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Key Matters reviewed by the Committee March/April 2020:
You may be aware that East of England Coroners Service recently issued a statement updating their position in light of recent COVID-19 related changes. Taken in conjunction with significant national changes to the rules surrounding death certification, this guidance has caused some confusion over who can verify a death.
For clarity, English Law:
(a) Does not require a doctor to confirm death has occurred or that “life is extinct”.
(b) Does not require a doctor to view the body of a deceased person.
(c) Does require the doctor who attended the deceased during the last illness to issue a
certificate detailing the cause of death (unless the death is referred to a coroner).
The concept of “life extinct” ie the fact, can be declared by ‘any competent adult with relevant training’. This may be a doctor, a police forensic medical examiner, or other suitably qualified clinicians e.g. paramedics, nurses. The coroners locally do not consider funeral directors, relatives or, in the vast majority of circumstances, police officers to be ‘competent persons’ for the purposes of death verification. It is therefore anticipated that practices will be asked to send a suitably qualified clinician to verify expected deaths in a high proportion of cases including COVID related deaths. Furthermore, it is clear that the Coroner expects verification of death to occur ‘in situ’ (i.e without the patient moving to a funeral parlour or secondary storage location) in order to exclude ‘suspicious circumstances’.
As a distinct process from death verification, certification should, where possible, be issued by the attending medical professional, but the altered regulations (see link below) allow a great deal more flexibility.
The guidance also informs us that across the region multi-agency response teams are being assembled to assist with timely verification & initial investigation of unexpected deaths. We hope to circulate further details of this service & how to access it shortly.
It is the view of the LMC that the local guidance on death verification places primary care clinicians at risk of COVID exposure unnecessarily & departs from the principle of risk mitigation that underpin other regulatory changes in this area. However, for now, practices will need to assume that other individuals e.g. a funeral director, a carer or a next of kin are NOT able to verify that a death has occurred, and that Coroner expects a member of the team to attend the deceased in hours at the place of death. Appropriate PPE should be worn.
As you can imagine, we are pressing East of England Coronial service to reconsider the guidance issued. At a national level, the BMA are pressing hard for further reform to the system so that telephone consultations as well as video consultations count as having ‘attended’ for the purposes of death certification & that the multidisciplinary nature of the modern primary care workforce is properly reflected in the regulations.
We are also aware of a consultation paper from NHSE outlining remote supervision (by qualified clinicians) of death certification by non-trained adults and that the possibility of commissioning a specific death verification service is being examined.
Following LMC discussions with the CCG it has been agreed that during the Covid-19 pandemic the requirement for a GP to sign the EOL drug administration chart has been ceased. The agreed procedure is detailed here
Following an NHSE webinar held on 16.4.20 it has been made clear that secondary care should be continuing to accept and hold clinical responsibility for GP referrals and therefore GPs should continue to refer where they feel this is clinically appropriate. It will be for secondary care to manage the referrals as they feel appropriate eg virtual consultations/F2F/or advice and guidance as required. NHSEI is putting together guidance which will be issued shortly.
Also see Nigel’s Surgery Mythbuster https://www.cqc.org.uk/guidance-providers/gps/nigels-surgery-97-responding-coronavirus-covid-19
The PCN DES documents have now been published: https://www.england.nhs.uk/gp/investment/gp-contract/ The current focus of the PCN DES is mainly to support practices to increase their workforce and deal with the national emergency of COVID-19. GPC have prepared a 2 page summary here
Advice from RCOG for pregnant women who are working in the NHS
Pregnant women’s choices on whether they work in direct patient-facing roles during the coronavirus pandemic should be respected and supported by their employers, according to updated national guidance from the Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives. This guidance is based on limited evidence from the pandemic so far with evidence extrapolated from other similar viral illnesses. We are actively seeking more evidence and will update this guidance when this is available.
See GP letter on the 2019/20 pension annual allowance tax solution here that should be on the NHSEI website now https://www.england.nhs.uk/pensions/
A reminder that practices are required to register a nominated administrator to action performers’ list requests that require practice validation. While practices will already have administrators registered with PCSE Online for purposes such as supplies and medical records, additional registration is required for the performers’ list role. PCSE have sent letters with registration codes and details via recorded delivery to all CQC registered practice managers. Practices can if needed request a new registration letter by contacting PCSE.
Following the roll-out of temporary registration by GMC for newly retired doctors last week, in order to return to work, individuals will need to complete identification and right to work verification. NHSEI and the Home Office have confirmed that this can be done remotely by using a video link and there is no need to do this via practices. See more information on the COVID Clinical Assessment Service website.
Dr Nigel Watson has put together some guidance for Retired GP Returning to Practice which can be found here
BMA Chair Chaand Nagpaul has written to the Treasury to extend Death in Service benefit to all NHS workers, including retired staff who have returned to the service. BMA is working with NHSEI on arrangements for locum GPs to be able to be employed as single lead employer and therefore enable death in service benefits, if they are part of pension scheme. Details should be produced shortly.
The BMA continues to put pressure on Government to provide the necessary PPE all healthcare workers need, through public campaigning, media work and political lobbying. As shown by the results of the survey undertaken last week, the majority of doctors do not feel safely protected from COVID-19 where they work.
Almost 90% of GPs in contact with COVID-19 infected patients reported either shortages or no access at all to eye protection, and 62% reported problems with supply of face masks. More than half of GPs who responded said they had had to buy their own face masks or eye protection, with only 2% saying they felt fully protected against the virus at work.
This unacceptable situation continues despite repeated assurances by the government that additional stock is being delivered to practices, and yet these assurances are not being matched by a reliable supply of PPE to practices.
PHE published new PPE guidance last week which advises that in primary care PPE should include eye protection and should be worn for all contacts. All patients must be assumed to have COVID-19 infection, and it is recommended that they should wear a mask during any face-to-face consultation.
GPC held a webinar for LMC officers and members of GPC to ask questions of Dr Susan Hopkins, Deputy Director, National Infection Service at Public Health England, regarding the serious concerns which many GPs have about PPE. This can be seen at https://bma.streameventlive.com/archive/205
The NHS 111 Online Get an Isolation Note service issues isolation notes to individuals with symptoms of COVID-19 or those having to self-isolate due to residing with someone with COVId-19 symptoms. Employers have received clear guidance that for all COVID-19 related illness they should accept the Isolation Note as medical evidence to support absence from work and not require employees to get a fit note from a GP.
If an employer asks for fit notes relating to non COVID-19 health conditions for payment of Statutory Sick Pay (SSP) or Occupational Sick Pay (OSP), GPs should complete a fit note in the normal way, scan this and then email it to the patient, with due consideration of GDPR and with the necessary consent in place. Should an employer insist on a paper copy fit note, this can be posted to the patient. GPs can issue fit notes for a clinically appropriate time, which can be up to 13 weeks within the first six months of a condition, in line with existing guidance
NHSEI have developed a national COVID-19 Clinical Assessment Service (CCAS) and are asking for GPs to help with it. The service has been set up to manage patients who need to speak to a doctor after contacting NHS111 and support patients to care for themselves at home, as a result helping to relieve the growing pressure on practices. This is an important service that will help support practices particularly as case numbers increase in the coming weeks. They are seeking GPs who are on the Performers List and currently work as salaried or as a GP partner and who can offer to work remotely with shifts available 24/7. There is, however, serious concern about the low pay rates being offered which do not reflect the level of experience this group of doctors has and this has been raised this with NHSEI.
Currently medical practitioners cannot provide GP services for the NHS unless they are GPs on the GPs performers list. New regulations to be published shortly, will change that so that medical practitioners who are not GPs can provide such services without being on the performers list if they are employed by or are registered with bodies designated by the Medical Profession (Responsible Officers) Regulations 2010, or are granted permission to practise as in hospitals owned or managed by such bodies (such as NHS bodies, the Department of Health and Social Care and the armed forces). This will create the flexibility for non-GPs who have a link to a designated body to be deployed in primary care for the duration of the emergency period, as required. These new arrangements will be removed at the end of the coronavirus emergency period. GPC England and RCGP are working with NHSE to produce guidance for practices in how these doctors may be safely deployed in primary care.
Government has announced that rules on carrying over annual leave to be relaxed to support key industries during COVID-19. The BMA legal department has confirmed that the annual leave entitlements through the Working Time (Coronavirus) (Amendment) Regulations 2020 (SI 2020/365) do apply to GP practices. Therefore, annual leave should be allowed to carry over into future years. However, the wording of the regulations is quite broad.
At present the law does not say that people are unable to take holiday because of the impact of coronavirus, therefore employees will be expected to take annual leave in the normal way unless it is not reasonably practicable for them to do so, for example because of COVID-related obligations.
Regulation 61 of the Pharmaceutical Services Regulations now applies, which means dispensing doctors can dispense to patients not on their list where a pharmacy is closed.
The DHSC, NHS Resolution, and NHSEI have written a letter with regards to the clinical negligence indemnity in response to Coronavirus. As part of efforts to respond to the Coronavirus outbreak, they have reassured healthcare professionals and others working in the NHS in England about the position in relation to indemnity for clinical negligence incidents. Read the letter >
The DVLA has now confirmed that they have ceased requesting any form of medical examinations with effect from 24 March. If members have outstanding requests they can just decline to do them and ask the patient to go back to the DVLA.
