Here are answers to some of those burning questions you've always wanted to know the answers to:
Firstly, e-mail is not confidential. Sensitive information should not be passed without encryption and except when kept within the secure NHS Net system our associated 'safe' addresses it is not acceptable to send personal information.
Also e-mail would introduce another area for us to to look for messages. We are already overburdened information sources: face-to-face contacts (40,000 last year!), telephone messages, letters, electronic test and radiology results, electronic hospital discharge summaries and scanned daily post. If we miss one message a life could be at risk. We think the extra source could not be supported by our limited resources at present.
One e-mail often spawns a whole saga, so we would need strict rules of engagement.
By answering an e-mail enquiry, we are giving a professional opinion and subject to the full legal responsibilities. This is an area of some concern to the profession. Again, disclaimers and protocols may get round this objection.
There are some system sin development which may help us manage email and integrate it with your clinical record (another important requirement). Watch this space.
We'd like to see more access by more routes to our patients and welcome suggestions and debate.
We do have a slightly larger 'outer area' where we can keep existing patients who happen to move.
This is also a Brent CCG-wide policy and is happening in many other parts of London and around the country. In fact many GPs routinely issue only 28 days' worth of repeat medicines for all patients.
Around £100m a year is wasted in unused medicines.
Why are we targeting the older age group?
Research has shown that, particularly in the older age groups, large quantities of medicines remain unused.
People over 75 years of age are, sadly, more prone to illness. Each time a condition changes, particularly with hospital admissions or clinic attendances, the medicines are often changed resulting in wastage of the existing supplies. Also, older people are often taking many medicines together for multiple conditions and confusion may occur when requesting them. Sometimes people stop taking medicines due to side effects but don’t tell us. We often see the result and sometimes huge quantities are returned to the pharmacist for disposal and we often find large quantities of old medicines lying about when we carry out home visits.
Communication between hospital and surgery is often delayed, resulting in duplication or missed changes. Often other people are requesting the medicines on behalf of the patient and further mis-ordering can arise.
It is almost certain we’ll have to carry out the same change in policy for the other age groups and we have to begin somewhere. It is most efficient to start with older people as this is where around half the drugs budget is spent.
We review patients' medication regularly and synchronise the items to try and reduce ordering to once a month for everything.
We’re sorry if patients are inconvenienced by this. However, by ordering on-line and using the Electronic Prescription Service it is easier than ever to get your medicines. Most pharmacies will arrange delivery if this is difficult for you and will often organise the regular supply of medicines without you needing to remember; please ask your pharmacist.
If you wish to discuss this, please phone or come and see your usual doctor.
Thank you for your understanding.
Grapefruit juice is now known to interact with more than 85 different drugs, many of them commonly prescribed. There are two different mechanisms:
First, grapefruit juice can inhibit an enzyme called CYP3A4 in the small intestine which breaks down many drugs, eliminating them from the body. By inhibiting this process, the concentration of the drug can build up in the body to sometimes more than seven times normal and the effect can last for up to three days after drinking the juice.
The effect can be seen from eating a whole grapefruit, fresh juice, or concentrate in a serving from as little as 200ml. Regular consumption seems to increase the interaction.
Common drugs affected include statins (anticholesterol drugs) such as simvastatin and atorvastatin, calcium channel blockers (for blood pressure) such as felodipine, amlodipine, nifedipine, lercanodipine and verapamil, some anti-arrhythmia drugs such as amiodarone (the effect can be seen for weeks or months after stopping the drug), some drugs acting on the central nervous system such as carbamazepine, buspirone and quetiapine and the anti-gout drug colchicine. Also affected are the antidepressant sertraline and drugs used in erectile dysfunction such as sildenafil, tadalafil and vardenafil. There are others but they are more rarely used.
The results from this can be clinically unimportant but in some case can be dangerous, even rarely lethal.
The second mechanism is not dangerous but may cause a decrease in the effectiveness of some drugs. As the effect of this is only up to four hours, it can be overcome by leaving a minimum four hour gap after drinking the juice before taking the medicine. Commonly used drugs which may be affected include the antihistamine fexofenadine (eg Telfast) and the antibiotic ciprofloxacin.
The consequences of both of these mechanisms are unpredictable and depend a lot on genetics as well as the type and quality of juice or fruit.
Similar effects can sometimes be seen in other fruits and juices such as oranges, pomelos and maybe even cranberries and apples can affect drug metabolism but to a lesser degree. More research is needed.
It is always important to read the directions included with the drug packaging and ask your GP if unsure.
In the 1990s a quasi-market structure was set up so that healthcare was ‘provided’ by hospitals and other organisations and their services had to be ‘commissioned’ – the needs of the population would be determined and services planned - within the budgets devolved to them - to meet these demands.
It used to be the job of Primary Care Trusts to plan services for its population and commission healthcare from hospitals, community care providers (district nurses, podiatrists, physiotherapists, dieticians and so on) and others.
Since April 1st 2013, the Heath and Social Care Act has abolished PCTs and handed this responsibilities to CCGs. GPs play a major part in their operation.
All GP practices have to be members of a CCG and many GPs are active within the CCG in different roles. In Kingsbury we are one of five localities within Brent CCG (see our blog on the new NHS structures for more details).
CCGs are responsible for commissioning the following services:
• Elective hospital care
• Rehabilitation care
• Urgent and emergency care
• Most community health services
• Mental health and learning disability services
Clinical Commissioning Groups will work with patients and healthcare professionals and in partnership with local communities and local authorities.
On their governing body, CCGs will have, in addition to GPs, a least one registered nurse and a doctor who is a secondary care specialist (a hospital doctor). Groups have boundaries fitting those of local authorities.
Clinical Commissioning Groups will be responsible for arranging emergency and urgent care services within their boundaries, and for commissioning services for any unregistered patients who live in their area.
The nuts and bolts or commissioning are complex and spawn many meetings, thick piles of documents and huge spreadsheets. Budgets and forecasts in the NHS have been notoriously crude and unreliable and we are having to grapple with huge information voids.
The nuts and bolts of commissioning involve a cycle of - Strategic Planning, Procuring Services and Monitoring and Evaluation
In more detail, this entails:
· The needs of the local population must be assessed (historical usage, statistical projections taking account of demographic shift and new developments and patterns of illness),
· assessing the effectiveness and value for money of existing provision,
· deciding priorities,
· designing new services (lots of consultation!),
· planning capacity and shaping the structure,
· supporting patient choice
· fitting national and local strategies
· agreeing contracts with Key Performance Indicators (KPIs) and Service Level Agreements (SLAs),
· Contract Performance Monitoring and management of the contracts,
· renegotiation or commissioning replacement services before the terms of the contracts need renewing.
Certainly complex, intensely time consuming and hugely responsible. How will it all shape up? Nobody knows- it has not been done on any large scale before and… well…we’ll see.
A succinct (only 7 pages!) and useful history of the development of the NHS by Allyson Pollock can be found here, courtesy of the excellent Keep Our NHS Public .
The GPs always have a lot of administrative work - it sometimes feels like an uncontrollable avalanche!:
After each surgery there are always referral letters and other correspondence to write. Writing letters to hospitals and other health and social care agencies has become an increasing part of the job. We also have many private certificates and reports to write for insurance companies, employers, DWP, DVLA etc
Each day we have prescription requests from 160 or more patients, a lot marked 'urgent'. These all need checking to ensure essential monitoring has been carried out, the hospital has not changed anything and that there are no interactions or contraindications. Some of the are printed, some are sent electronically and others go to third party suppliers. It takes around 3hrs for the doctor doing that day's prescriptions to sort all this out safely (and a staff member another 3hrs to organise them all, ready for the doctor).
Each day every doctor receives electronic test results from 10 - 20 patients and it takes around an hour to look at these, check against the records and arrange for the patient to be informed (often phoning or writing to the patient ), adjust the medication, refer to hospital, request more tests or whatever action is required.
Every day we each have a number of telephone calls to patients resulting from hospital letters received requiring action or calls from patients asking for advice. We encourage patients to call for simple enquiries , rather than make an unnecessary face to face consultation. The Duty Dr may deal with 20 or more such calls each day but each doctor has their own to deal with as well. We also have other telephone calls to and from other agencies such as the hospital, care homes or social servcies.
Each day around 100 letters about patients are received (such as discharge summaries, outpatient letters, contacts from social care, from private doctors, from patients , from DWP, DVLA, insurance companies etc). These are increasingly delivered electronically, though many still have to be scanned. One doctor each day has to view all of these and many require further actions, such as contacting the patient, booking some tests or maybe referring elsewhere. This can take a couple of hours to sort out.
We have a lot of practice administration requiring detailed searches of our computer database to report on progress towards various targets we are set by NHS England and the CCG and CQC requirements.
We have regular meetings within the practice teams and with the multidisciplinary teams sharing care with our patients (nurses, health visitors, palliative care team etc) and meetings with external bodies such as the Harness, our GP Network and the CCG as well as other internal team meetings each week to attend to management of the practice, building, staffing, finances and so on.
We have mandatory training requirements each year to maintain our fitness to practice - such as Infection Control, Resuscitation, Safeguarding etc. We also have an annual appraisal which requires us to attend education sessions and personal study.
Some of the GPs have commitments outside the practice such as part of the NW London Whole Systems Integration and the Complex Patient Management Group, one GP sits on the board of the local hospice and one is IT lead for the CCG and sits on the panel of the National User Group for the GP software system we use and teaches at the local medical school. More meetings!
Sometimes we have time for lunch!
Lastly, not all the GPs are full-time any longer. It has become an increasingly stressful job and some of the GPs at this practice have been working for over 25 years and feel increasingly fatigued and under pressure, with long hours , often late into the evening and weekends and increased fire-fighting, trying to patch together a fragmenting NHS and social care system. And with more and more stress put on practice budgets and more and more complexity and lack of support from the NHS. All around the country GPs have been retiring early or cutting back and some of the GPs at this practice have reduced their hours in order to remain fresh and enthused and see their families more often.
So, whilst we may not always each be available for consultations, please don't think we are out on the golf course, as sometimes depicted in certain newspapers!
It is important to understand that most GPs are not employed by the NHS.
They are self-employed and they have to cover their costs - staff, buildings, heating, lighting, etc - in the same way as any small business. The NHS covers these costs for NHS work, but for non-NHS work, the fees charged by GPs contribute towards their costs.
What is covered by the NHS and what is not?
The Government’s contract with GPs covers medical services to NHS patients, including the provision of ongoing medical treatment. In recent years, however, more and more organisations have been involving doctors in a whole range of non-medical work.
Sometimes the only reason that GPs are asked is because they are in a position of trust in the community, or because an insurance company or employer wants to ensure that information provided to them is true and accurate.
Examples of non-NHS services for which GPs can charge their own NHS patients:
• accident or sickness certificates for insurance purposes
• school fee and holiday insurance certificates
• reports for health clubs to certify that patients are fit to exercise
Read more information on certificates
Examples of non-NHS services for which GPs can charge other institutions:
• life assurance and income protection reports for insurance companies
• reports for the Department for Work and Pensions (DWP) in connection with disability living allowance and attendance allowance
• medical reports for local authorities in connection with adoption and fostering
Do GPs have to do non-NHS work for their patients?
With certain limited exceptions, for example a GP confirming that one of their patients is not fit for jury service, GPs do not have to carry out non-NHS work on behalf of their patients.
Whilst GPs will always attempt to assist their patients with the completion of forms, for example for insurance purposes, they are not required to do such non-NHS work.
Is it true that the BMA sets fees for non-NHS work?
The BMA may suggest fees that GPs may charge their patients for non-NHS work (ie work not covered under their contract with the NHS) in order to help GPs set their own professional fees. However, the fees suggested by them are intended for guidance only; they are not recommendations and a doctor is not obliged to charge the rates suggested.
Can a fee be charged by a GP for the completion of cremation forms?
It is important to differentiate between death certificates (which must be completed free of charge) and cremation forms. Cremation forms, unlike death certificates, require doctors to make certain investigations which do not form part of their NHS duties. A deceased person cannot be cremated until the cause of death is definitely known and properly recorded. Before cremation can take place two certificates need to be signed, one by the GP and one by another doctor. Cremation form 4 must be, as stated, completed by the registered medical practitioner who attended the deceased during their last illness.
Form 5 must be completed by a registered medical practitioner who is neither a partner nor a relative of the doctor who completed form.
A fee can be charged for the completion of both forms 4 and 5 as this does not form part of a doctor's NHS duties. Doctors normally charge these fees to the funeral director, who, generally passes on the cost to the family. Doctors are also entitled to charge a mileage allowance, where appropriate. The fees for cremation forms 4 and 5 (which are agreed with the National Association of Funeral Directors, NAFD, the National Society of Allied and Independent Funeral Directors, SAIF, and Co-operative Funeralcare) are available on our website.
Why does it sometimes take my GP a long time to complete my form?
Time spent completing forms and preparing reports takes the GP away from the medical care of his or her patients. Most GPs have a very heavy workload and paperwork takes up an increasing amount of their time, so many GPs find they have to take some paperwork home at night and weekends.
I only need the doctor's signature - what is the problem?
When a doctor signs a certificate or completes a report, it is a condition of remaining on the Medical Register that they only sign what they know to be true.
In order to complete even the simplest of forms, therefore, the doctor might have to check the patient's entire medical record. Carelessness or an inaccurate report can have serious consequences for the doctor with the General Medical Council (the doctors' regulatory body) or even the Police.
What will I be charged?
You should be informed in advance if how much you will be charged. We produce a list of suggested fees on our website and in the reception lobby.
What can I do to help?
• Not all documents need a signature by a doctor, for example passport applications. You can ask another person in a position of trust to sign such documents free of charge.
• If you have several forms requiring completion, present them all at once and ask your GP if he or she is prepared to complete them at the same time to speed up the process.
• Do not expect your GP to process forms overnight. Urgent requests may mean that a doctor has to make special arrangements to process the form quickly, and this will cost more. Ask the receptionist how long a form will take to complete.