ࡱ> 4>3j5@ %bjbj22 2UXXZ,8L,,=PP"rrUq }>=@=@=@=@=@=@=$?R/Bd=3"Ud=ry=48r>=>=(6{9.<D 9cp:"==0=:BP^B8.<,,B.<"d=d=,, (,,August 2006 Identifying services that should not be provided by GPs under primary medical (GMS, PMS, APMS or PCTMS) services Guidance for GPs  Identifying services that should not be provided by GPs under primary medical (GMS, PMS, APMS or PCTMS) services GPs should not be asked to accept overall clinical responsibility for patients in secondary care institutions or for those in any setting where the clinical needs of the patient fall outside the normal skills of GPs. On several occasions in the past, the GPC has been made aware of GPs being asked to provide services to patients residing in institutions or homes where the type of services expected do not fall under the responsibility of primary care. At the margins between secondary and primary care, most typically in various types of long-stay psychiatric institutions, it is sometimes difficult to define in any absolute sense where responsibility for patient care lies. This is not in patients best interests. Care for patients in intermediate care can also present problems of poorly-defined professional remits. This problem is salient in the light of the trend to discharge relatively high-dependency patients from hospitals to other institutions. Although GPs often provide vitally important care for patients in intermediate settings, the care these patients need will sometimes go beyond that which most GPs are trained, or contracted, to provide. With this in mind, this short guidance document has been put together to help doctors decide whether or not the patients they are treating in institutions and residential homes fall under standard primary medical services contracts. Identifying secondary care institutions When assessing institutions to determine who is responsible for patients, it is worth considering a variety of points which will help indicate whether GPs should be providing services: Who funds the establishment and patients care? Which organisation inspects the institution - the hospital or nursing home inspectorate? Is there a consultant or other non primary care doctor with clinical responsibility for the patients/residents? What are the historical care and funding arrangements? Do the patients qualify for secondary care services such as ambulance transport and pharmacy? Does the care that the residents or patients usually or regularly need fall within the GMS definition of essential services? Are there often instances where the level of care required is above that which would normally be provided by GPs? GPs are likely to be responsible for patient care if: the residents fall into the practices geographical area and social services pay for care in the institution the institution is registered as a nursing home sheltered accommodation and residential homes usually fall under primary medical services the home is inspected by the nursing home inspectorate. [These characteristics indicate that GPs MAY be responsible but they need not all be present, nor is this an exhaustive list. Moreover, even if these points apply, the GP may not be responsible if other factors outweigh these characteristics.] Even where GPs are required to take responsibility for residents or patients there is no requirement to provide any services beyond those set out in the GPs primary care (GMS, PMS etc) contract and GPs should be wary of working outside their normal clinical remit without the appropriate training. If a GP is working outside their normal expertise and training they put patients at risk as well as their own registration. GPs are unlikely to be responsible for patient care if: a consultant or other hospital doctor has clinical responsibility for the patients or residents hospital medication or documentation is used in the institution the institution is secure and staffed by psychiatric nurses patients in the institution have unlimited ambulance access the home is inspected by a hospital inspectorate the indemnity they have or are expected to have does not extend to the type of care in question (is the GP indemnified by the NHS or are they providing their own indemnity?) care has historically been provided by secondary services and funded out of a secondary care budget. What to do if you are being asked to provide primary care services to patients in secondary care institutions GPs are under no obligation to provide care to hospital patients and should not do so unless under a specialist private or NHS secondary care arrangement. Even where such an arrangement exists, it should be noted that some services simply do not fall within the competencies of a GP and should be provided only by a doctor with the appropriate specialist skills and training. GPs who are being pressured into providing care in hospitals should contact their LMC. In England, their case may be forwarded to the GPC which can refer the case to the Implementation Coordination Group (ICG) for a decision. The ICG should be able to confirm that the service falls outside contractual requirements. Each country has systems for dealing with cases of this nature. Patient care should not be allowed to suffer whilst disputes are being resolved; withdrawal of services will therefore need to be planned and well communicated. All doctors should of course remember that the GMCs guidance on emergency care states that, in an emergency, doctors must offer anyone at risk the assistance they could reasonably be expected to provide. Providing care to patients in non-hospital institutions or residential homes Neither the provision of services beyond those covered by the contract, or beyond the clinical skills of the doctor, nor the care of patients outside a PCOs area can be forced upon a contractor. If a GP determines a service or assessment is required a referral to a specialist service should be made; if no such service exists the GP should contact the LMC and the Director of Public Health; LMCs may wish to involve the PCT CEO and possibly its chairman. Practices that are providing care to residential patients or to patients in intermediate or continuing care institutions should ensure that the level of service required by the institution is not greater than that defined as essential services. If this is the case, the PCO could enter into an additional contract with the GP/practice or with another GP/practice (including one outside the area) through a local enhanced service or GPwSI arrangement. It is important to note in these cases that enhanced services funding should not be used to fund any service reaching specialist levels or that is provided by specialist. GPs should not allow themselves to feel morally blackmailed or contractually threatened to provide services beyond their level of competence. In providing care GPs must always: recognise and work within the limits of their professional competence be willing to consult colleagues be competent when making diagnoses and when giving or arranging treatment ensure they are properly indemnified for the services provided, according to the terms of their contract. Patients receiving NHS continuing care will often need an increased level of care such as the input of a specialist or GP with special interest. Institutions or PCOs should be made aware that asking GPs to provide services outside their competency can put patients at risk and that failing to provide proper care for patients could lead to enquiries by the Healthcare Commission. 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