Mais les résultats doivent être attendus longtemps et il n'y a généralement pas de temps amoxicilline prix L'autre cas, c'est que l'achat d'un ou d'un autre antibiotique dans une pharmacie classique nécessite des dépenses matérielles considérables et pas toutes les personnes ne peuvent acheter des produits pharmaceutiques aussi coûteux.
Microsoft word - gst lmc_minutes_15.4.13.doc
Minutes of Gateshead & South Tyneside Local Medical Committee Meeting held on
Monday 15 April 2013 at 7.30pm at the Holiday Inn, Washington
MEETING NO: 13/03
The Chairman welcomed Dr Vis-Nathan. Dr Vis-Nathan had been co-opted to the vacancy within the
Gateshead constituency, which had not been fil ed fol owing a recent request to Gateshead GPs.
Representatives from the Local Authorities were also welcomed and introductions were made. 13/03/01
To Receive Apologies for Absence
Apologies for absence were received from Drs Bolas, Heycock, Hutchinson, Orritt, Ryan, Sadhasivam and Win.
Public Health Local Enhanced Services
Gateshead Council – Carole Wood, Catherine Scott
South Tyneside Council – Amanda Healy, Christine Shields, Wendy Surtees
From 1 April 2013 Public Health Local Enhanced Services are to be commissioned by Local Authorities (LA). The LMC Officers had met with representatives from the LA in both Gateshead and South Tyneside to discuss/negotiate the new arrangements. Ms Healy reported that al current contracts would rol over in South Tyneside for 2013/14 and that the LA would work with the LMC to develop a ‘Life Style’ LES for practices to opt into from April 2014. Ms Wood reported that Gateshead Council’s legal department had wanted a contract drawn up based on the standard NHS contract; this was being developed in conjunction with the LMC. Specifications would remain unchanged; these would be reviewed in year. Ms Healy commented that whilst South Tyneside LA had intended utilising a Service Level Agreement for Public Health enhanced services for this year, the contract being developed in Gateshead may be considered as the way forward to maintain consistency across Gateshead and South Tyneside. It was noted that funding for Public Health Enhanced Services had been ring-fenced for 2 years and that pace of change was not yet known. The Secretary referred to payment arrangements; some practices were concerned
returns/payments for enhanced services would in future be via 3 separate organisations. Dr Kirk reported that Gateshead CCG was intending utilising the RAIDR software reporting tool, which was capable of carrying out a monthly trawl of practice data to assist with LES returns. Dr Kirk suggested that, subject to LMC agreement, this method of data collection could be used by the various organisations.
Clinical Commissioning Groups
Gateshead Practice Clinical Commissioning Project 2013/14
The proposed PCCP framework for 2013/14 wil encompass primary care quality indicators, QP QOF pathways, additional CCG commissioning pathways and engagement in clinical commissioning. The framework wil attract payments from the QOF and the CCG’s local incentive scheme to ensure that no duplication of payments wil be made. Participation in the PCCP wil attract £2.05 per head of practice population. Dr Kirk intimated that the funding might be reviewed in light of the 1.32% uplift to contract payments in 2013/14. It was noted that the reward element of the scheme, which required practices to collectively deliver financial balance had decreased from 43% to 20% when compared to the 2012/13 project. Practice wil access data via RAIDR when developed, as opposed to BIRT.
The proposed PCCP was discussed. The Committee considered that the scheme should be about good quality and not reducing referrals. Dr Kirk was advised that grass root GPs were of the view that such scheme were about reducing referrals and cost and therefore had a purely financial motive; the Committee believed that the CCG needed to be upfront about this aspect of the scheme or they would lose credibility. It was also believed that the CCG needed to be mindful that some patients would not be referred when they should be and that GPs were doing a lot of work when it was the pathways that needed reviewed. Evidence to support some of the quality indicators was questioned; differing views were voiced. The Secretary would col ate members’ views expressed and those submitted via email; these would be communicated to the CCG. (ii)
Risk Profiling and Care Management Scheme
Facilitating Timely Diagnosis and Support for People with Dementia
Remote Care Monitoring (Preparation) Scheme
In terms of Remote Care Monitoring, CCGs had to agree with practices a clinical area for remote care monitoring to be implemented in 2014/15; selecting something simple to monitor was acknowledged. In terms of the Risk Profiling and Care Management Scheme, it was hoped to continue the work established last year around COPD. The Chairman welcomed that the CCG planned to capitalise on the work that had already been done.
Dr Walmsley commented that the papers he was presenting had been through the CCG’s Executive Committee but had not been signed off by their governing body.
South Tyneside Improving Care Scheme 2013/14
The Improving Care Scheme involved delivering care in a different way to more vulnerable groups of patients in South Tyneside. It aimed to do this by building on existing skil s gained in Shared Decision Making (SDM) as well as the CCG supporting the development of additional skil s training and support for clinicians. The scheme had a number of small elements, which in total wil be funded at £2.05 per registered patient. It was noted that in terms of attending MAGIC+ training, which was a requirement of the scheme, practices were being surveyed on what training they wanted. The Vice-Chairman welcomed the concept of the improving care scheme, but expressed concern about the number of patients that practices were required to identify and the work involved for the funding on offer; the Committee believed that proactive care highlighted more work, which would result in more than the number of visits to patients estimated. The Committee considered that the numbers stipulated were “ridiculous” if the CCG wanted quality. In terms of timing, since it was already mid-April and the scheme had not yet commenced, the LMC was clear that should the CCG not be flexible in reducing numbers, there would be no flexibilities from a general practice perspective and the EMIS templates would have to be in place by 1 May 2013. The Secretary would col ate members’ views expressed and those submitted via email; these would be communicated to the CCG.
Management of Patients with LVSD – Local Enhanced Service
LMC comments were sought on the proposed Local Enhanced Service to fund practices to provide enhanced care to patients who had left ventricular systolic dysfunction. Changes to the previous specification included an ECG being performed (clarification was awaited on which patients required this) and an ACEI or ABR being introduced to maximum tolerable doses. LMC views would be col ated and submitted to the CCG.
Prostate Cancer – Local Enhanced Service
The document shared with the LMC was a very early draft of the proposed Local Enhanced Service for Prostate Cancer, which would formalise shared care between secondary and primary care. LMC views would be collated and submitted to the CCG.
The aim of the quality in prescribing scheme is to achieve cost-effective prescribing, improve quality of prescribing and ensure value for money from use of NHS resources in the interests of all patients. The freed up resources could be used to improve patient care and treat more patients. The Chairman commented on the inconsistency on the ‘headings’ in the draft document, which referred to the prescribing incentive scheme/prescribing engagement scheme; Dr Walmsley acknowledged this. LMC views would be col ated and submitted to the CCG.
To Receive the Minutes of the Meeting held on 25 February 2013
Subject to amending CPR to read CRP in minutes no. 13/02/05, the minutes from the meeting held on 25 February 2013 were agreed as an accurate record.
South Tyneside Improving Care Scheme 2013/14
Dr Walmsley had tabled at last meeting an outline of the proposed South Tyneside Improving Care Scheme for 2013/14. General comments had been submitted. The update scheme had been received and discussed under 13/03/03b(i).
The GPC had urgently commissioned external property lawyers to comment on a draft model lease agreement recently shared with them. If the lease was considered reasonable, GPC proposed to agree to it being used as a national template for al NHS Property Services owned premises occupations.
The LMC had queried some of the service charges that the former PCT were intending to levy on a local practice; a response had been received. Further discussions were needed, as some of the proposed charges were astonishing and some items listed should be covered under the rental costs. It was noted that reimbursements for premises had been maintained in the NHS (General Medical Services – Premises Costs) Directions 2013; reimbursement was at the discretion of the Area Team of NHS England. The Officers of the North East Regional LMC would be meeting with a local solicitor with expertise in NHS leases/service charges. Dr Ward reported that 4 local practices had contributed to obtaining a Barrister’s opinion on the situation.
There had been no response from Ms Stephenson or Dr Bradshaw concerning the updated shared care protocol framework. The Secretary was tasked with writing to South Tyneside practices to recommend that they do not to prescribe any amber drugs that they were not happy with until the LMC was in a position to advise otherwise.
The Secretary had written to practices twice to encourage them to participate in The Cameron Fund Charity Levy. To date, 6 practices had expressed interest in signing up. This would be communicated to The Cameron Fund.
The interim arrangement of GatDoc and Primecare having NHS 111 act as a cal handling service only, whilst NDUC in South Tyneside remained with the full service, was stil in place. Attempts were being made to resolve the issues around the messaging system; special patient notes were stil problematic.
There had been a lengthy exchange of correspondence between the Regional LMC and Dr Regnard about the new DNACPR Form. Whilst the revised form al owed a maximum 12-month review period, the necessity for a form with a ‘red border’ remained. The LMCs believed that it was unprofessional and an affront to the patient’s dignity if a paramedic was aware of a valid DNACPR, which was correctly completed and signed, and they ignored this because it did not have a red border.
Orthopaedic Outpatients/Fracture Clinic Med3 – Gateshead
The issue raised by Dr Ward concerning the orthopaedics department’s reluctance to provide a Med 3 (Fit Note) had been taken up by the new Medical Director at Gateshead Health NHS Foundation Trust.
Outpatient Admissions – South Tyneside
Concerns about the time delays that GPs were experiencing in contacting the bed manager had been communicated to Dr Wahid. South Tyneside NHS Foundation Trust had agreed to review this again. There would be a slight change to the audit previously conducted, as it would include GPs being asked how long they had been waiting on the line.
The issue of a local Consultant asking a GP to prescribe Esmya in place of Zoladex, as it was not on the hospital formulary, had been raised with South Tyneside NHS Foundation Trust. Dr Wahid had confirmed that the Consultant concerned would be making representations to the Medicine Management Committee to have Esmya included on the hospital drug list.
The North East Regional LMC had written to the Secretary of State for Health and all local MPs concerning ambulance response times for emergency admissions; the communication had included a copy of the letter received from Mr Reed, CEO of NHS North of Tyne (lead commissioners of the ambulance service), which was a response to concerns raised. A formal reply from the Regional LMC had been made to Mr Reed; it was noted that Mr Reed’s suggestion that NHS pathways be used to further triage a patient after a GP assessment was considered total y inappropriate and insulting to the profession. The final letter from Mr Reed on the matter read “The
matters you raise with the Regional LMC’s ongoing concerns are ones I share and I
have noted that you are not reassured. There is no doubt that improvements are
needed and as I depart this week I have to leave it to those involved from April to
take this forward. In doing so I have alerted the NHS Commissioning Board, the CQC
and Monitor to this matter and I enclose for your information a copy of that letter”.
Motions submitted to LMC Conference this year were: (1)
That Conference believes that with the formation of NHS Properties Limited (Prop Co) and the transfer of al PCT owned premises to that organisation that:
there must be a suitable, mutually acceptable pace of change when there is a significant rise in lease and service charges;
the present course of action with massive increases in costs wil lead to instability of inner-city practices;
practices must be able to shop around for providers of facility services, as other practices do in non-NHS premises.
That conference believes that the practice of “opting to tax” by PCT estate managers and therefore adding VAT to al aspects of charges, including rent,
rates and utilities, is an unacceptable added burden to practices.
That Conference insists that practices have a real increase in expenses so that GPs enjoy a pay freeze as the rest of the staff within the NHS.
That Conference believes that when new enhanced services are introduced there must be a substantial evidence base behind them, must be practicable, must be ful y resourced and must be free of political interference.
It was noted that the proposed lengthy motion regarding PCT owned premises had been cut down and split into two motions; this was on the advice of a former Conference Chair.
North East Primary Care Services Agency - NHAIS system
The National Health Application & Infrastructure Services (NHAIS) systems were being tidied up so that GPs and their patients would be hosted on one system. This involved only small numbers of patients at the present time, i.e. practices with less than 56 patients, but could involve practices re-registering larger numbers of patients in the future. No resources had been identified. The Secretary was tasked with enquiring of the Area Team why patients cannot be transferred electronical y and communicating that should this involve large numbers in the future then the work would have to be appropriately resourced. (b)
The GMC had developed a Regional Liaison Service for support and advice. The LMC Officers had met with Rachel Woodal , the Regional Liaison Adviser for this area. (c)
North East Primary Care Services – FHS Functions
A letter had been received from the North East Primary Care Services Agency concerning FHS functions, “Due to the major structural changes within the NHS
resulting in the abolishment of Strategic Health Authorities and Primary Care Trusts,
the North East Primary Care Services Agency wil no longer exist from April 2013.
I am therefore writing to inform you that with effect from 1 April 2013 the Family
Health Services functions wil transfer to the NHS Commissioning Board and wil be
part of Durham, Darlington and Tees Area Team. Office locations will not change and
we wil continue to be based at Partnership House and The Old Exchange.
There have been no major changes within the FHS infrastructure therefore your
normal contacts etc. wil remain the same.
The Committee was reminded that the annual uplift was generally in line with DDRB recommendations. Consequently, there would be 1% uplift to Officers’ and Members’ fees for 2013/14.
Secondary Care Trusts Matters
Winter bed pressures continued; an outbreak of vomiting/diarrhea and the large number of genuinely unwel people requiring hospitalisation had contributed to this. (ii)
Dr Nixon reported that appointments for two of her patients with cancer had been put back for what she considered to be an inappropriate length of time. Dr Wahid confirmed that it was for individual Consultants to determine how to manage their caseload, but the matter would be raised with the Medical Director on receipt of specific patient details. (ii )
In response to Dr Vis-Nathan, Dr Wahid confirmed that there were arrangements in place with other Trusts to enable the diversion of patients being transported to hospital by ambulance if the receiving hospital was under pressure.
To Receive Reports from Sub-Committees
The Local Representative Committees were working with Gateshead Council to establish a scheme, which would provide a transparent and efficient system for allocating work experience placements in the primary care sector. (ii)
An issue had been raised with the Local Ophthalmic Committee concerning patients being coerced into a hearing test at Spec Savers whilst attending for eye examination. Members reported that the hearing aid department at the Queen Elizabeth Hospital is requesting that patients are re-referred to them under an AQP procedure. The Secretary would clarify the position with the Trust. (ii )
There was a shortage of standard release Isosorbide Mononitrates, although there was a brand available, which is unlicensed at the present time. LPC representatives had confirmed that this brand is quite safe, but the prescription had to be marked with the words ‘unlicensed product’, and the GP had to endorse each script. The LMC had written to practices on this matter.
The online pharmacy company ‘Pharmacy2U’ is running a patient nomination mailing campaign, inviting patients to use the Electronic Prescription Service. The letter to patients seemed to suggest that this is a new NHS service working with doctors to arrange and deliver medicines, and this letter has been interpreted as having been
sent by the NHS and having been endorsed by local GPs. The LMC had made practices aware that this was happening. (b)
An update on the status of practice mergers across the area had been shared. (ii)
An update had been given on staff appointed to the Area Team. (ii)
It had been agreed that future Liaison Meetings would generally be held 2 monthly.
Reports (for information)
Northumberland, Tyne & Wear and Cumbria Area Team
Dr Malcolm Fulton Cheyne retired from Jarrow GP Practice on 30 September 2012
Dr Martin Terry Cope resigned from Bewick Road Surgery on 28 February 2013
Dr Manjit Singh Suchdev retired from Pelaw Practice on 28 February 2013
Dr Houda Ounnas joined Bensham Family Practice, as a Salaried GP, on 1 March 2013
Dr Fergus Edgar Francis McBrien resigned from Crawcrook Medical Centre on 28 March 2013
Dr Janette Merilees Foo resigned from Crawcrook Medical Centre on 28 February 2013
Dr Victoria Ann Parker resigned from Oxford Terrace Medical Group on 29 March 2013
Dr Anne-Marie Helen Rajan joined Oldwel Surgery, as a Salaried GP, on 10 April 2013
Merger of two GP Practices: Dr C K Mandal and Birtley Medical Group merged on 1 April 2013.
Dr Stanley Waters Chapman wil resign from Crawcrook Medical Centre on 30 June 2013
The N3 network is being upgraded under the GP Next Generation Access programme, which wil help ensure that GPs are equipped with faster broadband technology to help improve access to clinical applications and services. Al practices under this scheme wil have access to broadband of at least 2 megabits per second. Funding has been made available for every practice in England to be upgraded under the programme. The Secretary reported that he had written to North of England Commissioning Support (NECS) to recommend that they advise practices how to access ICT support. The Chairman advised that the IT department had yet again changed the type of
printer they were supplying to practices; this had been done without prior consultation with the LMC. Whilst the printers were reasonable priced, the cost of the cartridges were in excess of £190 each; the Secretary would write to NECS on the matter.
Incoming Documents (for information)
Any Other Business
Dr Groom presented this paper, which described her personal views based on the belief that the NHS no longer existed, and that general practice needed to retain its core characteristics but embrace major change in how they organise and provide care if they still wished to provide holistic care based on need and publical y provided. The paper referred to general practices seeing a major drop in income over the next 2-3 years and how GPs would be faced with some serious decisions if they wished to maintain current profit shares, as profits decreased. Dr Groom believed that GPs would either have to look for major new revenue streams, without increasing costs or look to decrease outgoings. Dr Groom’s paper proposed that acute and emergency care was an area that general practice needed to get back into and, in order to do so, that they needed to look at how practices were organised, working times and structures. The paper talked about practices reducing costs by centralising administrative functions. Next steps suggested were agreeing which practices wanted to be involved in the discussions, and setting up working groups (one in each area) to consider reducing costs by centralising administrative functions and re-involving general practitioners in some aspects of acute and emergency care. Dr Groom’s proposal was discussed and commented upon; it was general agreed that the concept should be pursued. It was not believed that the LMC should lead on this but considered it was appropriate to facilitate an open meeting and provide some initial funding to support the work involved. It was agreed that LMC members would share the paper with col eagues to gain wider views.
Dr F Nixon – South Tyneside Citizen Advice Bureau: Medical Reports
Dr Nixon brought to the Committee’s attention a letter to practices from the South Tyneside Citizen Advice Bureau advising that they would no longer pay for medical reports. Recognising the financial constraints that the CAB worked within, it was considered important that the organisation understood the situation that general practice faced at the present time in terms of huge funding cuts and workload imposition. Acknowledging that it was for individual practices to determine whether to write a report and charge for it, or provide a printed summary only, the LMC believed that if a formal report is requested then provision of such a report should be appropriately resourced. It was also believed that the CAB should not raise patient expectations in terms of getting a report and the usefulness of it; that it was more appropriate for the CAB to
write to GPs asking them whether they would be wil ing to provide a report and for what cost, as opposed to asking the patient to attend their GP to discuss this; and that the CAB needed to be sensitive to the fact that practices operating in deprived areas had a disproportion amount of requests for these reports. The Secretary would communicate the Committee’s view to the South Tyneside Citizen Advice Bureau.
Date of Next Meeting
Development of a fg/mL Level LC-MS/MS Method for Fluticasone Propionate in Human Plasma Mohammed Abrar, John Allanson, Philip Dalton, Ian Smith and Helen Young Unilabs York Bioanalytical Solutions, Cedar House, Northminster Business Park, Upper Poppleton, York YO26 6QR, UK ABSTRACT Selectivity MATERIALS AND METHODS There were no significant interferent peaks in the re
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