The professional voice of general practice in Hillingdon Londonwide LMCs is the brand name of Londonwide Local Medical Committees Limited Registered and office address: Tavistock House North, Tavistock Square, London WC1H 9HX. T. 020 7387 2034/7418 F. 020 7383 7442 E. info@lmc.org.uk www.lmc.org.uk Registered in England No. 6391298. Londonwide Local Medical Committees Limited is registered as a Company Limited by Guarantee Chief Executive: Dr Michelle Drage

HILLINGDON LOCAL MEDICAL COMMITTEE MEETING

To be held at 12.45 pm on Tuesday 19 June 2012 in The Hillingdon Health Centre 4 Freezeland

Way, Hillingdon, Uxbridge, Middlesex UB10 9QF

PART 1

LMC Members only 12.45- 1.30pm

AGENDA

1.0 Apologies

2.0 2.1

Declarations of interest Members to declare any conflicts of interest in connection with any items on the agenda or in the light of subsequent debate

3.0 Minutes and matters arising not listed elsewhere on the agenda: 3.1 3.2

Minutes of LMC meeting Part One on 17 April 2012 (paper attached) Actions of the NWL Cluster Meeting May 2012 (paper attached)

3.3 Actions Notes of the NWL Interim Meeting with Primary Care Contracting Team May 2012 (paper attached)

4.0 Items for discussion: 4.1 4.2

North West London Cancer Network- (representatives to attend meeting at 1pm) Quality Referral Standards for LMC comment (paper attached)

4.3 BMA Guidance on CQC (paper attached) 4.4 Out Of Hospital Strategy 4.5 Enhanced Services

- Medicines Management LES (papers attached to Part 2 agenda) 4.6 PMS issues – to raise any issues 4.7 Sessional GP issues 5.0 Part 2 agenda

To discuss the Part 2 agenda 6.0 Items to receive: 6.1 GPC News (paper attached) 6.2

LEAD:- to receive a list of forthcoming LEAD events (paper attached)

7.0 LMC newsletter To identify items for the next newsletter

8.0 Date of next meeting: Tuesday 16 October 2012, Kirk House, NHS Hillingdon

9.0 Any other business:

1

Draft and unconfirmed minutes of the Hillingdon LMC Part One meeting held on Tuesday 17 April 2012 at Kirk House, NHS Hillingdon In attendance LMC Members LMC Observers Londonwide LMCs

Dr Garsin (in the chair) Mrs Hopkins (LPC) Mrs Rogers Dr Sehdev Ms Khan (Practice Manager) Mrs Beech Dr Verma Dr Scott

Dr Mashru Dr Mort Dr Mukerjee

Dr Nathoo Dr Saleh Dr Ahmed

Dr Davies Dr Goodman

1.0 Apologies Apologies were received from Dr Thankappan, Dr Shapiro, Dr Dhanani, Dr Grewal and Dr Jowett

2.0 2.1

Declarations of interest No new declarations of interest were identified.

3.0 Minutes and matters arising not listed elsewhere on the agenda:

3.1 3.2

The minutes of LMC meeting Part One on 21 February 2012 were agreed. The actions of the NWL Cluster Meeting March 2011 were agreed.

3.3 The action notes of the NWL Interim Meeting with Primary Care Contracting Team March 2012 were agreed. Improvement grants (item 5.0 refers) Dr Garsin reported that he was aware that the money had been allocated but practices do not have it yet. The NWL cluster have stated that consulting rooms should not have carpet. Dr Davies agreed, if practices have carpet in their consulting rooms it can stay but if a practice was to replace it, it would need to be vinyl flooring. It was agreed that LLMCs would seek to find out what the regulations for this are and report back to the committee.

LLMCs

Olympic Planning (8.0 refers) Mrs Hopkins reported that the LPC were trying to secure use of special lanes for delivery of drugs. Dr Garsin added that it was unlikely to be a problem in Hillingdon.

2

4.0 Items for discussion:

4.1 4.2 4.3

Urgent Care Centre/A&E redesign Dr Garsin reported that Hillingdon had been awarded £12 million to develop the A&E site, this has to be completed within the year, Dr Garsin sits on the strategy board. The Paediatrician unit would like a separate A&E facility, but this is unlikely to be agreed. The UCC tender is going out soon also. 111 There was no update to report on 111. Referral Facilitation Service Dr Garsin reported that the RFS was currently on hold, the business case did not really add up. Dr Davies added that he had received a final version recently and the capturing of data is useful, suss data is no good.

4.2 North West London LETBs It was agreed that Dr Ahmed will be the lead for LETBs for Hillingdon LMC.

4.4 4.5

Out Of Hospital Strategy Dr Goodman reported he had received papers from Susan Sinclair. The Out Of Hospital strategy shifts care from secondary care into community care. There is an issue around GPs remuneration for attendance at Multi-Disciplinary Groups and the working up of individual care pathways. Dr Scott responded that it was a question of skills, it would seem that a LES is appropriate, a GP is taking on extra work with no extra training North West London Formulary Dr Garsin reported that this was an attempt to get primary and secondary care prescribing similar drugs. There will be a CQUIN attached to this; practices will be monitored on what drugs they prescribed. ScriptSwitch will be applicable to new patients only.

3

4.6 Enhanced Services Dr Garsin argued there was a conflict of interest as to where enhanced services come from. It is the responsibility of the CCG but three is a huge conflict given that the PCT no longer exists. CCG members feel uncomfortable about this. Dr Goodman added that this was not a unique situation to Hillingdon. PCTs have always had subcommittees including GPs. Dr Davies added that a streamlined LES process was needed. Dr Garsin added he had seen the medicines management LES but was not prepared to approve it on behalf of the LMC. Dr Scott pointed out the main conflict of interest comes from the money involved, but there are other conflicts too e.g. a LES which suggests cutting down on prescriptions. Dr Goodman added the real conflict comes in the allocation of the money. Mrs Rogers suggested that a meeting of the LMC executive could be a solution to this. Dr Garsin expressed his disappointment that the medicines management LES had not yet come to the LMC. Dr Ahmed commented the evening meeting she had attended had been characterised by a lot of anger/animosity and a feeling that things had not been transparent. Dr Garsin added this was a separate conflict of interest issue, this related to the inclusion of sessional GPs in the process.

4.7 Forthcoming bi-annual LMC elections Committee members were reminded of the forthcoming elections.

4.7 PMS issues No issues were raised.

4.8 Sessional GP issues Dr Nathoo pointed out issues with the ICP and the extra work which will be taken on by sessional GPs. Dr Davies agreed it was complicated, some of the remuneration is for backfill but others were for the doctor’s expertise. If a salaried doctor attends a Multi-Disciplinary Group, it goes to the practice.

5.0 Part 2 agenda To discuss the Part 2 agenda

6.0 Items to receive:

6.1 The GPC News was noted.

6.2

The list of forthcoming LEAD events was noted.

8.0 The date of the next meeting was noted.

4

9.0 Any other business: Boots UK relocation Dr Scott raised the issue of the relocation of Boots and a letter the LMC office had received from the litigation committee, given that a number of pharmacists have complained. Mrs Hopkins reported that it was a 500 metre relocation it was deemed to be against the competition act. The letter was noted.

Actions arising from the North West London Cluster Meeting held on Tuesday 29 May 2012 at NHS Westminster, 15 Marylebone Road, NW1 5LT

Item Action Responsible 4.0 Imperial Cancer SI and Practice Response

The LMC Office undertook to discuss the practice response to the Imperial Cancer SI with the CCG Governing Body, to determine whether practices should have to track referrals on a permanent basis and if so, which referrals. The LMC Office to obtain a GMC view on whether practices could be held legally responsible if referrals are not correctly processed internally by Acute Trusts. Mr Elkeles to look into how best the dedicated Imperial Cancer SI phone line can be communicated to practices. NHS NWL to consider using the NWL Cancer Network Review to help with their review of the SI.

LW LMCs LW LMCs DE NHS NWL

5.2 Clinical Commissioning Group Update Mr Elkeles to arrange a meeting between Mr Larkman, Ms Baker, Dr Scott and Mrs Michaels to discuss the feasibility of NWL CCGs using the BMA constitution.

DE

5.3 Delivery Support Unit Ms Sawtell to send an updated paper outlining the details of the selected DSU Programmes to the LMC Office.

TS

5.7 Integrated Care Pilot NHS NWL to provide the LMC Office with a copy of the ICP Interim Report at the next meeting. Ms Sawtell to send a copy of the Inner NWL ICP Business Plan to the LMC Office for information. Ms Sinclair to rephrase Section 18 – Confidentiality of the “ICP Establishment Agreement for the Outer NWL ICP” to outline that this section relates to patient data.

NHS NWL TS SS

8.0 Date of the Next Meeting The LMC Office to cancel the meeting scheduled for the 14 June 2012 and reschedule the meeting for early July 2012. The LMC Office to arrange for future meetings to be held at 15 Marylebone Road.

RS RS

Londonwide LMCs and NHS North West London Primary Care Contracting team interim meeting

Action notes from Tuesday 29 May 2012

1.0 In attendance: Rachel Donovan (RD) Andy Michaels (AM) Ariadne Siotis (AS) Alison Dalal (AD) Kathryn Charles (KCh)

2.0 Apologies: Karen Clinton, Julie Sands, Gill Rogers

3.0

Additional Items not listed on the agenda Matters arising from meeting 24 April QoF – RD noted that practices which submitted their evidence before 31 March should have received confirmation, however both KCh and AD noted that their practices had not despite submitting on time. RD undertook to look into why this was the case (RD) She also noted that there were about ten practices which did not submit any evidence at all and that the PCT was going to remove their points from the system. The LMC expressed concern that practices may lose QoF funding and queried whether practices were obliged to submit their evidence as the QoF guidance says it has to be available during a QoF visit but does not specify that it must be submitted to the PCT. RD pointed out that the evidence was being submitted in lieu of a visit. The group took advice from NB in the GP Support team at Londonwide LMCs during the meeting regarding the legitimacy of this and she felt that the PCT were within their rights to remove the points if evidence had not been produced. The PCT assured the LMC that they would first try to make contact with the practices to establish why they had not submitted their evidence however if they were not able to provide an explanation then the points would be removed from QMAS. RD agreed to let the LMC office know if it reached that stage so that GP support could offer advice. RD reported that for next year the PCT were planning to ask for different evidence taken from all the categories. KCh queried whether this was acceptable considering the guidance states that practices only have to make B and C evidence available to the PCT on a visit. RD agreed to send the LMC office the list the PCT are proposing to use to allow the group to comment on it before anything is agreed. (RD) Improvement Grants – RD noted that the Capital Group would be taking this forward and that they were hoping to work with the LMC.

4.0

ICP – the group agreed that as KC was not present this item was best left for discussion at the Cluster meeting.

5.0 List Maintenance – RD undertook to share the full programme with the LMC office and to outline what training would be made available to practices to support them through the process (RD). KCh expressed concern regarding volume of work for practices particularly in Brent where lists are being validated over one year and stated that this would be prohibitive unless a robust

electronic solution is developed for all GP systems to identify contacts within the preceding 15 months.

6.0 Infection Control – RD noted that the two infection control nurses were only working for INWL and that they were currently in the process of undertaking a scoping exercise to identify the different approaches across the patch. AM pointed out that there should not be inconsistency across NWL and that whatever is decided for INWL should really be applied to ONWL as well. KCh queried whether the visits were necessary given that infection control is a CQC standard. RD undertook to share the plan for INWL with the LMC office and it was agreed that this should be discussed further at the next meeting. (RD)

7.0 Enhanced Services – AS raised the issue of practices failing to achieve the PP DES and queried what the process for deciding had been. RD replied that all the decisions had been reviewed and that six of them were going to a formal dispute panel. NB from the LMC office would be on the panel as an observer. AS undertook to email the practices who had copied the LMC into their complaints to let them know that the issue had been raised and that there would be an LMC observer on the dispute resolution panel. (AS) KCh also raised the issue of the payment of the Extended Hours DES in Ealing which is made only on receipt of a monitoring form and therefore means that practices are paid one month after the quarter end and which creates cash flow issues. She added that the SFE states that payment should be made on the last day of the quarter. It was suggested that the PCT consider using the Westminster model across NWL where practices are paid monthly and then reconciliation is done at the end of the year, or quarterly. RD undertook to discuss this with KC and JS and to report back. (RD) KCh enquired as to progress of the childhood immunisation DES specification. RD confirmed that she had received KCh’s comments and did not disagree with them and that she was currently working on a revised specification.

8.0 Contracts – there was nothing new to discuss regarding the transfer of contracts to the NCB. Regarding the minimum standards visits RD undertook to share the template which would be used with the LMC once it was available. (RD)

9.0

GP Choice Pilot – AD pointed out that the out of area patients who register as part of the pilot do not attract an additional payment and that because her practice has a 5% list size threshold and the list is only calculated annually that would effectively mean that they would not be paid for registering those patients. AM said she would raise this with the project team at the office for them to consider. (AM)

10.0 Practice Vacancies and Procurement – There were no particular updates to report however the Cluster noted that they were in the process of drafting a policy on how to handle vacancies in the future and agreed to share the draft with the LMC office. RD

12.0 FHS Services – RD noted that due to some small problems with the premises the timeline had

slipped a little from the end of May, but that the service should be fully functional very soon thereafter.

13.0

Date of Next Meeting – Monday 25 June, 3rd Floor Meeting Room (BMA House)

Quality Referral Standards

(A quick guide to local criteria on secondary care referrals for some common conditions)

Date : 24/5/12

1

Table of Contents

CARDIOLOGY

CHEST PAIN ........................................................................................ 2

HEART FAILURE.................................................................................. 2

PALPITATIONS.................................................................................... 3

DERMATOLOGY

ACNE................................................................................................... 4

ATOPIC ECZEMA IN CHILDREN ......................................................... 4

PSORIASIS........................................................................................... 5

ENT

DIZZINESS ........................................................................................... 5

HEARING LOSS ................................................................................... 6

GASTROENTEROLOGY

ABNORMAL LFTs................................................................................ 7

IBS ....................................................................................................... 7

RECTAL BLEEDING ............................................................................. 8

GYNAECOLOGY

Menorrhagia and Amenorrhoea ...................................................... 8

PCO..................................................................................................... 9

MSK

BACK PAIN ......................................................................................... 9

HIP PAIN ........................................................................................... 10

KNEE PAIN........................................................................................ 11

SHOULDER PAIN .............................................................................. 12

PAEDIATRICS

CONSTIPATION ................................................................................ 13

UROLOGY

MALE CKD ........................................................................................ 14

MALE LUTs ....................................................................................... 14

2

SPECIALITY

CONDITION

REFERRAL CRITERIA

CARDIOLOGY

CHEST PAIN

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Referral to Secondary Care where Rapid Access Clinic criteria are not satisfied

• Diagnosis is unclear on tests ( ECG, FBC, NT/bnp TFT/UE and CXR)

and

One or more risk factors:

• Age (m >55,f>65), smoker, hypertension, diabetes, hyperlipidaemia, CKD, established atherosclerotic disease, erectile

dysfunction, obesity, Rheumatoid arthritis, sleep apnoea, arrhythmia/palpitations.

and

One or more of these symptoms:

• Restricting discomfort in front of the chest or neck

• Pain –jaws or arms

• Precipitated by physical exercise

• Relieved by rest or GTN

CARDIOLOGY

HEART FAILURE

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Routine referral

Confirm suspected clinical diagnosis with:

• ECG ( if normal consider different diagnosis)

• CXR

• BNP blood test ( if normal consider different diagnosis)

BNP < BNP <100 pg/ml or NTproBNP < 400 pg/ml: chronic HF unlikely

BNP 100-400 pg/ml or NTproBNP 400 – 2000 pg/ml: uncertain

BNP>BNP BNP> 400 pg/ml or NTproBNP > 2000 pg/ml chronic heart failure CXR

Other tests required before referral:

• FBC (if abnormal, consider investigation /treatment before referral)

• TFT (if abnormal, consider investigation / treatment before referral) (more on next page)

3

SPECIALITY

CONDITION

REFERRAL CRITERIA

• UE, LFT, glucose, lipids ( optimize management of co-existing conditions)

If breathlessness is the only symptom exclude respiratory cause:

• Spirometry

• PFR

If peripheral oedema is present exclude other cause:

• low protein diet,

• renal disease,

• venous stasis

CARDIOLOGY

PALPITATIONS

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Urgent referral to RAAC:

One or more of:

• Significantly symptomatic tachycardia or bradycardia

• Known major heart disease

• Significant ECG Abnormalities

• Family history of SCD (sudden cardiac death in young relatives)

• Syncope

• Heart murmur/Aortic stenosis

Routine cardiology referral :

One or more of:

• Recurrent palpitations despite medication

• Unremitting despite strategies to reduce symptoms or frequency

• Abnormal ECG e.g. long QT interval, delta wave

• History suggests tachyarrhythmia

• Family history of inherited heart disease/SADS

• Palpitations during exercise

4

SPECIALITY

CONDITION

REFERRAL CRITERIA

DERMATOLOGY

ACNE

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LOCAL acne guidelines have been consulted

And one of:

• Assessment for treatment with Isotretinoin

• Severe nodulocystic acne (refer immediately)

• Moderate-severe acne has failed to respond to prolonged treatment (i.e. More than 6 months of systemic and

topical treatment with at least 2 different oral courses)

• Patient unable to tolerate treatments recommended by guidelines

• Extreme psychological reaction to their acne

DERMATOLOGY

ATOPIC ECZEMA IN

CHILDREN

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LOCAL guidelines have been consulted

And one of:

• Assessment for treatment with

- Calcineurin inhibitors, Photochemotherapy, Cytotoxic drugs

• Moderate-severe eczema that has failed to respond to more than 4-6 weeks course of recommended

guideline treatment

• Eczema herpeticum – URGENT referral

• If allergic contact dermatitis suspected, for patch testing

• Recurrent infection and failed:

- Systemic antibiotics (especially if nasal swabs taken from family and positive infection treated)

• Parental concern

• Extreme psychological reaction as a result of condition

• Patient unable to tolerate treatments recommended by guidelines

(more on next page)

5

SPECIALITY

CONDITION

REFERRAL CRITERIA

DERMATOLOGY

PSORIASIS

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Local psoriasis guidelines have been consulted

AND one of:

• Unstable and generalised pustular psoriasis – URGENT referral

• Extensive severe acute guttate psoriasis – EARLY referral for PHOTOTHERAPY

• Extensive/severe disabling psoriasis

• Patient allergy/sensitivity to numerous treatments recommended by guidelines

• Diagnostic uncertainty (particularly consider unresponsive solitary patches/lesions)

• Rapid relapse post treatment

• Extreme psychological reaction to the condition

ENT

DIZZINESS

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Referral to Secondary Care

Non-Urgent

• Syncope and arrhythmia or other cardiac cause excluded

• Anaemia and diabetes excluded as a cause

and one of:

• Symptoms of vertigo lasting more than 4 weeks

• Associated hearing loss and/or tinnitus and more than 4 weeks

• History of barotraumas

Prompt : If Suspected BPPV, perform Dix-Hallpike test and attempt Epley’s Manoeuvre

6

SPECIALITY

CONDITION

REFERRAL CRITERIA

ENT

HEARING LOSS

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Referral to Secondary Care

Urgent- One of:

• Sudden complete hearing loss via ENT urgent referral clinic

• After excluding wax, unilateral loss.

Non-Urgent Audiology Clinic

• Presbyacusis

• and patient wants hearing aid

• and no wax occluding ear canals.

ENT One of:

• Drum abnormality (Hot link to Cholesteatoma pictures)

• Suspected foreign body unless battery (urgent)

• Impacted wax not relieved by wax softening drops and syringing

• Asymmetric sensorineural loss

• Chronic Infections; if swabs and appropriate antimicrobal treatment not effective

Prompt

Conduct a tuning fork test to distinguish Sensorineural from Conductive Hearing loss

7

SPECIALITY

CONDITION

REFERRAL CRITERIA

GASTROENTEROLOGY

ABNORMAL LFTs

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All of:

1. Persistently abnormal LFTs with ALT/AlkP more than twice upper limit of normal

2. Other +ve or abnormal findings on liver screen:-

• +VE HepBSag or Hep C Ab

• Raised ferritin

• Abnormal USS (other than fatty liver)

• Abnormal auto antibodies

Pre-referral required investigations:-

• FBC, fasting, glicose, lipids, ferritin, HepBSag, Hep C Ab, autoantibodies, USS

URGENT referral criteria;

• ALT/AST 200-1000 and/or

• ALP > 300 with raised GGT

• Possible Malignant lesion on USS

GASTROENTEROLOGY

IBS

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Patients with IBS not responding to following treatments

• Dietary advice

• Laxatives if constipation predominant

• Loperamide if diarrhoea predominant

• Trial of antispasmodics – buscopan, mebeverine and peppermint oil

And

alternative diagnosis has been excluded by:

• FBC, ESR, CRP, coeliac screen.

8

SPECIALITY

CONDITION

REFERRAL CRITERIA

GASTROENTEROLOGY

RECTAL BLEEDING

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URGENT REFERRAL CRITERIA ( use 2WW forms)

• Rectal bleeding with change in bowel habit to increased/looser stool for more than 6/52

• Rectal bleeding in over 60s without change in bowel habit

• Strong FH of colorectal cancer

• Associated unexplained weight loss

• Palpable abdo/rectal mass

• Iron deficiency anaemia

• Any radiolology suggesting possible cancer

ROUTINE REFERRAL

1. Refer for colonoscopy if; - rectal bleeding in under 60s persists > 6weeks

Pre-referral required investigations – FBC, ferritin or other iron studies

Prompt : Rectal examination is expected unless a stated clear reason why this has not been performed.

GYNAECOLOGY

Menorrhagia and

Amenorrhoea

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Routine referral for Menorrhagia

One of:

• A failed pharmacological treatment

• Endometrial polyps

• Submucous fibroids

• Thickened endometrium(> 12 mm) on ultrasound .

Gynaecological referral for infrequent bleeding :

• Sub fertility after 6 months of amenorrhoea otherwise 12 month

Endocrinology referral for infrequent bleeding:

• Prolactin > 1000mol/l – micro/macro prolactin needs to be excluded (more on next page)

9

SPECIALITY

CONDITION

REFERRAL CRITERIA

GYNAECOLOGY

PCO

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Patients with PCO do not require gynaecological referral.

If:

• Testosterone greater than 5mmol/l or significant hirsutism refer to endocrinology

• Acne or moderate hirsutism not responding to dianette and/or hair removal techniques after 6-12 months –

refer to dermatology

• Patients wishing to conceive after 1 year of unsuccessful trying – refer to fertility clinic

Prompt: Metformin is not recommended

MSK

BACK PAIN

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Before any referral, instigate a trial of GP Treatment, unless there are red flags:

– Advice and Self Help Exercises including posture and low back strengthening

– Patient education (weight loss, stay active, advice about prognosis, use of medication to allow patient to

stay active, stress management, coping strategies, activity modification. Emphasise that for chronic

conditions pain does not equal harm)

– Signposting to self help groups and exercise classes

• MSK Physiotherapy:

– Failing to settle with GP advice Recurrent problem of less than 3 months and , if patient has received

previous physiotherapy, this helped improvement by more than 50% and improvement lasted at least 6

months

• MSK Interface Clinic:

– Lack of persistent benefit with manual therapy plus slef help.

– Significant functional impairment

– Investigations needed (but only if needed to plan management, not for patient satisfaction – NICE 2009,

RCR 2012) (more on next page)

10

SPECIALITY

CONDITION

REFERRAL CRITERIA

• MSK Physician:

– Second opinion for failure to progress with initial management

– Severe pain, not controlled with standard analgesic ladder

– Multiple medical problems or possible underlying pathology (Note, the MSk service is not commissioned to

investigate known or probable red flags)

– Injections (caudal epidurals)

– Pharmacological treatments

– Biopsychosocial assessment

• Secondary Care:

– Severe or Progressive Neurology (e.g. cord compression, cauda equina syndrome – emergency referral)

– Infection

– Cancer

– Fracture

– Inflammatory disorders

– Vascular causes

– Pain Clinic if fails to settle with Amitriptyline (up to 100mg dose), and vigorous treatment of any co-morbid

mental health problems, and no identifiable surgically-correctable cause identified

MSK

HIP PAIN

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Before any referral, instigate a trial of GP Treatment, unless there are red flags:

– Advice and Self Help Exercises

– Patient education (weight loss, stay active, advice about prognosis, use of medication to allow patient to

stay active, stress management, coping strategies and activity modification, emphasise that for chronic

conditions pain does not equal harm)

– Signposting to self help groups and exercise classes

(more on next page)

11

SPECIALITY

CONDITION

REFERRAL CRITERIA

– GP Minor Surgery:

– Soft tissue injections e.g. trochanteric bursitis

– MSK Physiotherapy:

– Failing to settle with GP advice as per action referral line

– Recurrent problem of less than 3 months and , if patient has received previous physiotherapy, this

helped improvement by more than 50% and improvement lasted at least 6 months

• MSK Interface:

– Lack of persistent benefit with manual therapy

– Significant functional impairment

– Investigations

– Soft tissue injections as part of a package of care

• Secondary Care:

– PPwT thresholds met

– Red flags (e.g. dislocation, fracture, suspected tumour or infection)

MSK

KNEE PAIN

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Before any referral, instigate a trial of GP Treatment, unless there are red flags:

– Advice and Self Help Exercises

– Patient education (weight loss, stay active, advice about prognosis, use of medication to allow patient to

stay active, stress management, coping and activity modification strategies, emphasise that for chronic

conditions pain does not equal harm)

– Signposting to self help groups and exercise classes (more on next page)

12

SPECIALITY

CONDITION

REFERRAL CRITERIA

• GP Minor Surgery:

– Joint injections

• MSK Physiotherapy:

– Failing to settle with GP advice as per referral action line

– Recurrent problem of less than 3 months and, if patient has received previous physiotherapy, this

helped improvement by more than 50% and improvement lasted at least 6 months

• MSK Interface:

– Lack of persistent benefit with manual therapy

– Significant functional impairment

– Investigations

– Joint/soft tissue injections as part of a package of care

• Secondary Care:

– Locked knee (urgent referral to AE/fracture clinic)

– PPwT thresholds met

Red flags (e.g. dislocation, fracture, suspected tumour or infection)

MSK

SHOULDER PAIN

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Urgent referral orthopaedic, red flags:

• Symptoms and signs of cancer

• Unexplained deformity, mass, or swelling:? possible tumour

• Unexplained deformity, mass, or swelling:? possible tumour

• Red skin, fever, systemically unwell - suggestive of infection (more on next page)

13

SPECIALITY

CONDITION

REFERRAL CRITERIA

• Trauma, epileptic fit, electric shock; loss of rotation and normal shape - could the presentation represent an

unreduced dislocation?

• Trauma, acute disabling pain and significant weakness, positive drop arm test - possible acute rotator cuff

tear

Routine referral orthopaedic

• Pain and significant disability lasting more than six months despite physiotherapy and steroid injections

PAEDIATRICS

CONSTIPATION

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Urgent Referrals:

One of:

• Constipation reported from birth or first few weeks of life

• Failure to pass meconium/delay (more than 48 hours after birth [in term baby])

• Ribbon stools

• Previously unknown or undiagnosed weakness in legs; locomotor delay

• Abnormal appearance/position/patency of anus: fistulae, bruising, multiple fissures, tight or patulous anus,

anteriorly placed anus, absent anal wink

• Abnormal neurological findings or structural abnormality of spine or lower limbs

Routine Referrals:

One of:

• Failure to thrive

• Failure to respond to treatment. Refer children and young people with idiopathic constipation that does not

respond to initial treatment within 3 months to a practitioner with expertise in the problem.

14

SPECIALITY

CONDITION

REFERRAL CRITERIA

UROLOGY

MALE CKD

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Routine nephrology referral

One or more of:

• ACR ≥ 70mg/mmol unless explained by diabetes and already appropriately treated

• ACR ≥ 30 mg/mmol together with haematuria

• Rapidly declining eGFR (> 5 ml/mim/ 1.73m2 in one year or > 10 ml/min/ 1.73m2 within 5 years)

• Hypertension that remains poorly controlled despite the use of at least 3 anti-hypertension drugs at

therapeutic doses

• People with, or suspected of having rare or genetic causes of CKD

• Suspected renal artery stenosis

MALE LUTs

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Routine urological referral

One of:

• LUTs complicated by UTI

• Renal impairment due to lower urinary tract dysfunction

• Urinary stress incontinence

• Microscopic haematuria

• Bothersome LUTs with failed treatment

• Urinary retention residual >100ml

15

About this Document

This is a series of quick guides on criteria to consider before referring a patient to hospital. This is not an exhaustive list.

It is intended as a quick guide only that will link in with the processes of the Referral Facilitation Service (RFS).

The criteria cover the most common specialities common conditions that GPs refer patients for further hospital care.

The information has been developed by groups of GPs from Ealing, Hillingdon and Hounslow. Each specialty has had input from at least one GP from each of

the boroughs. It follows extensive discussion and development based on national, regional and local clinical guidelines.

Where appropriate local hospital clinicians have been engaged in developing these criteria.

The criteria will be under regular review. For the latest version of this document and related information see your Clinical Commissioning Group’s extranet

site under Referral Facilitation Service.

Any feedback would be most welcome and should be directed via email to : xxxx.xxxxx@nhs.net

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g

Friday 20 April 2012 Issue 8

0 BContent

BMA guidance on firearms licensing ............................................................................................... 8

BMA Law ....................................................................................................................................... 10

CCG constitutions ............................................................................................................................ 3

Cervical screening training update .................................................................................................. 7

Changes to practice boundaries from April 2012 ............................................................................ 5

Changes to the community pharmacy new medicine service (NMS) payment structure ................ 9

Department of Health model CCG constitution BMA Law ............................................................ 3

Dispensing doctor feescale changes 2012-2013 England and Wales ......................................... 5

Enhanced GP training ..................................................................................................................... 6

Ethnicity and first language recording guidance update .............................................................. 5

Facilities management ..................................................................................................................... 7

Fair commissioning charter ............................................................................................................. 3

Focus on anticipatory prescribing for end of life care ...................................................................... 9

GP Trainees Subcommittee newsletter ........................................................................................... 6

GPC annual report 2012 ................................................................................................................. 10

GPC meeting ................................................................................................................................... 2

Industrial action ................................................................................................................................ 2

NHS Reforms ................................................................................................................................... 2

NICE infection control guidelines ..................................................................................................... 8

Payments to practices from non-NHS bodies ................................................................................. 9

Practice premises leases .............................................................................................................. 7

Prescription charges ........................................................................................................................ 9

QOF guidance 2012-2013 ............................................................................................................... 4

Reminder on changes to HPV vaccinations .................................................................................... 8

Revalidation ..................................................................................................................................... 6

Supply of non-compliant nutritional products ................................................................................ 10

...................................................................................................................... 4

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1 BGPC meeting

The GPC held its meeting on 19 April 2012 and this newsletter provides a summary of the main

items discussed.

2 BIndustrial action

Plans are being finalised for the first ballot of doctors on industrial action in almost 40 years in

response to government changes to the NHS pension scheme.

The ballot will open on 14 May and close on 29 May. Most doctors working in the NHS will be

balloted, however for legal reasons we are not able to ballot certain categories of GP, including

self-employed locums.

The BMA has published an outline of the type of industrial action on which members will be

balloted (Urgent and Emergency Care Only) and is seeking a mandate only to undertake this

action. The Association continues to rule out the compl

The BMA is planning a series of actions but is committed to reviewing the impact especially on

patients at every stage before making a decision on next steps.

You will find lots of information on industrial action, including an audio slide show and frequently

asked questions, Hon the BMA website.H . Further information will follow including more detailed

FAQs. The BMA is also running a series of workplace events and road shows where you can find

out more; full details of the venues and timings etc are on the website, Htogether with details of

how to register H.

3 BNHS Reforms

The Health and Social Care Bill gained Royal Assent to become the Health and Social Care Act

amount of regulation and further guidance from the Department of Health is expected, providing

detail on how the new Act will work in practice. It is expected that regulations governing

commissioning will be released for consultation in July.

The GPC will continue to lobby the government and other stakeholders as the detail of the

secondary legislation is worked out and as the NHSCB, CCGs and the other new structures

continue their development. We will continue to provide GPs and LMCs will guidance and will

shortly be issuing guidance relating to the DH model CCG constitution. All of our current guidance

can be found on the HBMA NHS reforms webpagesH and although some terminology may have

changed, the underlying principles of this guidance remain relevant. You can email

Hinfo.commissioning@bma.org.uk H if you have any questions or concerns relating to the reforms or

the development of CCGs in your area.

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4 BFair commissioning charter

The GPC carried the following motion:

That the GPC would encourage any clinical commissioning group (CCG) which wishes to sign a Fair Commissioning Charter that includes that the CCG will: (i) Work to improve the quality of and access to local health services, and

reduce health inequalities;

(ii) Develop a culture of genuinely clinician-led commissioning, taking decisions in the best interests of the local population;

(iii) Engage with patients and the public with respect to decisions taken

about their health services;

(iv) Operate in a transparent and open manner, and in the interests of

transparency, not engage in any contracts or negotiations which impose conditions of commercial confidentiality;

In the further interests of transparency will take decisions in public unless

required to hold them in private for legal reasons. (v) Resist any qualified provider being imposed from sources outwith the

CCG; (vi) Always take decisions in the light of the likely effect on the important

relationship between individual GPs and their patients. (vii) Establish and strengthen working relationships with local medical

committees, further enabling successful outcomes in commissioning.

5 BCCG constitutions

As CCGs focus attention on authorisation, many are drawing up constitutions. HOur existing

constitution guidance outlines key elements of a constitution that GPs and LMCs should check

are includedH.

It is vital that the CCG constitution has the support of member practices and that the constitution

outlines how the CCG will engage with the LMC.

6 BDepartment of Health model CCG constitution - BMA Law

GPC / BMA Law have always advocated that any CCG constitution should be clear, robust and

comprehensible. Although the NHS Constitution is helpful, it is not really a template constitution,

it is more along the lines of detailed guidance. The main omission in the published NHS

Constitution is that it completely omits any role or involvement of local medical committees. Huge

sections of the Department of Health (DH) document are devoted to quotes and references to the

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Health and Social Care Act, which is confusing and unnecessarily burdensome in the context of a

comprehensible template. This makes it unduly difficult to convert into a working practical

document. Furthermore, the DH Constitution states that it has yet to be approved by lawyers.

BMA Law has a template constitution in place which is being updated in line with both the Act and

in respect of any agreed policy and guidance (whether current or future). This is accompanied by

a detailed seminar which addresses all salient issues such as conflict of interest, procurement,

engagement of consultants, internal governance, application for membership of the CCG etc.

This includes advice on how to handle these issues in a practical way and how to keep good

audit trails.

Other subsidiary documents such as the conflict of interest policy, procurement policy and the

also available.

If you would like to know more about this service including any training and seminars that BMA

Law offer, please call Diane Smith on 020 7383 6019 or email at Hinfo.bmalaw@bma.org.uk H.

7 B we know so f

Health Policy and Economic Research Unit has relaunched 'What we know so far...'

series of briefing notes on the NHS reforms.

The titles in the series are:

I. The NHS Commissioning Board

II. Health and Social Care Act at a glance (produced by the Parliamentary Unit)

III. Choice and any qualified provider

IV. New providers

V. Foundation trusts

VI Monitor and regulation

VII Local accountability.

Numbers 1 and 2 are new, and the rest have been updated to reflect any changes made in the

last stages of the Bill becoming an Act.

Each briefing has an accompanying 2-side executive summary. HThis is available on the BMA

website.H

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8 BQOF guidance 2012-13

The HQOF guidance for 2012-13H has now been published. This guidance has been produced

jointly by GPC and NHS Employers and forms part of the GMS contract changes for 2012-13 as

from 1 April 2012. HSupplementary Quality and Productivity (QP) guidance H, including frequently

asked questions, was published in February.

9 BEthnicity and first language recording guidance - update

The HEthnicity and first language recording guidanceH, which was originally published as part of the

Ethnicity and first language DES, and then published separately in 2011 after the DES was

withdrawn, has now been updated. This is to include extended classifications to the list of NHS

Data Dictionary codes for ethnic origin, which are based on a more comprehensive ONS 2001

census list, available within the Read Codes. Note that although practices may wish to continue

needs of their population, this is a practice choice as there is no longer any contractual

requirement to do so.

1 0BDispensing doctor feescale changes 2012-2013 - England and Wales

The GPC, the Dispensing Doctors' Association and NHS Employers have reached agreement

around the agreed changes for 2012/13 onwards for England and Wales. HThese are outlined on

the BMA's website Hand are effective from 1 April 2012.

1 1BChanges to practice boundaries from April 2012

As part of the agreement negotiated between GPC and NHS Employers for 2012/13, changes are

These changes have been introduced to help improve patient choice of practice and to amend

the closed list regulations, but they are unrelated to the piloting of remote registration and

consultation. Changes to practice boundary arrangements and the relaxing of the closed list

regulations, as described below, are permanent and apply across England.

(i) What changes are being made to practice boundaries?

The changes being made to regulations regarding practice boundaries really only

formalise what many practices already do. From the end of this April, PCTs will be

help patients who move a short distance outside the current practice boundary to stay

with their existing practice.

(ii) Do all practices have to create outer boundaries?

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Where a GP practice already has a large boundary area it may not be appropriate to

establish an outer boundary. This is recognised in the new regulations. However we

would expect most practices to work with PCTs to specify an outer boundary in some

cases this may only be a matter of a few streets larger than the existing practice

boundary.

agreement and should be advertised in practice leaflets and on websites. The

information will also be made available on the NHS Choices website.

(iii) What impact will the new boundaries have on patients?

Existing patients who move into the outer boundary area of a GP practice and remain

registered with that practice will be eligible for the normal range of services, including

clinically necessary home visits. Practices will need to bear in mind the feasibility of

home visits, and any possible impact on their patient population as a whole, when

agreeing their outer boundary.

Guidance will acknowledge that for patients requiring very frequent home visits, it may be

in their interests to register with a practice nearer their home rather than remaining with

their former practice simply because they live in its outer boundary area.

1 2BRevalidation

The BMA has written to the Department of Health, raising a number of concerns in relation to

England's readiness to implement revalidation. The letter expresses concerns about the

difficulties locum doctors will currently have in gathering supporting information, the lack of clarity

about how remediation will work and be funded, the uncertainty caused by the Health and Social

Care Act as to whom GPs' responsible officers will be, and PCTs implementing the evidence

requirements for revalidation before its start date. We will ensure that these concerns continue to

be taken forward with the relevant bodies.

1 3BEnhanced GP training

The RCGP's educational proposal for extending the GP training programme to four years was

approved by the Medical Programme Board on April 18. This follows an agreement between the

RCGP, COGPED, COPMED and GPC on a set of principles for the implementation of the

enhanced programme. An agreement will be required between the aforementioned organisations

as to how the implementation will work in practice, and the proposal remains subject to

confirmation by Medical Education England on 26 June.

HFull details of the proposal can be found on the RCGP website. H

1 4BGP Trainees Subcommittee newsletter

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of interest to doctors in GP training. HThe newsletter is available on the BMA website.

The newsletter includes information on education, training, contracts, terms & conditions of

service and the NHS reforms in England, as well as information on getting involved with the

subcommittee.

We would like this newsletter to reach as many GP trainees as possible, and would be grateful if

you could forward it on to trainers and trainees in your area.

1 5BPractice premises - leases

As th we are aware a number of practices operate

out of their premises under a licence to occupy. In light of the changing NHS landscape, it is

important for practices to have leases. As premises are moved into the nascent PropCo, this will

become more pressing: LMCs are asked to continue to put pressure on PCOs to supply practices

with a copy of their lease agreement.

1 6BFacilities management

The Practice Finance Subcommittee is aware that the abatement of service charges/facilities

management costs has been refused in some PCO areas. The GPC secretariat would be keen

to hear from LMCs who are aware of any practice that is currently facing a similar situation.

Please contact Alex Ottley ( Haottley@bma.org.uk H).

1 7BCervical screening training update

Officials from the GPC, Department of Health and NHS Cervical Screening Programme have met

to discuss the ongoing update training requirements for health professionals performing tests for

cervical screening in line with the principles for training set out in Barbara Hakin's letter of 15th

December 2011. It was agreed that:

sample takers need to be fully competent and appropriately trained in sample taking and

cognisant of the latest developments;

the GMS contract places a responsibility on practices both as providers and employers to

be satisfied this is the case;

the NHS Cervical Screening Programme supports practices both as a provider and

employer through its training and update programme;

individual training needs will differ between practices and between health professionals

and clinical governance systems should be in place to identify the training needs of all

clinicians involved in the screening programme (nurses and GPs).

The GPC would like to remind practices of their responsibilities as both providers and employers

- 8 -

who have a duty to ensure that staff are up-to-date. It is recognised that existing training

packages may not meet the needs of all, and practices may wish to explore different modes of

training delivery e.g. via cascade training or on-line tools.

We would also recommend that practices familiarise themselves with the primary care guideline

on unusual bleeding in young women. HThis can be found on the Department of Health website.

1 8BReminder on changes to HPV vaccinations

From September 2012 the HPV vaccine supplied as part of the HPV immunisation programme

will change from Cervarix to Gardasil. Until that time Cervarix should continue to be used, with

the aim of completing all courses by April 2013. A small supply of Cervarix will be available to

order after September 2012 for outstanding courses, but please note that quantities of this

vaccine will be capped.

For further guidance, please refer to the following Hletter from the Department of Health Director of

ImmunisationH which includes some helpful FAQs.

1 9BNICE infection control guidelines

NICE has published clinical guidelines for Infection control. HThese are available at the NICE

website.H

HThe consultation comments and responses can also be found on this page. H

2 0BBMA guidance on firearms licensing

The BMA has had further meetings with the Association of Chief Police Officers (ACPO) and the

police to GPs to

enquire whether there is any medical information th

suitability to hold a firearm.

We are aware the current system of obtaining information is causing concern for GPs. The BMA

and ACPO are looking for a longer and more enduring solution, however owing to the current

legislation governing firearms licensing it is anticipated that this will take longer than expected.

In the interim, the BMA has agreed that the letters will continue to be sent out to doctors. Doctors

are reminded that they are under no obligation to respond to these letters, but should they decide

not to, doctors should inform the police as it will otherwise be assumed that there is nothing

relevant on the medical record.

Where doctors are happy to respond to these letters, consent to the disclosure of any information

should be sought as the letter does not currently indicate that consent has been given. If the

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patient does not consent to disclosure, this should ordinarily be respected, although the police

must be informed to that effect. If, however, the doctor believes that the patient presents an

immediate risk of serious harm to themselves or others, information should be disclosed even in

the face of an explicit refusal.

Although the current letter from the police states that it does not have to be retained, the BMA

has been advised doctors can record the request for information in the medical record and

indicate what action, if any, they have undertaken. We are seeking to change the wording of the

letter to reflect the position.

There is no police should pay for

any work, but we are aware that the police do not accept this view. Serious concerns about a

2 1BPrescription charges

From 1 April 2012, the prescription charges in England increased from £7.40 to £7.65. The HBMA

has repeated the call for prescription charges to be scrapped in EnglandH in line with the policy in

the devolved countries. PCTs were informed Hvia a letter from the Department of Health.

2 2BFocus on anticipatory prescribing for end of life care

The GPC Clinical and Prescribing Subcommittee has published guidance to clarify issues on

anticipatory prescribing for end of life care. It includes an example an example of a drugs

administration document used for 'Just in Case' boxes. HThe guidance is available on the BMA

website.H

2 3BChanges to the community pharmacy new medicine service (NMS) payment structure

NHS Employers and the Pharmaceutical Services Negotiating Committee (PSNC) have agreed

changes to the community pharmacy new medicine service payment structure and have

published a Hbriefing document H to explain these changes. It is hoped that the changes will fairly

reward contractors and encourage them to deliver the service to the greatest number of patients.

Further information is available on Hthe NHS Employers website.

2 4BPayments to practices from non-NHS bodies

The GPC has recently received a request for advice with regard to local enhanced service (LES)

payments from non-NHS or third party bodies (eg third sector organisations). Payments made to

practices from a non-NHS funding stream can affect superannuation and notional rent payments,

as they are likely to be deemed as payments for private practice.

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Any additional activity that GPs undertake that is not arranged directly via NHS bodies is not

superannuable. Practices should not sign up to any additional arrangements unless they are sure

they are superannuable first.

The GPC will be publishing guidance in the future to remind practices and LMCs how to create a

LES in terms of arrangements with local authorities and other parties. National discussions

regarding LESs generally are also being actively pursued.

2 5BSupply of non-compliant nutritional products

The Department of Health Advisory Committee on Borderline Substances (ACBS), which is

responsible for advising on the prescribing of certain foodstuffs and toiletries, has produced a

guidance note on the supply of non-compliant nutritional products (attached).

This guidance highlights the problem of clinical errors created due to non-compliant stock

entering the medical supply chain. Non-compliance can include instances where nutritional

products have different formulations, are incorrectly labelled, or where there is incorrect

information provision. Further information is Havailable on the ACBS website.

2 6BGPC annual report 2012

This year's GPC Annual Report His now available on the BMA website.

2 7BBMA Law

BMA Law has an arrangement in place with Gateley's Solicitors to offer preferential rates to

members for the following services:

property / lease / landlord and tenant issues

dispute resolution and litigation matters including defamation

family law (divorce, co-habitation, residency applications and pre-nuptial agreements)

corporate, banking, finance and commercial matters in so far as they fall outside of BMA

Law's remit.

These services can only be accessed via BMA Law ( Hinfo.bmalaw@bma.org.uk H or 020 7383

6976) and Gateley will not accept instructions from members direct under this scheme.

The GPC next meets on 21 June 2012, and LMCs are invited to submit items for discussion. You may like to review these, beforehand, with the representatives in your area who serve on the GPC. The closing date for items is 12 June 2012. It would be helpful if items could be emailed to

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Christopher Scott at Hcscott@bma.org.uk H. You may also like to use the

GPC News

: Hwww.bma.org.uk

LMCs are reminded that their regional representatives can provide more detailed

information about the issues covered in GPC News, and other matters. Other members of the GPC would also be pleased to accept invitations to LMC meetings wherever possible. Their names and addresses are in the GPC Yearbook. The secretariat can also provide a written background brief if required, but it would be helpful to have such requests well in advance of your meetings.

This newsletter has been sent to:

Secretaries of LMCs and LMC offices Members of the GPC Members of the GP trainees subcommittee Members of the sessional GPs subcommittee

Events Calendar

June 2012

Tuesday ,12 Practice Nurse Workshop on Neurological Conditions

Contact: marie.vassallo@lmc.org.uk

GPNs

Wednesday, 13 Infection Control Workshop

Contact: Karen.cooper@lmc.org.uk

GPs and Practice Staff

Thursday, 28 Conversations concerning Child Protection for Clinical Staff Workshop

Contact: marie.vassallo@lmc.org.uk

GPs and Practice Staff

July 2012

Tuesday, 10 Practical Tips to meet CQC requirements

Contact: Karen.cooper@lmc.org.uk

THIS WORKSHOP IS FULL

GPs and Practice Staff

All events take place in a Central London venue and charge a delegate fee.

Full details are available on the LMC website: http://www.lmc.org.uk/news/news-detail.aspx?dsid=13906