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LMC weekly update 10 April 2020

Easter opening hours
NHS England have belatedly released details about the Easter weekend service in England. Emergency changes to GMS contract regulations published last week mean that today, Friday 10 April (Good Friday), and Monday 13 April (Easter Monday), are defined as core hours, and so are now regarded as normal working days for general practice, as they are for the whole NHS system.

Practices can claim for the expense of their employed staff, including NI and pension contributions, working as normally on these days. In addition for any GP partners working as they would normally do on Friday or Monday the practice can claim £289 per session, up to £578 for a full day. If a GP locum is contracted by the practice NHSE/I have set the rate of reimbursement for a maximum of £250 per session or £500 per day.  What a locum GP charges and what a practice pays them is, as for any other working day, subject to negotiation between the practice and the locum GP.

Whilst it is clear that all those working in general practice have responded to the COVID-19 crisis by going above and beyond what would normally be expected of them, it has been concerning that the details relating to bank holiday working were provided to practices only a day before the work will be done, leaving practices to manage an overly bureaucratic process and with very little time to work with their CCG and seek approval for the additional costs.  In addition, with the differential pay rates, it will mean some practices may still have to bear some additional costs.

Read our brief guidance on Easter opening hours - about what services to offer and staff pay - here
 
PPE update
The BMA continues to put pressure on Government to provide the necessary PPE all healthcare workers need, through public campaigning, media work and political lobbying. As shown by the results of the survey we undertook last week, the majority of doctors do not feel safely protected from COVID-19 where they work.

Almost 90% of GPs in contact with COVID-19 infected patients reported either shortages or no access at all to eye protection, and 62% reported problems with supply of face masks. More than half of GPs who responded said they had had to buy their own face masks or eye protection, with only 2% saying they felt fully protected against the virus at work.

This unacceptable situation comes despite repeated assurances by the government that additional stock is being delivered to practices, and yet, as our survey demonstrates, these assurances are not being matched by a reliable supply of PPE to practices.

As a result of our pressure, Public Health England published new PPE guidance last week which advises that in primary care PPE should include eye protection and should be worn for all contacts. All patients must be assumed to have COVID-19 infection, and it is recommended that they should wear a mask during any face-to-face consultation. We will continue to work hard to ensure that everyone gets the necessary PPE that they need to work safely. Read the BMA statement in response to this

We held a webinar for LMC officers and members of GPC to ask questions of Dr Susan Hopkins, Deputy Director, National Infection Service at Public Health England, regarding the serious concerns which many GPs have about PPE. This can be seen at https://bma.streameventlive.com/archive/205
 
Repurposing industry
The BMA has joined forces with other health and manufacturing unions in the call for a manufacturing army to keep UK workers safe from virus harm. We called for Government to unleash a national effort to produce the protective equipment millions of key workers desperately need to keep safe during the health crisis.

Identifying high risk patients and shielding
As previously reported, the CMO letter (21 March) asked you to identify additional patients who may be known to your practice as being at highest clinical risk. NHSE/I then advised that you disregard this and refer to the most recent advice provided. However this has now been further updated with a CAS message from NHSE/I and NHS Digital circulated to practices today describing the specific tasks they should try to do to complete this process and, where practically possible, to try to do this by the end of Tuesday 14 April.  Practices are likely to have already completed most of this work using previous data provided to them and may only need to check the most recent lists provided to them via system suppliers to ensure they are as accurate as possible. Some of the work of keeping clinical records up to date will be an on-going task should further information about individual patients be provided by hospital specialists.  Details can be found in the attached document and here CEM_COM_2020_016.pdf

The NHSEI letter on Caring for people at highest risk of COVID-19 also advises that, with regards to shielding, it is open to the practice to determine how to treat this group of patients.  The letter states that practices should “immediately review any ongoing care arrangements that you have with these highest risk patients. Wherever possible, patient contact, triage and treatment should be delivered via phone, email or online. However, if you decide that the patient needs to be seen in person, please arrange for your practice to contact them to organise a visit to the surgery, a hub or their home as appropriate.“

The Government has also published an update on their shielding policy and implications for general practice. The letter provides further information regarding the management and shielding of patients who are at the highest risk of severe morbidity and mortality from COVID-19.

NHS 111 isolation notes

The NHS 111 Online Get an Isolation Note service issues isolation notes to individuals with symptoms of COVID-19 or those having to self-isolate due to residing with someone with COVId-19 symptoms. Employers have received clear guidance that for all COVID-19 related illness they should accept the Isolation Note as medical evidence to support absence from work and not require employees to get a fit note from a GP.

If an employer asks for fit notes relating to non COVID-19 health conditions for payment of Statutory Sick Pay (SSP) or Occupational Sick Pay (OSP), GPs should complete a fit note in the normal way, scan this and then email it to the patient, with due consideration of GDPR and with the necessary consent in place. Should an employer insist on a paper copy fit note, this can be posted to the patient. GPs can issue fit notes for a clinically appropriate time, which can be up to 13 weeks within the first six months of a condition, in line with existing guidance 

Advance care planning

The BMA has issued a joint statement with the RCGP, CQC and the Care Provider Association, about the importance of continuing with advance care planning during the COVID-19 emergency. For those patients who are at greater risk of developing severe illness from coronavirus, discussions about their wishes and preferences with regard to future care and treatment has taken on increased importance.

When developing advanced care plans with patients, practices should adhere to some key principles:

  • Careful consideration needs to be given to which patients may specifically benefit from having these discussions at this time, based on relevant clinical factors.
  • All discussions must be tailored to the individual circumstances of the patient.
  • It is unacceptable for blanket decisions about advance care plans, and decisions about do not attempt cardiopulmonary resuscitation (DNACPR), to be applied to particular groups of people.
  • Care needs to be taken when considering how patients are first contacted with a view to initiating these discussions.
  • Discussions need to be managed sensitively and compassionately, ensuring that patients understand why they have been contacted and what they are being invited to do.
  • When discussing the possible treatment options in the event of them becoming ill with COVID-19, it is important that patients are not given the impression that decisions about access to intensive treatment will be made on the basis of their age or disability. It should be made clear that every patient will be considered individually based on clinically relevant factors, such as their physical ability to benefit from the complex and demanding treatment provided in intensive care.
  • Whilst patients should be encouraged to think about their wishes for future care and treatment, they must not be put under pressure to do so, or to reach a particular decision.

    NHSEI has also published a letter from Professor Stephen Powis and Ruth May about Maintaining standards and quality of care in pressurised circumstances.

Request for GPs to support NHS111 CCAS

NHSEI have developed a national COVID-19 Clinical Assessment Service (CCAS) and are asking for GPs to help with it. The service has been set up to manage patients who need to speak to a doctor after contacting NHS111 and support patients to care for themselves at home, as a result helping to relieve the growing pressure on practices. This is an important service that will help support practices particularly as case numbers increase in the coming weeks. They are seeking GPs who are on the Performers List and currently work as salaried or as a GP partner and who can offer to work remotely with shifts available 24/7. However we are seriously concerned about the low pay rates being offered which do not reflect the level of experience this group of doctors has, and we have raised this with NHSEI.

Find out more in the NHSEI Primary Care bulletin (3 April) or sign up here 

GP preparedness update
We published a GP preparedness update last week to help practices to safely support delivery of health care within the current extremely challenging and pressurised environment. We have set out four key principles to work towards:

  • Health Care Worker safety is paramount.
  • By protecting health care workers we protect patients
  • Do everything possible to reduce infection transmission
  • Procedures and pathways should be evidence based

The guidance includes advice on proactive care, repeat prescribing, workforce planning, PPE, death certification and cremation forms. 

Standard operating procedures for general practice
The NHSE/I standard operation procedures for general practice has been updated since publication last week and the latest version 2.1 is here.

Testing for Health Care workers
There is widespread acknowledgment that there must be a rapid increase in testing for COVID-19. We continue to push for testing of GPs and their staff to be rolled out across the country, following the announcement by the Government that healthcare workers and those they live with will be first in line to be tested when necessary for COVID-19. Although the NHSE/I  letter  about COVID-19 testing to support retention of NHS staff,  advises that staff in initial priority groups such as critical care and emergency departments will be tested first, GPs and their staff should be a priority. Read the BMA statement in response to the announcement here.

Remote consultations

Read about the rapid move to telemedicine in primary care, and some of the practical and ethical issues related to this, in the article ‘The doctor will hear you now’.

We have also updated out guidance on remote consultations which is available here

NHSE/I has published an appendix to The Primary Care (GP) Digital Services Operating Model to support remote working across general practice during the COVID-19 pandemic. 

GP Digital estate and infrastructure
We have written to NHSX to raise our concerns that digital estate and infrastructure in general practice remains in an unfit state going into this pandemic and is inhibiting our ability to respond as effectively as we believe we could. Many practices are struggling to gain access to basic pieces of IT equipment due to funding constraints and to ensure and maximally increase capacity, remote assessment of patients has to be enabled through centrally funded tools, whilst supporting remote working by sourcing fit for purpose and appropriate equipment.
 

Repository for GP data
The Joint GP IT Committee sent a letter to NHS Digital affirming their support for a temporary centralised repository for GP data sitting with NHS Digital. This interim measure would ensure a consistent approach to data handling and negate the need for individual practices to respond to requests for data to be used for Covid19 planning and research. The committee is expecting to receive detailed plans on how this measure will function shortly.

GMC temporary registration expanded
The GMC has been asked to grant temporary registration to additional doctors under its emergency powers so that they are able to help with the coronavirus pandemic. An additional 18,800 UK-based doctors will be given temporary registration or have their licenses returned and will be able to work if they choose to. These include a further 12,000 doctors with a UK address who are GMC registered, but who do not currently hold a licence to practise, and nearly 6,800 doctors with a UK address who gave up their registration between three and six years ago (2014–17). This follows the earlier registration of around 15,500 doctors who had given up their registration or licence to practise within the last three years. More information about signing up is available on the COVID Clinical Assessment Service website.


Performers list changes
Currently medical practitioners cannot provide GP services for the NHS unless they are GPs on the GPs performers list. New regulations to be published shortly, will change that so that medical practitioners who are not GPs can provide such services without being on the performers list if they are employed by or are registered with bodies designated by the Medical Profession (Responsible Officers) Regulations 2010, or are granted permission to practise as in hospitals owned or managed by such bodies (such as NHS bodies, the Department of Health and Social Care and the armed forces). This will create the flexibility for non-GPs who have a link to a designated body to be deployed in primary care for the duration of the emergency period, as required. These new arrangements will be removed at the end of the coronavirus emergency period. GPC England and RCGP are working with NHSE to produce guidance for practices in how these doctors may be safely deployed in primary care.

GPs on a devolved nation performers list can now make a ‘Fast Track Covid-19’ (FTC19) application to join the England Performers List, and if approved will be included on the list for the period of the emergency. GPs can make the FTC19 application using an online form. They can also email the national team at england.ftc19@nhs.net

Carrying over annual leave
Government has announced that rules on carrying over annual leave to be relaxed to support key industries during COVID-19, which appears to suggest that practices as employers do have an obligation to follow it. The BMA legal department has confirmed that the annual leave entitlements through the Working Time (Coronavirus) (Amendment) Regulations 2020 (SI 2020/365) do indeed apply to GP practices. Therefore annual leave should be allowed to carry over into future years. However, the wording of the regulations is quite broad.

However, at present the law does not say that people are unable to take holiday because of the impact of coronavirus, therefore employees will be expected to take annual leave in the normal way unless it is not reasonably practicable for them to do so, for example because of COVID-related obligations.

Temporary arrangements for dispensing doctors during current COVID-19 crisis
Regulation 61 of the Pharmaceutical Services Regulations now applies, which means dispensing doctors can dispense to patients not on their list where a pharmacy is closed.
 

Clinical negligence indemnity
The Department for Health and Social Care, NHS Resolution, and NHS England and NHS Improvement have written a letter with regards to the clinical negligence indemnity in response to Coronavirus. As part of efforts to respond to the Coronavirus outbreak, they have reassured healthcare professionals and others working in the NHS in England about the position in relation to indemnity for clinical negligence incidents. Read the letter >

COVID- 19 Cervical Screening Programme guidance for sample takers

The national draft guidance for providers of sample taking services within the cervical screening programme during the COVID-19 pandemic, has been published by NHS England’s Public Health Commissioning and Operations team. These are guidance notes to support the Screening and Immunisation guidance, which is yet to be published.

DVLA medicals
The DVLA has now confirmed that they have ceased requesting any form of medical examinations with effect from 24 March. If members have outstanding requests they can just refuse to do them and ask the patient to go back to the DVLA.

IR35 tax deferral

The Government recently published a raft of financial measures aimed at alleviating pressure on businesses and taxpayers due to COVID 19. Among these was the 1 year deferral of the IR35 tax legislation (relating to contactors) to now be implemented in April 2021. The working group that has been regularly meeting to ensure the smooth implementation of IR35 will be meeting again to discuss what the deferral means for the BMA group and will update you accordingly.  

GP trainers and employment tribunals

Following issues raised by LMCs regarding possible GP trainer exposure to Employment tribunal risk, GPC England has worked with Health Education England (HEE) to address the issue.  HEE has written to all GP trainers to provide reassurance. The letter states:

“HEE has considered the question of GP trainers who may face claims relating to employment and equality actions in an Employment Tribunal.  Recognising that such claims are not within normal insurance cover, HEE has determined that it will manage and meet the legal costs and any settlement or damages arising on the basis that it is vicariously liable for the actions of GPs and their staff.  This means that it will bear the liability in the same way as it does for its employees and officers, acting in accordance with its guidance and in fulfilment of their obligations to HEE.  HEE will therefore decide the conduct of such cases liaising with the employer and GPs involved.”

BMA COVID-19 webpage

We continue to update our COVID-19 Webpage daily with the latest guidance including links to the PHE guidance for primary care and the NHS England guidance for primary care

The BMA has published FAQs on your contract terms and conditions which will be updated regularly.

Read the practical steps that practices can take here

Read the BMA’s Ethics FAQs here

We continue to raise issues that need to be addressed with the relevant organisations, and will continue to disseminate information as it becomes available. 

For more updates, follow the BMA on Twitter @TheBMA and @BMA_GP

If you have any specific concerns or issues about COVID-19, please contact our First Point of Contact advisors on 0300 123 1233 and support@bma.org.uk.

The BMA also has wellbeing services, including 24/7 counselling, for your emotional health.

Make sure you’re signed up to our email updates – update your email preferences >

Other COVID 19 resources

BMJ – news and resources
RCGP COVID-19 information
NHSE/I daily primary care bulletins on COVID-19
NHSE/I COVID-19 webinars
 
Read the last GPC bulletin here 

As we all play an important role in supporting our patients through this unprecedented situation, including working today and Monday in our practices, as well as the many GPs, nurses and other primary healthcare workers doing shifts for out of hours providers or local hubs over the weekend, I hope that we can all find at least some time to look after ourselves and to rest over the coming days.

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