GOODWOOD COURT MEDICAL CENTRE

& THE EATON CENTRE

Document Control

CP 9 – Contraceptive implant fitting & removal

CP18- Maternity Care ……………………………………………………………….

AP 2C - Main terms and conditions of employment & staff handbook

INTRODUCTION

Last updated 05/10/2009

(1) Organisation Structure

Goodwood Court Medical Centre and its branch surgery, The Eaton Centre, aims to provide a Quality Service to its patients promoted by the continuous efforts of its Practitioners, Locums or Deputies, Management, Staff and any Health Authority or NHS Staff attached to the Practice.

This service will be maintained through appropriately selected, trained and motivated staff, by regular audits and reviews by the Quality Team and by monitoring patient views through Surveys. All who work at the Practice carry a responsibility to delivery a quality service. The Core Team consists of General Practitioners, Practice Nurses, Receptionists, Administration, Housekeeping and the Practice Development Team. Attached to the Practice are Midwives, District Nurses, Counsellor, Community Nurses, Social Care Workers and Complementary Therapists.

(2) The Running of the Surgery

The running of the Surgery is conducted in accordance with the General Medical Council (GMC) guidelines. Refer to GMC – Professional Conduct and Discipline: Fitness to Practice.

Each Practitioner provides a minimum of 15 ten minute appointments per session. In the event of all these spaces being filled the other Practitioners are informed and, if necessary, be willing to see extra patients. All consultations and treatment are recorded on the patient’s computer record.

The surgeries house other practitioners offering dentistry services and podiatry. Patients wishing to make appointments with any of these practitioners are able to do so during normal surgery hours.

The Surgery opening hours are

Goodwood Court Eaton Centre

Monday 08.00 to 20.00 08.00 to 14.00

Tuesday 08.00 to 20.00 08.00 to 14.00

Wednesday 08.00 to 20.00 08.00 to 14.00

Thursday 08.00 to 20.00 08.00 to 14.00

Friday 08.00 to 18.30 08.00 to 14.00

Weekend & Bank Holidays Closed Closed

(3) The Practice Commitment to Patients

"We promise to

• Offer you an appointment the same day with a doctor if you have a problem that you feel is urgent.
• Provide access to medical cover 24 hours a day every day(not necessarily provided by ourselves).
• Make authorised repeat prescriptions available by 0800 hours the following working morning if requested on our computer request slip by 1900 Monday to Friday".

"We endeavour to

• Keep to within 20 minutes of your appointment time.
• Deal with all requests for medical reports within 7 days.
• Obtain the best service we can for you from the hospital sector.
• Answer your telephone call courteously within one minute."

(3) Aims & Provisions of this Manual

This manual covers the provision, encouragement and maintenance of an efficient and respected medical practice for the patients of the surgery and to manage patient expectations by providing a clear statement of what the practice offers.

The manual describes a framework in which all staff are trained and motivated to provide a friendly, courteous and efficient service in a happy environment where they feel protected from the hazards of their job and are treated fairly and well.

This manual formalises the standards by which the practice is run and is in accordance with Quality Standards BS EN ISO 9002:9004 and in line with the guidelines set out in the New GMS Contract.

The manual does not claim to cover all the services provided however it is specific and detailed.

The protocols by which the Medical Practice adheres to are split into three areas. They are Patient Protocols (PP), Clinical Protocols (CP) and Administration Protocols (AP).

Patient Protocols (PP)

PP 1 – Appointments

PP 2 – Patients record summarisation

PP 3 – All patient contact must be recorded

PP 4 – Correspondence, Reports and Investigation Results

PP 5 – Protection and use of patient records

PP 6 – Prescriptions

PP 7 – Messages and requests for visits

PP 8 – clinicians availability by telephone

PP 9 – Out-of-hours service

PP 10 – Carers

PP 11 – Patient’s removal from the Practice List

PP 12 – Death of Patients

PP 13 –Statistical Techniques & Patients Surveys

PP 14 – Complaints procedures

PP 15 – Locums

PP 1 – Appointments

Last updated 30/08/2010

Objective

The aim is to minimise patient’s delay in waiting to consult a practitioner and to make optimum use of the hours available. Appointments, requests, messages and general enquiries must be handled quickly and courteous.

Procedure

PP 2 – Patient’s Record Summarisation

Reference Records 15 & 18

Last updated 30/08/2010

Objective

The practice is paper-light. This means that all practitioners and staff rely upon the computer for day to day entry and retrieval of medical information. New clinical information arising after the patient has registered with the clinic is entered on the computer by the clinician as it arises. All historical information has to be entered ‘in bulk’ though not necessarily by a clinician within two weeks of receipt of information from the previous practitioner.

Procedure

1. Children under the age of 16 years will have information entered regarding their parents/guardians using the "family members" facility in the information screen of the patient computer record.

1. All new patients will undergo a health check by Debbie Miller who enters all her findings onto the computer database.

2. All new medical records received by the practice (see 1 above) are collated chronologically to A4 format by Dr Higson or by Ms Miriam Corfield

3. All new medical records, if not summarised by Dr Higson, will be passed to Ms Miriam Corfield or Mrs Ann Long for clinical summarising. All data is summarised in date order. Minimum information included in a summarisation process comprises;

• All significant clinical morbidity
• Smoking and Alcohol consumption if information available
• Significant family history if available
• Childhood immunisations if the patient is a child
• Last cervical cytology result if patient is a female
• All current drugs (must be entered by medical practitioner) with coding to morbidity
• Other information such as "carer status" "living will" etc
• All drug allergies

1. Ms Miriam Corfield, Mrs Ann Long or Dr Nigel Higson will enter the information from paper records onto the clinical computer database with reference to Dr Higson with any queries on terminology.

2. After entering clinical data a Read Code (code: 9311.) will be entered to indicate that the records have been summarised. The morbidity code ‘Lloyd George Collated & Summarised’ appears on the computer record. Also 9344. is entered to show notes summarised.

3. All A4 Files which have been summarised will be placed on the records shelving at Goodwood Court Medical Centre or The Eaton Centre

4. All new patients’ records will be entered on the computer within 2 weeks of arrival of the notes at the practice.

5. Form Z68, note of new acceptance, is eventually received from PCSS either electronically or on paper. Upon receipt the patient’s computer record status is altered from Registered to Registered Approved. Ensure that the original date of registration has remained the same.

6. All historical paper records of patients registered at the Goodwood Court Medical Centre or The Eaton Centre starting have been fully summarised onto the practice computer database

Training

All training on clinical summarising is given by Dr Higson.

Audit

Once every twelve months a computer generated audit of numbers of records summarised is undertaken by Dr Higson.

Quality Control

Random case note selection will take place on a monthly basis by Dr Higson who will check the quality of summarisation by comparing computer listed morbidity to actual.

External references

The practice will take note of the recommendations of "Good Practice Guidelines for Electronic Records- version 3" as published by the GPC and Department of Health.

Storage of minutes & summaries of case conferences/discussions

This guidance is to assist GPs and is not intended to be prescriptive

PP 3 – All patient contact must be recorded

Last reviewed 30/08/2010

Objective:

Patient contact must be recorded to ensure that the practice meets the recommendations of the ‘Good Medical Practice for General Practitioners’ and the Medical Defence Organisations. It ensures that informed decisions are based on up to date records.

Procedure:

All patient contact with the practice must be recorded, this includes GP appointed nurses.

An entry in the patient’s Clinical Records must be made in the following circumstances. This list may not be exhaustive.

Following a visit to the surgery

Following advice given over the telephone

Following a visit to the patient’s home

Following a visit to the patient’s home by other doctors out-of-hours

Following a report received from hospital or consultant

Following a visit to the nurse for travel or other vaccination

Following a visit to the nurse for investigative treatment e.g. Blood Test, ECG, Asthma Check, BP etc.

All nurses must update the patient’s record after each consultation and note the reason for the visit. Any prescribed medication must be entered on the iSoft System.

Where possible the clinical record should include a description of the presenting problem, a diagnosis where possible –coded by using an appropriate Read Code – and if medication is prescribed, this should be linked to the appropriate morbidity. The entry should be structured such that each individual problem is identified with the same entry number and any continuing medical conditions should be coded as "on going problems" in order to create a problem-oriented record. If the condition is likely to need further intervention, a management plan should be entered onto the clinical record.

Attention should be given to the note PROMPT system which reminds the practitioner when certain activities need to be undertaken for a particular patient

PP 4 – Correspondence, Reports and Investigation Results

Last updated 30/08/2010

Objective:

To ensure that correspondence is dealt with in a quick, courteous and efficient manner and that records are kept of it for future reference. Patients must be informed of the results of any medical tests and investigation undertaken. The patient’s clinical record must be updated as soon as possible.

Procedure:

• All correspondence, hospital reports and investigation results received by Goodwood Court Surgery is opened and date stamped. Correspondence received at The Eaton Centre is similarly date stamped and forwarded to Goodwood Court daily.

• All correspondence is then passed to Dr Higson, his cover doctor, or other appropriate member of staff on the day it is received for review.

• Where possible, Dr Higson etc will review all correspondence on the same day it is received. The doctor will enter the result onto the computer system or will pass it to a trained member of staff (Mrs Ann Long) for scanning and appropriate entry. Once this has been carried out the report is passed to reception for filing or shredded by the doctor for confidentiality. Reports are filed by Centre (Goodwood or Eaton) for easy retrieval until they are placed in the patient’s file.

• Should the patient need to be recalled due to an adverse result, then the patient will be contacted by letter, which will be written at the time by Dr Higson.

• Blood pathology results are received electronically by the practice on a daily basis by transmission at approximately 1910hrs. These are imported into the practice clinical software system as they are reviewed by Dr Higson. Dr Higson will import and review these results on a daily basis. In his absence, Dr Williamson has responsibility for reviewing the results and actioning when necessary

• If the test is abnormal and Dr Higson or his cover doctor is unable to interpret the test, the test result will be passed to the doctor with whom the patient is registered or who ordered the test in order that appropriate action is taken.

• Patients are advised to telephone the Surgery between 14.00 and 16.00 hours in order to determine whether their test results have been received prior to making an appointment with the clinician who ordered their test. All patients who have a sample of blood or other body fluid/tissue taken should be advised that it is their responsibility to contact the practice for the result.

• The Receptionist may give out results to the patient only without any interpretation, and should consist only of the information indicated on the computer. Patients requiring further information should be referred to their doctor. Where an abnormality is detected which is USUALLY highlighted by a "red spot" next to the test result, the patient should be asked to make an appointment to discuss the results with the doctor who organised the investigation, or failing that, their own registered doctor

• In the case of cervical smear test, the nurse taking the test will advise the patient the smear result may not be received by the practice for six to eight weeks and that a written result will be forwarded to them by the Primary Care Support Services.

• When the Cervical Cytology result is received it will be reviewed by Dr Higson or his cover doctor, who will enter the result in the clinical database and the recall updated for the next cervical smear. If an earlier than normal recall is indicated, then the recall date is also entered onto a separate Excel database in order to ensure that patients are recalled appropriately. As before Dr Higson will pass the report to reception for filing in the patient’s record. If the cervical cytology result indicates that the patient is being sent an appointment for a colposcopy, then Dr Higson will enter a three month recall entry both on the clinical system and on the excel spreadsheet as failsafe

• Requests for information on or by a patient or Private Reports should be answered within 7 days. On receipt of a request for a private report, the receptionist will enter onto the computer records that a request has been received. The patient’s records will be extracted and a letter sent to the patient advising of the receipt of the request – offering the patient access to the report. The request and notes will then be passed to Dr Higson for completion. See AP 1, information Security. Ms Miriam Corfield coordinates all private medical reports and examinations

• If the patient has expressed a wish to view the report prior to its despatch, then Dr Higson will keep the report for the statutory 21 days prior to despatch. The patient will be contacted, if possible, to inform him or her that the report is available for viewing.

• After completion of the report Dr Higson will generate any appropriate invoice and the package passed back to the receptionist with instruction to photocopy the report. The original is despatched, the copy affixed to the patient’s notes. An entry is made on the computer record, on the day of the posting, that the report has been sent.

• Copies of medical examination reports undertaken for patients not registered with the Practice are kept in a file within the filing cabinets in reception at Goodwood for a period of 12 months. After this period, the reports are shredded.

• If notes go missing and are not awaiting collation, a search should be made. If this proves unsuccessful the relevant patient’s doctor should be informed and new medical records for that patient set up. Computer records are available as a back up should any notes become permanently lost.

Outgoing Post

• Whenever possible the post is to be taken to a separate room (e.g. Room 8) to be sorted, enveloped and stamped. This should be done in the late morning by Ms Angela Bryant or her deputy.

Post should also be sorted into that which goes through hospital "mail collection" and that which goes into the general Royal Mail. Staff should note that Orthopaedic Referrals go into a special "white" envelope which is posted to an orthopaedic management centre (these are logged with the names of the patients to whom the referral refers).

• The post must be weighed whenever more than a couple of sheets of paper are to be placed in a DL or C5 envelope. A new scale has been purchased for the purpose. Large items or bulky post must have correct postage for a "small packet or large envelope" applied – see Royal Mail size guide. Wherever possible C5 or smaller should be used rather than A4

• There is normally a smaller amount of post generated in the evening. Please check it visually to see if anything is urgent. If so please deal with it and post it in time to make the last collection of the day (6.30 pm from corner of Lorna Road). All other evening post can wait till the following day.

• To summarise, post is to be taken to a letterbox at lunchtime. Evening posting is only necessary if there is urgent post.

• The Post Book previously maintained by Reception need not be kept any longer.

Storage of minutes & summaries of case conferences/discussions

This guidance is to assist GPs and is not intended to be prescriptive

PP 5 – Protection and use of patient records

Last updated 30/08/2010NH

Objective:

Under the Data Protection Act, patients are entitled to know what information we hold about them, why seek it and how we may use it. This protocol outlines our model response to patients who ask.

Procedure:

A. Why we seek, keep and use information.

These are the points to bear in mind when dealing with a patient’s query.

We ask for information so that the patient can receive proper care and treatment.

We keep this information, together with details of care given, because it may be needed in future.

We may use some of this information for other reasons: for example, to help us protect the health of the public generally. It may also be needed to help educate tomorrow's clinical staff and to carry out medical and other health research for the benefit of everyone.

Sometimes the law requires us to pass on information: for example, to notify a birth.

The NHS Central Register for England & Wales contains basic personal details of all patients registered with a general practitioner. The Register does not contain clinical information.

The patient may be receiving care from other people as well as the NHS. So that we can all work together for the benefit of the patient we may need to share some information. We only ever use or pass on information if people have a genuine need for it in the patient’s and everyone's interests. Whenever we can we shall remove details which identify the patient. The sharing of some types of very sensitive personal information is strictly controlled by law. Anyone who receives information from us is also under a legal duty to keep it confidential.

Only with the patient’s agreement will relatives, friends and carers be kept up to date with the progress of the treatment given.

There are other reasons, perhaps less obvious, why information may be needed. These are:

Managing and planning our Practice and the NHS in general in order to (a) make sure that our services can meet future needs, (b) pay the doctor, nurse, dentist, or other staff, and the hospital for the care they provide, (c) audit accounts and prepare statistics on our Surgery’s performance and activity where steps will be taken to ensure the patient cannot be identified, (d) investigate complaints or legal claims.

Helping staff to review the care they provide to make sure it is of the highest standard.

Training and educating staff although the patient can choose whether or not to be involved personally.

Taking part in research approved by the Local Research Ethics Committee. If anything to do with the research would involve the patient personally, they will be contacted to see if they are willing.

If patients would like to know more about how we use information about them, they can speak to the doctor in charge of their care or to Dr Higson if he is not the patient’s doctor.

B. Privacy and confidentiality of medical records.

Anyone working for the NHS has a legal duty to keep information about the patient confidential.

The patient’s medical record is a life-long history of consultations, illnesses, investigations, prescriptions and other treatments. The doctor-patient relationship sits at the heart of good general practice and is based on mutual trust and confidence. The story of that relationship over the years is the patient’s medical record.

The GP is responsible for the accuracy and safe-keeping of all medical records. The patient can help us to keep it accurate by informing us of any change in name, address, marital status and by ensuring that we have full details of important medical history.

If a patient moves to another area or changes GP, we will send the medical records to the local Health Authority to be passed on to the new practice. The medical record is marked closed. All closed records are periodically deleted by iSoft.

C. The patient’s right to privacy

Patients have a right to keep their personal health information confidential between them and their doctor. This applies to everyone over the age of 16 years and in certain cases to those under sixteen. The law does impose a few exceptions to this rule, but apart from those, patients have a right to know who has access to their medical record.

D. Who else may see a patient’s records?

There is a balance between privacy and safety, and we will normally share some information about a patient with others involved in health care, unless the patient asks us not to. This could include doctors, nurses, therapists and technicians involved in the treatment or investigation of a medical problem.

Our practice nurses, district nurses, midwives and health visitors all have access to the medical records of their patients. It is our policy to try to have a single medical and nursing record for each patient. We firmly believe that this offers the best opportunity for delivering the highest quality of care from a modern primary care team.

Our practice staff need to notify the health authority of registration and claim details and perform various filing tasks on the medical records. All our doctors, nurses and staff have a legal, ethical and contractual duty to protect privacy and confidentiality of patients.

E. Where else do we send patient information?

We are required by law to notify the Government of certain infectious diseases (e.g. meningitis, measles but not AIDS) for public health reasons.

The law courts can also insist that GPs disclose medical records to them. Doctors cannot refuse to cooperate with the court without risking serious punishment. We are often asked for medical reports from solicitors. These will always be accompanied by the patient's signed consent for us to disclose information. We will not normally release details about other people that are contained in our records (e.g. wife, children, parents etc) unless we also have their consent. Often the patient may be unaware what is present in their medical records – hence we will do our best to contact the patient, even if authority to disclose without review is initially given, to advise that a report request has been received and offering access to review

Three or four times a year a "backup" tape of the computer clinical database is sent to the clinical software company in order to check the integrity of the data backup process. The tape is despatched suitably protected by Royal Mail Special Delivery and receipt is notified by the software company to the practice. If the tape is not received, a full investigation is launched with Royal Mail to determine the whereabouts of the package. Once the data check has been completed the software company erase the data from the tape before returng the tape by post. The software company does NOT access the content of patient records. The practice is currently seeking ways of encrypting the patient data prior to future despatch but is awaiting guidance from the NHS information technology team for this.

Limited information is shared with health authorities to help them organise national programmes for public health such as childhood immunisations, cervical smear tests and breast screening.

GPs must keep the health authorities up to date with all registration changes, additions and deletions.

Social Services, the Benefits Agency and others may require medical reports from time to time. These will often be accompanied by the patient’s signed consent to disclose information. Failure to cooperate with these agencies can lead to patients' loss of benefit or other support. However, if we have not received a signed consent we will not normally disclose information.

Life Assurance companies frequently ask for medical reports on prospective clients from the GP. These are always accompanied by a signed consent form. GPs must disclose all relevant medical conditions unless the patient asks us not to do so. In that case, we would have to inform the insurance company that we have been instructed not to make a full disclosure to them. Patients have the right, should they request it, to see reports to insurance companies or employers before they are sent. We will endeavour to advise patients when a request for a report has been received with a recommendation that the patient examines the content of any report before it is forwarded to the requesting party – whether or not prior consent to send "unseen" has been given by the patient.

From time to time a consultant will request sight of a patient’s records. On these occasions, the records will be taken out of their wallet and replaced with a card, indicating the date that the records were removed and the name and address of the consultant who requested them. A print out of the computer records of the patient will be placed in the file. Upon their return, the medical records are placed back in their wallet.

F. How can a patient find out what is in their medical records?

We are required by law to allow patients access to their medical records. If a patient wishes to see his records, he must contact Dr Higson for advice.

All requests to view medical records should be made in writing.

We are allowed by law to charge a small fee to cover our administration and costs.

We have a duty to keep our medical records accurate and up to date. The patient must feel free to correct any errors of fact which may have crept into our medical records over the years.

G. What we will not do

To protect privacy and confidentiality, we will not normally disclose any medical information over the telephone or by fax unless we are sure who we are talking to. This means that we will not normally disclose test results over the phone and may wish to call the patient back to ensure that we are talking to the right person.

This also means that we will not disclose information to family, friends or colleagues about any medical matters at all, unless we know that we have the patient’s consent to do so. Staff will not disclose any details at all about patients over the telephone - they are instructed to protect the patient’s privacy above all else!

Finally, if a patient has any further queries, comments or complaints about privacy and / or medical records, they must contact Dr Higson or talk to their own GP.

PP 6 – Prescriptions

Last reviewed 10/06/2010

Objective:

The aim is to offer fast, efficient processing of prescription requests and for these to be prepared only by those who are authorised to do so.

Procedure:

Repeat Prescriptions

• Requests received at The Eaton Centre are couriered to Goodwood every day after surgery. Repeat prescription requests are covered by the need for confidentiality. It is important that they are kept securely at all times especially during transportation between surgeries. A secure "letterbox" is available at the entrance of Goodwood Court Medical Centre for patients to leave the request 24 hours a day.

• All repeat prescription requests are placed in the repeat prescription clip sited in the reception area.

• All repeat prescriptions are prepared by Dr Higson or in his absence by Dr Williamson. Dr Higson will review the repeat prescription request for compliance to ensure that the medication is currently appropriate to the patient’s recorded medical needs.

• A signed prescription will be issued and placed ready for the receptionist to sort in alphabetical order each morning at 8 am. They are placed in a Prescriptions Box held on reception ready for collection.

• It is the aim of the practice that all prescriptions received by 8 pm; Monday to Friday will be available for collection by 8am the following working day. If a prescription is urgently required, perhaps because the patient has run out of medication, every effort will be made to have the prescription ready on the day of request. If no doctor is available and the patient requires an "immediate" prescription to replace regular medication, then the patient can be advised that he can obtain an emergency supply of medications from his pharmacy (for which he/she will have to pay)

• Prescription requests received by post are returned to the patient by post provided they have enclosed a sae. They are posted the day after receipt unless there has been a query. If a sae has not been enclosed, the prescription will be collected by the patient from Goodwood Court.

• Prescription requests received by email are read and dealt with by Dr Higson. They will be collected by the patient or representative from Goodwood Court.

• Prescriptions requests handed in at Eaton will be collected from Goodwood when they are ready.

• Before giving the patient his or her prescription, the receptionist checks the address of the patient to minimise mistakes due to similar names.

• Prescriptions to be handed to a Pharmacy will be recorded daily by the receptionist in a record book/folder and will be passed to the appropriate pharmacy agent who will sign to say that the prescriptions have been collected.

• Any pharmacy can collect prescriptions from Goodwood Court if they provide a list of the patients for whom they have been instructed to collect. When ready these prescriptions are placed in one envelope ready for collection.

• The practice reserves the right to charge patients the costs of postage or faxing the prescription when not considered clinically urgent and when it is purely for the convenience of the patient

Prescription issued following consultation.

• Each doctor is allowed by the System to issue and authorise prescriptions during patient consultation. See AP 1 ‘Information Security’, Section A, Bullet Point 5.

• The Senior Practice Nurse, Sister Elaine Higson is authorised to prescribe medication in accordance with the Nurse Prescriber’s Formulary. If Sister Elaine wishes to prescribe a medication which is outside the Nurse Prescriber’s Formulary, she will ask one of the doctors to help.

• Due to system limitations outside the influence of the Practice, Sister Elaine hand writes all her prescriptions but updates the patient’s computer record with a note of the medicine prescribed.

• If a non prescribing nurse feels that some medication is appropriate, she will discuss the case with one of the doctors or Sister Elaine Higson who will prescribe if necessary.

• Any drug prescribed should be "linked" with an appropriate morbidity whenever possible

• District Nurses may also prescribe medication from within bounds of the Nurse Prescriber’s Formulary. If this happens, the surgery will be informed by fax or letter which is used to update the patient’s clinical record.

PP 7 – Messages and requests for visits

Last reviewed 13/02/2010

Objective:

The system for message-taking must minimise or eliminate the risk of error or oversight. Patients are made to feel welcome when they contact the surgery. Requests, queries and comments are handled in a courteous and efficient manner.

Procedure:

• Patients in need of medical attention who are unable to attend the surgery may request a home visit. Patients should be encouraged to request a home visit before 11 am on the day of the visit is required – pre-booking home visits is not normal practice.

• The patient will normally receive a visit from his or her own doctor. In the absence of their own doctor working that session, then visits will be covered by any of the other doctors on duty. It is usual practice for the doctor to telephone the person requesting the visit at the end of the morning surgery to gather appropriate information and to decide whether or not a visit is appropriate or whether another means of fulfilling expectations can be implemented

• A Message Book will be maintained, one for each doctor in the practice. All messages whether left by telephone or personal visit, will be written in these books. The duty receptionist takes down the name, address, telephone number and the message together with the name of the patient’s own GP and enters these details into the massage book for that doctor. The time of the call should also be noted

• The person taking the message has the responsibility of prioritising these messages and the doctor’s advice may be sought immediately if in his or her opinion the case is urgent. In these cases the message will still be recorded in the Message Book.

• If the request is believed to require the interruption of a doctor’s consultation, the receptionist will ensure that a contact number is recorded before placing the call through to another extension in case the telephone call is "lost". The doctor may decide to telephone the caller back between consultations in order to be able to talk freely with the caller without another patient overhearing the conversation. This should be explained clearly to the caller.

• The Message Book will be regularly reviewed by the doctor concerned during the course of the day. At the end of morning surgery, each GP will attend to his or her own visits.

• Any further requests for visits made during the day will be passed to the patient’s own doctor or covering doctor for the day. If an ‘urgent’ message is received for a doctor who is away, the case will be referred to the doctor on duty but the message will still be entered in the Message Book of the doctor who is away. If the case in not urgent, it will not be referred to the doctor on duty but simply entered in the relevant book.

• The doctor taking the call for the visit may refer the visit to the ROVING GP service operated by "HERMES" passing appropriate information to the HERMES team and speaking, if possible to the roving GP to appraise of past history etc. This is particularly appropriate if the alternative choice is to call an ambulance.

• The doctor will document as fully as possible his/her action taken as a result of the request for the visit

• Each day, the Receptionist must ensure that all messages taken the day before have been actioned and cleared or there is good reason for being left outstanding.

• All records of visits are recorded on the patient’s computer record as soon as the visiting practitioner returns to the medical centre.

• The Message Book will be laid out as follows.

PP 8 – Clinician’s availability by telephone

Reference; Information 3

Last updated 05/10/2009

Objective:

To ensure that all patient contact is treated with the degree of urgency that it deserves but that no request to speak to a doctor or nurse is dismissed. Consideration is to be given as to whether it is appropriate to interrupt another patients consultation

Procedure:

PP 9 – Out-of-hours service

Last updated 05/10/2009

Objective:

Patients are offered 24 hour cover, 7 days a week. When seen by other doctors out-of-hours the patient’s clinical records must be updated in a timely manner.

Procedure:

• South East Health (formerly Brightdoc) is a commercial out-of-hours cooperative service. It undertakes all out-of-hours visits. NHS Direct is an organisation under the NHS which provides 24 hour telephone advice and support to callers.

• When the Surgery closes, the practice answerphone automatically comes on. It gives the caller a number of options; contact NHS Direct, contact your local pharmacist for advice or contact Brightdoc (also now known as South East Health).

• When the Surgery opens in the morning, the answerphone automatically comes off and the receptionist will take calls personally.

• Each day the practice may receive a fax or a note for each visit made by the out-of-hours service. These are bundled up by Reception and passed to Doctor Higson for review. If Doctor Higson is away, the notes will be passed to Doctor Williamson for his perusal. In this case all documentation will be retained for review by Doctor Higson upon his return. All communications are then passed for scanning to Ms Ann Long

• If a case needs to be followed up, the out-of-hours doctor will have told the patient to contact the clinic in the morning. This advice is marked on the note or fax sent to the clinic. Responsibility rests with the patient to do so.

• The patient’s computer records are updated by Dr Higson or by a trained member of practice staff. Although the content of the visit note, if legible, is entered as a free-text entry, there should also be a linked morbidity code indicating ‘out-of-hours cooperative’.

• All notes or faxes received from Brightdoc are filed by Centre (Goodwood or Eaton) and by doctor for easy retrieval until they are permanently filed in the patient’s records.

• The Out-of-Hours software system allows GPs to prime the out of hours database with information which might be of particular value to a colleague who is unfamiliar with the patient, or indicate special requirements for handling out-of- hours calls. This facility will typically be used to warn of patients who might be abusive or violent, and those who may be over demanding. It is also valuable where a patient may have an obscure medical condition, or for terminal care or intra-partum cases where the patient’s own GP wishes to be alerted in the event of any call.

• Use the form below and submit a completed copy under confidential cover to the out-of-hours manager. You will find a blank copy of the form on Word in Clinical/Torex/DOCSTORAGE/JOHN C/Forms/Brightdoc Fax Form.doc.

• Make sure to include the patient’s telephone number where there is one as this is the primary source of reference on the system’s database. All messages will carry a review date when they will be referred back to the Surgery for consideration of renewal.

MESSAGE TO BE FAXED TO SOUTHEAST HEALTH ON 687735

From Goodwood Court Medical Centre Tel; 0844 477 0925: Fax; 0844 884 0152.

Ask for Doctor Higson

PP 10 – Carers

Reference; Management 9

Last updated 05/10/2009

Objective:

To ensure that the practice identifies patients and their carers and provides help and support as required.

Procedure:

• Where the clinician considers it appropriate, the patient may be asked if they have a carer. If the answer is yes the Clinical Notes Screen is updated using code 918F. The Patient Information Screen is also updated by completing the Notes Box. The information will include the name of the carer and their contact number.

• Similarly, if the patient is a carer, an entry is made in the Clinical Notes Screen using code 918G. The name of the patient cared for, their contact number and any other data deemed relevant is entered in the Notes Box in the Patient Information Screen.

• If the carer requires help, he or she will be referred to one of a number of organisations, such as Crossroads (Care for Carers) 01273 273344, Health Advisor Service for Older People 01273 242229 or The Brighton & Hove Federation of Disabled People 01273 295710. He or she will also be referred to the Social Services for a Carer Assessment 01273 295555.

• If a patient requires a carer, he or she will be referred for a social services assessment. Reception Team members may refer to the social services either at the request of the doctor or the patient. When this happens a free text note is added to the patient’s clinical notes.

• At the beginning of each practice year, the practice will write to all those coded as carers (918G.) and cared-for (918F.) to request updated information and to advise them of the availability of a Care Assessment. A specimen letter is on the last page of this protocol.

• Patients may organise their own carer needs and reception will assist with names of organisations and contact details. If a relative of a patient asks reception for assistance in organising help for a parent etc, only self help will be offered. Reception must not do the organising as the patient consent is unknown. The GP will be told of the request.

• This practice only requires a verbal consent from the patient before a carer organisation is contacted. In most cases a written consent would be impractical.

• There are three types of carers. These are Carer, Parent Carer and Young Carer.

A carer is anybody who looks after a relative or friend who needs support because of age, physical disability, learning disability or illness including mental illness.

A parent carer is a parent of a disabled child. These parents often see themselves as parents rather than carers but their child will have additional care needs and may be entitled to additional services.

A young carer is a person under the age of 18 who has caring responsibilities for another family member who is either unwell physically or mentally or who is disabled.

• As soon as any clinician becomes aware that a child is a young carer, a letter will be sent to the child’s school informing them of this fact giving details of doctor’s names, address of surgery and contact telephone numbers.

• The following link concerns Attendance Allowance: http://www.dwp.gov.uk/lifeevent/benefits/attendance_allowance.asp#what

The following is a sample list of organisations that provide help to carers and those in need of care.

• Crossroads Care Attendant Scheme (based at Hove Polyclinic) Tel 242022
• Age Concern Crisis Line Tel 328555 (between 8am & 6pm)
• Brighton & Hove Disability Association Tel 203016 or 208934
• Carer’s Centre, Community Base, 3^rd Floor, 113-117 Queens Road, Brighton BN1 3XG, Helpline Tel 273344 Office Tel 234045. (Supports non-paid carers with emotional support, sitting-in, advocacy etc).
• St. John’s Ambulance (Private Ambulance Service) County Office 01903 235599
• Wheelchair Hire & Medical Aids (Southwick) 413999, (Worthing) 01903 505346
• British Red Cross for Wheelchairs and Daily Living Aids 731208
• Direct Mobility Hire 0208 807 9830, M & B 01323 721223, Southern 01323 641798,
• WRVS Meals on Wheels 410117
• Community Transport 505888

The following private organisations (paying) provide care across a wide spectrum.

• Allied Healthcare (Robert Anderson) Tel 278730

• Care UK (Laura Head) Tel 626161
• Carewatch (Terry Playford & Chrissie James) Tel 207111
• Community Careline Services (Joan Papworth) Tel 309393
• Goldsborough Home Care Ltd (Heather Bennett) Tel 624373
• Halifax Care (Anne Halifax) Tel 695444
• Independent Living Organisation (Debbie Fielding) Tel 728674
• Plan Personnel (Anna Matthews) Tel 203586
• Prime Care (Michaela Allen) Tel 01323 491975 or 01273 677314
• Sussex Homecare (Sarah Yaxley) Tel 770202

Dr. Nigel Higson, Dr. John Williamson

Goodwood Court Medical Centre & The Eaton Centre

52 Cromwell Road

Hove

BN3 3ER

Fax 0844 884 0152

NAME AND ADDRESS

Dear ____________________

According to our records, we have information to say that you are either a Carer or someone in receipt of the services of a Carer. If this is incorrect, please advise us.

We will write to you annually to ensure that the information we have is correct and to advise you of additional services which may be available to you.

Please would you confirm in writing the following information:

If you are a Carer –

Please advise us of the name of the person for you care, their contact telephone number and address. This is to ensure that we are able to make arrangements for that person in case you become unwell or we have to admit you suddenly to hospital.

If you work for an agency, please advise us of the name and contact phone number for the relevant Agency Supervisor.

If you are in receipt of care

Please advise us of the name, telephone number and address of your carer (s) in order that we can contact them if necessary

If you receive care from an Agency, please advise us of the name and contact phone number for the relevant Agency Supervisor

Every Carer and person in receipt of care can approach Social Services for a Care Assessment – the relevant department can be contacted on Brighton 295555. Our Health Advisor for the Elderly can be contacted on Brighton 242229 and our District Nurses on ___________. Other services are available to assist with care – please feel free to contact us for advice

PP 11 – Patient’s removal from the Practice List.

Last reviewed 05/10/2009

Objective:

To ensure that the patient is given a reason for the removal from the Practice List together with information on how to find a new one and to provide a simple efficient way of dealing with medical records when a patient is removed.

Procedure:

Reasons for removal from the Practice List

1. There are six main reasons why a patient may be removed from the Practice List. These are: (a) Physical or verbal violence,

   (b) The patient moves away from the Practice’s catchments area,

   (c) Breakdown of patient / doctor relationship,

   (d) History of failure to attend appointments or general abuse of system,

   (e) The patient moves to another practice,

   (f) The patient dies. This is considered under PP12.

   Who can decide to remove a patient from the list

2. It is the doctors in the Practice who instigate the removal in scenarios (a) to (d). They will decide with Dr Higson if a patient must be removed from the Practice List. In cases (e) and (f) it is the patient who forces the issue.

   Process for removing a patient from the list

3. Once the decision has been made to remove a patient, a letter is sent to the Primary Care Organisation with a copy to the patient. The letter will give the patient’s identification details and the reason(s) for the removal. (This is generated automatically within the "referral" letter option in the clinical software and a copy is retained in the clinical computer record)
4. It is the Primary Care Support Service’s responsibility to write to the patient informing him or her of the decision taken by the Practice and why. They will assist the patient in finding a new practice in the area by giving all relevant details. Notwithstanding this, the Practice also sends the patient a letter explaining the removal and how to find a new doctor.

   　

   Change of address

5. If the patient has moved away from the practice catchments area, the practice may not know this until;

   (a) The patient tells the practice,

   (b) The practice refers a patient to hospital or a consultant at which point the address is checked.

   (c) A Green Card, Form FP69, is received from the NHS.

   Green Card, Form FP69

6. The NHS occasionally calls up some individuals for check ups etc. If their letter is returned undelivered, they will generate a Green Card and send it to the Practice.

7. Upon receipt, the Reception staff will record on the card the date that the patient last visited the Practice and return it to the NHS.

8. If the card refers to a foreign student, that student’s clinical record is closed automatically on expiry of the due warning period noted on the greencard.

9. If the card refers to a regular patient, a freetext note is entered on that patient’s record and the next time that patient contacts the Surgery, the address is checked and updated. If the new address falls outside the catchments area, the patient will be asked to move to another clinic.

   Procedure for dealing with a patient’s medical records.

10. A daily request for patient records and closure of patient’s records may be received electronically from the ESBHPCSS. If an electronic request is not possible the ESBHPCSS sends Form FP22 to the Practice each Friday. Names contained on this list relate to patients of an individual doctor in the Practice.

11. Working from the list, the reception staff retrieve the medical records and cancel the patient on the computer system giving the reasons for the cancellation. A full computer print out for each patient is produced giving a summary of past medical history, a full chronological history of contacts and any drug or medication received.

12. All documents produced are boxed up and await collection by the PCSS courier when they call on Friday.

Goodwood Court Medical Centre & The Eaton Centre

Dr.Nigel Higson, Dr.John Williamson

Dr.Milind Jani & Dr S Janet Wilson

52 Cromwell Road

Hove

BN3 3DX

fax: 0844 884 0152

_longdate

Ms S Turner

Patient Services

Primary Care Support Services

Brooklands House

Marlborough Road

Lancing Business Park

Lancing

West Sussex

BN15 8AF

Dear Sue

Re: _patienttitle _patientforenames _patientsurname _patientdofb

_patientaddress1 _patientaddress2 _patientaddress3 _patientaddress4 _patientpostcode

NHS number: _patientnhs

Please would you remove the above patient from our medical list for the following reason:

• Failure to attend one or more booked appointments

• Abuse or violent behaviour

• Moved outside of practice area

• Breakdown of Patient-Doctor relationship

With many thanks

Dr.Nigel Higson

Goodwood Court Medical Centre & The Eaton Centre

Dr.Nigel Higson, Dr.John Williamson

Dr.Milind Jani & Dr S Janet Wilson

52 Cromwell Road

Hove

BN3 3DX

www.goodwoodcourt.org

surgery@goodwoodcourt.org

_longdate

_patienttitle _patientinitials _patientsurname

_patientaddress1

_patientaddress2

_patientaddress3

_patientaddress4

_patientaddress5

_patientpostcode

Dear _patienttitle _patientsurname

A request has been sent to the Primary Care Support Services ( PCSS) to ask for your name to be removed from our medical lists. This is for the following reason:

• Failure to attend one or more booked appointments

• Abusive or violent behaviour

• Moved outside of practice area

• Breakdown of Patient-Doctor relationship

You will only be able to receive medical care from us for a further seven days after which time you will need to seek the help of another medical practice.

If you have difficulty finding another medical practice, then you should contact the PCSS on 01903 756900 who will be able to give you a list of medical practices in the area or who will allocate your name to a doctor. Information is also available on www.nhs.uk

You will be unable to re-register with the practice while living outside the practice area

Sincerely

_reggptitle _reggpsurname

PP 12 – Death of Patients

Last updated 05/10/2009

Objective:

To ensure that relevant team members are informed about patients who have died. The aim is to avoid possible embarrassment and distress. Please note that this Protocol does not deal with the doctor’s duties relating to death but with the handling of death notification received by the Practice staff.

Procedure:

Notification of Death of Patient

This is to advise you that we have been informed of the death of:

Surname:

Forename:

Date of Birth:

GP:

Date of death:

Cause and place of death:

Date Notification Received:

PP 13 –Statistical Techniques & Patients Surveys

Reference PE 2, 3 & 4

Last reviewed 05/10/2009

Objective:

Statistical Techniques help to compare achievement with Quality & Outcomes targets. Trends are measured by periodic analysis of current and past performances. They also provide a measure of the performance of providers. The new GMS contract is based on the involvement of the public in service planning and delivery. This involvement is recognised as a key indicator of quality and responsiveness.

Patient Surveys provide active patient involvement in primary care by seeking out patient views and progressing to a situation in which patients have a role in planning, implementing and reviewing change and service improvement initiatives.

Procedure:

The analysis of performance indicators consist of;

• Patient complaints and patient satisfaction
• Surveys of patients referred for hospital treatment
• Clinical activity in areas listed under Quality & Outcomes, Appendix A of the new GMS contract.

Clear reasons must be stated as to why feedback from patients is required, specifying;

• How and why patients are selected for survey
• How many patients are targeted
• How many respond
• What use is made of the information and the ways in which it is used and why.

The Annual Patient Survey ensures that the basis of the service standards is met and that patients are receiving the kind of treatment they can reasonably expect from the practice. Improvement in patient experience is expected in these 5 areas;

• Improving access and waiting
• Building closer relationships
• More information, more choice
• A clean, comfortable, friendly place to be
• Safe, high quality, joined-up care.

Regular audits ensure that the practice is playing a full part in needs assessment and care management procedures for individual patients where required and meeting its obligations under community care legislation. Surveys are carried out through either one of the commercial services - CFEP – UK Surveys, Telephone 01392 252740; GPAQ on-line- or by in house analysis. When patients are requested to complete a questionnaire, it is important that the recipient is made aware of the purpose of the research.

Periodically, the Surgery targets patients registered with the practice informing them of various clinics, screening and health promotions available to them at one or the other of the medical centre. See Protocol CP4. In order to avoid contravention of regulations laid down by the General Medical Council (GMC) and the British Medical Association (BMA), the Practice adheres to "Guidelines to Doctors on Advertising – Appendix 1"

From time to time the Practitioners agree to distribute information on an unsolicited basis to homes within the geographical catchment area. When this occurs it is important to ensure that no individual or group of patients is singled out to receive such information and that the distribution is not carried out in such a way as to put the recipients under pressure. In addition, the information contained must inform the receiver that the service offered applies only to patients registered with the Practice.

Where unsolicited leaflet drops relate to advertising the practice, in order to encourage the receiver to join the practice, it is good practice for a copy of the proposed leaflet to be forwarded to one of the defence indemnity organisations for clearance or modification if necessary, before distribution takes place. All advertising material must contain a reference number which patients will be asked to quote when responding to facilitate advertising effectiveness analysis. All staff should be aware of the contents of any advertising venture and in particular to be prepared to deal with requests for services detailed therein.

PP 14 – COMPLAINTS

Responsible Complaints Manager: Mrs Wendy Pell-Stevens

Responsible Clinician: Dr John Williamson

Last updated: 12 October 2009

What is a complaint?

National regulations which apply

The Practice’s complaints procedure

It may be appropriate to invite a complainant or complained against to meet with practice staff (with or without the assistance of an independent lay conciliator) to address outstanding queries, either initially or following an exchange of correspondence. Complainants and complained against should be supported at meetings if they wish e.g. by a friend, relative, carer, advocate or Independent Complaints Advocacy Service (ICAS) officer.

Management of complaints files

1. It is important to keep a comprehensive and well-maintained record of a complaint that has been received, investigated and responded to. This ensures that:

• healthcare staff can work with maximum efficiency, retrieving and reviewing information quickly

• there is greater protection of information

• there is an ‘audit trail’ which allows any document to be traced to a named individual at a given date/time, and any amendment to be similarly traced

• anyone following up the complaint, or dealing with it following personnel or organisational change, can see what has been done, or not done, and why

• any decisions made can be reconfirmed or reconsidered at a later date

• healthcare organisations can draw on the experiences of people who have cause to complain about services in their work to improve services

• healthcare organisations can be seen to be transparent in their dealings with people who complain about services

• healthcare organisations can account for their work to the people they serve

• healthcare organisations can meet their obligations under access to records legislation

2. Sound professional practice in complaints file management will help secure swift, honest and comprehensive resolution of complaints about health services.

3. A complaint file has the same status as any other created by a healthcare organisation. It is a public record, its contents are confidential and an individual (usually the designated complaints manager) is responsible for making sure that it is maintained to an appropriate standard.

4. Once the need for a file has been identified, the complaints manager should create one and mark it with the name of the complainant (not the name of the patient, unless they are the same person). The date on which the file was created should be clear. It should also bear a reference that marks its place in the file library maintained by the complaints manager.

5. The file should include all important and relevant information in a legible form so that it can be read easily and reproduced when required. The file maintained by the complaints manager should include:

a) A summary sheet recording significant events in the management of the complaint

b) A full and legible copy of the relevant sections of the clinical records and communications sheets. The clinical record for a patient who is alive should be copied and the original returned to the record store as soon as possible.

c) A copy of any earlier clinical record that may be relevant to the complaint.

d) All written correspondence between the trust and the complainant, and with any other person or organisation about matters related to the complaint

e) Any notes from telephone or other conversations (for example records of telephone or face-to-face conversations regarding the progress of the complaint that required a fuller note than an entry on the summary sheet).

f) The report of the investigation into the complaint.

g) Notes from any meetings concerning the complaint (including meetings with the complainant, with independent experts, the outcome of conciliation meetings).

h) A copy of the response sent to the complainant by the practice.

i) A summary of any action taken in response to the complaint and/or evidence of changes made as a direct consequence of the complaint.

j) A record of any follow up communications with the complainant describing the effect of any changes made as the result of the investigation.

8. Since the complaints manager may not investigate the complaint personally, it is likely that the investigator will open a personal working file. The working file should include:

a) The text of the complaint made in the first place and any papers that carry any subsequent clarification or amendment to the complaint.

b) A copy of any information given to the complainant (by the PALS service, the complaints manager or the investigator) about the investigation process and who will be involved in it.

c) A list of staff involved in the events complained about, including full name, role and contact details.

d) Any statements from staff involved in the events complained about or who witnessed the events.

e) Records of any interviews with people (i.e. staff, other patients or members of the public) involved in the events complained about or who witnessed the events.

f) Notes made in the course of the investigation.

g) A copy of the report of the investigation into the complaint and/or the draft response to be sent to the complainant by the practice.

6. All these papers should be sent to the complaints manager at the end of the investigation for inclusion in the file held centrally.

7.. Whatever the medium, the file contents should be:

• kept in a secure environment (lockable cabinets, fireproof cabinet for original clinical records, password protected electronic files), designated for the purpose

• accessible only to those directly responsible for investigating and responding to the complaint

• kept up to date

• shared between those who need to use them, rather than copied and so increase the risk of compromising confidentiality

8. The minimum recommended period for retaining a complaint file is presently 10 years from the date on which action was completed. The principles outlined in paragraph 7 above apply equally to remote storage and retrieval. Files must be disposed of under confidential conditions.

9. The complaints received will be reviewed quarterly by the Complaints Manager and Complaints Clinician who will summarise all into a complaints log in order to identify any persistent themes. The log and comments will be distributed to all practice clinicians and administrative staff

10. An annual summary of complaints will be forwarded to the Primary Care Support Services at 36 Friars Walk, Lewes, on an annual basis

Complaints.

Please note:

1. Wendy is responsible for maintaining a Complaints Log for both Eaton and Goodwood.

2. Anyone who receives a verbal complaint from a patient or indeed wishes to complain about a patient must let Wendy Pell-Stevens know. Please do this by completing an Action Summary Sheet kept in the 2^nd drawer down in the RHS cabinet in Reception. Wendy will log the complaint and bring it to Dr Williamson’s attention.

3. Letters of complaint received in the post must also be passed to Wendy for logging and forwarded to Dr Williamson as soon as possible. No need to complete an Action Summary Sheet for these.

4. All complaints must be acknowledged as soon as possible and formally replied to within 10 working days. Please see Complaints Procedure Protocol PP14. This logging process must not be allowed to delay the process.

5. Please report every complaint

02/11/05

INFORMATION FOR PATIENTS/OTHER INTERESTED PARTIES

Introduction:

Guidance on a "good complaints process" can be found at:

http://www.healthcarecommission.org.uk/_db/_documents/04022289.pdf

How to complain:

We hope that most problems can be sorted out easily and quickly, often at the time they arise and with the person concerned. If your problem cannot be sorted out in this way and you wish to make a complaint, we would like you to let us know as soon as possible, ideally on the day. This is because the sooner we know about a problem, the easier it will be for us to establish what happened. In any event, please let us have details of your complaint:

• Within 6 months of the incident that caused the problem; or
• Within 6 months of discovering that you have a problem, providing this is within 12 months of the incident.

Complaints should be addressed to the Practice Complaints Manager, Mrs W Pell-Stevens. Alternatively, you may ask for an appointment with Mrs W Pell-Stevens to discuss your concerns. She will explain the complaints procedure to you and will make sure that your concerns are dealt with promptly. It will be a great help if you are as specific as possible about your complaint.

What we will do:

We will acknowledge your complaint within two working days and aim to have looked into your complaint within ten working days of the date when you raised it with us.

If the complaint is raised on behalf of another person – ie not directly by the patient – the complaints manager will apply the following tests to determine whether the complainant is a "suitable complainant" under the NHS complaints procedure section 8(3):

If the complaints manager determines that the complainant is not a suitable complainant then the Manager will write to the complainant informing him/her of the outcome and further options.

We shall then be in a position to offer you an explanation, or a meeting with the people involved. When we look into your complaint, we shall:

• Find out what happened and what went wrong.
• Make it possible for you to discuss the problem with those concerned, if you would like this.
• Make sure you receive an apology, where this is appropriate.
• Identify what we can do to make sure the problem doesn't happen again.

Complaining on behalf of someone else:

Please note that we keep strictly to the rules of medical confidentiality. If you are complaining on behalf of someone else, we have to know that you have his or her permission to do so. A note signed by the person concerned will be needed to authorize you to complain on their behalf. See section above regarding "suitable complainant"

Complaining to the Brighton and Hove
　　　Primary Care Trust (B&HPCT):

We hope that, if you have a problem, you will use our practice complaints procedure. We believe this will give us the best chance of putting right whatever has gone wrong and an opportunity to improve our practice. If for any reason you feel that the practice complaints procedure has not resolved your problem, then another step to take is to contact the local PALS (Patient Advice and Liaison Service), which is based at Prestamex House, 171-173 Preston Road, Brighton 01273 545337

However should you feel you cannot raise your complaint with us or you are dissatisfied with the result of our investigation. You should contact the Health Care Commission

Complaining to the Health Care Commission

If you feel that we have been unable to answer your complaint to you satisfaction or feel that there are other issues which are beyond the remit of our practice complaint procedure, then you may contact the Health Care Commission – A Statutory organisation – for advice and consideration of further investigation

http://www.healthcarecommission.org.uk/contactus/complaints/complainaboutthenhs.cfm

The Health Care Commission’s address is:

5^th Floor

Peter House

Oxford Street

Manchester

M1 5AX

02074489100

Fax: 02074489180

Goodwood Court Medical Centre & The Eaton Centre

Comments, Complaints and Suggestions Form

Please write in BLOCK CAPITALS - use this form to make any comments you wish about our services

Your Name:_________________________________________

Your Address (so that we can acknowledge your comments)

____________________________________________________________________________________________________

Date: _______________________ Practitioner or Service _________________________________

Your Comment or Complaint

You will receive a prompt reply. Please feel free to use an additional sheet if necessary.

We would also be grateful if you could score some specific aspects of our services:

NB: 1= LOW score 5 = HIGH score

Receptionist - Manner & efficiency 1 2 3 4 5

Contacting the Surgery by Phone 1 2 3 4 5

Convenience of Appointments 1 2 3 4 5

Punctuality of Appointment 2 3 4 5

Waiting Room Comfort 1 2 3 4 5

Comments

Please use the form overleaf either to make specific comments or to complete the questionnaire on key service areas. All comments will be passed to Mrs.Wendy Pell-Stevens who will ensure that they are actioned and that you receive a reply if appropriate. All procedural comments are discussed at our regular Quality Team Meeting

Complaints

We sincerely hope that it will not be the case, but you may feel in certain circumstances that the service you have received is not up to the standards that you feel you are entitled to receive. If this is the case, PLEASE TELL US.

If the complaint is of a clinical matter, then please write to the practitioner concerned. If it is in regard to standards of service, please complete the form overleaf and send it to us at Goodwood Court. Mrs Pell-Stevens will ensure that your views are noted, investigated and a reply sent to you.

As with comments we undertake to make a prompt reply, investigating the complaint and letting you know the action undertaken. If you are not completely satisfied we can advise you of the next most appropriate step.

GOODWOOD COURT MEDICAL CENTRE - where medical care and quality of service help us to care for you, your parents and your children.

Our Practice Commitment

• offer you an appointment the same day with a doctor if you have a problem that YOU feel is urgent.
• provide medical cover 24 hours a day EVERY DAY
• make authorised repeat prescriptions available by 8am the following day if requested by 8pm (Monday to Friday)

• keep to within 20 minutes of your appointment time
• deal with all requests for medical reports within 48 hours (Monday to Friday)
• obtain the best service we can for YOU from the Hospital sector
• answer your telephone call courteously within one minute.

• Inform us of any good or bad aspects of our service
• Come along to the Surgery rather than request a home visit
• Keep yourself as healthy as possible by taking advantage of the screening and preventive services that we have to offer

Goodwood Court Medical Centre

52 Cromwell Road

Hove

BN3 3ER

Comments

Suggestions

Complaints

To help us to offer you the very best in all-round health care we need to know what you think - when you are pleased with our services and when you are less satisfied.

YOUR COMMENTS INFLUENCE OUR POLICIES

Many thanks in advance for taking the trouble to complete this form.

SUMMARY OF COMPLAINTS RECEIVED DURING YEAR

PP 15 – Locums

Last updated 05/10/2009

NOTE that HPV vaccine is now administered to all females between the ages of 13 and 18 years – some through the school health system, others through Primary Care. This is not included in the above schedule as it varies year to year

Locums employed at Goodwood Court Medical Centre/Eaton Centre

PP16 Patient Confidentiality

PP5 also refers

Updated

Clinical Protocols (CP)

CP 1 – Preventive Medicine

cp 2 - Smoking cessation

CP 3 – PHLEBOTOMY

CP 4 – Child Abuse

CP 5 – Cervical Cytology

CP 6 – pre-conceptual care

CP 7 – Emergency Contraception

CP 8 – Purchasing & control of drugs

CP 9 – Contraceptive implant fitting & removal

CP 10 – Minor Surgery

CP 11 – EXPOSURE TO BLOOD BORNE VIRUSES

CP 12 – Management of the collapsed patient and anaphylactic shock

CP 13 – Asthma

CP 14 – Dementia

CP 15 – Mental Health

cp 16 – Child Health Surveillance

cp 17 – dEPRESSION

CP 1 – Preventive Medicine

Last updated 05/10/2009

Objective:

Medical services must be targeted towards the prevention of disease, and the promotion of healthy living for the benefit of all patients registered with the practice. Patients must be provided with information and guidelines on medical matters which may affect them.

Procedure:

• Patients receive periodic mail-shots offering cervical smears, a comprehensive immunisation programme and clinics which address special areas of preventive health care, for example obesity.

• Patients wishing to pursue the invitation are requested to telephone the surgery and make an appointment with the practice nurse who, unless otherwise indicated, will treat him or her.

• Information packs are produced for the benefit of the patients of the surgery. Those currently available are; New Patient, Maternity, Stop Smoking,. These packs contain information booklets and details of the services available together with any relevant forms. The packs are given out to patients upon enquiry or after consulting their doctor about these issues.

• The information packs are reviewed every six months or sooner if any new information pertaining to a pack becomes available.

• New patient packs are also sent out to anyone enquiring about the practice by telephone. This pack contains all forms that must be completed by the prospective patient.

• The practice brochure is included in the new patient packs and given out to enquirers at reception. The practice brochure contains information on how to contact the surgery and details of services and practitioners available. It is updated at least annually.

CP 2 – Smoking cessation

Reference; Information 5

Last updated 05/10/2009

Objective:

To ensure that the Practice identifies smokers and supports them in stopping smoking by providing literature and offering appropriate therapy.

Procedure

• Alyson Shaw will take the lead in smoking cessation management

• A Carbon Monoxide monitoring machine is used to monitor the carbon monoxide content in the lung. These are present in rooms 4 and 7 at Goodwood Court Medical Centre and in the Treatment Room at The Eaton Centre

• All new patients are required to complete a questionnaire. Three of the questions asked are (a) Do you smoke, (b) How much do you smoke and (c) Would you like to stop smoking? If yes, the new patient is asked to obtain a ‘Stop Smoking’ pack from reception and to make an appointment with a doctor or nurse. Alternatively they may complete a Self-Referral form and send it to the South Downs Health NHS Trust, Robert Lodge, Manor Place, Brighton BN2 5GG. Patients who complete a new patient questionnaire "online" can access smoking advice automatically on pressing a button on the questionnaire webpage

• Identification of smokers will be made using every opportunity – opportunistic in surgery, through questionnaires included in periodic mailings, during health checks and by response to information presented on the waiting room information displays.

• For existing patients every opportunity is taken to consider if the time has come to stop smoking. Patient who attend a clinic have their smoking status entered on the clinical system and updated approximately every 12 months.

• The ‘Stop Smoking’ pack contains up to date literature that helps and guides the smoker into giving up the habit. The pack is available on-line at http://www.goodwoodcourt.org/smoking_help.htm

• Other sources of information for smokers is available on a dedicated notice board in the waiting room at Goodwood Court Medical Centre, in patient leaflest available for collection and in dedicated mail shots sent periodically to patients who are known to smoke.

• Assessment of smoking will include

• Motivation to stop – whether there is true motivation to stop long term and how much support the patient has for this – family/work/health

• Smoking history – pack years and also current regular smoking quantity

This should be recorded in the patient record.

Last reviewed 05/10/2009

Taking blood samples may result from either a request by a Medical or Nursing Practitioner or when following protocols for disease management or prevention.

The patient can expect to be made welcome, comfortable and to be fully informed throughout the procedure

The requesting practitioner can expect to be informed if a sample has not been obtained or if there are any other problems.

The practitioner undertaking the phlebotomy procedure can expect to be made aware of any relevant information about the patient prior to taking the sample of blood.

Venepuncture is a potentially hazardous procedure and all care should be taken whilst ensuring the patient’s comfort and confidence.

Anyone undertaking Venepuncture should be fully immunised against Hepatitis B.

Those undertaking Venepuncture must have relevant qualifications or experience.

• CLINICAL INSTRUCTIONS

Requesting practitioner will complete the blood request form or will ensure information is easily obtained form the clinical records indicating the sample required and the reason behind the request.

It is the responsibility of the practitioner undertaking phlebotomy to ensure the completion of all details including checking the patient’s full name, sex, DOB and, where possible, Brighton Hospitals Record Number

Items used for the invasive part of the procedure will be sterile single use items and others clinically clean. Practitioners are responsible for ensuring that such supplies are available.

Entry for venepuncture should be as quick and painless as possible. Suitable veins should be identified in advance of venepuncture – inspecting both arms rather than the proffered arm. If tourniquets are applied they should be removed immediately before the venepuncture needle is taken out of the arm or immediately the needle is correctly inserted into the vein (particularly appropriate for calcium and cholesterol sampling)

Entry through the skin should only be considered if a vein is either palpable or visible. (No more than three attempts should be made at venepuncture.)

The needle should be exposed for as short a time as possible prior to venepuncture.

• PATIENT PROCEDURE

The patient is reassured and invited to make themselves comfortable whilst allowing access to a suitable site for venepuncture.

Necessary items are brought to the area of work.

Practitioners should be aware of the siting of resuscitation equipment and help-call facilities in the room

1. The needle is attached to the holder or syringe.

2. The details of the procedure are explained to the patient. (The patient may have previous experience of venepuncture and need very little explanation).

3. A tourniquet is applied.

4. The needle is introduced into the vein; care is taken to avoid puncturing both sides of the vein.

5. Vacuette bottles are introduced into the holder and blood is drawn directly into the Vacuette (or syringe).

6. The exchange of vacutainers/vacuette is smooth and the final blood tube must be removed prior to the needle being withdrawn from the vein. The tourniquet is removed prior to removing the needle from the vein.

7. Withdrawal of the needle from the vein is smooth but not dragging, cotton wool or a tissue should be applied to the site with firm pressure, often by the patient for a minimum of two minutes

8. A small dressing or pressure dressing can be applied in necessary.

9. Introduction of blood into a tube from a syringe should not be made through a needle but directly from the syringe.

10. Needles should be disposed of directly following venepuncture. The needle should NOT be re-sheathed. Disposal of sharps should be directly into the sharps box; other contaminants are transferred to the clinical waste bags.

In the event of a patient collapsing or feeling unwell,

• the patient should be laid flat and clothing loosened from around neck;
• The Alarm call should be activated to summon assistance
• The room should be cooled with fan/air conditioner
• If necessary first aid procedures may need to be implemented. See protocol CP12

If a patient has collapsed he/she should be observed for at least 15 minutes in the waiting room before being allowed to leave the premises. A drink and food should be offered.

In the event of blood spillage

Blood spilt onto the floor or other surface should be mopped using absorbent tissues by the phlebotomist (wearing gloves). The affected area should then be sprayed using the provided alcohol cleaning spray and left to dry before being further wiped-over with soap and water. If the floor remains wet, then a HAZARD warning cone should be placed over the affected area until natural drying occurs.

• COMPLETION OF CLINICAL PROCEDURE.

Filled blood tubes are immediately fully labelled with name and date of birth. Ensure that the name format matches the format on the request form. Where possible, please use the label printers provided to label the bottle directly from the patient’s clinical record. This will barcode the NHS number

Specimens are placed into the envelope attached to the form.

Data is entered onto the computer using code 41D0, and listing the tests ordered.

Patients are asked to contact the surgery in 5 days unless the Doctor has specifically requested to see them within 2 weeks.

Samples are deposited ready for collection in the collection box kept at Reception ready for transport by an approved contractor to the laboratories. Reception staff will check the identity of the Courier/Contractor prior to release of samples

Any needle stick injuries should be reported to a senior member of staff and a doctor as soon as possible. (see needle stick policy CP11)

Practitioners retain the right to refuse to perform phlebotomy on any patient.

If patients are referred to another practitioner or doctor for phlebotomy, details of why must be given to that practitioner prior to the patient’s attendance.

Domiciliary and hospital phlebotomy services are available if appropriate.

CP 4 – Child Abuse

Last updated 21/05/2010

PRACTICE LEAD Sister E C Higson

CHILD PROTECTION FOLDER Kept on bottom shelf of room 1 (treatment room), Goodwood Court

What is child abuse?

The Children Act 1989 provides the legal framework for defining the situations in which local authorities have a duty to make enquiries if it has ‘reasonable cause to suspect that a child who lives or is found in their area is suffering or is likely to suffer significant harm.

Child means any child or young person under the age of 18 years old.

Harm means ill-treatment or the impairment of health or development.

Ill treatment includes sexual abuse and forms of ill treatment, which are not physical.

Health means physical or mental health.

Development means physical, intellectual, emotional, social or behavioural development.

Where the question of whether harm suffered by the child is significant turns on the child’s health and development, his or her health or development shall be compared with that which could reasonably be expected of a similar child. There are no absolute criteria on which to rely when judging what constitutes significant harm.

Sometimes a single traumatic event may constitute significant harm, e.g. a violent assault, suffocation or poisoning. More often, significant harm is an accumulation of significant experiences, both acute and long-standing., which interrupt, change or damage the child’s physical and psychological development. Some children live in family and social circumstances where their health and development are neglected. For them, it is the corrosiveness of long-term harm. In each case, it is necessary to consider ill treatment alongside the family’s strengths and supports.

To understand and establish significant harm, it is necessary to consider:

The family context;

The child’s development within the context of their family and wider social and cultural environment;

Any special needs, such as a medical condition, communication difficulty or disability that may affect the child’s development and care within the family;

The nature of harm, in terms of ill-treatment or failure to provide adequate care;

The impact of the child’s health and development; and

The adequacy of parental care.

It is important always to take account of the child’s reaction, and his or her perceptions, according to the child’s age and understanding.

Categories of child abuse

Physical abuse – may involve hitting, shaking, throwing, poisoning, burning or scalding, drowning, suffocating or otherwise causing physical harm to a child. Physical harm may also be caused when a parent or carer feigns the symptoms of or deliberately causes ill health in a child whom they are looking after (Munchausen’s Syndrome by Proxy).

Emotional abuse – the persistent emotional ill treatment of a child such as to cause severe and persistent adverse effects on the child’s emotional development. It may involve conveying to children that they are worthless or unloved, inadequate, or valued only in so far as they meet the needs of another person. It may feature age or developmentally inappropriate expectations being imposed on children. It may involve causing children frequently to feel frightened or in danger, or the exploitation or corruption of children. Some level of emotional abuse is involved in all types of ill treatment of a child, though it may occur alone.

Sexual abuse – involves forcing or enticing a child or young person to take part in sexual activities, whether or not the child is aware of what is happening. The activities may involve physical contact, including penetration or non-penetrative acts. They may include non-contact activities such as involving children in looking at, or in the production of, pornographic material or watching sexual activities, or encouraging children to behave in sexually inappropriate ways.

Neglect – the persistent failure to meet a child’s basic physical and / or psychological needs, likely to result in the serious impairment of the child’s health or development, including non-organic failure to thrive. It may involve the parent or carer failing to provide adequate food, shelter and clothing, failing to protect a child from physical harm or danger, or the failure to ensure access to appropriate medical care or treatment. It may also include neglect of, or unresponsiveness to a child’s basic educational or emotional needs.

Recognising the signs

The child – Listen carefully to the child. Disclosure may be partial or disguised. Observe the child’s behaviour and demeanour. Take note of any ‘signs and symptoms’ in the way the child presents.

The parent / carer – How concerned is the parent? Note any admissions of responsibility. Be sensitive to any element of a ‘cry for help’. Be alert to inconsistency, vagueness or symptoms of stress shown by the parent / carer providing the report. Take particular note of avoidance, or the use of aggression to discourage enquiries.

The wider context / situation – delay in seeking help, poor or chaotic home / living conditions, lack of safety precautions or any previous pattern of abuse or neglect need to be taken into account.

Indirect signs – such as information from other sources, associations with a ‘known’ abuser, or general distress should be recognised as issues.

Medical assessments

Medical assessments must be carried out on all children where there are concerns that they may have been physically abused. This would include an assessment of the child’s growth and nutritional status and parental attention to the child’s health needs. An injury may be accidental but may have occurred as a result of inappropriate supervision by a parent. Often it is not possible to be certain whether an injury is non-accidental or accidental following a medical assessment. A medical opinion regarding the probability or likelihood may be given taking into consideration the following – the nature of the injury, the age of the child and the explanation as to how the injury occurred. Non accidental injury may co-exist with other forms of abuse. Where there are concerns about non-accidental injury it is essential that all siblings or children within the household are also considered and that medical assessment of them are also arranged.

Differentiation (bruises, bites etc)

Crown, Forehead, Nose, Spinal Protuberances, Elbows, Hands, Hips, Knees, Shins

Eyes, Cheeks, Ears, Mouth (in and out), Neck, Shoulders, Chest, Back, Upper Arms, Stomach, Genitals, Thighs, Calves, Feet

Petechiae: Results from sudden high pressure e.g. slap, squeeze

Hand-mark: A slap causes line of haemorrhage and bruising in skin. Gripping causes ovals from fingertips or lines from between fingers

Pinch: Small double bruises

Punch or kick: Irregular bruise with paler centre.

Human Bite: Two semicircles sometimes heal leaving just one or two teeth mark scars.

Ligature: Linear pink mark, haemorrhage or pale scar, especially at wrists, ankles, neck or male genitalia.

Implements: e.g. belt or stick may leave an outline.

* Head & Neck injuries

Bruised eyes: One bruised eye should be treated with some suspicion but may be accidental: two bruised eyes are highly suspicious.

Ear injuries: Ears are not often injured accidentally. Pulling, slapping, twisting cause redness, bleeding, bruising of ear or behind it. Internal ear damage needs to be excluded.

Face & Head: Bi-lateral injuries are suspicious.

Mouth: A torn frenulum is highly suspicious as are broken teeth and mouth injuries.

Genital area & thighs: Bleeding, bruising walking awkwardly.

* Burns & Scalds

The absence of an appropriate history raises concern. Multiple burns are concerning without a clear explanation: multiple old scars may be an incidental finding. Inflicted burns often have clear outlines of implements or objects and may scar.

Cigarette burns: Are characteristically circular punched out lesions 0.6 – 0.7cm in diameter; healing usually leaves a scar. Healing cigarette burns can be difficult to distinguish from other skin conditions. Accidental cigarette burns are usually superficial, asymmetrical and uncommon.

Friction burns: Result from being dragged.

Scalds: Non-accidental forced immersion scalds are more likely to have clear demarcation lines without splash marks. Non-accidental splash or thrown scalds are more likely to be on unusual sites e.g. backs of hands, genitalia, extending from mouth across face or on different sites of the body.

* Fractures

A vague or inconsistent history is highly suspicious.

Fractures in children younger than 12 months are more likely to be non-accidental than accidental unless there has been a major accident. Arrange x-ray.

Initial x-rays can e normal.

There may be no bruising after a fracture.

* Poisoning, and Fabricated or Induced Illness

Accidental poisoning usually has a clear history and response and is commonest between 18 months and 3 years. Poisoning may be associated with neglect. Deliberate poisoning should be considered when symptoms could not otherwise be explained. Fabricated or induced illness includes a range of symptoms and presentations – usually recurrent or persistent, often dramatic, unexplained or inconsistent and with a history of multiple presentations for medical advice.

* Self-harming and Siblings

* Infants (under one year olds)

Minor injuries in non-mobile infants, fractures, burns and major injuries in children below one year old must be regarded with extreme concern and a detailed history of the injury obtained from the parent / carer. In particular injuries to the head, face or mouth should be carefully investigated. Any injury and explanation of injury must be assessed in relation to the infant’s developmental abilities and matched against the likelihood of occurrence within a normal population of infants. Infants are particularly vulnerable to serious injury without obvious physical signs e.g. shaking injuries resulting in internal head injuries. Physical injuries in infants may be life threatening or cause permanent neurological damage.

* Shaken Baby Syndrome

Shaking a baby often results in no visible injury. Nevertheless significant internal injuries may be caused such as intra-cranial bleeding, brain injury, small fractures to the ends of the long bones, other fractures (such as ribs and neck) and retinal haemorrhages. Signs and symptoms can be non-specific which may result in a delay in seeking advice.

The infant can present with:-

Lethargy, Poor Feeding, Vomiting, Stops breathing or stops in breathing, Pallor, Variable consciousness, Irritability, Convulsions

In suspected cases it is essential that an opthalmological examination and skeletal survey be carried out.

3) Responsibilities of Staff

A) General Practitioners and Nurses

Have a vital role to play in the protection of children. They are well placed to identify at an early stage family stress that may point to a risk of child abuse. They may also notice in the child indications of significant harm, or likelihood of significant harm. Doctors have an extensive knowledge of the family background enabling them to make a particular contribution to child protection and to the long-term support of the child and family. With this in mine from 2006 the Goodwood Court Medical Centre will provide an Enhanced Child Protection Service. The recognised lead for this is Sr Higson.

• New patients who are under 16 must complete a New Patient Questionnaire specifically designed for children. Those who are 16 and over will be asked to complete the Adult Questionnaire. Reception staff will check the questionnaire through with the patient. Withheld information may result in the application being rejected.

• The doctor or practice nurse seeing the child on registration must update the contract system using the following morbidity codes:

9180. in free text, the main carer’s name, their relationship to the child (this should include parents or those with parental responsibility) and contact details.

13Z4. in free text, the child’s school. Do not forget to update this field if the child changes school.

13E.. in free text, inadequate or unsatisfactory housing or housing problems.

• Following registration, the doctor who sees the child or when notes are received from the previous clinic will update the clinical system with the following morbidity codes where or when applicable:

68R2. to indicate that new patient screening has been completed.

64RA.. to indicate that the child has been referred to Social Services.

13M. to indicate that the child has been placed on the Child Protection Register.

13IO. to indicate that the child has been removed the Child Protection Register.

13G2. to indicate that a Health Visitor visits the child.

13IS. to indicate a child in need.

• If after raising the matter with other doctors in the practice concern remains that a child may be at risk or is the subject of abuse of whatever nature, then Sr Higson will contact the social services and follow it up in writing within 48 hours. The contract system will be updated using code 64RA. as above.

• Contemporaneous and comprehensive notes where child protection concerns are raised, including all phone calls, must be retained in the patient file.

• Annually, the practice will hold at least one significant event analysis around child protection or around concerns about children in need.

• After obtaining parental consent, Sr Higson will inform the relevant authorities including schools or health visitors of families where severe mental health, drug or alcohol abuse or domestic violence has been identified. The aim is to provide additional support for the family.

• The practice will maintain a register of families that are targeted by the Health Visitor. Inclusion on the register will be noted on the clinical system so that anyone who uses their record is aware.

• For audit purposes the practice will maintain the following data:

The number of children <16 years old currently registered with the practice

The number of children <16 years old registered since 1^st April 2006.

The number of children >5 years old registered since 1^st April 2006.

B) General Practitioner employed staff

Non-clinical general practitioner employed staff have the opportunity to observe patients in the waiting areas. Any concerns must be reported to their General Practitioner.

There were concerns following the Climbé enquiry that the ability to recognise child abuse is believed to be limited to "professionals". Goodwood Court encourages its staff to learn more about recognising child abuse. The NSPCC have produced a four part "learning package" and this is being made available to all staff as part of the standard practice training protocol.

Brighton and Hove Child Protection Procedures

Useful Telephone Numbers

Child Protection Register

Weekdays 01273

Out of hours 01273

Social Services Duty and Assessment Team

Weekdays 01273

Out of hours 07699

Police CPT 01273

Designated Professionals for Child Protection

Dr Sian Bennett Consultant Community Paediatrician, MacKeith Centre, Royal Alexandra Children’s Hospital 01273

Pauline Lambert Community Nurse Consultant/Child Protection 01273

ACTIONS to be taken by practice staff/practitioners in respect of communications received for children at risk and to be actioned when a patient changes practice

Storage of minutes & summaries of case conferences/discussions

This guidance is to assist GPs and is not intended to be prescriptive

READ CODES and Child Protection

As a minimum the following READ codes should be used:

CP 5 – Cervical Cytology

Reference; Cervical Screening CS2

Last updated 09/01/2010

Objective

Female patients of the practice are offered cervical cytology screening to a default 3 or 5 year time interval depending on age. The responsibility for inviting patients to this screening service is passed to the Primary Care Support Service (PCSS). Failure to respond to two invitations alerts the PCSS to notify the practice. This protocol determines the action to be taken by the practice to continue to offer cervical cytology.

Procedure

1. Defaulters

Irrespective of the receipt or otherwise of defaulter notification from the PCSS an annual review of patients without cervical cytology recorded in the preceding 3 years (five years for those over the age of 50 years) is undertaken by Dr Higson in conjunction with Miriam Corfield. This will include accessing the NHS Open Exeter system which records cervical cytology. Where no record of a smear from the NHS or elsewhere is found, then a standard letter is forwarded to the last known address of the patient inviting them to have a cervical smear test. The computer is also programmed to alert the computer operator by an obvious "reminder" when a cervical cytology test has not been undertaken within the preceding 3 years (or for patients over 50 years of age – preceding 5 years).

Patients are not "exception reported" for failure to have a cervical cytology test. Those patients for whom a test is inappropriate may be exception reported by discussion with the patient/carer and the responsible medical practitioner. The practice will only exception report for patients who have had a hysterectomy (including removal of cervix) for benign clinical morbidity or who are genetically male.

PREGNANCY

Cervical screening in pregnancy

• If a woman has been called for routine screening and she is pregnant, the test should be deferred.

• If a previous test was abnormal and in the interim the woman becomes pregnant, then the test should not be delayed but should be taken in mid-trimester unless there is a clinical contraindication.

• If a pregnant woman requires colposcopy or cytology after treatment (or follow up of untreated CIN 1), her assessment may be delayed until after delivery. Unless there is an obstetric contraindication, however, assessment should not be delayed if a first follow up cytology or colposcopy is required following treatment for cGIN, or treatment for CIN 2/3 with involved or uncertain margin status.

The colposcopist may wish to perform only colposcopy at a follow up appointment in pregnancy.

If repeat cytology is due, and the woman has missed or defaulted her appointment prior to pregnancy,consideration should be given to her having the cytology or colposcopy during pregnancy.

2. Abnormal Smears

The practice is informed of the smear results by the PCSS / NHS recall system and an entry is made in the patient’s clinical record on the computer system. The results may be normal, abnormal or inadequate. The patient receives similar notification from the pcss/laboratory/NHS recall system unless the cytology report reports Severe dyskaryosis/?invasive carcinoma (cytology results code 5) or ?Glandular neoplasia (cytology results 6) – in the latter cases, the colposcopy unit at the Royal Sussex County Hospital will contact the patient directly with an appointment.

The laboratory will refer to a colposcopist within 2 weeks of the laboratory report if the following test results are present;

• Severe dyskaryosis with features suggesting possible invasion
• Severe atypical glandular cells are present suspicious of adenocarcinoma
• Malignant cells are present

The laboratory will refer to a colposcopist within 4 weeks of the laboratory report if the following test results are present;

• Moderate or severe dyskaryosis
• Atypical glandular cells present which suggest an in situ abnormality of the endocervix

Referral to be seen by a colposcopist within 8 weeks of the decision to refer includes women with persistent borderline or mild dyskaryosis.

Where neoplastic glandular cells are identified, it is not possible to distinguish in situ from invasive glandular neoplasia nor is it possible to ascertain the site of origin of the cells. Such cases should be referred to a gynaecologist and advice will be given on the laboratory report

Abnormal results are entered in an Excel database by Dr Higson. This includes names and address of the patient as well as recording the advised date of any early recall. This spreadsheet acts as a back up to the computer clinical system and is used to make early recalls as needed. Sample letter follows the Defaulter letters.

The following are Colposcopy Clinics in East Sussex and Brighton & Hove

3. Audits

Cervical screening reduces mortality from carcinoma of the cervix. It is vital that high standards are maintained to continue its success. Smear quality correlates with the rate of detection of significant cytological abnormalities. Therefore monitoring the frequency of inadequate smears is part of the quality assurance process of the cervical screening programme.

The minimum standard to which smears must be adequate is 93% and a continual audit by smear taker (doctor or nurse) is required by the PCT. The audit is carried out using extraction techniques from the computer system.

The breakdown of reasons for a smear (cytology specimen) being reported by the local laboratory as inadequate is shown below. Inadequate rates often reflect poor smear-taking technique which could be resolved by retraining. However please note that laboratories no longer give a reason why a smear sample is inadequate.

The NHS recommends that all smear takers undertake a recognised smear course, i.e. Marie Curie Cervical Screening (2 day), Cervical Screening and Women’s Health Issues Module (5 day, University of Brighton) or Family Planning Module (15 day, University of Brighton). All smear takers should update their skills every three years. The update courses also enable takers to obtain information on recent and/or future changes to the programme. The Goodwood Court Medical Centre endorses this recommendation. Please liaise with Dr Higson.

Exception reporting

The practice will only exception report patients who have no cervix. This may be for any of the following reasons:

• Hysterectomy for benign reasons (eg fibroid).
• Transsexual patients who are genetically male

The reason for exception reporting will be recorded in the clinical record but remains confidential to the practice and the patient. The vaccination of a women with HPV vaccine does NOT preclude the need for participating in the Cervical Screening programme.

As with all tests undertaken at the practice, the responsibility for obtaining a result of the test lies with the patient and she is informed of this at the time of the procedure with an indication of the current time period before which a result is expected (12 weeks at time of this protocol review). The responsibility for forwarding a normal or early recall result to the patient lies with the PCSS. The laboratory in liaison with the colposcopy unit is responsible for informing patient of the date and time of further investigation if colposcopy is indicated. The practice has a fail safe mechanism for ensuring patients are not lost to the system by a separate periodic check on those with abnormal or early recalls.

Should a patient move residence in between having the smear test taken and the result being forwarded, then that responsibility for ensuring a result is obtained is the patient’s. Should an abnormal smear result be undelivered and the practice are informed, then the practice staff will make all effort (mobile phones, emails etc) to contact the patient.

Disabled Patients

Disabled women have the same right of access to cervical screening as other women and as such should not be exception reported

Disabled women should not be assumed to be sexually inactive

Disabled women are entitled to information in an appropriate format in order to make their own decision about whether to attend for cervical screening

.

The community learning disability team has an important role in preparing a woman for her cervical screening test and should work closely with the test taker to ensure that women who attend for screening have an understanding of the screening process and how the test is taken. The following may be used by a screening practitioner to assess a woman’s understanding:

• Does the woman have a basic understanding of why cervical screening tests are taken?
• Has she had a test before?
• Has she been invited for a routine test, or for a follow up test after a previous one?
• Has she seen a copy of the picture leaflet?
• Can her supporter confirm that cervical screening has been explained to her?

The screening practitieorn may decide not to carry out the screening test if she thinks that preparation has not been adequate. The woman should be given the opportunity for further explanation and consideration before making another appointment to have screening undertaken.

Establishing consent to cervical screening can be a complex process and guidance and assistance should be sought from the Community Learning Disability Team based at 86 Dennmark Villas, Hove. In exceptional circumstances, where a woman is not able to consent to cervical screening but is thought to be at a very high risk, for instance where there is concern about multiple sexual partners or sexual abuse, a clinician may consider taking a cervical screening test under general anaesthetic. This is a clinical judgement and is not part of the cervical screening programme

Resources:

Equal access to Breast and Cervical Screening for Disabled Women – NHS Cancer Screening Programmes – NHS Cancer Screening Series No 2; March 2006 ISBN 1 84463 029 3

Keeping Healthy 'Down Below'

Training

All those registered as "smear takers" in the practice will undergo retrainng and updating at least once in every three years. This training is at the cost of the practice and will be training that has been approved by the Primary Care Trust senior nurse as appropriate

The training requirements are monitored through the Personal Learning Plans and annual appraisal

Dr. Nigel Higson, Dr. John Williamson

Dr. Milind Jani & Dr. Janet Wilson

Goodwood Court Medical Centre & The Eaton Centre

52 Cromwell Road

Hove

BN3 3ER

Fax: 0844 884 0152

Date as postmark

Dear Patient

Every so often I search through medical records to be able to remind patients about various matters which may help their health. One of these tasks – a rather massive task, hence I only do it once or twice a year – is to remind patients about cervical smears.

The cervical smear is a simple test where a few cells are lifted from the surface of the cervix using a plastic "brush". These cells are then checked under the microscope at the laboratory to see if there is any indication of infection or early pre-cancerous changes. By detecting changes before they develop into significant problems means that simple measures can prevent cancer. We recommend that all women between the ages of 25 and 49 years have such a test every three years and those between 50 years and 64 years have a test every 5 years. If you are over 65 and have not had a test for some years, we recommend two further tests to check all is well.

Our computer record has shown that we have no such test result for you in the past 3 to 5 years and hence I am writing to ask for your help in undertaking one or more of the following actions:

EITHER:

1: If you have had a test in the last 3 to 5 years, please write to me or phone my staff to advise when and where the test was undertaken and the result – we can then update your records – Also please let us know if you have had a hysterectomy for non-cancerous reasons.

OR:

2: If you would really rather not have a test, given all the stated benefits of regular testing, then please ignore this letter. We will write to you periodically just to offer the test as we believe in its benefits … please let us waste our postage and throw the letters away as you wish (there is no need to advise us)… if ever you change your mind, just get in touch to arrange a smear test .

OR

3: Please phone us on 733620 or 0844 477 0925 to arrange to have a cervical cytology (smear test / Pap smear) undertaken. This will usually be undertaken by one of our female nurses. It is best not to be in your menstrual period at the time of the test.

We will advise you if the result of your test is normal or if it requires any further action. At present test results take about 6 weeks to be returned to the practice.

Kind regards Dr Nigel Higson & team

Dr. Nigel Higson, Dr. John Williamson

Dr. Milind Jani & Dr. Janet Wilson

Goodwood Court Medical Centre & The Eaton Centre

52 Cromwell Road

Hove

BN3 3ER

Fax 0844 884 0152

30 August 2010

Letter to patient who requests no screening

Dear

Thank you for informing me that you do not wish to take part in the National Cervical Cytology Screening Programme. We are sorry that you have made this decision as we know how successful this programme has been in detecting changes before cancer develops. However, as a practice, we respect your views.

I would advise you to write to the cervical screening recall service – Primary Care Support Service, Brooklands Business Park, Lancing to request them to cancel further recall. Ms Boer is the administrator of the NHS Cervical Cytology recall system for this area. Ms Boer may send you a formal statement to confirm that you understand the implications of withdrawing from the programme.

As with all systems, sometimes things go wrong and I apologise to you if you do receive further invitations. please ignore them..

If at any time you wish to be reinstated into the screening programme, then contact me in person or by letter.

After an interval of five years from the date that you withdraw from the screening programme I am required to check that you still do not wish to be included in the recall system

Kindest regards

Dr N Higson

Dr. Nigel Higson, Dr. John Williamson

Dr. Milind Jani & Dr. Janet Wilson

Goodwood Court Medical Centre & The Eaton Centre

52 Cromwell Road

Hove

BN3 3ER

Fax 0844 884 0152

30 August 2010

To PCSS

Patient details:

Name:

Date of Birth

Address

NHS number

This lady has requested removal from the cervical cytology recall system. I have asked her to write to you to authorise suspension from the recall process.

With thanks

Dr. Nigel Higson

Dr. Nigel Higson, Dr. John Williamson

Goodwood Court Medical Centre & The Eaton Centre

52 Cromwell Road

Hove

BN3 3ER

Fax 0844 884 0152