NHS Wales needs doctors to stand up and lead change effectively. But we must do it together and not in a manner that sets up a clinician-fronted service paying lip service to our core values, emphasised in Good Medical Practice. Our first duty of care is to our patients.  We all acknowledge that change is needed and, as doctors, we have a huge opportunity to shape the emerging structure and culture of NHS Wales through both leadership and followership.

I’ll shortly be chairing the first in a series of online seminars called Doctors Championing Change, organised by 1000 Lives Plus. These are being presented by internationally renowned speaker Dr Jack Silversin, author of Leading Physicians Through Change, who believes that doctors have to be central if change in healthcare systems is going to work.

Jack will be addressing the known major obstacles to change and giving us helpful ideas of how to overcome them. He will directly address the frustrations we feel if we have changes imposed on us, and he will give us insights into how best to tackle those frustrations. These are recurring themes during our discussions around Wales as we engage with service reviews and proposals for reconfiguration of teaching, training and service.

The online seminars are open to all doctors and medical students – whatever specialty and whatever level you work at. They are easy to attend – all you need is a computer and a phone, and some organisations will be setting up ‘group hubs’, making it even easier to join in.

It is my firm belief that as a profession we have a responsibility to be at the forefront of changes in healthcare. This is even more important given the workforce and financial pressures we are facing every day because we are some of the people best-placed to know where the money is being spent, and where personnel are needed most.

I think it also starts with us because we are the ones who have the most direct responsibility for patients in our healthcare system. They are our patients. They depend on us to help them survive illness and surgery, recover from physical and emotional damage, regain confidence and independence and restore them to fully functioning lives as far as possible. Given the recent National NHS Staff Survey in Wales and the Francis report in England, we can see that there is an uphill struggle to reconnect those working directly with patients to those responsible for helping them to do this.

I believe these seminars will help all of us to position ourselves firmly in the change driving seat and help to lead change co-operatively, so that our organisations move forward in a united and cohesive way. I do hope you will be able to join Jack and me for the series and look forward to discussing the issues with you afterwards both in the BMA and as we seek to influence NHS Wales for better care for our patients.

Dr Phil Banfield is Chair of the BMA’s Welsh Council and a member of the 1000 Lives Plus Faculty.

The latest survey found that 42% of adults reported drinking above the guidelines on at least one day in the past week, whilst the 2011 survey found that

43% of adults reported drinking above the guidelines on at least one day in the past week.

A sensible approach to alcohol is always important. We want the public to be aware of the risks associated with drinking, and would like to see advertising for alcohol banned as well as minimum price levels set for the sale of alcohol. It may be a small change, but at least the figures have gone down. I wish I could say the same for smoking rates and obesity levels. I heard on the news today that since the 1960’s in the UK we’ve piled on 3 stone to our average weight. And yes, the figures from the Welsh Health Survey show that 59% of adults are now classified as overweight or obese, including 23% who are obese. These figures are rising year on year.

It’s extremely worrying news for our health, as vascular diseases like hypertension, heart disease and diabetes to name a few, are all related to weight among other things.

It is so important for our health to lead a lifestyle combining exercise with sensible eating. Hopefully the Welsh Government’s active travel bill will make it easier for more people to walk and cycle and incorporate physical activity into their daily routine. Current guidelines suggest 30 minutes of physical activity 5 days a week.

What really struck me were the stats on children. We are in danger of raising a generation who will be burdened with chronic conditions.

34% of children were estimated to be overweight or obese. There has

been little change in children’s reported health or levels of overweight / obesity since 2007.

These soaring rates in obesity over recent years has lead to an increase in childhood type II diabetes and will lead to more future cases of heart disease, osteoarthritis and some cancers. If current trends continue, the cost to the health service is likely to increase unless measures are put in place to halt this growing problem.

We need to prevent children from becoming overweight in the first place, and parents, schools, health professionals, the media, food manufacturers and the government all have an important role to play in this.

These results have really made me think about my own health, and I for one will be getting on my bike and going for a cycle this weekend. What will you do? Have a happy, healthy weekend all!

Passing the driving test is, for most new drivers, the key to freedom and independence. Unfortunately, for too many it also leads to high risk driving and around one in five new drivers crashing within six months of passing their test. New young drivers are at even higher risk and at around 18 months post-test their crash risk is still three times higher than their parents

It’s not surprising that new driver crash risk is high; driving is a complex motor skill. It takes time and practice to master it consistently and competently as well as deal with the whole host of new driving environments. For some new drivers, heavy rain or darkness may be completely new experiences.

For young new drivers, inexperience is complicated by age; with youth comes confidence, exuberance, risk taking, peer pressure, impulsivity and hormones. This all means that for new young drivers even driving within the law can lead to crashes.

The high risk circumstances for new young drivers are well known; night time driving, driving with teenaged passengers in the car and driving after drinking alcohol. At night, distances are more difficult to judge. With teen passengers the weight of the car is changed, and so is the handling, and there is likely to be more distraction and less concentration. Alcohol has a more pronounced effect on driving skills of new drivers, especially young ones, than it does older drivers.

This is not new knowledge and the high crash risk of new young drivers is not a new concern. But, in the UK, as overall crash rates have fallen, young driver crashes have become more important. Young driver crashes are falling in number, but not as quickly as for older drivers and, for some groups may actually be increasing.

So what can we do about it?

Perhaps not surprisingly, this is not just a UK problem – new drivers are new drivers wherever they are and teenagers are always teenagers! So, when we look to other countries to see how they have dealt with this, Graduated Driver Licensing (GDL) is often the answer.

GDL is used in countries including the USA, Canada, Austalia and New Zealand to reduce crash risk for new drivers. Some places use it for all new drivers, others just for new young drivers (usually under 25s).

So what is it?

It’s a system for allowing new drivers to gain driving experience in conditions of low risk. Exposure to high risk situations – night time driving, carrying teen passengers and drinking any alcohol – is limited. Differences between the countries that use GDL, such as, age for learning and legal age for drinking alcohol, mean that it is impossible to describe an ideal GDL, but we know that ‘best practice’ includes these three elements.

The way it works is to make learning to drive a three stage process. Stage one is the learner period, usually of a minimum length, with learners passing a test to move on to the next stage. Stage two is the intermediate stage, again of fixed length, and the new young driver can then drive unsupervised, but only during the day and not whilst carrying any teen passengers nor having drunk alcohol. A supervisor in the car removes all restrictions, as long as the supervisor is fully licensed, aged over 25 and sober!

One way to think of GDL is as a teenagers version of a toddlers stair gate. In fact, the whole learner driver process is very similar to a toddler learning to walk. There’s a world of difference between first steps and walking without falling. In the meantime, parents tend to keep toddlers away from dangerous places and these are generally agreed to be stairs and fires. The best way of doing this is with a stair gate and GDL is just a teen version of a stair gate.

Does it work?

Yes.

For the same reasons that we can’t state what the ‘ideal’ form of GDL is, we can’t say what the exact benefit of GDL is. But, a recent review of all of the available evidence relating to GDL concluded that it only has a positive effect on crashes and casualties.

In New Zealand, fatalities amongst 15 to 19 year olds fell by 57% with the implementation of a 10pm to 5am, no teen passengers and no alcohol GDL system. Learners there begin at 15. In Florida, crash injuries to 15 to 17 year olds fell by 8% with a night time curfew of 11pm to 6am for learners who can begin at 15 years 6 months, but not obtain a full licence until 18. Nova Scotia saw a 28% decrease in all crashes involving 16 to 19 year olds with a midnight to 5am curfew for learners who can begin at 16, but not obtain a full licence until 18 years and 3 months. Across 43 states of the USA, there has been a 31% drop in crashes involving 16 to 19 year olds.

GDL has also been shown to increase parent and teen empowerment; so, teens feel more able to ‘say no’ to carrying groups of friends as passengers, their parents feel more able to restrict teen driving.

So if it’s that good, why don’t we have it in the UK?

The UK Government know that the young driver crash problem is an important one that needs to be dealt with, but they are not currently willing to consider GDL. UK Government arguments against GDL include older learner age in the UK, that the effect of GDL is unproven, that improving training and education will reduce crashes and that introducing GDL will devalue the current learner process.

Of course, for every argument there is a counter argument! The UK learner age is higher than in many countries with GDL, but because of the length of time it takes to go through the GDL system, teens in many places are older than UK teens before they get a full licence.

The effect of GDL has been demonstrated in many places, but the effect of training and education is not clear. Obviously, basic driver training is an important part of the learning process, but there are no formal requirements of this in the UK – many other countries have learners use a workbook to guide learning. Also, programmes such as pre-driver training in schools and post licence training have an unclear effect on crash risk. Some feel that these type of programmes actually increase crash risk because they increase driver confidence.

GDL is not intended to devalue the current licensing system, but to complement it. Basic skills and competence are important to safe driving, but new drivers need time to build experience and to minimise their risk, and the risk to other road users while they are doing this. This is what GDL offers.   

Dr Sarah J Jones

Gwent Local Medical Committee, North Wales Local Medical Committee and Dyfed Powys Local Medical Committee.

For further information or a nomination form, please contact Miss Sarah Ellmes, Committee Executive Officer by calling 02920 474604 or emailing sellmes@bma.org.uk

Deadline: Friday 31^st May 2013

This survey reflects much that is good in NHS Wales from the perspective of the frontline staff who work in it, but clearly there is much to be done to change some of the unacceptable cultural norms.

Welsh NHS staff and doctors are committed to excellence in patient care and work hard each and every day to deliver above and beyond their call of duty, and this is reflected in the survey.  In particular, it is humbling to note the important role and contribution that each and every staff member makes to delivering patient care with 82 per cent agreeing that they felt their role makes a difference to patients/service users.

There appears to be an improvement in recognising that staff raising concerns is valuable – particularly around patient safety issues, and in the light of events in Mid Staffs this is encouraging and reassuring.

BMA Cymru Wales has consistently highlighted the lack of engagement of frontline staff and in particular doctors, in service development and redesign.  It is clear from this survey that staff do not feel engaged in the considerations of service change, and do not feel that senior management fully engage – with just 21 per cent of respondents agreeing that communication between senior management and staff is effective.

This must also reflect more widely on health boards in Wales, who do not listen sufficiently to frontline staff, nor do they engage to the extent that BMA Cymru Wales has been advocating for some time. 

In the same way that staff recognise their important contribution to healthcare delivery and development, it is high time that senior management and those appointed to health boards to oversee services recognise this too, and work to improve the low number of staff (22 per cent) who believe that they are engaged with on important decisions. 

The fact that in the past 12 months, 18 per cent of respondents have personally experienced harassment, bullying or abuse at work from manager/ team leader or other colleagues is totally unacceptable. Each employee should be treated with respect and dignity whilst at work. The highly pressurised target ethos in the health service only adds to the culture of bullying where it can be mistakenly seen as a way of motivating staff. The culture has to change to one of zero tolerance and it must be taken seriously from the top down.

BMA Cymru Wales welcomes the publication of the NHS staff survey in this open and transparent manner and looks forward to working with health boards and the Welsh Government to review this important feedback from NHS staff in order to address the concerns that are highlighted in the survey, and work towards a culture in the NHS that the staff can be proud of and best serves the patients of Wales.

What is a good clinical teacher? At the BMJ we focus on “Helping doctors make better decisions” and in the education section we produce great content. That’s the easy part. Teaching is much more than reproducing this content. Its about passing on knowledge and its also about encouraging, stimulating, and inspiring future generations.

Medical schools are doctor factories. Chatting to an academic colleague, he put it like this: if a medical student spent three hours researching, thinking about, and writing a single essay each week, how long should a tutor spend reading it? But, if there are 250 in a medical class and if a tutor spent just 10 minutes reading each one—you can work it out. Traditional models of teaching are unsustainable. A medical school might be able to pick up the poorer students and the high flyers will probably identify themselves. But, what about the majority—the medical students in the middle? (I didn’t use the word average—medical students are not average.)

More than ever, medical school teaching is about facilitating students to learn for themselves, pointing them in the right direction, helping them make the most of their time in medical school (which, for graduate entry, is not that long) being role models for professional development, and creating an environment where learning is fun, exciting and stimulating.

Are there teachers like this? Even those long retired can recall medical teachers who helped mould their careers, gave them values that they retained throughout their professional careers and who they remember for their teaching decades previously. I am sure we came across research wizards but we weren’t interested in how many papers they published, keynotes they gave, citations or awards. We knew who had the greatest influence on our student days and later careers—those who cared for their patients, who supported student medical societies, who were interested in student sport, helped our struggling classmates, came in early to take tutorials, stayed late to coach us for exams, and fired our enthusiasm for medicine and learning. And, they probably didn’t know how influential they were.

And, we knew the bad ones too—those who didn’t bother to prepare, whose slides hadn’t changed in decades and whose lectures were ill thought out or sloppy. University teaching is under increasing scrutiny now and not before time. Students expect value for money, there is formal feedback, students chat freely on social media, and there are websites to rate your teacher.

In recent years, universities focused on research assessment. I cringe when I hear academics bemoan the time they have to devote to teaching, implying that it takes them away from much more important business. But it really matters—medicine is a profession not a points race. When the pendulum swings back, as it will inevitably we will, I look forward to renewed emphasis on teaching, recognising its lifelong influence on careers, and how we can inspire future generations. Let’s recognise the great teachers.

As a consultant in occupational medicine, I am used to talking to patients about embarking on healthier lifestyles. However, recently, I’ve been made to realise just how hard that can be to do.

I have been taking part in Champions for Health, a national campaign for NHS Wales staff to attempt to make changes in the five areas we know are most detrimental to health in Wales – smoking, drinking, not exercising, poor eating habits and carrying excess weight.

I took two challenges out of the five – to take more exercise and eat more healthily, and it has been difficult. I have made progress. My energy levels have improved. But it hasn’t been as easy as I thought it would be. I have found it quite hard to find consistency even though I have really wanted to do as well as possible in my aims.

This has given me a real insight into what it’s like for my patients. The good news is I can now talk to them honestly about what I’ve been trying to do and how I know it’s not always easy. But I can also say it’s still important to do and encourage them to keep going.

I hope that by sharing my experiences, my patients can empathise with me and hopefully be inspired to at least start doing something positive in their own lives. I can tell them that they don’t have to do it perfectly, but doing something is better than nothing.”

I think it is important for those of us who work in NHS Wales to invest in our own health. I often treat NHS staff with back or neck pain that is aggravated because they are overweight.

However, it is possible to put regular exercise and healthy eating into your daily routine. It’s easy to whack the calories in on a long shift, or use the car even though you could walk or cycle, but we can find opportunities to be healthier in our ordinary working day. For example, I have been cycling to some of my clinics.

I’ve also realised that it is hard to go it alone and try to improve your health. I’ve discovered that if I have people to help support me it’s easier and I am more likely to go cycling or eat healthily if someone is doing that with me. My team at work have been fantastic as they have started to eat more healthily too so there are no temptations to snack on crisps or cakes.

These are important messages that I am able to pass on to my patients. I can tell them that change is possible, although it isn’t easy. I can encourage them to find ways to build exercise of better eating habits into their regular day. And I can help them identify people who will support them as they take control of their lives and begin to make changes.

Wherever we work in the health service, we are adverts for health. If I’m not healthy myself, then I don’t think my patients will take much notice of me when I tell them they need to improve their health. By becoming a Champion for Health, I hope to have changed that.

Champions for Health’s Twitter account: @C4H_Wales

A superficial interpretation of the important information recommendations in the Francis report is that we must start to measure quality alongside performance. So we will start to see pundits who grew up in the target culture, vying for position on what should be measured , how it should be classified etc. There are already Francis factories under construction to provide the NHS with the ready made tools to do the job! I wonder if Francis Compliant will become a new marketing term for future information systems.

That mindset, traceable back to Jeremy Bentham, completely misses the point of the information recommendations in the report. The changes required are much deeper and go to the heart of the citizens relationship with the service. The recommendations describe how information systems must be used to support the major cultural shift required to avoid future similar disasters. The Benthamite measurement approach is necessary but insufficient.

There are four additional major information themes in the report that are of equal importance.

The first of these is the provision of access for patients to their own records. This includes the  provision of copies of their records in a form that is usable to them. In England it is envisaged that this will include access to the summary care record. There is also a recommendation that the patient should be able to add comments to their record.

The second is a reflection on the fact that in secondary care across the UK we still haven’t finished the job of creating a usable electronic record. So there are recommendations on ensuring the record is available whenever the patient is seen, that key information is  communicated across the system,and that safeguards are in place to ensure that results etc are acted on.

Thirdly, and perhaps the most difficult recommendations for the NHS in the information section are cultural and directly relate to one of the  fundamental messages of the report. It is to industrialise the feedback mechanisms that enable the patient & carers to comment on their care. This as the report points out has been piecemeal in the past , usually by exception and at a small  scale. This change is an additional challenge to NHS informatics because it will expose the severe limitation of our traditional approaches to information and communication with patients. This theme combined with the those above, will require a fundamental shift in the way most people have traditionally thought about information in care services.

Lastly but not least are the recommendations on transparent publication of data and information. The key here is the independent verification of this data and information that has  traditionally  been processed behind the closed doors of the NHS and government.

Our patients, carers and staff  now have the consumer devices and connectivity to take many of the recommendations forward.  We need to change our mindset as clinicians to help to make this happen in partnership with our patients.

The Iraqi Medical Society International (a UK based voluntary organisation) organised a week long training course on laparoscopic surgery and a workshop in Iraq in February this year. The course aimed to address the need of Iraqi surgeons for a structured training course that would refine and improve their skills and knowledge. The course was conducted in collaboration with the Welsh Institute for Minimal Access Therapy (WIMAT), and a generous participation from 10 consultants and specialists from Wales and rest of UK.

The preparation for the course took about 9 months and went through many ups and downs, but with the determination of the team, we rode the tide smoothly!

The team of 10 arrived in Erbil on 17th February. The capital of northern Iraqi Kurdistan, Erbil is a vibrant fast growing city with a population of more than 1 million.

On the 18th February after a nice Iraq traditional breakfast, we headed to the course venue. The course was held in Rizgary hospital in Erbil. We met with team from Storz at the hospital and together we started prepared the workshop lab and the lecture theatre. We expected 60 candidates for the Basic laparoscopy course, and for this number we needed 60 animal Livers (for Lap. Cholecystectomy), and that was a real challenge.

The course started on the 19th February with a welcoming speech from myself and Neil Warren followed by representative of Health Minister Dr Mohammed Shuaib. Following the opening ceremony, delegates were split into 2 groups. The basic course lasted for 3 days, where candidates were introduced to the basic skills and groups, swapping between the lecture theatre and the workshop lab. Delegates were very enthusiastic and motivated and enjoyed the course immensely.

The advanced course started on 22 February and lasted for 2 days. The course was attended by 130 delegates. The course was focused on Bariatric Laparoscopic surgery by Mr Akeil Samier, from Darlington, and Laparoscopic Colorectal Surgery by Prof. Haray , from Merthyr Tydfil. We managed to perform 2 live link Laparoscopic Hernia operations, operated by Mr Samier. The course was well received by delegates and the feedback was excellent. In addition to the scientific value of the course, we managed to make many changes that would benefit the hospital in the long run.

We set up and tested the live link from the operating theatre to the lecture theatre. We also bought a 70 inch TV set and gave it as gift, to improve the visual equipment in the lecture theatre. There are demands from the Health Ministry to do a similar course in the near future. We are looking at how to make this course as part of continuous and long term training strategy. We are also looking at other specialities and ways to link Iraqi health institutions with counterparts in Wales and UK.    

The team members were:

1/ Dr Neil Warren – Director, WIMAT

2/ Mr Stuart Goddard – Senior Technician,  WIMAT

3/ Prof. P Haray – Consultant Colorectal Surgeon, Prince Charles Hospital, Merthyr Tydfil

4/ Prof. Asal Izzidien – Retired Consultant Surgeon.

5/ Mr Akeil Samier – Consultant Bariatric Surgeon, Darlington

6/ Dr Ali Al-Qaddo – Associates Specialist, General Surgeon, Royal Gwent Hospital, Newport.

7/ Dr Mohammed Aziz – Specialist Gynecologist, St Mary Hospital, London.

8/ Mr Faris Al-Badra – Manager, IMSI.

9/ Dr Amer Jafar – Physician, Royal Gwent Hospital, Newport.

10/ Dr Moayed Aziz – Consultant Anaesthetist, Prince Charles Hospital, Merthyr Tydfil. President of IMSI.

Every doctor has had an experience where despite our best efforts to get care right for our patients something has gone wrong.

But there is an increasing sense that when something goes wrong, simply blaming clinicians does not make care any safer. The same problems can occur again and again, involving different doctors and clinical colleagues.

Deep down we know that the problems lie in the complex systems of modern healthcare and often we feel powerless to change that – feeling we lack the skills, authority or responsibility to do anything about it.

This leads to a ‘there but for the grace’ mentality when something goes wrong, where we just have to hope that bad things don’t happen to us. This isn’t good for us as professionals, it isn’t good for us personally, and it is certainly not good for our patients.

Improving Quality Together is about doctors and other clinical professionals taking charge of processes and systems and introducing changes until those processes and systems work!  The new framework to give all staff the knowledge, skills and authority to improve the care we deliver.

As doctors, we know there are problems within the systems in NHS Wales, and we are best placed to make changes. After all, we work within these systems every day.

Improving Quality Together isn’t just for doctors. It’s a programme for all staff, in all parts of the service, clinical and non clinical, from frontline to Board. It will get us working together to fix things, speaking the same language, focusing together on the needs of patients.

We have to believe we can make the NHS a better place to work. If every doctor in NHS Wales believed we could change the way we work and felt confident about making those changes, just think where we could be.

To find out more about taking part in Improving Quality Together, please visit the website.

The existing support arrangements will continue for 2013/14.  Students undertaking a 5/6 year undergraduate medical course will continue to have their fees paid in full from year 5 of their course via the NHS Bursary.  Graduates on a 4 year accelerated programme will have the first £3,465 of tuition fees paid during years 2-4 of the course as part of the NHS Bursary.

For further information take a look at this page on the Welsh Government website.

This settlement is by no means a great deal for GPs – that was never on offer in the current financial crisis – but it does go some way toward recognising the spiraling workload of GPs and protecting funding and viability for every practice in Wales. And it still maintains the core of a general practice contract that offers patients across Wales and indeed across the UK a primary care service recognised by the independent Commonwealth fund as the finest primary care in the world.

Fundamentally the GMS contract does still do just that. It’s a system of weighted workload based funding with a quality based incentive scheme and locally and nationally driven add-ons to further enhance care. Our challenge over the next few years will be to protect and improve that contract.

To some extent this will depend on how much an ideologically driven rush to privatisation takes hold in Westminster. But it also depends on persuading our government of the fundamental value of GPs to Welsh patients and the need to protect the core of this value – the individual practice – in all its varieties across Wales.

This will mean recognising and celebrating variation and recognising that no formula can be completely fair, it will mean investing in staff and premises and most of all in new services to support left shift of care, it will mean listening to the conclusions of the Francis report that a target culture based on financial savings and a bullying management is bad for patients and most of all it will mean working with and not against GPC Wales and the Welsh LMCs to continually improve Welsh general practice and attract the very best future GPs to Wales.

The government has made a good start in listening to our serious concerns about the proposed imposition from Westminster. We told them about daft questionnaires which would have irritated patients and meant GPs working for below the minimum wage, we told them about a failure to recognise that organisational achievement is not a free good, about ever receding targets which fail utterly to learn the lessons of Mid-Staffs, thresholds which risk harming patients and about  DESs which go against the advice of their own advisory committees because the PM knows best…….I could go on but I won’t.

Now in Wales we have a few thresholds at the median achievement level without an intention to push them ever higher. We have recognition that safety is more important than pushing GPs to over medicalise patients. Recognition also that practices need stable resource to deliver patient care and also that patients have their own agendas, which generally don’t include tick boxes.

Most importantly we have some recognition that maintaining practice funding so that patients have a GP is more important than a doctrinaire policy that everyone can do the job for precisely the same per patient funding when all the evidence of our own eyes says that actually, they can’t every practice is different.

The government’s own data has recognised that the practices worst affected by changes to correction factor would almost all be in four rural counties out of twenty two which kind of makes the argument in a single sentence unless you believe you’re going to win the lottery tonight. Once you agree on both sides that there’s a problem then you have the possibility of a solution and hence the government commitment to consider issues around smallness, branch practices and rurality and that some of the solutions may be off formulary for outliers.

Welsh Government is not now committed to eroding MPIG although I suspect that’s an argument we will still have to revisit and they do at least understand that the simplistic conclusions of the Welsh audit office say more about their lack of understanding than the realities of providing general practice in Wales. We are committed to open discussion of the issues around practice funding variability and also to modeling down to practice level. Welsh Government have been told in no uncertain terms of the effect that never-ending uncertainty will have on partner recruitment and patient service provision in the worst affected areas.

Which brings me on to recruitment. The funding gap between the Celtic nations and England remains at over £10k although there is a real likelihood of this narrowing. Sadly the reason for that is not because of increased Welsh GP incomes but reductions in England. Recruitment to GP training is still under pressure particularly away from South Wales and the M4 corridor and there are motions this year on this issue.

What is particularly clear is that with reconfiguration, MPIG threats, hospital staff shortages, distrust of management and low take up of vacancies there is a perfect storm brewing in rural Wales and we have made certain that both the minister and rural AMs are clear about the dangers.

Pensions

Pouring petrol on the fire of course is pensions. GPs this year are actually seeing the reality of the income reductions they only heard about in abstract last year and there is worse to come – a further 2.4% reduction this year and 1.2% next. Add to that the stealth tax of changes to Annual allowance and Life time allowance from 2014 and every GP over 55 will need to take careful personal pensions advice about the cut-off point where they will effectively be paying for the privilege of remaining in the pension scheme. Many older GPs will find it financially nonsensical to remain in the pension scheme and whatever their intentions on continuing after withdrawal they may find the comfort of being a pensioner irresistibly tempting. The consequence of this on a workforce with large numbers of over 55s is potentially catastrophic.

The other significant issue for pensions is the transfer of responsibility for locum employer’s superannuation to practices. Unfortunately at least in this context we have an England and Wales pension scheme and this forms just one of the many unwelcome facets of the England imposition. We have agreed in Wales that money currently spent by LHBs will be delivered to practices through global sum equivalent so at least all practices will get some of the £782k it cost last year.

However there are two very unwelcome aspects to this change. Firstly it will not go to practices proportionate to their current costs – indeed pretty much the opposite as the highest locum costs are likely to be in small practices with less ability to cross cover. Yet again like with Carr- Hill small practices will be disadvantaged by changes to government policy – regardless of whether patients still like them (and they do!)

The second problem will affect younger locum doctors, as older retired locums will be cheaper to employ and practices may inevitably try to negotiate around their costs even though non of these increased practice costs relate to higher income for the locum.

Revalidation

In addition to everything else revalidation has started and in this, if little else, there is some good news for Wales. The all Wales appraisal process for GPs has been established and is working well, a free multi source feedback form is on the blocks for Welsh doctors and became available yesterday and GPs have an appraisal system that they generally trust. There are still concerns about remediation payments and revalidation for sessional doctors. GPC Wales is keen to promote the affiliated practice scheme for sessionals and we continue to work both at Welsh and UK level to make the process as straightforward as possible and ensure GPs are fairly treated over remediation.

Enhanced services

While the contract changes have inevitably been our main focus over the last few months there have been other important issues. Foremost probably with a contracting financial envelope is enhanced services and the need to ensure that this funding stream which is between 7 and 8% of GMS is spent on realistically priced services that are GMS provided. This clearly doesn’t mean ambulance booking, physio or wound dressings provided in secondary care  and it certainly doesn’t mean the same service as last year for 20% less money so LHBs can fund extended hours! We will continue to scrutinize LHB spending in this area and challenge any schemes which misuse or divert much needed resources from front line general practice.

Access

Welsh practices again rose to the challenge of delivering even better access to their patients this year despite rising consultation rates and rising population. Yet again the talk is of extended access next year but this seems much less strident and LHBs seem clear that this will only happen via a commissioned DES. I think they are finally waking up o the benefits of a collaborative approach on this.

Flu

We have had an ongoing dialogue with Welsh government about using community pharmacy to deliver flu vaccination where uptake was low despite the self-evident concerns about record keeping side effects and double dosing this raises. We repeatedly warned them of possible unintended consequences such as the risk that practices would reduce orders and commitment if they were uncertain of their likely uptake. This year was apparently a pilot and in total all the community pharmacists in Wales gave less flu jabs than my practice….

Clearly I can’t speak for how well the other 474 practices in Wales have done but it does raise value for money concerns and we have written to the CMO and await the evaluation with considerable interest. We also remain in ongoing dialogue with Public Health Wales as regards use and interpretation of GP vaccination data.

Systems procurement

Following an extensive procurement process where we were represented by Ian Millington we are all moving by 2015 to one of 2 hosted GP systems – Vision and EMIS – with extended functionality, security and connectivity We remain concerned about potential data loss and disruption of QOF work and have sought assurances around protecting practice income through the changeover and about timing of transfers.

Dispensing

On the dispensing front following the conclusion of the fee scale negotiations last year we are continuing to pursue a solution to the ongoing problem of drug reimbursement. This clearly also affects rural practice particularly small rural practices and needs urgent resolution. Welsh government are likely to follow DH in this matter and DH as often on issues which it prefers to avoid is moving with the sense of purpose of an arthritic snail…

We will maintain pressure to resolve this.

Madam chairman that concludes my report.