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General Practice in Birmingham Part 4

GENERAL PRACTICE IN BIRMINGHAM : PART 4 of 5

The 2016 Annual Report of the Birmingham Local Medical Committee was published in March 2017. It was a year that had seen further massive change and unprecedented challenges for Birmingham GPs, their practices and no doubt reflecting issues in other regions in the UK. During the year the LMCs’ constituents sought advice and support more than ever before, reflecting the huge and diverse problems now facing general practice and the wider NHS. The report has been divided into a series of blogs covering:

PREMISES ISSUES

The problems encountered by practices working in NHS premises, both LIFT buildings managed by Community Health Partnership (CHP) landlords and health centres managed by NHS Property Services (NHSPS) continued unabated and remained stubbornly unresolved as the year concluded. Both landlords continued to treat their GP tenants disgracefully, sending them invoices for grossly inflated and unjustified rises in service charges having no legal basis and threatening tenants with court action if these invoices were not paid. The LMC was active in offering support to affected practices and robustly challenging CHP and NHSPS over their behaviours. We advised practices to inform CHP and NHSPS that they were disputing the level of service charges and, until the matter was sorted, not to pay anything above historical charges that they agreed were appropriate.

The level of some of the service charge increases being demanded were staggering, and if practices were to have to pay them, would put their viability in jeopardy. The LMC raised awareness of the severity of the problem with the three CCGs, in order to ensure that they too supported their member practices insofar was possible. This resulted in the three CCGs embarking on a process of engaging external specialists to carry out work to determine appropriate and reasonable service charge costs for these premises. As of the end of the year the outcome of this work was as yet unclear. The LMC obtained commitment from the CCGs that they would look to support practices with their increased service charge costs should the outcome of the exercise still leave them having to pay considerably increased charges.

SAFEGUARDING

As always, matters concerning child safeguarding occupied the LMC considerably during the year. One particular issue related to a clear gap in fit-for-purpose services for school-aged children who were no longer the responsibility of the health visiting service. Safeguarding concerns for school aged children which social services did not consider met their threshold for statutory intervention were bounced back to referring practices with a suggestion that they be referred to school nursing services to take the lead in co-ordinating case enquiries and meetings. This was clearly not a task which school nursing was either able or willing to take on, leaving a situation where GPs had virtually no support in ensuring that these concerns were managed appropriately. The LMC had a number of meetings with CCG and Local Authority safeguarding personnel in order to attempt to resolve this extremely serious issue. Unfortunately, despite recognition by safeguarding leaders that there was a problem which required resolution, this had not been achieved by the end of the year. This is an area on which the LMC will continue to remain vigilant.

Another safeguarding-related issue on which the LMC was active during the year related to the request for practices to co-operate with serious case reviews where a child death had occurred, in particular to supply copies of patient notes. Whilst the legal basis for these requests was clear, the communications being sent to practices about this were far from ideal, and in particular, where it was felt that in those very few cases where there might be sufficient justification for releasing records without consent, the request letters to GPs simply did not supply sufficient information to put them in a position to make a decision that breach of confidentiality was justified.

Again meetings were held with safeguarding leads in an attempt to resolve the matter, and agreement was reached that communications with practices would be revised in order to make them fit for purpose. There was every hope that this work would be satisfactorily concluded in early 2017.

One very positive result over a safeguarding –related matter followed a meeting that took place with Birmingham City Council’s new head of safeguarding in order to discuss issues related to requests with unacceptable timescales from social workers to GPs for attendance at case conferences and/or provision of reports, as well as the thorny old problems concerning the arrangement for payment of fees under the collaborative arrangements by means of using the appropriate medical fee claim form. The meeting was extremely constructive and resulted in the head of safeguarding sending a very helpful communication to all local authority staff on these issues, which was shared with the LMC and forwarded to practices.

VACCINATION AND PUBLIC HEALTH ISSUES

During the year it transpired that NHS England Public Health had engaged a private company, Health Intelligence (HI) to operate a new data extraction service to share practice child immunisation data with the community trust. NHS England initially intended to introduce this by “piloting” in a number of Birmingham practices with supposedly “significant waiting lists” for childhood vaccinations and went about this without prior consultation, explanation or warning to the practices concerned, also without notifying the LMC, and by sending them an email giving just two days’ notice to sign up to a complex data sharing agreement (DSA) produced by HI. As well as this lack of communication and the ridiculously short timescale being wholly unacceptable, needless to say the DSA itself was completely unfit for purpose and would have put practices, as data controllers, at considerable risk.

Happily LMC intervention successfully halted the process, allowing for the acceptability of the proposal and the production of a fit –for- purpose DSA to be properly considered. The LMC arranged for the DSA to be vetted by the BMA Ethics Department and subsequently by expert independent legal opinion in order to ensure that the document was revised in order to provide a legally sound basis for data sharing and that there would be no other risks to practices in participating. Furthermore the LMC was successful in obtaining reimbursement for the full cost of the legal opinion jointly by NHS England and the General Practitioners Defence Fund, so that there was no direct cost to LMC statutory/administrative levies paid by our GPs.

The Pharmacy Influenza Vaccination Scheme, which had been rolled out nationally by NHS England in 2015/6 was, unsurprisingly, continued over the 2016/7 winter season. The various inevitable adverse consequences of this continued to be experienced by many practices and the LMC once more collated evidence of these problems in order to feed these back to both NHS England and the GPC, as well as liaising regularly with the Local Pharmaceutical Committee to discuss the reported inappropriate behaviour by some pharmacists in relation to the scheme and attempt to mitigate the damage so caused.

With the national recommendation that morbidly obese patients should be vaccinated against flu, but in the absence of this being funded through the DES, the LMC lobbied the three Birmingham CCGs to request that they commission these additional flu vaccinations from practices. Sadly all three Birmingham CCGs refused to commission this work.

The LMC was consulted by Crime Reduction Initiative (CRI), the substance abuse lead provider for the city, on a new contract for practices to provide substance abuse services. The LMC made a number of suggestions on the proposed new contract which were incorporated into the revision. It was noted however that despite these improvements the new service specification still placed considerable additional burdens on practices than did the previous contract, yet this was to be delivered with no increase in funding. It was also noted that there would be a very high chance that a subsequent contract, due in two years’ time, would both require even more work but also be even less well funded as a result of inevitable cuts in local authority funding. The LMC advised practices accordingly about this.

A number of practices raised major concerns with the LMC in respect of communications they received from Public Health England following their patients being tested positive for Hepatitis B. These letters to practices suggested that they were responsible not just for managing their Hepatitis B positive patients, but for contact tracing and screening of all their household and sexual contacts. Clearly this was wholly inappropriate, particularly bearing in mind that some of these patients would not even be registered with the practice. The LMC immediately took up the matter with Public Health England, NHS England and the CCGs and agreement was reached that communications to practices would be revised, making it clear that GPs were not responsible for any contract tracing, nor was it their contractual responsibility to screen or carry out initial vaccinations on asymptomatic contacts.

Whilst it was made clear and agreed that sexual contacts should be managed through sexual health services and not by general practice there remained the issue that there was no service currently commissioned to screen and carry out initial Hepatitis B vaccination of asymptomatic household contacts presenting to their GP and the LMC made representations to the CCGs and NHS England to ensure that this work was commissioned. As the year ended work to achieve a resolution to this issue was still ongoing.

NEWS

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