Items in normal text – for consideration / items in italics – for information / * indicates additional papers
Chiesi supported this meeting through the purchase of a virtual stand. Jane Westlake provided a short presentation and invited to an All Wales Adult Asthma Management Guidelines Update.
LMC MEMBERS: Drs R Beynon (RB), H Cowie (HC), P Cox (PC), H Dean (HDe),
S Hlaing (SH)(Chair), R Jones (RJ), J Kerrigan (JK), V Krishnamoorthy (VK),
S Perman (SP), P Ramkumar (PR), A Rayani (AR), M Rickards (MK) N Shah (NS),
A Stevenson (AS), R Thomas (RT), K Wallis (KW), H Wilkes (HW), P Williams (PW)
LMC Secretariat: H Curtis (Executive Officer)(HC), E Harris (EH)
SBUHB/PCCU: H Dover (HDo), A Mehta (AM), B Owens (BO), K Reid (KR)
PRACTICE MANAGERS: C Boland (CB), L Flowers (LF),
REGISTRARS: R Spacie (RS)(Swansea) L Zamen (LZ)(NPT),
OBSERVERS: Darron Smith (Exec Member DPLMC).
SH opened the meeting and welcomed all including Brian Owens (Group Director Primary, Community and Therapy Services) who will take over from Hilary Dover after Christmas, Darron Smith (Exec Member DPLMC) and Hannah Curtis (newly appointed LMC Executive Officer).
LMC Members: Drs T Cufflin (TC), S Karupiah (SK), K Mellin (KM), , D Williams (DW),
Co-opted members: R Tristham (RT), C Jones (CJ), W Slater (WS)
Dyfed Powys LMC: Drs P Horvath-Howard (PHH), L Williams (LM)
SBUHB: H Kemp (HK)
MLMC Meeting 8th September 2020: The Minutes were approved
|Chair’s Report (Appendix 2.1 circulated with the Agenda)
SH provided a brief overview of her report drawing particular attention to the following:
· Covid events are running faster than reporting
· Steve ??? email provided an update on hubs and field hospitals
· Primary care has reactivated to pre COVID levels – and never really deactivated. It is a challenging time due to there being more COVID-19 in the community currently than during the first wave.
· Trying to establish a cluster based approach to phlebotomy.
· Roche issue has been resolved.
· At a practice level it appears that a phlebotomy service will not be returning.
· Secondary Care has only half reactivated which continues to result in the transference of work to primary care. This remains on the HB Liaison Group agenda. SH and NS have been invited to attend the Outpatient Rest and Recovery Group to ensure Primary Care priorities are taken into consideration.
· The LMC continues to attend Cluster Lead and Heads of Primary care meetings to understand the funding landscape.
· Flu vaccination programmes all successful organised. Questions remain about the new age group for flu and the COVID vaccine.
NS shared that the LMC have received a lot of queries about the Flu, which are detailed in the circular. He explained that there is an enhancement on the standard flu vaccination on top of the dispensing fee for additional costs such as PPE, and another fee for administering the centrally supplied vaccine. The centrally supplied flu vaccine can be claimed from October onwards. The CMO has issued a letter which the LMC will share including the exact fees.
NS asked the HB what their current local plans were for the COVID vaccination and the extra age group for the flu vaccination due to this being delegated to the HBs.
AM stated that there hasn’t been an update due to waiting for national guidance. COVID vaccination DES has just been released in England which has given an example for England’s response. The HB recognise that a consistent approach is important and for this reason the HB are seeking national guidance stressing the need for an adequate lead time to prepare. Clarity is needed if primary care and GPs would like to participate.
Additional Flu vaccine remains a supply issue rather than an administration issue. There is clear guidance and the portal is live for the current flu vaccine groups but the HB are still awaiting clear guidance for the additional group. The interface between the two has therefore not been resolved and HB await national guidance.
NS queried that the HB were not taking a tailored response and would only be seeking a national response
AM confirmed this was the current situation but added that the role out of a COVID mass vaccination programme is being planned by the HB for mid December. The national guidance is needed to complete this programming.
Circulate CMO letter on flu vaccination to all Members
|MLMC/SBUHB Liaison Group Sept 2020: Draft Minutes were circulated (Appendix 2.2)
SH asked for questions or comments in relation to the minutes.
5.2 COVID-19 2nd Spike – AM stated that there had been some issues around the pre hospital pathways. These have been resolved and the pathway has been updated. The Consultant Connect advice line is fully operational.
NS shared that the HB Liaison Meeting happened every couple of months and the LMC take forward issues that have been raised by members. If members have any specific issues they would like to be shared please get in touch with the LMC and encourage other GPS to communicate with the LMC.
RT shared that the AGPU cant currently take electronical referral letters – an email is requried. LMC are asking for WCCG to have a consistent data management approach.
6.2 Reactivation of Secondary Care – RT asked about the link that had been discussed to provide a dashboard on available services, performance and capacity data.
AM responded by saying that the dashboard (developed by outpatients) remains in development. Snapshot audits across the geography are still needed. AM advised that the open discussions at the Outpatient Clinical Redesign and Recovery Group were still the most effective way for the LMC to engage.
SH stated that the audit data was not going to reflect the reality due to all GPs being too busy to collate evidence. AM encouraged the LMC to continue to collate and submit the data.
1: Am, 2: SH
|Issues raised by Constituents/Practices Sept-Nov 2020:
HC briefly summarised the paper previously circulated (Appendix 2.3) and invited the members to speak to their concerns.
Excessive referral updates – raised by RB
RB stated that practices are getting endless inappropriate referral updates from secondary care. Resulting in extra appointments and extra tasks that are having a detrimental to the service that GPS deliver. Secondary care continue to hold virtual clinics but appear to pass on the f2f to primary care. He shared examples from one department (ENT) to illustrate the point:
· USC referral requesting photographs of the oesophagus
· List of instructions on how to manage chronic sinusitis
· Douching and administering nasal sprays and checking compliance.
· Undertaking a core biopsy
· Unusual tonsil swelling simply advising douching.
NS stressed that this is one GP practice with examples from one department illustrating the scale of the problem.
AM stated the need for the LMC to use the Outpatient Rest and Recovery to reiterate the impact these referrals are having upon patients. Workloads are increasing but processes should not be different to before. Existing referal pathways remain. If pathways have changed they need to be reagreed through the appropriate channels and appropriate resources assigned. AM requested that this data be shared at the next HB Liaison Meeting to provide a snapshot of one department. Diet Datix system is in place every month there is a running item entitled the GP trigger report. This is an effective way for the LMC and its members to ensure that these issues are flagged.
AM requested that the data gathering exercise that the LMC undertook would be valuable to reflect the number of incidents a week and the main departments that are changing the pathways.
RB stated that he appreciated that secondary care needed to triage but would like this to be done by secondary care – not bounced back to primary care.
AM restated that if changes are necessary due to the new working conditions these need to be agreed and resourced appropriately.
NS shared that there are two issues. Patients are being referred in and bounced back and also secondary care are excessively referring out.
AS added that there were examples where referrals were being made from secondary care to a different secondary care dept but GPs were being asked for this rereferral within secondary care to be actioned. These were clogging up clinical records unnecessarily as well as creating extra administrative work.
The examples were agreed to be unacceptable and that they needed to be escalated. The LMC asked for RBs examples to take to the Liaison meeting.
Requesting a generic email for sharing results – raised by Clare Boland
Constant requests from various departments for generic emails to PMs when this should be going through WCCG. A specific concern was raised about Radiology requesting a generic email for sharing results and the safety risk. This is not an isolated incident with other departments sharing information with the PM account. Often information with no referrers details, nor an indication of what action has been taken. In short practices are being asked to do a number of things that they were not before, including deciphering what is to happen with communication sent to a generic email.
AS stated sending information through to GPs is important but it needs to be clear who requested and what actions need to be taken.
Agreed that this is a recognised problem to be escalated to Liaison.
1: RB, 2: SH, 3: ALL, 4: LMC/HB
LF shared that the email sent by AM had addressed some of the questions that the practices had raised specifically around Flu vaccine programmes. Concerns that have been raised include:
NS responded by saying based upon the English DES there would be no relaxation. He followed up by stating that the Enhanced Service payment was a national issue and would be informed by which vaccine was first to market due to different operational requirements.
HDe reported no concerns or issues.
HDo updated members on the field hospitals, stating that the hospitals were due to be opened this week but this had been put on hold. The firebreak potentially bought the HB area 3 weeks. The field hospitals are ready to be operationalised with 72 hours’ notice.
SH acknowledged that this would be HDo’s last meeting before her retirement and thanked her for her participation and contributions whilst she had been in role. SH welcomed Brian Owens who would be her predecessor.
HDo updated members on the following changes:
HDo thanked the LMC for all of the debate and hoped that the relationship would continue to expand into the future. Members congratulated AM on her new appointment. BO thanked members for the welcome and stated that he looked forward to continuing the relationship with the LMC.
No issues raised
Paper (Appendix 5.1) was shared and no issues were raised.
Keith Reid, Executive Director of Public Health, presented the latest epidemiology data sets for the Swansea Bay area including the Test and Trace performance dashboard. Index cases against contact cases suggest that as the number of cases increased the performance and management of contract tracing deteriorated. Indicating that there were capacity issues with test and trace.
Lockdown did not reduce the number of contacts indicating that people have not been complying. There were a large number of Halloween related events / super spreader events.
Currently Wales is not breaking the transmission rate due to the delay in the current test and trace process. 70-90% have test results within 48hours, taking a further48 hours to follow-up contacts. This is 4-5 days after symptoms first presented.
September 21st there were 14 cases in NPT and 33 in Swansea. The students arrived and there was a bulge in cases. During October the numbers flattered but October 17th for events unknown the numbers escalated. The October firebreak resulted in a drop as of November 3rd – ten days after the onset of the firebreak. This has brought NHS and test and trace a couple of weeks to recover and it is predicted that numbers will be back at similar levels in 4 weeks. As of 10/11/20 there are 200 acute cases in secondary care and 30 care homes with active cases.
Outbreaks have been found within certain GPs. Schools seem to have a low transmission rate but are being excessively disrupted due to the large bubbles. Some transmission within teaching staff and other workplace settings such as TATA and DVLA but these seem to relate to canteen and changing room areas where people are evidently relaxing upon safety precautions. It is estimated that workplace transmissions are higher but there is an economic disincentive to test related to SSP and employer pressure/abuse or fear of competition and loss of subsequent contracts.
Several mutant strains have resulted from the mink farms with currently 215 human cases. The concern is related to one strain mutation affecting the spike protein. The vaccine approach taken has specifically targeted the spike proteins so a change to the protein could reduce the effectiveness of the current vaccines.
Vaccination announcement by Pfizer that they have achieved 90% effectiveness is welcomed. Welsh blood service may be used to help distribute due to the vaccine being a very fragile compound and needing to be stored at -75°C. This vaccine will need a model that utilises mass vaccination centres and not an outreach model.
Oxford vaccine is more stable and can be stored in cold chain but most likely going to be January 2021 before this becomes available. This lends itself for primary care involvement. In England a GP will receive £12.58 for vaccinating. It is being suggested that CCGS come together to set up one Primary Care Centre. GPs are to note that this will not be a flu campaign model as a modified campaign is needed. There is pressure for a December 1st target but this is highly unlikely. KR stressed that this was going to be a long campaign and the programme would stretch to 1.5 years.
KR then asked for questions. His responses were as follows:
All of the vaccines that the UK government have procured are two stages apart from one still in development with an anticipated release date of at least 12 months.
There is no expectation that a GP should go to undertake a household test for someone who was housebound. Test and Trace have testers who can undertake home visits. Call 01639 862757 to organise. However if GPS are visiting for other purposes, they are encouraged to take a swab.
There are currently only 3 people who reside in the Swansea Bay area who have been taken into quarantine after returning from Denmark. These individuals are currently all well and have negative test results at Day 0. They will be tested again Day 8 before possible release on Day 14. There is always a risk that people will have travelled via a 3rd country into the UK.
Tracing has been voluntary but as of 6/11/20 it is a criminal offence to falsify information, which is punishable with a fine. It is recognised that those with a positive test result are more likely to engage with T&T. The greater concern is with those that do not test at all.
Significant contact is defined as 15 minutes or more of direct f2f contact within 2 metres of a person indoors. Wearing a mask does not exclude unless it is PPE in a clinical setting. This means a filtered surgical mask, eye covering, gloves, apron and ventilation.
Care homes receive support from Infectious disease department and Environmental Health (Local Authority) to advise on procedures, PPE and to minimise risk. Lessons learnt from the first wave have been implemented , such as changes to caring for dementia patients. Care home managers make the decision on access and if care homes are refusing the entry of clinical staff this is a potential regulator issue. Infection control rules are needed but this has to be balanced against quality of care. Clearer guidance is needed.
AM shared that the HB are working on guidance for Care Homes and the clinical indication for the need for a consultant.
There is a phased role out of the COVID vaccine programme which is based upon a rapid risk benefit analysis. This includes factors such as BAME. There is no local input and this is being agreed by an expert advisory group.
There is no plan to replicate the approach being taken in Liverpool to mass test (frequent asymptomatic testing). This approach has been taken for two reasons A) political and B) to assess the feasibility of undertaking mass testing on a large scale and assessing accuracy.
PR stated no issues to be raised
Darron Smith thanked members for being able to participate. He stated that DPLMC were experiencing very similar issues but within the context of a rural population. The COVID vaccination programme could be extremely challenging within their geography. Care homes were a challenge but for the opposite reason that MLMC had identified and that was that the GPS were being forced to attend regardless of the clinical need.
Internet connection failed at this point
SH thanked everyone for their attendance and advised Co-opted members and guests that the next session would be for elected members only.
|NS shared with members that a collection was taking place for Morag and if members wanted to contribute they were to contact the LMC for details.|