GP PRACTICE STAFF TRAINING MANUAL 2017

for Receptionists, Medical Secretaries

and Administrative Staff

GP Practice Staff Training Manual

This new Training Manual is intended for use by Practice Managers with Medical Receptionists, Administrative, Secretarial, Data Input Staff and Clerical Staff working in GP Surgeries.

July 2017

Author – Robert Campbell E – kingfisherpm@hotmail.comW – gpsurgerymanager.co.uk

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Introduction The Manual offers seven sessions to help Practice Managers train practice staff and includes exercises and questions that might be used during those sessions.

A starting point for training new practice staff is to implant an understanding of confidentiality. Then staff need to develop reception and telephone skills. Moving on the Manual looks at tasks that might occur whilst working at the reception or on the telephone. It has to be said that in general practice no two days are alike and whilst there is a regular pattern of issues and tasks that come up there is always something new.

Whilst CCGs provide some training for practice staff, there is limited on-site training available for practice staff. Many years ago, there were at least two video-based training systems, including Practice Makes Perfect along with local college courses for Medical Secretaries. Radcliffe Medical Press also published a series of books aimed at GP Practice Staff. There are specialist courses available for Life Saving Skills, First Aid, Fire Safety and Adult/Child Safeguarding, along with sessions for nursing and clinical staff but these sessions will come with a small cost or be offered free by the local CCG.

One to One or Group training can of course be supplemented by Staff Training Handbooks or Manuals and by documents setting out policies, procedures and protocols. Practices should consider appointing someone responsible for training and carrying out individual training needs assessments for staff so that each employee has a training and development plan.

A significant factor in the provision and take up of training is funding. The take up of ‘free’ training is fast whilst paid training sessions or courses suffer from a lack of willingness to pay. A manual of this type is easily kept up to date and can be developed and adapted to suit local circumstances ‘free of charge’. The author asks to be kept informed of any significant amendments made by Practice Managers or Trainers. Email – kingfisherpm@hotmail.com

Robert Campbell

July 2017

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Table of ContentsIntroduction.......................................................................................................................................2

SESSION ONE.....................................................................................................................................5

Confidentiality...................................................................................................................................5

Chinese Whispers..........................................................................................................................5

Visual and Verbal Breaches............................................................................................................6

Safeguarding Vulnerable Children and Adults...............................................................................7

SESSION TWO....................................................................................................................................9

Reception and Telephone Skills.....................................................................................................9

Reception Skills..............................................................................................................................9

Accompanying Children.................................................................................................................9

Telephone Skills...........................................................................................................................10

SESSION THREE................................................................................................................................11

Dealing with Difficult Patients – Tricky Encounters.....................................................................11

Zero Tolerance.............................................................................................................................14

SESSION FOUR.................................................................................................................................15

Administrative Activities..............................................................................................................15

Taking Messages..........................................................................................................................15

Registering Patients.....................................................................................................................15

Text Reminders and Online Services............................................................................................16

Appointments Systems................................................................................................................16

Repeat Prescriptions....................................................................................................................17

Test Results..................................................................................................................................17

Medical Certificates.....................................................................................................................17

Petty Cash....................................................................................................................................17

Chaperone Duties........................................................................................................................18

Patient Charges............................................................................................................................18

SESSION FIVE...................................................................................................................................19

Information Technology..................................................................................................................19

NHS Smart Cards..........................................................................................................................19

NHS Email Address.......................................................................................................................19

Use of Social Media.....................................................................................................................19

Practice Web Site.........................................................................................................................19

GP Clinical Computer System.......................................................................................................20

Scanning and Data Input..............................................................................................................20

Data Input....................................................................................................................................20

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SESSION SIX.....................................................................................................................................21

Medical Records..........................................................................................................................21

Access to Records by the Patient.................................................................................................22

Access to Records by a Third Party..............................................................................................22

Access to Records can be Refused or Not Disclosed....................................................................22

Competent People.......................................................................................................................23

Children and Young People - Gillick Competence........................................................................23

Parents.........................................................................................................................................23

Mental Capacity...........................................................................................................................23

Next of Kin...................................................................................................................................23

Police...........................................................................................................................................24

Solicitors......................................................................................................................................24

Anonymised Information from Medical Records.........................................................................24

Medical Terminology...................................................................................................................25

Prescription Writing Abbreviations..............................................................................................25

Consultants and their Clinical Areas............................................................................................26

SESSION SEVEN................................................................................................................................27

Complaints and the National Health Service...............................................................................27

Handling Complaints....................................................................................................................27

Practice Leaflet............................................................................................................................28

National Health Service...............................................................................................................28

General Practitioners...................................................................................................................29

Partners and Salaried GPs............................................................................................................29

GP Contract and Enhanced Services............................................................................................29

EPILOGUE........................................................................................................................................30

Use of Presentations....................................................................................................................30

BONUS SESSION...............................................................................................................................31

Time Out for Practice Staff...........................................................................................................31

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SESSION ONE

Confidentiality

This Session examines Confidentiality and offers guidance particularly for newly appointed practice staff. No matter what post or position you hold in a surgery a knowledge of the need to keep ‘mum’ is essential.

“Listen. Do you want to know a secret? Do you promise not to tell” (Lennon and McCartney)?

Bond of Confidentiality

Probably one of the most important cornerstones of training general practice staff in a medical surgery is emphasising the need for a strong bond of confidentiality in the practice and an awareness of the risks of breaching that bond and breaking patient and practice confidentiality.

“Closer. Let me whisper in your ear” (Lennon and McCartney)

Chinese Whispers

EXERCISE - Beware of “Chinese Whispers”, verbal messages that change their content as they are passed from one person to another. Always check the content of a message with the originator of the message. You could prepare your own message like this one.

“Dr Smith came in this morning having witnessed a robbery at 9:30am at the NatWest bank in Pudsey High Street. The two men were wearing Mickey Mouse and Donald Duck masks and one was carrying a sawed off shot gun.”

In a group of between five and ten staff ask the staff to quietly pass the message quickly along the line after you have read it out loud. Ask the final member to speak out loud. The likelihood is that the message will be quite different at the end if the line, which casts doubt on passing messages verbally around the Practice.

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Visual and Verbal Breaches

To this end, the bond of confidentiality needs to be adhered to equally by all doctors, nurses, clinical staff, practice staff and visiting health professionals. It should even extend to medical students, cleaning staff, work experience staff and apprentices. Confidentiality can be breached visually and verbally, by seeing things, hearing things and saying things. To quote a famous song it's a matter of remaining deaf dumb and blind kid!

Visual Examples

Visually care needs to be taken during the use of GP clinical computer systems, including the management of passwords and use of NHS Smart Cards. Computer screens should not be left live and unattended with smart cards connected. Computer users should ensure that screens revert to a screen saver when the keyboard has not been used after say five minutes. Handheld Clinical records and correspondence should not be left visible on desks or cabinets unless in a secure area. When moved around the surgery hand held records and clinical letters should be placed in sealable plain envelopes or folders. Staff scanning documents into a patient's records need to be aware of the importance of selecting the correct patient as an incorrectly filed letter is like finding a needle in a haystack. Unless responsible for data input staff should not spend time reading the documents.

Conversations

Verbally care needs to be taken in any public conversation with a patient or patients representative to be sensitive to the content of a conversation and be aware of being overheard. The use of a loud voice should be avoided as should the open use of names. The privacy of those talking at a reception counter should be respected for instance by organising the queue or offering an alternative location for the conversation. The taking of telephone calls at a reception counter by staff should be discouraged. Practice staff will frequently be in a position of overhearing conversations between other members of the practice and need to be aware of the dangers of repeating such conversations whether it be in or outside the practice premises. Conversations should not take place about one patient in front of another patient. Staff should be discouraged from ‘spending the time of day’ with patients at the reception counter whilst other people are waiting in a queue.

Privacy of Attendance

Practices should consider using a patient call system that avoids naming a patient. Patients can be allocated a number to represent their appointment. The attendance of a patient at the surgery in a personal matter for the patient and care should be taken not to reveal the presence of a patient in a consultation to anyone enquiringly, including a relative. Where a CCTV system is in use, ensure that warning notices are posted when in use. Disclosure of Information

Finally, members of the practice must not repeat outside the practice to for instance, family, friend and neighbours any information gleaned about a patient whilst working at the surgery. This would be regarded as a serious breach of confidentiality. Reception staff need to be aware that ‘bogus’ callers will attempt to obtain information about patients from the Practice. Staff should offer to ring back if in doubt and refer the enquiry to the Practice Manager. Staff should understand that clinicians, such as dentists, pharmacists, physiotherapists and chiropodist do not have an automatic

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right to access a patient's record. There are circumstances where information about a patient's health record might be disclosed and this is discussed in the Medical Records Session.Safeguarding Vulnerable Children and Adults

Practice Staff, in particular, receptionists will come into contact with large numbers of patients, their relatives, partners and friends. In doing so they will become aware of information about that person in the normal course of events. However, there may be occasions when that ‘information’ rings a bell and gives rise to concern. ‘Safeguarding’ according to the Care Quality Commission means protecting people’s health, well-being and human rights and enabling them to live free from harm, abuse and neglect. Each Practice will have appointed a lead clinician, doctor or nurse to deal with safeguarding issues. However, all practice staff are responsible for Safeguarding. The CQC expect Practices to provide training for their staff and for staff to be well versed in actions they might take should they witness or become directly aware of any abuse or neglect of a vulnerable child or adult. It is not necessarily a matter of leaving it to the clinician who has a clinical encounter with a patient as a receptionist may well witness (hear or see things) that might be rise to concern.

EXERCISE – Discuss the type of incident that might give rise to concern about the safety of a child or adult. Which patients might be more vulnerable than others?

Examples might include:Children at Risk RegisterRegistered DisabledWheelchair UsersHousebound patients, with or without a carerBlinds PersonsUnaccompanied ChildrenPatients with a Mental Disorder or Physical impairmentsRecord of Domestic ViolenceRecords of Falls, In the ElderlyRecord of Drug or Alcohol Abuse

Disciplinary Action

A proven breach of confidentiality might result in disciplinary action. Staff for instance should be discouraged from raising clinical issues about family with health care professionals attending the surgery, for instance, with community midwives, health visitors and district nurses.

Below is a gentle reminder of things to consider when trying to keep ‘Mum’.

CONFIDENTIALITY ‘Credit Card’

CAUTION - think before respondingCHECK – who wants to know - consent?CLARIFY – why do they need to know?

CALL-BACK – confirm ‘credentials’CODE – anonymise, when necessary

CONDENSE – stick to ‘relevant’ information

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EXERCISE - Thinking about your own position as a patient or as an interview candidate what ‘sensitive’ information about yourself would you not want to reveal to your doctor as a patient or to a GP as a potential employer.

Here is a list of the factors that you might include in your discussion:

AgeDate of BirthPlace of BirthNationalityEthnic OriginGenderSexual OrientationMarital Status – Single, Married, Divorced, Civil PartnershipReligious BeliefsCriminal RecordDriving licence – endorsementsHealth Status, long term conditions, regular medication, eye sight (wearing glasses)Disability, registeredSickness absence recordEducational QualificationsProfessional Registration

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SESSION TWO

Reception and Telephone Skills

The Reception and the Practice Telephone are the first point of contact for the Practice as would be an email address, a web site and a text message. The intention should be to present the best possible image of the Practice.

First Impressions – A Service to Patients

Patients can be easily offended, misunderstood, annoyed and uncooperative Patients should be dealt with speedily, accurately and courteously But, patients can be pleased, placated, cooperative and complimentary

Reception Skills

Receiving People

Next to the telephone, the Reception is a first point of contact for patients in the Practice. It is important to deal with callers and patients at the counter promptly. Staff should offer a polite welcome at reception, keep calm and not match or use raised voices. If the query requires looking at the patients record, staff should ask permission to look at the record first. Obtain the patients name as early as possible in the conversation so that you can find the patients computer entry and check that you have the right person. If a queue develops seek help from colleagues. A bell to call for help can be useful. Be calm and patient with difficult customers and again seek help if needs be. There should be a panic alarm at the reception counter if things get out of hand and the Practice may use a CCTV camera to record activities at the counter.

Accompanying Children

The Practice may have a clear policy about doctors and other clinicians seeing children under the age of 16 alone, without a parent or guardian present. Reception and telephone staff need to be aware of any age limits set by the doctors, for example age 12 and over, and what the arrangements might be to provide a chaperone during such consultation. (See Session involving Gillick Competence)

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Telephone Skills

Prompt Responses

Another important aspect of managing a medical practice is to ensure that the image presented of the practice during any first contact is positive. Telephone Calls should be answered promptly, politely and positively. Ideally, calls should be answered within five or six rings and an apology should be offered if the caller might have been waiting long in a queue. Try not to keep the patient hanging on before you speak. If a caller is placed on hold for a long period the receptionist should offer to call back. If the caller needs to be transferred to another extension, give the extension number and the name of the person whom you are transferring the call to.

Establishing Names

When answering the telephone Staff should introduce themselves and or the surgery and speak clearly and in plain language Staff should point out that they are answering someone else's phone if that is the case. Added to that if the call is being transferred to someone else, say so. The name of the caller and patient should be established carefully by checking at least two indicators, such as date of birth, post code, or address. There is a likelihood that patients with either the same or similar names might be registered with the practice, even at the same address. A patient may have a double-barrel surname, or use alias’s. Use the caller’s name once established and do not use terms of endearment or slang names such as ‘duck’, ‘love’ or ‘mate’.

Handling a Tricky Telephone Call

If faced with dealing with someone who becomes rude or aggressive on the telephone. Warn the caller that the call is being monitored or taped. Tell the caller that their behaviour is unacceptable. If the behaviour continues warn the caller that you will end the conversation and put the phone down. Tell the caller that you will make a record of the call and after a final warning put the phone down and report the matter to your Manager. Practices should have a system in place for advising staff about difficult people.

Being Comfortable

Staff should hold the phone in the most comfortable position bearing in mind that they might need to use a keyboard or write a note of the call. Keeping a note book to hand with lists of most frequently used telephone numbers and email addresses can be helpful. Have a pen and note pad to hand too.

EXERCISE –

List five problems you might encounter at a GP Reception desk or on the telephone and suggest solutions to those problems.

Discuss how call management systems, with introductory messages for extension selection and recording calls can help the Practice.

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What steps might you take to improve the ‘image’ or ‘first impression’ given to patients of the Practice?

SESSION THREE

Dealing with Difficult Patients – Tricky Encounters

Receptionist – “Can I help you? Oh, Dr Jones, it’s You”.

Incidents of verbal aggression and physical violence are dramatically increasing in GP surgeries.

Some A & E Departments & Ambulance crews now have a permanent security or police presence.

The right to remove violent patients from a doctors list is not enough. Some surgeries premises provide a ‘safe’ and controlled environment premises for offenders.

Physical barriers are no longer sufficient. Increased security is vital. Two doctors were murdered in 1990 at Pinderfields Hospital, Wakefield. This year, 2017 a doctor was stabbed in Manchester.

Surgery Staff need training in how to cope with aggression. Surgeries must have policies for handling aggression and adopt a Zero Tolerance Policy.

EXERCISE

What five things that wind you up generally.

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As a patient, what five things that might wind you up on the telephone or at the practice reception desk?

How do you think you could reduce situations that might cause conflict?

Receiving People

Practice Staff may have to deal with tricky encounters with patients and callers. Whilst there may be people who deliberately cause difficulties for staff and will only be satisfied when they speak to whoever is in charge and simply get their own way. Running a general practice office and reception demands good teamwork and no one person should be left alone and at risk of dealing with a difficult patient. The activity at a reception counter ideally should be constantly monitored.

What do you watch out for?

Raised Voice levels , shouting, attracting an audience Colourful Language - swearing, complaining, Body Language , pointing, table thumping, sighing, Strangers - new patients, emergencies Appearance - shabby, unwashed, unshaven Dress - untidy, ragged, rings in body parts Pre-determined Agenda - expects immediate attention, demands priority

Keeping Calm

When faced with a tricky encounter staff should remain calm, and polite. They should avoid mirroring the actions and behaviour of the person they are trying to deal with. Asking the person to sit down before a conversation is continued may help defuse the situation. If you need someone to help you or takeover, explain the problem to them before handing over. Getting the person to repeat their story may only inflame the situation.

How might you be feeling if you get upset?

Your heart beats rapidly, and your face goes red You feel hot and sticky, and start sweating,You feel a bundle of nerves, and become breathlessYou are either speechless, or become over talkative

Your mouth becomes dry as does your throatYour tummy is churning with butterfliesYour chest tightens, and your muscles tense upYou feel weak at the knees You remain still or rigid unable to move Going still or rigidYou become tearful and want to run

Reasons Not to be Cheerful

Patients or their representatives when attending the surgery or calling by phone may well be wound up because they are ill, have family or personal problems not related to health, and if faced with a brick wall at the surgery it may well be the last straw. It is important to emphasise that you are trying to help and will do your best to resolve the issue.

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Here is a list of ten things that might be winding a patient up!

Life’s Events, Home life problems Own Ill Health or that of family Problems and Stress at Work or at

Home Lack of Money and the Cost of things No holiday, always working

Car broken down and equipment not working

Poor Public transport Issues with children, family, relatives

and friends Someone saying No

What might be causing you stress? Here is an exercise known as the Holmes and Rahe Scale. Try it. See how stressed you really are.

STRESS FACTOR ASSESSMENT

No Life Event Value Score No Life Event Value Score1 Death of Spouse 100 2 Divorce 733 Marital Separation 65 4 Prison Term 635 Family Bereavement 63 6 Personal Injury/Illness 537 Marriage 50 8 Sacked from Work 479 Marital Reconciliation 45 10 Retirement 45

11 Family Health Problems 44 12 Pregnancy 4013 Sex Problems 39 14 New Family Member 3915 Business Readjustment 39 16 Financial Circumstances 3817 Death of Close Friend 37 18 Change of Work Type 3619 Arguments at Home 35 20 Large Mortgage or Loan 3121 Repossession 30 22 Responsibilities at Work 2923 Child leaving home 29 24 Trouble with In-Laws 2925 Personal Achievement 28 26 Spouse starts/stops Work 2627 Begin/End School/College 26 28 Living Conditions Change 25

29 Change in Habits 24 30 Trouble with Boss 2331 Change work hours etc 20 32 Move House 3033 Change School/College 20 34 Change Recreation 1935 Alter Church activities 19 36 Alter Social activities 1837 Moderate Mortgage 17 38 Sleeping habit altered 1639 Change Family events 15 40 Eating habits changed 1541 Holiday 13 42 Christmas 1243 Legal Offences - minor 11 Sub-totalSub-Total Overall Total

A score of between 11 and 150 would suggest that you have only a low to moderate change of becoming ill in the near future. A score of between 150 and 299 would suggest that you have a moderate chance of becoming ill in the near future. A score of 300 of above suggests that you have

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a high or very high risk of becoming ill in the near future. Be aware of what causes you the greatest stress. The Holmes and Rahe Stress Scale was designed by two psychiatrists in 1967 having surveyed 5000 patients looking at 43 life events.

Zero Tolerance

Where Staff are threatened or given abuse by patients, Practices should have no hesitation in take a Zero Tolerance approach towards such people. Practices should report to the Police any patients involved in violent incidents. Staff should be authorised to make a report to the Police should it be necessary. In such a case, a note should be made of the ‘crime number. Practice Managers should issue written warnings to patients whose behaviour towards any member of the Practice is intolerable. Ultimately the Practice might decide to remove the patient from the Practice List, normally after third written warning.

EXERCISE - Design a short poster for display in your surgery to promote the policy of Zero Tolerance.

NOTE: The Stress Questionnaire should be printed off for completion by those attending the session,

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SESSION FOUR

Administrative Activities

Practice Staff will be expected to deal with a variety of tasks and duties. This Session looks at some of the more common matters that might need to be dealt with on a daily basis. The list is not exhaustive.

Taking Messages

Use the call time efficiently by either taking a message, offering an appointment or dealing with the enquiry. Be mindful that a message will need the name of the patient, the nature of the query, the name of the person it is intended for, a contact telephone number and a date and time. The message should be written clearly so that the recipient can understand it and make sense of it. Messages should be recorded in a duplicate message book, or using the message or tasks system on the clinical computer system.

Registering Patients

Patient Registration, Form GMS1 and Records Transfer

Registration Forms can be printed off the NHS Choices web site, www.nhs.uk

Strictly speaking a patient who requires immediate treatment is entitled the general medical services, no matter whether evidence of a permanent domicile has been established in the practice area. In simple terms, the patient’s registration with the practice requires the completion of a registration form, GMS 1, the details from which are entered as a new patient on the clinical system. When searching for a patient, the full name, new and previous address along with a date of birth and if known NHS number should be sufficient to match the patients with records kept by a previous practice and for records to be transferred on line to be almost immediately available in the new practice. New born and immigrants will be allocated an NHS number centrally. Existing Medical

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Records held by another practice can be tracked by the National Spine and transferred using the GP2GP transfer system almost immediately. Hand held manual records will also be sought although the transfer may take weeks and may need chasing up. The service medical records of former members of HM Forces can also be obtained. Special arrangements for transferring and transcribing records for adopted patients will be made in the new name. Practice staff should ensure that a registration is completed promptly, particularly if the patient is to be seen by a clinician.

Reviewing Registration Details

Reception staff should take the opportunity when dealing with patients to check their personal details. Such details include the patients address, home, mobile and work telephone numbers and an email contact address. It is not unusual for patients to have more than one telephone number.

EXERCISE – Discuss ways of confirming the identity of a patient who has registered with your practice, particularly if you have a number of patients with the same name.

Text Reminders and Online Services

The Practice may have a text reminder service, which might be offered to the patient. The Practice might be in the process of offering the full range of online services, for appointments, repeat prescriptions and access to medical records. It might also be appropriate to check the nominated pharmacy for the transmission of electronic prescriptions is correct.

Appointments Systems

Ten-minute appointments

Practice Staff should become familiar with the structure and content of the appointments system, including how to deal with requests for immediate, emergency or urgent appointments. Normally appointments systems offer 10 pre-bookable minute time slots, although GP Registrars may be allocated 20 minutes per patient. Nurses may be allocated different period of time depending on the purpose of the appointment. GPs would normally offer two sessions per full working day, although the session start times might vary from early or late morning, to mid-day, early or late afternoon. Some Practices offer appointments before or after the ‘core hours’ of 8.00am until 6.30am known as Extended Hours and these services might be offered at the surgery of another local practice.

Number of Consultations

A consultation session may comprise of around 15 appointment slots. Doctors work up to 9 sessions per week. An appointment session may be broken down into urgent and routine appointments. Some appointments may be reserved or embargoed to be bookable from a specific point in time or only on the day. Staff should understand that there are never no appointments. Practices should also not expect patients to call back the next day. Practices should have contingency plans in place to deal with sudden absences of GPs.

Assessing Urgency

Practices use different ways of assessing the urgency of a request for an appointment, which may simply involve a question from a receptionist asking if a note can be made as to why the appointment has been requested. The actual words used by the caller requesting an appointment

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might help determine how soon an appointment might be required. Words such as ‘emergency’, ‘urgent’, ‘immediate’ and ‘today’. Practices might have a triage system where the request for an appointment is referred to a nurse or nurse practitioner. Another system involves a doctor carrying out a telephone consultation or a doctor calling back the patient to assess the need for an immediate appointment. Reception staff may be authorised by their Practice to ask patients questions. For instance, it might be reasonable to ask a patient whether they require a repeat prescription, or to ask for test results, or a repeat medical sickness certificate.

EXERCISE - What are the arrangements in the Practice for assessing and allocation urgent appointments?

Repeat Prescriptions

Patients receiving regular treatment may be authorised by their GP to receive repeat prescriptions. The issue of repeat prescriptions may be authorised for a period of time, say 6 months or one year, or a number of issues until a review is carried out by the patients usual GP. Patients now have the facility to order prescriptions online. Practices vary on whether they will accept requests for prescriptions in writing, be telephone or in person. Items that have been requested that are not authorised repeats need to be referred to the patients prescribing doctor. Prescriptions can now be transmitted to a pharmacy nominated by the patient. Patients may ask for a list of their medications which can easily be printed off the patients notes.

EXERCISE – What are your Practices arrangements for issuing repeat prescriptions in your Practice and how could it be improved?

Test Results

Test results from blood samples and other samples are reported to Practices on a daily basis and received via the internet. Practices will have systems in place to read, remark and act on results before filing the report to the patient's computer records. Practice staff should take great care to give test results only directly to the patient. The results of x-rays and other screening activities, such as cervical cytology, and breast screening may be received manually.

Medical Certificates

Medical Certificates issued to cover an absence from work due to sickness are now known as Fit Notes. The idea behind so-called fit notes is to allow the doctor to recommend that the patient may return to work on limited or restricted duties. For reception staff, a patient may already be off work sick and require a new medical certificate to extend the period of sickness. An appointment may not be necessary for a doctor to issue such a certificate. An Employer is not entitled to request a medical certificate from a doctor or a report on fitness to work without the written consent of a patient.

Petty Cash

All private income received must be recorded and receipted, whether it is by cash, cheque or by a card machine. The Practice may also have a mobile card payment device. The Practice should publish a scale of private fees, which should be available to the reception staff and on display in the waiting room. If money is taken from petty cash to purchase small items, such as postage stamps or

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refreshments make sure that a voucher is left in the petty cash box stating the amount taken, for what purpose and by whom, plus a date and time.

Chaperone Duties

Practice staff may be asked to act as a chaperone for a patient during a sensitive examination. This applies equally to male and female patients. The chaperone acts as a witness to the examination and should offer reassurance and emotional supporting to the patient. The chaperone should be introduced to the patient and should be visible to the patient. The presence of a chaperone should be recorded in the patient's notes.

Patient Charges

The normal NHS principle is that medical services are free at the point of delivery. However, there are occasions when a GP might charge a patient for private medical certificates or medical care provided outside the NHS. Some Practices provide international travel vaccinations, such as Yellow Fever, that are not available on the NHS. The Practice may have posted a list of charges in the waiting room. In addition, rural practices may have a dispensary and Practices will need to collect prescription charges.

EXERCISE - When dealing with requests from patients for an appointment when appointments are sparse what questions do you think a receptionist can ask of a patient to ascertain the urgency of the request and what other options might suggest or offered?

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SESSION FIVE

Information Technology

NHS Smart Cards

Practice Staff are issued with an NHS Smart Card, which authorises access to the GP Clinical Computer System. An application to obtain the photo-card will require documentary evidence of identity which might include a passport or driving licence, along with household bills, but not a mobile telephone bill. The card will be authorised for use at a specific medical practice. Staff will be responsible for the safe keeping of the card and must keep confidential any password issued.

NHS Email Address

Most Practice Staff will be issued with an NHS Email address, or have access to an internal mail or message system using the practice computer system. The NHS email system should not be used for personal matters. Staff should ensure that passwords issued are kept confidential. Staff should take responsibility for managing ‘junk’ mail and deleting ‘trash’. Care must be taken not to open emails that are from unfamiliar sources and include attachments that may result in adding viruses to their computer.

Use of Social Media

Practice Staff should be discouraged from using ‘social media’ to exchange messages about any matters relating to their work, employment by the Practice and details of any patients and practice workers. However, some Practices are openly using Twitter, Facebook and other platform to communicate with patients.

Practice Web Site

Most GP Practices have a practice web site, which provides information for patients about the services provided by the Practice. Normally, the web site will list the names of the clinicians and their qualifications, the opening hours of the surgery or surgeries, the days and time of consulting sessions offered by the doctors, the names and roles of practice staff. The site will also explain how

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to make an appointment and obtain a repeat prescription, and test results. It might also explain how to make appointments, obtain prescriptions and access to medical records online. Patients will need to register with the Practice to obtain online services.

GP Clinical Computer System

GP Clinical Computers systems are approved for use in general practice by NHS Digital. There are four principal suppliers of GP Clinical software system, namely EMIS Web, TPP SystmOne, InPS Vision and Microtest Evolution. Systems are now web based and are being required to move from using READ Codes to SNOMED codes by 2018. The coding systems allow data to be recorded in a consistent and searchable manner to help manage NHS payments, health needs assessment and health services planning.

Scanning and Data Input

Under the Quality Outcomes Framework introduced in 2004, GP Practices record data on patient’s computer records and are rewarded for the provision of ‘quality care’. Correct and accurate coding of health data, including diagnoses, and test results has therefore become an important part of the daily routine of medical practice. Practices are now in the routine of scanning all clinical letters and reports that are not automatically filed in the patients notes.

Data Input

Practices adopt different systems of processing incoming clinical mail, which may be either scanned first or passed to doctors to read first. Mail marked urgent or received by fax might be fast tracked. In any event mail will be scanned and attached to the ‘correct’ patient’s computer record. Data staff may select information from the letters to record in the patients notes using ‘codes’. The date of an outpatient attendance or in-patient stay will be recorded along with the name of the hospital, department and if known consultant. In addition, any new diagnoses will be recorded, along with any clinical findings that might be required for Quality Framework purposes. Doctors on reading the letters may add or make notes on the letters that more data should be recorded, including any action or follow-up that might be required. Any data input system not involving clinicians directly needs to have monitoring and audit procedures in place to ensure the correctness and accuracy of the data recorded.

EXERCISE – What types of ‘new technology’ are being used in your Practice. What problems are being created by the use of emails, text messages and social media for your practice and what solutions would you offer?

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SESSION SIX

Medical Records

Lifelong Record

NHS patients are issued with a lifelong GP medical record created when first registered with a GP Practice. The medical record comprises of a computer held record designed to be accessible on the internet by NHS GP practices, hospitals and urgent care centres. GP computer held records have been kept for around 15-20 years whilst hand-held manual records are still stored in GP surgeries.

History of GP Records

In 1948, the inception of the National Health Service, GPs inherited some medical records issued by Insurance Committees for people who worked. Prior to 5 July 1948, women and children were not entitled to ‘free’ medical care. From that date, general medical services were available to all, and the local NHS Executive Council issued NHS numbers, Medical Card and a Medical Record folder (male, red, female blue) along with immunisation cards, a summary card and continuation cards for keeping clinical notes. In the 1990’s there were over 50 GP clinical computer systems in use which today has reduced to only a handful of systems, which are linked to the National Spine and web based.

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Origin of National Health Service Number

The NHS number has become an important feature of the NHS when patients seek treatment and care in different parts of the NHS. The NHS number is required as an identifier whenever a patient is referred to a consultant, using the NHS E-Referral Service (formerly Choose and Book). Its origins lie in the Second World War when transcription books recorded residents in street and towns throughout the country and issued a National Identity Card with a number, for example MOTS/112/3. The Identity Number was adopted by the NHS, but over the years. In 1969, a five letter and three-digit number was brought into use (ZBWFG 345) and later in 1996 the current number format of 10 digits was introduced. (234 567 8967).

Use of NHS Number and Medical Card

Patients are now encouraged to be aware of their NHS number and make use of it when contacting hospitals about their treatment and care. However, whilst patients may receive a letter informing them of their NHS number when registering with a practice and it will be included on the birth registration form, an NHS medical cared is no longer issued in England.Computer Held Record

The structure or screen display varies between GP Clinical System providers but the principles of keeping records are similar, with a Summary Record, Records of Immunisations. Referrals and Repeat Prescriptions. The record will show a journal of entries setting out diagnoses and records of encounters, along with details of clinical letters, reports and test results that have been scanned. Clinical and other encounters are recorded by Codes. Practices can use the coding system to search for information about a group of patients. Achievement in the Quality Outcomes Framework depends on accurate and timely coding. Practices should have a record of the date which the computer held record became the prime record.

Access to Records by the Patient

Patients do have the right to view their GP records. This has been covered in a number of pieces of legislation in the past, but in the main is now governed by the Data Protection Act. This right of access relates to the whole record, both Manual and computer aspects. In the past, there was date limited access to records. Legislation has developed and changed over the years and now patients may ask for access to their records, and request a copy of a clinical letter or a report or test result. Such requests should not normally be refused unless there are exceptional circumstances where the patients doctor might take the view that access to the record might be prejudicial to the health of the patient. There is an Access Fee of £10 payable by the applicant and a fee of up to £50 might be chargeable for copying records.

Access to Records by a Third Party

Practice Staff should be familiar with the rights of third parties to obtain access to patient records. In the normal daily process of running a medical practice named health professionals providing medical treatment and care to registered patients will have access to patient records. These include doctors, nurse practitioners, practice nurses, health care assistants and phlebotomists. Other Practice Staff, such as data clerks, receptionists and medical secretaries will also have access to records to carry out administrative tasks. To this end individual members of staff will have been issued with an NHS Smart Card and have been allocated access rights. Visiting health care professionals, such as District Nurses, Health Visitors and Midwives may also have been issued with Smart Cards and have access rights. However, care needs to be taken by Practice Staff in allowing

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access to records by other health care providers such as dental practitioners, chiropodists, optometrists, and podiatrists. The same applies to private consultants, and NHS hospital staff without ensuring the legitimacy of the request. This limitation on access also extends to the Police, Solicitors, Employers and Insurance Companies without the written consent of the patient. Any consent given by a patient should be on an original document signed by the patient, not a photocopy.

Access to Records can be Refused or Not Disclosed

There are situations where an application for a patient or third party for access to a medical record might be refused. These include:

Where a doctor considers that it is likely to cause serious physical or mental harm to a patient. (A patient may apply to the Courts to overrule a decision of a doctor to refuse access.)

Where a patient has not given consent to a third party for disclosure and that third party is not involved in the treatment and care of the patient.

Where a third party has requested disclosure and the patient has indicated that the content of their record must remain confidential

Where access has been refused for the preparation of a medical report Where a Court has restricted access Where the records relate to keeping or using embryos Where a child has been adopted

There are other Situations where Access to Records is not quite so straightforward.

Competent People

Any ‘competent’ person, including young people below age 16 (See below – Gillick Competence) can apply for access to their medical record without giving any reason.

Children and Young People - Gillick Competence

An understanding of Gillick Competence is recommended to deal with requests for access to the records of a child, in particular by a parent. In legal case brought by Victoria Gillick, a Roman Catholic mother of 10 children, she challenged a DHSS circular that advised doctors on contraception for under 16’s at the discretion of the doctors without parental consent. Lord Scarman set out a test of competency, which states that as a matter of law the parental right to determine whether or not their minor child below the age of 16 will have medical treatment terminates if and when the child achieves sufficient understanding and intelligence to understand fully what is proposed. A child who is Gillick Competent is able to prevent parents viewing that child’s medical records. Lord Fraser expanded on the definition of Gillick Competence by stating that the clinician should be satisfied that:

The young person will understand the professional’s advice The young person cannot be persuaded to inform their parents The young person is likely to begin, or continue having sexual intercourse with or without

contraceptive treatment Unless the young person receives contraceptive treatment, their physical and mental health,

or both, are likely to suffer

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The young person’s best interests require them to receive contraceptive advice or treatment with or without parental consent.

Parents

Parents may apply for access to their children’s records as long as such a request is not against a competent child’s wishes.

Mental Capacity

Patients with mental disorders or learning difficulties should not automatically be regarded as lacking capacity. Doctors may share health information with an authorised representative of the patient.

Next of Kin

Normally, the next of kin of a patient does not have a right of access to their ‘kin’s’ medical record without the patients consent.

Police

Excepting a Court Order or Warrant, the Police can request voluntary access to a patient’s records, for instance, where a person is in custody and requires medical treatment or confirmation of prescribed medication, but a doctor has no legal obligation to allow access. However, where there is an overriding risk to the public at large, it may be in the public interest to allow access.

Solicitors

Solicitors may seek access to a patient’s records, but should have obtained the written consent of the patient. Practices should ask to see the original consent form not a photocopy.

Anonymised Information from Medical Records

Whilst it is quite clear that access to records by a third party normally requires direct patient consent, there are occasions when anonymised information can be shared for research purposes. It is also true to say that anonymised details of diagnosis, medical treatment and care is ‘shared’ for the purposes of supporting claims for NHS payments and for ‘health needs assessment’. Patients may opt out of allowing access to their records for research purposes.

Notification of Infectious Diseases

GPs are required by law (Health Protection Notifications Regulations 2010) to notify the local authority of any infectious diseases contracted by their patients. Public Health England is responsible for detecting outbreaks of infectious diseases as quickly as possible.

Here are some examples of the diseases covered by this legislation:

Acute EncephalitisAcute Infectious Hepatitis

Acute MeningitisAcute Poliomyelitis

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AnthraxBotulismBrucellosisCholeraDiphtheriaEnteric fever (typhoid or paratyphoid)Food PoisoningHaemolytic Uraemic SyndromeInfectious Bloody DiarrhoeaInvasive Group A Streptococcal DiseaseLegionnaires’ DiseaseLeprosyMalariaMeasles

Meningococcal SepticaemiaMumpsPlageRabiesRubellaSevere Acute Respiratory SyndromeScarlet FeverSmallpoxTetanusTuberculosisTyphusViral Haemorrhagic FeverWhooping CouchYellow Fever

Medical Terminology

When dealing with prescriptions, data input and referral correspondence, staff will become familiar with prescription terms, medical abbreviations and clinical terminology. Clinicians are discouraged from using abbreviations in medical records but it could be argued that abbreviations have almost been replaced by coding. Here is a brief summary of common abbreviations, and terminology.

Prescription Writing Abbreviations

Here is a short list of the most common prescription writing abbreviations:

a.c. ante cibos before mealsb.d. bis die twice a daydil. dilue dilutegutt. gutta or guttae drop[s]in d in dies dailyinj. Injecto injectionlot. Lotio lotionnoct nocte at nighto.m. omni mane every morningo.n. omni nocte every nightp.c. post cibos after mealspig. pigmentum paintp.r. per rectum by the rectump.r.n. pro re nata as desiredp.v. per vaginam by the vaginaq.d.s. quarter in die four times per dayq.s. quantum sufficit as much as requiredR. recipe takes.o.s. si opus sit if necessary

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stat. statum immediatelyt.d.s ter in die three times a day ung. unguentum ointment

Consultants and their Clinical Areas

Here is a summary of the types of hospital consultants and the clinical areas they cover:

CONSULTANT/DEPARTMENT DETAILS ANAESTHETIST Anaesthesia & pain management, Palliative careCARDIACTHORACIC SURGERY Heart, Lungs & Oesophagus, Transplant surgery CARDIOVASCULAR Treatment of heart diseasesDERMATOLOGIST/DERMATOLOGY Treatment of skin disordersENDOCRINOLOGISTS Treats glands, diabetes, & growth disordersGASTROENTEROLOGISTS Treat stomach, & intestinal problemsGENERAL MEDICINE Treat conditions, but no surgeryGENITO-URINARY MEDICINE As immunologistsGERIATRICIANS Treatment of older people GYNAECOLOGISTS/GYNAECOLOGY Female reproductive organsHAEMATOLOGISTS/HAEMATOLOGY Treat blood disordersIMMUNOLOGISTS/IMMUNOLOGY Treat immune system, & allergiesNEPHROLOGISTS/NEPHROLOGY Treat Kidney diseaseNEUROLOGISTS/NEUROLOGY Disorders of Nervous SystemNEUROSURGEON/NEUROSURGERY Brain, Spinal, & Nerve SurgeryOBSTETRICIANS/OBSTETRICS Deal with Pregnancy & childbirthONCOLOGISTS/ONCOLOGY Cancer treatmentOPHTHALMOLOGISTS/OPHTHALMOLOGY Eye injury & diseasesORAL AND MAXILLOFACIAL Dental surgeryTRAUMA AND ORTHOPAEDIC SURGEONS Treatment of Musculoskeletal problems OTOLARYNGOLOGISTS Ear, Nose & ThroatPAEDIATRICIANS/PAEDIATRICS Treatment of sick childrenPATHOLOGISTS/PATHOLOGY Diagnosis, from tissue or fluid samplesPLASTIC SURGEONS Reconstruction and cosmetic surgeryPSYCHIATRISTS/PSYCHIATRY Treatment of Mental illness PSYCHOTHERAPIST Treatment of Mental illness not using drugs

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RADIOLOGISTS/RADIOLOGY Using radiation treatment, x-rays RHEUMATOLOGISTS/RHEUMATOLOGY Treating joints, connective tissueTHORACIC SURGEON Surgery of the chest cavityUROLOGY/UROLOGIST Deals with kidney and bladder problemsVASCULAR SURGEONS Deal with veins and arteries

EXERCISE – What type of information would you expect to find in a patient’s hand held or computer record?

SESSION SEVEN

Complaints and the National Health Service

This Section provides a background to complaints procedures and general information about general practice and the National Health Service.

Handling Complaints

Complaints in Writing

Practice Staff may the first in line to hear or receive a complaint from a patient. Patients should be asked to put any complaint in writing and submit it to the Practice Manager. Normally, the patient should make a complaint unless written consent has been given for the complaint to be made by someone else. It is therefore important that Practice Staff do not discuss a complaint with any next of kin.

Time Limits

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Complaints should be made within a ‘reasonable time’ of the event that gave rise to the complaint. A reasonable time is defined as no more than 12 months after the event occurred or 12 months after the complainant became aware of it.

Complaints Leaflet

Practices will have in place a practice based complaints procedure details of which should be set out in the Practice leaflet or on the Practice Web Site. Practices may have an information leaflet to hand to complainants setting out the procedures that would be followed.

Discuss Informally

In the first instance, complainants might be encouraged to discuss their complaint informally with a doctor, nurse or the Practice Manager. Some complaints about the administration of the practice, including appointments and telephone systems can be dealt with by the Practice Manager, but others involving clinicians and clinical matters will need to be referred to the doctors or health professionals involved. Informally, a meeting might be offered to the complainant or an explanatory letter might be prepared to be sent to the complainant.

Acknowledge Complaint

Complaints should be acknowledged in writing within 2 working days and a timetable set out for a response – no more than 14 days. If the Practice is unable to reply within that timetable the complainant should be informed. In the initial response, the Practice should highlight any aspects of the complaint that should be responded to by any other NHS or health organisation and be careful not to comment on those aspects of the complaint. The complaint should be forwarded to the ‘correct’ organisation with the agreement of the complainant or the name and address of the person given to whom the complaint should be directed.

Taking Advice

If a complaint requires a formal response, Practices should take advice from their defence organisation before relying to a complaint about a clinical matter. The letter might offer an apology if one is due or an expression of sorrow that the incident or event that occurred has given rise to a complaint. The reply should give a thorough response, invite comments or questions and if necessary offer a meeting with those involved. The response should also make clear any right of appeal and reference to the NHS Ombudsman.

Suggestions, Comments and Questionnaires

Practices will need to keep a register of complaints and produce a summary annual report. Practices might also have a Suggestion Box for patients to make comments and offer short questionnaire such as the Friends and Family Test.

Practice Leaflet

Practices are required to publish a Practice Leaflet, which should set out the names and qualifications of the doctors working in the practice, along with details of the surgery premises, opening times and the days and hours appointments are offered by each doctor. The leaflet should explain how to contact the surgery during core hours and out of hours. Nowadays the content of a

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practice leaflet is almost outweighed by the quantity of information and online services that can be offered on the Practice Web Site. Staff should be familiar with the content of the practice leaflet, the practice web site and the NHS Choices web site.

National Health Service

The National Health Service in the United Kingdom was established on 5 th July 1948 with the intention that general medical services be provided ‘free at the point of delivery’, Prior to that the services of a family doctor had only been available to workers who contributed to an insurance scheme introduced in 1911. So called family practitioner services, included services provided by family doctors, dentists, opticians and dispensing opticians, and pharmacists. These services were administered by NHS Executive Councils (30 members), that provided ‘pay and rations’ services to contractors and issued medical cards to patients. In 1973, Family Practitioner Committees (31 members) replaced Executive Councils. The NHS has been subject to a series of ‘reorganisations’ over the last 60 plus years. In 1990 Family Health Services Authorities, with a smaller membership and a general manager, replaced FPCs, but were themselves replaced in 1994 by Primary Care Groups that subsequently became Primary Care Trusts in 2001.

General Practitioners

General Practitioners are independent contractors working in the National Health Service but not normally directly employed by NHS England or a Clinical Commissioning Group. GPs usually group together in partnerships and enter into a formal partnership agreement. There are relatively few singlehanded doctors working in the NHS nowadays. If a single-handed doctor resigns, retires or dies, the local Commissioning Group would take responsibility for finding a replacement doctor or dispersing the patient list to other practices. Otherwise, GP Practices are responsible for recruiting and appointing their own doctors. GPs undergo a three-year period of vocational training before being allowed to practice independently and may be attached to a GP Practice as a GP Registrar for two six-month periods. A member of the partnership will be appointed as a GP Trainer by the local Deanery and take responsibility for the training and development of the GP Registrar.

Partners and Salaried GPs

GPs need to join the National Performers List before practising in any capacity in general practice. The List is maintained by the Primary Care Support England Unit (PCSE). Doctors may join a Practice as a Partner or as a Salaried GP. Practices might also employ a Nurse Practitioner, a senior nurse, who is qualified to prescribe. Practices may employ other clinical staff such a qualified Practice Nurses and unqualified Health Care Assistants and Phlebotomists.

GP Contract and Enhanced Services

In 2004, the then Government introduced a new contract for General Practitioners which ‘enhanced’ their independence and removed the ’24 hour’ responsibility that had previously been a keystone of general practice. The Contract introduced ‘budgets’ for the financial management of a practice under a Personal Medical Services contract or ‘claims for payment’ under a General Medical Services contract. PMS practices were also awarded ‘growth money’ to develop their practices. In additional, the Government introduced the Quality Outcomes Framework, which was intended to improve the quality of general practice management and of the management of a range of clinical domains by rewarding efforts made by doctors and practices to record data about the health

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treatment and care provided for patients. Points were awarded for reaching and exceeding clinical targets set in each domain. Each year since 2004, the domains have been changed and targets altered. The ‘management’ domains have become part and parcel of providing good quality management and are now monitored more by Care Quality Commission inspections.

EXERCISE – Design an easy to read complaints leaflet using words containing no more than three syllables, using no more than 200 words.

EPILOGUE

Use of Presentations

The Sessions in this Manual can be made available on a PowerPoint Presentation, which can be amended to suit your Practice circumstances. It would be helpful if you could provide the author with a copy of any Presentation you develop for local use. Email – kingfisherpm@hotmail.com

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BONUS SESSION

Time Out for Practice Staff

This Session is offered as a Team Building Exercise for GP Practice Staff. It could be used when new members join the team or when there is an element of disquiet in the ranks and it is time to pull everything together with a smile and with positivity.

The session would last about two hours and some include light refreshments and maybe prizes to offer during exercises. Provide a flip chart, pens and plenty of post-it notes.

Getting to Know You

Getting into Order

As an opening exercise starting off in a line, ask those in attendance to stand in a line and then without speaking, sort the line into alphabetical order by forename. Repeat the exercise by sorting the line by length of service. The aim of the exercise is to provide some light relief, with a minimum of effort. Allow 10 minutes.

Did you know this?

Moving on time to sit down in a circle (chairs provided, of course). Ask each person to reveal something about themselves that the other do not know and might find unusual. It might be an unusual hobby, an extreme holiday, or maybe an unusual place of birth! Allow 10 minutes.

Chinese Whispers

The aim of this exercise is to stress the importance of passing messages.

Getting a little more serious, time to demonstrate how taking and passing a message can cause problems if the message is not passed on correctly and accurately. (The Exercise in mentioned earlier in the Confidentiality Session) Create a short message of around 50 words, which mentions

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names, times and places. Pass the message on a card to the first participant with instructions to read the message to the person sitting next to them quietly. Take the card back. The message should then be passed around the group quietly until it reaches the last person. The last person should repeat the message out loud. Read the message on the card and note the differences.

Oh, What a Jigsaw

This next Exercise examines what the make-up of a ‘team’ might be. Using children’s puzzle with around 10 pieces, split those attending into small groups of around 4 or 5. Hand each group a puzzle and suggest that they make up puzzle and in doing so think about the puzzle and what they are doing. Make notes of their findings and after 10 minutes call the groups together to report their conclusions.

Here is a summary of what their finding might be:

How is a Jigsaw like a Team?

There are boundaries to a ‘jigsaw’ and as there are to a ‘team’.Each piece of the ‘jigsaw’ and each ‘team’ member plays a specific role and has a specific purpose.When the ‘jigsaw’ pieces are joined together ‘teamwork’ occurs.Each piece of the Jigsaw like each person in the ‘team’ is unique in its, his or her nature.The solution to a jigsaw puzzle is a fragile one - it is easily broken. A team is easily broken up. New Teams go through a period of forming, storming, and norming before they can perform – Someone leaves and they mourn.The whole ‘jigsaw’ and the whole ‘team’ is greater than the sum of its pieces.Some jigsaw pieces are central; some jigsaw pieces are peripheral. Like cogs in a wheel some team members are vital and are difficult to replace. Some team members have lesser roles and responsibilities. ‘Team’ members have different, skills, talents, abilities and competencies. There are natural groupings in the puzzle of colour, shape, design etc. Pieces need someone to move them - to make the puzzle. Teams need to have a leader, a supervisor, a plan and objectives.Someone who can see the whole picture (who has an overall vision) helps a rapid solution to the puzzle.

Likes and Dislikes

After some light-hearted interventions, try something a little more serious. Ask those taking part to list on two post it notes, five positive things about the place they work in and five negative things. Ask them to be honest and if they want to criticise try not to be personal and be prepared to make

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suggestions as to how things might be made better. On your part say you will do your best to respond to all points.

Allow 15 minutes for preparing the notes, then post them on a flip chart and open a discussion. Might need a ringmaster! Allow another fifteen minutes for the discussion.

By now you will probably have reached 2 hours and might be the time to offer more refreshments. If do not want to run the session yourself invite another manager or someone independent of the Practice with no axe to grind to run it for you.

Robert CampbellJuly 2017

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