The Welsh Government will introduce a state backed scheme to provide clinical negligence indemnity for GPs in Wales (announced by Health Secretary Vaughan Gething on Thursday 10th May 2018
Stakeholder Reference Group
The Stakeholder Reference Group (SRG) met for the fifth time on 10 April 2019, the
first meeting since the GMPI scheme was launched.
The valued input and expertise of the SRG was highlighted at the meeting and
members were thanked for their support of the scheme launch on 1 April 2019.
NWSSP L&RS confirmed that they had received a number of queries, most of which
were relatively straightforward. We would urge any individuals or practices with
queries about the scheme to contact NWSSP Legal and Risk Services, either:
. By telephone: 029 2090 5454 (9:00 – 17:00, Monday to Friday)
. By email: GMPI@wales.nhs.uk
Detailed scheme guidance and FAQs have now been published on the GMPI homepage and will be developed as the scheme progresses. Colleagues are encouraged to regularly check both documents, particularly the FAQs, for updates.
It has been encouraging to note the positive feedback from colleagues, particularly around the informative nature of SRG communications, the guidance and the FAQs.
This is testament to the collaborative working of the group, which has been instrumental in ensuring the availability of the relevant information in the face of very challenging timescales.
The decision has been made to move to quarterly meetings of the SRG. However, communication channels will remain open, and, should the need occur to engage the group on specific issues, this will be done.
We would like to take this opportunity to again thank all members of the SRG for their insight, expertise and support of the GMPI scheme. We look forward to continuing to work collaboratively as we move through the early stages of the scheme.
The scheme for General Medical Practice Indemnity (GMPI) relates to potential or actual clinical negligence claims arising from incidents on or after 1 April 2019, and captures all General Medical Practice (GP practice) staff undertaking NHS ‘primary medical services’ as defined in The National Health Service
(Clinical Negligence Scheme) (Wales) Regulations 2019:
“primary medical services: health services provided under a contract, arrangement or agreement made under or by virtue of the following sections of the NHS (Wales) Act 2006:
(a) section 41(2) (primary medical services);
(b) section 42(1) (general medical services contracts);
(c) section 50 (arrangements by Local Health Boards for the provision of primary medical services).”
FAQs related to GMPI are available below:
The following link is a helpful collection of GDPR advice, privacy templates and blogs for GPs and practices to use, collated by Dr Paul Cundy from the GPC and there will be updates:
Please note this is a dropbox link and so may not be accessible from inside NHS secured networks.
Further information can also be found on the BMA website via this link.
The CMO for Wales issued a new set of Standards in 2018 which can be found at
These standards for clinical behaviours and communication across the primary and secondary care interface have been developed for adoption througout Wales. The standards were initially developed by Bro Taf LMC.
Health Boards are expected to put in place arrangements to ensure these standards are fully adopted and include processes to receive, collate and respond to concerns expressed from theirhealth community where these standards have not been upheld. Breaches of the standards in SBUHB should be reported via Diet Datix (can only be accessed from an NHS PC) which has been developed specifically for monitoring the standards and is easy to complete. You can also continue to use the letters in the documents section of the website and cc in the LMC (patient details to be anonymised.)
The BMA has received new legal advice regarding medical note requests received from the police, which are detailed below.
There is clear guidance regarding the obligations that GPs have with respect to copying and/or release of the GP record. For your reference, these circumstances are:
- If the police do not have a court order or warrant they may request voluntary disclosure of a patient’s health records under section 29 of the Data Protection Act 1998.
- However, while health professionals have the power to disclose the records to the police where section 29 applies, there is no obligation to do so.
- In such cases health professionals remain bound by the long-established common law duty of confidentiality and may only disclose information where the patient has given consent, or there is an overriding public interest. They may also be required to defend their decision to disclose before the GMC which is a statutory tribunal.
- Disclosures in the public interest based on common law are made where disclosure is essential to prevent a serious threat to public health, national security, the life of the individual or a third party, or to prevent or detect serious crime. This includes crimes such as murder, manslaughter, rape, treason, kidnapping and abuse of children or other vulnerable people. Serious harm to the security of the state or to public order and serious fraud will also fall into this category.
Your practice is entitled to a fee for producing the notes. There is no set fee for producing these notes, as they are not considered a subject access request that you may receive from a patient. Therefore the practice is able to set its own fee.
In order for you to proceed with the police request, please use thie pro forma which can be found on the documents page under useful documents, that we recommend you complete and send to the police authority. We recommend that you obtain each of the following:
- Provide written patient consent to release of their records OR provide written confirmation as to the nature of the serious crime allegedly committed by the patient and an explanation as to why the patient’s records, or other information requested, are considered necessary for the specific purpose you are pursuing. You will require one of these in order to fulfil your responsibilities as the Caldicott Guardian.
- Confirmation in writing that the fee of £xx will be paid within 28 days of the police receiving the record. This fee is due to the disproportionate effort placed on an already overburdened GP practice to provide these notes which recognises the need to support the police in their investigation of a crime, where appropriate to do so.
- Written confirmation from a senior police officer – ranked Inspector or above – that he or she considers that the crime being investigated is a serious crime in line with the examples provided above.
Once you are in receipt of each of these at the practice, and have checked the appropriateness of release of the records, you should respond to the police authority as soon as possible.
Alternatively, should it be appropriate for the police to view the record (based on answer to 1 above), then there is the option for them to view the record in the practice in the presence of a practice staff member. In this situation there is no fee chargeable.
There is no set fee for providing records in this manner. Therefore it is the responsibility of individual practices to set their own fee for this work. When completing the attached pro forma you must enter the fee you choose to charge.
It is vital that the police agree in writing to pay the fee, otherwise you will not be able to claim for the service. If the police authority do not agree to pay the GP can decide whether they would like to provide the service free of charge, or not at all.
Please note that if the police authorities have a court order or warrant for disclosure of the records, you may be required to comply with the request even where a fee has not been paid or agreed. This will depend on a number of factors, including the terms of the court order or warrant.
GPs should, in all cases where there is no patient consent, consider whether the benefits to an individual or to society of disclosing the records outweigh both the public and the patient’s interest in keeping the information confidential before agreeing to disclose the records.
For any queries please email email@example.com.
21 June 2017
FAQ: Health Board approach to taxation and employment status of GPs working in directly managed practices or Health Board managed Out of Hours servicesWhat is the problem? HMRC has recently taken a keen interest in the employment status of many independent contractors which includes GPs working in a sessional capacity. In essence, if it determines that you are employed, as opposed to being self-employed, then your tax and national insurance contributions will be removed by the organisation which pays you. In addition, if the organisation has, in HMRC’s opinion, wrongly treated you as self-employed then the organisation can face a significant fine and interest which can potentially go back as far as 20 years. Therefore, this is causing much angst amongst employers. In particular, Health Boards have become very concerned about their potential liabilities and have commissioned specific advice from Deloitte. The Health Board interpretation of this advice has concluded that GPs working for the Health Board but not in a salaried position (e.g. in out of hours centres; in prisons; doing shifts in a minor injuries unit; working in directly managed practices) should be classed as employed for taxation purposes but not for employment purposes. Thus, you would be unable to access employment rights, which includes annual leave / sick leave / maternity leave / and other parental rights. Their assertion applies to all sessional GPs whether working through an intermediary (where IR35 applies) or not. Please note, for avoidance of doubt, this guidance applies also to GP principals or salaried GPs offering services and directly contracting with the Health Board on a sessional basis for the types of work as outlined above.
Does GPC Wales believe that the Health Board interpretation of the taxation status is correct for GPs working in above settings?Sadly, it appears that the HMRC toolkit to determine whether an individual is employed or self-employed isn’t always that clear-cut, and thus there are risks to any organisation in getting it wrong. However, we support the guidance in other parts of the UK; namely that blanket application of the ruling is wrong as it doesn’t allow for differences in an individual’s circumstances.
Does GPC Wales believe that the Health Board interpretation is correct for the employment status / ability to access employment rights of GPs working in above settings?We do not feel this interpretation is correct. The tests to determine whether an individual is employed for taxation purposes and for access to employment rights are very similar, and it seems nonsensical to say they apply to one section and not to the other. We believe this could be open to challenge by GPs who contract directly with the Health Board. However, if you are working through an intermediary/ personal service company (see below) then it is unlikely that you could argue you are employed for employment benefits.
Isn’t this just about the HMRC IR35 regulation?This is wider than the application of IR35 regulations. IR35 solely applies to GPs working through an intermediary such as limited liability companies. These are often described as a personal service company which individuals have set up so that they avoid paying tax and are liable to a lower rate of tax via corporation tax (which currently stands at 19% rather than the tax levels for higher earners) and this is why HMRC at trying to close the loophole. The approach from the Welsh Health Boards applies to all sessional GPs working as above. Matt Mayer from the BMA sessional GPs committee has written an excellent blog on this issue which can be accessed here.
Should I just accept the HB advice?We would say no. There are a few issues to consider
- Lack of consultation: is this fair or right given the significant change to your terms and conditions of service?
- The assertion that employment status does not confer employment rights Do your own HMRC toolkit assessment and take individual accountant advice
- Talk to your LMC or contact the BMA if you are a member (unfortunately neither are in a position to offer individual legal or financial advice).
What actions are possible?
1. What can I do?
- Consider the BMA website advice, complete the HMRC toolkit and discuss the results with your accountant. You could use it to challenge the Health Board to apply non-employed status to you. However, it is unlikely the Health Board will change its stance and the toolkit isn’t quite clear cut.
- Consider whether you want to continue working for an organisation that has taken this unilateral action. Your accountant may be able to help guide this with respect to impact on tax brackets etc.
- Consider whether to ask your LMC to act on your behalf and outline what course of action you wish them to take. You should do this whether you continue working or not.
- Consider whether you are willing to withdraw services or not? The BMAs sessional
GP subcommittee states that you can consider the following:
- If you are willing to withdraw services, then further think about whether you would add your name to signatures to be gathered by LMCs threatening to withdraw services OR write to the Health Board declaring a termination of service in accordance with the contractual obligations to which you are subject.
- If you are not willing to withdraw services, then (if you are a GP who contracts directly rather than via an intermediary) consider writing to the Health Board telling them that you believe you are entitled to statutory employment protection and reserve the right to take them to an employment tribunal, and advise them, if employment tribunal found in your favour that you would be chasing historic holiday pay / sick pay / pension etc. back to your start date. This latter needs to be done by an individual GP.
2. What can your LMC do?LMCs do have the responsibility of acting on behalf of all GPs in their area in all their working roles. To do so effectively they need a clear mandate from the workforce affected – therefore you have to play your role in making your feelings known. The LMC can:
- liaise with Health Board to ask further questions as to validity of this change to terms and conditions of service through seeking to see evidence, challenging lack of consultation, highlighting potential adverse impact on sustainability of workforce and service provision (including whether this is on the Health Board’s risk register)
- work with the Health Board to find possible solutions e.g. deferred implementation date of changes to enable consultation, devising a zero-hours contract for local GPs to work under which could confer some employment rights etc.
- keep local GPs up to date with likely impact of these decisions and progress on solutions
- work on your behalf without you having to raise your head above the parapet e.g. gather signatures from affected GPs threatening to withdraw services; OR collate responses from GPs to the Health Boards declaring a termination of services in accordance with the contractual obligations to which they are subject.
3. What is GPC Wales doing?GPC Wales is:
- working closely with LMCs to support them in progressing local discussions and solutions on behalf of GPs in their area (that’s why it is important to make your views and situation known to LMCs)
- in our regular meetings with the Welsh Government, highlighting risks to service provision and workforce sustainability in an already creaking service area, requesting that it seeks assurance from Health Boards on how these risks have been considered, including in respect of winter pressure plans
- considering what other national solutions may need to be implemented after
listening to the profession and seeing how the Health Boards respond e.g. a national
zero-hours contract for GPs working in settings as above
What already happened in Wales and elsewhere?
- Betsi Cadwaladr UHB did not use Deloitte to determine its stance but instead worked directly with HMRC. This has already been put in place and GPs have made individual decisions whether or not to accept changes, and this has resulted in less GPs working in directly managed practices.
- In Dorset, a blanket policy was applied early in 2017 which was challenged by GPs, LMC and GPC. A new deal was offered to GPs with better pay and employment rights and a catastrophe was averted.
- In Swindon, the OOH trust applied a blanket policy but despite pressure did not back down and this resulted in great difficulty in sourcing doctors.
What should I do next?It comes down to whether you as an individual want to take action on this. Please review this guidance carefully and consider all the available options before deciding on your response. The Local Medical Committees and GPC Wales are here to help. We need to know your views to inform our next steps in discussions with Health Boards at a local level, and the Welsh Government on a national basis. Please inform your LMC about what you want to see happen.
Bro Taf LMCTel: 02920 899381
Dyfed Powys LMCTel:01597 860565
Gwent LMCTel:01495 764455
North Wales LMCTel:01745 825780
GPC Wales statement12th October 2017 Dear Colleagues,
Re: Potential taxation liabilities of practices using sessional GPs
As chair of GPC Wales am writing to remind you of the recent changes to HMRC regulations where there is a focus on taxation status of sessional GPs contracting with organisations including GMS practices either directly OR via an intermediary (the latter is known as IR35 – see below).
For the purposes of this letter we have purposely utilised the terminology of sessional doctors in this letter as although all sessional doctors are independent contractors like those in partnership, we felt this delineation brought clarity to updating you on this important issue.
In brief, HMRC is looking at whether sessional doctors should be considered employed or not for taxation purposes – this is different to employment status for employment rights. If HMRC determine that a sessional doctor is employed, then not only are you liable for taking tax and NI off at source, BUT, you run the risk of being liable for significant back taxes and penalties (possibly going back as far as 20 years)……. Therefore it is an area that we wished to highlight again to practices to make sure they were aware of this important issue.
Isn’t all this just the IR35 changes?No – IR35 ONLY applies to the small cohort of GPs who do their sessional work through an intermediary e.g. locum agency / chambers / limited company.
HMRC are taking a close look at ALL types of sessional GPs who directly contract with practices or Health Boards – this of course can include principals who also do sessional work in a non-salaried capacity (e.g. OOH work)
What should you do as a practice?
- Review arrangements through which you contract with sessional GPs and use the online HMRC tool to see what outcome you get as to whether they are to be considered employed OR not – we would recommend you keep a copy of the outcome of the toolkit. It may also be worth asking the sessional GP to do their own assessment and see if it comes out the same.
- Review the guidance on the BMA website regarding this issue
- Discuss with partners and accountants regarding what steps to take i.e. do you offer them a contract OR do you revise how you offer sessions to this group of doctors – keep a careful record of discussions on this issue
- If you continue to utilise their services on a self employed sessional basis, then keep careful records of agreement for provision of services from the sessional doctor
- If you are going to offer a contract remember that you should offer terms and conditions at least as good as them BMA model contract.
GPC Wales has recently developed guidance for sessional GPs directly contracting with Health Boards themselves or via an intermediary (i.e. IR35) following most Welsh Health Boards adopting a blanket policy of treating all such GPs as employed for taxation purposes but not for employment rights. You and your GP partners should have received this as we sent it out to all but if you would like a copy of this guidance for information, then contact your LMC.
GPC Wales and your LMC always welcome any feedback you may have on this and other issues so feel free to let us know your thoughts on this and any other issues where you feel the LMC and GPC Wales can be of assistance.
GPs are required under the GMS contract to provide certain information and certification free of charge. This includes sickness certification, death certification and clinical referral. A full list is set out in Schedule 4 of the NHS regulations can be found here.
GPs are often asked to provide medical reports or information for patients/outside organisations which are not contractual. These include:
- Insurance Company/PMA reports,
- Legal reports,
- Occupational Health reports,
- DVLA reports
- Reports for Case Conferences/Safeguarding meetings
- Evidence to support benefit claims &
- Blue Badge applications.
Practices are not contractually obliged to provide such information and therefore when such requests are received can reasonably:
- Decline to undertake the work,
- Undertake the work and not charge a fee (at a cost of clinical/administrative time and effort to the practice, which may be considerable and impinge on patient care),
- Charge a reasonable fee to the requester (outside agency/company/patient themselves).
Practices should satisfy themselves that before supplying any patient information to a third party that they have the appropriate patient consent in place. Since the Competition Act 1998, the BMA no longer recommends the levels of remuneration/fees payable for such work. Practices should set their own reasonable fees, taking account of the administrative and clinical burden involved in completion and preferably agree the fee prior to completion of the work.
Firearms licensing process:
Update from South Wales Police Firearms Licensing 30/03/20 as a result of Coronavirus epidemic:
As a result of the ongoing Covid-19 crisis we have adopted a practical and sensible solution to managing our certificate holders during these challenging times.
We are not accepting any new applications during this period.
As we are not able to accept on-line applications or payments, we are automatically extending those certificate holders that are due to expire.
We are notifying our certificate holders by email and text message of the extension period and providing them with a unique reference number.
Once business returns to normal we will expect those that have been extended to apply in the normal way and we will not issue a new certificate until that process has been fully completed.
From 1 April 2016 new information sharing processes between GPs and the police were introduced in an attempt to ensure those licensed to possess firearms and shotgun certificates are medically fit to carry arms.
We have significant concerns about these arrangements and we continue to raise them with the Home Office with the aim of agreeing a process that is fair to GPs in particular, and doctors in general, and safe for the wider public. Discussions are ongoing and any future improvements may necessitate the revision of this guidance.
The following advice on the current system takes into account our discussions with the Home Office, the police and the British Association for Shooting and Conservation (BASC), as well as external legal advice.
More information on the current situation, advice and workflow can be found on our Firearms Licensing Process page.
We have had several practices report an increase in consultations from school pupils and nursery age children regarding fitness to attend school/nursery. The GMS contract makes no provision for such work and therefore other than treating the patient who ‘is ill, or believes themselves to be ill’, there are no circumstances where a GP is required to issue a Med 3 or any letter/report to a school/nursery confirming fitness to attend. GPs are not contracted to advise schools on attendance or medication requirements whilst at school and head teachers have been reminded of this by the Education Minister and Local Education Authorities. Any such request may be considered as extra-contractual and could reasonably expect to be chargeable work.
Helpful advice about the managment of common childhood illnesses can be found at the following;
The Rapid Diagnosis Centre (RDC) based at Neath Port Talbot Hospital is for patients with vague but concerning symptoms that do not fit into any of the existing referral pathways. Referral Guidance is available here.
At the RDC, patients will have an individualised assessment with the aim of achieving a diagnosis and initiating a treatment plan, or gain the reassurance that nothing concerning has been found.
The Centre has radically reduced the average time to diagnosis from potentially 3 months to 6 days. Out of the case load cancer diagnosis is averaging at 10.5 % and a wide range of other conditions are also being rapidly diagnosed (30-40%) allowing treatment and management plans to be enacted.
If you would like to refer please consider the following:
- Referral via WCCG only but informal discussions are always welcomed
- Please ensure all Set A has been requested/documented – blood tests as per guidelines and a RECENT WEIGHT, URINE DIP AND FULL EXAMINATION FINDINGS IN TEXT OF REFERRAL LETTER. This is as per agreed referral guidelines
- If referrals are incomplete in detail or are unsuitable we will process and return as soon as possible
- Most common reasons for return – site specific symptoms so USC referral to that speciality is more appropriate, or – although we are a vague symptom clinic we are for patients where occult malignancy is the most likely cause – we are NOT a general vague symptom clinic. Again as per referral guidelines and advice.
The BMA have published “Sustainable and environmentally friendly General Practice” which outlines ways in which general practice can develop, and can be helped to develop, environmentally responsible practises.
Specific advice regarding reducing the carbon footprint of inhaler prescribing can be found here.
Information regarding NHS Wales’ Carbon Footprint can be found here.
This NHS report provides a detailed account of the NHS’ modelling and analytics underpinning the latest NHS carbon footprint, trajectories to net zero and the interventions required to achieve that ambition. It lays out the direction, scale and pace of change. It describes an iterative and adaptive approach, which will periodically review progress and aims to increase the level of ambition over time.
Information regarding NHS Wales’ Carbon Footprint can be found here.
Inhalers account for 3-4% of the whole NHS carbon footprint. To reduce the carbon footprint of inhaler prescribing we recommend that health professionals:
1. Optimize asthma and COPD care
2. Use dry powder inhalers or soft mist inhalers as first choice when clinically appropriate
3. If metered dose inhalers are needed then chose brand and regime with care to minimize carbon footprint
4. Ask patients to return all used inhalers to pharmacies for disposal
Further information regarding these measures and FAQs are available to download here.
WHERE CAN I FIND THE LATEST INFORMATION?
Covid-19 guidance can be found here
Guidance for Palliative care management of patients with Covid-19 infections can be found in the documents section of this website.
VULNERABLE DOCTORS & SHIELDING GUIDANCE
The BMA has published frequently asked questions here for doctors who are isolating, have underlying health conditions or live with someone who is in a high risk group.
All doctors should have a risk assessment, including those returning to the NHS and existing staff. The BMA has a toolkit here covering risk factors, tools to help you and what the process should be.
Guidance for BAME doctors is available here.
WHAT ARE THE CURRENT DETAILS OF THE COVID-19 VACCINE PROGRAMME?
The BMA’s latest guidance is here.
WHAT IS THE NEW GUIDANCE FOR DEATH CERTIFICATION & CREMATION?
The new guidance here replaces existing BMA guidance on verification and certification of death and cremation during the COVID-19 outbreak.
VIDEO CONSULTATIONS AND HOMEWORKING
Advice for doctors in all settings in getting homeworking equipment, when to consult patients via video, approved NHS tools for remote consultations and tips for running them is available here.
I HAVE AN ETHICAL ISSUE E.G. WITHDRAWING TREATMENT, INADEQUATE PPE, WORKING OUTSIDE MY SPECIALIST AREA
The BMA has published frequently asked questions here about COVID-19 and ethics, including withdrawing treatment, equality legislation, working outside your specialty and inadequate PPE.
If you have an issue that is not addressed here please email us here.
TERMS AND CONDITIONS: SESSIONAL GPS
Guidance on changes to your working patterns and contractual issues during the pandemic, such as annual leave, indemnity and working outside of your job plan are available here.
I HAVE A CONTRACTUAL ISSUE RELATED TO COVID-19
Common contractual issues pertaining to COVID-19 are discussed ont he BMA website here.
There is also a comprehensive guidance for GPs, partners and practice managers to manage employment and contractual issues and service provision during the coronavirus pandemic available here.
DOES THE BMA HAVE GUIDANCE FOR GPS, PARTNERS AND PRACTICE MANAGERS TO MANAGE EMPLOYMENT AND CONTRACTUAL ISSUES AND SERVICE PROVISION DURING THE CORONAVIRUS PANDEMIC?
Yes, it is available here.
AM I REQUIRED TO PROVIDE PATIENTS WITH CERTIFICATES OF EXEMPTION FROM WEARING A FACEMASK?
There is no contractual requirement to provide certificates of exemption for patients who are unable to wear facemasks.
The patient should be directed to relevant government sites which cover this in detail here.
The BMA has published clarification on PPE use in primary and secondary care, including procurement, use, safe working and CPR here.
There is also guidance here regarding the process for doctors to follow to identify whether your PPE is adequate and what you can do if it is not.
Information regarding latest changes to COVID vaccination passport information is available here.
A Home Office License is NOT required by a GP who keeps opiates in their bag which they have requisitioned themselves directly from the Pharmacist
A License is required in those surgeries that order a “central “ supply from which the GPs draw what they need.
It is recommended that surgeries which currently or intend to hold drugs in surgery should apply for a Home Office License if they do not have one already.
- Work out the cost of the service
- Look at current level of remuneration and cost to deliver service.
- Have a chat amongst clinical team and with practice manager to decide next steps.
- If you wish to continue then read no further
- Payment not covering costs and / or impacting on GMS care?
- You can withdraw from the service
- How to withdraw:
- Give 3/12 notice in writing to the Health Board of your intention and reasons.
- Ask for them to inform you of where to redirect patients once notice period has ended. Put a time date on response to this and put a diary marker in your diary to check this has been responded too.
- Copy in the other services affected by the decision
Top tip – make sure you get confirmation of receipt – email route perfect for this
- Continue to provide the service for 3/12
- Start updating your staff that service is no longer going to be provided and ensure all know where to refer patients once service has ended. Consider giving them a “script” to use when faced with such requests
- Start to inform your patients via posters / screen messages / during consultations of when this service will no longer be available and why (if appropriate)
- The LMC will be developing patient information materials for you to use in some cases
- Consider how you can best utilise the freed up resource/ time to provide additional capacity within your clinical team
- Keep track
- Make a note on your systems when service is due to end
- Remind all staff after that date that you no longer provide these services and where they should send patients.
- What if the HB don’t tell you what to do with patients after notice period?
- Contact the LMC Office on firstname.lastname@example.org
YOUR LMC IS HERE TO SUPPORT YOU.
It is not unusual to feel concerned at stopping work OR to think that you are the only practice considering taking this action. YOU ARE NOT. Practices can no longer continue providing services at financial or clinical capacity costs to themselves. Follow the checklist above, discuss as a practice and reach your own conclusion.