Dr Charlotte Jones: Welsh LMCs conference 2018 speech in full

GPC Wales chair Dr Charlotte Jones sets out priorities for contract negotiations and calls for more support for under-pressure GPs in her speech to the 2018 Welsh LMCs conference. Read the speech in full below.

Good Morning Conference – Bore Da Cynhadledd

Before I move onto the main thrust of my report to conference, I have some sad news to impart to conference.

Dr Sue Allanby, a hugely respected and vibrant GP who gave so much to patients and the profession sadly passed away following an accident in Spain. Sue, as you know, was married to Dr Charles Allanby - ex-GPC Wales negotiator and Cardiff GP. Our thoughts and own cherished memories of Sue will no doubt be with us all who had the honour of knowing Sue and there is a card available for people to sign but I would be grateful if you would join me in a minute’s silence. 

Thank you Conference.

Since we last met a year ago, there have been some positive developments in Wales.

GMS contract

We have reached agreement on taking forward the review of the Welsh GMS contract and this will be completed by April 2019,

We have continued to engage with the Welsh government’s train, work, live campaign which has resulted in recruiting more GP specialty trainees than the previous 136 limit, and the impact of winter pressures on GP teams has been recognised by relaxation of the QOF and a commitment to ensuring health boards that GPs are included in winter planning processes going forward and, given the recent rise of influenza cases, an outbreak DES has been agreed.

These achievements have only been possible through the collaborative, trusting and effective professional relationships based on trust between ourselves, the cabinet secretary for health and of course the Welsh government primary care civil service team of Frances Duffy, Karin Phillips, Alex Slade, Martyn Shipp and supported by a well known colleague, Dr Richard Lewis as national professional lead director for primary care.

You will recognise some new names amongst the Welsh government team and I think it is fair to say that it has been a steep learning curve for many on both sides going into a significant review of the whole contract as well as dealing with the myriad of challenges that need to be addressed but are not necessarily contractual.

I thank you for your positive engagement and input into that process.

These relationships have enabled positive change for the profession over a number of years and long may that continue.

Pressure on GPs

I believe it is important we recognise the value of these working relationships in order to build on, and deliver, the changes we need for the profession – change that may not be immediately visible to the profession but change that is happening and change that is addressing the recognised challenges and pressures facing individual GPs and practices across Wales.

So what can we expect to see in the next year?

Building on the government's clear commitment to the independent contractor status (supported by other models where needed), their firm commitment to finding a robust indemnity solution and the recent health and social care committee report into GP clusters which included recognition of and inclusion of many of the areas that we lobbied for in their recommendations, we have agreed that the following areas will be the focus for initial change in 2018/19 whilst the wider review of the entire GMS contract takes forward some of the challenges that need time to ensure they are resolved once and for all.

The areas that will see positive change for 2018/19 are:

  • Indemnity – improving the current offer whilst a more permanent solution is found – this needs to be adjusted for rising indemnity costs, not just for individual GPs, but particularly in relation to practice indemnity given the new ways of working in many practices and vicarious liability costs associated with this. This solution also needs to be extended to all GPs including sessional GPs as the current offer is for GP partners only.
  • Measures to reduce GP practice workload
  • Contract uplift
  • Revisions to QOF and cluster network domain – final proposals going forward include moving to just disease areas in active QOF and removal of the prescriptive detail in the cluster domain whilst reverting to a high trust low bureaucracy premise of the new contract and for this area, would solely mean engagement of practices with cluster working and the cluster determining its work programme.
  • Premises / last person standing liabilities – the health boards can assume responsibility for leases under the terms of the NHS Wales Act 2006, and are aware of ongoing work led by NHS Shared Services Partnership to set out options to enhance this capacity. However, we consider that more radical action is necessary. We would like to see action on new Head leases, binding commitments on existing new build leases and additionally an undertaking to consider assuming leases (where appropriate) on non-purpose built premises.
  • Workforce – firstly, incentives to retain current senior partners and attract new partners which would incorporate individualised ‘packages’. Secondly, improved returner / retainer schemes.

We are still in the process of negotiating and finalising the specifics of these areas but am sure you will agree these are important areas to tackle and give hope to the profession that we are cognisant of, and addressing, the issues which are much wider than just the contract.

Care models

So conference, despite the positives of having collaborative relationships where there is agreed strategic vision at a national level and the acceptance that the Welsh model of primary care needs to have multidisciplinary professionals wrapped around practices and/or available in the community, why is the reality on the ground so very different?

Why does our heat map show that despite the positive movements nationally, there are still large numbers of practices facing sustainability issues and worse, deciding there is no other option but to hand back their contract?

We are continuing to be aware that all practices are still reporting struggling day-to-day balancing the unrelenting demands from many sources such as:

  • sorting out the myriad of hospital administrative areas including appointments, expedite requests, waiting times for out patients or other interventions,
  • tasking the GPs with doing Med 3s that should have been given whilst the patient was in hospital
  • trying to ensure that patients who need input from our community teams can actually get it. The reality at practice level is they are finding it increasingly difficult to access due to unprecedented levels of sick leave, the geographical zoning of staff and siloed management which means fragmented relationships between practices and community staff and also between patients and families who often report they no longer know who or where to contact when they need help.
  • Ongoing requests to complete paperwork from agencies where there is no clear need for a GP to complete other than to rubber stamp that agencies decision making protocols.
  • Increasing difficulties in practices accessing onwards services for their patients which means continual pressure to deal with problems that should be dealt with by other teams in a timely manner.

Obviously this then all knocks onto the access for registered patients who deserve to be able to access us and onward services when they need and deserve to utilise the skills of the GP team.

Stress

Many of you will also still be aware of the anger and disappointment that came to a profession already struggling with high levels of stress and burn out when a Professor of Economics in a Welsh University suggested at a conference arranged by the Institute of Welsh Affairs that GPs could be replaced by simply using nurses and a computer algorithm to save money for the Welsh economy. This is akin to saying that one could replace an economics lecturer with an abacus and a book. This sort of attack on the profession is just symbolic of how little people understand of the intricacies of primary care and just what we contribute to the NHS in Wales and wider.

But this aside, there is actually a bigger threat to the profession than those I have already outlined and that is the ability and want of individual Health Board’s to deliver the national agreement in full and address the challenges facing local practices.

Sadly, not all health boards have enabled the warfarin DES to be offered by 1 November 2017 and are refusing to pay practices for the service despite them, in good faith, putting in place the requisite protocols and employing staff to deliver the service. This is unacceptable.

Another example of unacceptably damaging and dangerous health board behavior for conference to digest is the impact of the last minute intervention from Health Boards with the Diabetes Enhanced Service. This meant that a specification that would have been a gold standard model for others parts of the UK and wider to adopt was significantly amended at the last minute. Not wanting to lose the resource available to practices, the GPC Wales team negotiating this had to take pragmatic action but rest assured lessons on both sides have been learnt and we will not allow this to happen again.

Out-of-hours care

Moving onto out-of-hours, all out-of-hours services in Wales are struggling with workforce recruitment and it is not difficult to see why.

The lack of true investment in the service over many years has led to an inability for the service leads to truly invest in positive planned change in the service – the service is largely reactive – and at times outright passive - rather than proactive.

The lack of investment has contributed to the problems experienced by ShropDoc and we now hear worrying reports that their contract will not only not be extended but could well not be replaced in full. These services, which are wider than just out-of-hours care, if not properly resourced and delivered, will have a significant negative impact on patient care both in- and out-of-hours.

The recent HMRC taxation changes were implemented in each health board area quite differently and has led to the workforce in many areas feeling under valued and not appreciated.

Whilst GPC Wales understands the rationale for the changes and why the health boards moved to protect themselves, not all health boards engaged their GPs properly in the changes or offered the opportunity to ask questions. Further, not all health boards respond to their workforce when reasonable emails or letters are sent asking pertinent questions. That further enhances the sense that GPs have that they are just 'another cog in the wheel' rather than valued colleagues.

This has to stop, or else health boards will see more workforce challenges and an already creaking service being at risk of collapse.

Risk of collapse

So, are all Health Boards making life challenging for GPs?

In short no, but given the challenges that LMCs have to deal with when trying to get implementation of the national agreements put in place despite it their being clearly written down in national directions to health boards, it is with sympathy that I note the call for one primary healthcare board for Wales coming from GPs across Wales. GPC Wales has previously felt given there is a steer for integrating health and social care within Wales that a single board would not be in keeping with that direction, however, after this year, the mood of GPC Wales is changing – and unless health boards clearly demonstrate a willingness to deliver the national agreements it is something we may find ourselves actively pursuing.

Without naming names – Golden Gwent and Cwm Taf, oops, some health boards are dynamic and innovative in approaches to solving problems and we rarely, if ever, hear of difficulties with implementation of the national agreements in these areas but the same cannot be said elsewhere with two health boards in particular standing out.

What I would say to ANY board that thinks they are going get away with not delivering the national agreement OR the solutions needed to sustain practices unchallenged then THEY ARE VERY MUCH MISTAKEN. GPC Wales together with BMA Cymru, our proactive LMCs (always a step ahead of the other side) - will ensure all resources are utilised to address such issues.

I am delighted as well as reassured to announce that the GPDF is strongly supporting us in taking forward measures to address issues relating to implementation of the warfarin enhanced service in one health board – I wish to send a clear message to the health boards and the profession that WE WILL NOT rest until this dangerous precedent of a HB unilaterally not following its obligations under the SFE and contract directions is fully addressed.

Sadly, undermining national negotiations is not just restricted to health boards – it is with sadness and regret that I report unacceptable behaviour from those tasked with delivering a holistic service for transgender patients in Wales.

Transgender patients

Wales had a unique opportunity with the cabinet secretary’s announcement to deliver a service – the first in the UK – whereby GPs with a special interest would deliver a holistic local service for patients whereby prescribing and ensuring other services needed by the individual patient were all in place and specialist support given by a gender identity clinic based in Cardiff. This would have meant patients no longer needing to travel long distances to access their care; having the majority of their care provided close to their homes by GPs with the requisite expertise to deliver it; with GPs also providing proper oversight to ensure the holistic needs of the patient would be met.

Dr Kay Saunders spent significant amounts of time and expertise developing a proper specification for the GP element of the service. This model had been through various task and finish groups and sub group work and was shared with Welsh government leading to the announcement by Welsh Government and supportive commentary from ourselves and the transgender community.

GPC Wales, at the behest of the transgender task and finish group, sourced a network of interested GPs across Wales to provide the service.  Sadly since then, despite continuing pressure from GPC Wales, there has been no progress and, worse, a lack of transparency and seeming ongoing obfuscation as to whether there is a true appetite for delivering the enhanced service

With a want to try and ensure the transgender community would be able to access the right services, we have continued to engage and discuss and educate those involved in putting forward business cases for the service and have done this in good faith. However, the other side have continued to undertake actions that not only undermine the process with a lack of transparency over many key areas involved in developing the service and seeming obfuscation as to whether there is a true appetite for delivering the enhanced service. This has led to us losing confidence that they are able or willing to provide a proper service to patients and that they are instead ripping up the agreement and trying to impose a different and inferior service in its place.

The entire process has been unsatisfactory, unacceptable and GPC Wales now feels the time for engagement in good faith is over. We have no other option to ensure that the profession and transgender community know what awful behaviours have been displayed resulting in us having to go public with our concerns.

Those involved in delivering the service need to take heed that trying to fragment the profession will not work.

Those involved in delivering the service need to take heed that an inferior service for the transgender community is unacceptable and not in line with what was agreed with the cabinet secretary nor expected by the community and the GP profession.

Those involved in delivering the service need to take heed that if the GMC guidance on prescribing is enforced and threats to refer GPs to the GMC are actually implemented, then we will take strong firm action. RCGP Wales and ourselves are of a shared viewpoint that this work should be done by GPs with the requisite expertise in this area.

If those involved in delivering the service wish to engage in further talks with the representative elected statutory body for GP negotiation they will need to assure us of their intentions that they are fully signed up to delivering the service as previously agreed.  

GPC Wales, the GP profession and the transgender community deserve better than this and will not accept less than this.

Conference, I have taken up enough of your time and whilst our message to Health Boards and others is hard hitting, I would like to remind you that there is positive change in train through the effective relationships we have with the Welsh government team and we are lucky to have a cabinet secretary who truly wants to ensure a robust sustainable general practice for Wales and resolve the challenges we face.

Conference, I would like conclude my report by specifically referencing those individuals without whom, it would be impossible to do my job:

  • The BMA Cymru office team of Lucy, Rodney, Gareth, Penny, Natalie, Carla, Stacey, Liam all headed up by Rachel
  • The LMCs across Wales, GPC Wales committee and of course the GPC Wales negotiating team with my new deputy Dr Pete Horvath-Howard, David Bailey, Phil White and Nimish Shah, and
  • And, lastly to a few specific individuals – Dr Kay Saunders and for her extensive work over 18 months in the GP role in delivering holistic transgender services and to Dr’s Kevin Thomas, Ian Harris, Gareth Oelmann, Sara Bodey, Stephen Davies and Heather Evans for supporting the contract work streams undertaking significant amounts of work often at short notice.

Diolch i chi gyd

I personally thank you all for your valued contribution and am grateful that the GPC Wales negotiating team has been able to move forward in addressing the challenges facing the profession with laughter and fun making the hard work and inevitable ups and downs easier.

Dyna ddiwedd fy araith, diolch am wrando.

That concludes my speech Conference – thank you for listening.

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