Steps are being taken throughout general Practice to reduce the prescribing of medications for minor ailments that can be bought at a pharmacy ‘over the counter’.

NHS England have published a leaflet for patients which explains what GPs are trying to do, encouraged by CCGs and Practice Pharmacists.

https://www.england.nhs.uk/wp-content/uploads/2018/08/1a-over-the-counter-leaflet.pdf

But are those promoting the non-prescribing of OTC products overstepping the mark. Should they be telling patients that they can no longer prescribe OTC products. Are they simply trying to substitute cheaper products. Are they following national NICE guidelines are using a different product which they regard as just as effective whilst still saving money. What is going to happen to small pharmacies who loose dispensing fees

In my view Practices need to be very careful about the way they introduce these changes and the words and style of language they use when doing so. Each patients case needs to be treated on its merits and reference should be made to clinical letters and recommendations made by consultants.

My understanding is that the shift to OTC products not being on prescription is not a blanket decision and GPs need to be aware of that.

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Yet again the national Sunday press are harping on about ghost patients and the apparent cost to the NHS of over £500 million pounds per annum.

Ghost patients is a problem that NHS Managers in Primary Care have been aware of since the inception in the NHS on 5/7/1948. When I first started work in 1996 we used to send letters, known as Notices to patients when a doctor ceased to practice. If we sent out 2000 letters then at least 600 would be returned undelivered. This was a natural way of removing ‘ghost’ patients.

However in 2004, the new GP contract abandoned personal GP lists to be replaced by Practice Lists. Notices to patients ceased to be sent and medical cards ceased to be issued routinely too. Adam Smith the economist talked about war reducing the population – similarly notices to patients about Practice changes removed the, sorry, dead wood.

Nowadays there letters are only sent to patients about national screening programmes and  the dead wood effect by comparison is minimal. GP Practices are also expected to clean up their patient registration data but there are no real incentives for them to do this as they will simply loose income. Arguably it not the Practices fault that patients have moved on and not told them.

I would argue that ghost patients are a natural phenomenon of the system and it is unlikely that it will change. GP negotiations on Practice income do take into account the ghost element but the very idea of ghost patients always  captures journalists imagination.

Here are some reasons why ghosts occur :

• Practices do not normally become aware of Patients who die abroad.
• Patients move to a new address and for a short time may be registered twice or not at all at their new address.
• Children may be one adopted and former registrations not traced or removed
• Patients may change their name and still remain registered somewhere else
• Patients may register who are refugees or asylum seekers and  remain registered although they have move on or return abroad
• Emmigrants may remain registered but live abroad. In some cases thus may be deliver so they can return home for NHS treatment.

Looking at the figures quoted in the Sunday papers, about 6 patients out of 100 might be ghosts. This means around 55 patients per whole GP are ghosts. This amounts to around £8,350 per GP.

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I have added to the Practice Index Forum two new documents to help GP Practice Managers prepare Policies, Protocols, Procedures, Plans and Presentations that might be required by the Care Quality Commission.

It all started with the voluntary Quality Framework so the first shorter document give a summary of the topics that as a bare essential ought to be covered by a ‘document’. The second document is more detailed and attempts to provide the basis for a multitude of documents.

The link to the site, which you will need to join, membership of the Forum is free, at

http://www.practiceindex.co.uk/forum

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50% of Practice Managers new to the job

Some 50% of GP Practice Managers have taken up their posts in the last five years. There are many I am sure enjoy their job thoroughly, whilst there are others who are not so happy. The pay and working conditions vary significantly from practice to practice due to the independent nature of general practice. Added to that practice budgets have become tighter and tighter, but I also have to say that the nature of GPs working in general practice has changed too!

How has it Changed?

Since 2004 GP Practices arguably have become more independent with their own budgets and the right to decide how to man their practices with GPs or other health professionals and how many days and sessions each GP works each week. There are no longer any controls on how many GPs are allowed to work in one practice. The Medical Practices Committee, which decided who could work where was abolished. There are fewer singlehanded practices, around 800, and fewer GPs working full time.(around 15%).  Added to that female GPs now work in greater numbers than male GPs, but part time working has now overtaken full time working as the predominant feature of a modern partnerships or practices. The question arises as to whether the commitment to general practice is as strong as was say 20 or 30 years ago. Do part time GPs really want to own premises?

Uncrowned but not deterred 

For the Practice Manager, the role of leader and manager is uncertain. The expertise and skills required of a “manager” have increased over the years from being a good secretary able to type and work with a spreadsheet, yet the modern manager is normally not part of the ‘ownership’ of the practice and is just an employee just like all the other practice staff. A well managed practice will have a “chain of command”. The staff will be led by the Practice Manager and the GPs will only become involved when there are disputes, disciplinary and grievance issues to deal with and their are plans and policies to decide.  The Manager may be a signatory to bank accounts, not quite so rare these days, and be able to manage the finances of the practice, but I suspect it is more common place for at least one GP to be in charge of the money. Acmanager able to and allowed to manage the GP Team I still think is unusual.

Middle of the Pack

The Manager, therefore, has a role that is in the middle of the practice between the staff and the doctors. In fact, the manager may have no management control over the Nursing Team.  The Practice Manager May look after the premises, changing light bulbs and counting toilet rolls. There is often a balancing act going on in practices whereby for instance the manager sets up the appointments system, but then finds it has been tinkered with by the doctors. Staff may also have access to the doctors on a whole range of issues bypassing the manager. Its like shifting sands and the poor manager never knows whether he or she is heading for the quicksand and ends up swimming against the tide. I found the most enjoyable times were when I was left with the responsibility to get on with something with minimal interference. For me, this involved developing a major extension, including a new pharmacy, which I was very proud of. I also enjoyed developing the computer systems from one PC in 1997 to more than 40 in 2010.

Equal Status Quo

To me the solution lies in appointing a practice manager who has equal status with the team of doctors and is able to work with them and agree issues without constantly being overruled. The Managers pay should reflect the GPs pay, along with the same terms and conditions. This does not mean that the Manager should be a partner but of course this is happening in practices up and down the country. During the last decade, many Practice Manager Groups have been established supplemented by web sites that concentrate on providing positive support and information for Practice Managers. Being a Practice Manager can be a lonely affair and with Forums such as that provided by Practice Index Practice Managers can keep in touch with each other through a national network of like minded managers.

Pressure Points

I always enjoyed my work but I did not enjoy the conflict and the pressures. I was concerned that new technology was not being taken on-board by all members of my practice. I was also concerned about the loss of expertise in local NHS bodies only to be replaced by inexperience and yet more and more paperwork. How many experts can you find on NHS Pensions. I often wonder whether GPs understand how much ‘practice management’ has developed and changed particularly with the advent of the Care Quality Commission.  Who did GPs think we’re going to write literally scores of Policies, now expected by the Care Quality Commission.

The work levels have become ridiculous………

Robert Campbell

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A new page has been added setting out Interview Questions that might be used for Practice Staff Interviews.

The page looking at Time Management has had some time spent on it expanding the content.

July 2018

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