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
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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