Our reply to the paper from the Scottish Executive "SUPPLEMENTARY
MEDICAL LISTS FOR NON-PRINCIPAL GENERAL PRACTITIONERS"
12th July 2001
Dear John,
Many thanks for asking the NASGP to comment on the above consultation paper.
On receipt of this consultation paper, we also notified our members of its
existence via our website and as a consequence have received some feedback -
some of which would already have been received by you. We include this in Appendix
1. In Appendix 2 we include a copy of our response
to the same consultation for England and Wales.
General Points
In broad terms we welcome the paper. It is the first real tangible step in
the process of enfranchising non-principals into the structures and processes of
the NHS throughout the four countries.
The paper is very light on detail, and hence raises many questions on how
this is going to be administered:
: Is there going to be some standardisation across health boards?
: Is there going to be a centralised database, as locums may work in many
different health board areas?
: Are entry criteria for each health board list going to be the same?
Apart from the obvious financial advantage of being entitled to contribute to
the NHS superannuation, the paper fails to mention the far more important
potential advantages of have a national database of non-principals such as:
: Enhanced CPD
: Access to the processes of clinical governance
: Facilitation of appraisal/revalidation
: Clinical outcome measures such as prescribing data
: Peer support and mentoring
: Access to occupational health
Although superannuation is extremely important and very welcome, and that
increased regulation of non-principals may be necessary, we believe that the
main thrust of producing supplementary lists must be to enhance the quality of
care that non-principals can deliver - everything else must be secondary to
this.
Specific points and comments
Paragraph 13. ("Key Principle")
"A supplementary medical list should be introduced to provide the
opportunity to bring non principal GPs into the framework for the administration
and management of general medical practitioners."
As above - we believe the Key Principle should be to enhance the quality of
care that non-principals can deliver. Its use as a framework for the
administration and management should be secondary to this.
Paragraph 14
"the supplementary lists should be maintained by Island Health Boards
and Primary Care Trusts"
We believe the list should be maintained nationally and accessed locally -
non-principals are by their very nature peripatetic. The static nature of GP
principals suits locally held medical lists. This is not appropriate for
non-principals.
Paragraph 15
"maintaining the list accurately and up to date will be essential"
Give us one example of this happening elsewhere in the NHS and we would be
prepared to believe you! If it isn't accurate or up to date then the
consequences will have to be considered. A locum turning up to work at short
notice could be prevented from performing clinical duties because two health
boards may be unable to share information held on different lists. Because GPs
work 24 hours a day and seven days a week the supplementary lists too will have
to be available by every practice or out-of-hours co-operative 24 hours a day,
seven days a week. The ability for a GP principal to engage emergency medical
cover will otherwise be severely compromised; patients will be put at risk.
Paragraph 17
We see no problems with these principles, and in particular support the
principle that "The Scottish Medical Practices Committee … should have no
role in relation to supplementary lists"
In the 5th bullet, eighth line, should "attract" read
"attach"?
I hope our comments will be of some help to you. With best wishes,
Yours sincerely,
Richard Fieldhouse
Replies from members on this consultation received by the NASGP:
"There didn't seem to be much detail in the document about how these are
going to be administered. One thing did occur to me. That is, since all this
data is going to be collected about us all this seems like an ideal opportunity
to push for prescribing information for locums. Generally we need feedback and
support from SPA data, health board circular information, and public health
information. It's still not happening. We all want to provide an excellent
service but lack of feedback and support (educational meetings - why do
principal's brains get more stimulation than ours!) - makes life that bit
harder."
"Sad that there is no mention whatsoever about the potential benefits to
practice from supplementary lists. Yet again, the regulation side of things has
been pushed, with a throwaway line or two about pensions. I would want to see
this scheme incorporate some NP requirements for revalidation purposes, with
list eligibility bringing;
· educational opportunities - time, money, access
· information support - circulars etc. though I accept we are getting some
already
· data provision - referral rates, prescribing - you name it, I want it!
To name just a few!"
"I wonder if I may make a brief comment in my capacity as a Locum GP.
While very much welcoming the principle of Non-Principals being brought into the
quality assurance and pension 'fold' I am struck by the administrative
difficulty when a Locum works across several areas, as I used to do, in fact
working partly in England and partly in Scotland. For myself, rather than be on
one 'home' area's list I would rather see Non-Principals being registered on a
Scotland-wide or UK-wide basis with one central body.
If I might make one appeal on behalf of Non-Principals in addition, it would
be for help to establish a means to keep our bags stocked with safe and in-date
medicines and equipment. The current ad-hoc replacement system is extremely
unreliable, and to my knowledge the Stock Order system does not extend to
Non-Principals. This is an extremely important quality assurance issue that has
not, to my knowledge, been dealt with."
"I welcome the principal of the supplementary lists. It is recognition
of the valuable role of non-principals within the NHS. It confirms that all GPs
provide services to patients whether they hold a list or not.
I feel it is vital for clinical governance of non-principal GPs. I am aware
that in the recent GMC pilot of draft revalidation folders the non-principals
had difficulty in providing the evidence required to be revalidated. The areas
of difficulty included collection of routine indicators such as prescribing data
and peer and patient surveys. I feel the supplementary list offers an
opportunity to address these difficulties, for example, issuing non-principals
with prescribing numbers and pads.
The document does not clearly state how names would be added or removed from
the list, and the terms governing this. This must be determined at an early
stage of consultation in order to proceed.
I would like to see this move forward in consultation with health boards,
which will bear the financial burden, and non principals."
3 …"whether principals, non-principals, locums or Personal Medical
Services (PMS) doctors"…
Perhaps some clarification of the definition of a non-principal may help. The
term non-principal is generally and widely used to mean any GP working within
the NHS who is not a GMS principal. Thus a locum, an assistant and a retainer
are all non-principals.
"…will be required to be on a list of a health authority (HA) and be
subject to clinical governance arrangements…"
This is good news.
4, 3rd bullet point "The HA shall not approve a GP …when making a
reference to the MPC."
This is only currently applicable to principals and not non-principals -
perhaps the closest comparison for non-principals will be when the HA approves a
non-principal for work to a practice/PCG/PCT.
4, 7th bullet point "HAs will have the discretionary power to remove GPs
from their lists for past and future…"
We felt that it may need to be stated more clearly that it is ONLY for these past
and future misdemeanours.
4, 9th bullet point "All doctors providing out-of-hours services will
have to be on the medical, supplementary, or PMS lists. "
The first sentence is slightly misleading and would better read "As all
GPs will have to be on the medical, supplementary, or PMS lists, there will be a
requirement that GMS principals/PMS pilots will only be able to use deputising
organisations and locum agencies that agree to provide doctors only on either
the medical, supplementary or PMS lists." This then covers in-hours and
out-of-hours use of privately employed deputies.
4 10th bullet point "…written agreement of the deputising
service"
Or locum agency.
4 11th bullet point "Also a principal who wishes to employ a GP will be
required to make the same checks"
We felt confused here. We wondered that if the HA does all the checks for all
GPs on its various types of lists, why should a GP principal need to do this
again when he employs a GP non-principal? And what about when a GP principal
goes in to partnership (i.e. not employed) as we logically assumed (and later
confirmed in paragraph 9) that principals could only employ/engage
non-principals on the HA's supplementary list?
4 14th bullet point "GPs will be required to report to the HA any deaths
of patients on their premises"
We were surprised by the inclusion of this. GPs already have to report all
unexpected deaths to the coroner and, surely, deaths on GP premises. What can
the HA possibly do with this information? If anything, all deaths should be
reported to the HA, which we believe they are done anyway in reports submitted
to HAs by practices. We suspect this is a desultory attempt to prevent another
Shipman, in which case we don't see how it can, unless of course a death in a
practice is a proxy, crude or otherwise, of a potential murderous GP. Which it
isnt.
6 This paragraph will be unnecessary if a clearer definition of
"non-principal" is given earlier on.
9 "A GMS principal will not be able to employ"
Or sub-contract as in the case of a locum?
12 "…or GMS doctors (only for deputies and assistants)…"
Do you mean by this "non-principals"? A deputy is an employee as is
an assistant and retainer, whereas a locum is "sub-contracted" i.e.
they are self-employed. Are you trying to make a distinction here or is it that
your definition of a deputy includes locums?
12 "and he would be on the national list"
We're surprised that this way of making the list isn't being considered
foremost. Locums in cities such as London will need to apply to up to a six
different HAs. Also, one big reason for being a locum is that the individual is
unsure of where they want to live or work and so will naturally be much more
likely to move around. Also, for the secondary but extremely important purposes
of a HA being able to provide all GPs on their lists with appropriate relevant
clinical updates, BNFs, passwords for NHS net, superannuation and recognition of
seniority etc the fact that a non-principal is on several lists will
duplicate/triplicate administration, not to mention that by being able to be on
more than one list could leave many "ghosts" on the lists with all the
problems this entails.
13 "There will also be a requirement for a doctor to inform each HA
(whose supplementary list he is on) of the names of other HAs who also have his
name on their supplementary lists "
We believe that this will be cumbersome, and require the GP to regularly
update each HA every time he joins or leaves a list. There will be a temptation
to join as many lists as possible simply by replicating one application form,
and could be used by a locum to advertise that he is "on the lists of 20
HAs" as if it is a quality indicator. This could all be avoided with just
one national list.
37 "Applications to all lists will need to explain any gaps between
previous appointments or jobs "
We find this surprising and highly irrelevant. No individual should be forced
to tell an employer what he or she gets up to in their spare time. This probably
contravenes basic human rights. And if it were legal, think how would you
enforce this.
38 We felt the first paragraph and first bullet would be less confusing if it
read as follows:
"Refusing to admit to, or removing or suspending a GP from a list can be
for the following reasons:
· for a criminal conviction, disqualifications from appearing on another HA
list, and for action taken by a professional or regulatory body. In exercising
its discretion, the HA must take into consideration the following: "
40 "A doctor was charged by the police;"
For what type of crime? Is speeding, for example, worthy of suspension?
Squatting? Too vague - types of crime need to be listed. Again, are rights to a
fair trial applicable here. Surely the doctor is innocent until proven guilty.
41 "since the HA neither employs nor has any direct contractual
relationship with him"
But the employing practice does have a direct contractual relationship, so
will the employing practice have to continue pay? What if the GMC or police
later drop charges or the doctor is found innocent - is the assistant or deputy
then entitled to compensation for loss of pay from the HA? What about those
assistants and retainers whose pay is subsidised by the HA - there is a contract
in these cases between the practice and HA and assistant/retainer. Suspended on
partial pay?
49 "£25"
We felt this is perhaps too low, as at Christmas some GPs seem to get shelf
loads of single malt whiskey which, we are told, can cost well over this amount.
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