce the administrative burden on GPs.

L16/116 NHS England

See under CCGs

L16/117 Out of Hours Issues

Easington Members expressed continued concerns with regard to UC at Peterlee – one member confirmed that he had taken on two shifts to see what the present situation was like and was concerned with the massive workload for the GP within the UC. Lots of work carried out by the GP cannot be replaced by a prescribing nurse.

Members were concerned that they were now in a 3 year contract.

L16/118 Communication from the BMA/GPC

118.01 LMC Conference 2017

The following members agreed to attend the LMC Conference on 18 & 19 May 2017 (CD&D has four assigned seats):-

David Robertson

Tanya Johnston Kamal Sidhu Rushi Mudalagiri

L16/119 General Correspondence

L16/120 Date, Time and Place of Next Meeting

7 February 2016 @ 19.30 in the Board Room at ND CCG Rivergreen, Durham

Ref: CNE/MINUTES/AGENDAS/LMC/Minutes 2016/LMC Minutes 6 DECEMBER 2016