As part of ongoing work to identify patients at increased risk of significant liver disease, the Biochemistry Department, in conjunction with the Liver Unit will be launching a new tool to evaluate the likelihood of underlying fibrotic change in patients presenting with raised ALT. This tool will involve automatic measurement of serum AST in all primary care patients in whom ALT is raised for the first time and the calculation of an AST:ALT ratio. A comment advising the requester to refer to the liver plan pathway for guidance on further management will be appended to all results. Patients with a ratio ≥1 are considered to be at increased risk of developing significant liver disease, irrespective of the degree to which their ALT is elevated, while those with a ratio <1 are at low risk.

Dr Andrew Yeoman, Consultant Hepatologist, has devised an algorithm based on a combination of AST:ALT ratio, ALT concentration and relevant underlying diagnoses e.g. alcohol excess, obesity and the metabolic syndrome, to guide on further investigation and management (attached below). The algorithm will also be available on the Clinical Biochemistry Home Page http://howis.wales.nhs.uk/sitesplus/866/page/40863 and can be found in the ABUHB Pathology Handbook http://wphtrak.wales.nhs.uk/dept.cfm?t=8 by searching for LFT, AST or ALT and following the external link.

This service will be launched on Monday the 4th of July. However, as this is a work in progress the algorithm may be adjusted following a 3 month pilot period, during which we will be evaluating how well this approach identifies the target population.

I am pleased to inform that the regional elections for GPC Wales are now complete for 2016-2019. I can confirm the following candidates have been nominated without contest to represent their constituency for a period of 3 years, beginning in July 2016. Congratulations to the successful candidates:

Dyfed Powys

Heather Evans
Peter Horvath-Howard
Laurence Glyn Williams

Gwent

Susan Fairweather
Gareth Oelmann
Deborah Waters

The following candidates have been elected to represent their constituency via independent ballot:

North Wales (3 year term)

Phil White
Sara Bodey
Eamonn Jessup

Bro Taf (1 year term)

Stephen Davies

We are aware that many HBs have contacted practices to state that all persons involved in performing spirometry and reading spirometry are to undertake specific ARTP accredited training in order to continue offering this service within general practice. This has come about following release of the All Wales Respiratory Plan.

Whilst we acknowledge the good intentions of the All Wales Respiratory Health Implementation Group’s efforts to improve respiratory care, we are concerned that the unintended consequences of these proposals have not been considered. As well as the ongoing actual monetary costs of ongoing training, the practical implications for these proposals on General Practice and actual contractual requirements for GPs with respect to spirometry assessments have not been fully appreciated or realised.

That aside, the following issues have come to our attention:

· To date, no clarity or evidence base has been provided to GPs to explain why practice nurses need to attend this specific training course. Therefore, at present, we fail to see the value or merit to this proposal, over and above what training general practice staff have already done.

· Whilst initial costs are intended to be met by Welsh Government/Local Health Boards, there has been no consideration for providing resources for the ongoing training, which we understand is required every 3 years, nor the costs of renewal of accreditation or essential backfill to cover practice staff undertaking training. From reviewing this course it appears to require attendance at a 2 day course followed by around 250 hours of coursework. We are aware that some HBs have offered to fund the fees of the 2 day course but not for time / locum backfill for this training.

· The GMS contract does not require practices to perform spirometry. It simply requires practices to ensure patients can access the investigation. Given that GPs are operating at critical capacity, if this decision is not reconsidered, there is a very real risk that practices will disinvest in performing spirometry and will simply refer all patients requiring this test to secondary care.

· In terms of continuity of care, the reality is that there will be an expectation that patients will have ongoing monitoring of spirometry changes undertaken within the practice. However, this will not be possible if all practices are required to have completed ARTP training.

We hope the above clarifies the national position and can confirm that at no point have GPC Wales been consulted. We have raised this with representatives of the All Wales Respiratory Plan and will be in touch once these discussions have been concluded.

Best wishes

Dr Charlotte Jones

LMC are to convene a meeting between members of the directorate, ABHUB primary care team staff and LMC this is following the discussion at LMC as reported last month.
We are keen to ascertain whether the current annual review letters from secondary care for the super six patients– cover the nine point holistic review of diabetic patients monitored by the audit office. The letters should include consideration of Blood pressure; Body mass index; Cholesterol; Creatinine; Eye screening; Foot examination; HbA1c level; Micro-albuminuria; Smoking advice)

To inform this meeting we are asking for any practices to forward information to LMC directly using the audit template on the website – even if only one - two patients per practice could be reviewed in the next 2 weeks this will give us evidence on the quality of the correspondence.