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The launch of Pharmacy First

The launch of Pharmacy First

Pharmacy First was launched by the government and NHS England on 31 January 2024, as part of the primary care access recovery plan. The scheme enables community pharmacists to supply prescription-only medicines for seven common health conditions, so that patients can more easily access clinically-appropriate care without having to make a GP appointment.

More than 10,000 pharmacies in England (over 95%) are already signed up, and on the first day of the scheme they provided 9,800 patient consultations according to NHS England. With a publicity campaign running until the end of March 2024, greater patient awareness is expected to gradually increase use of the service, helping to relieve pressure on GPs.

So, what does Pharmacy First offer, and will it really help to reduce GP workload?

What services does Pharmacy First provide?

Pharmacy First aims to free up 10 million GP appointments a year by this winter, by enabling patients to consult a pharmacist instead of a GP for certain common ailments.

The service is in three parts: 1) minor illness consultations and 2) supply of urgent medicines (and appliances) – previously part of the Community Pharmacist Consultation Service (CPCS) – and 3) the new clinical pathway consultations. GPs can refer patients for minor illness consultations and clinical pathway consultations.

With the launch of Pharmacy First, patients can access a clinical pathway consultation, and receive prescription-only medicines where clinically appropriate, for the following seven common health conditions:

  • Acute otitis media (1–17 years) – this service is not provided by Distance Selling Pharmacies
  • Impetigo (≥1 year)
  • Infected insect bites (≥1 year)
  • Shingles (≥18 years)
  • Sinusitis (≥12 years)
  • Sore throat (≥5 years)
  • Uncomplicated urinary tract infections (women 16–64 years).

The scheme also includes the previously launched expansions to pharmacy blood pressure checks and oral contraception services.

How do patients access the service?

Patients can access Pharmacy First services by walking into a pharmacy, via video consultation, or by referral from NHS 111, the NHS app, urgent care or urgent treatment centres, A&E, 999, or general practice.

As most people in England live within a 20-minute walk of a community pharmacy, this will enable quick and convenient access to treatment. The service will be of particular benefit for people who often face barriers to accessing GP appointments, including working adults and those with children, as well as people living in deprived areas. However, patients can still visit a GP for these conditions if they choose to.

What protocols do pharmacists follow in clinical consultations?

A clinical pathway for each of the seven conditions determines whether a patient should be seen by a pharmacist as part of the Pharmacy First service or referred to another healthcare provider. Where the consultation is with the pharmacist, people with relevant symptoms can receive advice and, if clinically appropriate, a prescription-only treatment.

Pharmacy contractors must ensure that pharmacists providing the service have the relevant knowledge and competence to comply with the clinical pathways. NHS England has provided clinical examination skills training, including in the use of otoscopes, to enable them to provide high-quality care.

Some GPs have raised concerns about antimicrobial resistance when community pharmacies are allowed to prescribe antibiotics. However, the clinical pathways were designed to incorporate principles of antimicrobial stewardship, and NHS England confirmed that the impact will be monitored.

Pharmacists delivering the consultations must check patients’ GP records (with consent), unless there is a good reason not to do so. They should also record the consultation in the community pharmacy IT system, which will automatically send a structured message via GP Connect, so that the information can be easily reviewed and added to the GP record. In the case of any temporary problems with the system, the notification should be sent via NHSmail or hard copy.

Are concerns about workload justified?

Pharmacists expressed fears that early demand for the Pharmacy First service would exceed capacity while staff are still developing the necessary skills, especially when pharmacies are already under pressure. However, both capacity and uptake of the service is expected to increase gradually during the first year. Also, some pharmacies will not be able to offer consultations for otitis media until 1 April, while awaiting otoscope equipment.

GPs also had concerns about additional workload from checking patient record updates made by pharmacists. However, NHS England confirmed that IT systems would be updated in February so that practice staff are able to review and add the information to the patient record with one click of a button. This could be done by trained administrative staff, so in most cases GPs will not need to review the updates. Where specific action is required by the GP team, this should be communicated by an Urgent Action communication.

With time, it is hoped that any initial problems with the service in England will be ironed out. It is worth noting that in Wales, where the similar Clinical Community Pharmacy Service (CCPS) scheme was introduced in 2022, over 400,000 GP appointments were freed up in one year as pharmacists undertook additional training and began to offer advice and treatment for common illnesses such as urinary tract, ear, and skin infections.

If you need medico-legal advice about interactions between the GP team and the Pharmacy First service, please get in touch at Medical Defense Society.

MMR vaccination is a priority for GPs as measles cases rise

MMR vaccination is a priority for GPs as measles cases rise

Across Europe and the UK, health authorities are warning that urgent measures are required to protect people from measles as it spreads among poorly-immunised populations.

In the UK, MMR vaccination coverage is at its lowest for over a decade, and a spike in measles cases has reversed the elimination status that was achieved in 2017. In response, the UK Health Security Agency (UKHSA) recently declared a national incident and the NHS has launched a catch-up MMR vaccination programme.

Primary care practices are required to participate in delivering this campaign as part of the GP contract.

Catch-up MMR vaccination campaign

From November 2023 to March 2024, the NHS is inviting over four million people to make an appointment for a first or second dose of MMR vaccine for themselves or their children, as part of the annual national catch-up vaccination campaign, which is focused on MMR.

Since November, practices have been required to undertake local call and recall for children aged 12 months to 5 years. Now, practices are also asked to support requests for vaccination from individuals aged 6 to 25 years, in a phased national call and recall. In the West Midlands and London, areas with high rates of infection, the campaign will extend to over one million children and young adults aged between 11 and 25.

The national commissioner stated in a recent primary care bulletin that, “Practices should prepare to receive enquiries from their registered patients during February and March 2024 who have received a national MMR vaccination reminder, and should check immunisation records, book, and administer vaccination, if clinically appropriate.”

Outbreaks in areas of low vaccination rates

The World Health Organisation recommends a 95% uptake target for childhood vaccinations but coverage in the UK is in decline and the target was not achieved for any vaccine in 2022/23.

According to NHS figures, more than 3.4 million* children aged under 16 years are either unprotected or not fully protected by MMR vaccination. In 2023, 1,603 suspected cases of measles were recorded in England and Wales – more than double the 2022 figure, and mumps and rubella cases also rose.

Recent outbreaks of measles in the West Midlands and in London reflect the especially low rates of vaccine protection among some communities. UKHSA warned in 2023 that a large measles outbreak involving between 40,000 and 160,000 cases could affect London, if MMR vaccination rates did not improve.

Increasing uptake of vaccination is a high priority for general practice. Given that measles has a high rate of serious complications, causes one in five infected children to be admitted to hospital, is potentially fatal, and leaves children more susceptible to other illnesses, urgent effort is needed to immunise as many children and young people as possible.

Barriers to improving vaccination uptake

However, there are complex reasons for the declining rate of childhood vaccination, which is not only a problem for MMR vaccination. In 2022/23, vaccination rates in children aged five fell to 84.5% for the two-dose MMR vaccine, to 93.2% for the ‘5-in-1’ vaccine, and to 90.4% for the Hib/MenC vaccine.

Fears and myths about vaccination play a role, but so do socioeconomic factors, health inequalities, poor access to healthcare, complacency, and missed appointments due to COVID.

Overcoming these factors is difficult and needs GPs with local knowledge and community connections. The Royal College of Paediatrics and Child Health (RCPCH) has urged the government to publish the national vaccination strategy, which aims to address many of these issues.

Meanwhile, GPs can access the following resources with advice about improving uptake of MMR vaccination:

Standards for delivery of childhood vaccinations

GPs and practice staff involved in delivery of childhood vaccination services should be familiar with the standard campaign requirements. New for 2023/24, practices must:

  • Use opportunistic booking and clinically appropriate administration of MMR vaccine when eligible unvaccinated patients are presenting.
  • Implement a Make Every Contact Count approach for review of MMR vaccination status and administration of MMR vaccine.
  • Have a process in place to support patients aged 6 to 25 years who have received national MMR call and recall reminders, including checking the vaccination status and booking an appointment for vaccination if clinically appropriate or updating patient records accordingly (supported by the School Age Immunisation Service for the relevant age cohorts).

Importantly, NHS England has also updated its infection prevention and control guidelines in response to rising measles cases. Requirements include that healthcare professionals should now wear personal protective equipment (PPE) when they see patients with suspected or confirmed cases of measles, and practices should support staff to ensure that they are fully immunised.

If you need medico-legal advice related to childhood vaccinations, please get in touch at Medical Defense Society.

Five questions to ask before signing a ‘fit to participate’ certificate

Five questions to ask before signing a ‘fit to participate’ certificate

As winter arrives, many GPs will receive requests to certify patients for fitness to participate in winter activities. Given the potential for injuries from skiing, snowboarding, or even more extreme winter sports, GPs should bear in mind that signing without due consideration could leave them open to a complaint or claim for a large compensation amount should the patient come to harm.

In this article, we remind GPs of the key questions to consider when asked to certify ‘fit to participate’ forms.

1.   Is your indemnity cover adequate?

Before signing any ‘fit to participate’ forms, a GP must ensure that they have adequate indemnity insurance. Since this work is outside the scope of the NHS terms and conditions, GPs will not be covered by the Clinical Negligence Scheme for General Practice and must make their own arrangements for the relevant insurance.

Please contact Medical Defense Society today for advice about your level of cover.

2.   What fitness level is required?

A patient may pressure their GP to sign a ‘fit to participate’ form quickly, especially if they are making last-minute plans for the activity. But doing this without full consideration of the facts and potential risks could have dire medico-legal consequences.

The GP should first ask the patient for details of the activity in question and check what level of fitness is required. They may need to refer to an expert in sports medicine if they do not have sufficient knowledge of the activity.

Having this discussion with the patient is essential before providing certification of fitness. It may also prompt the patient to consider what they need to do to be well-prepared for the activity.

3.   What does the patient’s medical history show?

Careful assessment of the patient’s notes is required to see whether pre-existing conditions or recent medical events could impact the patient’s fitness to participate in a winter sport. Examination of the patient and additional investigations may also be needed.

Since the General Medical Council expects doctors to recognise and work within the limits of their competence, GPs must consider whether they have enough information to certify the patient’s fitness. If not, they should ask for advice or refer the patient to a colleague with relevant expertise. For example, it might be appropriate for a patient who recently underwent surgery to consult with their surgeon, or for a patient with a chronic condition to see a specialist in that field.

GPs should also direct any patient with relevant medical history to talk to their travel and/or insurance providers for further advice.

If you are in doubt about signing a ‘fit to participate’ form for any reason, please seek assistance at Medical Defense Society.

4.   Is the form worded responsibly?

It is important to remember that GPs cannot guarantee the future fitness of any patient for an activity or for the duration of a holiday, even after a full examination and medical history. Rather than signing that a patient ‘is fit to participate’, GPs should use wording that reflects the facts and the limits of their knowledge.

The British Medical Association guidance on medico-legal aspects of providing certificates advises using wording along the lines of: “Based on information available in the medical notes, the patient appears to be fit to travel.”

To accurately reflect the facts, GPs should also note any relevant medical information on the form, such as the severity and stability of a pre-existing condition.

5.   Does the patient understand and give their consent?

Discussing the form with the patient, and providing them with a copy, is important to make sure that they understand the wording and why it was chosen. An informed patient may be less likely to make a complaint or claim if they do have an injury.

Furthermore, the patient’s informed consent must be obtained before disclosing any confidential medical information to a third party through a ‘fit to participate’ form.

As always, these discussions should be accurately documented. This will support the GP in justifying their actions if they later become subject to legal action.

Please contact us at Medical Defense Society immediately if any patient is injured when participating in an activity for which you have certified their fitness.

Additional advice on ‘fit to fly’ forms

Many people will be travelling abroad for winter sports and may also need ‘fit to fly’ forms. Further advice on this is available:

Please get in touch at Medical Defense Society to review your indemnity cover and for advice regarding any ‘fit to’ forms.

 

Latest advances in weight management

Latest advances in weight management

The world of weight management is evolving, with several interesting developments announced in 2023, including updated National Institute for Health and Care Excellence (NICE) guidelines on pharmacological treatments, referrals for surgery and digital weight-management technologies, as well as new evidence on how GPs can best support patients.

Since primary care is often a first port of call for obese patients wanting to manage their weight and associated health conditions, it is important that GPs keep abreast of these new developments to provide the most effective support and direct patients to the most appropriate services.

GP support for weight management

Guidelines recommend that GPs screen for obesity (defined as a body mass index [BMI] ≥30 or ≥27.5 for people of Black, Asian and other minority ethnic groups) and offer patients support with weight management. However, many are hesitant to discuss the issue with patients for fear of causing offence and because they have limited knowledge of the most effective approaches.

Reassuringly, evidence shows that GPs can proactively offer weight management support in a way that is acceptable to patients. Indeed, new research has shown that a positive approach is most effective to encourage patient participation and weight loss. GPs are advised to offer patients the ‘opportunity’ to be referred for free specialist weight management services. Such conversations with patients should recognise the need for sensitivity, shared decision making and informed consent.

Many primary care practices will have signed up to the weight management enhanced service. One requirement is the appropriate training of healthcare staff involved in conversations around obesity. GPs may complete the health weight coach e-learning programme, and use other learning resources, such as those from Public Health England, NHS England, RCGP and The Nuffield Department of Primary Care Health Sciences.

Specialist weight management services

Primary care practices should maintain details of available specialist weight management services, such as:

One option that may ease access to specialist weight-management services is provided by recent NICE guidance detailing new digital weight-management technologies. Some of these will enable remote prescription of weight-management medicines. Importantly, a referral and full clinical assessment is needed before offering access to treatments through these technologies, which will not suit every patient.

The new obesity drugs

Patient demand for weight management medicines is growing as the options continue to expand. As of November 2023, NICE-recommended pharmacological treatments for weight management are:

  • Orlistat, which can be prescribed by GPs or obtained at a lower dose in pharmacies
  • Liraglutide (Saxenda®) and semaglutide (Wegovy®), which must only be prescribed in secondary care by specialist weight management services, alongside a reduced-calorie diet and increased physical activity. Semaglutide may be used for a maximum of two years.

Furthermore, the Medicines and Healthcare products Regulatory Agency (MHRA) licensed tirzepatide (Mounjaro) for weight loss in November; a decision by NICE is expected in March 2024.

GPs prescribing any medicines for weight management should discuss with the patient the potential benefits and limitations, and offer information, support and counselling. NICE recommends considering pharmacological treatment only after dietary, exercise and behavioural approaches have been started and evaluated.

Be aware that due to supply issues with semaglutide (Ozempic) for type 2 diabetes, caused in part by off-label prescribing for weight loss, GPs should only prescribe this for its licensed indication.

In June, the government announced a two-year pilot to expand specialist weight management services, including evaluation of how GPs could safely prescribe the new weight loss medicines. However, these pilots are still under development and further details are needed.

Update on referral for bariatric surgery

Updated NICE guidance on when to refer adults for assessment for bariatric surgery says that patients no longer need to be generally fit for anaesthesia and surgery and receiving support from a tier 3 weight management service, since this requirement may be a barrier to treatment.

NICE recommends offering eligible adults a referral for “a comprehensive assessment by specialist weight management services providing multidisciplinary management of obesity to see whether bariatric surgery is suitable for them”.

Eligible adults will have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 39.9 kg/m2 with a significant health condition that could be improved if they lost weight, and they must agree to long-term follow up. For people of South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background, referral should be considered at a lower BMI threshold (reduced by 2.5 kg/m2).

Referral for expedited assessment for bariatric surgery is recommended for certain patients with recent-onset type 2 diabetes.

Note that a new NICE guideline is expected in February 2024 for use of a minimally-invasive weight loss procedure (endoscopic sleeve gastroplasty) as an alternative to bariatric surgery.

Medical Defense Society has a team of experts on hand to offer support and advice to GPs. Please get in touch if you have any questions about provision of weight management support.

Update to Good Medical Practice standards

Update to Good Medical Practice standards

The General Medical Council (GMC) has updated Good Medical Practice (GMP), the professional standards for all registered UK doctors. The updated guidance places greater emphasis on the behaviours and values needed to create respectful, fair and supportive workplaces in healthcare.

Such changes have been broadly welcomed, although concerns remain about how easily the new 28-page guideline can be implemented amid the pressures faced within the NHS. Nevertheless, it is important for GPs to take the time to read and understand the new standards before they come into effect on 30 January 2024.

GMP updated and restructured for 2024

Following a consultation launched in April, this significant update to GMP was published in August. GMC will expect medical professionals to apply these GMP standards using their professional judgement and clinical expertise in the specific circumstances that they face.

The guidance has been restructured into four domains, as outlined below.

Knowledge, skills and development

This domain covers:

  • Being competent
  • Providing good clinical care
  • Maintaining, developing and improving performance
  • Managing resources effectively and sustainably.

Medical professionals are expected to be competent and keep their professional knowledge and skills up to date. Within this domain, GMC emphasises that doctors must provide safe and effective clinical care in both face to face and remote consultations. They must also take part in quality assurance and quality improvement systems to promote patient safety, participate in training, and respond constructively to the outcomes of reviews and audits.

A new section is included on Managing resources effectively and sustainably, which advises that doctors should choose sustainable solutions when possible, if this does not compromise care standards.

Patients, partnership and communication

This domain covers:

  • Treating patients fairly and respecting their rights
  • Treating patients with kindness, courtesy and respect
  • Supporting patients to make decisions about treatment and care
  • Sharing information with patients
  • Communicating with those close to a patient
  • Caring for the whole patient
  • Safeguarding children and adults who are at risk of harm
  • Helping in emergencies
  • Making sure patients who pose a risk of harm to others can access appropriate care
  • Being open if things go wrong.

The requirement for Treating patients with kindness, courtesy and respect is new to GMP 2024. This includes communicating ‘sensitively and considerately’, listening to patients, not making assumptions about what a patient will consider significant, and explaining the options and any recommendations about their care.

Colleagues, culture and safety

This domain covers:

  • Treating colleagues with kindness, courtesy and respect
  • Contributing to a positive working and training environment
  • Demonstrating leadership behaviours
  • Contributing to continuity of care
  • Delegating safely and appropriately
  • Recording your work clearly, accurately, and legibly
  • Keeping patients safe
  • Responding to safety risks
  • Managing risks posed by your health.

Significant new guidance is included on Contributing to a positive working and training environment. To do this, doctors should behave in a way that creates ‘a culture that is respectful, fair, supportive and compassionate’.

GMC makes clear that doctors must not abuse, bully, harass or discriminate against anyone because of their personal characteristics, or any other reason. The guidance is also explicit regarding sexual harassment: doctors must not ‘act in a sexual way towards colleagues with the effect or purpose of causing offence, embarrassment, humiliation or distress’.

GMC adds that anyone witnessing these behaviours has a responsibility to act to prevent them continuing. Depending on the circumstances, witnesses are encouraged to support anyone who was targeted or affected, verbally challenge the behaviour, or report the behaviour, preferably with the knowledge and support of the person targeted.

The new standards will also support staff who raise concerns regarding their workplace culture and safety, by putting the onus on healthcare professionals in management and leadership roles, who must act to ensure that such behaviour is addressed, dealt with promptly and escalated if necessary.

Trust and professionalism

This domain covers:

  • Acting with honesty and integrity
  • Maintaining professional boundaries
  • Communicating as a medical professional
  • Managing conflicts of interest
  • Cooperating with legal and regulatory requirements

Within this domain, GMC details how medical professionals are expected to uphold high standards of conduct, be honest and act with integrity to maintain and justify patients’ trust in them and their profession.

There is new guidance on communicating via social media or in private communications such as instant messaging. This includes that doctors must maintain patient confidentiality, ensure the accuracy of any information they provide, and declare any conflicts of interest. GMC also adds a reminder that messages in private groups may be made public. More detailed guidance is given in Doctors’ use of social media.

Importantly, this updated GMP domain also states that doctors must have adequate and appropriate indemnity insurance, covering the full scope of practice, and the level of cover must be regularly reviewed.

GMP 2024 and fitness to practise procedures

In the updated guidance, GMC explains that the GMP standards ‘describe good practice, and not every departure from them will be considered serious’.

When a concern is raised about a medical professional’s conduct, GMC will assess whether they pose ‘any current or ongoing risk’ to the health, safety and wellbeing of the public, public confidence or professional standards.

To determine whether regulatory action is required, GMC says it will consider the individual circumstances and relevant factors, such as the seriousness of the concern (including the extent of departure from the standards), the context of the medical professional’s working environment and their role and experience, and how they responded to the concerns.

Medical Defense Society provides medico-legal support to members if they are subject to GMC fitness to practise procedures – please contact us without delay if a concern has been raised about your own practice. We can also advise on how to apply GMP standards in your GP practice and review your indemnity cover.

New cancer waiting times standards for England

New cancer waiting times standards for England

NHS England recently announced changes to the cancer waiting times standards that will come into effect from 1 October 2023, supporting the NHS Long Term Plan objectives to improve early cancer diagnosis and cancer survival.

The current list of 10 standards will be consolidated into just three, to “reflect what matters most to patients and to align with modern clinical practice”.

The new standards will not change the way that GPs refer patients with suspected cancer. However, they will provide clarity for patients, and provide impetus to improve performance in the cancer diagnostic and treatment pathways.

GPs will need to understand the new standards and explain them to anxious patients with suspected cancer who have questions about the next steps in their care.

The new cancer waiting time standards

The new standards come with broad support from clinical experts and cancer charities. They follow on from an extensive review led by Professor Sir Stephen Powis, national NHS medical director, and take into account the recommendations of the 2015 Independent Cancer Taskforce to abandon the outdated two-week wait target.

The three key standards are:

  • 28-day Faster Diagnosis Standard (initial target 75%): people should have cancer ruled out or receive a diagnosis within 28 days of an urgent referral by a GP for suspected cancer, following an abnormal cancer screening result, or by a GP for breast symptoms where cancer is not suspected.
  • 62-day referral to treatment standard (initial target 70%): people with cancer should begin treatment within 62 days of an urgent referral by a GP for suspected cancer, following an abnormal cancer screening result, or by a consultant who suspects cancer following other investigations.
  • 31-day decision to treat standard (96% target): people who have been diagnosed with cancer should begin treatment within a month of a decision to treat their cancer.

Furthermore, hospitals will be asked to work towards a 10-day turnaround for delivering diagnostic test results.

Focus on the Faster Diagnosis Standard

The 28-day Faster Diagnosis Standard, in use since April 2021, puts the focus on people receiving a diagnosis of cancer or having cancer ruled out within 28 days of a GP urgent referral – a much more relevant measure for patient outcomes than the two-week wait target for a first appointment with a specialist.

The focus on faster diagnosis will enable wider and more efficient use of new technologies for diagnosing and treating patients, such as the use of artificial intelligence and teledermatology in the diagnosis of skin cancers, one-stop clinics for examination and biopsy of suspected breast cancer, and faecal immunochemical tests in suspected colorectal cancer.

Clarity for primary care patients

The focus on three clear and clinically-relevant standards will make it easier for GPs to explain to patients what to expect when they are urgently referred for suspected cancer: diagnosis or cancer ruled out within one month and cancer treatment started within two months.

As explained by Dr Amelia Randle, Clinical Director for Somerset, Wiltshire, Avon and Gloucestershire Cancer Alliance, “Being referred for a suspected cancer is an uncertain and worrying time for people, many of whom will not be diagnosed with cancer.”

“Since the introduction of the 28-day Faster Diagnosis Standard I have been better able to discuss with patients what to expect and the timescales involved – getting a speedy diagnosis is what matters to them so this is a much more relevant measure than the two-week wait. Those who do need treatment have had a co-ordinated start to their journey and are able to access high-quality, compassionate care in a timely way.”

Can the targets be achieved?

Current statistics show that every waiting time target is being missed, meaning anxious delays for many patients. With the new standards, NHS England has confirmed a renewed focus on supporting services to improve performance.

Expectations are that by March 2024, the Faster Diagnosis Standard will be achieved for 75% of patients and the 62-day referral to treatment standard will be achieved for 70%. However, NHS England aims to raise these targets, expecting the Faster Diagnosis Standard to be met for 80% of patients in 2025/26. For the 62-day standard, the eventual target is 85%, but the ongoing impact of strike action and patient backlogs may influence the time it takes to reach this goal.

Additional resources for primary care

Please get in touch with our expert advisors at Medical Defense Society if you have questions or concerns about patient referral for suspected cancer.