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Dilemma: Hospital sends patient for pre-op MRSA screening



A patient awaiting a hip replacement attends the practice to request MRSA screening – normally done in hospital. But you find the service has been stopped and patients are being sent to their GP. Your partners insist this is not a core service – what do you do?

Dr Sam Creavin duo

GP partner view: Check if screening comes under an enhanced service

Do you have the energy to push back against this workload shift, or will you agree to the request so the patient can get the operation that they have been waiting for in pain? GPs have no requirement under core PMS or GMS to deliver MRSA screening, but the practice manager should check there is no obligation under a local enhanced service or similar arrangement.

If not, government guidelines on MRSA screening indicate the onus is on the hospital, and the remuneration tariff for payment by results includes preoperative assessment.1,2 Trusts have an additional incentive to screen because they may be fined for cases of MRSA bacteraemia3 and indeed a post-infection review may be required.4

Given the importance of getting all this right, there is an argument that the work should be carried out by the specialist service that is remunerated for doing it.

Your decision may set a precedent for the practice, so try to reach an agreement with your partners. If you decide not to offer the screening then it’s important to observe the GMC’s Good Medical Practice. Paragraph 44 states that ‘you must contribute to the safe transfer of patients between healthcare providers’ and 46 that ‘you must be polite and considerate’.5 The BMA template letters for resisting workload shift may also help.6

You might decide to ask your LMC to take up the matter with the CCG and work with the trust to reach a solution.

Dr Sam Creavin is a GP partner in Thornbury, South Gloucestershire

dr john allingham crop

LMC view: Refuse the work collectively

The core principle of the GMS contract is ‘treat those who are ill or believe themselves to be ill’ and the provision of pre-op MRSA screening does not meet this criterion.7 This work sits with secondary care.

It is important that the partnership takes a unified approach and pushes back together, because if one GP agrees to do the work word will go round and divide and rule with prevail.

Politely refer the patient back to the specialist. Contact the orthopaedic commissioner via the CCG to ask whether they have authorised a change in the provision of the service. If they have, an enhanced service should be commissioned to ensure the work is funded and completed to an agreed specification.

You should inform your LMC so it can collate issues from any similarly affected practices and represent all in negotiations with CCGs and hospital trusts to ensure this transfer of work either stops or is funded.

You must also consider the needs of the patient and share information. Apologising to them for the inconvenience and copying them in on correspondence may gain you their shared understanding and even support.

You could also share this with the practice’s Patient Participation Group as an example of work that diverts appointments from sick patients.

Dr John Allingham is medical secretary at Kent LMC

Roopinder Brar duo

Medicolegal view: Ensure your patient’s care is not compromised

It is unfortunate that clear communication between the hospital and GP has apparently not occurred. The hospital should have consulted local primary care teams before stopping the service to discuss the feasibility of redirecting patients to primary care for MRSA screening.

That said, while GPs may not view MRSA screening as a core service, the patient’s care should not be compromised by the hospital’s decision. Both hospital and GP should understand their duties and work together to provide care to this patient, which in this case may mean the GP does the screening. This might seem to be just another thing on the GP’s plate, but not carrying out the screening could delay the procedure, cause additional pain or discomfort and may lead to increased consultations with the GP or prescription medications.

The GP can still relay concerns to the hospital that the primary care team is unable to offer an MRSA screening service long term. You may also want to discuss the matter with the BMA for advice about contractual obligations.

Dr Roopinder Brar is a practising GP and medical adviser at MDDUS

References

1 Department of Health. Implementation of modified admission MRSA screening guidance for NHS. 2014.

2 NHS England and NHS Improvement. 2017/18 and 2018/19 National Tariff Payment System

3 NHS England. NHS Standard Contract 2017/18 and 2018/19 Technical Guidance 

4 NHS England. Update on the reporting and monitoring arrangements and post-infection review process for MRSA bloodstream infections

5 GMC. Good Medical Practice. 2013

6 BMA. NHS England standard hospital contract guidance 2017-19

1 UK Government. Standard GMS Contract. 2013