GP practices need to carefully consider the risks of taking on specialist locally enhanced services (LES), after a coroner warned a practice had not followed national guidance, the BMA has said.
The union’s GP committee has advised GPs to reconsider providing compression bandaging through LES arrangements after a coroner singled out a practice for criticism, following the death of a 58-year-old woman from sepsis.
The advice issued to practices this month through their LMCs came after a coroner in West Yorkshire ordered a practice to set out how it would prevent future deaths.
In a report following an inquest, assistant coroner Emma Mather raised concerns that the GP practice did not follow the lower limb framework, failed to refer to tissue viability appropriately, and failed to escalate concerns around the deteriorating wound or consider appropriate measures to support the patient to attend more regular appointments.
The patient had injured her leg and was seen by her GP practice several times over 11 months for help managing the wound, before being admitted to hospital with an acute infection. She died two days later with the cause of death given as septicaemia and soft tissue infection leading to pneumonia.
In its advice to practices, the BMA GP Committee (GPC) said the case ‘has drawn attention to the potential risks in providing this specialist service’.
In the advice, seen by our sister publication Pulse, the GPC said: ‘Colleagues should now consider whether providing an enhanced service in a general practice setting remains appropriate for these patients in light of the coroner’s response to the case and the associated risks for both the GP practice and patients.’
Practices providing an enhanced service need to be ‘fully aware’ of the recommendations and timeframes for assessment and intervention in this ‘specialist clinical area’ before agreeing to take on this work, it continued.
It also noted that the Multi-Professional Advanced Capabilities Framework for Lower Limb Viability was 46 pages long and had not been developed with input from general practice.
‘Practices who sign up to a compression bandaging enhanced service must be well sighted on its contents as it has been clearly demonstrated by the coroner’s response in this case that the GP is expected to take on responsibility for all those working within the multi professional team including district nurses,’ it said.
The advice also pointed out that health secretary Wes Streeting has committed to three ‘strategic shifts’ for the NHS, which includes moving care from ‘hospital to community’.
It added: ‘Local enhanced services provide the ideal platform to enable this strategic shift but increasingly GPs and practices will need to consider whether they are adequately supported (in every sense of the word) to take on this specialist work in the community and whether they are willing to take responsibility for the actions and supervision of the wider multidisciplinary team.’
It is understood that West Yorkshire ICB has put in place a new leg ulcer service to start in April, so all lower leg wounds can be seen directly by this service rather than practices.
GPs in several areas are coming together to serve notice to their ICBs on ‘unfunded work’ as part of collective action.
Gateshead and South Tyneside LMC chair Dr Paul Evans said that because compression bandaging is not a GMS service, many practices including his own stopped providing it even before collective action, although there are some that still offer it.
He said: ‘Any practice that continues to undertake this work needs to understand the risks involved, as highlighted by this case, and ensure that payment for the service is enough to compensate for the time and expertise needed to mitigate these risks.
‘Of course, if practices wish to take on high-risk work without resource to compensate for the time of the staff needed to deliver it safely, this is up to them.
‘However, as an LMC representative I have advised practices locally to consider this case as an exemplar.’
A version of this article was first published by our sister title Pulse
