In this update: 1. PCN DES 2020/21 and Cambs LMC Open Meeting Webinar (Date TBC) 2. Message from the Peterborough Registrar around MCCDs 3. Message from Mr David Heming, Senior Cambs Coroner around MCCDs 4. Verification of Death – Cambs LMC view in light of new correspondence from BMA, and information from Ministry of Justice

1.  PCN DES 2020/21 and Cambs LMC Open Meeting Webinar

Long, long ago, in a galaxy far, far away, the Special Conference of English LMCs was held (11 March 2020) to discuss the outcome of negotiations and the 2020 GMS contract agreement.

The motions at the Special Conference focused on a wide range of contract related issues including: pay transparency, partnership incentives, fellowships, premises, vaccination payments, continuity of care, out of hours care, care home premiums and the future development of PCNs.

There was also an important themed debate on the ARRS with motions being passed by the Special Conference on this area. An Emergency Motion was also agreed on the response required to support practices during the then still developing Covid-19 pandemic which has now pretty much been enacted in full.

GPC England is still considering how to take the resolutions forward in the midst of the current pandemic. The conference resolved that a survey of the profession should be done to get feedback on whether practices intended to sign the PCN DES, and this is something GPCE will be trying to do as soon as practical, bearing in mind everything else on our plate currently.

The Special Conference resolutions are in the link below:

https://www.bma.org.uk/media/2154/bma-special-conference-of-england-lmcs-resolutions-march-2020.pdf

Cambs LMC was due to have an Open Meeting on 25 March, but events overtook us. We will however, be holding a virtual open meeting webinar and opportunity for Q&As on a weekday evening in early May. It is likely that the committee will decide the date at its next meeting on 30 April.

We know that NHSE wrote to you earlier this week. They have clarified with us that they are not imposing a local deadline strictly, but are adhering to the national 31 May deadline. We would however, echo our local NHSE team’s advice in liaising with your core network practices and clinical directors in any necessary changes to finances or membership, and sharing any queries you may have, that you may wish to voice when we have our webinar and Q&A. We will provide a summary of the information and discussion on our website afterwards, for those unable to login or attend.

We would advocate caution in signing up to the DES for the time being, primarily on account of some unanswered queries put to NHSE, and some outstanding assurances we are yet to receive.

Some of these are listed in the letter Richard Vautrey wrote to Ian Dodge on April 1 attached HERE

The LMC will take a view once we are in receipt of all the information so you can be in the best informed position to do what is right for your practice. We will keep you informed and let you know the date for the webinar as soon as it has been confirmed.

2. Message from the Peterborough Registrar

This relates to appointments at Peterborough Register Office, and applies to deaths occurring in the Peterborough district.

As you know, Peterborough Register Office has been registering deaths by telephone since 1 April 2020. Appointments are no longer being taken at the office. Please can you scan and email both sides of the medical certificate for a death registration directly to: registerofficecertificates@peterborough.gov.uk

Please keep the original medical certificate at your premises. We await guidance from General Register Office as to how and when these should be returned to us.

Please do not give the original medical certificate to the family. This is the case even if you have already emailed the medical certificate to us – the original should be retained by you for the time being.

If the family want a written version of the information in the medical certificate, any death certificates they order from us will include this. Thank you for your help with this. If you have any queries, please do not hesitate to contact us.

3. A message from Mr David Heming, Senior Coroner for Cambridgeshire regarding MCCDs

The local registration service have been in contact with me concerning the new MCCD procedures.

There are two points they make :-

There is no necessity for the family to personally collect the MCCD any longer as they simply need to be sent to the registration service electronically ( both sides of the MCCD need to be sent).

Where another medical practitioner attended the deceased during their last illness, or after death, the medical practitioner signing the MCCD should record the name and GMC number of the medical practitioner who attended the deceased during their last illness or after death at the ‘last seen alive’ section of the MCCD.

A failure to follow the guidance in the second point is causing a number of MCCDs to be returned. This was covered on page 2 of the NHS guidance document for medical practitioners issued 31 March 2020.

I would be grateful if you could circulate this as it will assist your colleagues on the second aspect in having to revisit returned paperwork. Thank you for your assistance.

4. Death Verification – Cambs LMC View

You may have seen the letter from the BMA around the stance taken by our region and the London Coroners re: the process for verification of death. I have attached it HERE, in case you have not. Read it. It’s helpful.

We have written to our Senior Coroner asking him to work with us to find a pragmatic and sensible outcome to what is rapidly becoming an unsustainable and highly variable national position, that compromises and confuses our GPs, practices and patients – especially those living and practising around county borders with differing positions. Whilst we appreciate that in normal times, it may be desirable for a GP, SCAS or TVP to have verified a death, there is no legal requirement for this.

Further to our email to you on 09 April, the General Practitioners Committee of the British Medical Association (of which both Diana and myself are members) has provided an update on the position on verification of death. We also note that the Ministry of Justice has now formally acknowledged the second and third of the three assertions below:

Anyone can verify

No need to have ever attended or seen after death to issue an MCCD.

No need to have attended or been in presence of body to complete Form 4

This is now formally evidenced in an email received by the GPC on 13 April 2020, in which the MOJ Policy unit confirms: “I note your points regarding attendance of the patient in a given period of time prior to their death and viewing the body not being statutory requirements, and it is correct that a crematorium medical referee can accept a form Cremation 4 where none of these two conditions has been fulfilled.”

The MOJ has also issued revised guidance, and these documents can be found here: https://www.gov.uk/government/collections/cremation-forms-and-guidance . Note in particular paragraphs 22 and 26, and the answers to Q7 and Q8, found in this specific guidance for Medical Practitioners found here: https://www.gov.uk/government/publications/medical-practitioners-guidance-on-completing-cremation-forms .

We are also aware of the statement that has come out from the Senior Coroner for Berkshire this week, aligning with the advice from Buckinghamshire, that supports any competent adult (e.g. a relative, a member of staff in a nursing home, ambulance personnel or police) in verifying a death, and that if a patient’s expected death is declared by any such competent adult, GPs would be acting correctly in prioritising the needs of their living patients. We clearly have differing, conflicting positions across the country. We note that we are yet to receive a statement from the office of the Chief Coroner.

Now that it is clear GPs are entitled to complete these forms as above, having had no “attendance”, Registrars and Coroners are likely to face a considerable number of referrals, with Medical Referees potentially receiving dozens of form 100A applications, to allow the crematorium referee to be satisfied that cremation can proceed.

We have put it to our Senior Coroner, that this may impact his office on body ‘turnaround’. As he himself has previously pointed out quite rightly, a medical practitioner completing an MCCD will specific the cause of death, not the fact.

We are certain, that our coronial colleagues are keen to ensure that the risks to families and all involved in the verification, transportation and funeral process are reduced, and, at the same time, avoid unnecessary delay. This is why we feel it is important to continue to liaise with them, with a view to agreeing a sensible position that meets the needs of interested parties.

Given the advice from the MOJ, and the BMA, we would advise our GPs that, once an expected death has been confirmed, funeral directors consider the manner in which that information has been provided to them, and by whom, and use best judgement to attend to those requests without initially seeking the attendance of a GP.

If you are informed of an expected death in the community, e.g. following an arranged EOL care plan, or following the end stage of an incurable condition where they have been seen and nursed over the preceding weeks and months – you take a history, you ask pertinent questions and on the basis of that information, you may well make a decision to have verified the death on the basis of that conversation alone. There is no legal requirement for you to have attended or seen the body after death prior to issuing a MCCD, or complete a Form 4.

Use your professional judgement on each individual case. Your responsibility as a GP is to place yourself in a position to be able to make a reasonable decision regarding the care of your patient, and that extends into death. You will be acting correctly by prioritising the needs of your living patients.

We will put this guidance on our website next week, but feel free to use it if you face challenge. And if you do face challenge, please contact us at office@cambslmc.org to see how we may be able to support you.

We do not expect this to be the final word on the subject, We will inform you of any changes, and we will continue to advocate on your behalf.

Have a good weekend,

Keep safe and keep well,

Katie

Dr Katie Bramall-Stainer – Chief Executive, Cambs LMC

Tel: 01954 268156

Email: katie@cambslmc.org

Tweet: @doctor_katie

Please email office@cambslmc.org on Mondays when I am in surgery.