How should we respond to negative comments made about our practice on NHS Choices or other websites?
The Medical Protection Society has produced some useful guidance on this.
Removing a Patient
A patient has just been very rude to and sworn at one of our receptionists. Can we remove him and the rest of his family from our list?
There are contractual steps that you must follow when removing a patient and the removal is done by the Family Health Service (FHS – formerly known as the PSU) not the practice.
The process is that the patient must have been warned by the practice within the last year that their behaviour could lead to a removal (unless they have been violent or threatened violence and the police have been informed). The warning does not have to be in writing but it is advisable that it is and the date the warning was given should be recorded. If the patient repeats the behaviour and the practice decides to remove them, the practice should then write to the Area Team of NHS England (firstname.lastname@example.org) requesting that the patient be removed, and stating the reason. FHS will write to the patient informing them that they will be removed eight days after the written notification was received from the practice.
In terms of removing other members of the family, the GPC advice is that this shouldn’t be automatic unless there is a risk of violence. You would have to warn the other members of the family that they are at risk of being removed before asking for them to be removed.
The GPC has detailed guidance on removing patients from your list.
Insurance Companies – Request for a Copy of Patient’s Notes
What is the procedure when an Insurance Company request for a copy of notes (Patient’s consent given) rather than a report? Therefore indicating that the Company will only pay up to £50 (the maximum cost allowed for copying a patient’s notes) rather than the higher fee normally charged for a GP’s report?
The BMA is aware that some insurance companies are now requesting full medical records (via a Subject Access Request – SAR) rather than asking for a report from the applicant’s GP, as previously agreed with the ABI. In the GPC’s view, requesting the full medical record for any patient is excessive and potentially in breach of the third data protection principle under the Data Protection Act 1998 (DPA) which states that personal data shall be “adequate, relevant and not excessive” in relation to the purpose for which it is processed. Under the DPA, patients are entitled to copies of their full medical record. The BMA is awaiting guidance from the Information Commissioners Office (ICO) regarding their concerns about the use of SARs. Until this guidance is received, the BMA would recommend that a letter is sent to any patients requesting their medical records via a SAR. The letter can be found here.
Charging Patients for Minor Operations
Can a Practice charge a patient a private fee for minor op procedures that NHS England/the Area Team have refused funding for?
The regulations are clear that a Practice cannot charge a registered patient except in the very specific circumstances listed in the regulations; this does not include minor surgery. For several years this came up at the annual conference of LMCs, with LMCs calling on the GPC to negotiate a change in the contract to allow this. Every year the motion was defeated, until 2012 when it was narrowly carried and therefore should be something that the GPC includes in its negotiations in the future.
So, to confirm, you cannot charge your own patients to provide minor surgical procedures that fall outside the NHS’s very tight criteria. It is possible to set up a completely separate company that provides this privately, but this is quite complex as it has to be completely separate from the practice and it is advisable that this is not even done on practice premises because it could otherwise appear that you are charging your patients. Another option would be to direct your patients to make contact with another practice which offers minor surgery and is able to charge your patients for this service.
Working within the limits of a GP’s knowledge and training
What should a GP do when a patient presents with a dental problem?
The GMC’s ‘Good Medical Practice’ is very clear about working within the limits of your knowledge and training – most GPs have very little or no training in dentistry. Therefore, GPs should not be treating dental problems.
Our advice is that you should direct the patient to a dentist. If they do not have a dentist then, at the moment, you should tell them to contact the Area Team to help them to access an NHS dentists or an emergency dental service.
The following case that has been brought to our attention highlights the risks of working outside your knowledge and training:
A London GP who saw a patient with a dental abscess, as he couldn’t get to the dentist quickly, prescribed painkillers and antibiotics, patient felt better and didn’t end up going to the dentist, but in the end developed osteomyelitis. The patient took civil action against the doctor successfully.
Don’t fall into the trap yourself!
Oral Typhoid Vaccine
(Confirmation from the NHS prescription services)
Should the oral single typhoid vaccine be given instead of the single typhoid vaccine, which is currently unavailable?
Due to reports of shortages of the Oral Typhoid vaccine Typhim Vi, it has been suggested that practices contact Crucell as they reportedly have stock of the Vivotif vaccine, which can be used instead.
Can the cost of the oral single typhoid vaccine be reimbursed?
The NHS prescription services has confirmed that the situation with the oral typhoid vaccine is somewhat unusual in terms of what is allowed. It is classed as personally administered and although it is not a vaccine in the conventional sense, it is listed as an Oral Vaccine and is a High Volume Vaccine on their system, it can, therefore, be claimed on the FP34 appendix. They will also accept it if practices were to print it on an FP10 and submit it with the end of month submissions.
Gun Licence Notifications
What is a GP required to do?
See the BMA guidance – in particular read the section under the heading “Post-grant letter sent to GPs” which explains what action a GP should take.
Referral Forms and Templates
Is a GP required to use referral forms and templates?
We receive a considerable number of complaints about the proliferation of referral forms and templates with which GPs are expected to refer patients. We have written to the Medical Directors of the hospital trusts pointing out that there is NO obligation on GPs to use these forms and that the hospitals must not reject a comprehensive referral on the grounds that it isn’t on the hospital’s form.
Can practices ask for deposits from patients for loaned practice equipment?
We have been asked if a practice can obtain a cheque or other deposit from patients when they loan equipment e.g. an ambulatory BP machine, or a nebuliser, which the practice would return/refund on return of the equipment in working order. If the patient damages the equipment in any way then the practice would retain the deposit towards the repair costs.
The GPC lawyer’s view is that under the GMS/PMS regulations practices cannot profit from patients. However, requesting a deposit against property does not constitute a ‘charge’ and does not allow the practice to profit from the patient. A deposit against property would therefore not breach charging regulations and the practice would be able to do this, although it should not be referred to as a ‘charge’.
Can a practice charge if a patient does not attend for a travel vaccine?
We’ve been asked by a practice what they could do in a situation where a patient books an appointment for a travel vaccine and then does not attend. It can often be the case that an entire family is booked for vaccination and then does not attend. The practice wondered if they could charge patients a fee for a travel vaccine appointment and refund the fee if the patient attends the appointment. If a practice is offering travel vaccines to its own patients, it cannot make any charge to its patients for this, including a refundable charge. If a practice is offering travel vaccines as a private service to non-registered patients, then the practice can charge for this service.
There has been a number of requests to the office about the legal position a GP would be in when prescribing drugs ‘off-licence’ – by that we mean when a GP prescribes a drug that has to be crushed or a capsule opened and the contents emptied out to give to a patient through a PEG tube, thereby breaching the licence of the product. This became an issue a few years ago as the PCT Medicines Management Teams were encouraging GPs not to prescribe ‘specials’ (medicines specially prepared for patients who are unable to take the medicine in the usual fashion, for example, liquid ACE inhibitors, which can be extremely costly). We asked for a legal opinion from the GPC which stated as follow:
“When prescribing the GP must take into account the needs of the patient and prescribe accordingly. So, where a special order product is necessary and unavoidable it has to be prescribed. Licensed medicines must be used where possible. As long as the GP has good justification to use off-licence products and as long as he isn’t doing this continually and irresponsibly then I cannot see why a GP cannot do this. Cost effectiveness must be weighed against the need of a patient and that is solely left to the judgement of the GP. If for example a GP did not issue a special order product to a patient and a patient became ill as a result of not being able to use the product in the manner prescribed and the GP was aware or should have been aware of this – then that to me would be a potential negligence claim against the GP himself or herself.
I totally agree that where possible licensed medicines should be used wherever possible and I would have thought that the use of unlicensed or special products would be the exception rather than the rule.”
What checks should a practice make on the eligibility of patients for NHS services?
Following a patient complaint that was upheld by the Ombudsman, after a patient was asked to show her passport when registering, a practice has been fined for maladministration of their policy on patient registration. We would remind all practices that GPC guidance is that it is not your responsibility to establish whether or not a patient is eligible for NHS services and therefore any guidance issued by your PCT or the PSU on this issue is exactly that – guidance and not a requirement. If you do decide to operate a policy for establishing eligibility then you must be consistent and apply the policy to all patients.
Registering Homeless Patients
How can a practice register a homeless person who has no address?
If a homeless patient wanting to register with a practice is not able to provide any address at all then the practice can register them using the practice address so that all the necessary fields for the registration can be completed.
Sick Notes/Fit Notes
After leaving work voluntarily, feeling depressed, a patient has asked for a sick note for Social Services to claim benefits. What should the GP do?
The decision to write a sick note – correctly now a ‘fit note’ – lies with the GP in collaboration and agreement with the patient; it is not a patient’s given right and the GP should not feel bullied into signing a note unless there really is a clinical reason to do so. Indeed the GP could be deemed to be complicit in committing fraud by issuing a false statement.
A patient may make a complaint if a ‘fit note’ is not written but the GP must act in accordance with her or his clinical judgement of the medical evidence and cannot be seen to be complicit in fraud.
Last reviewed on 8th December 2015 (HB)