1 minute silence for Donna
Before I start my annual report I would like conference to have a minute’s silence in memory of Mrs Donna Martin – for those of you who never knew Donna, she was our committee secretariat for many years but sadly developed pancreatic cancer and passed away last year. She was more than just the committee secretariat to many of us – she was a loyal, fun and engaging friend who always put the needs of her friends and committee above all else (unless Cardiff City were playing). Conference please stand…….
Conference, I am honoured to be standing here in front of you after being in post for 6 months – it has certainly been an interesting and challenging 6 months trying to fill David’s shoes – the addition of a stiletto has only done so much
The situation we are facing today in Wales is unprecedented and despite patient satisfaction scores showing that patients are very highly satisfied with the care they get and complaints remaining low, we have a profession that is under strain, demoralised and not seeing any relief on the horizon.
We have spent time consulting and listening to GPs across Wales highlight what the impact that the contract and increased demand was having on them individually and their practice teams.
We heard them confirm that the constant tick-box style medicine, bureaucracy and micro-management of the GP contract and the never ending annual QOF changes was taking GPs away from managing the individual needs of their patients and reducing their enjoyment of the job they trained to do and the care they wanted to provide.
We had confirmation that increasing patient demand and expectation had again led to an inexorable rise in consultation rates.
We have had confirmation from GPs that the constant shift left of care from secondary into primary care, and the relentless requests to medicalise social problems through form filling has led to their surgeries being workload saturated leaving no time / energy / capacity to consider strategic development of their practices.
We had confirmation that practices were anxious about the income streams coming into their practice – THIS WAS NOT about them wanting to increase their pay, this was about funding being cut through discontinuation of enhanced services and rising expenses all on the back of zero per cent pay uplift leading to concerns about how they could, as a business, continue to provide the same levels of service to patients.
We had confirmation that the predictions we had given Welsh Government about the significant recruitment and retention challenges facing practices were sadly coming true with many finding it difficult to recruit partners.
We heard about the impact that the consistent negative reports on an almost daily basis by Westminster, media and others denigrating our profession has led to many reconsidering their future in General Practice. One particular example of this is the widely publicized reporting that the A&E problems are as a direct result of the GP contract……… Conference, we see over 19 million patients / year in Wales alone, if we accepted the reports that 10% of their attendances in A&E were due to a lack of GP access, and we all know that the reality is significantly less, but even based on these wildly inflated figures that would mean an extra…….wait for it conference …… 2 patients / week – I think we could cope! However, it doesn’t take away from the moral sapping effect that these reports bring.
Given the above, GPs were further disappointed that the problems and issues being experienced within General Practice were not recognized by Welsh Government as we were not allocated any of the additional monies given to Welsh healthcare in the Assembly budget round this year – General Practice simply saw the maintenance of the Enhanced Services funding. Again, I must reinforce this is not about increasing GP pay – it is about having fair access to the resources needed to provide care to patients. The RCGP fairer funding campaign has confirmed that the NHS in Wales has had a significant drop in real terms over the last 5 years and the % spend on GMS care now stands at 7,87% from a high of 10.27% in 2005. This reduction in investment goes totally against Welsh Government strategic policies of providing more care in the community – how can this be done without investing in General Practice? All the evidence clearly demonstrates the value of investing in primary care and how effective we are – in these times that need prudent husbandry of resources, not investing in General Practice just does not make sense.
So conference, as you know, that is the reality of the situation facing GPs across Wales.
Focusing on what needed to change, together with Government civil servants who are prepared to listen and negotiate in the true sense of the word, we managed to come to a negotiated agreement on the contract which should go some way to alleviating some of the problems around workload. Most of you in the room will be aware of the details of this but in summary, we have:
- Removed 344 points from QOF
- Moved 300 of those into the global sum at full QOF point value without 6% OOH deduction – We believe it is better for practices to have more resources in core funding than in QOF and definitely safer in Wales to have it in core funding rather than in Enhanced Services – this also fits with our no new work without new resource mantra. I must stress that this does not mean that GPs and their teams will not stop providing clinical care to patients in areas where QOF points are removed – they will of course continue to do so but when the individual patient needs rather than against set pattern.
- Did not include any of the proposed NICE indicators for 2014/15 other than wording change for LD domain
- Agreed a process to protect the outliers when MPIG removal starts in 2015
- Removed the QOF QP domain 116 POINTS and replaced it with the GP cluster programme with the addition of 14 points – this programme will develop over 3 years
- Used 30 points to resource completion of the Clinical Governance Self Assessment toolkit to enable GPs to demonstrate that the governance in place in surgeries, identify areas for development and be prepared for HIW inspections of General Practice
- Agreed no changes to seniority
- Agreed to participate in a working group to look at publishing GP earnings but not gross earnings – these will be on net GMS income, based on a 37.5 working week to enable like for like comparisons
- Agreed inclusion of annual CPI adjustment in SFE which will ensure the value of a QOF point is increased annually in line with increases in average list size
The impact of the contract changes will be to:
- Reduce administrative and bureaucracy within the practice
- Reduce GP, practice nurse and admin workload
- Enable GPs and practice teams to manage the individual patient and not be chasing targets
- Enable practices to determine length of appointments and how they configure services
We believe these changes will be good for patients and good for practices in enabling them to get back to doing what they do best – determining how best to meet the needs of their patients.
I believe it is important to focus on the MPIG redistribution.
As conference will know, for many years, the negotiating team have been under pressure to agree to an MPIG redistribution. A number of factors have influenced this agenda – the current Health Minister believes it exacerbates health funding inequities and the Wales audit Office recommended its removal in 2008 – the Govt is required to act on its recommendations or justify why they have not done so. The team have faced criticism over the years from those practices who do not have a CF who have received less funding / patient than those with a CF. The reasons for a practice having a CF are multifactorial. These reasons were clearly highlighted to Welsh Govt both verbally and in a written paper at the time this was raised as part of this years negotiation round. The potential unintended consequences of removal of CF were clearly highlighted again verbally and in writing. However, it was made extremely clear to us that this was a non-negotiable area – the question for us as a team was whether we walked away and risked imposition OR we accept the inevitability of this and work on mitigating the losses as far as possible. As 54% of practices would gain from CF redistribution then they would certainly not have been happy for us to walk away and lose the other benefits that a negotiated agreement would bring. The additional benefits of QOF proposals would also advantage those practices losing from the CF changes. Thus, we decided to work on getting as fair a process and as good a deal as we could. To be fair to Welsh Govt they were willing to look at an income loss cap of 15% of the CF % of GSE. Whilst any loss to practice income is a strain and we know that this income loss is on a background of reducing monies coming into the practice including Enhanced Services being decommissioned BUT the harsh reality is it was going to happen. The average loss per affected practice is £5k per year for the next 7 years – this is hard and tough but could have been much worse without the protection for the outliers.
Moving onto networks and why these are being incentivized in this contract round. Conference, we have a one off opportunity for GPs to rise to the challenge, change the rhetoric and seize the agenda to get the resources primary care and patients need. The network development plan is a 3 year programme with year one being the foundation to build upon. We need to get the message out there that if we don’t engage fully and this opportunity is lost then the future is bleak for General Practice.
The network proposals offer practices the opportunity to support each other and learn from horizontal integration. They offer the opportunity to deliver services consistently across a population area and re-ignite inter professional dialogue. It affords the possibility of sharing staff / backroom functions / federating or merging where practices want to do so and I stress – where practices wish to do so. General Practice has served its patients well since its inception but to continue to deliver effective care it needs to modernize.
All sounding rather motherhood and apple pie but this work requires a significant mind set change from the Health board and in particular finance directors:
The deciding point will be whether finance directors will truly delegate a proper budget to networks OR will they keep back a contingency fund and thus nothing will change.
So, if WG truly want these networks to deliver, then they need to under write this risk – my challenge to Welsh Government is to demonstrate commitment to this agenda and put the necessary resources and support in – this will not happen without central direction.
That is enough about the contract because conference, the major challenge facing the profession at the moment is workforce – both recruitment and retention. GPC Wales has been working very hard on getting the various organisations in Wales to wake up to the fact that there is a crisis across Wales. I would like to specifically reference the highly publicized problems being faced in mid Wales, west Wales, the Lleyn peninsula and OOH organisations.
Primary care workforce planning has been in the too difficult or low priority box for far too long. We are now seeing the impact of this and none of us want to see our warnings of “too little too late” come true. We have to have a workforce that is fit for the future and recognizes the needs of the population and the wants of the professionals. The two can marry up but requires innovative thinking and progression of solutions to attract and retain GPs in Wales.
GP training numbers have remained static despite many representations to increase the numbers. Wales currently has 136 training places available – if it is to keep pace with England it needs 200 trainees. We need to ensure those that take a break can return to General Practice quickly and easily. Returner placements need to be appropriate to the needs of an individual GP – after all, these GPs have already proven their competency to do General Practice already. Why are they standardized 6/12 programmes? Do all GP returners need to do the AKT, a simulated surgery and a 6 month supervised placement – I would challenge this assertion and say no – some simply need a brief orientation in the NHS.
NHS Wales needs to consider the wants of the professionals coming through training today– we need to ensure the independent contractor status is understood and invested in as the main bedrock of primary care with other models complimenting this via salaried /portfolio or sessional working depending on the individual GPs wants and the network needs.
Welsh Government needs to look at mechanisms to retain GPs in the workforce – with the pension changes and ongoing complexity of work, increasing demand and stress within the GP why would a GP stay in practice unless they had to? We need to ensure they, and all GPs, feel valued and respected. Maintaining seniority is just one of the options – Welsh Govt urgently needs to keep these experienced GPs in the workforce so additional solutions need to be looked at.
For OOH GPs we have lobbied hard to get cover from the Welsh Risk Pool in recognition that the substantially higher indemnity premiums levied by many of the indemnity organisations has led to many GPs saying they can no longer afford to work OOH or increase shifts when organisations are struggling to fill rotas. Welsh risk pool cover is not enough on its own – we caution all GPs to ensure they maintain additional cover to protect / support them in the event of a criminal or regulatory body hearing. We welcome the move from the Welsh Risk Pool to extend cover to GPs working oOH as this may well enable individual GPs to reduce their premiums and we are hearing reports that the workforce has increased. We would like to see it extend beyond April 2014 else we are concerned that the workforce problems will worsen.
To those who believe that investing in the GP workforce is money ill spent and that there are cheaper options, I would like to remind them that no other healthcare professional can do what a GP can nor are they trained in the same way – that is not to denigrate their contribution to health care but to suggest they can replace GPs is something that we must strongly disabuse – they can do some but not all of our role. The cheapest option is not always the most cost effective.
Other achievements of the team in the last year:
- Worked with WG to ensure clear transparency of use of HB funds – this is critical going forward in this financial climate. This work has seen HBs working closer with LMCs and being more open re: finances / allocations – this will improve trust and certainty that GMS monies are being used appropriately and properly
- The principles of equitable access to remediation and resources has been written into the proposed remediation framework and guidance as well as ensuring that processes map across to agreed performance procedures for GPs.
- From an IM&T perspective – we have worked with NWIS to widen the use of IHR for safety of patients being admitted to acute medical intakes, GP2GP starts in Spring, worked through issues relating to systems of choice migration, negotiated 50% reimbursement of asbestos survey cost and actively participated in the data quality system procurement exercise which means that GPs continue to have a data extraction tool they can have confidence in.
We have got agreement for an exciting collaboration with the SAIL database to get information on deprivation – GPC Wales would urge all practices to sign up to this as this could potentially help us prove the need for additional resources into primary care. Conference I wish to assure you that SAIL is not like care.data – it is distinctly different and safer – practice information is split into two before it leaves practices – i.e. clinical data goes one way and demographic data another and they are never married up in a way that could identify the patient. Thus it is safe.
- We have worked with WG to ensure that any QOF losses from data migration to new systems of change or QOF point losses from services not available or the late production of business rules does not adversely affect practices – HBs have had guidance to adjust end of year QOF out-turns where it is needed.
- For sessional doctors we have negotiated: free seasonal flu vaccines for GPs which is continuing, developed an affiliation scheme for GPs who aren’t part of a sessional group and feel isolated or want to be linked to a practice to access some of the governance work of a practice and got the issues of need for each sessional GP to have their own individual email addresses and prescribing numbers back on the active agenda.
- We have had lots of “interesting” discussions around the inclusion of the community pharmacists in the flu programme and impact / issues that have arisen from this – there are many motions relating to this in the agenda today but suffice to say, we remain unhappy at the uneven playing field that we have compared with community pharmacy and the fact that nobody will be monitoring whether they have followed the specification they were contracted to provide.
- The Welsh version of 111 i.e. Phone First has GPC Wales engagement in each workstream and, again, seems to be a sensible approach linking into OOH organisations. It is important that despite Welsh Govt stating the service will be in place by July 2015 that it gets the right solution – not just any solution.
This isn not enough and we are not resting on our laurels– our focus for the next year is on:
- Workforce – this remains top of agenda for reasons outlined before
- We will be supporting networks and driving forward the changes needed to enable networks to have budgets, manage community staff and realise the benefits that these networks can bring to patients and the profession
- We want stability for practices so will be looking at the potential for a 2 or 3 year negotiated agreement next year
- We are working through some solutions to resolve the unintended consequences from CF redistribution and some of the specific issues that rural practices experience
- We are involved in ensuring that any inspection of General Practice is appropriate and does not follow CQC processes which have been likened by some to a “witch hunt” – early signs are promising that Wales is taking a separate approach
- Pushing for investment in premises
- Ensuring that sessional and salaried doctors continue to have their needs met and issues highlighted
- Finally, but importantly, we will be watching to ensure that the Health Ministers expectation that Health Boards will move more resources into the community is kept. I will be supporting the RCPG fairer funding campaign, and conference I would commend you to actively support this both personally and through your practices / workplaces too.
There will be the opportunity to ask us questions during negotiators question time this afternoon.
Conference, that concludes the report of the Welsh General Practitioners Committee.