Working as a GP for Fun and Profit (While staying out of trouble)

Working as a GP for Fun and Profit

(While staying out of trouble)

Mark BakerRebecca Adamson

GP Trainers, Haltwhistle

Types of Primary Care Contract

• General Medical Services

• Personal Medical Services

• Alternative Provider Medical Services

• CCG Medical Services

From 2014: all new contracts will be time limited APMS contracts

GPRs are employees so…

• GPRs and salaried GPs are also bound by a contract of employment

• Should work to that contract unless it conflicts with the law or the GMC

Before 2004

• a GP ‘should provide those services generally provided in general practice’.

A GP’s gotta do what a GP’s gotta do

Scope of GMS and PMS contracts

47: The Contractor must provide-

47.1: services required for the management of the Contractor’s registered patients and temporary residents who are, or believe themselves to be-

47.1.1: ill with conditions from which recovery is generally expected;

47.1.2: terminally ill; or

47.1.3: suffering from chronic disease

delivered in the manner determined by the practice in discussion with the patient;

Why is it important?

Trend in GP annual consulting rate0

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NOTE: Analysis by f inancial years

c o p y ri g h t QRESEARCH 2 0 0 3 -2 0 0 9 (Da ta b a s e v e rs i o n 2 3 )

All clinicians and all locations (England)

QRESEARCH crude consultation rates per person-year

GP Income

• 2004-5 Average Contractor income (non-dispensing) £102,388*, a 30% increase from 2003-4

• 2012-13 Average Contractor income (non-dispensing) £94,800

• £102,388 in 2004 is worth £144,631 in 2015

In summary…

• We are having to do more with less

• Some work we have to do, some we don’t

Which reports do we have to do?

• Med 3 sick notes (and medical reports relating to them)

• Mat B1 for pregnant women• Death and stillbirth certificates• Jury Service exemption• Unfitness to vote in person• Prescription exemption certificates• To support a claim of severe mental impairment,

for exemption on Council Tax

What reports to we have to do? (2)

• Must be provided free• Med 3s are for SSP and Social Security

purposes only• You aren’t obliged to issue certificates when

you believe they are inappropriate

So what don’t we have to do?

Just about everything else!

Because somebody wants you to do something…

…does not necessarily mean you have to do it!

Exercise

• First consider the three forms. Two are a request for medical examination

• Then think about the case examples

• Don’t get hung up on the medical details

• Discuss in threes the issues raised

DVLA Class 2 licence medicals

• Substantial change in 2013

• Optician may fill in part 1

• If patient needs glasses, you need to see a copy of the optical prescription

• Chart must measure to 6/7.5

“BMA rates”

As fees for this work have not been agreed since 2005 and are no longer set nationally, the BMA has decided to remove them from this schedule. The BMA therefore advises individual doctors and GP practices to establish and agree their own fees in advance of undertaking the work. Members of the BMA can access detailed guidance for doctors setting their own fees.

Source: BMA website 2011

Do be careful!

• Do you have informed written consent, where applicable?

• Consider the implications of what you are signing

• Take advice: colleagues, BMA, defence body

Passports

• Your counter signatory must sign the form … to confirm that they have known you for more than two years and that you are who you claim to beSource: Home Office, 2011

• GPs have been convicted and sentenced for not following the instructions

Courts

• GPs have been hauled out of their surgeries before now to appear before judges to explain their opinions that patients cannot attend court

• If you can’t, or think you shouldn’t sign something, don’t do it!

What happens if you say no?

• Data Protection Act 1998 applies• Governs, among other things, access to

medical records

Data Protection Act 1998

• Requests under the DPA should be made in writing

• 40 days to respond• May charge up to £50 to cover copying of

records• Maximum of £10 for computer-only held

records• May offer the subject the opportunity to

inspect the records on site, rather than copies

Data Protection Act 1998

• Organisations should have a procedure• Data holders must satisfy themselves that any

representative has the authority to act for the data subject

• Generally children over 12 are considered able to consent

• Third party data should be removed• Complaints go to the Information Commissioner

Armed Forces

• Medical care is provided by the Armed Forces*

• Medical Officers may be career doctors, or CMPs

• Medical services in the Forces are often of high quality, especially psychiatric and rehabilitation services

Armed Forces (2)

• All absence has to be certified (but not by you!)• Med 3s are not valid• NHS GPs will be asked to say if a patient is fit to

travel• If in doubt, discuss with unit MO• * From 2015: members of the Forces may

register with civilian GPs with express permission of DPMS

Oddities in the NHS contract

271: Subject to clause 271B and to clauses 290 to 298, a prescriber shall order any drugs, medicines or appliances which are needed for the treatment of any patient who is receiving treatment under the Contract by—

• 271.1. issuing to that patient a non-electronic prescription form or non-electronic repeatable prescription completed in accordance with clause 273…

Prescription form means: • a form provided by the Primary Care Trust and issued by a

prescriber…

Exercise (2)

• Divide into threes• Consider which drugs we prescribe under the

NHS, and which ones must go on a private prescription

• What rules apply, and are there sanctions?

What can GPs prescribe?

• Almost anything!

• But if it isn’t on the Drug Tariff, the pharmacist will not be reimbursed

• CCG guidelines are advisory

Blacklisted drugs

• Drugs that may not be prescribed on an FP10

• Enormously long list

• Issue private prescription, if appropriate

• Cabdrivers Adult Linctus• Cabdrivers Diabetic Linctus• Cabdrivers Junior Linctus• Cabdrivers Nasal Decongestant Tablets• Cadbury's Coffee Compliment• Cafadol Tablets• Caffeine & Dextrose Tablets• Cal-A-Cool Aftersun Moisturising Cream• Caladryl Cream• Caladryl Lotion• Calamage• Calcia Calcium Supplement Tablets• Calcimax Syrup• Calcinate Tablets• Calcium Syrup (Berk Pharmaceuticals)• Calendolon Ointment• California Syrup of Figs• Calpol Extra Tablets• Calpol Infant Suspension• Calpol Six Plus Suspension• Calpol Tablets• Calsalettes Sugar Coated Tablets• Calsalettes Uncoated Tablets• Camfortix Linctus P1• Camphor Spirit• Candacurb Capsules• Candacurb-E Capsules• Canderel Intense Sweetener Spoonful• Candermyl Liposome Cream• Cantaflour• Cantamac Tablets• Cantamega 1000 Tablets• Cantamega 2000 Divided Dose Tablets ¼ Size• Cantamega 2000 Naturtab Tablets• Cantassium Amino M.S. Tablets• Cantassium Discs• Cantassium Fructose• Cantassium Multivitamin Tablets• Capramin Tablets• Caprystatin Capsules• Carbellon Tablets• Carbo-Cort Cream• Carisoma Compound Tablets• Carnation Coffeemate

Selected List drugs• Mostly applies to erectile dysfunction drugs

• Generic sildenafil no longer SLS from 2014

• May only be prescribed on FP10 in certain circumstances

• FP10s should be endorsed “SLS”

• Otherwise private prescription

• NHS may seek to recover costs of overprescribing from the prescriber

Borderline substances

• Substances that may be defined as a drug in certain circumstances

• Sun creams, gluten free products, baby milks, emollients and many more

• FP10s should be endorsed “ACBS”• Otherwise they should be bought OTC

Antimalarial prophylaxis

• Prophylactic antimalarials are NOT prescribable on FP10

• Chloroquine and proguanil may be bought OTC

• Everything else on private script• GPs may charge for antimalarial prescriptions• Don’t forget to advise about risks and non-

drug precautions

Travel vaccines

• A minefield!

• Cannot charge for:– Smallpox (OK but it’s in there!)– Cholera– Typhoid– Polio– Infectious hepatitis

Travel vaccines (2)

• Can charge for everything else

• Cannot be prescribed on FP10

• Yellow Fever vaccine may only be given by a registered Yellow Fever Centre

Going abroad

• DH guidance says NHS entitlement ceases if a patient lives abroad for more than 3 months

• “Just in case” medicines should be on private scripts