LMC Postion paper on Collaborative Working
Introduction
With the passage of the Health Bill, the development of CCGs with their obligation to deliver the QIPP programme, and the continuing drive to provide services nearer to patients’ homes, there will inevitably be a growing wish to transfer of work from Secondary to Primary Care. This can result in considerable pressure on practices, who have to balance the wish to provide a wide range of safe services versus the limited resources available. In view of this, the LMC sets out in this paper its current policy on how this process should be managed.
The aim of this document is to avoid confusion amongst clinicians and managers, to foster co-operation between providers, and, most importantly, to ensure the safety of patients.
Agreements covered by this Document
Several Shared Care Agreements (SCA) have been in place for some time and these generally relate to prescribing and medicines management. Shared Care Pathways (SCP) and Flexible Care Pathways (FCP) have evolved more recently but many of the principles and guidance related to the establishment of SCA between parties can easily be transferred to the other processes.
Guidance
GPs may sometimes feel under pressure to participate in the shared care of patients despite having reservations about the appropriateness, safety or resource provision for doing so. The LMC accepts that it is generally more convenient for patients to receive as much care as possible in primary care with a minimal number of visits to the hospital, but there are some key matters that need to be considered before any particular agreement can be accepted. These can be grouped under the three broad headings of communication, the contract basis under which the work is to be done, and patient safety.
General Questions
Each proposed agreement should be considered using a standard set of questions. For prescribing and Shared Care Pathways we suggest:
What is the condition?
2. It is the condition suitable for shared care?
3. Is the patient's condition stable?
4. If involving prescribing - Does the GP have full knowledge and experience of any drug to be prescribed?
And, in addition, for Flexible Care Pathways:
1. Does the GP have enough clinical experience and knowledge to safely manage the condition in Primary Care before referral is triggered?
Resources
Work in general practice is not a “free good”, and activity transferred to primary care must be resourced. This leads to a further set of questions to be asked of all pathway developers:
Staffing:
1. Who provides the service at present?
2. What are the human resources required to provide the service?
3. Are there any other alternatives that could be used?
4. Does the general practitioner have adequate human resources to deliver shared care?
5. Does the general practitioner have adequate equipment and access to investigations to deliver shared care?
Finance:
1. What are the financial resources required to provide the service?
2. What will it cost to provide the service?
3, Are there any other financial resources which could be used?
4, Does the general practitioner have an adequate drug budget to pick up the costs of any prescribing involved?
Communications
Reliable, comprehensive and secure communication between the different providers involved in any agreement are essential.
1. Are there adequate communications between the consultant and the Practice to ensure safe management of the patient?
2. Do the Practice and Consultant both agree as to who carries the day-to-day responsibility and the ultimate responsibility for the management of patient should a problem arise?
3. Is there a fast-track route back to the specialist team should problems arise?
4. How will the patient be reviewed?
Contractual matters
All work done in primary care must have a contractual basis. By definition, transferred work is not within practices’ core PMS or GMS agreements.
1. What contract exists or is proposed for the work in question?
2. Do all parties know that unless specified otherwise in the contract, each GP is free to decline to take on the work, either generally or in a specific case?
3. If work is moving from secondary care, how is the relevant tariff being unbundled?
4. What are the arrangements for terminating the agreement?
Role of the LMC
Depending on the degree of work and number of patients involved the LMC believes it is normally best to negotiate a local enhanced service (LES) to cover the participation by practices in the provision of these services The LMC has a central role in negotiating on behalf of practices between the various bodies who produce shared care agreements. However, it remains to each practice to decide whether or not to sign up to the LES or other supplementary contract in question
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