Royal College of General Practitioners
Other
Action Planned
The RCGP and Royal Pharmaceutical Society will convene a multi-stakeholder group and establish a joint working group, including patients, to explore recommendations and develop a work program focused on shared standards, education and training. (AI summary)
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Dear Ms Henderson Inquest into the death of Lee Hollman RCGP response Thank you for your letter seeking comments from the Royal College of General Practitioners on factors relating to general practitioner care following the inquest you conducted into the death of Lee Hollman: On behalf of the College, set out below a brief description of the remit of the Royal College of General Practitioners. also provide some detailed comment on the specific concerns you raise in your report with regard to systems within a general practice for managing and monitoring the practice s interface with external organisations, records management and communications with colleagues The role_ofthe College The Royal College of General Practitioners is a registered charity under Royal Charter and is the largest membership organisation in the United Kingdom solely for GPs_ Founded in 1952_ it has approaching 50,000 members who are committed to improving patient care; developing their own skills and promoting general practice as a discipline_ We are an independent professional body with enormous expertise in patient-centred generalist clinical care. Through our General Practice Foundation, established by the RCGP in 2009, we also maintain close links with other professionals working in General Practice, such as practice managers, practice nurses and physician assistants. As well as running the postgraduate Membership examination (MRCGP) which is now required for doctors to qualify as GPs, the College also provides continuing professional development (CPD) for its members, and these continuing programmes are also available to non-members of the College_ However; not all GPs are members of the College, and older GPs may never have joined, The General Medical Council holds the register of all who are considered able to practise as GPs, and it is to the GMC that revalidated doctors will be notified: Similarly, it is not for us to comment on the performance of any individual GP and the information set out below is solely to show you what we do in the context of training and advice to our Members Royal College of Oenoral Practitlonere 30 Eueton Squaro London NWI 2Fp Tol 020 3180 7400 Fax 020 3108 7401 Emall Info@redp org uk Wob WWW regp org Uk Patron; Hls Royal Highness Ihie Duke 0f Edlinburgh Regletered charity number 223100
RCGP Education and Training Currently all doctors wishing to follow a career in general practice in the UK are required to undergo a 3 year programme of vocational training for general practice, based on the College's GP Curriculum: (The curriculum forms the foundation for GP training and assessment across the UK, prior to taking the College's Membership Examination (MRCGP) and is relevant to GPs throughout their career; including preparation for revalidation) http IIWWW rogp org Uklgp training-und- exams/gp curriculum_ overview aspX The death of Lee Hollman raises issues about the need for strictly accurate medical record-keeping in GP practices, GP workload, the need for close working relationships between GPs and pharmacists and the duty of the doctor to conduct regular medication reviews with patients as part of a sound practice repeat prescribing system. Best practice calls for patients with long-term conditions to be given medication review appointments at regular six-monthly or yearly intervals_ Record-keeping Addressing your concern about failures in maintaining accurate and updated medical records and, more specifically the failure to remove Trazodone from the repeat prescription record and the failure to delete the the 'old' dosage of Quetiapine from the record, the importance of accurate record- keeping is stressed in the section of The Curriculum entitled "Being a General Practitioner' http Ilwww rcgporg:uklgp-training-and-exams/~ImedialFiles/GP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-1-Being-a-GP ashx "This means that as a GP you should:
1.1.3 Use an organised approach to the management of chronic conditions
1.5 Make available to your patients the appropriate services within the healthcare system This means that as a GP you should:
1.5.2 Develop your organisational skills for record-keeping, information management;, teamwork, running practice and auditing the quality of care" The importance of record-keeping in the practice is further developed in the section entitled "Patient safety and quality of care" where you will also see highlighted the importance of close collaboration medical colleagues and other healthcare professionals http IlwwW rcgp.org uklgp-training-and-exams/~ImedialFilesIGP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-2-02-Patient-Safety-and-Quality-Of-Care ashx refer you to page 9 in particular: "1.13 Demonstrate an understanding of the connection between good data entry and improved patient health outcomes
1.14 Demonstrate how to use information management and technology (IM&T) to share information and co-ordinate patient care with other health professionals
1.15 Demonstrate an understanding of the need for information recorded in the practice clinical system to be fit for sharing with different health professionals in different organisations
1.23 Understand the concept of variation in clinical care, how it is determined and measured and what actions might need to be taken to address inappropriate variation, for example in referrals, prescribing, admissions
1. 30 Demonstrate an understanding of the principles of medicines management" Pages 10 and 11 further develop this theme: "This means that as a GP you should:
3.1 Compare the systems and processes in place in your practice to identify and manage risk in the primary care setting and compare these with other practices
3.3 Be aware of the limitations of your own skills in risk management and illustrate that you understand when the skills of colleagues trained more extensively in risk management should be called upon Royal Collere of General Praclillonere 30 Eubton Square London NWI 2FB Tol 020 3188 7400 Fax 020 3100 7401 Emall Info@regp Org uk Wob WWW rCOP,Ord Uk Patron: Hie Royel Highness (he Duke 0f Edlinburgh Registered eharity number 223/00 key with
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4.2 Reflect on the risks to patient safety in a care pathway in which a variety of healthcare professionals are involved, looking at interface issues and be able to comment on the ways in which, as a GP, you can work to minimise these' Other sections of The GP Curriculum of particular relevance in this case are given below: "3.10 Care of people with mental health problems http Ilwww rcgporg uklgp-training-and-exams/~ImedialFiles/GP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-3-10-Mental-Health-Problems.ashx" This section includes the need for the general practitioner to be able to assess and manage risklsuicidal ideation.
3.14 Care of people who misuse drugs and alcohol Section 3.14 of the GP Curriculum on the Care of people who misuse drugs and alcohol, whilst not directly relevant; highlights some interesting points about GP awareness of prescribing problems http Ilwww rcgporg uklgp-training-and-exams/~ImedialFilesIGP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-3-14-Drug-and-Alcohol-Misuse.ashx" In particular, the general practitioner should: "3.1 Always be aware of possible drug- or alcohol-related problems with almost any presenting problem or prescribing issue
3.4 Be aware of common long-term effects of drug and alcohol misuse including reasons for drug- related deaths
3.6 Be aware of urgent and important issues of safety including risks to self or others and the need for urgent medical or psychiatric care Relationship between GPs and Pharmacists The tragic death of Lee Hollman highlights the need for GPs and Pharmacists to work closely together. At its meeting on 18 June 2011, the RCGP Council approved a joint statement drawn up by RCGP members and the members of the Royal Pharmaceutical Society setting out guidelines for good working relationships between GPs and pharmacists: A copy is attached to this letter as an appendix You will see from the paper that one of the "building blocks for change" suggested is: Better transfer and sharing of patient information facilitated by improved inter-professional IT links_ Repeat Prescribing Guidance for doctors, including general practitioners, on repeat prescribing is set out in the GMC's document: Good practice in prescribing and managing medicines and devices (2013)" http /Lwwwsgme-ukorg/guidancelethical_guidance/ L43 "Prescribing guidance: Repeat prescribing and prescribing with repeats" http:/Iwwwemc-ukog/guidancelethical_guidance/ L4325a8p Relevant extracts are set out below: "55_ You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues so you must make sure that any repeat prescription you sign is safe and appropriate You should consider the benefits of prescribing with repeats to reduce the need for repeat prescribing: Royal Collede of General Pracllllonere 30 Euston Square London NWA 2FB Tel 020 3180 7400 Fax 020 3188 7401 Emall Info@regp org Uk Wob WWW rCOP Ord Uk Patron: Hie Royal Highnegs the Duke of Edinburgh Rogieterod charity number 223100
16.asp
56 As with any prescription, you should agree with the patient what medicines are appropriate and how their condition will be managed, including a date for review: You should make clear why regular reviews are important and explain to the patient what they should do if
a. suffer side effects or adverse reactions, or
b. stop taking the medicines before the agreed review date (or a set number of repeats have been issued) You must make clear records of these discussions and your reasons for repeat prescribing 57 . You must be satisfied that procedures for prescribing with repeats and for generating repeat prescriptions are secure and that:
a. the right patient is issued with the correct prescription
b. the correct dose is prescribed, particularly for patients whose dose varies during the course of treatment
c. the patient's condition is monitored, taking account of medicine usage effects
d. only staff who are competent to do so prepare repeat prescriptions for authorisation patients who need further examination or assessment are reviewed by an appropriate healthcare professional
f. any changes to the patient's medicines are critically reviewed and quickly incorporated into their record_
58. At each review, you should confirm that the patient is their medicines as directed, and check that the medicines are still needed, effective and tolerated. This may be particularly important following a hospital stay, or changes to medicines following a hospital or home visit: You should also consider whether requests for repeat prescriptions received earlier or later than expected may indicate poor adherence, leading to inadequate therapy or adverse effects_ 59_ When you issue repeat prescriptions or prescribe with repeats, you should make sure that procedures are in place to monitor whether the medicine is still safe and necessary for the patient: You should keep a record of dispensers who hold original repeat dispensing prescriptions so that you can contact them if necessary. hope you find these comments helpful.
RCGP Education and Training Currently all doctors wishing to follow a career in general practice in the UK are required to undergo a 3 year programme of vocational training for general practice, based on the College's GP Curriculum: (The curriculum forms the foundation for GP training and assessment across the UK, prior to taking the College's Membership Examination (MRCGP) and is relevant to GPs throughout their career; including preparation for revalidation) http IIWWW rogp org Uklgp training-und- exams/gp curriculum_ overview aspX The death of Lee Hollman raises issues about the need for strictly accurate medical record-keeping in GP practices, GP workload, the need for close working relationships between GPs and pharmacists and the duty of the doctor to conduct regular medication reviews with patients as part of a sound practice repeat prescribing system. Best practice calls for patients with long-term conditions to be given medication review appointments at regular six-monthly or yearly intervals_ Record-keeping Addressing your concern about failures in maintaining accurate and updated medical records and, more specifically the failure to remove Trazodone from the repeat prescription record and the failure to delete the the 'old' dosage of Quetiapine from the record, the importance of accurate record- keeping is stressed in the section of The Curriculum entitled "Being a General Practitioner' http Ilwww rcgporg:uklgp-training-and-exams/~ImedialFiles/GP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-1-Being-a-GP ashx "This means that as a GP you should:
1.1.3 Use an organised approach to the management of chronic conditions
1.5 Make available to your patients the appropriate services within the healthcare system This means that as a GP you should:
1.5.2 Develop your organisational skills for record-keeping, information management;, teamwork, running practice and auditing the quality of care" The importance of record-keeping in the practice is further developed in the section entitled "Patient safety and quality of care" where you will also see highlighted the importance of close collaboration medical colleagues and other healthcare professionals http IlwwW rcgp.org uklgp-training-and-exams/~ImedialFilesIGP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-2-02-Patient-Safety-and-Quality-Of-Care ashx refer you to page 9 in particular: "1.13 Demonstrate an understanding of the connection between good data entry and improved patient health outcomes
1.14 Demonstrate how to use information management and technology (IM&T) to share information and co-ordinate patient care with other health professionals
1.15 Demonstrate an understanding of the need for information recorded in the practice clinical system to be fit for sharing with different health professionals in different organisations
1.23 Understand the concept of variation in clinical care, how it is determined and measured and what actions might need to be taken to address inappropriate variation, for example in referrals, prescribing, admissions
1. 30 Demonstrate an understanding of the principles of medicines management" Pages 10 and 11 further develop this theme: "This means that as a GP you should:
3.1 Compare the systems and processes in place in your practice to identify and manage risk in the primary care setting and compare these with other practices
3.3 Be aware of the limitations of your own skills in risk management and illustrate that you understand when the skills of colleagues trained more extensively in risk management should be called upon Royal Collere of General Praclillonere 30 Eubton Square London NWI 2FB Tol 020 3188 7400 Fax 020 3100 7401 Emall Info@regp Org uk Wob WWW rCOP,Ord Uk Patron: Hie Royel Highness (he Duke 0f Edlinburgh Registered eharity number 223/00 key with
Page 11:
4.2 Reflect on the risks to patient safety in a care pathway in which a variety of healthcare professionals are involved, looking at interface issues and be able to comment on the ways in which, as a GP, you can work to minimise these' Other sections of The GP Curriculum of particular relevance in this case are given below: "3.10 Care of people with mental health problems http Ilwww rcgporg uklgp-training-and-exams/~ImedialFiles/GP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-3-10-Mental-Health-Problems.ashx" This section includes the need for the general practitioner to be able to assess and manage risklsuicidal ideation.
3.14 Care of people who misuse drugs and alcohol Section 3.14 of the GP Curriculum on the Care of people who misuse drugs and alcohol, whilst not directly relevant; highlights some interesting points about GP awareness of prescribing problems http Ilwww rcgporg uklgp-training-and-exams/~ImedialFilesIGP-training-and-exams/Curriculum- 2012/RCGP-Curriculum-3-14-Drug-and-Alcohol-Misuse.ashx" In particular, the general practitioner should: "3.1 Always be aware of possible drug- or alcohol-related problems with almost any presenting problem or prescribing issue
3.4 Be aware of common long-term effects of drug and alcohol misuse including reasons for drug- related deaths
3.6 Be aware of urgent and important issues of safety including risks to self or others and the need for urgent medical or psychiatric care Relationship between GPs and Pharmacists The tragic death of Lee Hollman highlights the need for GPs and Pharmacists to work closely together. At its meeting on 18 June 2011, the RCGP Council approved a joint statement drawn up by RCGP members and the members of the Royal Pharmaceutical Society setting out guidelines for good working relationships between GPs and pharmacists: A copy is attached to this letter as an appendix You will see from the paper that one of the "building blocks for change" suggested is: Better transfer and sharing of patient information facilitated by improved inter-professional IT links_ Repeat Prescribing Guidance for doctors, including general practitioners, on repeat prescribing is set out in the GMC's document: Good practice in prescribing and managing medicines and devices (2013)" http /Lwwwsgme-ukorg/guidancelethical_guidance/ L43 "Prescribing guidance: Repeat prescribing and prescribing with repeats" http:/Iwwwemc-ukog/guidancelethical_guidance/ L4325a8p Relevant extracts are set out below: "55_ You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues so you must make sure that any repeat prescription you sign is safe and appropriate You should consider the benefits of prescribing with repeats to reduce the need for repeat prescribing: Royal Collede of General Pracllllonere 30 Euston Square London NWA 2FB Tel 020 3180 7400 Fax 020 3188 7401 Emall Info@regp org Uk Wob WWW rCOP Ord Uk Patron: Hie Royal Highnegs the Duke of Edinburgh Rogieterod charity number 223100
16.asp
56 As with any prescription, you should agree with the patient what medicines are appropriate and how their condition will be managed, including a date for review: You should make clear why regular reviews are important and explain to the patient what they should do if
a. suffer side effects or adverse reactions, or
b. stop taking the medicines before the agreed review date (or a set number of repeats have been issued) You must make clear records of these discussions and your reasons for repeat prescribing 57 . You must be satisfied that procedures for prescribing with repeats and for generating repeat prescriptions are secure and that:
a. the right patient is issued with the correct prescription
b. the correct dose is prescribed, particularly for patients whose dose varies during the course of treatment
c. the patient's condition is monitored, taking account of medicine usage effects
d. only staff who are competent to do so prepare repeat prescriptions for authorisation patients who need further examination or assessment are reviewed by an appropriate healthcare professional
f. any changes to the patient's medicines are critically reviewed and quickly incorporated into their record_
58. At each review, you should confirm that the patient is their medicines as directed, and check that the medicines are still needed, effective and tolerated. This may be particularly important following a hospital stay, or changes to medicines following a hospital or home visit: You should also consider whether requests for repeat prescriptions received earlier or later than expected may indicate poor adherence, leading to inadequate therapy or adverse effects_ 59_ When you issue repeat prescriptions or prescribe with repeats, you should make sure that procedures are in place to monitor whether the medicine is still safe and necessary for the patient: You should keep a record of dispensers who hold original repeat dispensing prescriptions so that you can contact them if necessary. hope you find these comments helpful.