Items in normal text – for consideration / items in italics – for information / * indicates additional papers
Dr Brendan Lloyd, MD of WAST and Grayham McLean, Unscheduled Care Lead for WAST gave an interesting if somewhat gloomy presentation about the current challenges being faced by WAST. Sickness rates are one of the highest in the UK and handover delays in EDs are the worst in the UK. Although response rates to RED calls (patient could die within minutes) have improved there has been a deterioration in AMBER response times. The introduction of a clinical desk has resulted in a reduction (8k) in the number of patients being conveyed to hospital in the last year but as handover delays had increased in the same period there had been a resulting large increase in ‘lost hours’. This was predicted to be even worse during the forthcoming winter period.
There was a clear recognition that GPs are a key partner and Grayham presented data specifically related to calls from Health Care professionals which represent the highest number of the top ten WAST codes.
GPs and other HCP had asked for more information to be shared about the way WAST works, the role of the different types of ambulances and which type of transport is required to meet patients needs. Information had been prepared for circulation and was presented by Grayham. He advised that the clinical model in place does not reference anywhere as a ‘place of safety’ and made specific reference to surgeries and hospitals.
Members reported an increase in instances where patients had deteriorated following the paramedic’s assessment that it was safe ‘not to transport’ them. Brendan and Grayham agreed that this was something that was happening and there was increased emphasis on teaching good handovers. They asked to be made aware of instances where this occurred. A new clinical lead had been appointed to look at these events which would be used for further learning.
Brendan and Grayham explained that Cwm Taf Health Board’s approach to analysing risk differed to the other Health Boards and believed that the biggest risk was that a delay in the handover of patients at EDs could result in there being no ambulances to respond to emergency calls. Patients are therefore accepted into the hospital to ensure that there is no handover delay. Admission pathways are also different and not all patients go through ED which is where bottlenecks occur in ABMU. A whole system review would be required to achieve a similar model in ABMU. IH confirmed that GPC Wales and the LMC would support the implementation of the Cwm Taf Model.
Dr Steve Bassett, Clinical Lead for the OOH Service attended to respond to the LMC request for information about site closures, non-availability of GP cover, rota gaps and performance data over the 6 month period April – December 2018.
Steve provided some background information about the development of the 111/OOH model of which ABMU was the forerunner. He confirmed that the service was currently relatively stable and, due to improved recruitment of OOH GPs, had been since February 2018. Currently no overnight GPs were being rostered for the NPT site. This had been discussed with the CHC and although not confirmed as a permanent arrangement the number of face to face consultations overnight for NPT patients was very small ( ie less than 3 on average).
Although deemed to be stable Steve also confirmed that closures in the system had been recorded and confirmed that this was around 800 hours (this included the NPT site overnight). For a period of 4 hours on 15th Aug 2018 there had been no OOH GP available but during this time extra triage had been provided in NHSD when a Snr Nurse Advisor was available.
Steve advised that work continued around developing a suitable MDT skill mix with an SLA being agreed recently for a paramedic between 20:00-08:00 who would undertake home visits and confirm deaths. The number of pharmacists employed had increased to 57, dealing with between 15-20% of calls. HCSWs were being piloted and it was hoped that a roundhouse model could be trialled with 20 rooms having been identified for the MDT.
Steve confirmed that work was also ongoing to develop more appropriate standards in respect of response times for telephone call backs and face to face consultations
IH stated that the LMC was very supportive of the skill mix developments but the presence and availability of a GP was essential.
IH thanked Steve for attending.
LMC MEMBERS: Drs P Cox (PC), T Cufflin (TC), P Evans (PE), I Harris (IH) (Chair), S Hlaing (SH),
H Hunt (HH), R Jones (RJ), S Karupiah (SH), J Kerrigan (JK), P Ramkumar (PR), A Rayani (AR),
M Rickards (MR), N Shah (NS), A Stevenson (AS), R Thomas (RT)
LMC Secretariat: M Liddell (Executive Officer) (ML), E Harris (Secretarial Assistant) (EH).
ABMU/PCCU: Ms H Dover (HD), Dr A Mehta (AM)
PRACTICE MANAGERS: C Boland (CB), M Haynes (MH), S Kiley (SKi)
REGISTRARS: B Roberts (BR) (Bridgend), C Williams (CW) (NPT), R Spacie (RS) ( Swansea)
Observers: Dr E Thomas (ET) (NPT VTS)
INTRODUCTION / WELCOME:
IH welcomed Drs Phil Cox and James Kerrigan as new committee members representing the Sessional GPs and Swansea Constituencies respectively. Also welcomed was Dr Robin Spacie ST2 who would represent the Swansea VTS and Dr E Thomas (NPT VTS) who attended as an
Drs J Donagh, P Evans, C Jones, K Mellin, E Rees, K Wallis, H Wilkes, J Williams, P Williams
Dyfed Powys LMC: Dr P Horvath-Howard, Dr L Williams
ABMU: Mr J Crowl, Dr S Husbands, Dr A Roeves
Observers: Dr H Dean
• Full LMC Tuesday 11th September 2018 – the Minutes were approved and signed by the Chairman
Completed nomination forms had been received in respect of Dr Phil Cox (Sessional GPs constituency and Dr James Kerrigan, Swansea Constituency). An Expression of interest has been received from Dr Helen Dean (Sessional GP). There was one vacancy in Bridgend and four in the sessional / first five constituency.
Dr Robin Spacie (ST2) would represent the Swansea VTS.
No panels had been arranged since the last meeting. A list dispersal in Swansea had been successfully completed with minimal disruption to patients.
The practice support team continued to support practices although its main involvement was in the Health Board managed practice. Recruitment to the team continued.
Charlotte Jones, Chair of GPC Wales had emphasised the importance of future cluster development and the expanded role that LMCs would have. LMC members who had attended cluster meetings agreed that attendance at meetings was beneficial but attendance had recently dropped off. IH encouraged members to attend.
Members commented that the 12 month funding cycle prevented forward planning and the inability to carry forward funding resulted in an insufficient timescale to complete projects which could grind to a halt.
HD informed members that the IBG (Investment and Benefits Group led by the Director of Finance) had not received any submissions from cluster leads demonstrating cases which could utilise the pot of money available or release funds from secondary care. A complex template had to be completed but there was a process in place. The benefits had to be demonstrated in order to release funds for investment.
ALL TO NOTE
IH had attended the meeting on 26th September 2018.
HD advised that WG had, at very short notice, requested details of new models of care being proposed by clusters with funding being made available for one project. A Cwmtawe Cluster (Swansea) proposal had been accepted and was being supported by transformational funding. Some areas around mental health needed to be strengthened and WG wanted to know if it could be offered to all clusters in NPT and Swansea. Details of the proposal were available for any member who wished to see them. Primary Care support would be provided for clusters wishing to take it forward. HD confirmed that proposals had to be submitted and taken through by the Regional Partnership Board.
ALL TO NOTE
TC confirmed that the NPT PT4L November 2018 session was going ahead with clinical cover being organised by the clusters. The LMC welcomed the arrangement.
The Draft Minutes had been circulated for information. IH summarised the issues discussed noting the following;
• A significant number of practices had not signed up to the Diabetic DES gateway model
• An escalation process for primary care was continuing to be progressed
The draft minutes had been circulated for information.
• Members requested that fewer acronyms be included in the minutes.
Update provided by Dr S Bassett in his presentation
Two practices in Wales had made themselves available to provide OOH cover during the Christmas / New Year period, one of which was in ABMU. Interest expressed by clusters had still to be clarified.
The BMA was taking forward a legal case.
Neither medical secretary was able to attend. No report provided.
An updated schedule of issues / queries raised by Practices between April – October 2018 had been circulated.
Raised by CB. AM was surprised as referrals were accepted from nursing homes staff in Care homes and would take forward.
Referrals being rejected because they had been made by advanced nurse practitioners or other Health professionals had been raised with the Executive Nurse Director. A working group was being put together to formulate a protocol with agreed lines of accountability. There was also a need to push NWIS to include pharmacists.
MH raised the issue of lost practice income from meeting Subject Access requests under GDPR. Apart from copying costs a large amount of time was spent redacting third party details but there was no clear definition of what was considered to be ‘excessive’. IH advised that this was being included in contract negotiations with WG for 2019-20.
HH raised a question about SARs from patients who have left the practice which would retain the electronic record. IH confirmed that if the practice was holding patient data it was the data controller and a request would have to be met albeit the information may not be complete.
SK asked if there was a process for replacing Oxygen cylinders which had been used in surgeries as a result of a delay in an ambulance response. This would be raised at Liaison and a response provided for members.
HD confirmed Dr Richard Evans had joined ABMU on 5th November 2018. An invitation would be extended to attend the LMC meeting on 8th January 2019
IH had had a productive meeting with MH managers* and advised members to raise issues directly with them and copy in the LMC (anonymously). An antipsychotic shared care protocol would be developed. Ian had also written to the heads of Social Services in NPT and Swansea with a request to adopt the SPA (Single point of access) approach which worked well in Bridgend.
*Dr Richard Maggs – Consultant Mental Health: Richard.Maggs@wales.nhs.uk
*Dermot Nolan – Service Manager Mental Health and LD Unit email@example.com
ALL TO NOTE
Services would not change in the first 12 months. GMS contracts would be held by Cwm Taf HB from 1st April 2019. SLAs for services were being discussed. The OOH service would transfer when 111 was implemented in Cwm Taf HB.
ES claims were paid monthly in ABMU and quarterly in Cwm Taf and could result in Cash flow problems for Bridgend Practices if changed. It was subsequently confirmed at the Liaison meeting on 20th November 2018 that Cwm Taf would change to monthly payments.
HD confirmed that there would be a name change for both Health Boards with two each currently under consideration.
WG had announced Winter Pressures funding. The bids would be considered by the HB and should be known by December 2018.
DNs would only vaccinate patients currently on their caseload and did not include INR or B12 patients. Many practices were now organising flu jabs themselves or via clusters. A clear definition of the role of DNs was required to enable forward planning as constituents believed they were propping up a service which should be provided by the Community nursing service. This would be discussed further at the Liaison meeting on 20th November 2018.
An NHS alert letter had been circulated to practices without the prior agreement of GPC UK/ Wales and had caused concern about the implications of the additional workload. A letter of clarity was circulated jointly from ABMU / LMC to provide clarification of the recommended actions for practices.
IH had attended the meeting on 25th October 2018 and summarised the issues discussed.
The BMA legal challenge was ongoing, A GP from NPT had agreed to act as test case.
IH encouraged members to take up the NWIS offer and respond to the letter as soon as possible.
(ii) Remote access to GP systems: An email had been circulated to reassure practices that the agreement between GPC Wales and SSP regarding remote accesss for their post payment verification work did not put a practice at risk of breaching their responsibilities under GDPR legislation.
INDEMNITY SCHEME: NS updated members and advised that there were two strands – Future and existing . Future cover would be provided from 1st April 2019 but it would be around 12-18 months before existing liabilities would be covered to enable the legalities and funding issues to be discussed. GPs on Claims based policies would have to purchase run off cover while those on occurrence based policies would not. He emphasised that the state backed scheme included all attached practice staff and locums but only covered NHS work.
NS updated members and advised that there were two strands – Future and existing . Future cover would be provided from 1st April 2019 but it would be around 12-18 months before existing liabilities would be covered to enable the legalities and funding issues to be discussed. GPs on Claims based policies would have to purchase run off cover while those on occurrence based policies would not. He emphasised that the state backed scheme included all attached practice staff and locums but only covered NHS work.
ALL TO NOTE
Circulated for information
No update available
IH reported that it had been a good Conference with vibrant discussion and most Morgannwg LMC motions had been passed. BR and CW, the VTS reps for Bridgend and NPT had spoken well to motions.
The motions and outcomes would be circulated to members.
AR/ML would attend
SH & NS would attend as MLMC reps and AR as a GDPF rep. A motion around the DVLA issue would be written. HH would write up a motion around GDPR.
The list of changes April-October 2018 had been circulated to LMC GP Members.
• LMC Executive Committee 11th December 2018 – Bar 44 Cowbridge
• LMC Full Meeting 8th January 2019 – The Mercure Hotel Swansea