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:
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.
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.
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.
Whilst GPC UK / BMA are getting further legal opinion on firearms requests and our current guidance, we would recommend using the following statement as the basis of a response to any requests regarding firearms license applications:
Dear Chief Constable
Thank you for your letter.
My representative professional body, the General Practice Committee of the British Medical Association has stated the following.
The interpretation of medical evidence to assist the chief constable in their decision regarding the grant or renewal of a firearms or shotgun certificate should be undertaken by an appropriately qualified medical practitioner who is not the patient's General Practitioner. The role of the GP is to continue to provide access to the applicant's full medical record, in line with statutory legislation
I am not in a position therefore to respond to your request for an opinion for the reasons outlined but will provide copies of records with consent in order for you to apply an appropriate process.
We will of course forward you the updated guidance once written.
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:
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."
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