Information from Morgannwg LMC regarding responding to Private Healthcare requests for Bariatric Care follow up can be downloaded here BMA advice regarding private healthcare requests can be found here: https://www.bma.org.uk/advice-and-support/gp-practices/managing-workload/general-practice-responsibility-in-responding-to-private-healthcare Unfortunately, there is no useful local guidance. This issue has been raised in the past by the LMC with GPC Wales at national meetings and also locally with Mr Beamish (SBUHB's Clinical Lead). The discussions are ongoing, and a national solution is required. The LMC have recently approached SBUHB regarding this problem and highlighted the unhelpful response from the bariatric surgery department in that if they took this on they do not have the capacity. At recent meetings with MLMC, SBUHB and Tertiary departments the key message to GPs was that patients should be referred to secondary care and they should not be refused. They will be added to the waiting list so that referrals can be catalogued and the patient will be written to and given a leaflet on what to look for re complications. Patients will be advised by the service that there is “No prospect of them being seen within 2 years” due to current waiting lists. The department have reassured that for any complications patients will be seen. It is the view of GPC Wales and the LMC that post-bariatric surgery is not considered a general medical service. The primary responsibility that GPs have is to ensure that patients receive the appropriate follow-up that a GP decides is indicated. This includes referral to secondary care even where a specific service has not been commissioned by the Health Board. We note that you are having referrals rejected and whilst there is no other alternative patients will unfortunately have to continue within private healthcare until the secondary care infrastructure is resolved. Obviously, this is very difficult with the issue of private providers abroad. The LMC believes that an MDT approach is required and completely agree specialist input is required. The patient can and should be referred to NHS services even if the surgery was undertaken privately whether in the UK or abroad. Post-operative tests are required to ensure adequate nutrition is maintained. These tests are part of the patient’s follow-up which the surgical provider should provide, however, for pragmatic reasons practices can perform the phlebotomy and send the results to the surgical provider. If the patient chooses to have surgery privately, the practice’s responsibility is the same, as patients have the right to move between private and NHS at any time. It remains the responsibility of the private provider to advise the patient and practice of management of any abnormalities found. If the private provider is outside the UK the practice can seek Advice and Guidance from local gastroenterologists/bariatric surgery or dietician. Patients need to be aware that follow up is part of the procedure for 2 years following surgery and should have been organised by their private provider. If a patient did undergo surgery privately in the UK you can consider writing to the service provider stating that you consider it is their responsibility to undertake any specialist follow up which should be included in the contract that they have agreed with the patient. The LMC are aware that BOMSS provide specific guidance for GPs but the LMC feel that this level of monitoring should only be considered GPs with a special interest who are able to take on the legal risk. As GPs we are driven to try and do the best for our patients but in this instance the LMC would suggest that the practice reconsider the benefit of partially accepting the monitoring and therefore the legal responsibility. GPC Wales, and the LMC will continue to raise the requirement for the establishment and commissioning of an appropriate service. The bottom line is if you do not feel you have the experience to manage post operative bloods then you should refer into the bariatric service. If you have referred it will not be your responsibility if SBUHB do not have a service, but if you take on the bloods the responsibility will be yours to manage appropriately. For reference: NICE Quality Standard QS127: People who have had bariatric surgery have a postoperative follow-up care package within the bariatric surgery service for a minimum of 2 years. Follow-up care package This should be for a minimum of 2 years and include: · monitoring nutritional intake (including protein and vitamins) and mineral deficiencies · monitoring for comorbidities · medication review · dietary and nutritional assessment, advice and support · physical activity advice and support · psychological support tailored to the individual · information about professionally-led or peer-support groups. [NICE's guideline on obesity: identification, assessment and management, recommendation 1.12.1] For the first 2 years after surgery, follow-up appointments are likely to be with a dietitian or a bariatric physician. It is assumed that in the first year the person has 3 follow-up appointments, with annual follow-up thereafter. After the first 2 years, follow-up appointments are likely to be with either a dietitian or a GP within a locally agreed shared-care protocol. [NICE's full guideline on obesity: identification, assessment and management, section 8.1.3.2] Writing to the HB and also Llais would help increase the pressure on the HB. A recent Welsh Health Circular has been released which states that secondary care should be excepting patients onto waiting list and not referring back to the GP. The LMC are therefore advising GPs to refer into secondary care if your patient requires assistance with post bariatric care in the first two years. Included below a link to the WHC relating to post private Bariatric Surgery follow-up: https://www.gov.wales/sites/default/files/pdf-versions/2024/2/4/1706806067/private-obesity-surgery-and-welsh-nhs-whc2024005.pdf It states that if a post-op bariatric patient cannot, or chooses not to access private sector follow up, the GP may refer into secondary care, for specialist level 3/4 post-operative follow-up as per NICE guidance. Patients should be accepted onto waiting lists according to clinical priorities identified by the referrer and receiving health board. In line with NICE guidance, and once identified as clinically fit for discharge, the patient will be discharged in accordance with the local pathways (WHC/2024/005).

Firstly – thank you for coming to the LMC about this issue! There is a very robust document outlining responsibilities in communications between primary care and secondary care. It can be accessed here. We have also created a template letter which can be used to reply to the inappropriate request (available to download here), please remember to copy us into correspondence (removing any patient identifiable data) so that we can identify trends and take appropriate action! Dear Doctor, I note your recent request for investigations to be done in general practice which is attached to this letter. Upon discussion with Morgannwg LMC, We remind you of your professional responsibilities as agreed by Welsh Government, NHS Wales and BMA Cymru Wales: · If Secondary Care require investigations to be done then it is the responsibility of the requesting Secondary Care department to arrange the investigations to be carried out. · If Secondary Care organise investigations, then it is the responsibility of the requesting Secondary Care department to review the results and action them appropriately. · Handing over of responsibility for patient care from secondary care doctors to General Practitioners should only be done when the General Practitioners agrees to accept responsibility. The All Wales Communication Standards can be found via this link: Communication standards between GPs and secondary care | GOV.WALES This position is not intended to be obstructive, but to simply adhere to our duty to provide safe, consistent, and appropriate care for our patients. We are also supported by our statutory representative body Morgannwg LMC.I have copied this email to Morgannwg LMC at office@morgannwglmc.org.uk. Yours sincerely [name of practice]

There is an All Wales Information Leaflet which provides guide for clinicians in managing diagnostic requesting for patients receiving private healthcare treatment which is attached below: The leaflet is summarised here: Responsibilities for Testing: Private consultants are responsible for arranging and managing all aspects of their private patients' healthcare, including diagnostic tests. Patients pay for these services as part of their private care. NHS General Practitioners (GPs) and clinicians should not be arranging tests for private consultants or their patients unless those tests are part of the patient's NHS care. Transition Between Private and NHS Care: Patients who begin private care can transfer back to NHS care if their treatment is available on the NHS. However, they must: Undergo reassessment by an NHS clinician. Adhere to normal NHS waiting times. GPs are not obligated to arrange or prescribe treatments privately recommended if they go against normal NHS practices. Prohibition of Mixing Private and NHS Care: Private consultants cannot use NHS resources for private patients unless those services are explicitly identified as private and invoiced accordingly. GPs should avoid requesting tests through the NHS system for private care to prevent potential legal or ethical violations. Criteria for NHS Test Requests: Any tests sent to NHS services for private patients must be labeled as private. Private consultants are required to inform patients of the costs involved and ensure their consent before referring them for NHS tests. Examples of Scenarios: Patients transferring from private to NHS care must follow the standard NHS process, including reassessment and waiting times. Private consultants recommending tests must arrange them if they manage the patient’s care. NHS GPs are only responsible if they assume full clinical responsibility for the patient’s ongoing care. Additionally GPC England has written guidance to help practices reduce extra workload generated by requests from private providers which is an excellent resource in responding to requests from private healthcare which can be found here. AWTTC also have a document "Prescribing dilemmas: A guide for prescribers" which contains information regarding this query, as well as many other prescribing issues.

The LMC is not aware that it is National or SBUHB policy to refuse a referral if a template is not completed. The GMC also specifies that relevant information should be included, and this is considered sufficient for appropriate referral. GPC Wales policy is for a universal referral form via WCCG, and not for individual templates. A template does not need to be used if all the information requested on the template is on a referral via WCCG. The LMC therefore advocate for a WCCG referral in the free text box, with the correct referral information. However, if referrals are missing essential information ( which should be made clear on the health pathway), this can be sent back to the practice to be amended and in the future ensure that this information is included. Please do let the LMC know if you have been asked to complete a template, as we can support you in reminding the department of the local & national policies.

If your query is regarding clinical responsibility, prescribing duration, foodstuffs, complementary medicines and alternative therapies, common ailments, fertility treatment, erectile dysfunction, prescribing for self and family, visitors from overseas, travel and occupational health vaccines, prescribing situations not covered by the NHS including private care and private prescriptions, unlicensed medicines, or prescribing outside national guidance then please review the AWTTC document "Prescribing dilemmas: A guide for prescribers" attached below.

There is no GMS obligation to request this Xray and you may reply declining to undertake this unfunded additional work. RCEM guidance states that "in general, for patients the ED discharges the ED must take responsibility for the checking of reports and acting on any abnormal or missed findings" and that "Emergency Departments should try to avoid requesting primary care teams to ‘follow-up’ or ‘chase’ the results of tests requested by the ED team."

Unfortunately the LMC have established that the CMO breach forms that practices have been using to report breaches of the All Wales Communications Standards were not being collated by the HB. Practices should therefore cease to use this reporting tool and log ALL breaches on the All Wales General Practitioners Datix page. ​ General Practitioners - NHS Wales Shared Services Partnership ​ To ensure that SBUHB Primary Care colleagues have access to these it is necessary to use the “Logged Out datix form”. If the logged-in form is used this goes straight to the department being reported, and this is not being affectively governed. By sending all datix reports via primary care it will be possible for the HB to monitor trends which will be extremely beneficial as these will be shared with the LMC. ​ You need to use a NHS email and also need to use the link above and not save the link to SB logged out form directly as the link changes every few months . ​ Could the LMC ask that you remove and delete any saved links to the previous datix or CMO Reporting tool. We recognise the effort that reporting takes but feel that this is a significant step towards greater transparency and appreciate your support. ​ Any specific concerns or questions about Datix submitted, please contact Amanda Reece- Quality and Governance IT lead for primary, community of therapies group. amanda.reece@wales.nhs.uk

Use of the Welsh Clinical Communications Gateway for all clinical correspondence has been agreed by the Local Health Board and the Local Medical Committee. This process has been agreed as there have been instances where email and other, non-WCCG, forms of communication have not been promptly actioned due to the inherent lack of robustness in the process (staff being on annual leave etc). This is to ensure adherence to the “All Wales Communication Standards between General Medical Practitioners and Secondary care” (available here). A sample letter for you to use when replying to such requests is available here.

The Clinical Online Information Network (COIN) houses local clinical guidelines and protocols from across the entire Health Board ensuring high quality consistent cost-effective practice. Library Services play an integral part in maintaining the quality assurance of COIN, in addition to linking to electronic resources such as Full-text Finder and UpToDate. (Please note that this link is to a Swansea Bay Intranet only site and is therefore accessible to Health Board employees only)

Enhanced services vary across Wales, and there is no single resource describing them. Morgannwg LMC has created a summary spreadsheet (in both excel and pdf format) describing the services available in every Healthboard in Wales. The information was obtained by making freedom of information requests to each Healthboard and also to Welsh government. All information in the spreadsheet comes directly from these public sources. Please use it to support your business planning and negotiations. This project was made possible through a generous grant from GPDF. If you have any questions or suggestions please contact Morgannwg LMC. The information is available as an Excel spreadsheet or PDF and the source information is available here. Budgeting and forecasting To help practices to calculate costs incurred in providing supplementary services, Gwent LMC have developed a useful calculator which has been included below. It is necessary to factor in human resource expenses (salary, oncosts and mandatory training) , building expenses (including insurance) and materials and fixed costs. This means including proportionally the number of clinical and admin staff involved and all the running costs such as fridges, beds, lights in minor surgery room, extra cleaning etc. Enhanced Service Financial Calculator Gwent LMC have developed a calculator to aid business decisions about the viability of enhanced services for practices. It will allow additional costs such as pension, NI contributions etc to be automatically included. Just input hourly staff rates and time spent by differing members of the practice team to get an overall estimate of practice costs to complete an activity. Gwent LMC Enhanced Service Calculator Recent Uplift from SBUHB Please note that MLMC were unable to reach a mutually agreeable position regarding an uplift with SBUHB. SBUHB felt that their offer of a 5% uplift was reasonable considering their financial position, but MLMC did not feel that they could endorse the offer based upon the information contained in the comparative spreadsheet. If practices would like a further discussion about supplementary services please do not hesitate to get in touch with MLMC. The letter from SBUHB can be downloaded for reference here.

The Welsh Clinical Portal (WCP) (please note that this link is to a Swansea Bay Intranet only site and is therefore accessible to Health Board employees only) is a patient record across hospitals and health boards in Wales which is available to doctors and health professionals through a single application. The Welsh Clinical Portal makes it easier for health professionals to collaborate and access vital information about the patient. It shares, delivers and displays patient information from a number of sources with a single log-on, even if that information is spread across health boards. With information in one place it means clinicians always have access to up to date and accurate patient records. The main features include: Requesting tests Electronic test requesting allows clinicians to create test sets, bulk order tests for multiple patients and request tests for a patient on selected days. Prioritising referrals Helps clinicians sort and display electronic referrals into levels of urgency, place them on hold, or request more information from the GP. Creating patient ‘watch’ lists Allows clinicians to keep track of patients more closely by organising patient care in a way similar to how shoppers sort their lists on consumer websites. Viewing your patient’s GP record Clinicians can access a summary of important information held on a patient’s GP record, such as current medication, recent test and allergies. Accessing results Diagnostic test results and reports for are available to view in the portal, regardless of where they are produced in Wales. Accessing radiology images Patients’ x-rays, ultrasound, CT and MRI scans taken anywhere in Wales are available to view in the portal. There is a new National Imaging Viewing User Guide available. Viewing your patient’s medical history Patients’ referrals, discharges, letters, outpatient assessments, clinical notes, care plans, contact lists, and much more are available for clinicians to view at any point in a patient’s journey. Listing medication and prescriptions A pre-populated list of medicines can be important from a patient’s GP record.

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. 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? Consider the BMA website advice, complete the HMRC toolkit 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. 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. 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. 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: 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) 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. keep local GPs up to date with likely impact of these decisions and progress on solutions 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: 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) 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 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.

Azathioprine/Mercaptopurine Rheumatoid arthritis Inflammatory bowel disease Diffuse Interstitial lung Disease Misc Inflammatory diseases Ciclosporin Rheumatoid arthritis Psoriasis/atopic dermatitis Denosumab (Prolia) Osteoporosis Bone loss Leflunomide Rheumatoid arthritis Psoriatic arthritis Amiodarone Ventricular arrhythmia Paroxysmal atrial fibrillation Wolff-Parkinson- White syndrome Lithium Treatment and prophylaxis of mania, bipolar disorder, and recurrent depression, aggressive or self-mutilating behaviour Sulfasalazine Rheumatoid arthritis Inflammatory Bowel Disease Methotrexate oral and subcutaneous Rheumatoid arthritis and psoriasis Psoriasis/psoriatic arthritis Neurology indications (MS, MND) Mycophenolate Mofetil Rheumatoid arthritis Penicillamine Rheumatoid arthritis Auranofin Rheumatoid arthritis Sodium Aurothiomalate Rheumatoid arthritis Any other medications prescribed under a shared care arrangement are not funded under an Enhanced Service. For information on how to withdraw from an enhanced service please see this FAQ.

GPs are not contracted or have any other requirement to provide support or advice to the ambulance service. Practices should aim to support their patients by cooperating with other organisations who may also provide care to their patients. However, there is no contractual obligation for practices to give clinical advice to ambulance crews. There are senior clinicians in the ambulance control centre available when crews have a clinical query. Sometimes, crews may need to contact the GP practice to gain medical history, which your administrative team may be able to provide from the patient medical summary. It is the choice of the practice if their team give advice to ambulance crews but is not contractual and practices are under no obligation to respond in certain timeframes. Practices may wish to consider developing their own policy which may cover: - Ascertaining the reason for the ambulance contact to the practice. - Provide medical history relevant to support ambulance assessment of the patient. - Escalate the contact to appropriate clinician if the practice has chosen to do so. - Informed the ambulance crew of possible timeframes of any response. - Practice may offer advice if they choose but may also redirect ambulance colleagues to their own clinical supervision and advice pathway. If offering clinical advice to an ambulance colleague, do consider that you are advising based on a clinical assessment you did not perform and so you must be confident in that assessment. If you do provide advice to ambulance crews that you keep very clear contemporaneous records as there has been later differences of account between ambulances and the practice. If the ambulance service inappropriately request your practice to provide help outside of your contractual obligations or reasonable practice policy, then let us know so we can raise directly with WAST.

Being a GP is a challenging job at the best of times and if you are struggling you shouldn't hesitate to reach out to us for pastoral support, or look into some of the organisations listed on our "support for GPs" section of the website. If you have a specific issue, such as an issue with Swansea Bay UHB, a complaint, practice finance queries or a reference panel then please reach out to office@morgannwglmc.org.uk and we will help.

The GPDF exists to ensure representation, influence and support for Local Medical Committees, GPs and general practice. GPDF Limited has its roots in the early 20th century when its predecessor organisation, initially called The Insurance Defence Fund was founded in 1911. The remit, structure, focus and name (variously General Medical Services Defence Trust and General Medical Services Defence Fund Ltd), has changed and evolved several times over the years but always with a common purpose to support the best interest of publicly funded general practitioners. The GPDF funding structure is on a mutual basis across all GPs throughout Great Britain, based on a principle of shared investment for the common good. This payment is made on a ‘per patient’ basis, collected initially by the LMC, and then contributed on a ‘quota’ basis to GPDF, based on the reported patient population for their area, which they confirm to the GPDF every three years. In this way, every GP and LMC contributes on the same basis for mutual benefit and the collective good of general practice. To find out more have a look at the new GPDF Website.

The Rapid Diagnosis Centre (RDC) based at Neath Port Talbot Hospital is for patients with vague but concerning symptoms that do not fit into any of the existing referral pathways. Referral Guidance is available here. At the RDC, patients will have an individualised assessment with the aim of achieving a diagnosis and initiating a treatment plan, or gain the reassurance that nothing concerning has been found. The Centre has radically reduced the average time to diagnosis from potentially 3 months to 6 days. Out of the case load cancer diagnosis is averaging at 10.5 % and a wide range of other conditions are also being rapidly diagnosed (30-40%) allowing treatment and management plans to be enacted. If you would like to refer please consider the following: Referral via WCCG only but informal discussions are always welcomed Please ensure all Set A has been requested/documented – blood tests as per guidelines and a RECENT WEIGHT, URINE DIP AND FULL EXAMINATION FINDINGS IN TEXT OF REFERRAL LETTER. This is as per agreed referral guidelines If referrals are incomplete in detail or are unsuitable we will process and return as soon as possible Most common reasons for return – site specific symptoms so USC referral to that speciality is more appropriate, or – although we are a vague symptom clinic we are for patients where occult malignancy is the most likely cause – we are NOT a general vague symptom clinic. Again as per referral guidelines and advice. More information is available at their website here or by downloading the Patient Information Leaflet (available in Welsh here).

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 can be found here. 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.

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. Helpful advice about the management of common childhood illnesses can be found at the following; Is My Child Too Ill For School Health Protection in Schools and Other Childcare Facilites – Chapter 9 Managing Specific Infectious Diseases

The BMA provides guidance for medical practitioners about common fees, including what and when to charge here.

Enhanced services vary across Wales, and there is no single resource describing them. Morgannwg LMC has created a summary spreadsheet (in both excel and pdf format) describing the services available in every Healthboard in Wales. The information was obtained by making freedom of information requests to each Healthboard and also to Welsh government. All information in the spreadsheet comes directly from these public sources. Please use it to support your business planning and negotiations. This project was made possible through a generous grant from GPDF. If you have any questions or suggestions please contact Morgannwg LMC. The information is available as an Excel spreadsheet or PDF and the source information is available here. Budgeting and forecasting To help practices to calculate costs incurred in providing supplementary services, Gwent LMC have developed a useful calculator which has been included below. It is necessary to factor in human resource expenses (salary, oncosts and mandatory training) , building expenses (including insurance) and materials and fixed costs. This means including proportionally the number of clinical and admin staff involved and all the running costs such as fridges, beds, lights in minor surgery room, extra cleaning etc. Enhanced Service Financial Calculator Gwent LMC have developed a calculator to aid business decisions about the viability of enhanced services for practices. It will allow additional costs such as pension, NI contributions etc to be automatically included. Just input hourly staff rates and time spent by differing members of the practice team to get an overall estimate of practice costs to complete an activity. Gwent LMC Enhanced Service Calculator Recent Uplift from SBUHB Please note that MLMC were unable to reach a mutually agreeable position regarding an uplift with SBUHB. SBUHB felt that their offer of a 5% uplift was reasonable considering their financial position, but MLMC did not feel that they could endorse the offer based upon the information contained in the comparative spreadsheet. If practices would like a further discussion about supplementary services please do not hesitate to get in touch with MLMC. The letter from SBUHB can be downloaded for reference here.

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 Payment not covering costs and / or impacting on GMS care? You can withdraw from the service 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 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 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. What if the HB don’t tell you what to do with patients after notice period? Contact the LMC Office Morgannwg 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.

A Home Office License is NOT required by a GP who keeps opiates in their bag which they have requisitioned themselves directly from the Pharmacist A License is required in those surgeries that order a “central “ supply from which the GPs draw what they need. It is recommended that surgeries which currently or intend to hold drugs in surgery should apply for a Home Office License if they do not have one already.

The BMA have published “Sustainable and environmentally friendly General Practice” which outlines ways in which general practice can develop, and can be helped to develop, environmentally responsible practises. Specific advice regarding reducing the carbon footprint of inhaler prescribing can be found here. Information regarding NHS Wales’ Carbon Footprint can be found here.

At a Morgannwg LMC Committee Meeting, held 13th July 2021, we discussed Global Warming, the contribution from healthcare provision and declared a Climate Emergency. Global warming might be viewed by some as an existential threat to humanity which has to be addressed by politicians not doctors. The 2019 report of The Lancet Countdown on health and climate change outlines the many harms to health which will result from unchecked global warming. These are unfortunately becoming increasingly evident and we believe this makes addressing it the responsibility of all healthcare workers. The Welsh Government have set a Wales wide initiative to achieve a net-zero carbon public sector by 2030. This includes NHS Wales. The LMC believe that Practices that wish to reduce their carbon footprint could do so through the following actions. These are the simplest steps, bringing the biggest reductions, yet do not require large amounts of work in this time of high workload due to the ongoing Covid crisis: * Shift away from using inhalers such as Ventolin Evohaler towards those such as Salamol which have a smaller carbon footprint but can be used in the same way. Global warming from one Salamol inhaler is equivalent to a 60 mile car journey compared to 175 miles for one Ventolin Evohaler. This change can be implemented immediately allowing time for slower changes such as implementing the new All Wales Asthma Guidelines (which emphasise the use of prophylaxis over reliever therapy) or switches to dry powder inhalers. * Find ways to procure sustainably (such as energy from renewable sources). * Reduce car travel to and from surgeries and continue using different ways to consult. The LMC will continue to petition for the implementation of Electronic Transfer of Scripts which will reduce travel associated with obtaining prescriptions from surgery buildings. Further useful resources can be found at: The Greener Practice website links together those in Primary Care who want to deal with the environmental impact of healthcare. The Green Impact for Health Toolkit outlines actions that Practices can take. Green Inhaler website has more information on the environmental costs of different inhalers; a shorter and less detailed comparison is produced by North East Devon Inhalers4u has videos of how to use different dry powder inhalers which can be shared with patients Wales’ small size on a global scale actually makes it easier to achieve change on a nationwide basis. Recognising these factors, Morgannwg LMC accepts that we have a responsibility to act to address the Climate Crisis and seeks to collaborate with other organisations to achieve the aim of net-zero carbon for healthcare in Wales.

This NHS report provides a detailed account of the NHS’ modelling and analytics underpinning the latest NHS carbon footprint, trajectories to net zero and the interventions required to achieve that ambition. It lays out the direction, scale and pace of change. It describes an iterative and adaptive approach, which will periodically review progress and aims to increase the level of ambition over time. Information regarding NHS Wales’ Carbon Footprint can be found here.

Inhalers account for 3-4% of the whole NHS carbon footprint. To reduce the carbon footprint of inhaler prescribing we recommend that health professionals: 1. Optimize asthma and COPD care 2. Use dry powder inhalers or soft mist inhalers as first choice when clinically appropriate 3. If metered dose inhalers are needed then chose brand and regime with care to minimize carbon footprint 4. Ask patients to return all used inhalers to pharmacies for disposal Further information regarding these measures and FAQs are available to download here.

Morgannwg LMC is committed to providing and sustaining a working environment free from any form of inappropriate or unacceptable behaviour; and wish to ensure that all those operating within the organisation are treated, and treat others, with dignity and respect. Discrimination and harassment are unacceptable and that all employees and Members have a role to play in creating a thriving environment for everyone. If you feel you are being harassed, bullied or otherwise discriminated against by someone associated with Morgannwg LMC, or you are aware of others being subjected to such treatment, we strongly encourage you to raise this with us and there are three suggested routes available: Informal direct approach – You may wish to consider first whether you feel able to address the problem informally with the person responsible. If so, you should explain clearly to them that their behaviour is not welcome, or makes you uncomfortable. Informal approach with support – If is difficult for you to engage directly we would encourage you to speak to our Executive Officer / Chair or another member of the Executive Team. They can provide confidential advice and support and also offer to speak to the individual on your behalf. Formal complaint – If informal steps are not appropriate, or have not been successful, the matter can be escalated and formally presented as a complaint in writing to the Chair or any member of the Executive Team. You can be assured that such complaints will be investigated in a timely and confidential manner as per the LMC’s Complaints Policy. Once an investigation is complete you will be informed of its outcome. If it is found that you have been harassed, bullied or otherwise discriminated against by an employee or Elected Member of Morgannwg LMC the matter will be dealt with under the Disciplinary Procedure or via the Constitution. If the harasser, bully or discriminator is a third party, we will consider what action would be appropriate to deal with the problem. Whether or not your complaint is upheld, we will consider how best to manage any ongoing relationship between you and the person concerned. We want people to come forward and anyone, who in good faith makes complaints or participates in any investigation, must not suffer any form or retaliation or victimisation as a result. Morgannwg LMC recognises that certain treatment of or by particular individuals is unlawful and you may wish to seek legal advice. It is however imperative that we know about these matters, regardless of whether or not legal protections and liabilities are triggered, so these bahaviours can be properly addressed.

Morgannwg Local Medical Committee is committed to protecting and respecting your privacy. As part of our representative function we collect certain personal data. This privacy policy will outline the basis on which we hold and use any personal data provided to us in connection with our support and representation of General Practitioners. This policy applies to: The General Practitioners that we support and represent (‘Represented Practitioners’ and ‘Constituents’) Individuals whose personal data we receive in connection with our support and representation of Represented Practitioners (‘Non-Constituents). Our privacy policy can be found using the link at the bottom of this page.

Morgannwg Local Medical Committee is the statutory voice for all NHS GPs and practice teams across the areas of SBUHB. The LMC provides assistance for general practitioners on all matters relevant to general practice such as NHS Regulations, GMS contracts, GPs Terms of Service and Conditions, complaints and partnership issues. The LMC represents GPs in discussion with local and regional health authorities. In addition, Morgannwg LMC is a gateway to pastoral care and provides personal and totally confidential support for GPs and practices in difficulty or experiencing major change. We want to be able to make improvements to ensure that the LMC operates efficiently, effectively, equitably, respectfully and lawfully. Morgannwg LMC therefore encourages constituents, Members and employees to feedback on ways that the LMC needs to improve or to report on any wrongdoing. How to make a complaint or a personal grievance Morgannwg LMC aims to provide the best service possible and operate in a professional and ethical way, but we may sometimes fall short of the mark. If this is the case we would encourage you to speak to whoever you feel most comfortable with within the organisation at the earliest opportunity. We welcome feedback to help us improve our standards and will do our very best to put right anything that has gone wrong. All feedback we receive gives us a chance to know how we are doing and where improvements can be made. All formal complaints, concerns or grievances will be confidentially recorded. If you would like to make a formal complaint or to raise a grievance, you can do this by emailing office@morgannwglmc.org.uk or alternatively by contacting the Medical Director personally. How your complaint, concern or grievance will be managed The Chief Executive Officer of Morgannwg LMC will be designated to lead investigations however concerns can be raised to any member of the Executive team. Oral complaints and concerns satisfactorily resolved informally, will not be subject to the formal procedure as outlined below: All complaints, concerns or grievances will be handled anonymously, if this is deemed appropriate. Details of the investigation, your name and the name of any person accused will only be disclosed on a “need to know” basis (which may include enabling an individual to properly answer any allegations). We will of course consider with care whether any steps are necessary to manage the ongoing relationship between you and the person/s accused during the period of any investigation. Where possible, any investigation will be conducted by someone with appropriate experience and no prior involvement in the situation. You should normally make a complaint or raise a concern within 6 months of the incident causing the problem or within 6 months of the date you discovered the problem. This time limit can be extended, depending on circumstances, as each complaint is treated individually. If you are complaining on behalf of someone else, we will need to make sure they have given their consent for you to do this. Morgannwg LMC will acknowledge your complaint within 5 working days of receipt in writing. The acknowledgement will include the offer of a discussion (which might be by telephone or a meeting) to agree a plan of how the concern will be handled and agree reasonable timescales (response period) for investigating and concluding the complaint. You are very welcome to be accompanied by a family member or colleague for meetings. If you choose to decline the offer to discuss the issue, or do not agree with the response period proposed, the Executive will decide how the complaint will be handled. A letter will be sent setting out how the complaint will be investigated and confirming the expected response date. You should expect to receive a full written response from the LMC Executive team within 25 working days. Some complaints are more complicated and may take longer to investigate. If a full reply cannot be provided within the 25 working day timescale you will be kept updated on progress and the reason for the delay. On concluding investigations the delegated Executive Member will write, confirming how the complaint has been investigated, the evidence considered and giving the conclusion. This will include details of actions the LMC has and will be taking as a result of its findings as appropriate. If you are unhappy about the response you can appeal and we can arrange a conciliation meeting between yourself, the relevant staff and an independent conciliator. The conciliator will talk to both parties and try to help resolve matters for you. You may also be accompanied for this meeting. An appeal should be made within 28 days of the outcome of the investigation. Whistleblowing Some concerns might be of public interest and therefore categorised as whistleblowing. These include: a criminal offence, for example fraud or breaking the law when someone’s health and safety is in danger you believe someone is covering up a wrongdoing You can raise your concern at any time about an incident that has happened, is happening now, or you believe will happen in the near future and can do this either with a prescribed body (more details available via gov.uk) or via the LMC. As a whistleblower you’re protected by law. You must say straight away if you do not want anyone else to know it was you who raised the concern and we will of course consider with care steps that can be taken to manage the ongoing relationships. Due to the potential severity of the wrongdoing, the LMC will take advice from a legal or a prescribed body and you will unfortunately not have a direct say in how your concern is subsequently managed.