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  • The CMO for Wales issued a new set of Standards on 3rd May 2018 which can be found at 

    https://gov.wales/topics/health/publications/health/guidance/allwales/?lang=en

    The new set of standards for clinical behaviours and communication across the primary and secondary care interface have been developed for adoption througout Wales.  The standards were initially developed by the Bro Taf LMC.

    Health Boards are expected to put in place arrangements to ensure these standards are fully adopted and include processes to receive, collate and respond to concerns expressed from theirhealth community where these standards have not been upheld.

    Morgannwg LMC is currently in discussion with ABMU about the monitoring of the standards but in the meantime would ask that you continue to use the letters in the documents section of the website and cc in the LMC (patient details to be anonymised.) 

  • INDEMNITY-WALES - Statement from Dr Charlotte Jones Chair of GPC Wales

     

    No doubt many of you will be asking "so what will happen in Wales"? now that Jeremy Hunt has announced a state backed indemnity solution for English GPs.

     

    GPCWales and RCGPW have been lobbying hard to ensure the need for a sustainable solution is found here too. Welsh Government have listened and understood the problems that rising indemnity is having on the GP workforce and has today publicly confirmed that Welsh GPs will not be disadvantaged by this announcement.

     

    Like England, the provider for indemnity has yet to be formally determined but the solution will have state backing - you will know that the Treasury have put aside £5.9 billion for the NHS across the U.K. to cushion the impact of the discount rate changes (which in short is amount of money paid out in event of accident including clinical negligence and with the discount rate changes those amounts would rise significantly leading to higher indemnity fees).

     

    Wales has commissioned an independent review of all options which is due to report shortly. By utilising this approach it means that the right solution will be found and unintended consequences or risk of challenge to eventual provider will be minimised. Welsh Government together with Welsh Risk Pool experts and GPC Wales will continue to work closely in ensuring the profession gets the right solution and in a timeline that mirrors England.

     

    The total funding required for this will be dependent on a number of factors and, like England, any negotiation on contribution from profession will go through the usual Welsh negotiation process.

     

    For now there is no change to current indemnity provision and support - i.e. Each GP needs their own indemnity; the short term support for indemnity into GMS practices continues and Welsh Risk Pool remains in place for HB commissioned Out Of Hours Services and working in salaried / HB commissioned services (if only working in these roles remember you still should have "top up" legal insurance for things like disciplinary / 

     

    We'll keep you fully up to speed as this important area develops.

     

    If you have any questions please do not hesitate to contact your LMC or GPC Wales.

     

    Warm Regards,

    Charlotte

    12th October 2017

     

     

  • October 2017
    FAQ: Health Board approach to taxation and employment
    status of GPs working in directly managed practices or
    Health Board managed Out of Hours services

    What is the problem?
    HMRC has recently taken a keen interest in the employment status of many independent
    contractors which includes GPs working in a sessional capacity.
    In essence, if it determines that you are employed, as opposed to being self-employed, then
    your tax and national insurance contributions will be removed by the organisation which
    pays you.
    In addition, if the organisation has, in HMRC’s opinion, wrongly treated you as self-employed
    then the organisation can face a significant fine and interest which can potentially go back as
    far as 20 years.
    Therefore, this is causing much angst amongst employers. In particular, Health Boards have
    become very concerned about their potential liabilities and have commissioned specific
    advice from Deloitte. The Health Board interpretation of this advice has concluded that GPs
    working for the Health Board but not in a salaried position (e.g. in out of hours centres; in
    prisons; doing shifts in a minor injuries unit; working in directly managed practices) should
    be classed as employed for taxation purposes but not for employment purposes. Thus, you
    would be unable to access employment rights, which includes annual leave / sick leave /
    maternity leave / and other parental rights.
    Their assertion applies to all sessional GPs whether working through an intermediary (where
    IR35 applies) or not.
    Please note, for avoidance of doubt, this guidance applies also to GP principals or salaried
    GPs offering services and directly contracting with the Health Board on a sessional basis
    for the types of work as outlined above.


    Does GPC Wales believe that the Health Board interpretation of the
    taxation status is correct for GPs working in above settings?

    Sadly, it appears that the HMRC toolkit to determine whether an individual is employed or
    self-employed isn’t always that clear-cut, and thus there are risks to any organisation in
    getting it wrong. However, we support the guidance in other parts of the UK; namely that
    blanket application of the ruling is wrong as it doesn’t allow for differences in an individual’s
    circumstances.

    Does GPC Wales believe that the Health Board interpretation is
    correct for the employment status / ability to access employment
    rights of GPs working in above settings?

    We do not feel this interpretation is correct.
    The tests to determine whether an individual is employed for taxation purposes and for
    access to employment rights are very similar, and it seems nonsensical to say they apply to
    one section and not to the other.
    We believe this could be open to challenge by GPs who contract directly with the Health
    Board. However, if you are working through an intermediary/ personal service company (see
    below) then it is unlikely that you could argue you are employed for employment benefits.


    Isn’t this just about the HMRC IR35 regulation?
    This is wider than the application of IR35 regulations.
    IR35 solely applies to GPs working through an intermediary such as limited liability
    companies. These are often described as a personal service company which individuals have
    set up so that they avoid paying tax and are liable to a lower rate of tax via corporation tax
    (which currently stands at 19% rather than the tax levels for higher earners) and this is why
    HMRC at trying to close the loophole.
    The approach from the Welsh Health Boards applies to all sessional GPs working as above.
    Matt Mayer from the BMA sessional GPs committee has written an excellent blog on this
    issue which can be accessed here:
    https://www.bma.org.uk/connecting-doctors/the_practice/b/weblog/posts/a-locum-sguide-
    to-the-changes-to-ir35-legislation


    Should I just accept the HB advice?
    We would say no. There are a few issues to consider
     Lack of consultation: is this fair or right given the significant change to your terms
    and conditions of service?
     The assertion that employment status does not confer employment rights Do your
    own HMRC toolkit assessment and take individual accountant advice
     Talk to your LMC or contact the BMA if you are a member (unfortunately neither are
    in a position to offer individual legal or financial advice).

    What actions are possible?
    1. What can I do?
    a) Consider the BMA website advice, complete the HMRC toolkit
    (www.tax.service.gov.uk/check-employment-status-for-tax/setup) and discuss the
    results with your accountant. You could use it to challenge the Health Board to apply
    non-employed status to you. However, it is unlikely the Health Board will change its
    stance and the toolkit isn’t quite clear cut
    b) Consider whether you want to continue working for an organisation that has taken
    this unilateral action. Your accountant may be able to help guide this with respect to
    impact on tax brackets etc.
    c) Consider whether to ask your LMC to act on your behalf and outline what course of
    action you wish them to take. You should do this whether you continue working or
    not.
    d) Consider whether you are willing to withdraw services or not? The BMAs sessional
    GP subcommittee states that you can consider the following:
     “If you are willing to withdraw services, then further think about whether you
    would add your name to signatures to be gathered by LMCs threatening to
    withdraw services OR write to the Health Board declaring a termination of service
    in accordance with the contractual obligations to which you are subject.
     If you are not willing to withdraw services, then (if you are a GP who contracts
    directly rather than via an intermediary) consider writing to the Health Board
    telling them that you believe you are entitled to statutory employment protection
    and reserve the right to take them to an employment tribunal, and advise them, if
    employment tribunal found in your favour that you would be chasing historic
    holiday pay / sick pay / pension etc. back to your start date. This latter needs to
    be done by an individual GP.”

    2. What can your LMC do?
    LMCs do have the responsibility of acting on behalf of all GPs in their area in all their working
    roles. To do so effectively they need a clear mandate from the workforce affected –
    therefore you have to play your role in making your feelings known.
    The LMC can:
    a) liaise with Health Board to ask further questions as to validity of this change to terms
    and conditions of service through seeking to see evidence, challenging lack of
    consultation, highlighting potential adverse impact on sustainability of workforce and
    service provision (including whether this is on the Health Board’s risk register)
    b) work with the Health Board to find possible solutions e.g. deferred implementation
    date of changes to enable consultation, devising a zero-hours contract for local GPs
    to work under which could confer some employment rights etc.
    c) keep local GPs up to date with likely impact of these decisions and progress on
    solutions
    d) work on your behalf without you having to raise your head above the parapet e.g.
    gather signatures from affected GPs threatening to withdraw services; OR collate
    responses from GPs to the Health Boards declaring a termination of services in
    accordance with the contractual obligations to which they are subject.

    3. What is GPC Wales doing?
    GPC Wales is:
    a) working closely with LMCs to support them in progressing local discussions and
    solutions on behalf of GPs in their area (that’s why it is important to make your views
    and situation known to LMCs)
    b) in our regular meetings with the Welsh Government, highlighting risks to service
    provision and workforce sustainability in an already creaking service area, requesting
    that it seeks assurance from Health Boards on how these risks have been considered,
    including in respect of winter pressure plans
    c) considering what other national solutions may need to be implemented after
    listening to the profession and seeing how the Health Boards respond e.g. a national
    zero-hours contract for GPs working in settings as above
    What already happened in Wales and elsewhere?
     Betsi Cadwaladr UHB did not use Deloitte to determine its stance but instead
    worked directly with HMRC. This has already been put in place and GPs have made
    individual decisions whether or not to accept changes, and this has resulted in less
    GPs working in directly managed practices.
     In Dorset, a blanket policy was applied early in 2017 which was challenged by GPs,
    LMC and GPC. A new deal was offered to GPs with better pay and employment rights
    and a catastrophe was averted.
     In Swindon, the OOH trust applied a blanket policy but despite pressure did not back
    down and this resulted in great difficulty in sourcing doctors.
    What should I do next?
    It comes down to whether you as an individual want to take action on this. Please review
    this guidance carefully and consider all the available options before deciding on your
    response.
    The Local Medical Committees and GPC Wales are here to help. We need to know your
    views to inform our next steps in discussions with Health Boards at a local level, and the
    Welsh Government on a national basis.
    Please inform your LMC about what you want to see happen.
    Bro Taf LMC
    Tel:02920 899381
    brotaflmcltd@btconnect.com
    www.brotaflmc.org.uk
    Dyfed Powys LMC
    Tel:01597 860565
    jan@dyfedpowyslmc.co.uk
    www.dyfedpowyslmc.co.uk
    Gwent LMC
    Tel:01495 764455
    vcgwentlmc@btconnect.com
    www.gwentlmc.org.uk
    Morgannwg LMC
    Tel: 01792 815954
    morgannwglmcltd@btconnect.com
    www.morgannwglmc.org.uk

    North Wales LMC
    Tel:01745 825780
    northwaleslmc@yahoo.co.uk
    www.northwaleslmc.co.uk

  •    GPC Wales statement    12th October 2017

     Dear Colleagues,

     Re: Potential taxation liabilities of practices using sessional GPs

     As chair of GPC Wales am writing to remind you of the recent changes to HMRC regulations where there is a focus on taxation status of sessional GPs contracting with organisations including GMS practices either directly OR via an intermediary  (the latter is known as IR35 – see below). 

     For the purposes of this letter we have purposely utilised the erminology of sessional doctors in this letter as although all sessional doctors are independent contractors like those in partnership, we felt this delineation brought clarity to updating you on this important issue.

     In brief, HMRC is looking at whether sessional doctors should be considered employed or not for taxation purposes – this is different to employment status for employment rights. If HMRC determine that a sessional doctor is employed, then not only are you liable for taking tax and NI off at source, BUT, you run the risk of being liable for significant back taxes and penalties (possibly going back as far as 20 years)……. Therefore it is an area that we wished to highlight again to practices to make sure they were aware of this important issue.

     Isn’t all this just the IR35 changes?

    No – IR35 ONLY applies to the small cohort of GPs who do their sessional work through an intermediary e.g. locum agency / chambers / limited company.

    HMRC are taking a close look at ALL types of sessional GPs who directly contract with practices or Health Boards – this of course can include principals who also do sessional work in a non-salaried capacity (e.g. OOH work)

     

    What should you do as a practice?

    ·     Review arrangements through which you contract with sessional GPs and use the online HMRC tool to see what outcome you get as to whether they are to be considered employed OR not – we would recommend you keep a copy of the outcome of the toolkit. It may also be worth asking the sessional GP to do their own assessment and see if it comes out the same.

    ·     Review the guidance on the BMA website regarding this issue

    ·     Discuss with partners and accountants regarding what steps to take i.e. do you offer them a contract OR do you revise how you offer sessions to this group of doctors  - keep a careful record of discussions on this issue

    ·     If you continue to utilise their services on a self employed sessional basis, then keep careful records of agreement for provision of services from the sessional doctor

    ·      If you are going to offer a contract remember that you should offer terms and conditions at least as good as them BMA model contract.

     

    GPC Wales has recently developed guidance for sessional GPs directly contracting with Health Boards themselves or via an intermediary (i.e. IR35) following most Welsh Health Boards adopting a blanket policy of treating all such GPs as employed for taxation purposes but not for employment rights. You and your GP partners should have received this as we sent it out to all but if you would like a copy of this guidance for information, then contact your LMC.

     

    GPC Wales and your LMC always welcome any feedback you may have on this and other issues so feel free to let us know your thoughts on this and any other issues where you feel the LMC and GPC Wales can be of assistance.

     

    Yours sincerely,

     

    Charlotte

    Chair GPCWales

    • Review arrangements through which you contract with sessional GPs and use the online HMRC tool to see what outcome you get as to whether they are to be considered employed OR not – we would recommend you keep a copy of the outcome of the toolkit. It may also be worth asking the sessional GP to do their own assessment and see if it comes out the same.
    • Review the guidance on the BMA website regarding this issue
    • Discuss with partners and accountants regarding what steps to take i.e. do you offer them a contract OR do you revise how you offer sessions to this group of doctors  - keep a careful record of discussions on this issue
    • If you continue to utilise their services on a self employed sessional basis, then keep careful records of agreement for provision of services from the sessional doctor
    • If you are going to offer a contract remember that you should offer terms and conditions at least as good as them BMA model contract. GPC Wales has recently developed guidance for sessional GPs directly contracting with Health Boards themselves or via an intermediary (i.e. IR35) following most Welsh Health Boards adopting a blanket policy of treating all such GPs as employed for taxation purposes but not for employment rights. You and your GP partners should have received this as we sent it out to all but if you would like a copy of this guidance for information, then contact your LMC GPC Wales and your LMC always welcome any feedback you may have on this and other issues so feel free to let us know your thoughts on this and any other issues where you feel the LMC and GPC Wales can be of assistance.

     

    Yours sincerely,

     

    Charlotte

  • GPs are required under the GMS contract to provide certain information and certification free of charge.  This includes sickness certification, death certification and clinical referral.  A full list is set out in Schedule 4 of the NHS regulations www.legislation.gov.uk/uksi/2004/291/schedule/4/made

    GPs are often asked to provide medical reports or information for patients/outside organisations which are not contractual.  These include:

    • Insurance Company/PMA reports,
    • Legal reports,
    • Occupational Health reports,
    • DVLA reports
    • Reports for Case Conferences/Safeguarding meetings
    • Evidence to support benefit claims &
    • Blue Badge applications.

     

    Practices are not contractually obliged to provide such information and therefore when such requests are received can reasonably:

    • Decline to undertake the work,
    • Undertake the work and not charge a fee (at a cost of clinical/administrative time and effort to the practice, which may be considerable and impinge on patient care),
    • Charge a reasonable fee to the requester (outside agency/company/patient themselves).

    Practices should satisfy themselves that before supplying any patient information to a third party that they have the appropriate patient consent in place.  Since the Competition Act 1998, the BMA no longer recommends the levels of remuneration/fees payable for such work.  Practices should set their own reasonable fees, taking account of the administrative and clinical burden involved in completion and preferably agree the fee prior to completion of the work.

  • From 1 April 2016 new information sharing processes between GPs and the police were introduced in an attempt to ensure those licensed to possess firearm and shotgun certificates are medically fit to carry arms. We have significant concerns about these arrangements and we continue to raise them with the Home Office with the aim of agreeing a process that is fair to GPs in particular, and doctors in general, and safe for the wider public. Discussions are ongoing and any future improvements may necessitate the revision of this guidance.

    From 3rd March 2017 new advice on the current system has been issued which takes into account our discussions with the Home Office, the police and the British Association for Shooting and Conservation (BASC), as well as external legal advice.

    Click here to read this information. Or download a sample letter here.

    Please note, it is not acceptable to:

    • disregard the letter
    • not inform the police
    • delay a reply

    In doing any of the above, you could place yourself at professional risk.

    Where there is a reasonable belief that an individual either applying for a firearm or shotgun license or already holding one, may represent a danger to themselves or others, we strongly advise doctors to encourage the applicant to reconsider or revoke their application.

    If the applicant refuses, you should consider breaching normal confidentiality and inform the police firearms licensing department as a matter of urgency.

    This advice only relates to the initial letter asking GPs to add a marker to the patient record. Applicants are still being advised by BASC to pay their GP for any full medical report being requested by the police as part of their application.

    Further information

    If you are in any doubt, you should seek further ethical and legal advice from the Ethics department and the defence bodies.

    Ethics department
    E: info.ethics@bma.org.uk

  • The BMA has received new legal advice regarding medical note requests received from the police, which are detailed below.

    There is clear guidance regarding the obligations that GPs have with respect to copying and/or release of the GP record. For your reference, these circumstances are:

    · If the police do not have a court order or warrant they may request voluntary disclosure of a patient’s health records under section 29 of the Data Protection Act 1998.
    · However, while health professionals have the power to disclose the records to the police where section 29 applies, there is no obligation to do so.
    · In such cases health professionals remain bound by the long-established common law duty of confidentiality and may only disclose information where the patient has given consent, or there is an overriding public interest. They may also be required to defend their decision to disclose before the GMC which is a statutory tribunal.
    · Disclosures in the public interest based on common law are made where disclosure is essential to prevent a serious threat to public health, national security, the life of the individual or a third party, or to prevent or detect serious crime. This includes crimes such as murder, manslaughter, rape, treason, kidnapping and abuse of children or other vulnerable people. Serious harm to the security of the state or to public order and serious fraud will also fall into this category.

    Your practice is entitled to a fee for producing the notes. There is no set fee for producing these notes, as they are not considered a subject access request that you may receive from a patient. Therefore the practice is able to set its own fee.

    In order for you to proceed with the police request, please use thie pro forma which can be found on the dcouments page under useful documents, that we recommend you complete and send to the police authority. We recommend that you obtain each of the following: 

    1. Provide written patient consent to release of their records OR provide written confirmation as to the nature of the serious crime allegedly committed by the patient and an explanation as to why the patient’s records, or other information requested, are considered necessary for the specific purpose you are pursuing. You will require one of these in order to fulfil your responsibilities as the Caldicott Guardian.

    2. Confirmation in writing that the fee of £xx will be paid within 28 days of the police receiving the record. This fee is due to the disproportionate effort placed on an already overburdened GP practice to provide these notes which recognises the need to support the police in their investigation of a crime, where appropriate to do so.

    3. Written confirmation from a senior police officer – ranked Inspector or above – that he or she considers that the crime being investigated is a serious crime in line with the examples provided above.

    Once you are in receipt of each of these at the practice, and have checked the appropriateness of release of the records, you should respond to the police authority as soon as possible.

    Alternatively, should it be appropriate for the police to view the record (based on answer to 1 above), then there is the option for them to view the record in the practice in the presence of a practice staff member. In this situation there is no fee chargeable.
    There is no set fee for providing records in this manner. Therefore it is the responsibility of individual practices to set their own fee for this work. When completing the attached pro forma you must enter the fee you choose to charge.

    It is vital that the police agree in writing to pay the fee, otherwise you will not be able to claim for the service. If the police authority do not agree to pay the GP can decide whether they would like to provide the service free of charge, or not at all.

    Please note that if the police authorities have a court order or warrant for disclosure of the records, you may be required to comply with the request even where a fee has not been paid or agreed. This will depend on a number of factors, including the terms of the court order or warrant.

    GPs should, in all cases where there is no patient consent, consider whether the benefits to an individual or to society of disclosing the records outweigh both the public and the patient’s interest in keeping the information confidential before agreeing to disclose the records.

    For any queries please email info.professionalfees@bma.org.uk

    21 June 2017

    1. 1.     Work out the cost of the service
    • Look at current level of remuneration and cost to deliver service.
    • Have a chat amongst clinical team and with practice manager to decide next steps.
    • If you wish to continue then read no further

     

    1. 2.     Payment not covering costs and / or impacting on GMS care?
    • You can withdraw from the service

     

    1. 3.     How to withdraw:
    • Give 3/12 notice in writing to the Health Board of your intention and reasons.
    • Ask for them to inform you of where to redirect patients once notice period has ended. Put a time date on response to this and put a diary marker in your diary to check this has been responded too.
    • Copy in the other services affected by the decision

     

    Top tip – make sure you get confirmation of receipt – email route perfect for this

     

    1. 4.     Continue to provide the service for 3/12
    • Start updating your staff that service is no longer going to be provided and ensure all know where to refer patients once service has ended. Consider giving them a “script” to use when faced with such requests
    • Start to inform your patients via posters / screen messages / during consultations of when this service will no longer be available and why (if appropriate)
    • The LMC will be developing patient information materials for you to use in some cases
    • Consider how you can best utilise the freed up resource/ time to provide additional capacity within your clinical team

     

    1. 5.     Keep track
    • Make a note on your systems when service is due to end
    • Remind all staff after that date that you no longer provide these services and where they should send patients.

     

    1. 6.     What if the HB don’t tell you what to do with patients after notice period?

     

     

     

    YOUR LMC IS HERE TO SUPPORT YOU.

    It is not unusual to feel concerned at stopping work OR to think that you are the only practice considering taking this action. YOU ARE NOT. Practices can no longer continue providing services at financial or clinical capacity costs to themselves.  Follow the checklist above, discuss as a practice and reach your own conclusion.

  • We have had several practices report an increase in consultations from school pupils and nursery age children regarding fitness to attend school/nursery.  The GMS contract makes no provision for such work and therefore other than treating the patient who ‘is ill, or believes themselves to be ill’, there are no circumstances where a GP is required to issue a Med 3 or any letter/report to a school/nursery confirming fitness to attend.  GPs are not contracted to advise schools on attendance or medication requirements whilst at school and head teachers have been reminded of this by the Education Minister and Local Education Authorities.  Any such request may be considered as extra-contractual and could reasonably expect to be chargeable work.

     

    A useful Public Health Wales document can be found here which gives explicit advice on whether pupils with common childhood diseases should be excluded from education: https://www.gov.uk/.../infection-control-in-schools-poster     

  • The following is a link to BMA guidance

    https://www.bma.org.uk/advice/employment/gp-practices/service-provision/nhs-primary-care-medical-services-in-institutions-and-care-homes-in-the-uk

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