The Practice Manager's Manual 2017 110 pages on everything you need to know as a GP practice manager. 

Written by three highly skilled and long-serving practice managers; Michele Petrie, Robert Campbell and Alan Moore. Includes additional input from PM colleagues with significant experience of CQC inspections.

INTRODUCTION

The aim of this manual is to provide anyone involved in managing a practice (new or existing) with a briefing document, covering many of the aspects of their role. It is intended to be a briefing paper for a new or replacement manager and might form part of a Business Continuity Plan.

Clearly, each medical practice has its own way of doing things and it may well be organised and managed differently, have different attitudes and policies, and different ways of keeping accounts and running computer systems. It may take part in local commissioning. It may be a training practice. It might own premises or share premises and may be part of a Federation or a Collaborative.

It includes, in alphabetical order, the details of how the practice accounts and payroll are kept and provides information on how to prepare the annual accounts for submission to the practice accountants.

There are sections too on the administration of the NHS Pension Scheme using the agency website, along with the submission of Inland Revenue payments and Value Added Tax returns for practices that may be VAT registered. This is at a time when the Revenue has started to require Internet submissions of annual returns and new joiners and leavers. Other sections look at personnel matters, and provide a background to practice computing. Furthermore, it sets out details of the General Medical Services contract with the local health organisation and discusses how it is managed and reviewed, although PMS (Primary Medical Services) contracts and APMS (Alternative Provider Medical Services) are also found. In these cases the contract will provide specific standards and services that must be carried out and are likely to be more relevant to the type of provider or local health issues. It also looks at the ever-changing Quality Framework, as well as providing sections on property and estate management, and purchasing for the practice. There is also a section on service charges. There is information about partnership shares and how a doctor joins the medical list. The work of the local Central Services Agency (for patient registration and GP contracts) and the Prescription Pricing Authority are explained.

This document can never be complete as the very nature and organisation of general practice and the NHS are forever changing. Managers in primary care have to be very conscious of environmental monitoring and practise it every day as a result.

STAFFING

The practice may be managed by a practice manager or a business manager who is responsible for the day-to-day, overall management of the practice. The practice manager may be supported by an assistant practice manager, reception manager who looks after the reception staff and a dispensary manager who looks after the dispensary staff if the practice is a dispensing practice. There are often medical secretaries unless the practice is using one of the software packages that type as dictation is spoken, and probably summarisers for the medical records and/or data managers as well as others carrying out specialised roles.

The nursing team usually includes practice nurses (RGNs with or without degree qualifications), nurse clinicians or advanced nurse practitioners (practice nurses with additional qualifications and higher degrees who can prescribe and/or diagnose and treat

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patients without the need to consult a GP). Nursing teams are supported by healthcare assistants who should normally hold a Level 3 Diploma or NVQ, and advanced practitioners who are qualified to Level 4 or hold a foundation degree. There are also other qualified staff who may be found in a practice such as physician assistants (degree qualified but not doctors who can see and treat some medical conditions), as well as pharmacists (again degree qualified who may have additional qualifications to permit them to treat patients and change medication etc.).

Practices regularly host GP registrars and medical students, and can have strong links with the multi-disciplinary team including district nurses, the MacMillan nursing service, integrated care practitioners, social workers, health visitors, midwives, mental health and dementia nurses. The same relationships are being made in many areas with the local authority and particularly social services departments.

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A

Accountant

The practice should appoint an accountant who prepares the formal annual accounts and deals with the partners’ tax returns for submission to the Inland Revenue. The documentation is usually submitted to the accountant following the year end. A practice year end does not have to run concurrently with the tax year although often this will be the case. The annual accounts are later presented to the partners at a practice meeting which may take place two or three months after the year end.

Accounts

Accounts are these days generally kept in a computer format. Iris GP Accounts software complements the Iris Payroll package but practices may also use other software such as Sage, Quicken or Microsoft products. Software packages are made secure by setting a password and this is an essential requirement in the interests of practice financial security and confidentiality. A backup floppy disc or memory stick file should be kept at regular intervals, at least each month or quarter end, and certainly at the end of each financial year. An added feature of Iris Accounts is being able to upload data from Open Exeter. Iris Payroll also has a personnel record and an annual leave record but other software may be employed for a similar purpose.

Probably the most widely used staff payroll software is Iris GP Payroll, formerly Ferguson Payroll, which is updated two or three times a year to take account of tax changes and year-end processes. There is a maintenance fee, payable annually in March to Iris Software. The practice will be able to regularly update the system online, when requested to do so and for the new financial year. At the year end, it is important to take a backup copy of the year’s accounts before undertaking a close-down of the year.

Pay increases will usually be agreed with the practice partners or executive management and should be added to the payroll system according to the practice or company policy. Many practices outsource their payroll to an agency or their accountants, so the system that might be found can vary widely. Annual increments need to be amended in the personal pay details of each employee. The Iris GP Payroll can also be used to keep personnel records, including sickness absences, appraisals and personal details, although there are other packages that can maintain the same information such as Intradoc or iQ Compliance Manager. Again, this will be according to what systems are in place in individual organisations.

Where payroll is outsourced, a monthly list of overtime, new starters, etc. is usually required by the agency who will use it to build the payroll, PAYE, payslips and other documentation that might be needed. You will need to have some system to get the payroll actioned at the bank and it is worth noting that practices sometimes pay partners through the payroll system while others set up monthly standing orders to pay drawings directly. In all cases involving partnerships, however, the involvement of the practice accountants will be necessary in making pension and HMRC annual returns.

With any accounts software package, it is important to set it up with all bank accounts individually and not blend them into one. It is also vital that sufficient categories are set up to reflect the income and expenditure of the practice adequately and to monitor increases and decreases along the way. The categories should at least reflect those shown in the practice’s

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annual accounts. It can be useful to set up categories to keep track of expenditure on expensive items such as printer cartridges. It is also useful to keep additional ‘accounts’ (not bank accounts) for all NHS income as well as petty cash. You will want to keep track too of any private income received in the form of cash, cheques or direct credits.

Accounts – Entering payments

The process of entering payments should take account of both the Category (main heading) and Class (sub-heading) of payment (or income). It is important to provide sufficient information which should be recorded to enable the accountants to easily and readily prepare the annual accounts without reference back to the practice manager. In this respect each entry records the actual date of the transaction, the type of transaction, such as a cheque with number, online banking, auto pay, BACS, direct debit, credit or cash. Entries should also show which financial year is being recorded, e.g. 2017. The description of the payee should be accurate, and the memo field should expand on the reason for the payment. The Category can be followed by a Class which will help to check the accuracy of the accounts at end of the financial year.

NHS income is received via BACS into the practice’s current account. The NHS income is supported by statements from Open Exeter. Records need to be kept of superannuation payments attributed to each partner, whether it is the employee’s or employer’s contribution. A careful watch will need to be kept on payment statements received from NHS England to ensure that all payments expected have been received. NHS income can be entered directly into accounts software using the Open Exeter system as a source of information.

Inputting NHS payments:

Open Exeter Download EML Click File Click Save As to Desktop Go to Accounts and click ‘Add NHS entry’ Click on ‘Open Exeter import’ Select middle one, ‘Import NHS Payment’ ‘Open Exeter File’, click on File Click Print Click Next

Inputting NHS drug payments:

Open Exeter Select Drug Payments Tick Partnership box (remember three months behind) Select month Print Go back into Account Click on Add NHS Entry Click PPA drug statement Enter manually from printout. Don’t sub-divide for doctors.

TIP: There is a tendency for the local health organisations to delay payments and

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convert payments from monthly to quarterly payments. Sometimes the superannuation deductions shown on the Open Exeter statement can be out by 1p due to rounding.

The process of entering ALL payments should take account of both the Category and Class of payment. It should also record the cheque number automatically, where a cheque has been used. Sufficient information about the type of payment should be recorded to enable the accountant to easily prepare the annual accounts without reference back to the practice.

Any NHS reimbursements, refunds or grants received should be properly associated (or reversed) with the practice expenditure it relates to.

It may also be necessary to re-credit any bounced cheques. Be watchful for any failed transmissions of bank payments, although this is more likely to occur with transmissions to Inland Revenue or the NHS Pension Agency.

The details of Inland Revenue payments, including student loans, statutory sick pay and statutory maternity pay, will need to be shown in the practice accounts system. Payments made in respect of GP registrars and salaried GPs should be shown separately from practice staff costs.

It is extremely important to ensure that the accounts are reconciled on a monthly basis and before the VAT Return is made, should the practice or organisation be VAT registered.

Accounts – Income, expense or deduction categories and classes

EXPENDITURE (Main categories/classes)

AdministrationDispensary (as appropriate)DrawingsFinance chargesITLocums externalMiscellaneousPartners subscriptionsPostage and stationeryPremisesRefreshmentsRepairs and renewalsStaff costsTelephone

INCOME

Cash introducedNHS income on templateNon-NHS incomeOther incomeTransfer from

This list is not exhaustive and will vary from practice to practice.Accounts – Year-end checklist

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The formal year end for the preparation of the practice’s annual accounts is the date when business accounts close.

The accounts may comprise print-offs from the accounts software package, which could be filed in a ring binder. However, some accountants are able to accept digital transmission of the practice accounts or a CD with the details as they have the accountant’s version of the same software package as the practice. It is good practice, in all cases, that a hardcopy folder should be kept for each financial year.

The accountant will provide a list of everything that is required to be sent after year end, when all invoices relevant to the year end will have been paid. This is usually:

Records covering the practice accounting year. Remittance advices and statements dated a few months after the year end are always helpful, but there is no need to wait for these prior to sending in the accounts papers as these are not necessary for the initial stages of accounts preparation and can be forwarded at a later stage.

Bank statements for practice current accounts and any other bank/building societies held.

Accounts backup/cash books/backup discs (including a couple of months after the year end if possible). If Iris GP Accounts, the backup can be emailed to the accountants – go to File, backup accounts data, choose Windows Desktop and press Next until it has stated finished. Attach backup to an email from your desktop.

Bank reconciliation

Cheque stubs

Paying-in books

Area Team/CCG statements/remittance advices – including any received since the year end

Other income remittance advices

Invoices

Petty cash records

Details of payroll for all staff including nurses, GP registrars (where the practice still retains responsibility for them), retained GPs, salaried doctors, cleaners and spouses’ salaries to include all employee and employer deductions and positions held in the practice. Often the monthly summary sheets give all the information required. Please remember if your year end is not March, information will be needed from two payroll years.

A list of employees and their job roles – administrative/nursing/dispensing/salaried GP, etc.

Confirmation of profit-sharing ratios

Quarterly list size calculations

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Copy of the CQRS printout showing points and pounds achieved for the last QOF year

List of debtors and creditors at year end

Details of rates paid by the Area Team on the practice’s behalf

Salaried appointment payslips

Drugs stock

Analysis of doctors’ drawings

Loan or mortgage statements

PMS backup paperwork

Confirmation of property ownership ratios

VAT returns and any backup paperwork/Iris reports

Dispensing list size

At the year end, the first task is to make sure that all transactions have been accounted for and entered into the accounts package. A reconciliation of all bank statements against the entries in the bank’s current account should then take place. It may be helpful if online banking is used to print a complete set of the year’s accounts.

This year end process may mean entering all cheques issued, and completing all auto-bank line payments and printing off payment schedules and remittances. It will also mean breaking down certain payments in more detail. For instance, any assets purchased, such as furniture and equipment, will need to be shown separately in the accounts. Computer hardware should normally be provided by the NHS IT provider without charge to the practice. Office and medical supplies are broken down in more detail. For instance, drugs, vaccines and medical consumables, such as minor surgery packs, should be shown separately.

In many cases the accountant will prepare the ‘Type One’ certificate, which NHS England requires, showing the superannuable income for practice partners. This certificate allows NHS England to adjust the deductions for partners’ superannuation, which is done through Exeter payments, and it is the responsibility of the practice to see that it is sent by the due date – usually the end of February, one year in arrears. Salaried GPs must provide a ‘Type Two’ certificate through the practice, who should fill it in with all practice payments made, but it is the responsibility of the salaried GP to ensure income from outside the practice (e.g. out-of-hours or locum fees) is included – and he/she will often employ their own accountant to collate the amounts.

Adastra

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This is a system that provides limited details of a patient’s clinical record for out-of-hours providers to use when necessary but that needs Special Patient Notes uploading to it. All notes will need to have a review date entered (this is automatically set to 6 months from the day of entry but can be amended as appropriate). There may be a different programme in different areas; however all will normally provide a similar data set for the practices it serves.

Notes that have passed the review date will show up in red and you will find that most of these will probably be old. Special Patient Notes can never be deleted, however you can access the note and tick the box to mark the note as hidden which will remove it from your screens. There are two tick boxes both titled ‘Share with external agency’. These should automatically be ticked when you enter a new note, but please always check this and ensure that any notes already on the system have this box ticked. This allows information to be passed to 111.

111 do not have the same access to Special Patient Notes as out-of-hours providers.

They are only able to access one record for each patient so please ensure that any new information about a patient is added to a current note and that a new note is not created (unless the previous note is no longer relevant in which case it would be hidden). 111 will always see the most recent note if more than one is on the Adastra system.

Alerts

Alerts may be for patients who are suspected of trying to obtain drugs by fraud, problems with drugs, or equipment that is unsafe or which is being withdrawn or is unavailable for other reasons. It is important that all staff who need to see any particular alert are made aware of it, and it has been checked that they have read it. Alerts will often be set up to come in via the practice manager. You must review them all in a timely fashion and seek guidance and expertise from the team where appropriate. There is now no requirement to inform the Area Team whether these are applicable or not, but you will need to log each alert to the Alerts spreadsheet and hyperlink the alert. Or if the practice is using Intradoc, or another similar back-office intranet facility, there may be a process for alerts to be saved there and distributed or reviewed by a clinician as appropriate.

Annual leave

It is vitally important to keep accurate records of annual leave taken. Each member of staff should be given a leave sheet with either a full year entitlement or a pro rata entitlement depending on their start date.

Leave may be recorded in days or hours, according to practice procedures, but hours would seem to be the fairest way where staff work variable shift lengths or different days. Bank holiday working complicates leave allocations, where they are calculated on days, as the statutory minimum leave entitlement for workers is 5.6 weeks. An employee on a five-day week receives 28 days (i.e. including bank holidays), however an employee on a three-day week is only entitled to 16.8 days’ leave per annum (i.e. 3 x 5.6). How the leave records are maintained is for the practice to decide but there are several software packages available (IRIS/Intradoc, etc.) to assist.

Appointments

All patient appointments are made through the clinical system. Templates are set up for each

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clinician to their specification through the system. The following are the first areas that a new practice manager may want to obtain training for:

Finding and booking appointments information

Configuring the appointment book information

Creating session templates information

How to audit staff access to records and DNAs (patients who fail to attend appointments – ‘Did Not Appear’)

Creating appointment slot reports

Appointments are usually based on a ten-minute slot for doctors working under the GMS system but this may vary according to the specification of the practice contract in other cases. Nursing and other staff may have differing slots according to the nature of the consultations they carry out, and many practices have a set scale, particularly where patients have co-morbidities or complex needs. It is good time management for staff, as well as being good for patients, if they can have their regular appointments grouped together into a single slot.

Practices in some cases will use a clinic system where one nurse with specialist knowledge sees patients with the same condition on the same day. This system can mean patients are brought in several times if they have several conditions and on each occasion height, weight, blood pressure, etc. are taken.

Appraisals

The practice is required to undertake annual appraisals for all practice staff including practice nurses. Appraisals are important for staff to feed back issues as well as management, and it is good practice for that appraisal to be carried out by people with the appropriate management role.

Practice staff appraisals

As part of the Quality Framework the practice is expected to operate an annual appraisal system for all practice staff and nurses. The practice manager should be appraised with the other staff (unless the practice manager is a partner, when other arrangements may apply). It is good practice for appraisals of nursing team staff to include both relevant clinical as well as management appraisers. Registered nurses (RGNs) are required to undergo revalidation and also maintain an average of 12 hours CPD each year which should be checked by the employer at appraisal. In addition RGNs, as part of revalidation, are required to have a ‘professional discussion’ ideally with another RGN and that discussion is reported online as part of the process. It would seem appropriate that RGN appraisals could be conducted by the lead RGN and the practice manager, which would therefore have relevant clinical as well as managerial input.

Staff should always be given time to prepare for their appraisal and a careful record should be kept of appraisal interviews and any action taken. Staff should have the opportunity to be given reasonable objectives to achieve in relation to their duties. The SMART objectives should be reviewed as part of the next appraisal. The written document should be circulated to the relevant member of staff for signing. The practice manager then should sign the

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document, take a copy for the staff member, and keep the original in the staff member’s personal file.

GP appraisals

The doctors have their own peer review appraisal system and keep a portfolio of their objectives and achievements during the year. The practice manager may be required to provide support to that process by ensuring complaints and Significant Events are available for the GP to include as part of their portfolio.

Area Team

NHS England (NHSE) now uses the NHS email system as its prime method of communication with GP practices. It is important that NHS England’s mailing lists are kept up to date and that arrangements are in place for urgent emails to be received and acted upon when the practice manager is absent.

Constant monitoring of your NHS email account is essential as the NHS email system has become the prime method of communication within the NHS – below are examples of the type of communication now received.

GP and practice management bulletins

The Department of Health, NHS England and CCGs (Clinical Commissioning Groups) usually issue newsletters to GP practices and in many places either attend or facilitate practice manager meetings where information can be cascaded. Representation by the practice at these meetings is vital as it presents the opportunity to provide feedback on how systems are operating as well as what ‘initiatives’ might not be workable.

Local Medical Committee (LMC)

The LMC also uses emails to circulate information about agreements reached or being negotiated with the BMA. The practice pays a statutory levy to the LMC to fund its activities. It also pays a voluntary levy to fund negotiations at the British Medical Association (BMA). Practices also receive a monthly payment for LMC attendance via BACS and this needs to be put into the accounts as income.

Medicines management – warning

NHS England issues ‘hazard’ warnings to practices on a regular basis. Refer all incoming warnings to the prescribing lead. Sometimes copies may need to be given to the practices nurses to check stock in use and whether it should be withdrawn. NHS England will need to be notified of any products found by the practice to be hazardous.

National Institute for Health and Care Excellence (NICE)

Up-to-date information about decisions made by NICE, the National Institute for Health and Care Excellence, are sent via email. Forward these emails to the nominated GP for clinical education issues. Website: https://www.nice.org.uk/

Child protection

The Child Protection Manual should be maintained and updated as well as always available

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for reference by all staff and locums. Forward these emails to the safeguarding lead. The CQC during its inspections has taken a special interest in ensuring the practice staff are aware of and familiar with safeguarding procedures. Staff training courses are provided to make staff more aware of the issues surrounding reporting problems with vulnerable children and adults.

Cervical cytology

Open Exeter notifies the GP practice, using the NHS email system, of the numbers of patients to look up on the Open Exeter system to call for smear tests. The cervical cytology target figures are shown in the GP clinical system (e.g. Population Manager in EMIS). Practices need to be aware that patients who do not respond to invitation letters may be removed from the practice list. (See also ‘Cervical screening’.)

GP systems of change

NHS England is monitoring progress made towards adopting a clinical system that is compatible with country-wide systems so that the National Spine (Patient Demographics Service – PDS) can be used to view patient summary records. Many practices now have web-based GP clinical systems and the need for local ‘backups’ of data has been removed. Practices are also able to transfer records between practices using the GP2GP records transfer system. This does not remove the need to check that an effective summary of the patient’s health record has been recorded. Patients now have the option to agree to the sharing of their records with other parts of the NHS and to allow other NHS services to send data to their GP record. There are issues about using patient data anonymously as the patient has to choose to opt out of allowing the National Spine to be used by third parties.

National Demographics Service website: http://systems.hscic.gov.uk/demographics/pds

Audits

GP practices are still expected to monitor the quality of their work using clinical audits of referrals, prescribing and clinical domains. Again, the Care Quality Commission (CQC) may want to see evidence that the practice is a ‘safe’ practice. Practices are moving towards appointing prescribing advisers to help management prescribing in the practice.

The practice should maintain a log of all audits and this can often be combined with second-cycle audits/revisits of Significant Events and complaints. Audits should be undertaken during the year, both clinical and administrative, e.g. DNA analysis, appointment analysis, patient surveys, but while many practices use students or registrars to run audits this alone will not satisfy the CQC inspectors and the direct involvement of doctors in their own audits as well as other staff, both clinical and non-clinical, is essential.

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B

Banking

A practice’s main business current and savings accounts are usually placed with a mainstream ‘high street’ bank. Account transactions should be more manageable using the web-based online banking service. This should only be accessible by approved users who are allocated a username and a series of passwords. Banks and building societies have rules about opening accounts in the names of large partnerships. It may be easier to open accounts in the name of one or up to four ‘trusted’ partners. Most banks have relationship managers who should be able to help with setting up all banking processes and advise on the fees they charge, as well as explain what account benefits you may have with your account. Remember that banks make interest out of your credit balances and this should be offset against the charges they make for processing cheques, payroll, etc. Changing banks, while not always a seamless process, is improving and may result in significant savings in charges and better benefits.

It is good practice for a file containing all bank statements and building society statements received to be compiled and retained in folders with invoices. It may be necessary to request annual statements for any building society accounts held to show interest earned and tax paid during the financial year.

The practice often has an overdraft facility on the current account but the objective is to use it sparingly on the grounds of cost. Overdraft facilities usually carry an arrangement fee which needs to be factored in, and taking the advice of the practice accountant is always recommended. In addition, should there be any significant expenditure needed in the practice, which cannot be covered by reserves, then as part of the borrowing research the use of an overdraft should be considered as it may work out to be more cost-effective than a loan.

The exact details of who can authorise expenditure, especially should there be Internet banking available to the practice, needs to be clearly set down and understood. Consideration needs to be given to the limits of authorisation, not forgetting that monthly payroll needs to be processed when the required number of signatories may not be present – holiday periods can prove particularly testing when it comes to the availability of someone to authorise expenditure.

An annual statement of any mortgage account and loan should also be available for the annual accounts.

TIP: It is important to complete a transaction in one go and not to be distracted. When bank account details are changed for staff, doctors and suppliers, make sure you have deleted the old bank details.

BACS payments

Fees can be paid directly into the practice bank account. A software package that accepts online information may be used for invoicing, including all requests for payment of pre-agreed fees such as those paid by the DVLA (Driver and Vehicle Licensing Agency), the Criminal Injuries Compensation Authority and collaborative fees paid by local government bodies for

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the disabled badge scheme and fostering and adoption medicals.

See the Invoices section for information regarding the paying of supplier invoices by BACS and procedures.

Banking cheques and cash

Banking must be done appropriately to avoid large amounts of cash being held onsite and to ensure cheques are paid into the accounts to maintain cash flow. The banking documentation is then input into the accounts package.

Banking payments

The online bank accounts will have an approved administrator of the account who can authorise individual users to operate the online, web-based bank account. The GP who acts as the finance lead in the practice will normally be the administrator. The practice manager will normally be authorised by the administrator to set up payments and to enter bank details for suppliers. The practice manager will also be able to view accounts and print remittances. The approved administrator will normally be the person who authorises payments online, but remember the need to make payments when they are on holiday or ill.

An application will need to be submitted to the bank to approve new users and issue passwords or to vary any authority given to approve payments.

The normal payments process in a practice is to make general payments to suppliers once or twice monthly; mid-month and at the end of the month. The Inland Revenue staff payment must be made by the tenth working day of the next month otherwise a fine may be levied, and most if not all accounts or payroll packages now have the facility for online submission of payroll data. HMRC do not have a direct debit arrangement for income tax and National Insurance and as the amount varies from month to month a standing order is not appropriate, so remember that individual monthly payments need to be made. The practice is also required to make monthly payments of VAT, if registered, and it is important to remember to make a NIL VAT return if no payments are due; however, this is usually a reclaim of VAT due to the dispensing aspects of the practice.

Payments to the NHS Pension Scheme are collected by direct debit and need to be made by the 10th by submitting the amount to be deducted to the NHS Pensions website. Details on how to access the website are mentioned later. There may be other direct debits set for regular collection, including to your water authority, the gas and electric power supply providers, and the surgery and employers liability insurance providers.

The partners’ drawings are reviewed by all the partners at the review with the practice accountant, usually at the presentation of the year’s accounts. The practice accountant will make recommendations on drawings levels, usually attributable to their capital accounts.

TIP: Direct debits and standing orders for drawings will need to be cancelled when a doctor leaves the practice upon resignation or retirement.

Payments can be made by cash, cheque or online banking. The use of cash and cheques,

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however, is to be discouraged and is becoming rare for businesses. GP practices may have bank cards; however each partner and the practice manager also could have credit cards for charging practice expenses to, which are then settled monthly. Cheques are now rarely used and many suppliers no longer accept cheques. To enter the website, the bank will issue an account code and a username. Each user is then allocated a password to affect entry onto the website. A password generator device may be used to select a series of numbers to authorise a payment. Any payments set up to be approved should be processed within a time limit (normally the same day). Systems vary from bank to bank.

Select a bulk list in which to make a payment, set the date the payment is to arrive, and enter the amount against the supplier’s name. Confirm the payment and print a copy of the payment record. Inform the authorising doctor by email that a payment is ready for transmission.

A schedule of payments made should be printed off and copies associated with the batch of invoices for each payment made. This will make the process of bank statement reconciliation much easier. The normal processing time for banking payments is two bank-working days, although some banks now make payments on the next working day. Tuesdays, Wednesdays and Thursdays are good days to make payments, thereby avoiding bank holidays and weekends, but remember the moveable holiday days of Easter and Christmas. You can always set a forward payment date. This is particularly useful for the monthly Inland Revenue staff payments, which can easily be forgotten.

TIP: Make sure you are aware of the holidays and days off of those doctors authorised to make payments; otherwise chaos may ensue, particularly if it’s pay day for the staff.

Bank statement reconciliation

Bank statements issued by the bank can be received monthly, fortnightly or as and when requested. The need for hard-copy bank statements has reduced as more and more clients use online banking services. Bank statements can also be viewed using password access. The bank reconciliation process requires that the entering of all income and payments is brought up to date. The following tips may need to be taken into account when balancing the books.

TIP:Are all cheques issued entered?Are all NHS income statements entered?Are all private income credits entered?Are all standing orders and direct debits entered?Is all petty cash banked and entered?Are all bank payments entered?Are all bank charges and interest received entered?

Reconciliation needs to be undertaken before any VAT return can be calculated and submitted to HMRC online. To undertake reconciliation you will need to utilise the reconciliation report on your chosen accounts package for all accounts each month.

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British Medical Association (BMA)

The British Medical Association (BMA) is the trade union and professional body for doctors in the UK, however not all GPs choose to belong to it. It is extremely useful, however, for at least one partner or executive of the organisation to be a member to gain some of the benefits.

The BMA is led by a team of executive directors working towards objectives set by the BMA council. The council sets overall policy which is informed by the needs of grass-roots doctors, as determined by the BMA Representative Body, which itself is drawn from practice and regional committees throughout the UK. The BMA has a very useful team of employment advisors who will advise members not only on their own employment matters but also, if they are employers, will assist with advice in dealing with staff. Practice managers can have guest access to most of the guidance on the BMA website and this is very useful when taking on a salaried doctor as the draft contract is available as a download. At the time of writing, the GMS contract requires practices to put salaried doctors on the BMA contract.

Website: www.bma.org.uk

Business planning

The purpose of the plan is to set out clear objectives about what the practice is trying to do and to describe something about the practice and the changes you and the partners think are important to introduce over the next three years.

Business continuity plan

The practice is required to have a comprehensive Business Continuity Plan that is regularly updated. The updated plan is then circulated to all relevant staff when a change is made. A copy must always be held off-site to be available when there is no access to the building (e.g. during fire or flood, etc.) or there is no access to IT. The plan must contain details of ‘buddy’ practices, relocation venues and essential contact details for key staff and services. Remember that the security of the personal data of staff and essential external personnel is required by the Information Commissioners no matter where or how it is held, so hard copy must be locked away and information held on data sticks or other digital formats must be password secure.

In some practices there is a box or bag available in the reception area, or kept close by but off-site, with paper copies of all the main forms needed to keep the practice running for an hour or two should they have had to evacuate the building. A pro forma sheet for consultations is part of this stock and once there is online access to the clinical system, the consultations can then be retrospectively input – it will be a matter of practice policy whether this is done by the completing clinician or as an admin task.

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C

Care Quality Commission

The Care Quality Commission inspects all GP surgeries in England in order to monitor standards against set key areas such as safety and responsiveness. Each practice must be registered with the CQC and appoint a registered manager, normally a doctor. The practice is expected to be able to evidence how it is run in considerable detail, helped by the prior preparation of a series of policy documents, protocols and procedures. The CQC has published on its website how a practice is expected to meet its requirements across the whole spectrum of running a medical practice. The most important area for practices is probably ‘Nigel’s Surgery’ where the CQC offers advice on queries about the interpretation of their standards. The importance of knowing what the CQC is looking for cannot be overstated.

Website: www.cqc.org.uk

The CQC may conduct inspections that are ‘comprehensive’ (i.e. covering all the areas where they have set standards) or may select particular topics relevant either to that surgery, a CCG area, or the whole health economy including Social Services and secondary care.

Some of the areas that have been inspected previously include:

General management

Registered manager: Checking the skills and knowledge of the registered manager on the day of inspection, along with the practice manager and senior nursing staff. Inspectors may speak to any staff present along with patients in the building at the time.

Statement of purpose: That the practice has published a clearly defined statement of business purpose – a mission statement that has been submitted to the Care Quality Commission.

Business Continuity and Succession Plan: The practice should have a Business Continuity and Succession Plan, setting out its aims and objectives and demonstrating ‘leadership’. The plan should refer to arrangements to keep the practice running with a minimum core staff and how it would deal with major emergencies that would affect the day-to-day operation of the practice.

Practice Agreements: A copy of the Partnership Agreement, the NHS Contract (GMS/PMS) Agreement and any company registration documentation should be in order and being properly applied.

Personnel contracts

Disclosure and Barring Service Checks – DBS Checks (Policy): The Practice should have a clearly defined policy of carrying out CRB/DBS checks. Copies of reports should be available for inspectors to view. The practice should be clear about which staff require a CRB check. NHS England’s advice points to nursing and reception staff, but opinions vary and may include all staff except cleaners! It has also been suggested that a risk assessment be carried out to assess which staff/posts should be checked and what type of check should be requested – Standard or Enhanced. Remember that the DBS risk assessment relates to the post and the role performed, not to the individual and many practices have taken the view that everyone should be checked at the Enhanced level on the basis that it is not possible to say

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they would never be left alone to supervise children or vulnerable adults. It is also important to be aware that a DBS check done previously for another organisation is not acceptable.

Staff recruitment: Staff files should show at least two formal references and evidence of appropriate DBS checks, passport checks (photo identity) to ensure entitlement to work in the UK and, where appropriate, confirmation of professional membership registration.

Staff contracts: Staff files should be available for inspection. Files should contain a signed copy of the staff contract and be tidy and in date order. Other documents might include training records and certificates, and appraisal records.

Staff terms and conditions of service: Staff contracts or manuals should set out the pay arrangements including salary scales, increments and overtime rates, along with the other terms and conditions of service under which staff are employed. It should cover such areas as annual leave, maternity and paternity leave, jury service, etc. Has the practice adopted ‘Agenda for Change’? Are all staff paid in excess of the National Minimum Wage? Are staff paid the National Living Wage?

Employers and medical indemnity cover: Evidence of professional indemnity (insurance) cover in the form of annual certificates may be asked for along with the employer’s public liability certificate, which should be on display. Evidence of sickness insurance cover taken out by the doctors might also be requested as this might demonstrate a commitment to keeping the practice running in the event of a long-term absence.

Staff appraisals: A policy document should set out the arrangements for carrying out appraisals which should also be referred to in staff contracts. Records of staff appraisals should be available to view either in a central file or in the personnel files.

Personnel policies

The following section gives examples of recommended policies:

Confidentiality Policy: The practice should have a clearly defined Confidentiality Policy with which all staff should be familiar. A manual of all policies could be prepared and signed by staff when read. The practice should have a named Caldicott Guardian.

Access to Records Policy: Practice staff should be aware of the procedure involved in allowing access to records. The practice should be able to provide evidence of registration with the Information Commissioner under the Data Protection Act.

Disciplinary and Grievance Procedures: As part of a raft of personnel policies, the practice should include these procedures in its personnel manual which should be available to staff.

Equal Opportunities Policy: As part of a raft of personnel policies, the practice should include these procedures in its personnel manual which should be available to staff.

Bullying and Harassment Policy: Staff policies should cover violence, abuse, bullying and harassment. Copies of the policy should be available to staff.

Equality Policy: Staff policy setting out the employer’s approach to the equality of employees no matter what their gender, age, sexual orientation and religious beliefs. The policy should be available to staff.

Working Hours Policy: Staff policy setting out the duty of care toward employees to monitor their health (stress) in relation to extended working hours. Both employers and staff should be

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aware of the obligations.

Whistleblowing Policy: Staff should have no fear of reporting irregularities of any type during their employment. Staff should be aware of the policy.

Personnel records

GP and Nurse Annual Registration: A central file should be kept to demonstrate that the national registration of GPs and nurses with the General Medical Council and the Royal College of Nurses has been checked annually on the respective websites of those organisations (where available). Practice nurses should be asked for confirmation of the payment of the annual retention fee. In addition, GPs should be included in NHS England’s Performers List. NHS England carry out DBS checks on GPs when adding them to the list and CQC do the same when adding anyone to the practice registration file (partners in the practice); however it does not absolve the practice of the need to also run the check when taking on anyone new (clinicians included).

Staff training records: Personnel records should show the internal and external training certificate of attendance records for each member of staff.

Practice staff training: Records of attendance for safeguarding, resuscitation and anaphylaxis training for all staff should be available.

Training needs assessments: Evidence of Personal Development Plans or Learning Plans should be available. Assessments might cover the use of computers.

Staff name badges: The CQC inspectors may ask to speak to any member of staff and, as such, a name badge would be very useful. Staff will be expected to have read practice policy documents and be aware of the main aspects – or at least be able to know how to find them as reference.

Staffing (manpower): The practice should have a policy setting out how it intends to maintain adequate staffing levels at all times, particularly where the need to employ locums arises.

Staff induction handbook: An induction handbook for new clinical and practice staff is highly recommended. A handbook for trainee GPs/medical students, etc. is also suggested and having a locum handbook is essential (see Locums), as well as a file on each locum used that contains sufficient information to ensure they are fit and proper persons to be seeing and treating patients.

Infection control

Infection control lead: Ensure that the practice has nominated an infection control lead and that that person is available to see inspectors and has run the annual audit.

Cleanliness and infection control inspection: Make sure that the most recent infection control report, carried out by the practice lead and signed off by the registered manager, is available.

Cleanliness and Infection Control Policy: The practice should have a policy document and provide evidence of its review.

Decontamination Policy: The practice should have a policy document and provide evidence of its review. What type of steriliser is used, if any? Are minor surgery instruments properly packed and labelled after sterilisation or single-use? Do staff know what the ‘single-use’ logo is (a circle with a figure ‘2’ crossed through)?

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Vaccine refrigerator: The practice should have regular records kept of temperatures found in the vaccine fridge. Are the contents of the refrigerator insured against loss?

Legionella testing: Inspectors may ask for evidence of legionella testing.

Health and safety

Health and Safety Policy: The practice should have a policy document and provide evidence of its review.

Health and Safety Risk Assessment: Records should be available setting out the results of a Health and Safety Risk Assessment carried out within the practice (at all surgery locations). Was any asbestos used in the original construction of the surgery premises? What action, if any, was taken as a result of any negative findings?

Waste disposal: The Practice should have in place a policy for disposing of business waste and clinical waste including ‘sharps’. Evidence of collection for clinical waste should be kept.

COSHH (Control of Substances Hazardous to Health): The practice should have a policy document and provide evidence of its review, and ensure that a copy of all hazardous products factsheets are available for all staff. Hazardous substances should be marked or labelled. If an independent cleaning service is used, the practice should ensure that legislation is complied with.

RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations): The Accident Book should be available for inspection, along with evidence of action taken if any entries occur.

Fire Precautions and Evacuation Procedure: Inspectors may check both inside and outside the surgery for regularly serviced fire extinguishers, alarm points and exit signs. Ensure that fire exits are not blocked and surfaces are clear. Also ensure that ‘exit’ doors are operational and any keys are readily available.

Equipment maintenance: Ensure that records of equipment maintenance and PAT testing of electrical equipment are available. Equipment might include scales, ECG machines and spirometry machines, and also include kettles, refrigerators, televisions, telephone systems and computer equipment. Ensure that medical equipment used for measuring patient data (e.g. sphygmomanometers or thermometers) have been checked and calibrated professionally each year. Having a practice asset register (a list of everything that the practice owns in the building, including medical equipment and especially anything in doctors’ bags) is advisable so that the list of what has been calibrated or PAT tested can be checked off against what should have been done.

Medical Alerts Policy: Ensure that there is a policy/system in place for the dissemination of medical, drugs and equipment safety alerts. This may include having a single point of contact for incoming alerts and then evidence of circulation.

Practice arrangements

Registration of New Patients Policy: A policy should describe whether the practice has an open list, the extent of the practice area, and the approach towards temporary and out-of-area patients. The practice should also review the number of patients who live outside their practice boundary.

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Violent and abusive patients: The practice should have an alert system in place for disseminating information about patients reported to be violent or abusing drugs.

Appointments system: Any ‘examination’ of the appointments system should reveal that same day and immediate appointments are available, that continuity of care is feasible and that there is not an undue wait for regular appointments with a named doctor.

Telephone services: The practice should be accessible via a local geographical telephone number and that number should be clearly ‘advertised’ to patients.

Texting/messaging services: The inspectors may express interest in the development of texting services to remind patients of appointments and to seek health data from patients.

Home visits: The practice should maintain records of requests for home visits, either by computer or in diaries, and ensure that patient records are updated.

On-call arrangements: The practice should be able to explain the daily on-call arrangements within the surgery. There may be a noticeboard displaying the names of duty clinicians and the duty manager.

Out-of-hours arrangements: The practice should be able to explain what out-of-hours arrangements are in place and this should be demonstrated by notices in the surgery, the practice leaflet and website. Patients should be aware of the ‘111’ service or the local alternative. The inappropriate use of A&E services should be highlighted and attention drawn to Minor Injury Units.

Absence records: The practice should keep a ‘business diary’ setting out records of absence and cover provided for all clinical staff. It should record holidays, sickness and training absences. It should also record internal and external meetings (e.g. CCG) and who attended.

Patient services and information

Practice leaflets: The practice is required to have an up-to-date practice leaflet and copies should be available for the inspectors. A safeguarding leaflet should be available for patients. The leaflet should be in a tidy condition.

Practice website: The practice website should reflect the practice leaflet and offer contact points for making complaints, making appointments and ordering prescriptions.

NHS Choices website: The NHS Choices website should be kept up to date at all times (this is often forgotten!).

Consent procedure: The procedure for seeking consent to treatment in the practice should be set out in a policy along with sample consent documents. Patients’ clinical records should show evidence of consent sought and consent given.

Chaperone Policy: The practice policy/procedure for arranging a chaperone should be visible in the practice and the offer and use of a chaperone recorded in the patients’ notes by both the clinician and also the practice member who acted as chaperone.

Identification of minors: The practice should have a procedure in place to identify patients who are minors or who are vulnerable adults.

E-referral procedures: Information should be available to patients about the system for referral

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to secondary and community care. Patients’ clinical records should show evidence of the treatment referrals offered.

Palliative care: The practice should keep a palliative care register and ensure that out-of-hours service providers are notified of new patients added to the register. There should also be evidence of regular meetings with community staff regarding palliative care patients.

Vulnerable patients: The practice should have clearly defined policies for dealing with vulnerable patients (children and adults). Staff should have had safeguarding training and be aware of the name of the practice lead.

Complaints: The practice Complaints Procedure must follow the current legislation and be freely accessible to the public. It should not require anyone to have to ask for it at reception but be available to be downloaded or picked up in the waiting area. It should also advise that instead of making the complaint to the practice they can go directly to NHS England, and that having had the complaint finalised they can appeal to the Parliamentary and Health Service Ombudsman if they are not satisfied. There should also be evidence of reviews of all complaints on a practice basis at least annually and second-cycle reviews to ensure learning or procedural changes are being adhered to.

Accessible Information Standard: The practice is required to ensure that anyone with communication issues (e.g. deaf, blind, etc.) can still access information on services and the practice’s processes. The availability of large-print documentation, hearing loops, etc. will often be enquired about.

Computing services

Computer Security Policy: This policy deals with passwords and access rights as well as backup routines.

Computer housekeeping: There should be evidence of an IT support system for all computer hardware and software used in the practice.

Use of Social Media Policy: This policy sets out rules about the use of social medical such as Facebook and Twitter whilst at work and in relation to colleagues and ‘confidential’ practice business.

Patient Access to Online Services Policy: This policy sets out arrangements for patient access to online prescriptions, appointments and contact with the surgery. The arrangements for issuing ‘usernames’ and ‘passwords’ should be set out.

NHS Smart Card Policy: This policy sets out the arrangements for issuing smart cards to NHS GP practice staff, and for authorising and managing their use in the practice.

Prescribing practice

Repeat Prescribing Policy: This policy sets out the procedures for issuing, monitoring and reviewing repeat prescriptions.

Prescribing practice: This policy sets out arrangements for issuing prescriptions, such as the period of supply and any agreed restrictions or limitations on the drugs prescribed.

Drug formulary: This policy sets out the arrangements for drug formularies in the practice including personal or practice-based formularies and the arrangements for monitoring and review.

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Controlled Drugs Policy: The practice should have a clearly defined controlled drugs policy and evidence of a system of checking and updating the content of doctors’ bags. It is unusual for controlled drugs to be kept in a surgery unless it has a dispensary or the practice is rural.

Dispensing Policy: A dispensing practice may need to provide an explanation of the dispensing service provided.

Medical records

Record-keeping: This policy sets out the arrangements for ensuring the quality of medical records. Records should be timely and accurate. There should be evidence of regular case reviews (e.g. minutes of practice meetings). Records should demonstrate that patient choice has been offered.

Summarising records: The practice should have a system in place to summarise all records kept in the practice including those newly received. Who is responsible for summarising records?

Allergy Recording Protocol: The practice should have a protocol that sets out the procedure for ensuring that allergies are recorded in patients’ computer records and that any allergies shown on manual records are transferred to the computer record.

Clinical Letters Procedure: The practice should have in place a procedure to deal with the receipt of clinical letters and reports to ensure that action is taken when and where appropriate. The procedure should provide for deputies to act in the absence of the patient’s own doctor. The procedure should cover both manual and computer reports.

Quality Outcomes Framework (QOF): This policy sets out the arrangements for maintaining, updating and reviewing the QOF/CQRS records. The policy should specify who is responsible for each clinical domain.

Clinical audit: Is there evidence of regular clinical audit in the practice and in particular case reviews of patient notes, particularly of cancer referrals (e.g. minutes of practice meetings) and of second-cycle reviews of audits previously undertaken to ensure changes and learning are embedded in the daily working practices?

Death reporting: The practice should have a protocol setting out how deaths are to be reported in the practice. A death occurring in the practice premises will need to be reported to the CQC. The protocol should set out whom in the primary care team, and in secondary care, should be informed that a patient has died.

Transfer of medical records: This policy sets out the arrangements for ensuring that medical records are transferred when patients leave or join the practice list, using the GP2GP transfer system where and when available.

Clinical management

Continuity of care: This protocol should include the arrangements for deputies and for dealing with out-of-hours reports.

Referrals: What are the arrangements for processing e-referrals? Can the practice demonstrate that new referrals are checked to ensure that a booking has been made? Can

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the practice demonstrate that choice is offered and the referrals are managed?

Standard and quality of referral letters: What steps are taken to ensure that the standard and quality of referral letters are adequate and that sufficient information is provided in the letter to enable an efficient, effective and appropriate referral to be made?

Health checks: Ensure that the practice has in place procedures to offer health checks to newly registered patients and patients aged 40 and over where appropriate.

Clinical Emergency Plan: The practice should have set down in a policy document the procedure for dealing with a medical emergency such as an epidemic (e.g. Ebola, Asian flu, etc.)

Lifestyle Information Protocol: The practice should set out its policy on providing lifestyle information for patients and managing their care.

Quality and performance

Significant Events: A Significant Events recording system should be in operation and records should be provided to show events over at least the past year, including action taken, second-cycle reviews and learning outcomes – if any.

Patient survey: The inspectors may wish to see the results of any patient survey carried out along with a report of any action taken. Remember, information is already available to inspectors online.

Friends and Family Test: The practice should be able to show what steps are being taken to carry out the Friends and Family Test and show the results so far.

Patient Participation Group: The CQC inspectors will ask to speak to members of the PPG. Keep a list of contact names available. Have copies of minutes and reports available, along with copies of any recent practice patient survey. (These should also be online on the practice website.)

Financial management

Standing Financial Instructions: The practice should have a policy setting out how the finances of the practice are managed. The CQC expect practices to demonstrate that they are financially viable and able to provide the services they are contracted to provide.

Practice accounts management (Standing Financial Instructions): The procedure for managing the practice accounts should be set out in a policy document and the practice should have processes to counter fraud.

Petty cash control: The procedure for handling petty cash in the practice should be documented and staff should be aware of it.

Private fees and charges: The practice should have a clear and visible policy on charging patients for private, non-NHS services. A poster should be on display in the surgery.

Business management

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Disaster Recovery Plan: The practice should have in place a Business Continuity, Disaster and Recovery Plan to activate should there be a major disaster such as a fire or perhaps the sudden loss of a senior member of the practice, such as a partner or practice manager. It does happen!

Practice premises

Ownership or tenancy of surgery premises: The practice should be able to provide information about the ownership of the premises. If leased, a copy of the lease should be available along with any evidence of building maintenance that is required to be provided under such a lease.

Disabled access: The practice should be able to demonstrate that access to the premises for disabled people has been provided along with suitable toilet facilities and accessible treatment and consulting rooms.

Nursing mothers: The practice should provide facilities for nursing mothers who wish to breastfeed, and a notice should be displayed in the reception and waiting room.

NHS contracting

Clinical Commissioning Group: There should be evidence of involvement and interaction with the local Commissioning Group (and Federation, if one exists) and with NHS England.

Directed and Locally Enhanced Services: The practice should be able to provide copies of any current agreements to provide enhanced services along with evidence of activity and claims.

Once an inspection is over, you will receive a report which must be published on the practice website and a notification put into the waiting room. This is a mandatory requirement.

Clinical Commissioning Group

The practice will be a member of the local Clinical Commissioning Group which brings together GP practices to buy and shape health services for the people of the area. The CCG may hold ‘delegated’ contracting, which means that the CCG is responsible for the NHS contract that the practice works to and not NHS England.

Cervical screening

Invitations for screening are sent out from the NHS screening programme and not the practice. Recalls are issued every three years for patients between 25 and 49, and every five years for patients between 50 and 64. Cervical smear sampling can only be carried out by appropriately trained clinical staff and responsibility for managing both initial training and continuing training rests both with the clinician and the practice.

Website: http://www.cancerscreening.nhs.uk/cervical/index.html

Chequebooks and stubs

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The accountant will need to be sent the cheque stubs for the year. It is important to complete cheque stubs with date, payee, purpose of payment, if not apparent, and value. The cheque number should be entered on the invoice as a record of payment. Cheque stubs should be kept with the annual accounts records and bank statements for at least six years.

See ‘Accountant’ section for more information.

Claims

The practice receives income from a variety of sources, some of which are paid for by Public Health, the Area Team, NHS England or the CCG. Claims are monthly, quarterly or annually. The majority of claims are made via CQRS, which involves the data being taken automatically – although this is not the case for all! Automatic claims are being added to CQRS regularly so you will need to keep checking what you have to do manually and what will be extracted automatically. Regular updates are given by the HSCIC if you subscribe to their newsletter and this helps you to keep abreast of the changes – but not always!

You will need to be very careful and review the Claim Submissions & Payments spreadsheet which will give you an idea of what needs to be done and when.

In addition, a spreadsheet is kept of all payments claimed and when they are received as there is a tendency not to get this right! Practices experience significant problems with payments made through the NHS and the need to keep on top of what is owed and what is received is vital. The practice may decide to issue all claims and invoices under the regulations relating to the payment of debts to small businesses which entitles you to add interest of 8% over the Bank of England base rate at the time should the invoices not be paid within a specified timescale (often 30 days).

You will also need to sign off the QOF claim at year end via CQRS (see QOF section).

Further information can also be found in the Direct Enhanced Services section (DES).

Complaints

The practice policy sets out the practice’s approach to the handling of complaints and is intended as an internal guide, which is made readily available to all staff. Also, a summary setting out the approach to complaint handling should be available for any patient requesting a copy.

There is a very set process to undertake; you need to investigate and respond within the set timescales. The complaint also needs to be added to a practice complaints record as these need to be reported to the Area Team annually when required as part of your contract.

The complainant has the right to make a complaint direct to NHS England or to the practice. An interview room should be set aside for dealing with complainants in privacy. Patients should be encouraged to discuss any complaints informally with the practice manager to see if they can be resolved within 24 hours – in which case they do not need to be formally recorded and reported. It is, however, good practice to make a note of informal complaints

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and include them in the regular practice reviews of patient feedback (and not forgetting comments and complaints on NHS Choices). If still unhappy after the final decision letter has been issued, there is a right of appeal to the NHS Ombudsman whose contact details must be given to the complainant in every case.

Receiving complaints

Complaints should normally be taken by the practice manager verbally or preferably in writing. Any complaint received should be investigated by speaking to the staff involved and giving a copy to the doctor or nurse concerned for his or her comments. Normally the doctor will prepare a clinically appropriate response and may take advice from his/her colleagues or professional defence organisation.

Acknowledging a complaint

Normally a complaint, which should be made in writing, should be acknowledged within three working days and responded to within a period agreed with the complainant.

Keeping records

The practice is required to have a register in place for recording the investigation of complaints that complies with the NHS Complaints procedures, and it should keep a file of complaints correspondence. Under the GMS Contract, the practice is expected to review complaints annually and have that available at a Care Quality Commission inspection. Having the records available on a spreadsheet or otherwise on an intranet is good practice.

Consent to complain

Complaints should normally be made in writing by the patient or someone who has the patient’s written consent. Consent would not be expected if the patient was physically or mentally unable to make a complaint personally. Anyone can make a complaint where the patient has died. Care should be taken to record the complaint accurately if it is made in person and not in writing. The transcript record of the complaint should be agreed with the complainant.

Time limits for making complaints

Complaints can be made for up to one year after the event that gave rise to the complaint or after the time it became apparent.

Professional advice

Those involved in the matter complained about should be asked to comment. Sometimes it may be necessary to take professional advice before a response is sent. The doctors are usually members of a defence union such as the Medical Protection Society or Medical Defence Union. Some doctors may be members of and seek advice from the British Medical Association. The Local Medical Committee may also offer advice.

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Complaints response

From a practice manager’s perspective, a careful and thorough investigation should take place of any complaint received about clinical and non-clinical issues. A response should open with an expression of concern about the need to make a complaint and an assurance that the complaint has been noted and the points made taken into account. Give an explanation and, if necessary and warranted, an apology. The response should be factual and avoid expressing an opinion or comment. The response may conclude by offering further discussion and/or a meeting. Reference should also be made in the final letter to the options for appeal. If given the opportunity, the practice manager should check that the response includes a reference to further comments made by the complainant and rights of appeal. The final response must come from either the responsible person (i.e. usually a partner or senior executive appointed to oversee the proper functioning of the complaints system) or the complaints manager (usually the practice manager) who does all of the investigation.

Complaint to local health organisation – NHS England Area Team

The complainant has the choice to make a complaint directly to the local health organisation such as the local NHS Area Team, the local Clinical Commissioning Group, if the provider, the local community nursing provider, or the local government authority of the provider. The provider may also be an out-of-hours service, or the management of the ‘111’ service.

The practice and practice manager should be careful not to respond to or comment upon a service provided by another NHS provider even though it may have been provided within the practice premises. The practice should simply forward the complaint to the correct body and inform the complainant accordingly.

Annual review of complaints

A file should be kept of papers relating to complaints received and investigated by the practice. The practice will need to carry out a review of complaints annually and keep a record of the outcome of the review as part of the Quality Outcomes Framework process. Some complaints might have been the subject of a Significant Event review. A practice complaints spreadsheet will give you the number of complaints for each category, saving a lot of collation time at year end.

Significant Events

Complaints might become the subject of a Significant Event review, and discussion may take place at a partnership meeting with a view to avoiding a similar event in future.

Practice complaints leaflet

A complaints procedure leaflet should be freely available. The complaints procedure should also be outlined on the practice website. It might be helpful to have a poster on display in the waiting room inviting comments and suggestions. Practices are now taking part in the Friends and Family Test with a ‘voting’ box provided for replies.

Confidentiality

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Confidentiality is a legal responsibility for employees and is overseen by a Caldicott Guardian who should also be the nominated data controller for the purposes of information governance as the roles are closely in parallel. This responsibility relates to all records, whether they concern patients, staff or the general working of the practice. In particular, the Caldicott Principles emphasise the importance of the security and confidentiality of patient information and the need to consider reasons for passing on patient-identifiable information.

Staff need to be reminded that during the course of their employment they may find themselves in possession of information the disclosure of which could be construed as or may be a breach of confidentiality. Such a breach could be a serious disciplinary offence. The exception to this would be the relaying of information in the ordinary course of, and as necessary to undertake, any duties or where expressly authorised by the partners.

On receipt of their Contract of Employment, staff are encouraged to familiarise themselves with the practice’s policies on the following subjects in particular:

Information Governance Policy Information Governance Factsheet for Staff Information Security & Confidentiality Policy Confidentiality Policy for Under 18 years of Age Confidentiality Policy for Practice Staff Confidentiality Code of Practice Access to Medical Records and Medical Reports Policies

Staff will be required to read and confirm their acceptance of the practice’s Confidentiality Policy for practice staff, and if they are a current patient of the practice they will be asked to review the practice’s Staff as Patients Policy and will be required to sign an access disclaimer as detailed in the policy.

Contract of Employment

There are three types of Contracts of Employment in most surgeries, based on the same protocols – Standard Contract, Salaried GP Contract, and Zero Hours Contract. There is also a GP Registrar Contract but please see the GP Registrar section for further information. You will need to keep abreast of contractual legislation and update contracts as necessary.

Refer to the following documents in your practice:

Contract Template

Contract Template Salaried GP

Contract Template Zero Hours

Formal recruitment procedures must be followed prior to the issuing of a formal contract, including completing employment checklists and sending the prospective employee formal offer letters. These are legal requirements and need to be followed. Contracts of Employment should be available within two months of the employee commencing in post, unless a detailed terms and conditions of employment has been issued with the job offer; however, these should be signed either before or on the first working day.

CQRS

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The information-collection process involves gathering information in the form of data and copying it from one system to another. Data is collected automatically over a specified period of time, known as an extract.

Typically GP information is collected using the following process:

GPs record activity for the services they provide in their clinical system NHS England, or another organisation, requests information about a particular GP

service NHS England area teams offer GPs the option to participate in collections for that

service GPs agree to participate in collections for that service on CQRS CQRS collects information from GP clinical systems using GPES over a specified

period called an extraction If required, GP staff enter information manually into CQRS CQRS displays the information collected in CQRS GPs check the information collected is the same as is in their own clinical system If it’s payment related, GPs then have to ‘declare’ information from that collection to

area teams to approve using CQRS CQRS then provides the information to the organisation that requested it for

authorising payment or analysis

User guides can be found via http://systems.hscic.gov.uk/gpcollections/usersupport/userguides/2014-15/index_html

Report guides can be found via http://systems.hscic.gov.uk/gpcollections/usersupport/reports

Detailed information on how to use CQRS can also be found in the Claims section.

Website: https://login.cqrs.nhs.uk/cas/

Critical Events/Significant Events

The practice must keep a record of Significant Event investigations. The practice should be able to present a well-documented record covering at least three years’ worth of Significant Events. This includes a record of a meeting, with details of the event and any learning outcomes. Event sheets are usually completed by the person presenting the incident and filed under the relevant year and added to the practice spreadsheet or other intranet/software package in use. Once reviewed, the narrative needs to be added to the relevant sheet and the spreadsheet updated, so that the file can then be moved into a completed file.

It is important that events are widely shared within the practice so clinical matters need to be included, albeit briefly, in all meetings with staff throughout the practice where events are reviewed and learning points discussed.

Refer to the following documents in your own practice:

Practice Incident Reporting Log

Critical/Significant Event Sheet

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D

DBS checks

There are several providers – both online and otherwise – who can provide the practice with a DBS checking service. You will need to be aware of the eligibility for a DBS and the list of ID documents required (as given below) and it is important to be aware that these checking services will often decline to process an application should you not have specified a role where a DBS check is clearly required.

All employees requiring a DBS check will need to complete a form, either hard copy or online, and make a note of the reference number given at the completion of the application, particularly if an online service is used.

An online reference number should be provided to the practice manager who will then be able to review the ID documents required and complete the DBS1 form verifying the ID. Once this has been done, it can then be forwarded.

If using an online service you will receive a copy of the overview of the DBS check and the employee will receive the full check and a copy of this will need to be taken for the personal file. Staff should not work until the DBS has been received and is acceptable.

If there is anything other than a ‘clear’ DBS check when using an online service, you will normally be advised to refer back to your employee – a rather delicate position to be in. And, similarly, you should not use an online service when the potential employee produces a check showing convictions, etc. In the event that you have such a situation, you need to decide whether what you are presented with is sufficiently significant to withdraw the offer of employment. Remember that for the purposes of a DBS check there is no such thing as a ‘spent’ conviction and all such items need to be considered.

It is important to document any reasons to withdraw the offer and it would be essential to involve either the safeguarding lead or the data protection/Caldicott lead in that decision. A confidential discussion with the subject is necessary to be sure that you feel the entry is either very old/not significant/not relevant and that discussion should be similarly documented and any decision as to how to go forward also discussed with the relevant lead. It is important to document every stage of the process and if the decision is to allow the subject to continue to employment, a copy of the discussions along with the decision and a copy of the DBS check sheet should be placed in a sealed envelope within the individual’s personnel file, or password protected if a digital personnel record is what the practice uses.

Deanery

Registrars (i.e. GPs in training) will be on a three-year programme (known as ST1 through to ST3) which places them in both primary and secondary care settings until they pass both examinations and assessments. Their programme is set by the local university deanery covering the area, and the deanery is the first point of contact relating to their clinical training. In some areas the registrar is a practice employee and needs a contract (provided by the deanery) when they join you, and in others there is a ‘lead’ authority who will hold the contract and place the registrar with you as a secondment. In those cases all employment issues should be taken back to that authority (leave, maternity pay, etc.).Debtors and creditors – Private work and NHS income

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The invoices for collaborative fees, which are paid by the local authorities via NHS England, should also be checked for the amount owed. A separate file of invoices owed is usually kept. A list and value of invoices received prior to the year end but paid afterwards should also be prepared for the accountant. The practice accountant will also wish to know what income is owed for the last quarter of the financial year. Some NHS payments may remain unpaid for much longer periods.

Diary

It is suggested that you link your email account to Microsoft Outlook to enable you to use the calendar functions. You can then provide copies of the plan for the week or month to other staff. NHS mail does not provide a link to any diary. Set up regular reminders; this would be particularly useful for ensuring that safeguarding reports are produced in a timely fashion. There is so much to remember and to do, you simply cannot remember it all…

Direct Enhanced Services (DES)

NHS England has set up a series of payment systems for services provided by the practice, although this may vary from area to area. CQRS automatic extractions are being added regularly and therefore this section will need to be reviewed with the current guidance from CQRS and NHSE. (See the Claims section for each individual claim process.)

Annual agreements

Annual agreements exist for the following services, which are claimed on an individual claim basis each quarter.

Minor surgery, incisions, injections and excisions

This is a quarterly claim made manually by the practice as a result of running a series of searches on the clinical system. The searches are found in the Enhanced Services directory. The date range on the saved searches will need adjustment each quarter. NHS England may require an audit of one quarter of the claims per annum, requesting detail of procedures undertaken, the site of the procedure and the clinical reason for it. (See Claims section.)

IUD fitting and annual checks

This is a quarterly claim made manually by the practice as a result of running a search on the clinical system kept in the Enhanced Services directory. The date range on the saved searches will need adjustment each quarter. (See Claims section.)

Pneumonia vaccination

This is a quarterly claim made manually by the practice as a result of running a search on EMIS. The date range on the saved searches will need adjustment each quarter. (See Claims section.)Influenza vaccination

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Data is now collected automatically from your clinical system and is therefore dependent on recording ‘codes’ when a vaccine is given. Experience suggests that checks need to be carried out to ensure that stock used matches vaccines given, as practice staff and GPs do not always code adequately. (See Claims section.) Careful checks need to be made when community staff and others draw on practice stocks for housebound patients, etc.

Childhood MMR vaccinations

This is a quarterly claim made manually by the practice as a result of running a search on your clinical system. The date range on the saved searches will need adjustment each quarter. (See Claims section.)

PCV vaccinations

A series of searches may be set up in a clinical system directory which can be updated and run each quarter. The date range on the saved searches will need adjustment each quarter. (See Claims section.)

Childhood immunisation targets

Quarterly reports can be prepared and printed off using the clinical system. The quarter date will need to be set and the target report run. It can then be printed and checked for children who have not been recorded as immunised. Various steps can be taken to chase up non-attenders, including sending reminder letters to parents. As a last resort it may be necessary to remove patients as ‘gone away’ if there is no response to attempts to contact the parents. When a child has been immunised the Child Health Computer System should be notified so that their computer system can be brought up to date. It is this computer record that is used by community health to award target payments to the practice. (See Claims section.) Childhood immunisations are also recorded in a red book kept by the parent for every child, and it is important that this book, as well as any records on the clinical system, are reported against targets and correspond.

Disciplinary

The practice should have a very comprehensive Disciplinary Policy. There are a number of steps that need to be followed and the policy should explain these in detail. From the legal perspective you will need to follow this pathway to the letter! In addition standard template letters are often available to use.

Dispensary

Repeat prescribing

The practice should continue to monitor repeat prescribing and ensure that regular reviews of patients on repeated medication are carried out. The use of a ‘diary’ facility on the clinical system (if it has one) is a good way to monitor call/recall and medication reviews

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Dispensary stocktake (if a dispensing practice)

Near year end, the practice nurses should be asked to undertake a numerical stock count of all vaccines. An independent valuation is undertaken annually of the dispensary stock in readiness for the annual accounts, which should then be passed to the accountant for the preparation of end-of-year accounts.

Docman

Docman is a system used in many practices to store all the patient documentation. You will be set up with a password on commencing at the practice. Depending on your level of access you may also be able to see the restricted documents which include child protection and safeguarding notifications, etc.

Letters are received electronically from hospitals into Docman’s workflow engine and filed into the clinical system. Benefits include zero scanning, auto-patient matching, pre-populated filing fields and significantly improved document-processing times.

BackOffice Apps will enable the busy ‘engine room’ of the practice to transform the way they manage their information. A range of back-office apps will allow practices to move away from paper records, notebooks, spreadsheets and simple access databases to a structured central electronic database record, all accessed through a familiar intuitive user interface. All users (depending on their access rights) will be able to access and report on their BackOffice data. The system is similar to Intradoc and other back-office-type software

Applications available include the Accident Log, Asset Register, Birth Register, Death Register, Fridge Temperature Log, Practice Feedback, Room Temperature Log, and Significant Events.

iWorkflow in Docman has been designed specifically to improve processes within the practice. Action Based Workflow enables the actual flow of documents to be determined automatically based on the type of action required. This saves a significant amount of time, particularly for common processes; Quick Steps allow the user to group a collection of actions together, creating one-click actions. This allows frequent operations such as ‘add comment’, ‘mark as seen’, ‘add action’ and ‘summarise’ to be carried out via a single click. A quick step can be created for use by an individual or published for all users to benefit from.

Doctors’ annual leave

Doctors’ annual leave is often an issue and each practice will have its own system. Salaried GPs and partners may be treated differently and there should be either a Partnership Agreement which governs absences or a policy for employed doctors. It is important to maintain cover, and good practice is for leave absences to be monitored well ahead so that locum cover or additional doctor sessions can be booked.

Doctors’ contracts

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Practices are entitled to make their own appointments to partnership practices. They can choose to appoint a salaried doctor or engage a locum if additional help is required in the practice. The practice receives a Global Sum Budget to run the practice which does not take account of the number of doctors working in the practice. Payments generally are now related to the overall weighted list size and to the type and volume of enhanced services provided.

The structure of the practice often dictates whether doctors are on contract (usually larger organisations running multiple premises or part-time doctors providing additional sessions in a partnership) or are partners (the most common model). Partners are not on contract but could be either ‘equity’ partners (taking a share of the profit agreed between them as their salary) or salaried partners (paid a fix amount each month and not dependent on the profits). Partnerships should always be governed by a Partnership Agreement setting out how they will work together and preferably written by someone with legal knowledge as the most common cause of problems in a partnership is where there is no agreement in place or it is badly written!

Performers List

GPs are required to register to practice by gaining admission to the national Performers List. GPs will have gained a Certificate of Prescribed Experience which results from satisfactorily completing three years working in six specialist posts – two in general practice and four in the hospital service. With a certificate in place, a prospective GP needs to apply to NHS England for admission to the Providers List. Applications for inclusion in the Performers List can be made online. This also includes a Disclosure and Barring Service check. Be warned, this can take some time to confirm and there are many hoops to jump through. However, it is the doctor’s responsibility to gain access to the Performers List, not yours. GPs cannot work without being on this list and it also does not mean that you can use that DBS check in place of your own when they take up employment with you.

Website of National Performers List: https://www.performer.england.nhs.uk/

Practice Contract or Agreement

On admission to the Medical List, the GP can start working for the medical practice either as a salaried doctor or partner. For salaried doctors the British Medical Association recommends the content of a contract of employment. A model contract is available on the BMA website. A new doctor taking up a contract should agree his/her own working arrangements, hours of availability, days of work and number of sessions worked, and this is set down in a Job Plan appended to the BMA contract and reviewable yearly.

For a new partner, the practice would need to amend or redraft the Partnership Agreement. There may also be a change to who owns the practice premises, which may require an amendment to the Trust Deed. Model partnership agreements are also available from the BMA website but care needs to be taken when making changes to ensure there are no legal loopholes created by poor and imprecise wording.

Doctors' drawings

Whilst the practice accountants will often give advice on the level of drawings, it is advisable to set aside each month for Inland Revenue taxation payments, sometimes in an interest-bearing savings account. The practice manager should advise the lead finance partner accordingly

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when credit balances are high to transfer excess funds to savings accounts. If additional drawings are made, these need to be added into the practice accounts and clearly annotated as being a drawing.

Control of drawings will be a matter for each practice but some system will still need to be in place to make the agreed drawing payments to each partner at the end of each month using the BACS process or standing orders, etc.

Doctors’ personal expenses

Some or all of the personal expenses of the GP partners may be paid by the practice and attributed to the partners’ drawings account, including the General Medical Council annual registration fee, membership fees of the Royal College of General Practitioners and personal home or mobile telephone bills. Some doctors charge their car expenses to the practice. The GPs should be encouraged to introduce direct debit arrangements for such payments. The practice may pay some of the professional fees due for any salaried doctors working in the practice. It is wise to check the up-datedness of records held by the General Medical Council as it is not unknown for a doctor to change address and find that the annual retention fee has not been paid. Keep a file for each doctor with copies of annual certificates for the GMC.

Doctors’ files

Like all employees, the partners also have HR files which give relevant information such as DBS checks, interview records when joining the practice and also include superannuation forms and any revalidation and training information. These should also be available for CQC inspection as required, and they consider it essential for the practice manager to maintain a personnel file for each partner and to monitor and prompt when training, registration, etc. is due.

Doctors’ rotas

There is often a set rota but this does change to cover annual leave, sickness and any other absences. Locums are used on occasions but in many cases, as a cost-saving measure, partners do try to cover any sessions themselves. Additional sessions done by the partners are paid on an agreed basis. You will probably need to make the payment and add it to the accounts as drawings for that particular doctor.

Doctors’ superannuation

This is paid via the GMS statements every month and then a reconciliation is done once a year following submission of the superannuation form, which is completed by the practice accountant and then passed on to the partner’s own accountant for any additional information (see Accountants section above). You will be asked to confirm the figures for the partners at some time before the end of the financial year with the Area Team.

Salaried doctors, paid through PAYE by the practice, also need to send the relevant (different) form annually and this should be completed by the practice prior to being signed by them. If a salaried doctor has other earnings outside the practice, they need to ensure themselves that pensionable earnings for that work is similarly advised to NHSE.

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E

EMIS Web

This is the provider of the computer system for many practices. This provides the day-to-day usage of the system for consultations, appointments, prescribing, reporting, etc. and in addition gives patients access to be able to book appointments, request repeat prescriptions and view a limited medical record.

EMIS Web has now integrated with a number of other companies to form EMIS Health and it is envisaged that EMIS Web will provide new developments in technology moving forward. There is an annual conference every September which provides invaluable insight into new ideas and also gives you time to discuss any issues that you may have with members of the training team and attend workshops that provide hints and tips on how to do things more easily.

EMIS Web has launched an EMIS App for access to Patient Access and they are currently trialling EMIS Mobile – although this is very difficult in a rural practice with no mobile signal!

Equality and diversity

The practice must have a clear policy on equality and diversity and what it means in practice. In addition, all staff members have to undertake equality and diversity training (whether face to face or e-learning) and refresh every three years.

Equipment

An asset inventory is essential and lists all practice equipment and where it is kept. It should include doctors’ equipment (and if provided by the doctor, that fact noted) to ensure nothing requiring calibration or other testing is missed.

All medical equipment is calibrated annually at a time organised by the practice and usually with an outside contractor. A folder with all calibration certificates should be kept in the practice manager’s office or, if provided in digital format, on the practice intranet/Intradoc/iQ Manager, etc.

The asset register is important as it should ideally contain a reference number (sequential) for each item owned – both medical and any other equipment or furniture – and give the date and cost of purchase (and where it was bought from) as well as when it was due for calibration and/or PAT testing and the result of that testing. Items that have ‘failed’ or have otherwise been disposed of should also be noted. The register will be invaluable should any major incident happen and the practice insurance company requires details of what items are being claimed for. It may also assist the preparation of the annual accounts as it forms the basis of depreciation of assets and tax-deductible replacements.

Equipment fund

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A practice will be very lucky to have an Equipment Fund that may be run by a number of willing volunteers who are patients. Donations may be given to the Equipment Fund via the practice and this fund does much to provide equipment, etc. for patients that would not be provided from other sources. It is important to remember that NHS rules require ALL donations to be recorded to prevent fraud or other allegations of impropriety.

Expenses

The practice may have an Expenses Policy which gives guidance on the payment of expenses that will apply when staff members travel between main and branch surgeries, and the payment of travel and subsistence allowances that will apply whilst staff members are away from home for the purposes of business (including training courses and conferences).

This policy document should be read with reference to any Study Leave Policy and Training Costs Agreement (see Training section for more information).

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F

Fire

The practice must have a very clear Fire Safety Policy. All staff must have undergone Fire Training and every member of staff should have completed an annual Fire Safety refresher. Risk Assessments should be in place, reviewed annually, and fire alarms, emergency lighting and fire extinguishers are regularly checked and professionally serviced within legislative requirements. In addition, a fire evacuation drill should be undertaken at least twice a year. Fire routine notices must be available in all locations.

The practice should also train and appoint fire marshals who are available to manage situations at any time they might arise during periods when the surgery is occupied.

Fire evacuation drills are problematical in many surgeries where infirm and elderly patients are present, however must be carried out. It will be more important for staff to know how and when to evacuate, so careful planning is needed to ensure patients are not distressed when drills are carried out.

Flu clinics

Practices who take part in the annual flu vaccination programme may either set up pre-determined clinics or opportunistic occasions to administer vaccines – or both! The programme usually starts at the end of September or beginning of October and lasts until early New Year – or as long as stocks last. Local arrangements for the supply of the vaccine may involve central purchasing, buying groups or individual surgery direct purchases from either wholesalers or manufacturers. (See Vaccines section.)

Eligible patients are contacted by letter indicating when they should arrive and what to wear on the day (a pro forma letter is a good idea and also there are texting services that a practice can buy for the purpose when they have sufficient numbers of patients’ mobile numbers in their system).

A mop-up session can often be held a few weeks before stocks are exhausted or the programme ends to capture those patients who couldn’t attend a main session. Patients who are in care homes or housebound may receive their injections via community nursing, who will sign the appropriate documentation when removing vaccines from the premises and indicate in a timely manner when this has been given.

Staff who volunteer to attend clinics outside the normal days of opening (practices often take Saturdays to provide clinics) will be asked to book in, help with the administration of the injections, and add the information to the computer on returning to the surgery. All staff who help at the flu clinics should be remunerated in accordance with practice arrangements.

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G

GMS contract

NHS England may have entered into a General Medical Services contract with the practice, which sets out in general terms what the practice is obliged to do while working for the NHS and updates to this are received regularly and should be filed for reference. It is important to understand the basic requirements of the contract as NHSE (or the CCG if working to delegated powers) are able to impose significant penalties for breach of the contract. The practice can, however, designate themselves to be an ‘NHS Body’ under the contract and that limits them to the use of the NHS mediation services in the event of a contract dispute. Many practices remain outside this designation, which allows them to take legal action for any breach of the contract on the part of NHSE, and this does seem to bring with it some obvious benefits.

Premises – Rent reimbursement

Practices are expected to provide proper and adequate premises to practice from. The Area Team will reimburse a notional and/or cost rent in respect of approved premises. The notional rent is reviewed by the district valuer ever three years. The practice will need to complete a form and submit it to the Area Team. There is a right of appeal if the practice considers the notional rent offered unacceptable and it is advisable that the practice takes advice from an independent valuer to support their argument. Cost rent is a sum paid by NHSE which is related to the cost of any mortgage and in some cases also relates to any practice payments under a lease to private landlords. Notional rent is usually more generous as it relates to an assessment of the market rent of the premises but it is worth noting that once a practice taking cost rent has later opted for notional rent (which under market forces could possibly decrease) then it cannot revert to cost rent.

Reimbursement, depending on how the arrangements were set out with the NHS originally, can also cover business rates and water rates/charges. It is also worth noting that reimbursement of rent payable to a private landlord could also cover cleaning and electricity and gas costs if it proved impossible to separate them out of the sum payable (shared premises with a single metering, for example).

Telephone contact

Practices are expected to be contactable by telephone during surgery hours and ideally should have an arrangement in place whereby patients have only to make one telephone call to contact a doctor or an out-of-hours service, such as NHS Direct, when the surgery is closed.

Home visits

Doctors are under an obligation to make a home visit only if the condition of the patient warrants such a visit. A home visit may only be made to the last known registered address that is located within the practice area unless the practice has taken on a patient from outside the boundary and accepts home visiting to that address.

New patients

Patients will be registered with a named doctor in the practice but the patient has the right to

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see any doctor in the practice, subject to the availability of that doctor.

The practice is expected to offer a health check to all new patients, to patients who have not been seen for three years, and patients who have attained the age of 75 and over. A record should be kept of any offer and rejection made. Several questionnaires are almost always given to new patients, including a basic health questionnaire, an alcohol questionnaire and an ethnicity form.

Temporary patients

The practice may accept patients who are staying for a short time in the practice area. There is no longer an individual payment made when a service is provided. Patients returning from university should be accepted as regular patients. Patients are also removed from the practice list when patients stay for a short time in a residential (nursing) home.

Allocation of patients

The Area Team is under a legal obligation to ensure that every patient is registered with a GP. Sometimes the practice refuses to accept a patient. The Area Team has the power to assign or allocate a patient to the practice list as long as the patient resides within the practice boundary. The Area Team rarely takes this course of action. There is a right of appeal against an allocation, but a patient can still be removed from the practice list at a doctor’s request for limited reasons such as violence towards the practice or its staff (there is a requirement to advise the police and obtain an incident number to prove the removal was within the rules) or a breakdown of the doctor/patient relationship to the extent that it is not possible to provide an effective service. (See below.)

Removal at doctor’s request

The practice has the right to request the removal of a patient from the list. It is expected to write to the patient and give a reason for the removal. The practice should also write to the Area Team to request the removal in seven days’ time although in cases of violence this can be immediate. If the patient has only moved out of the practice area, the Area Team would allow a one-month period before the removal becomes effective. If a patient has been violent towards a member of the practice and the matter has been reported to the police, the Area Team will remove the patient immediately and allocate the patient to a doctor working in a special secure practice.

Vaccine storage

The practice is expected to monitor the temperature of any vaccine storage and to clear out any out-of-date medications or vaccine stock. The practice should keep a record of controlled drugs kept in the surgery and have a secure place to keep all dangerous drugs and vaccines.

Infection control

The practice should carry out a risk assessment on infection control and ensure that adequate arrangements are in place for the disposal of clinical waste and for cleaning clinical areas. The Area Team reimburses the cost of removing clinical waste. (See Infection Control section.)

Out-of-hours service

The practice has the right to opt out of providing out-of-hours services and, as a consequence,

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the budget would be reduced in value.

The practice is obliged to ensure that there are adequate arrangements in place to switch telephone systems to any out-of-hours services. It should also ensure that adequate notices are posted outside the surgery premises setting out contact arrangements when the surgery is closed. The practice should ensure that information received about services provided out of hours is clinically reviewed, acted upon when necessary and then filed in patients’ notes.

Range of services

The GMS contract and budget should allow for a range of services to be provided. Additional services include cervical screening, contraceptive services, including the fitting and checking of IUDs, vaccinations and immunisations, childhood vaccinations and immunisations, child health surveillance, maternity medical services, and minor surgery. It has been a matter of dispute and discussion for several years that there is no contractual definition of the core services a practice is obliged to provide and from time to time it seems that enhanced services become absorbed into the core contract.

Prescribing practices

Under the Quality Framework practices are expected to provide a 48-hour repeat prescription service. A doctor is under a contractual obligation to provide any medication that might reasonably be required for the treatment of a patient. The GP may follow recommended prescribing practices and may be working toward objectives set by the Medicines Management section of the CCG. A series of objectives are agreed annually and prescribing statistics are available on the Prescription Pricing Authority website. The site is accessed via a password. All practices appoint one of their GPs as prescribing lead.

Electronic prescribing

With a smart card logged in, a doctor or other prescribers can issue a prescription which can be transmitted electronically to the NHS Spine to be downloaded by a pharmacy. The system requires the patient to have nominated a pharmacy of their choice beforehand and the practice should make every effort to encourage patients to nominate in the interests of efficiency and cost reduction. Patients who order online and who have their prescriptions delivered by their chosen pharmacy can therefore enjoy a seamless process which does not require any printed paperwork and reduces the risk of errors. In those cases where the patient prefers to collect their prescriptions from the surgery, a paper-print prescription has a barcode printed which can be read by the pharmacy to aid the easy and safe issue of the prescription. There is also an option for the patient to nominate their pharmacy but not collect the printed prescription from the surgery but instead attend the pharmacy to collect – this can be useful when patients requiring repeat prescriptions are away from home as the practice can send the prescription to a nominated pharmacy wherever they are staying in England.

Drugs administered personally

The practice can provide a range of travel vaccines and other injections required for treating patients or carrying out minor surgical procedures. A claim is submitted to the Prescription Pricing Authority for payment at the beginning of each month. For a common range of vaccines, the practice need only submit numbers of vaccines given but a record must be kept of the names of patients, dates given and batch numbers. In other cases, a prescription is printed and signed by the doctor for submission to the PPA in the same way that a retail pharmacy would submit monthly prescriptions for pricing. The only difference is that the patient does not pay a prescription charge in a non-dispensing practice. It is worth noting that only a limited range of travel vaccinations are allowed under the NHS; the remainder are private

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prescriptions only.

Keeping records

A GP is under a contractual obligation to keep accurate records of consultations and treatment provided for patients. Records can be kept manually or in computer format. All incoming clinical letters are scanned into patients’ computer notes.

Medical certification

GPs are required to issue certain medical certificates to support claims for statutory sick and maternity pay free of charge. These relate to employment only and not for any other reasons.

Private fees and charging

GPs are entitled to charge fees for a range of private fees which can be set at the discretion of the practice. The British Medical Association does offer guidance on setting fees. Some collaborative fees paid by local government authorities are ‘set in stone’. There are standard fees for issuing cremation certificates, and for advising the Driving Vehicle Licensing Authority and the Criminal Injuries Compensation Board. Police forces do ask for medical reports or statements from practices and in criminal cases there is a standard fee. In relation to firearms and shotgun licensing, where there is no fee payable, most practices will only respond should they be aware of any impediment to issuing the licence and this is not chargeable. (BMA guidance indicates this is a public protection duty and cannot be refused or charged for.)

GP Patient Survey

The GP Patient Survey is an independent survey run by MORI on behalf of NHS England. The survey is sent out to over a million people across the UK. The results show how people feel about their GP practice. You also have the option to compare up to three practices. Use of this survey to shape and manage your services better is an issue that CQC often uses in assessing responsiveness on the part of a practice.

Website: https://gp-patient.co.uk/

GP registrar

Specialist training scheme

Information about the appointment of a GP registrar may be provided by the deanery, NHS England or directly from the appointee. The new GP registrar will probably visit the practice to meet the trainer a few weeks before starting their attachment. The practice manager may need to prepare an initial programme of activities for a new trainee, which might include days or time visiting a local pharmacy, or working in the surgery reception. (See Deanery section.)

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Performers List – New GP registrar

It is the responsibility of the GP registrar to ensure that they are on the Performers List. Any GP registrar not on the Performers List cannot work and will therefore not be paid.

GP registrars used to be contracted to and paid by the practice, however lead employers have now been appointed to undertake all HR-related and payment activities in most deaneries. The GP practice now simply hosts the registrar.

Travel expenses

GP registrars are able to claim a limited amount of travel costs and expenses which may need to be signed off by the practice manager and then forwarded to the lead employer.

Defence union payments

GP registrars can claim reimbursement of professional fees, subject to the production of evidence of payment. The confirmation from the professional body must indicate that payment has actually been made. The lead employer will be responsible for the reimbursement.

Student loan repayments

Some GP registrars are required to make repayments of their student loan to the Inland Revenue. It is collected from their gross pay and paid directly to the Inland Revenue by the lead employer.

Practice handbook

The practice should provide a GP Registrar Handbook which is often combined with the Locum Handbook for all new registrars, to give them an insight into the practice.

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H

Health and safety

The practice is obliged under legislation to ensure continual improvement in the management of health and safety and other safety-related issues. The practice must have a clear Health and Safety Policy and all relevant information should be held in the health and safety files which should be easily accessible – either in hard copy or on an intranet or other software back-office programme.

The areas where the practice will need to evidence their procedures and assessments are:

Asbestos COSHH Disability discrimination Emergencies Fire First aid Fixed wire testing Fridge temperature logs Health and safety Infection control Legionella Lone working Manual handling PAT testing PPE Premises Risk assessments and planning Sharps handling and needle-sticks Waste management

Hepatitis B

The practice must have a clear policy on checking the hepatitis B status for all clinical staff at a minimum. All staff who perform exposure-prone procedures should be immunised against hepatitis B, unless immunity has been documented. Their response to the vaccine should be subsequently checked and recorded. Many practices ask all staff to be checked as a matter of routine, irrespective of their role.

Health workers who are HBeAG positive should not perform any procedures in which injury to the worker could result in blood contaminating the patient’s open tissue.

Health workers who are HBsAG positive but who are not HBeAG positive need not be barred from these areas of work unless they have been previously associated with the transmission of HB virus to patients. Specialist advice should be taken.

Where a staff member is classed as a ‘new’ staff member (see below), it is a usual condition of employment that they are checked and are non-infectious for HIV, Hep B, and Hep C (this

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is subject to specific clinical requirements). The checks will need to be completed prior to appointment to a post involving risk to the patient, as they will be ineligible for the role if infectious.

New workers are usually defined as being new to the NHS or the practice, returning to the NHS, new to performing exposure-prone procedures and a few other categories.

The checks will be completed prior to an offer of employment or be a condition of it. This is not to stop these candidates working for the NHS, but may restrict infected people from working in ‘non-risk to patient’ jobs. This policy is consistent with the working restrictions placed on persons known to be infected.

HMRC payments

The payments for partners’ taxation to Inland Revenue are made during late January and late July each year. The practice accountant will estimate the taxation due and submit returns to the Inland Revenue – each partner signs an annual tax return. The partners receive a notification of tax due each half-year which is normally sent to their home address. Any notifications received at the practice should be passed to the named partner for payment unless the practice operates a system whereby the practice covers the tax liability payments which are adjusted in the annual drawings calculations. The individual partner’s payments will be made by themselves direct to Inland Revenue in most cases.

A capital account shows the income and drawings that can be attributed to each partner. In effect, it shows the partner’s share of the practice finances. This is usually monitored by the accountant.

The payroll system must keep a record of National Insurance and PAYE contributions for each member of staff employed in the practice including any salaried doctors employed by the practice. Members of the NHS Pension Scheme now pay Class A NIC contributions. The payroll system should maintain a P11 record of deductions form. Monthly returns are now made online via a Government Gateway in relation to all PAYE and NIC payments made for each staff member. It is vital to make submissions before the end of the working month.

TIP: If an employee joins or leaves the NHS Pension Scheme, the rate of NI contributions must be changed: non-members at Rate A, members at Rate D.

HMRC – Annual returns

The P32 return must be submitted to the Inland Revenue by 19th May each year, which is now mandatory, and the submission arrangements have been significantly simplified as they are submitted electronically. The P32 return is produced by the chosen payroll software or agency. A reconciliation of monthly payments made to the Inland Revenue should be prepared and checked against the annual return to show that no further balancing payments are due. A balancing payment might need to be made if any errors are revealed or late payments are due.

In addition to the P32, the practice must prepare the following forms:

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Form P11 – this is a large deduction working sheet used as a PAYE and NIC summary sheet for each employee. The form is usually generated by your software or agency.

Form P60 – this is the certificate of total pay and tax issued by the practice as the employer to each employee for the tax year.

Form P14 – this is a copy of the P60 which is submitted to the Inland Revenue, one form for each member of staff.

The PAYE and NIC payments must be made no later than 19th of each month. Separate payments are made for PAYE and NIC. (See Accountants.)

Health and Social Care Information Centre (HSCIC)

HSCIC collect information about a wide range of general practice (GP) services for a number of different organisations and purposes.

Organisations HSCIC collect information for include:

NHS England to calculate GP payments for achievement under the Quality and Outcomes Framework (QOF) and delivery of Enhanced Services and vaccination programmes (collectively known as quality services)

Other government departments about certain medical conditions and GP activity

Universities and other organisations for academic research and services such as screening programmes

Types of collection

Quality and Outcomes Framework (QOF)

HSCIC collect information about GP achievement under the Quality and Outcomes Framework (QOF) and supply this to payment agencies at specified points throughout the year. GPs then receive payment for these services.

Enhanced services

HSCIC collect information for NHS England about GP delivery of designated Enhanced Services. The annually published Enhanced Services Overview gives information about collections for these services and which ones need some information input by hand.

Contract requirements

HSCIC collect information about other GP activities and other initiatives aimed at improving care, such as the alcohol-related risk-reduction scheme.

Other collections

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HSCIC collect information for organisations for approved non-commercial research or planning purposes. Collections planned for past years have included the general practice to the diabetic retinopathy screening (GP2DRS) service for Public Health England (PHE). The GP2DRS service will help improve processes for the NHS Diabetic Eye Screening Programme (NHSDESP) which screens people at risk of developing diabetes-related blindness.

Data Provision Notices and Section 259s

The Health and Social Care Act 2012 (the Act) gives the Health and Social Care Information Centre (HSCIC) statutory powers, under Section 259, to require data from health or social care bodies or organisations that provide health or adult social care in England.

The Department of Health (on behalf of the Secretary of State) or NHS England may direct the HSCIC to establish a data collection.

When the HSCIC receives such a direction, they issue a Data Provision Notice to the appropriate providers of the required data.

Human resources (HR)

This section gives general advice about personnel issues that may arise in the day-to-day running of the practice. But firstly, set out below is a summary of the staffing structure found in many partnerships.

Staffing structure

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Practice manager

The practice manager, who is accountable to the partners, is responsible for the overall management of the practice including personnel, financial and estate management. The practice manager is the key lead in contacting the NHS organisations and will attend meetings associated with practice-based commissioning, contracting and practice management.

Assistant practice manager (where appointed)

The assistant practice manager provides support to the practice manager and partners in dealing with administration, financial and computing services management, rotas, IT, etc.

Professional staff

The professional staff comprise practice nurses who may be independent prescribers (i.e. can prescribe, limited to their agreed competency areas), advaned nurse practitioners (usually with a higher degree and who can see, diagnose and treat patients, limited to their trained competency) or RGNs. Many practices also have healthcare assistants (HCAs) who are not registered nursing professionals but who would normally be expected to have a diploma or NVQ at levels varying from 3 to 5. The higher qualified HCAs are also known as ‘advanced practioners’. HCAs are only allowed to carry out duties under the supervision and direction of either a doctor or registered nurse and in most practices the responsibility for what they do lies with a GP. RGNs may administer certain vaccinations under a Patient Group Direction (i.e. they can decide whether a number of patients fall within the general definition and act without referring to a GP); however HCAs may only work under a ‘Patient Specific Direction’ when administering flu/pneumococcal/B12 and other similar injections. A PSD is an individual authority from a GP to give the patient named the injection specified. During campaigns such as ‘Seasonal Flu’, it is acceptable for a GP to sign off the clinic list for a HCA prior to the start of the session but it is necessary that each patient’s record carries some record that the injection under a PSD had been duly authorised.

Salaried GPs are also covered under professional staff (see above for details), as are practice pharmacists (who may have gained additional qualifications to see and vary prescriptions for patients), and physical assistants (a very new status for persons trained to degree level in life sciences and who have taken additional training to enable them to carry out the work of a GP in less complex situations and for less serious conditions).

Dispensary staff (where appointed)

The dispensary team is managed by a dispensary manager who leads a team, where the practice is a dispensing practice, providing a full dispensing service to patients, often in more rural areas.

Reception staff

The reception team is frequently managed by a reception manager, leading a group of medical receptionists whose role is mainly clerical, including medical records filing, test results, booking appointments and home visits, cervical cytology call and recall, data input, scanning and GP registration links.

Administration staff

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In many practices medical secretaries provide a full secretarial service to the GPs and others and are often responsible for the administration of referrals including the use of the e-referral system. Practices may have digital dictation systems which enable doctors and others to dictate referrals and letters onto the practice server from where the secretarial staff can bring forward the voice file and audio-type up the required documentation. In some cases practices may still use hand-held tape recorders while in others they have installed voice-recognition software and doctors dictate directly into the system which then types the document onto their PC screen.

HR absence recording

The practice needs to have very clear policies and procedures on reporting sickness absence and know what is required of both the employee and employer.

It is vital to keep accurate records of any absences as these will be needed for payroll purposes and the monitoring of any sickness patterns.

On return to work following a period of absence, either a self-certification form is completed (for a period of up to five working days) or a formal sickness Return to Work meeting will need to take place with either the immediate line manager or practice manager.

The practice needs to have decided and made clear to staff exactly what is classed as a long-term absence and, where appropriate, a referral may be made to the occupational health service that the practice uses. The referral needs to be discussed with the employee, completed and signed by both the employee and the referring manager. A copy should be kept in the personal file.

Where the practice makes payment in times of sickness, this could be only an entitlement to statutory sick pay (SSP) or to a sliding scale of contractual sick pay. It is for the practice to decide what contractual sick pay will be paid and for how long, and also whether it will be minus any SSP and whether the staff member has to make a claim for SSP themselves. The essence of the practice sickness policy must always be fairness – both to the employer and the employee.

HR assistance

If you are unsure regarding a HR matter you may have a number of options for advice. Commercial companies providing personnel services along with payroll functions will often also include HR assistance as part of their package. As previously mentioned, having a GP who is a BMA member also allows access to employment advice, and two defence unions (MPS & MDDUS) also will provide assistance or have access to online advice. MDU, however, do not provide employment advice and refer practices to the BMA. ACAS, a governmental organisation, are an additional source of help and their online services are extremely helpful and free.

MPS: www.medicalprotection.org.ukTelephone: Medico-legal Advice 0800 561 9090; Membership Advice 0800 561 9000Email: querydoc@medicalprotection.org

BMA: www.bma.org.uk

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Telephone: Employment support 0300 123 1233Email via website or web live-chat: Will need BMA registration number of one of the Partners

MDDUS: Medical and Dental Defence Union of ScotlandTelephone: 0333 043 4444Email: info@mddus.com

ACAS: Advisory Conciliation and Arbitration Servicehttp://www.acas.org.uk/index.aspx?articleid=1339

HR performance and disciplinary issues

Dealing with performance and disciplinary matters can be the most difficult part of being a manager. It is helpful to take advice from a HR expert when taking any disciplinary action. It is also vital to record each part of the process carefully. Discuss any action you propose with the partners. Be aware of the complexities of employment law particularly in respect of working hours and family friendly contracts. Failure to follow published processes or following a path which can be construed as unfair may lead the practice into costly legal proceedings or an Employment Tribunal, and sometimes this is avoided by practices coming to a severance agreement with the employee where they are ‘paid off’ to avoid more costly problems.

The practice should have very clear policies on the processes and procedures and these should be followed.

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I

Income including remittance advices

NHS income is mainly received from three different sources; NHS England, the Clinical Commissioning Group (CCG) and the local government authority. In addition, income is received from private sources. Income is received by cheque, direct credit and cash. Some income is received from the local deanery and may be attributable directly to the GP trainers. Work carried out by the doctors for the CCG during practice time can also be attributable to the practice, depending on the partnership agreement terms.

All remittances, copy invoices or BACS payment notifications should be entered into the accounts software package including a reference which enables the practice accountant to correctly attribute income at the year end. Income from the NHS – either directly through the “Exeter” payment system or through an agency (presently CAPITA – 2017) – may be very difficult to account for as the agencies in particular seem to have their own referencing system that bears little resemblance to any invoices a practice may issue. (See Accounts for more information.)

Infection control

Each practice is required to have a properly trained lead on infection control. Regular audits need to be undertaken and every year the lead must produce an infection control report for the registered manager to ensure actions that were needed are taken before they can sign the report off. Infection control falls within the ‘Safe’ domain for CQC inspections and is always checked.

The infection control audits and checks must be specific and not general in structure as each part of the surgery will have location-specific issues (e.g. the treatment room requires more specific control than the reception area or the waiting room).

Information governance

Policies

The practice must have robust information governance protocols and should ensure that all staff have received regular training and have signed a declaration to say that they understand the policies.

See your own relevant practice policies, such as:

Caldicott Policy

Computer and Data Security Policy

Data Protection Policy

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Disclosure of Patient Information Policy

Information Governance Factsheet

Information Governance Policy

Information Governance Statement

Information Security and Confidentiality Policy

Patient Data Security and Protection Policy

Recording Patient Data Policy

Information Governance Toolkit

The practice has to complete/update the online Information Governance Toolkit on an annual basis and before the financial year end. The IG Toolkit is an online system which allows NHS organisations and partners to assess themselves against Department of Health Information Governance policies and standards.

Website: https://www.igt.hscic.gov.uk/

Internet access

The practice computer system will be connected to the Internet and this should only be used for NHS business. Favourite links are set up on most computers to NHS sites. Staff should be discouraged from using the Internet for personal purposes. In particular the use of Facebook and Twitter during working hours from practice-based computers should be prohibited. Staff often, however, will be in possession of mobile telephones/smartphones, and it is good practice to limit their use. Many practices prohibit mobile telephones from being in the possession of staff during working hours.

Invoices

Invoices may be filed in alphabetical or date order which makes it easier to locate previous invoices when reconciling account statements. As previously indicated, invoices are paid probably twice a month, although urgent payments can be made as required and many practices are using Internet banking systems in preference to the BACS system. When paid, it is good to note the date of payment, amount and any online banking payment reference number. A copy of the payment advice could also be printed off from the banking online system and filed. For payments made by cheque, it is important to record the cheque number, value and date of payment on the original invoice. Keep cheque stubs along with cancelled cheques for submission to the accountant at the end of the financial year. The accounting software in use will also have a facility to note invoices and payments.

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IT

The clinical system used in the practice is bespoke software which helps the practice manage the Quality Outcomes Framework/CQRS system as well as maintain patient consultation records, appointments and test results including prescribing and any other information required for the safe and effective treatment of patients. There may also be many other software packages in use such as Docman, a filing system that hosts all patient documentation linked within the patient record, Lexacom, a digital dictation system that replaces hand-held dictation tapes, Dragon Naturally Speaking, a direct voice/typing programme, and Intradoc or iQ Manager which are programmes that hold and file policies and much more. These are in addition to accounting and payroll and many practices also now use texting software such as MJog which interacts with the clinical system to remind patients of appointments. This list is not exhaustive.

New staff will also need a log-in to the practice Windows system, a clinical software username and password, to be allocated an NHS email and issued with an NHS smart card.

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J

Job descriptions

Job descriptions and person specifications must be available for each post and kept up to date following review at annual appraisal. Each staff member should have a copy, along with the practice copy in their personal file.

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K

KLOEs – Key Lines Of Enquiry

These are the five areas where the Care Quality Commission group the standards they inspect:

Safe Effective Responsive Caring Well-led

Safe: This covers all issues of safe practice and the CQC define it as protection from avoidable physical, emotional or psychological harm, abuse or coercion. It covers infection control, clinical practices, health and safety, safeguarding (children and adults) and learning from safety-related incidents, amongst other issues.

Effective: This covers the way practices meet the needs of their patients and that the care offered results in the best quality of life. In practice it relates to adhering to the best standards, benchmarking against others, audits of effectiveness that result in changes and learning, proper recruitment of qualified personnel, induction and training.

Responsive: This means that individual needs are met without undue delay and includes demonstration by the practice that it understands the needs of different sectors within its patients and acts to meet those needs, monitors how and what services it provides, acts on feedback from surveys and complaints (wherever posted) and ensures appropriate levels of access to the services provided.

Caring: This means that people are treated with compassion, respect and dignity appropriate to their personal needs. It requires staff to be effective and appropriate communicators, especially where there are issues of capacity, mental health or communication disabilities. Staff must be supportive, maintain confidentiality, ensure patients understand what is happening or what is being said, no matter what language issues there may be, and that patients feel safe and are treated with respect.

Well-led: This KLOE is the one that tends to cause most problems as it needs to be demonstrated by effective governance, management and leadership across all of the other four areas. Governance is about having the guidance, policies and procedures necessary to ensure the proper running of the practice and treatment of patients, and more especially it is about ensuring these instructions are adhered to. It is the control of risks, clarity about the role of individuals, the proper use of data and service reviews, reflective learning, openness and candour, but more especially that the practice is led effectively and individual responsibility is taken and applied by its leaders.

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L

Leaflets

The practice will have a number of leaflets that are prepared in-house and others provided by various sources that can be ordered online or downloaded from web pages. The practice should have an information leaflet that is available for patients listing all the information required as per the GMS contract. The main leaflets that should be freely available to patients will also include details of how to make a complaint, safeguarding, information for carers, the prescribing processes, how to make appointments and how to obtain services outside normal opening hours.

Legionella

Legionella assessments must have been undertaken at every practice. Regular reviews are required to monitor water temperatures in the practice and these readings need to be recorded. An annual review of the assessment is required and updates made. Legionella is particularly an issue where the practice has shower facilities and/or where there are taps, etc. that are not regularly run (often known as ‘dead legs’ where water may stand idle for some time).

List size

Technically, under the General Medical Services and Personal Medical Services contract agreements, all patients are now registered with a practice, not a named doctor, although recent changes require the practice to nominate a ‘named doctor’ for elderly patients. However, the technical side of managing a patient list has not kept up with the times and the NHS England’s Registration Department still keep individual panels of patients. Patients are still registered under the name of an individual doctor. However, the Registration Department no longer issues medical cards automatically and no longer sends letters to patients when a doctor resigns or retires. Should a doctor be away from the practice for a period of time, all patients need to be informed of this and made aware of who will be seeing them in the practice.

Locum insurance

The practice locum insurance is provided by several commercial suppliers and may cover all GPs, practice managers and practice nurses although this is by no means always the case. The degree of cover for partners may be governed under the partnership agreement.

Locums

Locum doctors are utilised to varying degrees in various practices as the partners may sometimes do additional sessions to cover. Locums will need to provide all the relevant information as required in the locum checklist. Practices have to provide all this information for CQC purposes and ensure all relevant working requirements are given, so each locum should have a file within the practice system that mirrors the requirements for partners or

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employees (i.e. DBS check, proof of indemnity, referees, GMC registration, Performers List entry, etc.).

Following a session, the locum will normally forward their invoice for payment with a GP Locum Form A. Check that the figures given match the invoice and then complete the practice details and sign. Keep a copy of the signed form with the invoice for payment in the usual way and return the original to the locum for their records.

Locums may sometimes be obtained through a locum agency where the process may differ, however it is still a requirement on the practice that the locum is a fit and proper person to see and treat patients. A contract with the agency confirming that the necessary qualifications have been met may be acceptable, however requesting a copy of that information, which the agency should have on file, is less risky.

It is good practice for each locum to be provided with the necessary information to allow them to work safely and effectively when they arrive at the practice. Having a hard copy Locum Handbook is appropriate, however it may serve to delay the locum starting to see patients while they make themselves aware of its contents. Emailing a digital copy in advance to the locum with a request that they make themselves familiar with it can shorten the lead-in time on arrival to a considerable degree.

An issue that sometimes causes problems is where the practice receives a complaint about a locum. It is still a requirement on the practice to deal with its complaints so it is not acceptable to pass the matter over to the locum or their agency to deal with it and respond. The practice should advise the locum that they are involved in a complaint and ask for their response, but the practice must deal directly with the complainant and make the final response. Keeping the locum or their agency advised of the outcome is also important as these matters are part of annual appraisal and revalidation for GPs and RGNs.

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M

Medical records

Access to medical records

Patients have an unrestricted right to see the whole of their hard copy and computer medical records unless the patient might be adversely affected by knowing the content of all or part of their medical record. The practice policy must be to allow access to the patient and a third party, if written informed consent has been obtained. Care should be taken where the patient has a history of mental health problems or where the record makes reference to a third party – especially if that third party has not consented to the release of their identity. Such cases should be referred to a doctor for agreement before the records are released. Practices sometimes decide that requests should be referred to a GP before release, particularly if a complaint is made against the practice, although having made a complaint can never be a reason to refuse access but it is useful to have some idea of what may lie behind it. A review of records would always be part of the investigation in any event. The right of access to medical records is governed by the Data Protection Act and fees are restricted to an access fee of £10 and a maximum statutory fee of £50 for copy records.

Requests from third parties

Requests are often made from third parties, such as health visitors, a ward sister and hospital doctors for information from patient records. The practice can share information that is relevant with other healthcare professionals subject to care being taken about being satisfied with the credentials of the enquirer. Practice staff should call back as a matter of policy, and only give relevant information. If unsure in any way, staff should either speak to the practice manager or a GP.

Access to medical reports

In the case of medical reports the patient has the right to see a report before it is sent to a third party, if they request to do so. A copy in these circumstances may normally be sent to the patient for approval before it is sent to the third party. Access to medical reports is governed by the Access to Medical Reports Act. Consent given under the Access to Medical Reports Act does not give consent to the release of medical records to a third party but merely to a report compiled by the practice from those records.

Fees for access to records or for compiling a report are best obtained before they are released – for obvious reasons! An invoice is usually prepared for payment of pre-agreed fees such as those paid by the DVLA, the Criminal Injuries Compensation Board Authority and collaborative fees paid by local government bodies for the disabled badge scheme and fostering and adoption medicals.

Medico-legal insurance

All partners at the practice must be covered by some form of indemnity or insurance and this may be through one of the defence unions (see above) or, as is increasingly common, through a commercial insurer. You will need to check with the defence union whether or not individual cover is required for nursing and other clinical staff, as well as the practice manager, as and when new employees start. Defence unions may offer additional benefits when all or most of

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the GPs belong to the one organisation and it is worthwhile making enquiries. Doctors can be reluctant to change, however any issues which arise from past practice following a change to another provider are legally the responsibility of the provider at that time so there should be no problems in that area.

Meetings

All agenda and minutes files should be accessible and may be found by accessing a link to an intranet or shared directory on the practice server.

Agenda and minutes

Agendas, minutes and reports should be prepared for meetings and a permanent copy kept preferably as a digital record, but hard copy may exist – though preferably not as the sole record. Regular meetings are usually held to discuss management of the practice, prescribing and audit, along with Significant Events, complaints, Multi-disciplinary Team meetings, Palliative Care and Gold Standard Framework. It is good practice that there is an attendance sheet to record who has participated in each meeting and also, if the practice software package permits, that each staff member is able to prove they have seen and read the minutes – especially important if they were not present.

MDT meetings

Held on a regular basis (at least quarterly in most cases) with attendance usually by partners or salaried GPs, practice manager, social worker, district nurse, palliative care nurse, community physiotherapist, etc. The discussion will cover all patients on the Unplanned Admission list, those who are housebound, etc.

Practice business meetings

Usually attended by all partners and the practice manager. Formal minutes should be made and filed and the agenda covering all aspects of the running of the practice and finances, building, etc. These minutes may need to be confidential so can be passworded in MS Word to restrict them on any open-access server or locked away if in hard copy.

Protected time meetings

Some practices close for a protected time meeting monthly or quarterly. Attendance is usually mandatory for staff as most sessions are utilised as training sessions for the whole practice team or an opportunity to give and receive feedback on what does and does not work and also brief all staff on complaints, Significant Events, survey feedback, etc.

Reception/admin meetings

As the clinical staff meet to discuss medical issues, so practices should hold regular non-clinical staff meetings as a means to gauge how well that side of the business is operating and to settle queries.

Dispensary meetings (if a dispensing practice)

As decided by the practice. Minutes circulated by the dispensary manager.

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Nurse meetings

Nurses do need time to discuss issues relating to their clinical practice and review NICE and other guidance. This meeting may be able to count towards their Continuing Professional Development so should be minuted and also provide a record of issues that the GPs/partners and/or the manager needs to be aware of.

Clinical meetings

Held regularly with partners and the practice manager, and should also include a representative of the nursing team to discuss clinical issues, interesting cases and critical events.

CCG meetings

Quarterly meetings organised by the CCG where doctors and/or practice managers come together with CCG clinicians and managers to discuss commissioning and relevant topics. They should be minuted and copies received at the practice both filed and circulated for reading by staff. It is important for such meetings to have a practice representative to gain knowledge of the developing health economy and to feed in the practice view on those matters.

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N

National Performers List

The practice manager should ensure that any doctor working in the practice is registered with the General Medical Council, and has joined the National Performers List. The doctor is required to update his/her entry on the Performers List when joining a new practice. A copy of the doctor’s DBS report and annual medical indemnity certificate should be requested.

The national website is: www.performer.england.nhs.uk

Forms and guidance below:

SOP Medical Performers List

National Performers List Application Form

Performers List Health Assessment

Supplementary Guidance re Occupational Health

National Performers List Change of Status

National Performers List Change Notification

Newsletters/circulars

There are a number of regular newsletters and circulars received into many practices. A copy of each of these is usually filed according to practice protocols and it is usual to inform the relevant members of staff that these are available and where to find them.

NHS Choices

Website giving information for patients and professionals including choice of GP, lifestyle, hospital, consultant, treatments, comments on NHS services, symptoms checker, treatments and conditions explained for patients. NHS Choices also carries a feedback section where patients and others can comment on the practice and this is an area where practices should both respond to comments (on the basis that negative ones should be challenged, if unfair) and also gain feedback on the practice service. CQC do use Choices as a source of information prior to inspections and will expect a practice to be able to evidence that they take the comments seriously.

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NHS Employers

Website giving information for GP practices including employing in the NHS, emerging healthcare issues, practical advice and information, sharing of knowledge and best practice, information and frequently asked questions, documents including DESs, GMS contracts, QOF, technical guidance, Vaccs and Imms, etc.

Website: http://www.nhsemployers.org/

NHS England

The practice is either contracted directly by NHS England through the local NHS England Area Team or through the delegated powers being rolled out to CCG across England. The ultimate responsibility for the contract the practice are on still remains with NHSE and it is essential, when delegated contracts are in place, to be aware of what responsibility has been passed to the CCG and what remains under central control.

NHS England is the NHS organisation with the responsibility of carrying out the ‘pay and rations’ function for general medical practice which was formerly performed by Primary Care Trusts, the family practitioner committee and prior to that NHS executive councils. It now does this through business agencies located throughout the country. Family doctors now register with the national Performers List rather than enter into a contract with the primary care trust. The contract now rests firmly with each GP practice. Doctors, including GP registrars, join the Performers List (medical list) after a criminal records check and after completing a complex application form. Each doctor has an obligation to keep the national Performers List up to date with location of work, home address, hours of work, etc. The Central Services Agency (formerly registration department) now maintains the National Spine, keeps the practice list of patients formerly known as doctors ‘panels’, issues medical cards to patients only on request and transfers ‘manual’ medical records, it also processes cytology recall letters. The finance ‘agency’ makes payments to doctors and practices under instruction from NHS England or Open Exeter. It administers payments for GMS and PMS contracts and enhanced services and keeps superannuation records for practitioners, not practice staff.

NHS mail

Each member of the practice is entitled to use an NHS email address. It is likely that the NHS email system will become the prime method of communication within the NHS. New staff should be allocated a personal email address by the local NHS IT Support Service. Proof of identity will be required for the issue of an email address.

Link to NHS mail: https://web.nhs.net

Tracking and reading own incoming mail

Emails should be opened and read on a regular basis – at least once per day. The pace of email contact now suggests that at least an hourly review of incoming emails is more appropriate, particularly in the management roles. Some may require acknowledgement. NHS

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England, CCGs and other NHS bodies now use the NHS email system as the principal way of communicating with practices and practice managers. Letters are now rarely received by Post Office mail. Be aware – turnaround timescales for the Area Team can be very short. You have been warned!

Administering email accounts

Email users should monitor the content and retention of read emails. Emails can be sorted and kept in folders. Emails received can be marked as Junk Mail and blocked in future. A systematic approached should be adopted toward deleting emails as each user is allocated a limited amount of storage space.

NHS 111 (out of hours)

NHS 111 is a free-to-call, single, non-emergency number, medical helpline operating in England and Scotland. The service is part of each region’s National Health Service and has replaced the telephone triage and advice services provided by NHS Direct, NHS24 and local GP out-of-hours services. The transition was completed in England during February 2014, with Scotland following during April 2014. NHS Direct Wales continues to use the 0845 46 47 number. The service is available 24 hours a day, every day of the year and is intended for ‘urgent but not life-threatening’ health issues and complements the long-established 999 emergency telephone number for more serious matters, although 111 operators are able to dispatch ambulances when appropriate using the NHS Pathways triage system.

Nurses

Each practice will have their own level of nursing staff according to their needs, having a skill mix that reflects the abilities of the staff from phlebotomists through to advanced nurse practitioners, as well as reflecting how the practice is structured and the available finances. The registration for RGNs, as for all other professionals, should be checked annually.

Nursing and Midwifery Council

The Nursing and Midwifery Council is the professional regulatory body for nurses and midwives in the UK. Their role is to protect patients and the public through efficient and effective registration which is an annual process that practices need to be aware has been done. Registered nurses undergo periodic revalidation to ensure they are fit to practise and this is a complex process involving CPD at a level of 35 hours over a three-year rolling period, of which 20 hours must be practical ‘hands-on’ learning, conduct five written reflective learning reports and ‘professional discussion’ with another RGN who has to enter details of that discussion through the online validation software. The RGN must also have completed 450 hours in clinical practice in each three-year period.

Website: http://www.nmc.org.uk/

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All nurses and midwives have to work to The Code which is professional standards of practice and behaviour. A copy can be found on the website.

You can sign up for regular newsletters from the NMC to keep abreast of all nursing issues and updates, etc. This is especially useful if you are not a clinical manager.

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O

Open Exeter and NHS statements

A copy of the Open Exeter payment schedules for each month of the first quarter of the new financial year will be required by the practice accountant to include in the annual accounts any payments received that relate to the previous financial year. In particular the accountant will need to see the prescribing drugs statement, the trainee payments statements, and details of any payments for Enhanced Services that relate to the period prior to the end of the financial year.

Open Exeter statements can also be downloaded directly into many of the accounts packages, especially Iris.

Overtime

Overtime should always be controlled and monitored on a monthly basis to ensure that the rules on overtime the practice has set are being adhered to and recorded properly. Overtime is usually agreed with the line manager and staff should not assume they are entitled to undertake this. Time off in lieu (TOIL) is an alternative way to ‘pay’ staff for extra hours, but some practices consider that this merely transfers staff shortages to other times or days. TOIL can present problems when staff accumulate excessive time and many practices set a time limit by which TOIL should be taken, and when that ceiling is reached require the time to be paid. Paid overtime can be at whatever rate the practice has set and sometimes can be a more cost-effective option than employing extra staff, but this takes careful analysis of the cost benefits of doing so.

Oxygen cylinders

These should be provided at each practice as part of the ‘safe’ standards looked for by the CQC and be readily available, along with a defibrillator and emergency drugs. Practices need to be aware that they should critically assess whether having oxygen and other emergency equipment in a nurse’s or doctor’s consulting room makes them readily available in an emergency, and perhaps in a locked cupboard in or near reception creates far less risk. Wherever oxygen is stored, there must be the regulation warning signs on the door of the room as it is a major hazard in the event of a fire and Fire Service personnel must be able to know where cylinders are stored.

Oxygen supplies must be regularly checked to ensure cylinders are sufficiently charged for use and most practices source their supplies, along with an annual maintenance check, from commercial companies such as BOC.

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P

Panic alarms

Panic alarms are often used in practice premises to alert staff to emergency situations in consulting rooms and treatment rooms. Panic buttons are often concealed under desks but many premises now use emergency buttons on computer screens such as the ‘Little Green Button’ from WigglyAmps or the red button at the top right-hand corner of an EMIS Web screen. The advantage of these digital systems is that they are more unobtrusive in use than reaching under the desk and they will highlight an emergency by location to everyone else in the building. The disadvantage of buttons included in the clinical system screens is that the emergency is only transmitted to others who are logged in, whereas other systems only require other PCs to be on the network where they can be using software other than the clinical system.

Partnership

Partnership is only one of a number of organisational structures that can operate a practice and as noted previously, they should be governed by a robust partnership agreement.

Partnership agreement

Resignation or retirement

Normally unless partners agree otherwise, a doctor is required to give a specified notice of the intention to resign or retire. That being agreed with NHS England and the practice, the remaining partners are entitled to be regarded as ‘logical successors’ to the outgoing partner’s list of patients. NHS England will ask to whom the patients should be transferred and the senior partner will need to sign a logical succession form setting how the patients are to be distributed. You will need to inform the Area Team of the resignation by completing the relevant forms.

New partnership

On the retirement or resignation of a member of the practice, the new ‘practice’ will need to agree the name of the senior partner, and allocate new partnership shares and complete and sign a shares distribution form for NHS England. The senior partner and new member of the partnership need to sign a Declaration of Partnership which needs to be a formal legal document.

Partnerships can be disbanded for many reasons and this does put the practice into significant problems with regard to who may take it over, who will provide patient services, who might run the premises and will NHS England agree! One of the reasons for changes in partnerships relates to extended ill health and many partnerships require a partner who is absent for 12 months or more to resign. The agreement should also give details of what constitutes reasons for a partner to be ‘dismissed’ and the usual reason is that they are no longer able to practise because they have had their GMC registration withdrawn for misconduct.

Partnerships in dispute cause a major problem for practice managers, and it is a matter of self-

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interest that the practice manager ensures that the Partnership Agreement is both fit for purpose and understood by all partners.

Partnership superannuation returns and partnership shares

The practice accountant will prepare the annual returns of superannuable NHS income and pensions payments for the GP principals for submission to NHS England in February each year for the previous complete financial year (i.e. not the year you are in!) (Type One certificates.) It is best not to overestimate NHS income as this may result in awkward overpayments. Normally, the practice will need to make a balancing payment to the local Area Team where income has been underestimated. The NHS now has local finance hubs from where payments are made and superannuation contributions will normally be agreed with the practice accountant.

The practice is also required to submit a revised statement of superannuable NHS income and partnership shares estimate in February each year, which is effective from 6 th April, and make any balancing payments for the previous year of employer and employee contributions and added years.

Passwords

Passwords are essential for confidentiality. You will need passwords for software such as:

Accounts software Adastra CQC CQRS Docman EMIS GPES HMRC IG Toolkit Internet banking NHS Choices NHS Net Nursing and Midwifery Council Open Exeter Pensions Online Practice intranet Primary Care Web Tool PRIMIS

There are proprietary software packages which can generate and store encrypted passwords so that you do not need to remember every one or write them down, which is a security risk. It is important to check that, with so much software needed by the average practice manager, these password packages are able to interact with what you use!

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Patient records

Patient records are held on the clinical system, back-office software such as Docman, and hard copy in the Lloyd George folders, filed in the appropriate lockable cabinets. The use of hard copy is now mostly reserved for historical records and many practices have adopted off-site archiving where a commercial or other NHS organisation stores the notes in a repository and either scans them and emails them to you when needed, or sends individual sets of notes back to the practice on request.

Patient survey

The practice is no longer required to carry out a standard patient survey each year. However, the Department of Health has commissioned a national surgery and a proportion of patients registered with the practice will receive a questionnaire to complete. Practices now may carry out a survey designed by the practice, with the help of the Patient Participation Group, and publish the results on the practice website each year. The survey might cover access arrangements, telephones, extended hours services, the standard of the premises and the quality of the doctor/patient contact. Practices are also expected to carry out the Friends and Family Tests. The practice needs to discuss the findings with the PPG and record those discussions as effective use of surveys is an area where the CQC expects to see practices responding to concerns and issues.

Patient tasks

Tasks relating to patients can be utilised within EMIS Web, and other clinical systems have similar facilities. This allows staff members to set reminders with reception, arrange appointments, ask reception to give information to patients, request investigations, etc. The use of Tasks, or their equivalent, is important as they should be able to be recovered once actioned, and filed to prove actions, and provide an audit trail.

Payroll

The payroll is either run in-house using proprietary software or sent out to an agency or the practice accountant who may offer this service to practices. On-site software will need to be accessed using a password. The payroll software usually can be used to calculate wages for practice staff, GP registrars and salaried doctors.

An agency etc. will require information regarding the following:

Salaries

The pay rates that the practice uses which may be their own local rates or those adopted and tied to Agenda for Change. Annual pay rises will need to be advised to the agency once agreed.

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Additional hours and overtime

Practice staff should be aware of the cut-off dates for submission of any approved additional hours or overtime. Additional hours and overtime will be paid at the agreed hourly rate. The usual full-time working week in the NHS is 37.0 hours or 37.5 hours per week. Practices may use a different standard for the working week, but for pension purposes anything over 30 hours per week is considered full-time.

Running the payroll

The payroll should be run monthly. Prior to making payments to staff it is important to remember whether any or all of the following need to be taken into account:

• Have any employees been off sick for more than three days? Statutory Sick Pay is due.• Are any employees wishing to claim overtime or additional hours?• Have any employees started or are on maternity leave or paternity leave?• Are employees due for an annual increment?• Are all employees due for a cost of living increase?• Have any new staff been employed by the practice?• Have any existing staff left or are leaving during the month?• Have staff claimed expenses, travelling, etc.?

New employees

For new employees, the practice will need to have decided at the time of the job offer the number of hours to be worked per week, and the hourly rate of pay. New staff should be asked whether they wish to join the NHS Pension Scheme and complete the appropriate joiner form or sign a SD502 form indicating that they do not wish to join the scheme. The employee completes Part One and the practice completes Part Two before sending to the NHS Pensions Agency.

For new employees, the practice should receive a P45 form from the previous employer with total pay and tax paid to date. The P45 contains the tax code to be used. Failing that, the new employee should complete and sign the HMRC form P46 which should be used to notify a new starter to HMRC either via the payroll software or agency. An emergency tax code basic rate (BR1) should be used for the time being. In return, the practice or agent will receive a Form P6 electronically from HMRC which will set out the tax code to be used and will need to be actioned to effect the record. Employees include the salaried GPs employed by the practice.

P46, pension opt-in and pension opt-out forms should be available in each practice.

Monthly staff payments

Wages should always be paid on the date due and in the event of that date falling on a weekend or bank holiday date, on the first working day prior to the due date.

Statutory sick, maternity and paternity pay

Your payroll software hopefully provides an effective wizard to make payments of statutory sick and maternity pay. Be careful to ensure that any periods of full pay and half pay are recorded correctly. Be careful also that the periods of full pay and half pay tie in with the employee’s contract of employment. For statutory sick pay if an employee has had two periods of absence within 56 days, there are no waiting days for payment for the second absence. SSP should only be paid for a period 28 weeks. Staff may also need to return to work for a specified period

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between episodes of sickness to claim contractual sick pay.

Employer’s/contractual sick pay

A member of staff may be entitled to a period of employer’s/contractual sick pay. It is important to check an employee’s entitlement against the contract and length of service and adhere to the agreed policy.

Annual increments

Annual increments are not compulsory unless contractually required. An annual pay increase may be given at the discretion of the partners following consultation with the accountant at the year end. If a pay rise is agreed, then this uplift and back pay will need to be reflected in the next payroll run. Practices who have adopted Agenda for Change in its entirety may find that they are obliged to uprate pay in accordance with national pay awards in the NHS.

Agreed expenses

Travelling expenses incurred by staff for attending meetings or training courses are often reimbursed at the rate of 45p per mile. The GP registrar will be able to make mileage claims via the lead authority. Staff should keep a record of journeys, miles travelled and addresses travelled to and from, and provide an expenses claim form should the practice have agreed to cover those costs.

Deductions

Student loan deductions are made from staff salaries on a monthly basis if and when an instruction is received from the Inland Revenue to start deductions. Payroll software will calculate the deduction once the earnings level has been reached. These are statutory deductions. Similarly, the deductions should be stopped if and when an Inland Revenue instruction is received.

Attachment of Earnings: On rare occasions the practice may be asked by a court to recover a sum of money from employee earnings, known as Attachment of Earnings. This may be as a result of a court judgement where the employee is required to repay a debt or unpaid Council Tax by the court direct from their salary. Such a request does not require the employee’s agreement. Otherwise all other deductions, apart from PAYE, NIC and pensions contributions, require the written consent of the employee. Do not forget to pay the amount collected to the body requesting it or to the court.

Staff leaving

A P45 should be printed off and issued promptly to staff who are leaving. The payroll software or agency will be able to print a computer version of the required form.

Payroll enquiries

Occasionally the practice, as employer, is asked to respond to enquiries on behalf of staff from the Department of Social Security, Work and Pensions and from mortgage companies. Information should be provided only with the agreement of the member of staff concerned.

Previous years’ payrolls

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Backup copies must be retained and it is important not to decommission the payroll computer without transferring annual backups to any new computer.

Payslips and P60s

Payslips will either be forwarded by the agency or otherwise produced by the payroll software for distribution prior to the pay date as will the P60s at year end. P60s are unique documents and staff must be careful to retain them as copies cannot be provided once the first has been printed.

Pensions

Auto-enrolment

A new law means that every employer must automatically enroll workers into a workplace pension scheme if they:

Are aged between 22 and State Pension age Earn more than £10,000 a year Work in the UK

As an employer, practices need to keep abreast of the information required to be sent to members of staff requiring opting in and opting out. Running a payroll service might be part of the work of an agency; otherwise the practice must be registered with the NHSPA as an NHS pension provider and be issued with an EA number against which all pension deductions must be forwarded. Employees must be registered with the NHSPA on taking up their role, and all enrolment etc. is done online using a form 55, when the employee will also be given an SD number to mark their inclusion in the scheme. Although the majority of staff will opt for the NHS pension, the practice will need to be aware that it may need to offer an alternative private pension arrangement if requested.

Assess and enrol your staff

By your staging date (i.e. the date at which your organisation has been told it must start to offer a pension to staff and which should in all cases have now passed), you should have everything in place and be ready to enrol your staff into your automatic enrolment pension scheme.

You must write to each staff member after your staging date to tell them how automatic enrolment applies to them and explain their rights. You must let them know that contributions will be deducted from their pay and that they have a right to opt out of your pension scheme if they wish to do so.

You must write to staff who are being automatically enrolled, explaining what you have done and providing details of the pension scheme you have chosen for them.

You must write to staff who have a right to opt in to an automatic enrolment pension scheme, explaining how automatic enrolment applies to them.

You must write to staff who have a right to join a pension scheme, explaining how

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automatic enrolment applies to them. This must be done in writing and within six weeks of your staging date. Letter templates

are usually provided to help you do this.

Postponement

You can choose to postpone automatic enrolment for up to three months for some or all of your staff. You must write to your staff to tell them you are postponing automatic enrolment for them. One of the times you can postpone is from your staging date.

Write to your staff

After your staging date, you must write to your staff to tell them about your pension scheme and how automatic enrolment applies to them.

Your on-going automatic enrolment duties

Once you have put your staff into your pension scheme, you will have ongoing responsibilities. You will need to continue to pay contributions, keep records, and constantly review your staff including new starters.

It is against the law to try to influence your staff to opt out of your pension scheme.

You must make sure that you comply with your ongoing responsibilities.

Keep records: You must keep records of how you have complied with your automatic enrolment duties, including:

The names and addresses of those you have enrolled Records that show when contributions were paid Any opt-in and opt-out requests Your pension scheme reference or registry number Any information you send to your pension provider

You must keep these records for six years and opt-out notices for four years.

Monitor your staff: You must monitor the ages and earnings of your staff (including new starters) to see if anyone who was not eligible for automatic enrolment at your staging date has since become eligible. You must enrol and write to them within six weeks from the day they become eligible.

Manage opt-out requests: If any of your staff choose to opt out within one month of being enrolled, you need to stop deductions of contributions and arrange a full refund of what has been paid to date. This must happen within one month of their request.

If you fail to complete your on-going automatic enrolment duties, you could be fined.

NHS Pension Scheme

The NHS Pension Scheme website is now the main method of communication with the NHS business services authority.

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Website: Http://www.nhsbsa.nhs.uk/pensionsonline.aspx

Employer’s Helpline: 0300 3301 353

Pensions Online Technical Help: 0870 011 7108

Member Helpline: 0300 3301 346 or 0191 279 0571

Stationery Order Line: 0300 123 1002

NHS PensionsHesketh House200-220 BroadwayFleetwoodLancashireFY7 8LG

The Pensions Online website is used to notify the authority of details of joiners and leavers to the scheme, of monthly payments due to be collected by direct debit from the practice, for obtaining pension estimates, pension award applications, and for the submission of annual returns. Sometimes members’ records are incomplete as a result, for instance, of changing employers and may need updating.

Administering the scheme

Salaried doctors or staff joining the scheme will need to complete a joiner’s form and be added to the scheme using the NHS Pensions website. For members leaving the scheme, the Pensions website will require amendment. Changes of name and address should also be notified on the website. The final salary payments made to members retiring will need to be submitted before a pension award application can be considered.

Employee pension contributions

When entering new staff in the payroll or increasing the pay of existing staff, it is important to check that the correct employee pension contribution is being levied. The employee’s percentage rate deduction now depends on the level of their annual salary. Check the NHS Pensions website for the correct percentage value. Pension contributions should always be worked out on the basis of the full-time equivalent. NHS Pension codes are usually:

Opt-in to Pension – D

Opt-out of Pension – A

Over 60 – C

Joiners to the NHS pension

Joiners to the NHS Pensions Scheme will need to be added to the Pensions website and the payroll. Continuity of NHS employment will ensure the employee’s membership service is

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enhanced. The personal details for the new employee will need to be amended to show that the employee has joined the scheme – a start date will be needed, along with an indication as to whether it is part-time or full-time work.

Leavers from the NHS pension

Following the last payment you will need to print out an SD55 and submit this via the Pensions Online system.

Pension estimates for practice staff

The website also allows the employer to prepare a variety of pension estimates for practice employees but not general practitioners who are considering their retirement arrangements. These include estimates at retirement age and estimates for voluntary retirement before reaching the age of 60. The reports produced provide members with options to consider.

Annual returns

The annual individual returns (SD55s) for staff employed by the practice who are members of the NHS Pension Scheme must be submitted using the Pensions Online website during the first week in April each year. A printed copy of the annual return can be provided to each member of the scheme with the April payslip, along with the annual P60. A copy should be kept in the payroll records for the financial year.

Monthly direct debit notification

A notification must be submitted via the pension agency’s website by the tenth day of each month showing the employee and employer contributions for the previous month. The website is entered using a password. You will need to make sure that this is also entered into the practice accounts.

Login to the website: http://www.nhsbsa.nhs.uk/pensionsonline.aspx by selecting N3 Pensions Online and using the login details below. Select the reason for leaving and then fill in the information directly from the SD55 as requested.

NHS pension website access

The NHS Pension Agency allocates a user code along with a password to allow the employer entry to the website. The NHS email address of the authorised user should also be notified to the agency via the website.

Pension awards

The employer is responsible for initiating pension awards using forms obtained from the pension agency website or stationery provider. The employee will need to produce their birth certificate and marriage certificate and various certificates and personal details of themselves, their spouse or civil partner and the bank details where they wish their pension to be paid. Care should be taken when filling in the award form as it might affect the accuracy of the pension award and it is a time-consuming and complex process. The NHSPA recommend starting the process at least three months before the pension date to ensure payment is made

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without any gaps after the last salary pay date.

The Pension Agency will ask to have sight of original birth and marriage certificates if the practice does not certify that they have seen them and taken copies. The employer will be asked to provide information about earnings over the actual final three years of employment. These figures will need to be calculated individually. It may be necessary to print off the last four years’ annual pension returns for the member of staff concerned.

Added years

Employees

The employer will need to process applications for added years, subject to a scheme being available, and apply the agreed percentage additional deduction from the employee’s salary. The ‘added years’ contribution is paid to the NHS Pension Agency each month along with the employee’s and employer’s contributions and is a means for some employees to enhance their pension amounts.

General practitioners

Added years payments made by the doctors need to be attributed to their capital accounts. Applications for enhanced pensions or lump sums are dealt with by NHS England. Some doctors may be subject to an earnings cap on their pension contributions and may be entitled to a refund of overpayments of contributions.

Pension estimates – Practice staff

The pension administrator (practice manager), by using the NHS Pension website, can prepare various pension estimates for practice staff. The estimates include retirement and voluntary early retirement estimates. Practice staff have been able to join the Pension Scheme since 1st

September 1997.

In-service changes

The practice, as employer, must administer membership of the scheme by notifying the authority (using the website) of staff who join or leave the scheme. Notification must also be made of changes in hours of work, part-time to full-time and vice versa. The NHSPA will need to know changes of address and marital status of both spouses prior to retirement.

Refund of contributions

Staff who have joined the NHS Pension Scheme but have only been members for less than two years can apply for a refund of contributions. The application forms are available on the Pensions website. The application needs to be completed by both the employee and employer and kept by the practice whilst the application is submitted via the Pension Authority website.

GP superannuation payments

NHS England deducts from the monthly income of the practice both employees’ [varying rates] and employers’ [14% in 2017] NHS Pension Scheme contributions. The deductions are based on a provisional calculation that is made once a year around February, looking at the total estimated NHS income and matching it with the partnership shares of each GP (see previous sections).

Partnership shares are based on the number of individual sessions worked by each partner

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when compared with the total number of sessions worked in the practice by the partners. Sessions worked by GP registrars and salaried doctors are not included in the computation.

A session is normally regarded as a morning or afternoon consulting session. This excludes extended hours sessions and a session has been defined by the BMA as 4 hours 10 minutes (based on the standard working week).

GP employees’ contributions are based on a percentage of the estimated income of each GP. The highest percentage deduction is 14.5%. GP employers’ contributions are 14.0%. (Figures correct at 2017.)

Annual superannuation certificates

The practice accountant will carry out a review of income and superannuation payments due for the previous financial year on February of the following year. Certificates (Type One) will be prepared setting out the total income and superannuation payments due for signature by the doctors and for submission to NHS England along with cheque payments for the balance due. The payment made will need to be broken down carefully and shown in the GPs’ capital accounts. A cheque should be sent to the local Area Team of NHS England made payable to ‘NHS England’.

Performance management

The purpose of this procedure is to set out the way in which the practice will deal with employee performance issues. On occasion, work performance can suffer for different reasons and it is necessary to have a policy to deal with substandard work performance in a fair and reasonable manner.

The practice is entitled to expect all employees to do their jobs to the best of their ability. The practice acknowledges the efforts made by staff towards achieving and maintaining high standards of work performance.

The practice policy should be clear and robust and the pathway must be followed to ensure relevant HR legislation is met. Work Performance Guidance is available from ACAS and other HR advice sources available to the practice (BMA etc).

Performance reports

The practice is usually provided with a number of performance reports compiled outside the practice by the CCG, etc. which are usually reviewed at the practice business meetings.

These include:

Monthly Performance Dashboard Reports from CCG Practice Profile Primary Care Practice Reports Primary Care Web Tool Reports

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The Primary Care Web Tool

Website: https://www.primarycare.nhs.uk/

You will need to regularly review the contents of this website. Once logged in, select ‘Medical’. You will have a number of options:

General Practice Outcomes Standards User will give you access to:

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General Practice Higher Level Indicators User will give you access to:

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Practice Declaration User will give you access to and allow you to submit the annual declaration on behalf of the practice. You will see when declarations are open and those that

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have already been submitted previously:

Workforce Census User gives you access to the census that needs to be submitted. However, should there be any new starters or leavers it is probably best to add them to the census as

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they start or leave. Saves a lot of hassle doing it at the end of the year.

Dementia Prevalence User gives you access to all the dementia data:

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KO41b Complaints Data gives you access to the annual Complaints Return that needs to be made to NHS England in March. You can review previously submitted returns and those

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awaiting completion/submission. The way the Complaints Spreadsheet is set up allows for filtering to the same categories used in the submission so this should cut down on the amount of work required to fill this in.

Personally administered drugs (PA)

A personally administered item is classed as a prescription item which is prescribed and administered by a member of the practice team and attracts payment under the General Medical Services Statement of Financial Entitlement 2005 section 17.4.

Net Ingredient Cost (NIC) is the basic price of a drug as stated in Part II Clause 8 of the Drug Tariff. The BNF Code is a 15-digit code in which the first seven digits are allocated according to the categories in the BNF and the last 8 digits represent the medicinal product, form, strength and the link to the generic equivalent product. The NHS Prescription Services have created pseudo BNF chapters, which are not published, for items not included in BNF chapters 1 to 15. The majority of such items are dressings and appliances, which the NHS Prescription Services have classified into four pseudo BNF chapters (20 to 23). Items show the number of times a product appears on a prescription form not the quantity prescribed.

The practice should have a system that provides management with a list of the PAs for the month and there will need to be someone allocated to complete the necessary forms for the Prescription Authority to make the claims for these and other items provided (e.g. influenza vaccines in the campaign period, etc.).

Petty cash

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An Imprest system is usually utilised to manage any petty cash used in the practice. Cash income can be received for private work, and cremation fees amongst others, such as Goods Vehicle Driver and Taxi Driver medicals. A careful record should be kept of all incoming cash. Practices may have different ways of sharing private income amongst partners. The cash income can be utilised to fund the petty cash used in the practice thereby avoiding bank charges when cashing cheques. All petty cash that is topped up using the cash income needs to be added to the accounts as such.

It is vital that a dated receipt is obtained for all cash purposes and that a clear record is kept of the type of purchase made. Some purchases may simply be consumables and attributed to stationery or cleaning supplies, but other purchases might be assets such as a television or fridge. The receipt may also need to show the VAT element if the practice is VAT registered. Otherwise a voucher must be created giving details of the value of the payment made, the date of payment and the type and nature of the purchase. The voucher should be signed by the purchaser and a manager.

Normally any incoming cash in excess of £200 should be banked. Cash should be kept in a practice safe or other secure receptacle. A portable tin is not a safe way to hold anything other than very minor cash amounts, and banking frequently is good practice.

A safe should be provided in a practice to secure cash and cheques prior to banking. Access to the safe should be restricted to senior staff and the lead partner. It should be noted that there has been a history in the UK of theft and fraud in general practice by practice staff, as there has been in all environments where cash is handled routinely.

PGDs and PSDs

A Patient Specific Direction is a written instruction, signed by a doctor, dentist or non-medical prescriber for medicines to be supplied and/or administered to a named patient after the prescriber has assessed the patient on an individual basis.

A Patient Group Direction (PGD) is a written instruction for the sale, supply and/or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.

These are usually forwarded to practices from the Area Team and must be signed by all clinicians who would undertake the PGD. These then need to be signed by the senior partner and kept for review by CQC. It is extremely important that these are signed!

Policies and protocols

The practice should have a readily accessible directory of policies and protocols that all staff can get to when needed. They can be kept in a practice intranet (either using a proprietary software package such as Intradoc or iQ Manager) or on a shared drive on the main server. In this latter instance, it will need to be well constructed in a logical format to be properly effective. In exceptional cases a practice may keep hard copy policies but it is important in all cases for the copy that is accessible to be the most up-to-date version.

CQC will look for ‘Document Control’ when reviewing policies so each must be clearly annotated with the date it was written and version number as well as the planned date it should

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be reviewed. There is no requirement for policies to be slavishly reviewed each year but good monitoring of the working environment should help a practice manager to spot when operating issues change and a digital filing system/software should prompt when review dates are due.

Practice Index Ltd

Practice Index is a fantastic resource. It provides information and help for practice managers to get their practice compliant with regulation and to stay compliant. The forum allows members to keep up to date with the latest legislation and provides support, guidance and time-saving resources that help drive practice efficiencies.

Practice Index is free to join and there is an enhanced service – ‘Practice Index PLUS’ – which is subscription-only but offers premium content. Both provide access to a wide range of information, guidance and support resources, including:

Policies and protocols library Job descriptions/person specifications library Toolkits HR/employment law guidance HR and operational advice lines Health and safety guidance Mentor scheme Community resources

The website is a valuable resource, offering support to all practice managers, and can be accessed at: https://practiceindex.co.uk

Practice insurance

The practice insurance can be with a wide range of providers and can cover a wide range of risks and situations. Practices need to consider a policy or policies to cover the following:

Public liability Locum cover for doctors and nursing staff Key staff insurance for those whose absence would cause problems such as the

practice manager and specialists such as pharmacists or IT staff Legal protection cover against financial, contractual, property and other disputes Building and contents cover Vehicles (if the practice owns ‘pool’ transport)

Practice leaflet

This has to be provided as part of the NHS Contract and the contract provides detailed information of the requirements. The leaflet as well as being in hard copy may also be available as a website download and practices do need to remember the Accessible Information Standards when producing this type of document.

Practice list and area

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Open list – Checking patient list size

The practice will have a designated catchment area that has been agreed with NHSE and anyone applying to join the practice from within that boundary has an expectation that they will be accepted without question. Applications to join the list from patients living outside the normal practice boundary will normally be referred to the senior partner and/or practice manager as it is possible to accept these patients but on a limited service basis. Patients who are complex or have complex needs cannot normally be refused on those grounds, and should they be refused and complain to NHSE it is uncomfortable, to say the least, should NHSE instruct the practice that they have to take them on. NHSE has the power to allocate patients to any practice but usually would seek to negotiate first.

A system also exists where some patients may register with two practices – one ‘at home’ and the other nearer to their workplace. Not all areas and practices operate this system and there are arrangements in place with regard to sharing clinical data, responsibility for home visits, etc.

A regular check should be kept on the practice list size. The practice would wish to review their policy of accepting all new patients once the list size has reached an agreed level. There is a process to close the list to new patients but it is not possible to close a list without NHSE approval.

End of quarter

There is a closing-down process at the end of each quarter when effectively the list is counted at the quarter end for payment purposes. No new acceptances or alterations to patient records should be submitted to NHS England after the end of the quarter for a period of about five working days until notification is received to the effect that the quarter can be closed down.

Quarterly list count

The list count for each doctor can be printed off from the clinical system or Open Exeter. The list size for the practice and individual doctors can be checked. Technically, the maximum list size for an individual doctor is 3,500 patients; however, the national average list size is in the region of 1,800. NHS England now regards patients as being registered with a practice rather than an individual doctor. Patients would also need to be notified of the retirement or resignation of a partner, and the patients would be administratively transferred to one or more of the remaining partners.

Registering new patients

New patients may sometimes be placed with the partner who has the lowest individual list size. On the retirement or resignation of a partner, NHS England will require the outgoing doctor’s patients to be notified of their transfer to one or more of the remaining partners’ lists. However, patients can legitimately be registered at the practice if they live outside the practice boundary without the requirement to provide out-of-hours or home visits. The practice may, however, decline to undertake this commitment if the partners feel it would be detrimental to the provision of a service to their patients registered within the recognised practice boundary.

Daily transactions

The daily process of transactions involves new acceptances and changes to patients’ details being stored for transmission to NHS England in real time. The process is automatic. In real

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time, NHS England records any amendments to patients’ details and an acknowledgement of any new acceptances is sent. The amendments may include new NHS numbers. These changes need to be accepted and processed. The introduction of GP-to-GP electronic data transfer has made the process easier; however, delays in following-up a transfer with the paper records which could be needed have caused problems. The transfer of records also highlights where practices are below standard in summarising notes and this, too, can be an issue when the receiving practice has to review and perhaps correct summaries.

Unmatched transactions

Sometimes transmitted files for individual patients are not matched and a manual process is required to correct details, which normally involves adding the correct NHS number via the high-level security section.

Practice area boundary

A GP medical practice has a defined practice area, which is stated on the original application for inclusion in the Medical List of a local health organisation. The area can be defined by streets and geographical boundaries, or local government or constituency boundaries. A practice would be best advised to keep a map on which the agreed boundaries are drawn and keep the boundaries under review along with the practice list size. The practice usually has a copy of this in each reception area for reference and it should also appear on the practice leaflet.

From time to time the practice may wish to review its list size and the extent or boundaries of its practice area. The practice would normally be expected to have an Open List and to accept patients without question. However, if a practice decided to close a branch surgery to restrict its list size, it would need approval of NHS England before doing so. Practices are now being afforded the option of providing limited services to patients who live outside their practice area, as indicated above.

Removal at doctor’s request

A GP practice is entitled to request the removal of a patient from the practice list by the Registration Department of NHSE should the doctor/patient relationship break down or there are acts of violence (see section above for details), subject to the patient having been advised in writing of the practice’s intention. A set of standard letters is advisable to ensure consistency and should be made available for use.

Telephone number formats

GP practices have been asked by NHS England to ensure that standard telephone number formats are used in the registration of patients which include the area code followed by a space, three digits and then a space before the final four digits, or a mobile number without spaces. This will also be the format used by the clinical system.

Use of NHS numbers

Connecting with the National Spine should introduce the NHS number into the record of all new patients. There are exceptions – babies and immigrants. The patient’s NHS number must be used on all referral documents and when using the e-referral system. A new NHS number might not be immediately available for immigrants who may not be entitled to hospital treatment until resident for more than 90 days.

Validation of NHS Spine – Registration database

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New patients should be registered by practice staff using a smart card to ensure that the patient’s registration data is matched on the National Spine. There is also an exercise to be carried out to check that the practice patient database matches the National Spine. This involves checking the registration database screen for each patient systematically with a NHS smart card logged in. This will reveal any Spine differences which can then be corrected.

Practice Participation Group (PPG)

Since 1st April 2015, it has been a contractual requirement for all English practices to form a Patient Participation Group (PPG) during the year ahead and to make reasonable efforts for this to be representative of the practice population. Generally made up of a group of volunteer patients, the practice manager and one or more of the GPs from the practice, they meet on a regular basis to discuss the services on offer, and how improvements can be made for the benefit of patients and the practice.

In practice, PPGs can play a number of roles, including:

Advising the practice on the patient perspective Organising health promotion events Communicating with the wider patient body Running volunteer services and support groups to meet local needs Carrying out research into the views of those who use the practice (and their carers) Influencing the practice or the wider NHS to improve commissioning Fundraising to improve the services provided by the practice

PPG agenda and minutes should be made available to all patients and the practice website is a good vehicle for this purpose.

Terms of reference should be available for the PPG as there is a danger that the group or some individuals may feel they are the final decision-making authority for the services the practice provides. A PPG nonetheless is a very valuable tool for demonstrating responsiveness for the CQC. The PPG may wish to join the National Association for Patient Participation in order to widen their knowledge and usefulness. They have a website at: www.napp.org.uk

There is also myPPG, an online discussion forum where Practice Managers and GPs can connect with a diverse range of their patients to discuss matters at the practice. myPPG is a ‘sounding board’ for ideas and helps identify new services to meet patients’ needs, through posts, easy to run polls and questionnaires. You can visit the site here www.myppg.co.uk/

Premises management and maintenance

Keyholders

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The arrangements will differ according to the ownership and operation of the practice premises but in practice-owned premises the main keyholders to the property are usually the partners and the practice manager. Permanent staff may also have keys to the buildings in which they work.

In some areas the keyholding function might be outsourced to a contractor – usually the same one who provides the practice intruder alarm – so a clear Service Level Agreement and regular monitoring of who comes in and out of the premises when it is closed would be good practice.

Burglar alarm maintenance

The burglar alarm should be maintained regularly and this may be a requirement of the buildings/contents insurance. The alarm may also be connected to a central monitoring station and if so it is important that the station is kept up to date with the keyholders’ details and advised when they are on holiday.

Fire alarm – Maintenance and testing

The main fire alarm should also be regularly maintained and the sensors throughout the building checked and cleaned as dust can adversely affect smoke alarms. Nationally there is an increased likelihood that the Fire Service will not attend unconfirmed fire alarms which are transmitted directly to the Fire Control or through a central monitoring station. The policy is intended to reduce false turn-outs but does place the practice at risk of major damage before someone spots the fire and dials ‘999’ to confirm it. Having a well-constructed Disaster Recovery and Business Continuity Plan is therefore even more essential.

Testing alarms and exercises

The fire and other alarms need to be tested regularly and a fire evacuation exercise undertaken regularly. New staff should be inducted in fire and alarm procedures.

Repairs

The practice manager should be able to arrange and authorise minor repairs to the property such as problems with the plumbing, central heating or electrical installations without the need to refer back to partners. A list of usual contacts should be kept for those occasions when the practice manager may be absent.

PAT testing

The level of inspection and testing required is dependent on the risk of the appliance becoming faulty, which is in turn dependent on the type of appliance, the nature of its use and the environment in which it is used. Testing is often carried out annually by a nominated electrical or other contractor. You will then be provided with a file with all the reports and each tested piece of equipment should have its test date sticker. There is a great deal of uncertainty about when and what needs testing but as a general rule of thumb the degree of ‘portability’ is the main test, so where a kettle in the kitchen is moved regularly and probably needs annual testing, a computer printer may stay in the same place for years so needs testing less frequently. Confidence in the contractor doing the testing is important as the practice should not be charged for unnecessary testing. In addition, there is a view that routine PAT testing may be carried out by someone in the practice who makes a visual check of cables, wiring, etc. for signs of damage and records the check. However, this may not be considered appropriate.

Improvements

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Improvements to the property will invariably need to be agreed in the first instance with the partners or may be covered by the lease with the owners where the property is not practice-owned. Sources of funding may need to be investigated as there are funds for practice development being flagged by the NHS and private contractors all the time. The issue for practices, regarding making improvements, is the change that may follow with respect to the cost or notional rent reimbursement so NHSE approval may be needed and may not always be forthcoming!

Fire extinguishers

The fire extinguishers must be checked and maintained annually by a competent contractor. The date of the last inspection should be marked on the extinguisher and a certificate of inspection kept in the practice building file.

Cleaning contract

The practice may either be employing its own cleaners, be employing a contract cleaning company, or have their cleaning provided by the landlord. If the practice employs its own staff to clean then the rules regarding employment of proper persons and governance for confidentiality, etc. will be the responsibility of the practice. The advantage is that the practice has a greater degree of control and flexibility over what is done and when. If the practice has ‘outside’ cleaners then it is vital that the Service Level Agreement is sufficiently detailed that the practice is content that the service matches what they want. COSHH, health and safety, infection prevention and control, security and premises access, the cost of materials used and their suitability for the work, training, and confidentiality are all areas where the SLA needs to reflect the practice needs. In all cases, however, monitoring of the cleanliness rests with the management of the practice and as it forms part of the safety KLOE it will need to be evidenced for the CQC on inspection.

Waste

Practices will need to apply to the Environment Agency every three years for registration as a producer of controlled waste where they dispose of clinically contaminated dressings, speculums, sharps, etc. In premises where there are other clinical staff employed by community providers, etc. who also produce controlled waste, it is important that it is not mixed up with that from the practice and is collected and labelled separately. The reason for this is that the practice is responsible for all problems that may arise and which are traceable back to them. Should a community nurse inadvertently place an unsheathed sharp in a plastic bag which has the practice identity label attached, and that results in a needle-stick injury to the waste carrier, it will be the practice that is prosecuted. For the same reason, it is highly inadvisable for the practice to accept any clinical waste, particularly sharps, from patients (diabetics, etc.) and it is the responsibility of NHSE and the CCG to have arrangements in place for the collection and disposal of patient-produced hazardous clinical material.

Clinical waste must be stored in a clearly labelled facility, preferably away from any public areas and only collected by a licensed waste carrier – who will be contracted to NHSE or the CCG depending on the delegation of role that exists in individual areas.

Prescriptions

Many practices purchase vaccines for administration to patients. This includes travel vaccines

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and the seasonal influenza vaccines. The practice may also purchase certain painkilling injections and vaccinations for patients with certain conditions and other injectables for the treatment of prostate cancer or contraceptive preparations, etc.

Monthly claims

Apart from travel vaccines and the influenza vaccines, a signed prescription is required for each vaccine administered. A claim is submitted to the Prescription Pricing Authority within the first few days of each month.

Searches

A series of searches should be set up on the clinical system which normally only require the date range updating. The claims are submitted with two claim forms; one for printed prescriptions and one for an agreed range of vaccines – where numbers of vaccines administered only are required.

Prescription Pricing Authority

The Prescription Pricing Authority is based in Newcastle upon Tyne and is responsible for pricing the prescriptions issued in general practice and dispensed in retail pharmacies. It also prices prescriptions issued in prescribing and dispensing practices. In addition, the PPA provides detailed PACT data to CCGs and practices to help monitor prescribing and encourage more efficient prescribing. The PPA also issues prescription charges exemption certificates and prepayment certificates.

Private income

In addition to NHS income received for entering into a General/Personal Medical Services agreement with NHS England, a practice can undertake a limited amount of private work which supplements the NHS income stream. It is worth noting that under NHS contracts, a practice cannot provide private treatment to any registered patient apart from travel vaccinations but this restriction does not extend to making private referrals which are permissible. It is also important to be aware that travel advice is an NHS service so cannot be charged for (as are some vaccines used to protect travellers). Specialist training for nurses and reference to the ‘Green Book’ on vaccines will provide the latest advice in this area.

Private work includes:

Heavy Goods and Public Service Vehicles Medicals Life insurance reports and medicals DVLA reports Criminal Injuries Compensation Authority Applications for disabled parking badges, disabled bus passes, adoption, fostering,

childminding, Disability Living Allowance Forms from patients claiming against insurance policies for sickness absences,

accident claims, occupational health, pension applications, holiday cancellations

The practice receives a miscellaneous list of requests for reports. These include requests for expert witness reports for the courts and medical reports to support accident claims. The doctors also receive requests to report on patients where a power of attorney application is

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being lodged in court. Reports are also requested in children at risk cases.

Private fees – Review

The level set for private fees is normally reviewed in April each year, and practices should take care that if they canvass what other practices charge for private work it may give the appearance of price-fixing and result in an embarrassing prosecution. The fees set for copy records are limited by statute to £50.00. The fee for access to medical records only is £10.00.

Purchasing

Liquid nitrogen

The practice may undertake the removal of warts, etc. (known as cryosurgery) and will need to arrange the provision and storage of liquid nitrogen supplies. There are contractors who will attend a practice on request and decant liquid nitrogen into a ready-to-use flask on cryosurgery days, or the practice may purchase single-use equipment already filled under pressure. Should the practice wish to hold and decant its own stock, there are detailed health and safety requirements as well as a requirement for the storage facility to be indicated with a hazard warning sign, as is the case with the storage of oxygen cylinders.

Courier services

Various courier services are provided for the practice each day. The services collect and deliver mail and pathology samples to hospitals, laboratories and NHSE or CCG according to the local arrangements.

Stationery and other purchasing

The practice may be part of a buying group or other collaborative where purchasing of much essential equipment is carried out collectively. Alternatively there may be local or national suppliers who are able to offer better terms, and this will be a practice decision based invariably on a cost/quality assessment.

Practices also have a need to purchase what are known as ‘ethicals’. These are items which are medical products such as drugs, vaccines, equipment and dressings. They may sometimes be directly purchased from the manufacturer or through specialist pharmaceutical wholesalers.

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Q

QOF

The Quality Outcomes Framework originated in 2004 as part of the new GP Contract and at that time revolved around ten clinical domains, and a lengthy series of management requirements, including the service provided to patients, appointments and access. 1,000 points were available. It does seem highly likely that the QOF work will be subsumed into the core contract work and the finances into the Global Sum or Contract price (depending on the contractual status of the practice). However, year by year since then, indicators have been included, revised or dropped and currently there are considerably less standard clinical domains giving much fewer points available. Added to that, the dimensions of the indicators that have remained have changed and become harder to achieve as rather than a focus on ‘input’ on the part of the practice they now require ‘outcomes’ to be achieved. This still means that the average-sized practice can earn in excess of £90,000 and adjustments are made where the preference of clinical domains is higher in a practice list.

The key to success with QOF is to encourage all doctors, nurses and staff involved in any indicators to record ‘codes’ vigilantly. As for the practice manager, it has been a case of preparing policies, protocols and procedures and ensuring that appraisal and mandatory training requirements are met.

For practices finding it difficult to achieve higher scores, it is recommended that templates be introduced for doctors and others to use to allow the automated entry of codes. It is also possible to set up around 26 ‘Quick Key’ entries on some clinical systems. Practices should appoint a lead doctor or doctors to look after difficult clinical domains and ensure that regular, and not last-minute, reviews are undertaken each year.

Below is a summary of the domains covered (2017 list) and the management action required.

Quality Outcomes Framework

Clinical domains

Atrial Fibrillation (AF) Secondary prevention of coronary

heart disease Cardiovascular disease – primary

prevention Heart failure Hypertension Peripheral arterial disease Stroke and Transient Ischaemic

Attack TIA Diabetes Mellitus – all types Asthma

Chronic obstructive pulmonary disease (COPD)

Dementia Depression Mental health Cancer Chronic kidney disease Epilepsy Osteoporosis Rheumatoid arthritis Learning disability Palliative care

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Public health domain

Cardiovascular disease Blood pressure Obesity Smoking Cervical cytology Contraception

A schedule of points achieved in the monthly reports should be reviewed. Any significant shortfalls should be brought to the attention of the lead doctor for any particular domain that is failing to achieve.

Information on current QOF guidance for the year can be found by following the subject on the NHS Employers website as well as the BMA and other sources. Please refer to:

QOF Guidance

QOF Technical Guidance

QOF Changes Summary

QOF Vaccs & Imms Guidance

Year-end preparation – January to March

It is important to check during the last quarter of the financial year but especially during March that the practice has achieved as many points as possible in each domain. There are software programmes available, some written by clinicians in primary care, which will search the patient database and prompt where the practice can improve its financial position in QOF. In the event that QOF is fully absorbed into the GP contract, it is reasonably sure that it will be replaced with another form of outcome measurement.

Annual submission – April

CQRS automatically uploads the practice achievement ready for declaration. Guidance on how to check and declare the information is made available by HSCIC each year in advance.

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R

RCGP

The RCGP is the professional membership body for family doctors in the UK and overseas. They are committed to improving patient care, clinical standards and GP training. Many of the long-serving GPs in practice may not have taken the necessary exams to gain member status of the RCGP; however, it is a mandatory GP qualification taken in recent years and affords the designation MRCGP.

Website: http://www.rcgp.org.uk/

Recruitment

The practice will have a Recruitment and Staffing Policy which clearly sets out the processes and procedures required to adhere to appropriate legislation when recruiting staff and making appointments.

Staff vacancies are normally advertised in publications appropriate to the post on offer and on the NHS Jobs websites. GP vacancies would best appear in one of the GP magazines (Pulse/GP/BMJ) while nursing posts would gain the best responses through the RCN members’ magazine, etc. Advertising free in Job Centres or at more cost-effective rates in local free newspapers should not be discounted either. Vacancies may also be posted on the practice’s website.

Application packs (include the advert for the post, job description, person specification) should always be made available, and when using NHS Jobs (a service the practice must register with in order to use) their own application form is compulsory and does allow the applicants to provide all the required information, including statutory declarations, to enable you to shortlist. Practices may also instead ask for the applicant’s own CV for the application process as this does show something of their reasoning and communication skills but whatever process is used the essence must be fairness.

A shortlist of normally five or six candidates may be called for interview. It is important to set out the shortlisting criteria and be aware of the risk of challenges due to discrimination on the grounds of age, gender, race, creed and disability. A shortlisting scoring card should always be used by all those who are undertaking the shortlisting process, and applicants marked against a standard list of skills and attributes required.

The interview panel may comprise of the immediate line manager and practice manager for non-clinical posts on the basis that two heads are better than one. Normally the partners or other senior clinicians would only become involved in interviews for staff at a senior management level and for professional staff such as practice nurses, HCAs, etc. However, it is very likely that one of the partners will wish to attend the interviews at some practices. A standard set of interview questions should always be discussed and agreed by the panel, along with a marking sheet for each candidate.

It is important that everyone on the interview panel makes notes of the answers given by each applicant and those notes should be retained in the event of any challenge to the final decision and to counter claims of discrimination. The interview notes of staff may also be asked for during CQC inspections.

In some practices there may be a short exercise or a presentation required from those applying for the more senior positions. If this is done then the criteria for marking must similarly be clear and shared amongst the panel.

A conditional offer letter should be sent to the successful candidate setting out the basic terms and conditions of service including hours of work, hourly rate of pay, annual leave entitlement and an offer to join the pension scheme. Depending on the role, staff will be asked to undergo a DBS check and provide details of two referees, one of whom should be the last employer. It is difficult to ask for references from the last (i.e. current) employer until an offer has been made and practices will need to be discreet up to the offer being made. Once all the additional information in the letter has been received and documents have been reviewed, a formal offer letter can be sent and the start date agreed.

Employment checklists are a must! There is so much to remember and there are so many requirements with regard to employment legislation. While employment checklists for different roles have much in common and have been referred to in previous sections, they do have specific provisions mainly relating to professional standards and qualifications.

Contracts of employment for new staff should be issued within two months of the commencement of employment. However, it is preferable to have these signed either prior to commencing work or on the first day in the practice, and as a minimum the new starter should have been given a statement of particulars already which covers the main areas such as hours, pay and leave. (See the Staff Contracts section for further information.)

Rent review

In practices where the partners own the building or rent is paid to a landlord, the NHS will reimburse either a notional rent amount, a proportion of the cost of a mortgage, or the lease charges (see above). These amounts will be reviewed every three years (or when the premises situation changes) by the District Valuer and the NHS may increase – or decrease – their reimbursement dependent on the assessment made.

In many cases, practices have engaged the services of specialist surveyors who can challenge decreases or negotiate increases, usually for a percentage of the gain made by the practice. It is a CQC inspection item to check whether practices respond promptly when such a rent review is notified to them as the process can be lengthy and it is always best to get money in the practice bank rather than leave it in the Treasury.

Reports

Reports on patients, particularly children and vulnerable adults, are often requested by other organisations in the NHS. You will need to check whether it is acceptable to send information

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and be mindful of data-sharing policies and protocols.

Practices often send a list of all newly registered under-5s to the health visitor to ensure that they have them on their review list – and of course safeguarding policies will require reports to be made as required and shared accordingly. Reports for insurance companies and solicitors are a regular feature of practice work and are governed by legislation. (See above.)

Retained doctors

The NHS has for several years used the ‘retained’ system to encourage GPs to come back into primary care part-time (often female doctors who have taken extended breaks to look after children, or doctors who have gone abroad and returned but who are not wanting full-time roles). NHSE will subsidise practices to take such doctors on their payroll but have restrictive rules on how many sessions they may work and what proportion of the salary they will reimburse. Practices have to submit regular and detailed paperwork to gain the reimbursement and certify that the working time has not been exceeded.

Revalidation – Doctors and nurses

Revalidation is the process by which licensed doctors are required to demonstrate on a regular basis that they are up to date and fit to practise. Revalidation aims to give extra confidence to patients that their doctor is being regularly checked by their employer and the GMC.

Licensed doctors have to revalidate, usually every five years, by having regular appraisals and will also have to collect supporting information that demonstrates how they are meeting the standards in this guidance.

GPs undertake this process with an e-profile but need to keep you abreast of when they have undergone revalidation, and it would be helpful to them for the practice manager to be alert to SEAs and complaints which they might find it useful to include in their appraisal and revalidation portfolio.

Revalidation, and thereby continued inclusion on the GMC register, is an area inspected by CQC so each practice should check online annually that every partner and salaried GP is still on the GMC List and without any restrictions on their practice. The reason for this check is that from time to time the GMC will discipline a doctor for a misdemeanour committed while working for another employer (e.g. OOH providers) or for an incident that occurred before they started working in the practice, and you may never find out about it because neither the doctor nor the GMC will have advised you.

For nurse revalidation, see the Nurses section.

Rotas

Compiling clinical session rotas is a task carried out by either an administrative member of the staff or the partners themselves on occasion. Nursing rotas may also be drawn up by a lead

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nurse in some practices. However, in all cases it would be good practice for the management to review clinical staffing levels on a regular basis to ensure patient services are at an acceptable level.

Royal College of Nursing

The RCN is the usual ‘union’ for nursing staff and they represent nurses (including in disciplinary proceedings) and nursing, promote excellence in practice, and shape health policies. Nursing staff sometimes also belong to other ‘unions’ such as the Royal College of Midwifery (if they initially qualified as a midwife) or Unison. They too will represent their members as necessary.

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S

Safeguarding

The practice must have robust safeguarding policies for both vulnerable adults and children.

Each practice must also have a safeguarding lead – although this may differ for children and adults – and their identity must be known or be readily accessible to every staff member and, of course, locums.

Contact details for the safeguarding team constantly seem to change and therefore careful attention needs to be given to emails and other correspondence notifying variations. Up-to-date contact lists can usually be found in each consulting room and on the intranet or Docman address book.

Security

The security of the building is the responsibility of all. There are usually designated opening-up and closing procedures.

Service charges

Calculation of service charge

The practice may allow outside parties to use the surgery accommodation to provide NHS services. These services might include outreach clinics or a community nursing base. A service charge, but not a rent, might be reasonably levied and the amount that a practice can gain through outside lettings is limited and may have a negative impact on the rent reimbursement from the NHS. It is important to clearly define the charge as a ‘service charge’ rather than the rent of floor space for this reason.

The service charge may be calculated by apportioning the internal floor area occupied by the third-party users of the surgery set against the running expenses of the surgery. This charge needs to be reviewed annually. The calculation should include depreciation, cleaning and security costs, light and heating, and use of equipment including telephones and photocopying. It also needs to reflect surgery insurances and an element of staff costs to administer the arrangements and provide reception facilities.

Other third-party users

Any other users would be charged per session depending on the length of time a room is used. Other users might include, for instance, the dementia workers and mental health workers. The practice also may offer accommodation free of charge to a variety of others including the midwife, health visitor and others should the partners feel that it afforded a patient benefit and were prepared to accept the cost.

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Review of service charges

From time to time the practice will need to review to whom a service charge is levied. VAT should be added to any invoice for service charges if the practice is VAT registered.

Shredding

The practice should have a robust Waste Management Policy of which the Confidential Waste Policy is part. The shredding of confidential material may either be done by the practice itself or by a contractor who takes the confidential papers off-site to a shredding facility or destroys them on-site, usually in a specially equipped lorry. It is important when using a contractor to ensure that you receive a certificate each time a load is shredded to prove secure disposal.

Sickness

See Human Resources section.

Smart cards

The NHS smart card is now required in order to use the e-referral online systems and to deal with patient registrations to allow the transfer of records between practices electronically. In addition, NHS smart cards are used in electronic prescribing. The GP clinical system will need to be switched on at each user terminal for these services to be used.

Issuing new NHS smart cards

The process for issuing smart cards involves completing an RA form which is signed by the applicant and the sponsor. The applicant will need to have a passport-sized photograph taken by an officer of the NHS IT Support Unit unless alternative delegated authority has previously been given to the practice. Applicants will need to provide proof of identity.

Managing NHS smart cards

It is important that smart cards work at all times and any failure to function should be reported immediately to the practice/computer manager. The smart card needs to be updated or reactivated promptly and there are several different RA forms for reporting the processes required.

Staff contracts

Most practices use a standard model staff contract that can be personalised for all new staff. In addition, there may also be a format for a zero-hours contract, and the salaried GP contract must be based on the BMA recommended contract as a condition of the practice NHS contract.

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Staff files

Each member of staff must have a personal file. This gives information such as emergency contact details, bank details, pension details, DBS information, contractual information, pay and terms of conditions information, immunisation status, CV or application form, copies of references and proof of qualifications, etc. In addition, each member of staff may also have an electronic file.

To have a personnel file checklist is good practice for every new starter and all existing staff members as this will make any CQC inspection of personnel files much more straightforward and also serve to highlight any gaps.

Staff handbook

The practice may provide a number of handbooks or guides for staff:

Full Staff Handbook that gives an insight into policies and procedures in addition to practice information.

GP Registrar and Locum Handbook that gives clinical information as well as outlining some useful information about the practicalities of the job, information on how to use the various practice software for intranet, dictation, etc., referrals, safeguarding arrangements, and the clinical system.

The practice may also have a Medical Student Handbook, should they accommodate students (nursing or doctors), and this is used in conjunction with the full Staff Handbook. This gives relevant health and safety information that medical students will need to know about their placement.

Staff training

Different staff members have different training requirements and these should always be based on the role that they are employed to do.

There is, however, statutory and mandatory training that needs to be undertaken by all members of staff. A record should be kept of the date when each individual member of staff received their training. All staff training should be logged both in their personnel file and also in a management file, preferably one which highlights due dates for retraining. Many practices now use online systems for training provided by the NHS or a commercial company such as Blue Stream. These online services often provide a management facility that records successful training sessions and automatically flags up retraining dates. Intranet programmes and back-office software may also provide the same function. It might also be worthwhile for a practice to keep a record of partners’ as well as employees’ training in order to ensure they do not miss retraining opportunities, particularly during extended absences such as maternity or sick leave.

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Stationery

Free stationery

There is a range of free supplies. This mainly relates to forms required for day-to-day operations:

GMS1 forms, continuation cards and medical records envelopes are ordered from CSA.

Pathology forms and bloods bottles are ordered from the local Hospital Trust responsible for testing services.

These can often be ordered by accessing the relevant websites.

Supplies purchasing

General purchases for the practice fall into two main categories: office supplies and medical supplies.

Stationery supplies, photocopying and computer consumables are usually sourced from commercial companies at the most cost-effective price. Buying groups and collaboratives are common. Larger organisations providing GP services may have a centralised buying department. Scanning being a frequent back-office function, many practices now have either leased or purchased photocopiers capable of colour printing up to A3 size (for posters, etc.) and which can scan onto a network storage server or can be utilised as a network printer and reduce the reliance on desktop printers, thereby reducing toner and ink consumable costs.

Medical supplies have been mentioned previously as falling into the categories of ‘ethical’ and ‘non-ethical’. Again, buying groups and collaboratives have the opportunity for independent practices to gain the buying power to negotiate discounts and favourable trading terms.

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T

Telephone

The telephone system is the most important facility, next to the clinical system, as it provides the main interface with patients.

Telephone systems are either purchased or leased from contractors on a per-practice basis or may be part of a Wide Area Network or Local Area Network and tied into a building which has a single telephone system or the provider for a large NHS organisation – often a CCG or Secondary Care Trust.

There are arguments on both sides as to what is the best. Independent practice systems may offer flexibility and be configured to exactly what the practice wants, but larger systems across several sites may have a more responsive support capacity and the ability to call between sites at no direct call charge. The choice is not always with the practice as legacy systems are in place in many areas.

The use of 0844 telephone numbers for practices has now largely stopped following complaints that callers were having to pay more than local rates to access their healthcare provider. The increased use of online email communications and Skype etc. may serve to reduce the reliance on the telephone in due course, but that seems to be some considerable time away. In the meanwhile practices will need to critically examine their telephone needs and facilities.

Call recording has been shown in many practices to assist both in being able to review the information being given by a patient and the clinician’s responses as well as aid the investigation of complaints where telephone conversations are in dispute. The EMIS Web system, and probably others, has the ability to ‘attach’ a digital voice recording to the patient records in the same way that a photograph or other scanned document can. This has been useful when patients have given verbal consent over the telephone for their spouse or other family members to have access to test results and referral information. To use this facility, however, the telephone system must have the capability for recorded calls to be extracted and saved.

Mobile telephones have also proved to be an invaluable aid to practices. Mobiles in the reception area on a pay-as-you-go basis can provide an essential backup should the main system go down. Mobiles possessed by patients can be used to receive text messages about appointments (reducing DNAs), advising patients who are in the annual flu vaccination cohort that clinics are ready to be booked, and some clinical systems also allow the texting of blood test and other diagnostic results. Practices will need to be content that there are no breaches of confidentiality in using texting should a telephone be shared between family members however.

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U

Unpresented cheques

A list of cheques issued but not presented to the bank should be prepared for the practice accountant. There has been some experience of bounced cheques both from patients and insurance companies. You will need to ensure that these are also recorded in the practice accounts.

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V

Vaccines and storage

Vaccines in the practice may come from two main sources: purchased in by the practice from a wholesaler or manufacturer and to be ‘personally administered’ (see the Prescriptions section), or provided directly by the NHS through central purchasing and delivered to the practice. The latter category usually comprises of childhood vaccines although others may be provided such as for hepatitis. (The ‘Green Book’, available in hard copy or online, is the ‘bible’ for vaccines information and should be kept available by the RGNs in the practice.)

Storage of several vaccines in a way known as the ‘cold chain’ which is not carried out properly is an area where the practice may run considerable risk. The cold chain requires delivery to be kept at an appropriate chilled level and that level to be maintained once it arrives in practice, right through to administration. If staff are unaware of the cold chain process then there is a risk that a delivery might not be immediately placed into the relevant refrigerator and that may damage its integrity to the extent that it could injure a patient when given to them.

In many practices maintaining the cold chain is the responsibility of the nursing team, who should check the fridge temperature at least twice daily to ensure the correct low temperature is maintained. In some places the fridges have data loggers which give an hourly reading saved to a memory card and which can be downloaded, but checks still need to be undertaken. Vaccines which are shown to have been at too high or low a temperature should be destroyed and if they are practice-purchased the cost could run into thousands of pounds, especially at flu clinic time.

VAT and VAT returns

VAT registration

A medical partnership or other NHS provider organisation may form a registered company and register for VAT purposes in relation to a building project or may need to register on the basis of their income (as defined) being in excess of the VAT threshold – mainly relating to dispensing practices or practices with large private income streams. This may require complex negotiations with HM Customs.

Input and output tax

The practice can claim a refund of VAT paid on purchases and supplies relating to any premises development project. In effect this includes all of the building costs and the cost of professional fees to the architect, structural engineers, quantity surveyors and other advisers. The practice must also declare any VAT added to rent and service charges levied on third-party users of accommodation in the new surgery development. The invoices must be clearly addressed to the ‘development project’.

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Refund of VAT

Depending on the terms of any development project, an agreement may been reached with HM Customs that the development can be partially exempt from VAT and the refund of an agreed percentage of any expenditure on the premises development can be recovered. The agreement is based on a calculation of floor area in the new development that might be occupied by a third party. The VAT rate is currently 20% but was 17.5% prior to 31st December 2010.

VAT returns

The practice is required to make a monthly return to HM Customs setting out the total value of purchases and the refund amount requested. Failure to do so may lead to a fine being imposed. The VAT return schedule is:

TIP: Beware of changes in VAT rates during a financial year. Also check that VAT has been applied correctly to, for example, food [0%] and certain drugs [5%].

Violent and aggressive patients

Details of patients who may cause problems relating to violence are forwarded to the practice from the Area Team or CCG, as appropriate, and should be treated as alerts and disseminated to those who might be at risk. The practice may also have signed up to the DES as a practice prepared to accept patients with a track record of violence towards NHS staff or removed from practice lists after a violent episode. When the details of a patient allocated because of violent behaviour are received, these need to be forwarded to the reception for review and dissemination to ensure staff members are aware.

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Month to go to HMRC

Month PA drugs When to send

April April End MayMay May End JuneJune June End JulyJuly July End August

August August End SeptemberSeptember September End October

October October End NovemberNovember November End DecemberDecember December End JanuaryJanuary January End FebruaryFebruary February End March

March March End April

W

Website

The practice should have a website which is kept updated and provides information to assist patients in all their dealings with the practice. PPG reports and surveys, details of the complaints procedure and appeal process to the Ombudsman, details of partners’ NHS earnings, Freedom of Information Act details, the appointment system, contact details, staff details and any other policies and procedures that would assist patients should normally be freely accessible there.

Websites generally are only as good as the updating process and that may depend on where the practice website was obtained. An in-house constructed website would clearly be maintained by whoever constructed it, but one sourced commercially would need the practice to be clear about what the updates should be and when they should be done, and by whom.

Work experience

The practice may have work experience students and would need a robust Work Experience Policy and Procedures as well as a thorough Health and Safety review – essential where young people are concerned as they may have limited hazard awareness.

This policy should be designed to cover the situation where non-medical students are to be considered for work experience placements. It may also be applied where medical students acting outside the formal medical school/university placement scheme request work. This may occur where students, or pre-course students, ask for summer vacation work to enhance their CVs. These students will generally be sixth form school students considering a medical career and the practice does need to be clear at what age work experience youngsters are taken, and where from, as this may relate to the risks associated with confidentiality.

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X

X-ray results

Many of the clinical systems, as already mentioned, will have the facility to attach X-ray results to the patient notes. This raises the question of whether copies of X-rays should be provided when a patient makes a subject access request for their notes. The BMA guidance includes X-rays and their reports/interpretation notes as part of the health record and should be supplied unless it requires disproportionate effort, and that decision can only be made on a case-by-case basis. It is therefore for the practice to decide if they are able to supply the X-ray as a print or in digital format or not at all.

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Y

Yellow fever

A number of practices operate as a yellow fever vaccination centre, and this is undertaken on a private patient basis. There is an annual subscription to the National Travel Health Network and Centre (NATHNAC) and as well as a fee for registration, the practice is obliged to have a nominated GP lead and ensure that there is a vaccinator (usually an RGN) who has been through initial training and retrained every two years. That training may be classroom-based but now may also be via e-learning, both at a cost to the practice.

Information for health professionals can be accessed via:

https://www.nathnac.org/pro/Yellow_Fever_Vaccination_Centre_Information.htm

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Z

Zero-tolerance

GP practices should consider adopting a zero-tolerance policy regarding patients who behave in a threatening manner toward staff or clinicians. GPs who encounter patients who adopt threatening or violent behaviour towards them or their staff should report the incident to the police. Having done so, the doctor would have the right to request the immediate removal of the patient from the practice list. NHS England has in place arrangements to register violent patients with a special ‘secure’ practice. (See ‘Violent and aggressive patients’ section.)

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NotesPlease use this space to record any notes or reminders of your own.

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Notes

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