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Expansion of the shingles vaccination programme

Expansion of the shingles vaccination programme

From 1 September 2023, the shingles vaccination programme will be expanded in England in line with recommendations made by the Joint Committee of Vaccination and Immunisation (JCVI) in 2019, to ensure that individuals at greatest risk from shingles are vaccinated at an earlier age.

In the first of two stages, extension of vaccination to severely immunocompromised people aged 50 and over, and to immunocompetent people turning 65 years of age, is expected to protect nearly 1 million more people this year against developing the extremely painful and potentially serious symptoms of shingles.

GP practices will be required to offer shingles vaccination according to this expanded programme and should ensure that GPs and nurses performing vaccinations are aware of the changes.

Shingles vaccination protects vulnerable individuals

Approximately 1 in 5 people who have had chickenpox will develop shingles (herpes zoster) later in life – typically triggered by advancing age, medicines, illness or stress. Elderly and immunocompromised patients are particularly vulnerable to shingles and its complications. Among patients with shingles aged over 70, each year about 14,000 develop postherpetic neuralgia (PHN), over 1,400 are admitted to hospital, and around 1 in 1,000 patients die as a result of the condition.

However, vaccination significantly reduces the risk of developing shingles and protects against severe symptoms. Evidence shows that in the first 5 years of shingles vaccination in England, there were large reductions in GP consultations and hospitalisations for shingles and PHN.

The JCVI recommendation to expand the vaccination programme was issued in February 2019 based on positive impact and cost-effectiveness modelling.

Eligibility for shingles vaccination

In line with recommendations from JCVI, eligibility will be expanded to offer shingles vaccination to immunocompetent individuals routinely at 60 years of age (implemented in stages), and to immunocompromised individuals aged 50 years and older.

Immunocompetent individuals: Over a 10-year period, the eligible age for immunocompetent individuals will change from 70 to 60 years:

  • Stage 1: From 1 September 2023 to 31 August 2028, individuals turning 70 and 65 years of age should be offered the vaccine.
  • Stage 2: From 1 September 2028 to 31 August 2033, individuals turning 65 and 60 years of age should be offered the vaccine.
  • From 1 September 2033 onwards, individuals turning 60 years of age should be routinely offered the vaccine.
  • Individuals who have been previously eligible will remain eligible until their 80th Those aged 80+ years are not eligible as it is less effective in this population.

Immunocompromised individuals: The highest priority for the expanded programme is to vaccinate all immunocompromised individuals aged 50 years and over from the first year, since this group is most at risk of severe disease. There is no upper age limit for the immunocompromised cohort.

How will the vaccine schedule change?

From 1 September 2023, all newly eligible people will be offered two doses of the non-live vaccine Shingrix®:

  • Immunocompromised individuals should receive Shingrix®, with their second dose at 8 weeks to 6 months after the first dose.
  • Immunocompetent individuals receiving Shingrix® should receive the second dose 6 to 12 months after the first dose.

Shingrix® will replace the live vaccine Zostavax® for the whole shingles programme because clinical trials have shown efficacy and safety of Shingrix®, with a substantially longer duration of protection against shingles than Zostavax®.

However, immunocompetent people aged under 80 years who were previously eligible for Zostavax® will continue to be offered one dose of Zostavax® until central stocks are exhausted; after this time, they will be offered two doses of Shingrix®. Both vaccines are available to order via the ImmForm website.

Anyone who has already received one dose of Zostavax® or two doses of Shingrix® does not need to be revaccinated with Shingrix®.

What are GP practices required to do?

Shingles vaccination is an essential service under the GP contract 2023/24 and practices will receive payment of £10.06 per dose administered.

Practices must undertake call/recall for patients as they become eligible throughout the year. Shingles vaccination may also be offered opportunistically, during routine visits or check-ups, or with other vaccinations, to maximise vaccination coverage.

To minimise waste, local stocks of vaccine should be rotated in fridges and practices should hold no more than 2 weeks’ worth of stock. Practices are also expected to continue accurate and timely recording of all vaccinations.

Useful resources for shingles vaccination

If you have any questions or concerns about the expansion of the shingles vaccination programme, please contact us at Medical Defense Society for advice.

Removing barriers to effective working between general practice and secondary care

Removing barriers to effective working between general practice and secondary care

The interface between primary and secondary care is increasingly a source of friction, unnecessary workload and frustration. A recent GPonline survey revealed the extent of the problems regarding GP workload, with 83% of respondents saying that limiting the transfer of work from secondary to primary care should be prioritised.

Barriers to effective working across primary and secondary care are varied and complex, frequently arising from cultural differences, inflexible processes, and communication difficulties. They strain working relationships, add to stress, and hinder safe and efficient patient care.

While the government is introducing new measures to tackle the problems, GPs may find inspiration for locally-tailored solutions in a report by the Academy of Medical Royal Colleges (AMRC), discussed below.

Guidance to reduce inappropriate transfer of workload

Existing requirements introduced under the NHS contract in 2017 aim to delineate responsibilities and avoid inappropriate transfer of workload, and the British Medical Association (BMA) provides a useful summary of these requirements. Secondary care providers should:

  • Make onward outpatient referrals for immediate or related needs, without referring patients back to GPs.
  • Not ask GPs to re-refer patients who do not attend scheduled appointments.
  • Manage patient queries and communicate test results directly to patients.
  • Send discharge summaries to the GP within 24 hours.
  • Send standardised clinic letters electronically, and within 10 days when there are actions for the GP in relation to the patient’s ongoing care.
  • Issue medication upon discharge for at least seven days (or as clinically appropriate).
  • Issue fit notes at a suitable time (e.g. at discharge), when required, to cover an appropriate period of time.
  • Only initiate shared care protocols when the individual GP has accepted clinical responsibility for the patient.

Further clarity was provided by NHS England in guidance on the Responsibility for prescribing between primary and secondary care, and by the AMRC in Onward referral guidance.

However, the GPonline survey highlights the fact that these guidelines are often not followed. As a result, GPs have increasing amounts of administrative work, while patients are frequently left in limbo waiting for information. Many GP appointments are booked by patients purely to ask about delayed secondary care, or about test results, medications and fit notes that should have been provided by the hospital.

BMA: Practice checklist

The BMA provides advice and a template letter pack for GPs to push back on inappropriate hospital requests. Their advice includes:

  • Develop a practice policy on how to push back on inappropriate hospital requests.
  • Ensure all GPs in the practice are aware of the standards.
  • Use BMA template letters when hospitals fail to meet the standards.
  • Keep a practice record of all breaches and regularly feedback to the Local Medical Committee.

Government plans to reduce administrative burden

The government’s ‘Delivery plan for recovering access to primary care’ acknowledges the burden on GPs from ‘work generated by issues at the primary-secondary care interface’, and sets out measures to reduce this. Under the plan, Integrated Care Boards (ICBs) must address these four areas:

  • Onward referrals within hospitals.
  • Complete care (fit notes and discharge letters with ‘clear actions for general practice’).
  • Call and recall systems for follow-up tests or appointments.
  • Clear points of contact between primary and secondary care (e.g. single outpatient department email for GP practices or primary care liaison officers in secondary care).

ICBs are also tasked with setting up systems to enable GPs and consultant-led teams to discuss and address local challenges at the interface of primary and secondary care. The ICBs are expected to update their public board with progress in October or November 2023.

Initiatives for working together effectively

ICBs have been advised to look at the AMRC report: ‘General practice and secondary care – Working better together’. GPs may also find ideas among the case study examples in the report, which describe local initiatives to improve aspects of culture, communication, and clinical process at the interface of primary and secondary care.

Results have been remarkable, in many cases demonstrating reduced referral rates, fewer hospital stays, more rewarding interactions, and reduced workload in the long term (often after an initial period of more intense effort).

Successful projects have included elements that could be incorporated into practice more widely, summarised as:

  • ‘Potential quick wins’, including non-public phone numbers and shared email boxes for ease of communication; outpatient helplines for administrative queries about hospital appointments; education of trainee doctors in completing discharge summaries; guidance on use of fit notes for secondary care clinicians; regular ‘interface groups’ involving GP and secondary care representatives (in various formats, such as MDT huddles, clinical advice meetings, lunch-and-learn sessions); access to electronic health records across the interface; primary care liaison officers to resolve queries; and standardised outpatient clinical letters.
  • ‘Drivers for success’, including strong relationships between clinicians in general practice and secondary care; healthcare leaders open to change; an enthusiastic ‘champion’; administrative, IT and financial support; being clinically led, with balanced representation from general practice and secondary care, and tailored to local need; being focused on facilitating dialogue and removing unnecessary administrative steps; having an educational component; considering the impact on clinician workload; and being focused on involving patients in discussions about their care.

If interactions between your practice and secondary care teams are problematic, please contact us for expert and friendly advice at Medical Defense Society.

Delivery plan for recovering access to primary care: Key points

Delivery plan for recovering access to primary care: Key points

NHS England’s ‘Delivery plan for recovering access to primary care, was unveiled on 9 May 2023, with two central ambitions:

  • Tackle the 8am rush and reduce the number of people struggling to contact their practice.
  • For patients to know on the day they contact their practice how their request will be managed.

The plan focuses on addressing the well-known challenges of access to primary care. This is seen as a prerequisite first step ahead of longer-term reforms that will deliver the vision set out in the Fuller Stocktake for the future of primary care.

GPs should be aware of the plan’s key points about how primary care practice will evolve in the next two years. Note that funding and transitional support is available for practices that sign up to implement changes by the relevant deadlines in 2023/24, as indicated below.

Roll-out of ‘Modern General Practice Access’

By the end of 2023, it is hoped that most practices will have adopted the ‘Modern General Practice Access’ approach, using online tools, digital telephony, and triage by trained care navigators to make it easier for patients to contact the practice and learn how their request will be handled. It will also make it easier for practices to receive, navigate, assess, and respond to requests.

The plans are aligned with NHS contract changes for 2023/24, requiring patients to be offered ‘an assessment of need, or signposted to an appropriate service, at first contact with the practice’ from May 2023.

In Modern General Practice Access, patients should be told how their request will be managed on the day they first contact the practice:

  • Clinically urgent: same day assessment by telephone or face-to-face appointment (next-day assessment is allowed where clinically appropriate if the patient contacts the practice in the afternoon).
  • Non-urgent: telephone or face-to-face appointments scheduled within two weeks.
  • Where appropriate, patients will be signposted to self-care or other local services such as community pharmacy or self-referral services.

Dates to be aware of:

  • From May 2023, training and transformation support will be available through a National General Practice Improvement Programme.
  • Practices on analogue phone systems that commit by 1 July 2023 to adopt digital telephony will receive support and funding up to about £60,000 over two years.
  • Funding will be available for practices that sign up by March 2025 to adopt digital tools and care navigation training.
  • All analogue phone systems across the country will be switched off by December 2025.

A major communications campaign will explain to patients how primary care is evolving and how they can best use the NHS. The hope is that many patients will find it more convenient to make requests and receive responses online, freeing up phones for those who prefer to call.

Empowering patients, relieving pressure on GPs

The plan also aims to employ tools that people can use to manage their own care, to relieve pressure on GP practice teams. Self-referral pathways will be expanded by September 2023, and by March 2024, it is expected that >90% of practices will enable patients to use the NHS App to see their health records, read practice messages, book appointments and order repeat prescriptions.

Subject to consultation, the Department of Health and Social Care (DHSC) will also expand the role of community pharmacies in 2023, potentially saving 10 million GP appointments each year by:

  • Increasing provision of oral contraception and blood pressure services.
  • Launching the Pharmacy First programme, allowing pharmacies to supply prescription-only medicines for sinusitis, sore throat, earache, infected insect bite, impetigo, shingles, and uncomplicated urinary tract infections in women.

Increasing capacity and reducing bureaucracy

Within the plan is a commitment to publish the long-awaited NHS Long Term Workforce Plan, which will detail future GP training, recruitment, and retention plans. In the meantime, the plan intends to deliver more appointments with extra staff, with measures including:

  • Larger multidisciplinary teams: increasing additional roles reimbursement (ARRS) funding and flexibility, to deliver on the commitment to fund more direct patient care staff.
  • More new doctors: expanding GP specialty training; helping newly qualified GPs who require a visa to remain in England.
  • Retention and return of experienced GPs: through pension reforms, and simplifying return to practice.
  • Requiring higher priority for primary care in housing developments.

The plan also details how administrative workload in primary care will be eased, building on the Bureaucracy Busting Concordat published in 2022, by:

  • Improving the interface between hospitals and primary care, including a reduction in inappropriate transfer of hospital administrative workload.
  • Increasing self-certification to reduce medical evidence requests to GPs.
  • Streamlining the Investment and Impact Fund and consulting on the Quality and Outcomes Framework clinical indicators.

Although the plans have been broadly welcomed, GP leaders in the British Medical Association and Royal College of General Practice remain concerned that more investment and support is crucial to deal with workforce and infrastructure problems, if the measures are to be implemented effectively. It remains to be seen how future long-term plans for reform will address these issues.

If you have questions or concerns about the NHS plans and how they will affect your practice, please contact us for advice at Medical Defense Society

Dealing with medicines shortages in general practice

Dealing with medicines shortages in general practice

Recent months have seen serious shortages of certain HRT products, antibiotics, antidepressants, and other essential medicines, due to a complex interplay of factors, including global supply and distribution issues, high demand, and longer prescription cycles.

Although the Department of Health and Social Care (DHSC) has processes in place to prevent and mitigate the issues, the MIMS live tracker shows that drug shortages have risen markedly during 2022–23.

The problems bring concerns about potential harms to patients: a risk of worsening symptoms, withdrawal symptoms and other complications, if access to treatments is delayed. They also add to the pressure on pharmacists and primary care teams, who report increasing workloads, stress, as well as abuse by frustrated patients.

Serious shortage protocols (SSPs) allow pharmacists to substitute prescription medicines in short supply

Community pharmacies and dispensing doctors receive regular updates and follow national guidance to implement management plans in case of drug supply issues. They should share information with prescribers and patients as appropriate, and work to obtain or locate stock from suppliers or at other pharmacies.

SSPs, first introduced in 2019, may be issued if the DHSC determines that there is a serious shortage of a specific medicine or appliance. The protocols allow community pharmacists to use their professional judgement to decide whether it is appropriate to substitute the patient’s prescribed order according to the protocol. They must obtain the patient’s valid consent for this, and check their allergy status and Summary Care Record, but they do not have to refer the patient back to the prescriber. This ought to help patients access treatment sooner and save time for clinicians.

SSPs are developed with advice from expert clinicians and specialist societies, and specify:

  • Actions pharmacists can take to substitute the prescription with an alternative quantity, strength, or pharmaceutical form, a generic equivalent, a therapeutic equivalent, or an alternative device product.
  • The appropriate circumstances, suitable patients, relevant dates, and geographic locations.

In the case of a therapeutic substitution, the pharmacist should inform the prescriber, ideally by the following working day. This information may need to be entered into patients’ records.

Dispensing doctors may also follow SSPs if necessary, but generally they can amend the FP10 prescription form to supply an available medicine.

The NHS Business Services Authority provides a list of currently active SSPs and SSP Operational Guidance.

When is referral back to the prescriber required?

Even where an SSP exists, there are situations in which the pharmacist must refer the patient back to their GP for an alternative prescription:

  • If the patient does not consent to the substitution.
  • In case of concerns regarding the patient’s medical history or individual circumstances.
  • For patients with complex medical regimens or complex health needs.
  • For patients with certain conditions, such as epilepsy, where generic or therapeutic substitution would not be appropriate.

Limitations of SSPs

A recent survey of UK pharmacists suggested that despite SSPs, medicines shortages are having a worsening impact on patient care. Not all drug shortages are subject to an SSP, and supply issues may occur before advice on alternative medications is available. Where SSPs exist, pharmacists report that they are bureaucratic and inflexible – leading to extra workload and financial risk.

The Royal Pharmaceutical Society has called for pharmacists across the UK to be allowed to make minor amendments (for example, changes to quantity, strength, formulation, or generic substitution) to allow the prescription to be dispensed in the absence of an SSP, without having to contact the prescriber. In Scotland, this is already the case.

The prescriber’s role in managing supply issues

GPs may be notified of shortages by local communication networks, or, in the case of high- or critical-impact shortages, by ‘Supply Disruption Alerts’ via the Central Alerting System. All nhs.net email users can also register to access the Specialist Pharmacy Service website to find communications from the DHSC about specific medicine shortages and their management.

Once GPs are aware of a supply issue, they may request suitable alternative drugs or formulations on prescriptions, thus reducing the pharmacist’s work and the need for prescription amendments.

For example, as shortages of HRT products continue to cause frustration for all concerned, prescribers should refer to the advice of the British Menopause Society (BMS) to find suitable alternatives. MIMS also provides an HRT comparison table for hormone doses, formulations and costs.

Note that from April 2023, GPs are required to write listed HRT items on separate prescriptions, to facilitate use of annual HRT Prescription Prepayment Certificates, which may help to ease supply pressures.

Please contact us at Medical Defense Society for advice if you have concerns about the impact of medicines shortages on your practice or the wellbeing of your patients.

Safe working limits for GPs

Safe working limits for GPs

The GP workforce is experiencing extreme pressure, exacerbated by staff shortages and unprecedented demand from patients with increasingly complex needs. Long working hours and excessive workload are leading to stress, burnout, and low morale. These factors impact on the quality of patient care and increase the risk of errors in decision-making.

April is Stress Awareness Month, so we take this opportunity to look at how practices and GPs can prioritise care to deliver health services within safe working limits.

Pressure on GP services is unsustainable

The winter of 2022/23 has seen exceptional demand for GP services. Many surgeries have struggled to cope with the deluge of patients requiring same-day appointments, leaving some practices with no choice but to cap the number of urgent appointments.

Based on its ‘Fit for the Future: GP Pressures Report 2023’ report, the Royal College of General Practice (RCGP) has warned that one in four practices is at risk of closing, with “unmanageable workload and workforce pressures fuelling an exodus of fully qualified GPs”.

Clearly, support is needed to retain the practice workforce and manage ongoing demand in a way that prioritises safety and wellbeing of both staff and patients.

What does a safe workload look like?

The British Medical Association (BMA) report on ‘Workload Control in General Practice’ highlights the importance of agreeing individual limits for safe practice, which will depend on the practice setting, contractual status and preferences of the individual, as well as the complexity of patient needs.

In its guide to ‘Safe working in general practice’, the BMA recommends that:

  • A safe level of patient contacts for a GP is not more than 25 per day. However, the number of daily contacts considered ‘safe’ may vary according to the above factors.
  • Practices should move to 15-minute appointments. This is in line with evidence on quality of care, reduces the need for repeat consultations and maintains patient satisfaction.
  • A standard GP session lasting 4 hours 10 minutes should include a maximum of 3 hours with patients as well as adequate rest breaks to avoid risk of harm to patients and clinicians.
  • Practices should consider closing their practice list if they are at the limit of their capacity to provide safe care.

Strategies to promote safe working limits

The BMA states, “The present crisis is so severe that we recommend practices take urgent action to preserve patient care and protect the wellbeing of their staff.” This must be done within the constraints of the general medical services (GMS) contract.

Strategies the BMA recommends include:

Manage same-day demand. The BMA strongly recommends moving away from a duty doctor system with uncapped demand. Triage by appropriately-trained staff should prioritise care according to clinical need, and when the daily safe limit on capacity is exceeded, patients should be redirected to other services or placed on a waiting list. If a waiting list is used for non-urgent care, patients should be given instructions about what to do if their clinical condition deteriorates.

When demand outstrips capacity, patients may be redirected to services including NHS 111, urgent treatment centres, extended access hubs, walk-in clinics, clinical pharmacy consultation services, or ARRS staff. Emergency or urgent problems may be directed to emergency departments or 999.

Importantly, the GMS contract for 2023/24, which is being imposed from April 2023, states that “patients should be offered an assessment of need, or signposted to an appropriate service, at first contact with the practice. Practices will therefore no longer be able to request that patients contact the practice at a later time.”

Prioritise core GP functions. The BMA urges practices to focus on providing core GP services within the GMS contract and to cease doing unfunded non-core work. Practices are not obliged to undertake non-contracted work on behalf of secondary care providers and other agencies. Such requests may be pushed back and the Integrated Care Board notified (the BMA provides template letters).

In addition, practices are advised to consider whether the requirements of the Primary Care Network Directed Enhanced Service (PCN DES) outweigh the benefits. Practices may tell their Integrated Care System that they wish to discontinue the DES between 1 and 30 April 2023 or whenever there is a change to the DES.

The BMA says: “It is likely to be the case that practices provide fewer services to their patients in order to preserve the central core services of general practice.”

Record data on all patient contacts and monitor working hours. Accurate data is essential for effectively managing workloads. The BMA encourages practices to account for all patient contact within their appointment books, so that NHS England data reflects reality. Once recognised, excessive work demands can be prioritised and appropriately managed or delegated.

Please contact us at Medical Defense Society if excessive workload in your practice may be affecting your wellbeing or compromising the safety of your patients. We provide members with expert medico-legal advice 24/7.

Supporting junior doctors in general practice

Supporting junior doctors in general practice

Junior doctors in England have voted overwhelmingly for strike action as they campaign for increased pay. The 72-hour walkout, on 13–15 March, will include GP trainees, who make up 15% of all junior doctors in England. Therefore, GP practices should be prepared for potential disruption to services during this time.

The real-terms pay cuts and unsustainable working conditions that lie behind the wave of NHS strikes are also driving junior doctors to leave for better pay and quality of life in positions elsewhere. Given the GP workforce shortages, it is vital that primary care teams make every effort to support junior doctors in general practice to encourage increased recruitment and retention of GP trainees.

Employers’ responsibilities towards junior doctors in general practice

Many junior doctors choose to specialise in general practice and see it as a potentially rewarding, if challenging, career to pursue. However, the experiences they have as GP trainees will influence whether they continue to work as GPs for the NHS in the long-term. Their employers in general practice have an important role in helping them feel valued, supported, and safe as they undertake their training. In return, GP trainees can bring new skills and ideas to a practice and contribute to appointments and administrative work.

The British Medical Association (BMA) provides advice for practices in England that choose to employ GP trainees under the 2016 contract. In particular, practices and employers must be aware of their contractual obligations in work scheduling, exception reporting, and provision of guardians of safe working:

Work scheduling:

  • Each trainee receives a generic work schedule, detailing work commitments, training objectives and a rota. The trainee and their clinical supervisor must personalise this to suit the trainee’s learning needs and the opportunities available, with ongoing review to ensure that it remains fit for purpose. Employers are also required to take account of reasonable requests to ensure the work schedule fits around the trainee’s life (e.g. caring commitments).
  • GP specialty training in a general practice setting is subject to specific requirements with regards to work scheduling; the relevant guidelines, templates and examples are available from NHS Employers.

Exception reporting:

  • Trainees must be provided with an electronic system for submission of exception reports and encouraged to use it to detail instances where their actual work and training differ from their work schedule.
  • Clinical supervisors must review and discuss exception reports with the trainee to agree any actions, such as revising the work schedule and approving claims for additional pay or time off in lieu.

Guardians of safe working:

  • Trainees must have access to a guardian of safe working who will oversee compliance with safeguards in the 2016 contract and be a champion of safe working hours for junior doctors.
  • The guardian will receive a copy of exception reports and should be consulted about any concerns over working hours or training opportunities if the GP trainee and clinical supervisor cannot find a solution together.
  • The guardian may levy a penalty fine if the trainee’s working hours breach certain limits, although this should never occur if work scheduling and exception reporting systems are applied correctly. If a fine is necessary, it should prompt an investigation and remedial action to ensure that the breach is not repeated.
  • Information and resources for guardians are available from NHS Employers.

Supporting industrial action by junior doctors

In previous NHS strikes, the BMA has urged doctors to support their colleagues and advised members on how to show moral support without compromising their professional responsibilities. With the upcoming industrial action by junior doctors, practices employing GP trainees can demonstrate their support by understanding and upholding their junior colleagues’ employee rights.

The BMA guidance for junior doctors about strike action considers their employee rights including protection from unfair dismissal, allowances for annual leave, as well as the consequences for pay. Note that all GP trainees working under a contract with an NHS employer (single lead employer and/or GP practice) can join the strike, although the decision to take part is a personal choice.

Ahead of the industrial action, NHS trusts and employers will need to plan carefully to minimise disruption of essential services. In primary care, some patient appointments with GP trainees may need to be rearranged and certain clinics may have to be cancelled. However, the full impact of the strikes may be difficult to predict. It is important to know that junior doctors are not obliged to inform their NHS trust about their intention to participate in strikes and the BMA advises that to do so would undermine the action.

If you would like more advice about junior doctors’ rights during strike action or if you need medico-legal support regarding any other aspect of GP training, please get in touch with our expert team at Medical Defense Society.