Items in normal text – for consideration / items in italics – for information / * indicates additional papers
Lorna Thyer from Reckitt Benckiser supported this meeting through the purchase of virtual stand space and provided a 5 minute presentation prior to the meeting
LMC MEMBERS: R Beynon (RB), T Cufflin (TC), 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), D Williams (DW),
LMC Secretariat: E Harris (EH)
SBUHB/PCCU: A Mehta (AM), Brian Owens (BO), K Reid (KR)
PRACTICE MANAGERS: C Boland (CB), C Jones (CJ),
REGISTRARS: R Spacie (RS)(Swansea), L Zamen (LZ)(NPT), W Slater (WS) (NPT)
OBSERVERS: Darron Smith (Exec Member DPLMC), Shanti Karupiah
GUESTS: Joanne Abbott (CAHMS), Izzy Davey (CAHMS)
LMC Members: K Mellin (KM), H Cowie (HCo), H Curtis (Executive Officer)(HC), P Williams (PW)
Co-opted members: L Flowers (LF)
Dyfed Powys LMC: P Horvath-Howard (PHH), L Williams (LM)
SBUHB: No apologies
SH opened the meeting and welcomed all.
The Minutes from the Committee meeting held 10th November 2020 were accepted as accurate.
LMC Committee 2.2 – AM updated that the Outpatient dashboard has been developed but not released.
ACTION: SH will clarify when the Outpatient dashboard will be launched at the next Outpatient Group meeting
LMC Committee 2.3 – AM has forwarded the evidence of inappropriate work transfer sent by LMC 1/12/20 to the Outpatient Group project team and Phil Coles was preparing a communication around the breaches.
HB Liaison 5.1 – The draft escalation cards were discussed at the HB Liaison meeting and shared with the LMC.
ACTION: AM to check if these have been circulated to Practices.
SH invited PC to feedback on the Outpatient Group meeting that he attended on SH’s behalf:
There was no discussion about the live bulletin board.
There are urgent F2F appointments only and no routine outpatient appointments are taking place. NPTH hope to set up a new ophthalmic clinic running on a Thursday afternoon. Money has been allocated for extra projects (£50K) to help with new ways of working to be spent before April 2021. Ideas to date include issuing patients with mobile devices and potentially increasing the use of sessional doctors to reduce waiting lists.
Patient Initiated Follow-up (PIFM) testing takes place w/c 11/1/21. This will go-live from the 14th January. By the end of March if a patient has been on a PIFM for more than 24 months they need to be removed. Secondary care have proposed triaging patients who have been waiting for over 12 months. GPs were identified as a potential resource but PC stated that there has been a significant volume of work transferred so any additional proposals would have to have robust processes and increased capacity and resources. Informal ideas include utilising sessional GPs who are shielding to review patient notes to provide shortlists and make clinical decisions on next steps. Any additional ideas to be sent to Phil Cox.
SH updated members that the LMC have asked HB to be involved with more planning meetings. Outstanding meetings include meeting with HB Exec and also an ACT meeting in relation to Care Homes.
The LMC have not received a reply from Richard Maggs.
Joanne Abbot did discuss the paper with the Mental Health Directorate and they agreed to speak to the points that have been raised at a future LMC Meeting ( Joanna and Izzy intended to speak to the CAMHS points during the meeting).
ACTION: LMC to organise a representative from the Mental Health Directorate to attend future LMC committee meeting.
JK raised a point from the HB Liaison minutes. The MGUS issue was raised last Autumn and taken to Liaison to discuss further. The minutes state that no further cases have been received and it has been closed – however more issues are arising.
SH reported that the LMC had asked the practices for update on MGUS and received no further examples. This item was therefore put on hold.
HW’s understanding was that the LMC was going to ask practices whether they thought it reasonable that practices monitor MGUS or not. If this was not acceptable and it was work being transferred from secondary care, the LMC were to write to Haematology.
AR apologised if this had not been resolved and LMC had not carried out the actions requested. An email was distributed to practices and it raises a concern that not all LMC emails are being read by a lead colleague and therefore not being responded to. The LMC need responses to understand how important these points are.
JK reviewed the MGUS email that was circulated and agreed that it asked the correct questions.
The LMC need to establish the reason why practices do not complete requests.
ACTION: run a session to discuss LMC engagement and communications to inform new ways of working
No discussion points were raised.
Additional points were pre submitted for the Covid vaccination programme/Public Health discussion.
CB – PMs would welcome confirmation and clarity about when practices will receive doses and assurance of the second dose.
AM – In terms of supply all of the latest deliveries that the HB have received have been issued. The HB have received confirmation that everybody who receives a first dose will be receiving a second and this has been factored into the planning. This week there was a limited amount due to a batch failing. Unfortunately it is a fluctuating situation and the HB do not know exact amounts until it actually arrives.
CB – When will practices have more guidance on the next tiers to plan appropriate staffing?
AM –The 70 – 79 year old tier will be going to Mass Vaccination Centre and the clinical extremely vulnerable patients will be allocated to Primary Care. There are 25K 80+ year olds in the SBHUB Population and this cohort will be vaccinated over next three week to complete early Feb. The HB aim to issue instructions about the Clinically vulnerable end of next week and an easier sign-up process.
AR – Can I clarify the sign-up process because practices have signed up to deliver the programme not each tier.
AM – The HB need confirmation that practices are happy to continue with the next cohort. Hoping that this will be a simple email to confirm allocations.
AM wanted to express her gratitude to all of the practices on behalf of the HB. The HB and practices should be proud that all 8 Clusters signed up for Care home delivery, which is exceptional across Wales, and all 49 practices signed up to support further delivery.
HDo shared that there is good coverage with good fill rates both at the base and remotely. Urgent Primary Care Day time centre is now up and running Monday to Friday.
111 have in the pipeline a new initiative called Phone First. The LMC to consider inviting Steve to present to the Committee at a later date.
No additional points raised.
Dr Isobel Davey (Clinical Lead) and Joanne Abbott-Davies (Commissioner) presented to members.
The PPT has been circulated.
Waiting times have been a historical challenge and the HB have looked at commissioning to support this including taking a multiagency approach and reviewing demand and capacity and increasing service provision. CAMHS developed a regional model during COVID and are trying to secure this as a permanent model moving forward.
• Single point of access for CAMHS was achieved in March 20.
• Joint agency development for Tier 1 and 2 to mitigate referrals into CAMHS where possible.
• Extra staff have been recruited and plan is to centralise staff within NPT Hospital. A new facility will be developed on the Kingsway – seeking to co-locate to reduce stigma and ensure the site is accessible. Kingsway clinic aims to be finished summer 2021 to create an integrated CAMHS.
COVID is exasperating issues and demand is increasing and CAMHS are currently remodelling to be able to plan. School based counselling has assisted in reducing waiting list. Looking to find ways to continue to identify early indicators. Swansea waiting times have increased and it is currently 2-3 weeks for school counselling. Started Early help hubs to try and support referrals within secondary schools.
CAMHS Emotional Health and Wellbeing Service is being rolled out with a phased approach starting within clusters within Swansea.
Specialist CAMHS waiting lists between Swansea and NPT were merged in March.
Significant numbers of children and young people are being redirected from Specialist CAMHS.
There is a need to increase liaison within schools and social care. Secured money via Integrated Care Fund to increase the liaison input within the local authority.
Covid allowed the department to push forward the SPOA telephone advice line 01639 862744 operating Monday to Friday 9-5pm including general enquires, about open cases, advice or referrals. Email is preferred mechanism to receive enquires. The Single Point of Access email address is: CTM_SBCAMHS_user@wales.nhs.uk
The Crisis Team operate 9am – 9.30pm 7 days a week. Outside of those hours crisis response is covered by psychiatry on-call covering three health boards (SBUHB, CTMUHB and C&VUHB). Experiencing an increase in calls during OOH.
Eating disorder clinical pathway is in development and CAMHS are now asking for a baseline level of physical assessment and investigations including bloods prior to referral. Communication yet to be sent to GPs.
Medication is rarely a first line treatment and only used in combination with psychological therapy. Only to prescribe following assessment and diagnosis by a C&A psychiatrist. CAMHS asked GPs to make contact if waiting lists are resulting in GPs wanting to prescribe to mitigate the waiting time.
SH asked that GPs would prefer a WCCG referral pathway even for email as it can be audited and logged. The Outpatient Group did not think there would be an issue for the CAMHS department.
Joanne subsequently has updated the LMC on this point 27/01/21 – CTM CAMHS management have been pursuing this and currently at the stage of training admin staff. The ‘go live’ date is set for 23 February.
AM – agreed to revisit this and continue to implement. SPOA is a positive way forward and welcomed the access from multi agencies and parents/guardians suggesting that this should help to reduce the movement or recycling of young people from school to GP.
SH – ADHD referrals and Eating disorder Clinic are coming back with not enough information. GPs would benefit from knowing what is needed.
SH – 28 day referral a long time for parents to supervise vulnerable young people.
Joanne suggested that more resources are being developed.
Updated information 27/01/21 – The Silver Cloud online therapy resource is available for all young people aged 16 years and over. There is no longer a need for a ‘code’ to access it – Welsh Government have fully funded it as part of covid response.
DW – Asked question about what percentage require specialist CAMHS support.
Joanne stated that there are estimates but need local level data. Planning has been challenging. Agreed to work out a proportion.
SH thanked Issy and Joanne for their contribution
SH shared that at the HB Liaison meeting the uptake of the Care Home DES was discussed.
LMC have not received any feedback. HB have specifically asked Clusters to consider buddy arrangements in their next meeting.
No additional points raised.
The area has seen a significant reduction in testing. Prior to Christmas testing 11K a week, currently testing less than 6k a week. Still 1 out of 5 are testing positively indicating that testing is not picking up all the cases in the community.
Wider epidemiological picture the UK the variant of concern showed a significant increase November 2020 and an increase in younger cohorts. Overall not good surveillance in South Wales due not testing for S-Gene therefore not sure of actual impact within region.
100 cases lead to 115 cases of the new variant. Therefore when the R number is higher than 1 it will not be possible to contain.
PC – Case definition for testing is too strict and missing a lot of cases.
AGENDA – Morgannwg LMC Meeting 12.01.21
KR agreed and stated that this would probably need to be a 4 nation approach which they are actively lobbying for. There is additional testing capacity available including up to 800 additional tests a day so this could be accommodated.
SK – Testing approach is different within the different testing centres across Swansea Bay.
KR stated that PHW only use dry throat swab whereby biological materials tested direct from the swab.
Lighthouse using liquid medium which needs to have a higher loading therefore a throat and nasal swab. Liberty stadium are using a hybrid of testing, both lighthouse and HB.
AR – Patients denied tests seem to be presenting with Long Covid. Will there be opportunity to request antibody testing to confirm diagnosis and refer into the long covid service?
KR will take this back to colleagues. Long Covid is defined as having symptom 3 months after diagnosis.
Vaccination – as of 1pm 12th January vaccinated 12, 859 people. Just under 500 received Oxford. 7/8 clusters vaccinating in care homes. 8th cluster on board 13th Jan. Virtually all Oxford/AstraZeneca vaccine being directed to primary care due to supplies being so constrained. This means that the mass vaccination centres using Pfizer only.
Minister announced cohorts 1-4 to be vaccinated by mid-February 2021. Residents and staff in care homes 80+ front line health workers 75+ 70 + and clinically vulnerable estimated locally to be 93K people. HB have been assured vaccine for 69K people. Expecting that additional Pfizer vaccine to make up the shortfall.
Oxford vaccine supply pathway promised 23K does before Christmas but didn’t have temporary authorisation until after Christmas. Vaccine approval is undertaken batch by btach which impacted upon supplies. Projection is that supply will dry up first week in February. Ongoing challenge using vaccine, planning approach and supply.
Launched a programme of support to clusters and there has been a lot of hard work from Anjula and Sharon Miller to navigate the WG temporary authorisation.
Positive to see how clusters have responded and this has been welcomed. Extremely positive that all practices have taken on responsibly of 80+ and vulnerable cohorts. KR stressed that this is a joint venture – HB trying to support GPS and GPs trying to support patients.
HW – It is not like flu but GPs are experienced with a multidose vial associated with swine flu. The 11th dose is an issue. Experienced staff were accompanied by a pharmacy technician. Obvious doses in the vial and these were physically removed and put into the sharps bin.
KR – Medicines Management were there to ensure that vaccinators were comfortable working to the national protocol to provide advice and guidance. Opportunity to use the 11th dose is contained within the advice to professionals. The local HB made a decision after consultation that people were not confident to draw up the 11th dose. After checking national protocol and advice to UK if an individual can satisfy themselves that there is an adequate dose to administer they can.
Practice Manager question – What do we do if we have a patient we have vaccinated and the carer is not in the criteria for vaccination?
KR – They do not qualify and will qualify later. The question here is do we vaccinate all four groups simultaneously or in turn. The view is to get through the over 80’s and the clinically extremely vulnerable. There is a subsequent discussion as to whether a carer will qualify if they do not receive the carer allowance. Further guidance will be issued. If they qualify for another reason there is the scope to give the vaccine if the practice has the capacity to do so. Underlying strategy is to provide maximum protection against mortality not safeguard.
Practice Manager question – If there are temporary registered residents in your area and in the over 80 group do we vaccinate? KR – yes
Rydian – Colleagues told to put the needle into the bung take it our resheaf it and use the same needle to administer the vaccine. Apparently this is in the SOP for this HB area. This goes against all other guidance and the online training. Increasing risk of needle stick injuries and contamination.
KR – This will be related to protecting the integrity of the vaccine and the time required. If it is in the SOP, vaccinators are to do this.
Committee member question – Any confirmation that the second vaccine will be the same variety for second dose?
KR – Yes there is a commitment to offer same vaccine formula for both doses.
AR –What happens if that individual is ill and unable to attend in the 11th /12th week?
KR – Temporary authorisation says Contra-indication and unable to administer you wait and administer week 13 or 14. You do not start the programme again. For longer intervals related to speiic conditions it would be necessary to seek advice.
AS – A lot of discontent around extra training required not recognising the skills within practices.
KR – There are elements of the drawing up process that are different to other vaccines. The training aspects are for the particular aspects of the handing of this vaccine. It is not a licensed product and therefore training was required as part of the governance. This is the system in which vaccine was rolled out.
DW – Can all mobile people go to the Mass Vaccine Centres?
KR – Commitment to get as many people through the Mass Vaccine Centres as possible to move as quickly as possible through the cohorts. There is not enough Oxford/AstraZeneca vaccine to meet the campaign. The Campaign will continue into summer.
Committee Member question – For the second dose do people need to ring up and book or await communication?
KR – It will be up to the individual practices to decide how they would like to administer and manage this process. Health professionals will be called back to hospital sites if this is where they were originally vaccinated.
RJ – Are the lessons being learnt?
KR stated he is happy to take feedback. Due to size of the programme a governance approach has been critical and a legal framework has to be followed. The HB are not putting barriers up, just working within the legal requirements of this unlicensed vaccine on temporary authorisation. The programme has not excluded primary care and the HB recognise that they are critical to its delivery.
SH – Can the LMC email practices about 11th dose to
KR – HB are developing a communication to circulate. This covers point discussed so this can be shared with the LMC and circulated.
NS – the person administrating the 11th dose is liable, this is despite the CMO and WG saying you can. How is this documented?
KR – Nobody is documenting this. It is about taking personal responsibility.
SH thanked KR for his time.
PR did not have an issues to raise.
SH asked about sessional staff receiving the vaccination and PR did not have any concerns.
AR asked about the additional requirement for locums to complete additional paperwork with the GP hub prior to delivering a session and the unnecessary burden on a valuable part of the workforce.
PR fed back that this is currently under discussion and the deadline is Feb 8th. Main concern was asking about payment and the level of additional detail. Discussed the possibility of going into Chambers but this is also an expensive approach.
NS met with SSP who apologised for sending out the change of terms with no discussion with GPC Wales. SSP have accepted that there is information that is not required for indemnity. In a meeting with SSP and WG they stated that they actually want work force data. Letters have been sent by GPC Wales to change the parameters. Such as compulsory and non-compulsory elements.
The English and Welsh indemnity process is different. Within Wales the HB is the named defendant. The personal indemnity alternative is expensive (circa £6K) so in short the WG are offering indemnity if you complete the paperwork. NS stated that it is unfair but it is legal.
Clarified that it is possible to complete the sessions retrospectively at the end of the month.
Full LMC Meeting – Tuesday 9th March 2021 – arrangements tbc