[Private & Confidential]
GLASGOW AREA MEDICAL COMMITTEE
General Practitioner Subcommittee
MINUTES of the MEETING of
the COMMITTEE held on 15th
June 2015 in the Committee’s
offices at 40 New City Road,
Glasgow G4 9JT
SEDERUNT:
Drs Bob Ballantyne, Ronnie Burns, Maureen Byrne, Vicky Clark, John
Dempster, Mark Fawcett, John Ip, William Macphee, Mike McDonagh, Chris
McHugh, Kathryn McLachlan, Hilary McNaughtan, Paul Miller, Patricia
Moultrie, Kerri Neylon, Jim O’Neil, Alan Petrie, Alex Potter, Jean Powell,
Michael Rennick, Paul Ryan, Mohammed Sharif, Alastair Taylor, Chris Tervit
and Raymund White.
CHAIRMAN:
Dr Alastair Taylor, Chairman of the Committee, chaired the meeting.
APOLOGIES:
Apologies for absence were received from Drs Gordon Forrest, Norrie Gaw,
Michael Haughney, Susan Langridge, Jim Mackenzie, Andrew McCall, Alan
McDevitt, Bob Mair, Graeme Marshall, Andrew Townsley and Professor
Graham Watt.
ATTENDING:
Mrs Mary Fingland, Secretary of the Committee
REVISED AGENDA:
The GP Subcommittee received the Revised Agenda.
MINUTES: 15/108
The GP Subcommittee received the Minutes of the meeting held on 18th May
2015.
The Minutes of the 18th May 2015 were approved and signed by the
Chairman.
MATTERS ARISING:
15/109
(a) Heat Target Steering Group: Maternity Services Hub and Spoke
Redesign – Michelle McLauchlan, General Manager Obstetrics and
Gynaecology
The Chairman welcomed Ms McLauchlan to the meeting and introduced her
to members.
Ms McLauchlan thanked the GP Subcommittee for the opportunity to speak to
them and outline the Board’s view of the way forward for Maternity services.
The GP Subcommittee heard that the Board was looking at the central
booking office and whether it was working well. Members heard that the
redesign of the hub and spoke model was first discussed in 2012 when a
‘direction of travel’ was agreed in general. The Board was now revisiting this
with the GP Subcommittee and also at staff level. Members noted that any
changes need to be reviewed and agreed before they could be taken forward.
The service had started by pulling together all the information that would
inform that decision.
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Ms McLauchlan outlined some of the problems facing the service and the
drivers for change which included:
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Some hub and spokes not having an area for expansion.
The need for well-equipped midwifery in one location.
Where possible the ability to work with other health care providers.
The service having ‘missed the boat’ on a couple of new premises
developments.
Reviewing current locations including frequency of attendances and the
need to re-establish stenography in some sites.
Risk assessments are still to be undertaken at those hubs identified for
closure.
Six or seven sites have already been identified for potential closure.
The need to centralise services in the Clyde sectors.
Members heard that in the next few months the service would be making a
reasonably robust argument to Medical Directors for the redesign. A member
asked what number of sites the six or seven identified would be withdrawn
from and heard there were currently nineteen sites in GG&C. The member
noted that, in essence, the service was closing at least a third of its current
provision. Another member asked what the criteria were for potential closure
and heard frequency of clinics, transport links and usage. Ms McLauchlan
told the GP Subcommittee that accommodation was a problem and that it was
difficult to analyse completely as some patients were not able to attend
because of a lack of clinics in some areas.
A member noted that midwifery services had been moved out of GP practice
into the hub and spoke model and was concerned that the service was now
moving further away. Ms McLauchlan told members a detailed piece of work
had still to be undertaken but the driver was the need for accommodation that
could meet the service’s needs. A member advised that he had participated in
the RIE vision event and stated that the reduction from 19 hub and spokes to a
possible 10 was more radical that what had been envisaged in the first place.
The member noted that even 19 sites were too few and that there was a real
deficit in the service. The GP Subcommittee heard that the ‘vision’ for the
spokes as a ‘one stop shop’ had not materialised and felt that the changes were
to do with centralising equipment and staff and there was now a need to think
carefully about the service being offered. The member noted that feedback
from both GPs and patients about the centralised booking service was not
good and that the interface between GPs and midwives had suffered and had
not improved communications between the two. A member from Clyde stated
that it was good to have the midwife in the practice and good for patients. He
agreed that one disadvantage may be that midwives might not always have a
dedicated room but that could be worked around. Members heard that
vaccination of pregnant patients was also suffering and this was a great
advantage of having midwifes seeing patients in the practice. Ms McLauchlan
told members she didn’t disagree but advised that this was not the best use of
stenographers and that having machines in multiple locations was not good.
On the issue of the central booking line Ms McLauchlan advised that ‘netcall’
was now established in the Southern and they were aware of frustrations but
could not move over until the move to the Southern was complete. Members
heard that the supervisor of the central booking centre was speaking to
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practice managers at local level and the service was also speaking to the
Scottish Government. Ms McLauchlan was unsure how the service could be
further improved at this time and heard a response to telephone calls from
patients and practices would be one way. Ms McLauchlan told members that
the new netcall service should improve think and the service was also looking
at alternative communication links possibly via EMIS web. In addressing
immunisation members heard that Public Health were very keen to get better
uptake and that midwives will now check that patients have actually attended
their GP for vaccination, which they don’t do currently. Members heard there
was an issue around storage of vaccines and that the service does not carry a
stock of vaccines.
A member advised that the problem was that GPs rarely see the patient if the
patient attends the ante-natal spoke. He thought that midwives should be able
to carry out immunisations at the spoke especially if the spokes are well
attended. Ms McLauchlan told members she was happy to feed this back.
Another member asked if there was any reason why midwives wouldn’t
undertake immunisation and heard that the booking visit normally takes
around 40 minutes and midwives might not be keen for this timescale to
increase if immunisation was included and there may be some resistance for
this. Ms McLauchlan asked whether GPs would want midwives to give
vaccinations and heard yes especially as patients were now being encouraged
to use the service as their first and only port of call on becoming pregnant. A
member asked if there were different immunisation uptake rates in GG&C as
midwives were still based in Clyde practices and the hub and spoke model
operated in Greater Glasgow and heard this information could be got.
Another member asked if patients had to have their booking scans at the
ACAD and heard there was scanning available in the Royal Alexandra
Hospital, Southern General and Princess Royal Maternity. The same member
asked if there was any scanning carried out in the hubs and heard no although
there may be some available at the Vale of Leven. Members wondered if
immunisations could not be given at the same time that scans were
undertaken.
Members commented that the list of site closures looked like a who’s who of
deprivation and noted that patients in Clydebank and Drumchapel would have
major transport difficulties to attend the Southern General. Another difficulty
highlighted was patients never bringing their ante-natal booklet when
attending their GP and it was suggested that midwives should remind patients
of the importance of doing this. A further member suggested that if work was
on-going to produce an electronic patient record then linkage to GP systems
also needed to be included in that piece of work. Ms McLauchlan thought that
should happen regardless. A member asked if there would be an opportunity
when the final draft recommendation paper goes to the Board for it to come
back to the GP Subcommittee for discussion and heard that it would be
brought back to the GP Subcommittee when it goes to the Clinical Directors.
A member commented on the loss of clinician to clinician communication
now that patients are advised to simply phone the midwife service. He
expressed his disappointment at the loss face to face contact with midwives
since they were removed from his practice. Members heard it was important
for the service to keep lines of communication open.
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Ms McLauchlan took the opportunity to flag up that Termination of Pregnancy
(ToP) referrals will now go to the Sandyford from 1st August.
The Chairman thanked Ms McLauchlan for attending and advised that the GP
Subcommittee looked forward to commenting further on the final draft of the
Service Redesign paper.
Ms McLauchlan left the meeting at this point.
The Chairman asked if anyone had any further comments on this issue before
moving to next business. A member agreed it was a good opportunity to
compare the immunisation and adverse events rates between the current
practices based service in Clyde and the Hub and Spoke service in Greater
Glasgow. It was agreed that this would be taken back to the next HEAT
Maternity Services meeting.
Action: Make enquiries about immunisation and adverse event rates between
the two service models.
Subsequent to meeting this was discussed at the AMC on Friday 21st August
and rather than wait for draft final recommendations it was decided to write
to the HEAT Target Subgroup: Maternity Services – Hub and Spoke Redesign
summarising GP Subcommittee concerns.
(b) District Nursing (DN) Service and DMARD Phlebotomy
The GP Subcommittee heard that the Board was of the opinion that if the DN
service carried out DMARD bloods then this service should continue. The
same applied to treatment rooms. Members noted that managers could not
simply withdraw services already agreed. A member was unsure whether this
message had been sent out to the DN service by the Board.
Action: Newsletter article to be drafted.
DOCUMENTS
REQUIRING A
RESPONSE 15/110
(a) Administration of Subcutaneous Fluids in Care Homes which
Provide Nursing: A Guideline for NHS Staff and Care Home
Registered Nurses
The GP Subcommittee received and commented on draft guidelines on the
Administration of Subcutaneous Fluids in Care Homes which Provide
Nursing, copies of which were emailed and tabled.
The GP Subcommittee heard that this had been a work in progress for about a
year and was seen as a short guidance document. Members heard that the
main concern was that by having a policy it might make GPs think that this is
something they have to do but this was not the case and in the main provision
of subcutaneous fluids would be the responsibility of care home nurses.
Members noted there had been some concern about any impact out of hours
(OOHs) but that OOHs are not generally involved in this.
A member thought that nursing homes might try to ‘bully’ GP into doing this
work. However, another member with substantial experience in nursing
homes care stated that in his experience nursing home staff training was very
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good and this should have very little impact on attending GPs. Members
heard that subcutaneous fluid should only be used in patients who have been
identified as having a high risk of hospital admission and that when used
appropriately it would benefit those patients most at risk of (and hopefully
stop) hospital admission. A member reiterated that the use of subcutaneous
fluids should only be considered in an acute situation and should not continue
for longer than 48hours. He noted that it has to be for acutes episodes only
and this was not stipulated in the guidance document.
A member who worked in OOHs was concerned that there was the possibility
that this could impact on OOHs regardless. Members heard that since the
transfer to a Local Enhanced Service for Nursing Homes over 6500 patients
were waiting to be assessed for their Key Information Summaries (KIS).
Another member thought that GPs need to be careful what there were
agreeing to. Another member was happy with appendix 2 as it laid out the
legislative responsibility of care homes as employers.
Action: Medical Secretary to respond on behalf of the GP Subcommittee.
(b) Pre-operative Anaemia in Orthopaedic Patients
The Committee received and commented on the Pre-operative Anaemia in
Orthopaedic Patients documents together with an extract of the draft GP
Subcommittee Executive minute of 1st June 2015 on these documents, copies
of which were emailed and tabled.
The GP Subcommittee heard that Orthopaedics would like pre-operative
anaemia to be picked up and dealt with at an earlier stage. However there
were workload implications for GPs should this work be passed from
Secondary Care. Members queried why patients had to be referred back to
their GP and wondered why the service could not do the necessary tests (TFTs
and Paraproteins) when the patient was in front of them. Another member
wondered if there was the possibility of DMARD type funding being found
for this additional work and heard there was not. Another member thought it
would be appropriate for patients to come back to GPs for their anaemia to be
managed. However another member felt that GPs should decide what
appropriate tests were needed and not be directed by the service.
Action: Medical Secretary to respond on behalf of the GP Subcommittee.
(c) Heart MCN Hypertension Guideline
The Committee received and commented on the Heart MCN Hypertension
Guideline together with an extract of the draft GP Subcommittee Executive
minute of 1st June 2015 on this guidance, copies of which were emailed and
tabled.
The GP Subcommittee supported the Executive Committee agreement in
principle as detailed below.
“The Executive agreed in principle to the promotion of home monitoring over
ambulatory but would need to review home ambulatory guidance before final
decision could be made”.
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(d) Novel Oral Anticoagulants (NOACS) and Response from Dr Jennifer
Armstrong, Clinical Director NHS GG&C
The GP Subcommittee received and commented on Dr Armstrong’s response
regarding the introduction of NOACs in Primary Care, copies of which were
emailed and tabled.
The GP Subcommittee welcomed agreement for a GP Subcommittee
Representative to the Medicines Utilisation Prescribing Education Committee.
Members heard that, in light of the difficulties around NOAC introduction, GP
representatives on Area Drug Therapeutic and Prescribing Committees need to
have a high level of awareness of how the introduction of new drugs might
have an impact on Primary Care services. It was suggested that GP
representatives on these committees should raise any concerns as soon as
possible with the GP Subcommittee, especially if it appeared GP concerns
were being overridden or not taken into account in other fora.
A member asked about the use of creatine clearances in NOAC prescribing
decisions and the difficulty GPs faced trying to work it out. A member
pointed out that there was a need to establish where responsibility lay as many
clinicians were unfamiliar with creatine clearance and felt that this needed to
be addressed as there may well be a significant number of patients on the
wrong dosage as a result. The member felt this was an issue that affected both
Primary and Secondary Care. Another member told the GP Subcommittee
that the anticoagulation issue was still not resolved and that it had now been
taken to a higher level as it was becoming clear that the Board needed to
establish an anti-coagulation service rather than simply a warfarin monitoring
service. The GP Subcommittee also heard that Apixaban had now been
passed for long term use in place of warfarin and that could also potentially
impact on General Practice. Members thought that the NOAC guidance
issued was not helpful and needed to be redressed as there were a number of
issues arising especially around monitoring and dosage as new information
about these drugs emerged.
Action: Contact Drs Campbell Tait, David Stewart and Ronnie Burns
regarding the guidance around Apixaban and other NOACs.
GP
REPRESENTATION
REQUIRED:15/111
(a) Medicine Utilisation Prescribing Education Subcommittee of the
ADTC
Dr Raymund White was nominated as GP Subcommittee representative to this
group.
NOTES AND
REPORTS OF
MEETINGS (FOR
COMMENT) 15/112
(a) Report of the Medical Cause Certificate of Death (MCCD) Local
Implementation meeting held on Tuesday 26th May 2015
The GP Subcommittee received and noted the report of the MCCD Local
Implementation meeting held on Tuesday 26th May 2015, copies of which
were emailed and tabled.
(b) Report of the Referral Management Group (RMG) meeting held on
Tuesday 2nd June 2015
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The GP Subcommittee received and commented on a report of the RMC
meeting held on Tuesday 2nd June 2015, copies of which were emailed and
tabled.
Termination of Pregnancy and Referrals to Sandyford
The GP Subcommittee noted that the referral pathways would remain the same
but that the first appointment would be with Sandyford Central. Members
queried why a GP referral was now being included as the service had always
been open access. A member thought this was a good suggestion as it would
allow the safe transfer of information especially where a patient may be
vulnerable. Members heard this was about making the service more equitable
with more patients being seen earlier and undergoing medical termination
rather than surgical, which was better for the patient. The change would only
apply to Glasgow City.
However another member thought that local hubs would be more appropriate
and was especially concerned about travel links to Sandyford Central for
vulnerable patients. Another member told the GP Subcommittee that the
service that the Sandyford was working very hard to equalise its service and
give the same level of care to all patients which this change would do.
Members heard that patients would have one appointment at Sandyford central
and then an appointment for termination which would take place locally.
Action: RMG representative to respond on behalf of the Committee.
Child Vulnerability and Paediatric Referrals
The GP Subcommittee supported the inclusion of child vulnerability and child
protection fields in line with those currently on Obstetrics referrals.
Action: RMG representative to respond on behalf of the Committee.
Orthotics Service
Members noted that it was proposed that from September 2015, AHPs will be
able to refer patients directly to the Orthotics Service and that from early 2016
patients already known to the service will be able to self-refer. This removes
the need for further GP involvement.
Action: newsletter article welcoming the proposed changes.
(c) Report of the GMS IM&T Committee meeting held on Thursday
28th May 2015
The GP Subcommittee received and noted a report of the GMS IM&T meeting
held on Thursday 28th May 2015 together with an extract of the draft GP
Subcommittee Executive minute of 1st June 2015, copies of which were
emailed and tabled.
NOTES AND
REPORTS OF
MEETINGS (FOR
(a) Report of the Area Medical Committee meeting held on Friday 15th
May2015
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INFO): 15/113
The GP Subcommittee received and noted a report of the Area Medical
Committee meeting held on Friday 15th May 2015, copies of which were
emailed and tabled.
(b) Report of the Glasgow Royal Infirmary (GRI) ‘on the move’ meeting
held on Tuesday 5th May 2015
The GP Subcommittee received and noted a report of the GRI ‘on the move’
meeting held on Tuesday 5th May 2015, copies of which were emailed and
tabled.
(c) Report of the Area Drugs and Therapeutics Committee (ADTC)
Polypharmacy Subcommittee meeting held on Wednesday 20th May
2015
The GP Subcommittee received and noted a report of the ADTC
Polypharmacy Subcommittee meeting held on Wednesday 20th May 2015,
copies of which were emailed and tabled.
(d) Report of the Primary Care Prescribing Management meeting held
on Thursday 21st May 2015
The GP Subcommittee received and noted a report of the Primary Care
Prescribing Management meeting held on Thursday 21st May 2015 together
with an extract of the draft GP Subcommittee Executive minute of 1st June
2015, copies of which were emailed and tabled.
CHANGES TO THE
MEDICAL LIST 15/114
(a) Inclusions, Mergers, Resignations and Retirements
The GP Subcommittee received and noted the list of changes to the Medical
List to 15th June 2015.
H.S.C.I.
(a) HSCI Partnerships and GP Forums
PARTNERSHIPS 15/115
The GP Subcommittee was told that the joint Locality Lead and GP
Subcommittee/LMC meeting on Wednesday 3rd June 2015, had gone very
well and the group was keen to continue meeting every few months.
(b) Cross Border Community Nursing Services
The GP Subcommittee received and commented on a communication from
NHS Lanarkshire and NHS GG&C to all GPs with patients now registered in
NHS Lanarkshire regarding Cross Boundary District and Community Nursing
Services together with an extract of the draft GP Subcommittee Executive
minute of 1st June 2015, copies of which were emailed and tabled, copies of
which were emailed and tabled.
A member whose practice had cross border patients advised that the practice
had yet to receive a communication or guidance on how to contact nursing
services in NHS Lanarkshire. The GP Subcommittee heard there was concern
especially around childhood immunisation and where children would be
immunised and communications with practices. Members were told that
practices need contact details and good communication links with
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Lanarkshire. Members were told that cross border practices should be given
health visitor information when the move was complete.
Action: Write to Mr Sloey; NHS Lanarkshire and Ms Renfrew; NHS GG&C
outlining GP Subcommittee concerns.
ITEMS FOR THE AMC
AGENDA: 15/116
There were no additional items for the AMC.
AOCB: 15/117
There was no further competent business.
DATE OF NEXT
MEETING
The date of the next meeting of the GP Subcommittee is Monday 21st
September 2015.
GP Subcommittee business was conferred to the Executive for the summer
recess.
The date of the next Executive is Monday 29th June 2015.
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