This is my last annual report to Welsh Conference and it may be a cliché but it’s been an interesting year.
I started my time as chairman with an imposition and very nearly ended the same way but happily some sanity prevailed in Wales leading to a negotiated settlement.
This settlement is by no means a great deal for GPs – that was never on offer in the current financial crisis – but it does go some way toward recognising the spiraling workload of GPs and protecting funding and viability for every practice in Wales. And it still maintains the core of a general practice contract that offers patients across Wales and indeed across the UK a primary care service recognised by the independent Commonwealth fund as the finest primary care in the world.
Fundamentally the GMS contract does still do just that. It’s a system of weighted workload based funding with a quality based incentive scheme and locally and nationally driven add-ons to further enhance care. Our challenge over the next few years will be to protect and improve that contract.
To some extent this will depend on how much an ideologically driven rush to privatisation takes hold in Westminster. But it also depends on persuading our government of the fundamental value of GPs to Welsh patients and the need to protect the core of this value – the individual practice – in all its varieties across Wales.
This will mean recognising and celebrating variation and recognising that no formula can be completely fair, it will mean investing in staff and premises and most of all in new services to support left shift of care, it will mean listening to the conclusions of the Francis report that a target culture based on financial savings and a bullying management is bad for patients and most of all it will mean working with and not against GPC Wales and the Welsh LMCs to continually improve Welsh general practice and attract the very best future GPs to Wales.
The government has made a good start in listening to our serious concerns about the proposed imposition from Westminster. We told them about daft questionnaires which would have irritated patients and meant GPs working for below the minimum wage, we told them about a failure to recognise that organisational achievement is not a free good, about ever receding targets which fail utterly to learn the lessons of Mid-Staffs, thresholds which risk harming patients and about DESs which go against the advice of their own advisory committees because the PM knows best…….I could go on but I won’t.
Now in Wales we have a few thresholds at the median achievement level without an intention to push them ever higher. We have recognition that safety is more important than pushing GPs to over medicalise patients. Recognition also that practices need stable resource to deliver patient care and also that patients have their own agendas, which generally don’t include tick boxes.
Most importantly we have some recognition that maintaining practice funding so that patients have a GP is more important than a doctrinaire policy that everyone can do the job for precisely the same per patient funding when all the evidence of our own eyes says that actually, they can’t every practice is different.
The government’s own data has recognised that the practices worst affected by changes to correction factor would almost all be in four rural counties out of twenty two which kind of makes the argument in a single sentence unless you believe you’re going to win the lottery tonight. Once you agree on both sides that there’s a problem then you have the possibility of a solution and hence the government commitment to consider issues around smallness, branch practices and rurality and that some of the solutions may be off formulary for outliers.
Welsh Government is not now committed to eroding MPIG although I suspect that’s an argument we will still have to revisit and they do at least understand that the simplistic conclusions of the Welsh audit office say more about their lack of understanding than the realities of providing general practice in Wales. We are committed to open discussion of the issues around practice funding variability and also to modeling down to practice level. Welsh Government have been told in no uncertain terms of the effect that never-ending uncertainty will have on partner recruitment and patient service provision in the worst affected areas.
Which brings me on to recruitment. The funding gap between the Celtic nations and England remains at over £10k although there is a real likelihood of this narrowing. Sadly the reason for that is not because of increased Welsh GP incomes but reductions in England. Recruitment to GP training is still under pressure particularly away from South Wales and the M4 corridor and there are motions this year on this issue.
What is particularly clear is that with reconfiguration, MPIG threats, hospital staff shortages, distrust of management and low take up of vacancies there is a perfect storm brewing in rural Wales and we have made certain that both the minister and rural AMs are clear about the dangers.
Pouring petrol on the fire of course is pensions. GPs this year are actually seeing the reality of the income reductions they only heard about in abstract last year and there is worse to come – a further 2.4% reduction this year and 1.2% next. Add to that the stealth tax of changes to Annual allowance and Life time allowance from 2014 and every GP over 55 will need to take careful personal pensions advice about the cut-off point where they will effectively be paying for the privilege of remaining in the pension scheme. Many older GPs will find it financially nonsensical to remain in the pension scheme and whatever their intentions on continuing after withdrawal they may find the comfort of being a pensioner irresistibly tempting. The consequence of this on a workforce with large numbers of over 55s is potentially catastrophic.
The other significant issue for pensions is the transfer of responsibility for locum employer’s superannuation to practices. Unfortunately at least in this context we have an England and Wales pension scheme and this forms just one of the many unwelcome facets of the England imposition. We have agreed in Wales that money currently spent by LHBs will be delivered to practices through global sum equivalent so at least all practices will get some of the £782k it cost last year.
However there are two very unwelcome aspects to this change. Firstly it will not go to practices proportionate to their current costs – indeed pretty much the opposite as the highest locum costs are likely to be in small practices with less ability to cross cover. Yet again like with Carr- Hill small practices will be disadvantaged by changes to government policy – regardless of whether patients still like them (and they do!)
The second problem will affect younger locum doctors, as older retired locums will be cheaper to employ and practices may inevitably try to negotiate around their costs even though non of these increased practice costs relate to higher income for the locum.
In addition to everything else revalidation has started and in this, if little else, there is some good news for Wales. The all Wales appraisal process for GPs has been established and is working well, a free multi source feedback form is on the blocks for Welsh doctors and became available yesterday and GPs have an appraisal system that they generally trust. There are still concerns about remediation payments and revalidation for sessional doctors. GPC Wales is keen to promote the affiliated practice scheme for sessionals and we continue to work both at Welsh and UK level to make the process as straightforward as possible and ensure GPs are fairly treated over remediation.
While the contract changes have inevitably been our main focus over the last few months there have been other important issues. Foremost probably with a contracting financial envelope is enhanced services and the need to ensure that this funding stream which is between 7 and 8% of GMS is spent on realistically priced services that are GMS provided. This clearly doesn’t mean ambulance booking, physio or wound dressings provided in secondary care and it certainly doesn’t mean the same service as last year for 20% less money so LHBs can fund extended hours! We will continue to scrutinize LHB spending in this area and challenge any schemes which misuse or divert much needed resources from front line general practice.
Welsh practices again rose to the challenge of delivering even better access to their patients this year despite rising consultation rates and rising population. Yet again the talk is of extended access next year but this seems much less strident and LHBs seem clear that this will only happen via a commissioned DES. I think they are finally waking up o the benefits of a collaborative approach on this.
We have had an ongoing dialogue with Welsh government about using community pharmacy to deliver flu vaccination where uptake was low despite the self-evident concerns about record keeping side effects and double dosing this raises. We repeatedly warned them of possible unintended consequences such as the risk that practices would reduce orders and commitment if they were uncertain of their likely uptake. This year was apparently a pilot and in total all the community pharmacists in Wales gave less flu jabs than my practice….
Clearly I can’t speak for how well the other 474 practices in Wales have done but it does raise value for money concerns and we have written to the CMO and await the evaluation with considerable interest. We also remain in ongoing dialogue with Public Health Wales as regards use and interpretation of GP vaccination data.
Following an extensive procurement process where we were represented by Ian Millington we are all moving by 2015 to one of 2 hosted GP systems – Vision and EMIS – with extended functionality, security and connectivity We remain concerned about potential data loss and disruption of QOF work and have sought assurances around protecting practice income through the changeover and about timing of transfers.
On the dispensing front following the conclusion of the fee scale negotiations last year we are continuing to pursue a solution to the ongoing problem of drug reimbursement. This clearly also affects rural practice particularly small rural practices and needs urgent resolution. Welsh government are likely to follow DH in this matter and DH as often on issues which it prefers to avoid is moving with the sense of purpose of an arthritic snail…
We will maintain pressure to resolve this.
Madam chairman that concludes my report.