Background

From 1 April 2016 new information sharing processes between GPs and the police were introduced in an attempt to ensure those licensed to possess firearm and shotgun certificates are medically fit to carry arms. We have significant concerns about these arrangements and we continue to raise them with the Home Office with the aim of agreeing a process that is fair to GPs in particular, and doctors in general, and safe for the wider public. Discussions are ongoing and any future improvements may necessitate the revision of this guidance.

The following advice on the current system takes into account our discussions with the Home Office, the police and the British Association for Shooting and Conservation (BASC), as well as external legal advice.

 

Health Secretary Vaughan Gething has today taken action to relieve pressure on GPs during the busier than usual winter period.

Vaughan Gething, in partnership with BMA Wales, has taken the decision that the Quality and Outcomes Framework (QOF) element of the GP contract will be relaxed until 31 March 2017

This move will create more capacity for GPs and practice nurses to manage their most vulnerable and chronically sick patients during the winter period where there is a significant increase in demand for their services. 

The Health Secretary said: “The positive action we’ve taken today will help ease pressure on primary care. I’d like to thank GP and practice nurses across Wales for their hard work and commitment to their patients during this busy winter period.

“Instead of patients being called in for routine appointments automatically at the busiest time of the year, doctor and practice nurse’s time will be freed up to see patients, prioritising those urgently requesting appointments because they are ill.

“Both BMA Wales and Welsh Government remain committed to working positively and collaboratively to improve access to services. No GP practice will lose out financially as a result of QOF relaxation.

“I hope that both primary care and patients in Wales will feel the benefits of this decision.  It’s a common sense approach that shows the agility of NHS Wales – especially when it’s under pressure.”

Chair of GPC Wales, Dr Charlotte Jones said: “This welcome move will have a positive effect on practices by reducing bureaucracy and box ticking, as well as releasing capacity which will enable GPs and practice nurses to focus on the complex care needs of their patients at a particularly busy time.

“We are committed to working in partnership with Welsh Government to continue improving working conditions for GPs in Wales, and this agreement demonstrates what can be achieved through collaboration on an agreed vision.”

URGENT CONTRACT UPDATE from Charlotte Jones.

On behalf of the GPC Wales negotiating team I wanted to update you on where we are with regard to progress on the current status of contract negotiations.

So far, the contract talks have not progressed as quickly as we would want them to - and you will appreciate that, after our detailed preparations, this is proving highly frustrating and disappointing. That said, we continue to engage in a constructive way with Welsh Government and Health Boards, and all meetings have been in good faith. Our mandate, however, is to ensure that the profession has the best outcome possible, given the unprecedented pressures and constraints General Practice is currently facing. It is fair to say that GPC Wales and Welsh Government have been working to find an agreed way forward, however, completion (albeit being near) is being held up at the Health Board level.

As you will no doubt be aware, I am constrained in what I can say as “nothing is agreed until everything is agreed” but here is a brief update:

15-17 CONTRACT
There are 4 outstanding areas yet to be concluded:
· Care Home DES – virtually fully agreed pending a review of the final wording
· Anticoagulation ES – two of the Health Boards have stated they would have difficulties in delivering a DES – they are supposed to be providing further information on this given that this piece of work was part of the negotiated agreement back in 2015 – this information has not yet been received.
THIS IS HOLDING UP NEGOTIATIONS.
· Diabetes ES – this is going to be more complex as there is some ongoing lack of clarity of the whole delivery of diabetes care (not just within primary care). This is going to take longer to deliver and we have raised a need to ensure there is no loss of progress and have advised that in order to conclude this quickly, that this simply requires a small working group taking forward the GP and primary care elements. We have agreed that this may take up to end March but that, provided other areas are agreed for 15-17, then this work can take place in parallel with 17-18 negotiations but has to be concluded during this time..
· Phlebotomy resources for work generated outside of GMS – despite GPC Wales having prepared a very clear briefing on why the costing of the WG proposal was inadequate there was no further progress on this until Dec 2016. Following resurrection of these meetings and with a revision to the personnel involved in this work on the Health Board side, we now believe that we can find an acceptable way forward. However, if this proves impossible, there is always the possibility that we may pursue other avenues in order to achieve a satisfactory resolution

17-18 & BEYOND
· GPC Wales believes it would send entirely the wrong message to move forward with 17-18 negotiations without a clear agreement on the outstanding areas of the 15-17 negotiated agreement. We hope you agree.
A brief summary of our wants for 17-18 include:
a. resources for practices (financial /workforce / premises etc), b. reduction of workload and look at safe working options
c. reduction of bureaucracy and last man standing liabilities,
c. resources to enable sustainability
d. solution for indemnity
· Both Welsh Government and ourselves recognise that the future of the GMS contract is in need of review – as many of you are aware, the usual shelf life of a contract is 7 years and that we have had the nGMS contract in place now for 12 years.
However, any change to contract involves considerable resources and expertise– this is something we will be progressing with Welsh Government in the near future once 17-18 negotiations are complete.

The key message I want to convey to you today is: Please rest assured that the team is not sitting on its laurels awaiting events – we have chased up the timeline for completion and highlighted our concerns on the obstacles that need overcoming. We will continue to push hard to get the resources that General Practice needs and hope to have some further information in the near future.

If you have any comments / questions etc then as always we would like to hear from you – please contact me at This email address is being protected from spambots. You need JavaScript enabled to view it.

Warm Regards,

Charlotte

The attached template has been produced by GPC Wales after consultation with BMA Law department to support practices with responding to police requests for medical notes.

 

The issue

GPC Wales has been lobbying Welsh Government regarding last man standing liabilities and written formally to Vaughan Gething regarding this.
GPC Wales highlighted the following issues:
• When a partner(s) leaves the practice, business related liabilities such as lease responsibilities, mortgage loans and employers TUPE responsibilities transfer to the remaining partner(s). In some circumstances, we have seen a single partner sometimes of retirement age, sometimes much younger, being left holding full business liability.
• The fear of this outcome can lead to a succession of resignations driven by both workload pressures and fear of being left with sole responsibility for business liabilities of a size that would be individually crippling.
• A practice that was once stable can destabilise within a matter of months, or for a small or rural practice, a matter of weeks, with for example retirements following unexpected sickness and new recruitment to practices is frequently unsuccessful in the current climate.
• The repercussions and implications on both a personal and professional level for GPs are potentially catastrophic with some cases experiencing severe financial hardship.
• Our strong view that LHBs need to take more ownership of the strategic decisions they make.
When strategic premises decisions are made the HBs are in effect saying that a given set of infrastructure is needed to discharge the LHB’s responsibility to provide universally available primary care in that area. These strategic decisions, allowing for minor local tweaking, would also lead one to conclude that a given level of clinical and administrative staff is needed to support that provision.
If this were accepted, we would argue that whilst nearly seventy years experience suggests that the independent contractor model is the most efficient way of providing that care, if the current financial, contractual and manpower environment makes that impossible it should not alter the need for the staff and buildings to provide it. In addition, we believe that the HB should also commit to covering TUPE for the practice staff.
• Need for a range of solutions to be put in place to support the recovery and stability of a practice following the loss of a partner(s) which will need to be flexible and appropriate to the context of the practice.

These solutions could include:
1) LHBs underwriting new premises leases (or increasingly rarely GP practices personal investment in premises) and
2) LHBs underwrite the staff employment within those premises
3) Consideration to exploring whether solutions in other nations would work in a Wales context e.g. the Republic of Ireland’s Department of Health acts as head lease holder and sublets premises to general practices for a period of 5/10 years, mitigating risks for GPs. England is currently exploring Limited Liability Partnerships, a step which provides means of legally separating the person from the business liabilities.
• These issues are having a significant negative effect on the sustainability of General Practice in Wales and this will only worsen without effective solutions being urgently put in place.

The response from Welsh Government
• They recognise the problem – that is a start
• There is already in place the ability within Wales for Health Boards to seek consent to obtain a lease under the NHS Wales Act (2006) and this has already been used in Briton Ferry and Brynmawr
• Their belief that the approach from Health Boards to premises lease issues, whether new or historic, can include:
1. Working with practices and providing letter of comfort detailing the approach to sustainability in the event of “last man standing”
2. Taking the head lease in the case of a managed practice
3. Taking the head lease for a period whilst practice sustainability solutions are put in place and then the lease assigned over to the practice
4. Taking the head lease and subletting this to the practice for a term of 5/10 years or such agreed between both parties


These options need to be considered within the premises estates strategy including the need for robust infrastructure to deliver local primary care.
• The solution needs to be dependent on the individualised circumstances, business and GMS planning between the practices and the Health Boards - Welsh Government would recommend early discussions where a practice is concerned about “last man standing” liabilities
• In addition, Welsh Government confirmed that they are committed to delivering care closer to the patients home and prioritising further investment in primary and community care infrastructure

What this means
• There is the ability for Health Boards to take on and provide solutions to the problems that are being experienced across Wales – we need to highlight these to the profession.
GPC Wales will put this in a newsletter but it would be worth LMCs disseminating this to practices as it will bring some assurances
• More is needed – we will be pursuing this both within the contract negotiations (e.g. additional investment directly into practices, reducing workload pressures etc that may well help with recruitment challenges around partnership and GP practice employed salaried GPs) and also measures to address issues that fall outside of the parameter for contractual negotiations.

Charlotte Jones
Sept 2016