Uncategorized – Gerard Bulger

General Medical Services, Primary Medical Services, APMS and the “Undifferentiated GP” Problem

The starting point is probably not the performers list, nor appraisal, but the statutory idea of general medical services.

Under the National Health Service Act 2006, a general medical services contract is a contract under section 84 for the provision of primary medical services. Section 85 then requires a GMS contract to include prescribed primary medical services. Those prescribed services are found principally in the NHS (General Medical Services Contracts) Regulations 2015, especially regulation 17, dealing with “essential services”. Regulation 17 describes essential services in broad patient-facing terms. A contractor must provide services for the management of registered patients and temporary residents who are, or believe themselves to be, ill, terminally ill, or suffering from chronic disease. “Management” includes consultation, examination where appropriate, identifying the need for treatment or investigation, providing treatment or investigation where necessary and appropriate, referral, and liaison with other healthcare professionals.

This is the closest statutory foundation for the idea that NHS general practice is broad, first-contact, generalist work. It is not narrow specialist practice. It is concerned with patients who may present with almost anything, including early, unclear, or non-specific illness. That is where NHSE can plausibly find the conceptual root of “undifferentiated” general practice. But the statute does not itself use the term undifferentiated GP, and it does not define a GP by an obligation to maintain active competence in every possible domain of community general practice. The duty in regulation 17 is framed primarily on the contractor or practice, not on each individual doctor personally. A practice must provide the service. The individual doctor must work safely within competence and within the contractual and governance arrangements of the service.

The performers list legislation then sits on top of this. The NHS (Performers Lists) (England) Regulations 2013 define a “general medical practitioner” as a registered medical practitioner who is either a GP registrar or whose name is included in the GP Register. Regulation 24 says, broadly, that a doctor may not perform primary medical services unless they are a general medical practitioner included in the medical performers list, subject to exceptions. So the performers list does not define a GP by “undifferentiated” scope. It defines eligibility by GP Register status, licence, registration, and inclusion on the list. The work protected by the list is primary medical services.

That matters because primary medical services are wider than GMS. They may be delivered under GMS, PMS, APMS, section 92 arrangements, and other arrangements under Part 4 of the 2006 Act. The performers list regulations expressly recognise this. They define an APMS contract as an arrangement under section 83(2) of the 2006 Act for the provision of primary medical services. They also require the medical performers list to record whether a doctor provides primary medical services under, or pursuant to, an APMS contract.

That is fatal to any simplistic argument that APMS work is somehow not GP work or not primary medical services. A doctor working under an APMS contract may not be providing “general medical services” in the strict contractual sense, because GMS means a section 84 GMS contract. But they may very much be providing NHS primary medical services and, in ordinary clinical language, GP-type work.
This is important for prison doctors. A prison GP working under an APMS contract may have a restricted patient population. For example, they may not treat children, pregnant women, or the full demographic range seen in community general practice. NHSE may label that “differentiated” because the scope is narrower than full community general practice. That label is not wholly irrational. Prison practice is a specialised setting. It has a defined population, particular clinical risks, and areas of GP work that may be absent.

But the legal conclusion does not automatically follow. A prison APMS GP is still capable of providing primary medical services. The question is not whether the doctor is identical to a community GMS GP. The question is whether the doctor is safe, current, and fit to practise within their actual scope, and whether they are performing services of the kind relevant to inclusion on the performers list.
The RCGP and GMC material helps explain the professional background. The RCGP curriculum describes the GP as a generalist, dealing with complexity, uncertainty and risk, and addressing early undifferentiated presentations (which in any case prison GPs have to do). That could be seen to support the idea that undifferentiated work is part of the core identity of general practice at qualification. But it remains curriculum and professional language. It does not by itself create a statutory condition that every doctor on the performers list must personally maintain full undifferentiated community GP scope.

The NHSE low-volume guidance is the most relevant document I found. It concerns doctors on the NHS England Medical Performers List undertaking a low volume of NHS GP clinical work, defined as fewer than 40 sessions per year. It says that fewer than 40 sessions should trigger structured reflection and discussion at appraisal. It asks whether the doctor’s work is general undifferentiated GP work or a more differentiated role. It treats restricted scope as a possible risk factor, especially because loss of a skill set through restricted practice may affect future decisions about scope.

However, the same guidance is careful. It says the 40-session figure is a benchmark, not a pass/fail test. It is a trigger for reflection and discussion. It says doctors doing 40 sessions or more do not need extra reflection purely because of volume, but it does not say doctors doing fewer than 40 must be removed or must complete 40 ordinary community sessions.

The structured reflective template is even more useful. Its stated aim is to allow doctors to demonstrate that they are safe, up to date and fit to practise at what they do, particularly if they have an unusual or restricted scope of practice, or do a low volume of a particular scope of work. That phrase, “at what you do”, is central. It supports reflection on actual scope. It does not support forced reflection on imaginary or unwanted work outside scope.

NHSE can say that full-scope community general practice is broad, generalist and often undifferentiated. It can say that a doctor whose work is restricted, such as a prison APMS GP who does not see children, should reflect on the risks of deskilling and the implications for any future return to unrestricted community GP work. It can require annual appraisal, supporting information, and reflection across the doctor’s whole actual scope of practice.

NHSE does ask for reflection where a doctor’s work is low-volume or restricted in scope, but any such request must be grounded in the doctor’s actual scope of practice and cannot convert full-time specialised/APMS primary medical work into ‘low-volume’ work merely by excluding it from NHSE’s preferred concept of undifferentiated community GP.”

I have not found authority for the proposition that such a doctor must perform 40 sessions of ordinary non-specialised NHSE community general practice. Nor have I found authority for a requirement that the doctor must keep up skills in areas outside their declared and actual scope, such as paediatrics, if they do not treat children. Nor have we found authority for requiring a doctor to create a personal development plan to become “undifferentiated” where their actual work is safely and lawfully differentiated.

The proper distinction is between current scope and future scope.
For current prison APMS work, the doctor should demonstrate fitness, CPD, governance, feedback, significant events, complaints, peer benchmarking, and safe practice within prison primary care. If they do not treat children, they should not pretend to maintain paediatric competence as though they do. They can instead state that paediatrics is outside their current scope.

For future unrestricted community GP work, it is reasonable to acknowledge that a return would require appropriate updating, supervision, induction, refresher work, or staged re-entry. That is a safety position, not a concession of current inadequacy. This is the same for any doctor wishing to change his scope of practice and we would reflect that in our CPD

A GP must:

• engage with annual appraisal
• provide supporting information across their actual scope
• demonstrate they are safe, up to date and fit to practise in what they do
• reflect honestly on significant changes or limits in scope
• not misrepresent competence in areas they do not practise

But they do not to have to:

• accept NHSE’s “undifferentiated” label as a legal category
• treat full-time prison GP work as low-volume GP work
• complete a “low volume” template if the factual premise is wrong
• make a PDP to maintain or regain skills outside their intended scope
• perform 40 sessions of ordinary community general practice if they do not intend to practise ordinary community general practice

The relection can be this

“I have reflected on my actual scope. My current scope is full-time prison/APMS primary medical care. I do not practise unrestricted community general practice and do not currently intend to do so. I therefore maintain competence, CPD, governance and appraisal evidence for my actual scope. If I later wished to move into unrestricted community GP work, I accept that I would need appropriate updating and reflect this in my CPD. I do not accept that I am required to maintain competence in areas outside my current and intended scope.”

Summary

Primary medical services are broad enough to explain how NHSE values undifferentiated generalist capability. But neither GMS law, APMS law, performers list law, nor the low-volume appraisal guidance can impose a freestanding duty on every GP to maintain full undifferentiated community GP practice regardless of actual scope. A prison APMS GP may be differentiated in the descriptive sense, but the lawful appraisal question is whether they are safe, up to date and fit to practise at what they do, and what safeguards would be needed before moving into a broader or unrestricted role.

See more at https://bulger.co.uk/blogs/?p=266

Junk is stuff in the wrong place

I was back down working in the Falklands in 2020. Behind the house was a yard with local TV tower with assorted radio junk scattered about. I was sure cared for and some is in locked containers, perhaps to be shipped back one day. It belongs to KTV Falklands Digital Channel https://en.wikipedia.org/wiki/KTV_Ltd. Later of course once out of Covid isolation, I met its owner Mario, VP8EME. In such Isolation, with no RS store or Amazon to deliver the next day, he needs to keep stuff.

To any amateur radio operator this would have seemed mouth watering stuff. Rows of parabolic dishes, some with various transponders still attached. Then power supplies, heat sinks, cables.

I suspect the reason for apparent discarding is that there now decent internet here via satellite, 4g mobile phones, a few free TV stations and more if you pay a fee to KTV. So individual dishes are no longer needed. There are issues with the local telecoms monopoly…even bringing down your out Satellite Phone with data is illegal, let alone setting up your own satellite data dish. All about those problems and more is on https://openfalklands.com

Upgrades to the telephone system filled the yard with even more stuff. BAS seems to have left a container here once used for HF coms.

Enough here to build a few antenna towers. Then there coils of fat low loss coax piled up. I assume too expensive to ship any of it back to the UK so it sits here waiting to be used, but I imagine the next project here would bring in new materials. This stuff is the wrong place. I assumed parts would be used and appreciated by many back home.

In memoriam: Looking at some of the old kit I appreciated the work and engineering involved in creating it within the last 30 years. Unless you build a cathedral everything we do is ephemeral. Much of this was so beautifully made with professional screening of parts, solid aluminium casing. A lot of thought and brain power, time and care went into each part, now not used. A graveyard of effort. Some of the boards have rows for Z80 chips which were used until quite recently, even a 555s.

Then I realised that even for hams and electronic enthusiasts little of all this is of use to us nowadays. It’s frankly simpler to write line of code into a computer than it is to make stuff. So we use the internal complexity of millions of transistors in a PC chip to achieve something that could be achieved in “simpler” manner by old school working.

Waveform Old school with op amps and 555 chips

Waveform Generator using Raspberry Pi

But the old school in inflexible. Once made with wires and components it does its one thing. A Raspberry pi is cheap and light. Make an error reformat and start again. Reliable too. I had one doing its thing as router/VPN for over year without a reboot.

Some of this stuff here could be used for interfacing, a PC’s output need to attach to something in the end.

VP8DPD G3WIP

Doctors Cause Crime

Prison Healthcare

There has an exponential in the use of gabapentin and pregabalin medication amongst prisoners over the last decade. These drugs are now almost exclusively used by those with other dependencies in prisons. During this time of increasing use of these gabapentinoids and other prescribed medications, we saw an increase of violence in prisons. This violence may not be due to illicit Spice use and reductions in the number of security staff.

I am the suspicious that us doctors may not be doing any good. Doctors do not have any medication to treat crime, but our best of intentions may now be causing criminal side effects.

Many of my prisoner patients have recognised themselves in the following scenario:

You have a criminal tendency, making you feel nervous, or you may have heroin habit, whereby you have to “find” £100+ a day for that. This make you very nervous, an anxiety state. You go to your kind GP who gives you diazepam at least, but clonazepam is your preferred benzo choice (10x more potent). You now feel relaxed and invulnerable. You feel better inside yourself, but you are now worse to others. Relaxed you can thieve more. Then there is that paradoxical aggression these medications give, so that knife you have with you is now more likely to be used. Of course you prefer the similar effects given by the gabapentinoids, the new benzos, which you can seek for that old ankle fracture and back pain. Gabapentinoids can give a high on their own, make heroin highs better and cheaper, and any spare capsules can be sold on.

Your life is now a mess, and you feel grief, guilt and remorse. These are uncomfortable sensations, which should protect you from more damaging high-risk behaviour. These feelings are depressing and annoying. Your GP now adds in an SSRI for your “depression”, but you may seek Mirtazapine, as you cannot sleep (perhaps partly caused by the cocaine), and you may want a bit of weight on. The anti-depressant detaches you from your emotions (that’s partly how they work in depression), releasing you from guilt and remorse.

You now have ideas that others do not like you, you have no insight as to why that is so. Your mood swings are violent, disinhibited, so now you now have added quetiapine or olanzapine to the cocktail. These major tranquilisers were designed to stop the overthinking in a psychosis and schizophrenia, but here the tranquilisers block thought, further imagination and hope and they also make you fatter.

With this concoction of these prescribed medications you now are free of anxiety, grief, guilt, remorse and hope. You are detached and have no feelings for others. You now have full blown Iatrogenic Antisocial Personality Disorder with multiple convictions.

Weight goes on and on, blood sugar rises. You are now diabetic.

Gapabentinoids and opiates are a lethal combination. Apart from anything else they block with the opiod antidote Naloxone. Patients arriving in prison have their Gabapentindoids quickly reduced to stop but will still be given detox or maintenance for their opiate dependency.

Full latest prison blog is here

More of the pointless NHS Administration

Most of the boxes are NHS related 1993-2008

I have added back an archive of NHS Commissioning documents based in Hertfordshire, 1999-2008.

Perhaps someone will copy and paste some of the old documents for yet another new project, as all has been done before under different names. Family health Authorities, Regional Health Authorities, Area Health Authorities. Primary Care Trusts. Practice Based Commissioning Groups, and now Clinical Commissioning Groups. It’s pointless.

All NHS reforms do is play musical chairs. No reform dares start on the basis that these functions are simply not needed. They are moved to different named bodies.

I have worked in Australia where these layers of NHS administration simply do not exist, despite the fact that Australia is considered to be over governed.

https://bulger.co.uk/dacorumhealth

Shared Care Records Flawed. Wasted my time too

Shared Clinical Records Fallacies and its waste of time

Some of the work being binned and shredded

I am clearing out paperwork at our old office. This pile is some of the work I did for NPIT and then CfH, Connecting for Health, the UK health service plan for a single NHS record. It cost billions. It failed.

Although I got reimbursed for some of my time on committees this was such a waste of time and I knew it. I was not popular as never liked the concept of a single health records anyway, and detested the idea that Government should write software. The Government’s agenda and civil service procurement contracts were so precise that it was as if they were writing code.

The main effect, indeed aim at the time, was to kill off multiple medical UK IT businesses. Only four primary care system survived. NHS bureaucracy believed that it would be so much better if there was only one system, one supplier in the NHS. The next best option, as far as they were concerned, was that systems should all look and behave in the same way. The result is that the fast and innovative clinical systems we had have become stuck in aspic. The drive to innovate, to compete was killed off by the pressure and time needed for government conformance. Little attention paid to what doctors, nurses or for that matter what a patient might need. The systems in use now are slower and much less ergonomic than the medical system in place in the late 1990s. Most UK GPs had systems on their desks by then because they saved time and created legible scripts and records. Now systems slow down consultations and act as a barrier between doctor and patient. The doctor has to glare at the screen point a mouse at a tiny icon.

Fallacies of a single record

1 “It saves so much money and time, and improves patient safety if there was a single system and NHS record” Not true. A single record lead to sloppy thinking and lazy doctors. The patient is a day older. The past record is just as likely to bias you in the wrong direction by what was written the past. There is likely to be something new. Take a history and examine the patient. It works every time! This is especially true in an emergency situation. Junior doctors should be forbidden to look at old records for 48 hours.

In the UK GPs can have access to records (paper for the most part) going back to 1927 as the records follow you around. When working in Australia there is no such thing, and lo! to my surprise I did not miss the records clinically. As a matter of prurience I might have. When I told and Australian patient of GP UK record access she said that would a be gross invasion of her privacy. She had a point.

2 “But we must know if a patient is allergic” . If only recording allergy was that simple. Most people who report that they are penicillin allergic are not. A patient may report that she felt upset on that green pill, so not unreasonably the GP puts on his record allergy to green pill, so now the system will almost block the GP annoying the patient when attempting to prescribe green and related hues in the future. Alas a hospital will interpret that to mean the patient will collapse with anaphalaxis to green pills. To avoid this the GP now needs to record green pill allergy in greater detail, more than the patient nor he needs in his practice. Detailing what was reaction, what type, intolerance of allergy, rash, urticaria, wheezing and so on and on. It may need a tree of many codes to describe the reaction and how serious. It is so tedious that it is left. But this coding dilemma occurs with recording of almost any disease. Heath Data has fractual properties, like the length of the coast of Britain, seemingly approaching infinity once you draw round each pebble or then grain of sand. The level of detail you need to record depends on your need in front of the patient, its use to you, the patient and locality.

3 That leads onto the provenance of data. Where is comes from has a huge effect on its meaning. A nurse may find a patient confused, so she might record dementia on her system (it might even be recorded as Alzheimer’s). For her work that all she needs to do to remind her. However this could be any different type or dementia, or even psychological, dementia-precox (psychosis). Who and when was the data entered changes its meaning, and then who can correct it should it turned out to be a toxic confusional state. Correcting data entered by others is a minefield in shared records. A GP may record heart failure, but a Cardiologist may need to know what type, or worse it has since resolved and is still there on the record.

4 “Clinical systems can improve safety by warning doctors of interactions of patients other disease and between drugs”. Unfortunately the fear of being sued by suppliers for failure to provide warnings, means that the most idiotic warnings pop up. Such as in treating blood pressure: “Adding X with Y will cause BP to fall”…. YES that is what I want! No intelligence in offering up these warnings which are so frequent, so minor, or that the risks are already fully understood beforehand, that doctors simply flash past all warnings as they are wasting time, in doing so increasing the risk a genuine high risk warning will be missed. This is true for current systems and would be worse if there was a central record as that has to be designed for the most junior nurse doctor or admin clerk.

Solution. Competing Systems: Healthcare Secure Search Engine.

Keep encouraging different systems. The can use common coding systems as they do now. They can work differently, have different interfaces functions and innovate.

When a patient is seen at a different place, such as at hospital, an authorised doctor should be able to do a search of all NHS records within date ranges or selected places, to create a new record. Preferably a day later. This NHS search engine would be secured with two factor authentication or more, with swipe card; the patient notified that such a search was made and by whom and when.

That way provenance of each item is clear. There would be no need to create a single record. There is the NHS spine record, but it is only a summary with few details, and keeping it in sync with GP records is not easy.

Connecting for Heath was doomed. Its premise was wrong, but those concepts and wish for a single patient record still come up. It still a dream of civil servants everywhere. It is not needed and it kills innovation in healthcare computing. Without NHS meddling we would now have slicker, faster, even tablet based clinical systems by now. More patients could be seen in less time.

Gerard Bulger

PS if you invent such a search engine I will need 5% stake in it.

https://bulger.co.uk/message.htm

Using Satellite Slow Connections, Reducing cost.

EXPENSIVE CONNECTIONS

I have just revised my blogs on keeping internet costs down with narrow expensive connections. Its still rather longwinded, so here is a summary!

All gadget providers now believe that every one has unfettered access to broadband. Alas there was still part of the world where that is expensive or does not exist, and those of us forced to use Satellite communications from the field have big problems. The costs are so high an update would break the bank. We cannot control what out phones and PCs do in the background.

My solution was to make sure that anything I plugged into the satellite device/route never knows the route to the internet. I set them so that there was only one route in the IP tables, the route via the satellite to a proxy server. Then I used another browsers such as Opera or Sea Monkey as they have email clients. These browsers can set their own connections via a proxy server independent of the operating system, so nothing else can connect to the internet.

This is detailed on https://bulger.co.uk/satellitecost.htm

other ideas to reduce costs on satellite are here https://bulger.co.uk/satellitecost2.htm

Revising the Web pages

Once we had various businesses such as the doctor’s surgery in Bovingdon, the Fundholders’ Support Agency and Archway Development and Consulting. In those days then having a web space made sense.

But a personal space, which is what this has since become, is much less necessary now that Facebook and the rest has taken over any need for a vanity sites.

I think I will keep the website going and add my thoughts, partly because old URLs should never die! Also I feel slightly more in control. I am not alone with that thought. If I hit delete. It’s gone.