Over recent months the LMC has received a number of queries from practices, who have or are considering terminating their GMS contract.

One of the questions raised was with regard the handling of QOF payments (Aspiration and achievement) with particular reference to contracts which may be ended during the the financial year.

To clarify the exact position as applied from the Statements of Fees & Entitlements the LMC has sought opinion from BMA Law. The outline position and explanation is as follows:-

"Having looked into Gwent LMC’s query, our advice is that Aneurin Bevan University Health Board’s (ABUHB) method of calculation appears to be correct, although we can understand that this may seem unfair/ perverse from the practice’s perspective.

The provisions relating to the Quality and Outcomes Framework (QOF) are set out in Part 2 of the General Medical Services Statement of Financial Entitlements Directions 2013 (SFE). We have set out the relevant provisions below:

“Achievement Payments

4.7. Achievement Payments are payments based on the points total that the contractor achieves under the QOF – as calculated, generally speaking (see paragraph 6.2), on the last day of the financial year or the date on which its contract terminates (see paragraph 6.3) – this points total is its Achievement Points Total. The payments are to be made in respect of all Achievement points actually achieved, whether or not the contractor was seeking to achieve those points, but the final amount also takes into account the deduction of the Aspiration Payments that the contractor has received in respect of the same financial year.
…
Assessment of Achievement Payments where a GMS contract terminates during the financial year

6.3. In a case where a GMS contract terminates before the end of the financial year, the assessment of the Achievement Points to which the contractor is entitled is to be made in respect of the last date in the financial year on which that contractor is required under the contractor’s GMS contract to provide essential services.

Returns in respect of Achievement Payments

6.4. In order to make a claim for an Achievement Payment, a contractor must make a return in respect of the information required by the Board in order for the Board to calculate the contractor’s Achievement Payment. Where a GMS contract terminates before the end of the financial year, a contractor may make a return at the time the contract terminates in respect of the information necessary to calculate the Achievement Payment to which the contractor is entitled in respect of that financial year.

6.5. On the basis of that return but subject to any revision of the Achievement Points Totals that the Board may reasonably see fit to make to correct the accuracy of any points total, the Board must calculate the contractor’s Achievement Payment as follows.
…
Calculation of Achievement Payments
…
6.10. If the contractor’s GMS contract had effect—

(a) throughout the financial year, the resulting amount is the interim total for the contractor’s Achievement Payment for the financial year; or

(b) for only part of the financial year, the resulting amount is to be adjusted by the fraction produced by dividing the number of days during the financial year for which the contractor’s GMS contract had effect by 365 (or 366 where the financial year includes 29th February), and the result of that calculation is the interim total for the contractor’s Achievement Payment for the financial year.”
…
Recovery where Aspiration Payments have been too high

6.12. If the resulting amount from the calculation under paragraph 6.11 is a negative amount, that negative amount, expressed as a positive amount (“the paragraph 6.11 amount”), is to be
recovered by the Board from the contractor in one of two ways—
…
(b) if it is not possible to recover all or part of the paragraph 6.11 amount by the method described in sub paragraph (a) (for example, because of the termination of the GMS contract after a partnership split), the amount that cannot be so recovered is to be treated as an overpayment in respect of the contractor’s Monthly Aspiration Payments for the year to which the paragraph 6.10 amount relates, and is to be recovered accordingly (i.e. in accordance with paragraph 25.1).”

The upshot of these provisions is that where the GMS contract terminates before the end of the financial year, the contractor’s Achievement Points are assessed as at the termination date (i.e. 30 June 2015). The relevant amount is then subject to a reduction based on the number of days during the financial year for which the contract ran (i.e. 91 days/366 days). This means that the Achievement Payments are effectively pro rated twice.

We have sought the BMA GPC’s view (since they negotiate the GMS contract and SFE) and we are waiting to hear from them. Their preliminary thoughts are that the rationale for this may be to prevent contractors from front-loading QOF knowing they are going to end the contract, so that, for example, they cannot get the full amount they would get for 12 months of work, if they do the same amount of work within 6 months. They also noted that a significant proportion of the available points (around 100 out of a total of 559) are for maintaining registers etc and having strategies/protocols e.g. if the contractor maintains a register for patients with diabetes then they get 6 points, no matter how long they have maintained that database; if they have a protocol for managing cervical screening services then they get 7 points. These are set points for doing a set thing, no matter how long the contractor does it for. There may be an argument that if a contractor maintains a register, has a protocol for managing cervical screening etc for only 6 of 12 months (e.g. because the contract has ended) then they should only get half the number of points.

If we receive any further information from GPC we will pass it on."

GPC Wales met and discussed the recent Welsh Health Circular with Sarah Watkins on 28/09/16 with Welsh Government who brokered the meeting.
It was agreed that whilst the circular's intention was to draw attention to GMC guidance around prescribing for Transgender patients, GPs in Wales are well aware of this guidance as it has been discussed extensively UK wide and will decide themselves, as they do with all other consultant initiated drugs, whether in governance terms they are best placed to prescribe.
If they do not, it is the responsibility of Health Boards to ensure that these wider arrangements are in place.
GPC Wales has also pointed out that the GMC guidance clearly states that if prescribing is carried out in primary care, it should be as part of a properly commissioned and supported shared service.
GPC Wales looks forward to further meetings with interested parties to ensure this group of patients receives the best care possible.

GPC Wales
05/10/16

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

Uptake of this vaccine for teenagers and those going to higher education under the age of 25 was not good last year.

This year we have the advantage of the uprated vaccination fee at £9.80!

Children D/B 1/9/1997 – 31/8/1999 should be pursued and jabbed!

Anyone unvaccinated under the age of 25 THINKING of going to University / College should also be vaccinated.

Vaccines are available through the Paediatric Vaccine Supply Chain.

Any further queries please contact your Health Board Vaccination Co-ordinator.