Question 1

Does my practice have to provide a GMS Collaborative Lead lead within a cluster network?

Accepted Answer

We have been made aware that from 31/12/26 there will be no financial support available to those undertaking the GMS Collaborative lead role within cluster networks. SBUHB state that the Welsh Government have advised them that they are no longer able to use the SPPC funds to support the GMS Collaborative lead roles and will no longer be able to provide a contributory payment in recognition of their commitment to the leadership role from 31/12/26 and will just be relying on the contractual requirements for the role. The LMC would like to draw practices attention to the following contractual requirement (full wording further down): (c) contribute to delivering specific cluster-determined outcomes, including engagement in planning of local initiatives through engagement with the cluster via the GP Collaborative lead.The collaborative GP therefore needs to engage through a GP collaborative lead but there is nothing in the contract that says you have to have a lead from the members or undertake any preparatory work.  The LMC understands that the contractual requirements would be met by a rota of allocated GPs undertaking the lead role without involvement in preparatory work, providing participation and attending contractual requirements are met.The LMC is not aware of any wording in the contract that states that there has to be a GP Collaborative lead nominated from the collaborative membership, nor that practices have to:Prepare for and chair four collaborative meetings per annum including time for liaison and preparation (estimated at equivalent of 1.5 sessions p.a.)Prepare to attend and feedback to colleagues from the four LCC meetings  (estimated at equivalent of 2 sessions p.a.)    Attend four GMS collaborative leads peer support groups to share and gain experience and knowledge. (estimated at 1 session p.a.)Action and management of ancillary activity generated via the Cluster Development Team (estimated at equivalent of 1.5 session p.a.)Contractual Requirements for Professional Collaborative Action(s) 2026 / 27 can be found here:The full wording of the relevant 2023 GMS Regulations can be found below: Duty of co-operation: cluster working16.—(1) A contractor must comply with the requirements in sub-paragraph (2) where registered patients or temporary residents are provided with services by the contractor's cluster.(2) The requirements specified in this sub-paragraph are that the contractor must—(a)co-operate, in so far as is reasonable, with any person responsible for the provision of the services,(b)comply in core hours with any reasonable request for information from such a person or from the Local Health Board relating to the provision of the services,(c)agree the mandate for the GP Collaborative representative at cluster meetings and take account of feedback from those cluster meetings,(d)take reasonable steps to provide information to its registered patients about the services, including information on how to access the services and any changes to them, and(e)ensure engagement in the planning and delivery of local services, as agreed within the cluster action plan, which includes suitable arrangements to enable the sharing of data, where appropriate safeguards are met, to support the delivery of the services and discussion of cluster funding and budgets. Membership of a GP Collaborative17.—(1) A contract must contain a term which has the effect of requiring the contractor to be a member of a GP Collaborative.(2) A contractor must—(a)appoint at least 1 health care professional with authority to act on the contractor's behalf in the dealings between the contractor and the GP Collaborative to which the contractor belongs, and(b)attend at least 4 meetings of the GP Collaborative to which the contractor belongs in each financial year (unless agreed otherwise in writing by the Local Health Board), or appoint a senior practice clinician, or where appropriate a senior administrator, employed by the practice to attend those meetings and to act on the contractor's behalf in those meetings. Contribution to clusters and GP Collaboratives18.  A contractor must—(a)contribute relevant information, including demand and capacity planning, to the cluster Integrated Medium Term Plan via the GP Collaborative, and the contribution must include information on demand and capacity planning,(b)demonstrate how they have engaged in planning and delivery of local services agreed within the GP Collaborative's contribution to the cluster plan, including evidence of wide partnership, multi-professional/multi-agency working, and development of integrated services, and(c)contribute to delivering specific cluster-determined outcomes, including engagement in planning of local initiatives through engagement with the cluster via the GP Collaborative lead Demand and capacity19.  A contractor is required to engage with a GP Collaborative to assist the collaborative in—(a)undertaking a population needs assessment of its patients,(b)analysing the current services available to the GP Collaborative population, identifying any gaps in provision,(c)analysing the current numbers and skills of the workforce and its development needs,(d)undertaking a measurement of local health needs as determined by the GP Collaborative, and(e)providing evidence of the demand and capacity assessment undertaken which is to be evidenced in the GP Collaborative Integrated Medium-Term Plan (Note :- this was subsequently confirmed as being the Cluster IMTP and not a separate Collaborative document) Activity and Appointment Data23.—(1) A contract must contain a term requiring contractors to—(a)maintain their mapped appointments in the relevant section of the Primary Care Information Portal;(b)review their submission data at least once a month;(c)ensure the mapped categories are up-to-date; and(d)ensure their server is at all times switched on, maintained and available to enable the relevant software to extract the data.(2) The activity and appointment data across the GP Collaborative must be discussed at GP Collaborative meetings by the authorised representatives from the member practices comprising the GP Collaborative, with the aim of developing measures across those member practices to manage demand and standardise good practice and, where applicable, data qualityWe advise practices to make a business decision as to whether to participate in the role of GMS Collaborative lead role based on these contractual requirements.

Question 2

The school nursing team have requested our Practice to upload flu vaccination records onto The Welsh Immunisation System (WIS), is this a GMS requirement?

Accepted Answer

The LMC are aware that some practices have been receiving flu vaccination records from the school nursing team with requests for the practice to upload onto WIS.This is not a GMS responsibility and does not meet the WIS flu clinical governance protocol. The LMC have received national reassurance that GPs are not responsible for WIS data entry on behalf of other departments and have been advised that a Welsh Health Circular is currently in development.To minimise data entry delays, the LMC have proposed that vaccination records are sent to the SBUHB Immunisation team directly until the school nursing service have access to WIS.  Until we receive alternative guidance, we would suggest that practices send any vaccination records received with requests to upload onto WIS via blue bag to the HB Immunisation team.

Question 3

What are the All Wales General Practice and Health Board Clinical Interface Standards?

Accepted Answer

These standards have been designed to improve the safety and quality of patient care in NHS Wales and ensure that our patients have the best possible experience as they navigate their pathways. It is a consensus document that has been co-produced with Primary and Secondary Care Clinicians and endorsed by the All Wales Medical Directors.They apply to all NHS Wales clinicians communicating clinical information between General Practice and Health board run services. They also apply to clinicians working in the private sector who interface with General Practice.They replace WHC (2018) WHC/2018/014 - All Wales Communication Standards between Primary and Secondary care (AWCS)Individual professional standards:1 Investigations: Any clinician managing a patient’s care who deems an investigation is necessary should: Request the investigation Take responsibility for actioning of the result Communicate the result directly to the patient and help them understand it. Delegating these responsibilities is appropriate if there is agreement to do so (see Standard 5).2 Referrals: Any clinician referring a patient for a consultation should: Ensure the patient understands the reason for the referral  Ensure the patient knows who is responsible for their care Ensure the patient knows what should happen next Ensure the referral contains all information needed to determine the priority of the referral Make the referral themselves when they have the competence to do so When not making a referral themselves, a clinician should never direct a patient to another clinician to ask for a specific referral or expected timeframe for action. Clinicians should respect colleagues' autonomy and allow them to determine what is best for the patient. 3 Med3: The clinician who advises the patient to refrain from work must: Issue the Med3 Ensure the duration of the note covers the time period to expected return to work or the next planned review 4 Prescribing: A clinician recommending that a patient starts a new medication must: Issue a prescription if that medication needs to be initiated within the next seven daysIssue a prescription for a minimum of two weeks but longer if clinically appropriate Communicate all necessary counselling of the patient if recommending another clinician starts the medication Ensure prescribing and prescribing recommendations should be within the scope of practice of the clinician to whom the recommendation is being made Name the responsible clinician when recommendations are from non-prescribers. Adhere to shared care prescribing processes by retaining prescribing responsibility until the GP has accepted the request and received the stable handover letter Take account of guidance provided in the health board’s prescribing formulary and the availability of the medicine in primary care, when initiating or recommending a GP initiates medication(s)  Be prepared to retain prescribing responsibility if the medication does not have a UK marketing authorisation (i.e. the medication is unlicensed)Be prepared to retain prescribing responsibility if the medication has a UK marketing authorisation but it is being prescribed in a way which is outside the terms of its authorisation (i.e. the medication is licensed but prescribed ‘off-label’), where such prescribing is not generally accepted clinical practiceOrganisational Standards5 Investigations: Organisations should have standard operating procedures (SOPs) to mitigate against clinical governance risks and transfer of clinical responsibility when requesting investigations and actioning the results There should also be SOPs with regards communication of results to patients These SOPs should support clinicians in adhering to the individual professional standards 
6 Referral and Outpatient Communications:Must be compliant with data protection regulations. Must be made via the nationally or locally agreed electronic method where it exists.  Must be actioned promptly, including requests for further information Changes to priority must be communicated to the referrer and the patient Should be addressed to the referrer with copies to the patient and their GP if not the original referrer.  Referrals that are declined, must be clinically justified and require timely communication to the referrer within the timeframe stated in Planned Care guidance (currently 48 hours).7 Expedite Requests:Patients who make contact to expedite appointments should be dealt with accordingly: Should be based on clinical need; a long waiting time does not alter priority For patient experience, clinically valid expedite requests should be dealt with by the team who they contact, rather than directed elsewhereFollow-up appointments for review or treatment should be brought to the attention of the specialist overseeing their care for action.  8 Did Not Attend:Care needs to be taken to ensure reasonable adjustments are made for patients with protected characteristics under the Equality Act. Where patients do not attend for out-patient appointments without giving notice, in line with WG guidelines for pathway management, they will be discharged. The original referrer, the GP (if not the original referrer) and patient should all be advised of the discharge. Where the patient has reasonable grounds to challenge the decision, they should be reappointed without a new referral. In the case of vulnerable adults and children who do not attend refer to the local “was not brought” policy 9 Patient Discharges:  Electronic discharge advice letters (eDAL) should be completed at the time of discharge, and a copy sent with the patient Patients should be discharged with at least two weeks of medication (which may be supplied from the hospital or from medication already in the patient’s possession. Where there may be a longer than usual time needed to source a medication in primary care (e.g. where a special formulation or unlicensed preparation is prescribed), consideration should be given to providing at least four weeks of medication at discharge  Discharges out of hours should ensure appropriate handover to Out of Hours providers e.g. End of Life Care. Similar information should be provided for completion of an ambulatory care assessment. 10 Pre-operative Assessment Clinics Must have named medical support  Should first use the named medical support when unexpected findings are identified. Refer internally for optimisation for surgery, or an appropriately commissioned optimisation service  If you are aware of a breach of these standards, please datix the incident and contact us so that we can ensure these standards are upheld throughout Swansea Bay. Our Deputy chair has created some resources, including a video, for training staff on these Standards and are ideal for induction training or department training within a primary or secondary care setting. Slides are available here:Video of presentation available here:# AWCS

Question 4

I've been asked to prescribe antibiotics for a patient that has been seen by a secondary care team, who state that they do not have a prescriber, do I have to do the prescription?

Accepted Answer

Providers must supply patients with medication following an outpatient appointment or discharge from inpatient or day case care.

This is made clear in point 4 of the All Wales General Practice and Health Board Clinical Interface Standards (see below). If the service does not have a prescriber within their team then this does not become a GMS responsibility and being extra contractual it's a matter for personal choice whether to undertake the non-contractual work. It is not reasonable to expect or demand a GP to prescribe this medication on behalf of a secondary care service. Please do datix any instances when they occur and please do contact us if you need support regarding declining this inappropriate transfer of work.

4 Prescribing: 
A clinician recommending that a patient starts a new medication must: 
Issue a prescription if that medication needs to be initiated within the next seven days
Issue a prescription for a minimum of two weeks but longer if clinically appropriate 
Communicate all necessary counselling of the patient if recommending another clinician starts the medication 
Ensure prescribing and prescribing recommendations should be within the scope of practice of the clinician to whom the recommendation is being made 
Name the responsible clinician when recommendations are from non-prescribers. 
Adhere to shared care prescribing processes by retaining prescribing responsibility until the GP has accepted the request and received the stable handover letter 
Take account of guidance provided in the health board’s prescribing formulary and the availability of the medicine in primary care, when initiating or recommending a GP initiates medication(s)  
Be prepared to retain prescribing responsibility if the medication does not have a UK marketing authorisation (i.e. the medication is unlicensed)
Be prepared to retain prescribing responsibility if the medication has a UK marketing authorisation but it is being prescribed in a way which is outside the terms of its authorisation (i.e. the medication is licensed but prescribed ‘off-label’), where such prescribing is not generally accepted clinical practice

Question 5

Do I have to allow audiology to request MRI results in a GPs name? (Updated September 2026)

Accepted Answer

Why was the pathway for audiology MRIs changed? The LMC investigated the previous arrangements because they presented a serious patient safety issue. Previously, GPs were held responsible for the results of scans that they did not order themselves (these were requested by others without the GP's knowledge). The LMC highlighted that these investigations must not be requested or recorded under someone else’s name due to the associated medicolegal risks. Addressing this issue has allowed us to resolve a critical gap in patient safety as it became apparent during discussions that, from inception of the previous pathway, GP's felt that audiology were actioning abnormal results, audiology thought that radiology were sending them directly to ENT.Following further discussions and a review of the available documentation, it become apparent that the original pathway agreement made by the three leads from Audiology, ENT and Radiology at the time, none of whom continue to work for the health board, was not well documented in all departments. Whilst Audiology relied on the wording of the scope of practice, this did not become the working understanding in radiology and radiology have found no evidence that the direct notification of significant findings to ENT was ever implemented. What has been done to address this patient safety concern? Audiology undertook an urgent audit of all MRI referrals sent from Primary Care Audiology between July 2025 and February 2026.  Any missed referrals for further investigation and management will be dealt with immediately and reported via DATIX with all subsequent necessary processes.The Primary Care Audiology lead is designing and expediting implementation of an audit that is able to capture assurance from each of the surgeries whose patients Audiology have referred onwards over a number of years. The LMC will be updated as to the results of the audit and any further steps required.Audiology will attach an addendum to all scope of practice documents held within radiology for audiologists on the Non-Medical Referrer register altering the reference to significant findings going directly to ENT.All cases of unilateral hearing loss follow a clear standard Operating Procedure (SOP)Audiology will continue to consider the circumstances leading to this situation to develop further learnings and actions. Audiology will share these with radiology so that similar consideration may be undertaken as appropriate.What is the new Standard Operating Procedure (SOP)? Following a lengthy process working alongside ENT and audiology, a new pathway has been established. The purpose of the SOP is;to provide a pathway which significantly reduces the demand on GPs for hearing related conditions and significantly expedite the pathway for appropriate imaging for patientsto provide a pathway that met the All Wales General Practice and Health Board Clinical Interface Standardsto provide practices with a clear pathway, which sufficiently outlined roles and responsibilities in order that they could make individual practice-based decisions about whether to opt-in to the proposed pathwayWho makes the decision to refer a patient for an MRI of the IAMs within the SOP?The Advanced Audiology Practitioner is responsible for determining whether a patient meets the NICE referral criteria for an MRI scan of the Internal Auditory Meatus (IAM). This decision is based on a comprehensive assessment, including the patient's symptoms, clinical history, consultation findings, and audiological test results, such as the audiogram.  Where the referral criteria are met, the Advanced Audiology Practitioner will arrange the MRI scan in accordance with local and national guidelines.In whose name is the MRI requested?The Advanced Audiology Practitioner is listed on the referral form as the referring practitioner, as they are responsible for requesting the investigation. A covering note accompanies the referral, clearly identifying the patient's GP and requesting that the  MRI report is sent directly to them for review and management. This ensures that the MRI findings are reviewed and managed by an appropriately qualified medical professional, with any necessary follow-up, referrals, or treatment arranged through the patient's GP.Does this comply with the All Wales General Practice and Health Board Clinical Interface Standards?The Clinical Interface standards recommend that if there is agreement for investigation request responsibilities to be delegated, there must be "standard operating procedures (SOPs) to mitigate against clinical governance risks and transfer of clinical responsibility when requesting investigations and actioning the results". The new SOP ensures that any clinical governance risks are addressed and so complies with the standards.  Why does Audiology not manage the MRI results?Audiology practitioners are not medically trained clinicians; their expertise is primarily focused on the diagnostic assessment and audiological management of hearing and balance disorders. MRI reports should be reviewed and managed by an appropriately trained medical professional who can interpret the findings within the context of the patient's overall health and medical history.What happens if an Acoustic Neuroma or CP angle lesion is reported?If an acoustic neuroma or other cerebellopontine (CP) angle lesion is reported on the MRI scan, it is expected that the GP will review the findings and make an urgent referral to ENT for further assessment and management. The GP practice will also communicating the MRI results to the patient and advising them of the next steps in their care pathway.What happens if any other incidental findings are reported?If any incidental findings are identified on an MRI scan, the GP will review and manage these findings. This includes interpreting the results in the context of the patient's overall health, symptoms, and medical history and making appropriate onward referral for further investigation or advice. This approach ensures that MRI findings are reviewed and managed by a primary care clinician with responsibility for the patient's overall medical care and coordination of any subsequent treatment pathways.Doesn’t this pathway place more demands on the time of GPs?The primary care audiology service saves GPs practices around 15000 patient contacts per year for hearing, tinnitus and ear/wax related enquires. The number of MRIs reported back to GPs represents small proportion of activity when compared the numbers of patients seen. Therefore, whilst there is an expectation of an increase in workload specifically related to reviewing and managing MRI results compared to the traditional secondary care pathway, the benefits of primary care audiology in controlling demand on practices related to ear and hearing conditions outweigh the time demands relating to the management of the MRI reports.Are practices mandated to use this new pathway? No. Practices can choose to opt in to this pathway or opt out if they prefer in their management of unilateral tinnitus using this link or by emailing sbu.audiology.primarycare@wales.nhs.uk. What will opt-in mean for the practice?Practices who opt-in will receive notification by letter each time that the Primary Care Audiology service makes an MRI referral for one of their patients. Once the scan is completed, Radiology will send the completed report to the GP for actioning and communication to the patient.What will opt-out mean for the practiceWhen a patient who is booked in to the primary care audiology clinic by a practice meets the criteria for MRI referral the audiologist will inform the GP so that the patient can be reviewed and the  appropriate investigation requested. ENT would not expect to receive referrals only to request an MRI referral in the absence of any other ENT related assessment or management required. Therefore, the MRI referral must be created by the GP. If a practice opts-out of the MRI pathway, patients will continue to be able to access the primary care audiology service, on the basis described in the paragraph above, and all other activity and onward referrals managed by the primary care audiologists will continue.What is the benefit to your patients of your practice opting in to pathway.Patients are able to access the Primary Care Audiology service quickly, which means that any required imaging can be requested within a couple of weeks of them raising a concern regarding their ear or hearing. This is a significant benefit compared to the traditional secondary care pathways where patients would spend time on waiting lists and attend multiple health contacts along the pathway. The one-stop primary care audiology opt-in pathway can reduce patient waiting time for an MRI referral by up to twelve months.What is the benefit of the pathway to the GP practiceUtilising the full primary care audiology service, including the MRI pathway means that the practice does not need to see the majority of patients with wax, hearing or tinnitus concerns, equating to a saving of up to 330 contacts per average sized practice per year. With regards to unilateral or asymmetric symptoms or results, practices can be assured that any necessary onward referrals are being made in line with NICE guidance for their patients and only those with an MRI finding requiring review, approximately 8 per average sized practice per year, need contact with their GP.Why are the MRI results not sent to ENT for reviewThis pathway relates to patients seen in the Primary Care Audiology service. This is a first contact service within primary care and booked via GP surgeries in lieu of a patient needing to see their GP practitioner regarding their hearing or tinnitus. These patients are not known to ENT at this point and for the majority of patients, their investigation can be requested and managed within primary  are without requiring secondary care input. ENT will accept referrals for patients for whom there is an ENT related finding following review of the results by the patient's GP.What is the suggested wording for future ENT referrals? For future patient referrals, the LMC suggests taking the following approach when referring to ENT:"Dear ENT Team, This patient has unilateral hearing loss. This is a specialist area outside the expertise of a GP. I am not the most appropriate professional to assess this further. Please investigate and treat as you feel indicated. I enclose a copy of the audiology assessment and MRI report."

Question 6

Do I have to prescribe Benzodiazepines/sedation (including diazepam) for a patient who is anxious of, or has a fear/phobia, of flying?

Accepted Answer

There is no obligation for you to provide medication for this for the following reasons:

the use of any sort of CNS depressant causes longer reaction times & slowed thinking, which during a flight will put the passenger at significant risk of not being able to act in a manner which could save their life in the event of a safety critical scenario (& there will be no-one else to do it for them - cabin crew are there to guide them & not do it for them); 
the use of any sort of CNS depressant has potential to increase the risk of DVT - these drugs can induce non-REM sleep which tends to be of a type where the person does not move in their sleep, and therefore increases the possibility of sitting without moving for more than 4 hrs (the amount of time which has been shown to increase the risk of developing DVT whether in an aeroplane or elsewhere); 
the sedating effects have the possibility of causing some respiratory depression, resulting in a drop in 02 sats. Normal sats for a healthy person at 8000ft are around 90%, so with the 2 effects added together, this may become significant, and even more so if the consumption of alcohol is added.
A paradoxical increase in aggression may be reported by patients taking benzodiazepines (see BNF) & therefore has potential to put other occupants of the aircraft at risk; 
benzodiazepines are contraindicated in phobic states (see BNF); 
for some countries it is illegal to import these drugs and so the passenger will need to use a different strategy for the homeward bound journey and / or any subsequent legs of the journey; in addition, standard GP indemnity does not cover you for treatment initiated outside the UK, so you would only be covered for doses to be taken on journeys starting in the UK;
NICE guidelines suggest that medication should not be used for mild & self limiting mental health disorders; in more significant anxiety related states - benzodiazepines, sedating antihistamines or antipsychotics should not be prescribed; Benzodiazepines are only advised for the short term use for a crisis in generalised anxiety disorder (if they are having a GAD crisis they are NOT fit to fly & fear of flying in isolation is not generalised anxiety disorder).

Question 7

We have received abusive/threatening comments on social medial (Twitter/Facebook etc), how should we respond?

Accepted Answer

This can be a very distressing experience and please get in touch with us so that we can advise and support you.

The BMA have a template letter you can use and have advice on dealing with abuse of practice staff on social media from patients.

Dealing with abuse of practice staff on social media from patients

Question 8

I'm thinking of using an AI medical scribe such as Heidi, what do I need to consider before setting it up?

Accepted Answer

There is a recent Welsh Health Circular "The safe and responsible adoption of ambient voice technologies (‘AI Scribes’) in clinical and practice settings". The BMA also have guidance below which is worth reading before starting to use an AI medical scribe. NHS England also have a comprehensive document "Guidance on the use of AI-enabled ambient scribing products in health and care settings" which is recommended.  An overview of this document is available below, courtesy of Gill Farmer from GPC/LMC Interface:

Overview
This document, published by NHS England on 27th April, provides guidance on the deployment of AI-enabled ambient scribing products including advanced ambient voice technologies (AVTs) used for clinical or patient documentation and workflow support in health and care settings. It is of relevance to GPs aiming to implement a specific product.  This is the first in a series of documents to be published over the next six months.  An AI Ambassadors network will be established to support best practice and sharing of insights. 
 
What are AI-enabled Ambient Scribing Products?
These are speech recognition and natural language processing (NLP) systems that:
Record and transcribe conversations between clinicians and patients during consultations.
Use AI algorithms to generate structured clinical notes, such as SNOMED-coded entries.
Can auto-populate sections of the patient record, with clinician approval.
·         Can generate outputs in the form of medical letters or other documentation.
Can recommend actions such as onward referral.
Some tools include features such as:
Automatic summarisation of discussions based on text transcripts.
Intelligent prompts for missing clinical information.
Real-time transcription during the consultation.

Question 9

Can I refer patients to secondary care who have had non-NHS (private) weight loss (bariatric) surgery?

Accepted Answer

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 accepting 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).

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

Question 10

What should I do if I am inappropriately transferred work from secondary care?

Accepted Answer

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 (The All Wales General Practice and Health Board Clinical Interface Standards (replacing WHC (2018) WHC/2018/014 - All Wales Communication Standards between Primary and Secondary care - AWCS). Please remember to copy us into correspondence (removing any patient identifiable data) so that we can identify trends and take appropriate action!

You can use the template letter below to respond:

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 which are laid out in All Wales General Practice and Health Board Clinical Interface Standards

1 Investigations:
Any clinician managing a patient’s care who deems an investigation is necessary should: 
Request the investigation 
Take responsibility for actioning of the result 
Communicate the result directly to the patient and help them understand it. 
Delegating these responsibilities is appropriate if there is agreement to do so (see Standard 5).

5 Investigations: 
Organisations should have standard operating procedures (SOPs) to mitigate against clinical governance risks and transfer of clinical responsibility when requesting investigations and actioning the results 
There should also be SOPs with regards communication of results to patients 
These SOPs should support clinicians in adhering to the individual professional standards

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]

Question 11

What is my responsibility in responding to private healthcare requests?

Accepted Answer

PCIC team in Cardiff & Vale Health Board have jointly created a template letter for responding to requests from Private Healthcare providers:

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.

Note that private provider requests for information regarding GLPI-1 agonists are addressed in the BMA guidance here, which includes a template letter.

Question 12

I've been asked to fill in a template before a department will accept my referral - do I have to complete it?

Accepted Answer

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.

Question 13

I have a prescription query...

Accepted Answer

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.

Question 14

I've been asked to do a follow up Xray for a patient seen in A&E, am I required to do this?

Accepted Answer

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."

Question 15

How can I report a clinical issue in Swansea Bay?

Accepted Answer

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

Question 16

Should our practice sign up for an enhanced service?

Accepted Answer

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 / PDF along with the source information 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 below for reference 
 
.

Question 17

What is the Welsh Clinical Portal (WCP)?

Accepted Answer

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.

Question 18

What Drugs are funded "shared care" medications under an Enhanced Service in Swansea Bay UHB?

Accepted Answer

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.

Question 19

The ambulance service (WAST) are asking my practice for advice/support, do I have to respond?

Accepted Answer

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.

Question 20

How much does Consultant Connect cost and is it frequently used?

Accepted Answer

Dr Robin Spacie, on behalf for MLMC, put in a request to the Welsh Government for information under the Freedom of Information Act (2000) regarding how much Consultant Connect has cost per year for the last 5 years and how many completed calls are made on Consultant Connect per year for the last 5 years, across Wales in total and for each health board.

The costs given are:
 
Health board and total numbers of calls and messages from 2020- to end of financial year 2024/25 are available in Appendix A within the full document available below.

.

Question 21

I've been asked to prescribe melatonin for a paediatric patient, what should I do?

Accepted Answer

The prescribing of melatonin in children and adolescents has been approved by PCPAG only for paediatric behavioural insomnia, where it has been initiated by a specialist. It should not be initiated in primary care.

Question 22

I am having an issue related to the District Nursing team being understaffed, what do I do?

Accepted Answer

After discussing directly with the HB we would like to ask that  practices attempt to datix all concerns related to the District Nurse staff shortages. The LMC are aware that there are delays accessing the SPOA phone line,  waiting lists for Wound Clinics,  and an inability to request bloods for housebound patients. We appreciate the time that it takes to report but this will illustrate the importance of the service and the levels of concern that practices have about how this is affecting patient care.
 
The inappropriate commissioning and expanding of the DN workload, without adequate staffing,  has created an overstretched service that is not working for patients nor for the DN team. We have made it clear that this is not a complaint regarding any one individual but rather a way to report that the service is not adequately equipped to deliver the volume of work.

We have raised our concerns with the HB and they agree re shortfall in service but have advised that it will help to escalate if practices datix.

Question 23

We are constantly being asked by patients about whether they can have Mounjaro (GLP-1 analogues), are there any resources to help us?

Accepted Answer

The BMA have produced guidance as GLP-1 analogues, including Tirzepatide (Mounjaro), have recently been licensed for weight management in adults with obesity or overweight with comorbidities. While NICE has approved Tirzepatide for use under specific criteria, they have not been commissioned for prescribing or monitoring in Welsh General Practice.

Until a national or local supplementary service is negotiated, GPs should not initiate or monitor GLP-1 analogues for weight loss. Prescribing for weight management remains the remit of specialist services only.

Private prescribing of GLP-1 analogues is becoming increasingly commonplace and generates requests to practices for access to patient medical information. This guidance seeks to assist practices in appropriately managing these requests, taking account of professional guidance and patient safety considerations. The guidance also includes a template letter for practices to respond to requests for medical information following a private consultation.

Ty Elli Surgery have created leaflets to clearly lay out eligibility which they are happy for other Practices to use. There is a patient information leaflet and a  structured eligibility‑criteria form tailored for Type 2 diabetes patients in Wales who may be considered for prescription of tirzepatide (Mounjaro®), based on the final NICE Technology Appraisal TA924, as implemented via Welsh policy.

It may be useful to put the following on your practice website:

THINKING ABOUT PRIVATE TREATMENT?
Please ask staff to print out, or email to you, a copy of your ‘Summary Sheet’.
Summary sheets are computer generated and contain only the main diagnoses in your medical history and current medications.
You can share this with your private provider so that you can both make a shared decision about safe treatment. 
You are responsible for being truthful. 
The practice is unable to provide free information verification services for private providers.

# glp # glp-1

Question 24

I've been told to send an ADHD referral to the SPOA email address, shouldn't I use WCCG?

Accepted Answer

There have been reports that Local Primary Mental Health Support Services (LPMHSS) have informed practices that all referrals for ADHD assessments should be sent to the SPOA email address. We have confirmed with Mental Health Services and Digital Services that ADHD referrals should be made via WCCG, choosing Adult Mental Health as the service. ADHD is not a separate service in Swansea Bay.

# wccg

Question 25

I've had an ADHD referral rejected, asking for lots of information not feasible for a 10 minute consultation, do I have to include all this information?

Accepted Answer

We are aware that template rejection letters are being sent in response to ADHD referral letters, even those including extensive detail. These template emails often include requests for information beyond what is feasible in a 10 minute consultation such as:

"Does the Service user experience any suicidal ideation or thoughts of self-harm? Does the Service user use any substances or Alcohol which may exacerbate their current difficulties? Has the service user engaged in any self-help techniques? How is the service user’s current level of functioning impacted by their current difficulties?
 
In order to do this your referral should include an objective view of  …….. history; whether there is significant inattention, increased motor activity, impulsive behaviour seen as reckless or dangerous without regard to consequences, how these affected them as a child, have there been any significant life events and whether this is affecting home/work life and how. Also, a medication history will be required and any information in regard to what self-help resources they have sought in the first instance.
 
As such, the Single Point of Access Team are unable to accept this referral until the information requested is received. Once this information is received the Single Point of Access Team will be able to triage this referral appropriately."

It is not feasible or usual practice for a 10 minute GP appointment to provide detailed objective evidence of ADHD symptoms. In patients with possible ADHD we refer on for specialist services to do this detailed objective review e.g. the DIVA (which takes 90 minutes). ADHD referrals should be made via WCCG, choosing Adult Mental Health as the service and use of the Adult ADHD Self-Report Scale (ASRS-v1.1) Symptom Checklist (which is completed by the patient) provides sufficient information for the referral to be accepted.

Question 26

I'm confused by the "cap" on injections under the minor surgery DES, can I only do 4 injections on a patient in a year?

Accepted Answer

There is no "hard" cap to the number of injections. SBUHB have mentioned 4 per patient/year to focus on patient safety as any more than this will require the patient to have a steroid card. If the patient requires more injections, the practice can give these and they will be reimbursed, but they will need to be justified in the practice's yearly audit.

To confirm, there is no limit to the number of injections a patient can have which will be reimbursed as long as they can be justified clinically.

Question 27

Why was the Welsh Clinical Communications Gateway (WCCG) introduced?

Accepted Answer

The death of Penny-Ann McLachlan, a 33-year-old mother who died from sepsis in March 2016, became a landmark case for NHS Wales, leading to a direct overhaul of how the Welsh Clinical Communications Gateway (WCCG) is used for urgent clinical handovers.

1. The Patient: Penny-Ann McLachlan
Penny-Ann McLachlan was a patient in North Wales who sought help from an Out-of-Hours (OOH) GP service. The GP correctly identified that she was suffering from life-threatening sepsis and needed an emergency hospital admission.
However, because of a failure in the communication systems between the Out-of-Hours GP and the hospital (Betsi Cadwaladr University Health Board), the emergency doctors at the hospital were not fully aware of the urgency or the GP's specific clinical findings when she arrived. She died shortly after.

2. The Coroner’s Report (Prevention of Future Deaths)
Following the inquest, the Coroner for North West Wales, Dewi Pritchard Jones, issued a Regulation 28 Report (Prevention of Future Deaths). The report was highly critical of the "original setup" of clinical handovers in Wales.
Key Findings in the Report:
Systemic Gap: The Coroner found that while the GP had recorded the "red flags" for sepsis, the information was trapped in the GP’s computer system and did not "travel" with the patient to the hospital.
Reliance on Verbal Handover: The hospital relied on verbal information or paper notes, which were easily lost or misinterpreted in a busy A&E environment.
Lack of Integration: The report stated that it was unacceptable for different parts of the same NHS system to be unable to share life-saving data instantaneously.

3. The Recommendation and the WCCG Setup
The Coroner recommended that a national, electronic, and integrated system must be used for all urgent referrals to ensure that hospital clinicians have immediate access to the GP's clinical notes.
In response to this specific report, the Welsh Government and the NHS Wales Informatics Service (now Digital Health and Care Wales) fast-tracked the rollout of WCCG as the mandatory tool for these communications.

The "New" Setup post-recommendation included:
Electronic Audit Trail: Every referral sent via WCCG has a time-stamped record of when it was sent and when it was opened.
Standardized Sepsis Templates: New templates were added to WCCG to force clinicians to tick specific "Sepsis" boxes, which triggers an automatic high-priority alert at the receiving hospital.
Visibility: It ensured that the "Emergency Department" or "Medical Admissions" screen would flash or alert staff that a WCCG referral had arrived for an incoming patient.

# wccg

Question 28

I have been sent a detailed questionnaire regarding Learning Disabilities from Swansea Bay Health Board, am I obligated to complete it all?

Accepted Answer

You may get a questionnaire about learning disabilities from the health board which asks for information over your contractual obligations.

The contractual requirements for monitoring are clearly defined:

Total number of patients on the LD register.
Number of health checks offered.
Number of health checks completed.

The questionnaire asks for considerably more granular information, including staff training percentages, the availability of read easy materials, and a detailed breakdown of reasonable adjustments (e.g., direct phone lines, specific spaces for carers, outreach capacity).

Gathering this level of detail would be entirely voluntary for the practice but not contractual.

Can we also bring to your attention that a tile is now available in PCIP: Learning Disabilities Health Checks - Tile in the Primary Care Information Portal

Following the transfer of the requirements of the Directed Supplementary Service (DSS) for Learning Disabilities (LD) into ‘unified’ services in the GMS contract 2025/26, an Audit+ module was deployed to Practices to support the monitoring requirements that all Practices are required to provide:

The total number of patients on the LD register
number of health checks offered
number of health checks completed

The Audit+ module whilst supporting Practices with day-to-day activities also submits aggregate data (to support contractual requirements) which we are pleased to say is now available and presented within the Primary Care Information Portal

Question 29

Does our practice have to provide home visits to undertake influenza vaccinations as part of the 2025-26 Influenza vaccination requirements?

Accepted Answer

Regarding the provision of home visits for flu vaccinations and the recent direction of patients from the immunisation team, we understand the significant capacity pressures the practice is currently facing, particularly when managing "opportunistic" vaccination alongside routine care. However, we have reviewed the 2025-26 PCCS:I Service Specification, and we must clarify the practice's obligations to ensure you remain compliant with the contract you have signed.

Contractual Requirements and Equality
Under the service specification for Immunisations and Vaccinations, the practice is responsible for delivering the service to its eligible registered population. Specifically, regarding accessibility, the specification (page 25, sections s–u) states:
Accessibility: Services must be accessible, appropriate, and sensitive to the needs of all persons.
Equality Act 2010: Eligible persons must not experience "particular difficulty" in accessing the service due to protected characteristics, specifically disability.
Home Visiting: If a patient has a disability or clinical condition that prevents them from attending the surgery, the practice is required to provide a reasonable adjustment to ensure they are not excluded. In this context, that adjustment may be a home visit.

Determining Eligibility for Home Visits
While the immunisation team may be directing patients to you, the practice retains the clinical responsibility to determine if a home visit is strictly necessary.

A home visit should be reserved for those who are truly housebound due to illness or disability. If a patient is physically able to attend the surgery (or does so for other appointments), the practice is within its rights to insist they attend a clinic. However, if a disability truly prevents them from attending, the PCCS:I framework requires the practice to facilitate the vaccination at their place of residence.

As per section (u) of the specification, if capacity makes this impossible, you should engage with the Local Health Board to discuss how they can support your equality plan for under-served or housebound groups.

Failure to provide these visits for eligible disabled patients could be viewed as a breach of both the PCCS:I specification and the Equality Act 2010.

We hope this clarifies the guidance but ultimately it is up to the practice that they do not discriminate against a patient who has a true disability that prevents them from leaving their house.

The practice may wish to take this into consideration in deciding on whether to participate in next year's influenza campaign.

Question 30

What are my obligations for dealing with requests to provide letters or supportive information to patients?

Accepted Answer

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.

Question 31

What can I charge a fee for and how much can I charge?

Accepted Answer

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

Question 32

A new patient is refusing to sign a "Behaviour Contract" or "Unacceptable Behaviour Policy", do we still have to register them?

Accepted Answer

This can be an incredibly difficult for staff and GPs to provide care, especially when there is a documented history of verbal abuse and missed appointments.

However, the current NHS position regarding these circumstances should be clarified to ensure the practice remains compliant with its contractual obligations.

Under current NHS regulations, a practice cannot make the signing of a "Behaviour Contract" or "Unacceptable Behaviour Policy" a mandatory condition for registration. While these documents are excellent tools for setting expectations, a patient has a right to be registered regardless of whether they sign. If a patient refuses to sign, the practice must still proceed with the registration.

The NHS operates on the principle that a patient should be treated as a "new" case upon re-allocation. Effectively, they must be treated as "innocent until proven guilty" in this new registration period. The practice cannot pre-emptively remove a patient or deny care based on past history until a new incident of unacceptable behaviour occurs under the current registration.

Should the patient’s behaviour fall below acceptable standards again, the following pathways apply:

Violent or threatening behaviour: If the patient is physically violent or causes staff to fear for their safety, you can report the incident to the police. Once a police crime number is obtained, the practice can request an immediate removal via the Alternative treatment scheme.
Sub-threshold abuse: For disruptive behaviour (such as persistent DNAs), the practice must follow the standard disciplinary pathway. This involves issuing formal warning letters clearly outlining why the behaviour is unacceptable.

If a patient refuses to sign the policy, this actually places the practice in a stronger position should the practice need to "off-list" them in the future.

The fact that the patient was offered a framework for a positive relationship and flatly refused it should be clearly documented in their medical notes. If the patient does go on to miss appointments or become abusive, this documented refusal serves as evidence that the professional relationship had irreducibly broken down despite the practice's best efforts to engage.

A detailed log should be kept of all interactions moving forward

Following these steps ensures that any future removal is robust and protected against potential appeals to the Health Board or Ombudsman.

Please do reach out to the LMC if you have any concerns, questions or need support. we are here for you.

Question 33

I've been asked to complete a letter exempting a patient from jury service, do I have to complete this?

Accepted Answer

The GP is not contractually obligated: An NHS GP in Wales is not required to provide a medical exemption letter as part of their standard NHS contract. It is considered a non-NHS service, and they may charge a fee for it. However, I personally tend not to charge for these letters as I am providing factual information rather than an opinion.

Issuing a letter to support a request for excuse from jury service on medical grounds is generally at the discretion of the individual GP or practice. It falls under "non-NHS services."
Due to the potential legal implications for the GP (they could be summoned to court to swear under oath) and the court's ability to make "reasonable adjustments," GPs typically reserve these letters for exceptional circumstances. Examples include:#

Patients who are housebound with a terminal illness.
Patients admitted to hospital during the period of service.
A condition that would seriously and completely prevent them from serving effectively or cause them significant harm.

The Court's Decision: The GP's letter is just supporting evidence; the ultimate decision to excuse a person from jury service rests with the courts (the Jury Central Summoning Bureau).
In short, a GP is not required to provide the letter, but they often will if they feel the medical condition warrants excuse and if they meet their criteria.

I would also suggest you contact your Medical defence union for their advice either from their website or by telephone contact.
I would advise the patient to Contact the Court First:
The first step is to contact the Jury Central Summoning Bureau and apply to be excused.

On your summons reply form, you must state the detailed reason for seeking excusal on medical grounds.
The court will then decide if a supporting medical letter is required.

Excusal is typically reserved for very good reasons where serving on a jury would be impossible or cause serious harm
You can contact them via telephone on 0300 456 1024 for the general enquiries line, or if you prefer to speak in Welsh, the dedicated Welsh language line is 0300 303 5173. Both telephone lines are open from 9:00am to 5:00pm, Monday to Thursday, and 9:00am to 3:00pm on Friday. Alternatively, you can communicate with the Bureau by email at jurysummoning@justice.gov.uk. It is strongly advised that you contact the Bureau first to get clarity on what supporting medical evidence they require before approaching your GP for a letter.

Reasonable Adjustments: Keep in mind that the court's first option is often to offer reasonable adjustments (like providing a ramp, accessible toilet, or specific seating) rather than excusal. You should outline any adjustments you would need when you reply to the summons.

Question 34

Does our practice need a home office license to store medications (opiates) in a surgery?

Accepted Answer

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.

Question 35

Is there a plan to address the long waiting times for phlebotomy appointments?

Accepted Answer

The LMC has had numerous meetings with SBUHB regarding the unacceptable waiting times for phlebotomy (blood test) appointments. SBUHB acknowledging that the Health Board shares the LMC's serious concerns. The main issues highlighted in these meetings include:

Staffing Crisis: Since April, there has been a cumulative turnover of approximately 10 Whole Time Equivalent (WTE) staff, affecting both primary and secondary care services. This has been compounded by HB’s recruitment policy.
Patient Impact: The staff shortage has led to very poor patient experiences, particularly for vulnerable patients and those on cancer pathways. These concerns have been escalated to the Chief Executive via correspondence from MPs and MSs (Welsh Government) and patients themselves.
Historical Problem: The Health Board has had this problem before, and the current, temporary fixes are not sustainable or future-proofed.
National waiting time initiatives and the increasing requirements to monitor medication have impacted demand.

The HB has resolved to take the following immediate & Short-Term Actions:
Recruitment Drive: RP has signed off on 5.5 WTE posts for recruitment, with interviews held on November 20th and 21st. Candidates will undergo rapid onboarding including being pulled early, where possible, from their notice periods.
Redeployment: The secondary care phlebotomy offer at Neath Port Talbot will be reviewed and rationalised to free up capacity. Capacity will be redeployed to the primary care phlebotomy offer.
Short-Term Staffing Boost: Shifts are being offered to anyone qualified to take blood, including medical and nursing students, as a short-term measure to boost capacity.
Service Relocation: The phlebotomy service, recently moved to a new, non-ideal location within Singleton Hospital and will be moved again within Singleton to allow for extra chairs and improved patient throughput.

SBUHB is keen to work with the LMC to design a sustainable, future-proofed, 3-5 year model for the phlebotomy service, noting that recent data from 2 years ago indicated that approximately 12K blood tests were taking place in practices and not being claimed for. It should also be noted that the Welsh Government have an agenda to transform the phlebotomy service illustrating that it is a national area of concern.
Please continue to datix related issues and contact us regarding your concerns about this important patient safety issue.

Update 27/1/26:

The issue was discussed at the SBUHB Board meeting on 26/1/26 and the paper is attached below.

MLMC have been informed by SBUHB that the current waiting time (median) is now (as of 27/1/26) 13.5 days actual days (not working days) and this is down from ~22 days in December. There remains significant variation across sites with the best areas (Gorseinon and Port Talbot) averaging a 5 day wait whereas Singleton remains at >20 days.

Rather than running at 100% capacity the service is now holding back specific capacity in some areas for shorter notice release for urgent appointments and the extended hours trial, allowing for patients working 9-5 to access the service, is looking to be extended.

Another issue which has been acknowledged is patients having to travel to secondary care sites to access phlebotomy services and consideration is being given into increasing community phlebotomy provision.

A national benchmarking exercise is being completed by SBUHB and this will inform a new operating model, acknowledging that there are challenges with the current booking system.

Question 36

Whilst working in the Out of Hours (OOH) Service I have been asked to sign prescriptions for clinicians working remotely, am I obliged to sign them?

Accepted Answer

OOH Remote Prescribing Risks

Prepared by Dr Nimish Shah January 2026

Overview      
The LMC have received reports of increasing pressure on GPs to sign prescriptions for remote clinicians—including non-GP specialists—within the Out of Hours (OOH) service. The feedback the LMC have received suggests that the current "Crown Indemnity" assurance may be creating a false sense of security. While it provides financial cover for the Health Board, it does not mitigate the personal professional risk to a GP's registration when signing for a clinical assessment they did not perform.

This briefing note covers:
The distinction between Financial Indemnity and Professional Défense
The specific risks of signing for non-GP specialists (e.g., Paediatricians)
The contractual obligations and the role of the LNC in negotiating these terms

1.      The Core Risk: Responsibility vs. Cover

There is a significant distinction between financial protection and professional protection. It is vital that clinicians understand the limits of Health Board cover:
Financial Indemnity (Health Board/Crown Indemnity): This covers the financial cost of a clinical negligence claim (payouts to patients). It does not provide personal legal representation.
Professional Protection (MDOs e.g., MPS, MDU): This provides legal defense for GMC investigations, Coroner’s Inquests, and Disciplinary hearings.

Key takeaway: A GP who signs a prescription based on a remote assessment they did not perform inherits the legal responsibility for that prescription. If the assessment is later found to be flawed, the "signer" remains accountable to the GMC.

2.      Specialist-to-GP Prescribing (Paediatrics)

The recent request for GPs and Pharmacists to sign for remote Paediatricians carries a heightened professional risk:
Scope of Practice: GPs are frequently asked to sign for dosages or medications (e.g., weight-based calculations or off-license uses) that sit outside standard primary care guidelines.
GMC Guidance: Good practice in prescribing (2021) states that you must only prescribe if you have sufficient knowledge of the patient’s health and are satisfied that the medication is clinically justified.

3.      Contractual & Negotiation Routes

Responsibility is often dictated by the "fine print" of employment:
Individual Contracts: GPs must verify if "remote cross-signing" is a specified duty in their signed OOH contract. If it is a contractual requirement, the GP is obliged to perform it, provided it is clinically safe.
Local Negotiating Committee (LNC) Role: While the LMC represents the profession broadly, the LNC is the formal body responsible for negotiating terms for those on Health Board contracts. Collective disputes regarding these working conditions should be escalated through the LNC.

4.      Recommendations for GPs

Seek Individual Advice: Every GP should contact their Medical Defence Organisation (MDO) for a written opinion regarding their specific OOH role and the "line of sight" required for safe signing.
Document Concerns: If signing under protest or due to contractual obligation, ensure the rationale and the remote clinician's details are clearly logged.
Competence First: If a prescription feels clinically unsafe or is outside your competence, you have a professional right (and duty) to decline and suggest an alternative pathway.

Update 27/1/26

Further to enquiry from SBHB they can confirm that when an OOH service is provided directly by a HB—whether the HB employs staff or engages locums/agency workers—those individuals are fully covered under the longstanding NHS indemnity not GMPI, just as hospital doctors are with no requirement for this work to be recorded in Locum Hub Wales. There is of course the additional requirement for MDU/MPD etc indemnity for professional issues. The same applies to NHS 111 workers.

Do I Need to Register for the All Wales Locum Register?

Question 37

Can Healthcare Support  Workers (HCSWs) consent patients for Immunisations?

Accepted Answer

It has been queried recently about the process of obtaining valid consent for  immunisation and it is worth clarifying the role of HCSWs in vaccination, in line with UKHSA advice and  relevant professional standards. There is no change to registered nursing  associates; you can find further information regarding legal mechanisms for vaccination from  NHS England.  This was provided by Avon LMC information should be read in conjunction with all the links, references and further reading.

Principles of Consent
Consent must be freely given, voluntary, and without coercion. 
The individual providing consent must have the mental capacity to do so. 
Consent is a process, not a one-off event. It may be withdrawn at any time. 
Consent for one immunisation does not automatically apply to future doses or other  vaccines unless explicitly agreed.

Consent can be given by: 
The individual themselves (if competent). 
A person with parental responsibility (for children lacking capacity). 
An authorised representative under a Lasting Power of Attorney (LPA) for health  and welfare.
A court-appointed deputy.

Responsibilities:
Prescribers (e.g., under Patient Specific Directions) 
Responsible for seeking informed consent when prescribing vaccines. 
Must ensure the patient understands the risks and benefits of the vaccine. 
Consent may be obtained verbally, via Accurx, or using a written consent form. 
Must document the consent process in patient records.

Healthcare Support Workers (HCSWs)

Patient is not receiving the vaccination for the first time 
HCSWs may administer subsequent vaccinations previously consented to by a registered HCP,  such as seasonal flu vaccines, if the following apply: 
Consent has been previously obtained by a registered HCP eg by a nurse under a PGD,  or a presciber under a PSD and the patient confirms this is still valid. 
There are no changes in the patient’s medical history or circumstances. 
The HCSW has undertaken basic checks, for example, checking that the patient is non-febrile and no other contraindications apply since the original assessment to ensure  patient safety.

They must seek support from a registered HCP if: 
The patient has concerns 
The patient wishes to discuss risks/benefits further. 
The patient requires in depth assessment for contraindications e.g.  immunosuppressive therapy 
Any other concerns arise

Patient is receiving the vaccination for the first time 
HCSWs may administer vaccinations to those who have never received the vaccination if the  registered HCP has undertaken a clinical assessment and the registered HCP ensures the patient understands the vaccine being offered,  including risks and benefits and consent is obtained and recorded appropriately. This  may be done in one of the following ways: 
Speaking with the patient directly or through other communication, eg accurx, a  letter or an email. This should include NHS information on the vaccine being offered  (Flu vaccine , COVID-19 vaccine, Shingles, RSV vaccine).  You can find example Covid consent letter on the gov.uk website. 
Other staff, eg non clinical may be able to pre-screen in advance; however, the  registered HCP must be able to review and confirm responses as needed (NHS  England, 2023).

What Legal Mechanisms can be used for HCSW to administer if the patient has been  assessed and consent has been obtained by a registered HCP or prescriber as outlined  above?

Good Practice Principles

Always check that the patient is content to proceed before administering subsequent  doses.

Re-seek consent if:
The patient withdraws consent or wishes to discuss further
New safety information arises 
The vaccine formulation or indication changes 
The number of doses required changes.

Provide information in accessible formats, including translations and interpreters where  necessary.

Record that consent has been obtained, even if verbal.

References and further reading:
UKHSC Green Book, Chapter 5  
NHS Specialist Pharmacy Service guidance on PGDs. 
General Medical Council (2021) Good practice in proposing, prescribing, providing and  managing medicines and devices - GMC 
NMC (2025) Useful information for prescribers - The Nursing and Midwifery Council  
Annual flu programme - GOV.UK

Question 38

A patient who is on a waiting list is asking for an expedite letter, what should I write?

Accepted Answer

It is not your responsibility to provide an expedite letter for patients on a secondary care waiting list. We are aware that many patients report that they are explicitly informed to request an expedite letter from their GP when contacting secondary care services but this is not correct. Patients should not be encouraged to see their GP for reassessment unnecessarily and secondary care services must accommodate the reality that patients' health will unfortunately deteriorate whilst waiting and there is a need to manage patients expectations. Patients should be advised that secondary care colleagues will be in touch to discuss results and that GPs will not have access to the latest clinical management plans - until the consultant formally writes to them.

Expedite letters for patients on hospital waiting lists should not be requested from GPs and if there is a need for waiting lists to be triaged, a Health Board solution will need to be identified.

This is made clear in point 7 of the All Wales General Practice and Health Board Clinical Interface Standards

7 Expedite Requests:
Patients who make contact to expedite appointments should be dealt with accordingly: 
Should be based on clinical need; a long waiting time does not alter priority 
For patient experience, clinically valid expedite requests should be dealt with by the team who they contact, rather than directed elsewhere
Follow-up appointments for review or treatment should be brought to the attention of the specialist overseeing their care for action.

Question 39

What is the Rapid Diagnosis Centre (RDC)?

Accepted Answer

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).

Question 40

How do I refer to the Immunology and Allergy service in Swansea Bay University Health Board (SBUHB)?

Accepted Answer

On 21st February 2024 we sent an email update regarding Immunology and Allergy service in SBUHB:"Dear PracticesThe LMC has been seeking an update from the HB since practices shared that the Cardiff allergy services and immunology specialist service had been decommissioned.The SBUHB Commissioning and Contracting Manager has shared the following with the LMC:"We have had clarity that Cardiff service would continue to accept referrals for patients who have been seen and treated within local secondary care allergy services who continue to have significant symptomatic burden despite the interventions made and where the secondary care allergy service requests a tertiary opinion. For SBUHB residents, new referrals are being sent to West Sandwell & Birmingham NHS Trust via the Prior Approval route as an interim arrangement whilst alternative commissioning options are being explored. I would advise that any referrals are submitted via SBU IPFR team at: Planning.Office@wales.nhs.uk. This would also support in quantifying the ongoing demand for this service requirement toward establishing a sustainable resolution.As notice was provided to cease activity to all South Wales Health Boards, a task and finish group lead by Powys THB are collectively exploring a joint commissioning route via bordering English Trusts to support with the demand for Welsh patients. Primarily, ongoing discussions are taking place between North Bristol and Powys THB for this commissioning approach but appreciate that due to the specialist nature of the service we are faced with limitations.I aim to continue with further internal conversations to explore the viability of a potential local SBU resolution, but note that this will take time to plan, design and implement but will ensure the primary care colleagues are updated as soon as possible with any developments."A commissioned service would be in the LMCs opinion the most robust and safe approach. As soon as we have more information we will distribute.Many thanksNimishThe LMC have been continuing to seek updates on the commissioning of a local adult allergy service. There have been no substantial developments. Can we therefore ask that you utilise the attached partially pre-populated form to submit via IPFR. This form will only require patient details and your electronic signature. If there are further developments the LMC  will update practices.We note that SBUHB have sent out correspondence on 24th August 2026 which updates that referrals should be sent to Heartlands Hospital, BirminghamDear Colleagues, We have been advised that referrals submitted to West Sandwell and Birmingham for Allergy Services are now being returned. Please note that the designated provider for Allergy referrals is now Heartlands Hospital, Birmingham. An updated referral form reflecting the new provider details is attached. I would be grateful if practices could begin using this revised form with immediate effect when making Allergy referrals. In addition, should any referrals submitted to Heartlands Hospital be returned or rejected, please notify the IPFR Team @Planning Office as soon as possible so that they can investigate and follow this up directly with the provider. Thank you for your support and cooperation in implementing this change. If you have any queries, please do not hesitate to get in touch. Kind regards,Ceri#Individual Patient Funding Requests #IPFR

Question 41

What are the changes to managing Care Home Respiratory Infections?

Accepted Answer

To address high Tier 1 infection rates within SBUHB, the responsibility for swabbing is shifting from the Health Protection Team (HPT) to Care Home staff. The objective is to facilitate faster testing and enable antimicrobial stewardship reviews.

The New Protocol

Testing: Care Homes are being issued their own swab testing kits. Staff will now perform swabs themselves when 2 or more residents display respiratory symptoms. GP surgeries should not be asked to visit solely to swab patients; if a home lacks kits, they must contact the SBUHB Health Protection Team.
Timing: Guidance has been issued to IPC leads that swabs must be taken before empirical antibiotics are started to prevent false negatives or masking of bacterial infections.
Results Routing: Samples are sent via post. Results are returned to the Care Home or requesting clinician only, not automatically to the GP surgery.

Action Required from GPs
If a patient was started on empirical antibiotics but the swab result subsequently confirms a viral infection, the Care Home has been instructed to contact the patient's GP surgery.

Clinical Review: As the clinician who prescribed the initial course, you will be asked to review the new clinical picture (the viral result plus current observations provided by the Care Home).
Deprescribing: You will need to decide if it is appropriate to discontinue the antibiotics to reduce resistance and patient harm. Care Home staff have been explicitly instructed that they cannot make this decision independently.

Question 42

Is it my responsibility to write an expedite letter for a patient on a Hospital waiting list?

Accepted Answer

Expedite letters for patients on hospital waiting lists should not be requested from GPs and if there is a need for waiting lists to be triaged, a Health Board solution will need to be identified.

This is made clear in point 7 of the All Wales General Practice and Health Board Clinical Interface Standards

7 Expedite Requests:
Patients who make contact to expedite appointments should be dealt with accordingly: 
Should be based on clinical need; a long waiting time does not alter priority 
For patient experience, clinically valid expedite requests should be dealt with by the team who they contact, rather than directed elsewhere
Follow-up appointments for review or treatment should be brought to the attention of the specialist overseeing their care for action.

It is not your responsibility to provide an expedite letter for patients on a secondary care waiting list. We are aware that many patients report that they are explicitly informed to request an expedite letter from their GP when contacting secondary care services but this is not correct. Patients should not be encouraged to see their GP for reassessment unnecessarily and secondary care services must accommodate the reality that patients' health will unfortunately deteriorate whilst waiting and there is a need to manage patients expectations. Patients should be advised that secondary care colleagues will be in touch to discuss results and that GPs will not have access to the latest clinical management plans - until the consultant formally writes to them.

Question 43

Am I responsible for dealing with post-operative complications or inadequate post-op discharges (such as inadequate analgesia or post- op antibiotics)?

Accepted Answer

The GP is not responsible for dealing with post-operative complications or inadequate post-op discharges (such as inadequate analgesia or post- op antibiotics). Any instances where a patient has been told to see their GP regarding this, or the discharge summary states this, should be datixed and the patient directed back to the operating team to resolve.

Please do inform us if this happens to you, it is often a distressing experience as patients can understandably become frustrated at having to return to the hospital and view the GP as being "obstructive" but inadequate provision of service from secondary care does not mean that additional, unfunded work should be undertaken by already overstretched GP surgeries.

Question 44

What are the All Wales Communication Standards between General Medical Practitioners and Secondary care (AWCS)?

Accepted Answer

The All Wales Communication Standards between General Medical Practitioners and Secondary care (AWCS) have been superseded by the All Wales General Practice and Health Board Clinical Interface Standards. These standards have been designed to improve the safety and quality of patient care in NHS Wales and ensure that our patients have the best possible experience as they navigate their pathways. It is a consensus document that has been co-produced with Primary and Secondary Care Clinicians and endorsed by the All Wales Medical Directors.They apply to all NHS Wales clinicians communicating clinical information between General Practice and Health board run services. They also apply to clinicians working in the private sector who interface with General Practice.They replace WHC (2018) WHC/2018/014 - All Wales Communication Standards between Primary and Secondary care (AWCS)Individual professional standards:1 Investigations:Any clinician managing a patient’s care who deems an investigation is necessary should: Request the investigation Take responsibility for actioning of the result Communicate the result directly to the patient and help them understand it. Delegating these responsibilities is appropriate if there is agreement to do so (see Standard 5).2 Referrals: Any clinician referring a patient for a consultation should: Ensure the patient understands the reason for the referral  Ensure the patient knows who is responsible for their care Ensure the patient knows what should happen next Ensure the referral contains all information needed to determine the priority of the referral Make the referral themselves when they have the competence to do so When not making a referral themselves, a clinician should never direct a patient to another clinician to ask for a specific referral or expected timeframe for action. Clinicians should respect colleagues' autonomy and allow them to determine what is best for the patient. 3 Med3: The clinician who advises the patient to refrain from work must: Issue the Med3 Ensure the duration of the note covers the time period to expected return to work or the next planned review 4 Prescribing: A clinician recommending that a patient starts a new medication must: Issue a prescription if that medication needs to be initiated within the next seven daysIssue a prescription for a minimum of two weeks but longer if clinically appropriate Communicate all necessary counselling of the patient if recommending another clinician starts the medication Ensure prescribing and prescribing recommendations should be within the scope of practice of the clinician to whom the recommendation is being made Name the responsible clinician when recommendations are from non-prescribers. Adhere to shared care prescribing processes by retaining prescribing responsibility until the GP has accepted the request and received the stable handover letter Take account of guidance provided in the health board’s prescribing formulary and the availability of the medicine in primary care, when initiating or recommending a GP initiates medication(s)  Be prepared to retain prescribing responsibility if the medication does not have a UK marketing authorisation (i.e. the medication is unlicensed)Be prepared to retain prescribing responsibility if the medication has a UK marketing authorisation but it is being prescribed in a way which is outside the terms of its authorisation (i.e. the medication is licensed but prescribed ‘off-label’), where such prescribing is not generally accepted clinical practiceOrganisational Standards5 Investigations: Organisations should have standard operating procedures (SOPs) to mitigate against clinical governance risks and transfer of clinical responsibility when requesting investigations and actioning the results There should also be SOPs with regards communication of results to patients These SOPs should support clinicians in adhering to the individual professional standards 6 Referral and Outpatient Communications:Must be compliant with data protection regulations. Must be made via the nationally or locally agreed electronic method where it exists.  Must be actioned promptly, including requests for further information Changes to priority must be communicated to the referrer and the patient Should be addressed to the referrer with copies to the patient and their GP if not the original referrer.  Referrals that are declined, must be clinically justified and require timely communication to the referrer within the timeframe stated in Planned Care guidance (currently 48 hours).7 Expedite Requests:Patients who make contact to expedite appointments should be dealt with accordingly: Should be based on clinical need; a long waiting time does not alter priority For patient experience, clinically valid expedite requests should be dealt with by the team who they contact, rather than directed elsewhereFollow-up appointments for review or treatment should be brought to the attention of the specialist overseeing their care for action.  8 Did Not Attend:Care needs to be taken to ensure reasonable adjustments are made for patients with protected characteristics under the Equality Act. Where patients do not attend for out-patient appointments without giving notice, in line with WG guidelines for pathway management, they will be discharged. The original referrer, the GP (if not the original referrer) and patient should all be advised of the discharge. Where the patient has reasonable grounds to challenge the decision, they should be reappointed without a new referral. In the case of vulnerable adults and children who do not attend refer to the local “was not brought” policy 9 Patient Discharges:  Electronic discharge advice letters (eDAL) should be completed at the time of discharge, and a copy sent with the patient Patients should be discharged with at least two weeks of medication (which may be supplied from the hospital or from medication already in the patient’s possession. Where there may be a longer than usual time needed to source a medication in primary care (e.g. where a special formulation or unlicensed preparation is prescribed), consideration should be given to providing at least four weeks of medication at discharge  Discharges out of hours should ensure appropriate handover to Out of Hours providers e.g. End of Life Care. Similar information should be provided for completion of an ambulatory care assessment. 10 Pre-operative Assessment Clinics Must have named medical support  Should first use the named medical support when unexpected findings are identified. Refer internally for optimisation for surgery, or an appropriately commissioned optimisation service  If you are aware of a breach of these standards, please datix the incident and contact us so that we can ensure these standards are upheld throughout Swansea Bay.Our Deputy chair has created some resources, including a video, for training staff on these Standards and are ideal for induction training or department training within a primary or secondary care setting. Slides are available here:Video of presentation available here:# AWCS

Question 45

Do I have to supply an acute prescription for medication following an outpatient appointment or discharge?

Accepted Answer

Providers must supply patients with medication following an outpatient appointment or discharge from inpatient or day case care. Medication must be supplied for the period established in local practice or protocols but must be for a minimum of seven days (unless a shorter period is clinically necessary).

This is made clear in point 4 of the All Wales General Practice and Health Board Clinical Interface Standards

4 Prescribing: 
A clinician recommending that a patient starts a new medication must: 
Issue a prescription if that medication needs to be initiated within the next seven days
Issue a prescription for a minimum of two weeks but longer if clinically appropriate 
Communicate all necessary counselling of the patient if recommending another clinician starts the medication 
Ensure prescribing and prescribing recommendations should be within the scope of practice of the clinician to whom the recommendation is being made 
Name the responsible clinician when recommendations are from non-prescribers. 
Adhere to shared care prescribing processes by retaining prescribing responsibility until the GP has accepted the request and received the stable handover letter 
Take account of guidance provided in the health board’s prescribing formulary and the availability of the medicine in primary care, when initiating or recommending a GP initiates medication(s)  
Be prepared to retain prescribing responsibility if the medication does not have a UK marketing authorisation (i.e. the medication is unlicensed)
Be prepared to retain prescribing responsibility if the medication has a UK marketing authorisation but it is being prescribed in a way which is outside the terms of its authorisation (i.e. the medication is licensed but prescribed ‘off-label’), where such prescribing is not generally accepted clinical practice

Question 46

How much does Community Health Pathways cost?

Accepted Answer

Morgannwg LMC submitted a FOI request to ask:
1. What is the total amount of money spent on this project?
2. How has this money been divided between health boards, ie what percentage and total amount has been allocated to each health board in Wales?
3. How much money has Swansea Bay University Health Board been allocated for the project?
4. When does the funding stop?

We received a response from Cynnar Health, Social Care and Early Years Group stating that:
1. Total cost incurred up to the end of September 2025 is £5,939,420.08 (From April
2023 to September 2025)
2. See enclosed tables in Appendix A (see below)
3. Total allocation for Swansea Bay UHB across the project up to end of September
2025 is £434,259.62
4. The current contract is due to finish end of March 2026.

Question 47

We have received a request from ADHD 360 to provide medication for a stabilised patient, do we have to agree to shared care regarding this patient?

Accepted Answer

No, ADHD360 has been used as an outsourced provider by Swansea Bay but this was not communicated to GPs and so has caused some confusion regarding the GP's role.

MLMC has confirmed that stabilised patients must be referred back to secondary care by ADHD 360, not onto GPs directly. ADHD360 has been used as an outsourced provider by Swansea Bay but this was not communicated to GPs and so has caused some confusion regarding the GP's role.

If you need assistance or clarification regarding this matter, please do get in touch

Question 48

I've been asked to arrange wound care at a weekend for a patient, what do I do?

Accepted Answer

To be clear, weekend daily wound care (such as post-operative packing) is entirely outside the GMS contract, and the responsibility to provide a continuous community pathway sits squarely with the Health Board. The LMC has been consistently lobbying on this point; while the HB agreed to temporary cover over Easter, they have unfortunately not responded to our requests to extend this into a permanent service.We have escalated this directly to the HB management on multiple occasions and have done so again on 26/5/26. However, in the meantime, if you are faced with a patient requiring urgent weekend wound care and no community pathway exists, the LMC advises you to take the following steps to ensure patient safety:Hospital / ED Referral: If there is no safe community provision, you will unfortunately have no choice but to refer the patient to Morriston Hospital / SDEC for their weekend care.Submit a Datix: Please robustly Datix every single occurrence where a patient is refused weekend DN care. This data is vital for the LMC to demonstrate the systemic failure and force a Health Board solution.Communicate the Issue: Inform the discharging hospital team (if applicable) that the community DN service is currently refusing weekend continuity of care.
We will keep you closely updated on the Health Board's response.# district nurse # wound

Question 49

Do I still use Putting things right to respond to complaints or Listening to people?

Accepted Answer

Listening to People has replaced Putting Things Right regarding how to raise a concern about NHS services from 31 March 2026, unfortunately MLMC was not given advance notice of this being implemented to advise practices.

Question 50

Are GPs involved in the MenB (Meningococcal group B) vaccine ?

Accepted Answer

No, Practices are not involved in the MenB (Meningococcal group B) vaccination programme and this will be run by Health Boards (Swansea Bay UHB). The MenB (Meningococcal group B) vaccination will be offered to all those aged 17 and 18 who were born between 01/09/2007 and 31/08/2008.  The vaccine is also available to those turning 25 after 31/12/2026 who will be attending Higher Education or Residential Further Education for the first time from Autumn 2026. This includes international students and those from the UK Devolved Administrations and Crown Dependencies. The vaccine will not be offered to: those who turn 25 on or before 31/12/26, presenting for their first dose those under 25 years continuing their studies – not attending further or higher education for the first time, including post graduates  those in school-level residential settings, for example boarding schools, unless they are eligible due to their age.Seventeen and 18 year olds who were born between 01/09/2007 and 31/08/2008 will receive an invitation letter from their health board. Letters will be sent after 1 July.  For those under 25 and attending Higher or residential further Education for the first time this Autumn, you will not receive an invitation letter but you can contact Swansea Bay University Health Board after 20 July to find out where to get your vaccination. Swansea Bay University Health BoardWebsite: Visit the Swansea Bay University Health Board website.Address: 1 Talbot Gateway, Baglan Energy Park, Baglan, Port Talbot, SA12 7BRPhone number: 01792 200492Email: sbu.imms@wales.nhs.ukPlease do not contact your Swansea Bay University Health Board before 20 July 2026 as further information will not yet be ready.  If you are under 25 and attending Higher or Residential Further Education for the f irst time this Autumn you will be expected to provide evidence of your offer letter from university or college when you arrive for your appointment.First doses will be offered in Wales from 20 July until 31 December 2026. Second doses will be offered in Wales until 31 March 2027.The second dose of the MenB vaccine is recommended at least 4 weeks (28 days) after the first dose to give you the best protection against MenB infection. It takes at least 2 weeks from the second dose of the vaccine for your body to achieve a good level of protection, so delaying the second dose delays protection.  Those eligible should aim to get both doses before starting at college or university this Autumn.Patients will need to have both doses of the vaccine, 4 weeks apart and then wait 2 weeks for the best protection.  The MenB vaccine has been thoroughly tested and meets strict safety criteria. It has been routinely used in the infant vaccination programme in the UK since 2015 and has led to 75% reduction in MenB disease in vaccinated groups.

Question 51

Podiatry are asking our practice to prescribe antibiotics for patients with osteomyelitis, do I have to issue a prescription?

Accepted Answer

It has come to the LMC’s attention that practices are still receiving requests from Podiatry to prescribe long-course, broad-spectrum antibiotics (such as clindamycin) for patients with suspected or confirmed osteomyelitis.The Morgannwg LMC position, consistently reiterated to the Health Board, is that General Practitioners are under no obligation to undertake this prescribing.The LMC strongly advises practices not to assume this responsibility for the following reasons:Outside GMS Remit and Competence:The management of osteomyelitis is considered outside the scope of GMS and a GP’s core competence. Podiatry's own guidelines recommend a multidisciplinary team approach, including Trauma & Orthopaedics, which suggests it is beyond the capability of primary care.Inappropriate Workload Transfer:Requiring GPs to prescribe constitutes an inappropriate and unfunded workload shift, often resulting from the Podiatry service's lack of an Independent Prescriber. General Practice should not be expected to subsidise non-GP work.This is in accordance with the new All Wales General Practice and Health Board Clinical Interface Standards and consistent with the approach MLMC has taken with other such requests. Financial and Clinical Risk:Prescribing long-term, broad-spectrum antibiotics can negatively impact practice prescribing data (4C categorisation) and result in financial penalties for the practice. Furthermore, local guidelines require regular monitoring (e.g., weekly blood tests), which is unsafe and impractical for primary care given typical outpatient blood waiting times.Action for Practices:If you receive a request from Podiatry for long-course antibiotic prescribing for osteomyelitis, you should:1. Decline the request and ideally datix the request, informing the LMC once patient information is removed from correspondence.2. Inform the Podiatry team that, as this falls outside GMS and requires specialist prescribing and monitoring, they must arrange to manage the prescription and follow-up.We appreciate the difficult position this places you in, but acceding to these requests perpetuates the problem and diverts precious GMS capacity.We will continue to raise this matter at the highest level of the Health Board Liaison meetings.

Question 52

How do I become a Veteran Accredited Practice?

Accepted Answer

Veteran Accredited GP Practices play a vital role in strengthening pathways between primary care and the veteran community. Accreditation enables practices to:• Identify and code ex forces (veteran) patients within their systems• Signpost individuals to veteran hubs for tailored, non‑clinical support• Prioritise access to healthcare where appropriate• Train staff on military‑related physical and mental health conditions • Refer directly to dedicated services such as NHS Veterans WalesTo find out more or to enrol, visit Y Ty Dysgu Veteran Friendly Accreditation Course:https://ytydysgu.heiw.wales/courses/517e9008-929b-44da-b7e3-e182d910f557Locally, Swansea Veterans Hub provides a trauma informed support service for veterans across south Wales. Veteran Accredited GP practices can signpost veterans, reservists and family members to this local service. The hub provides practical, emotional and wellbeing support to veterans, reservists and their families. This includes assistance with mental health challenges, physical health concerns, the cost‑of‑living crisis, digital exclusion, social isolation and wider welfare needs.Click on the link below to find out more:Home - Learn More About Swansea Veterans Hub

Question 53

Rheumatology / Nuclear Medicine have asked me to organise repeat DEXA tests in 3 - 5 years, do I have to do this?

Accepted Answer

The LMC are receiving queries again about Rheumatology and Nuclear Medicine continuing to ask GPs to organise repeat DEXA tests in 3 - 5 years. The HB have been advised that GPs do not have a multi-year recall function to track secondary care patients on behalf of secondary care.  We hope that an IT solution will be made available for our colleagues. Whilst this is in development could we kindly ask that patients are advised directly to contact their GP at 3 - 5 years to enable a repeat to be organised rather than consultants writing to the GP asking for the GP to arrange. We ask practices to write back to WCCG to state that this will not be actioned due to not having access to a multi-year recall system to ensure that any medicolegal risk is removed.  The lack of a suitable secondary care recall facility does not make the repeat request a GMS responsibility, in keeping with the All Wales General Practice and Health Board Clinical Interface Standards.The LMC were under the impression from previous discussions that the outcome was to place the onus on the patient to present in 3 or 5 years time.

Question 54

What information do I need to provide to ensure my request for a pelvic ultrasound is not rejected?

Accepted Answer

The LMC has been in discussions with the radiology department regarding the confusion over pelvic ultrasound scans. The department understandably receive a significant number of referrals, and they do need to triage the referrals based on the information that is provided in the request appropriate national and local guidelines. Following is the information provided by radiology which is needed for the department for them to be able to do effective triage and to reduce rejections Working diagnosisGuidelines for PMB require and USS to determine the endometrial thickness for cancers. Certain conditions such as fibroids have both structural and physiological impact on patients.  If we state the working diagnosis correctly, it will improve the chance of acceptance and prioritisation. Conditions such as PCOS are considered not benefiting much from USS and the department will advise referral to gynae if primary care measures have not been effective. HistoryBleeding Pattern & duration: IMB, PCBMenorrhagia or increased frequencyAnaemia, Timing in relation to HRT would be useful to explain if the patient is on continuous HRT where bleeding is not expectedGuidelines accept a 3-month window to settle the bleeding down for any new HRT start or change in regimenPresence or absence of Mirena/ other coils ( image quality can be affected)Any associated pain – abdominal or inguinal fossa, deep pain on VEIndicators of Cancer - bloating, loss of appetite, tiredness, Hb , Ca 125Risk factors for endometrial cancer - High Body Mass Index (BMI).PMH- diabetes or PCOS, Lynch Syndrome, prior gynaecological issues, or scans ExaminationAny palpable uterus per abdomen or fullness per vagina  ( palpable fibroids require USS measurements as per the guidelines )Documentation to indicate that infection is excludedA vaginal and speculum examination has been performed to rule out obvious cervical or vaginal causes of bleeding, which cannot be reliably visible in USS

Question 55

I need to test for multiple myeloma, how can I request Serum Free Light Chains (SFLC) for my patient?

Accepted Answer

Why is there concern regarding the current testing pathway for Multiple Myeloma?Current national guidance (including NICE, Myeloma UK, British Society for Haematology/UK Myeloma) states that diagnosing myeloma requires testing for both monoclonal paraproteins and Serum Free Light Chains (SFLC) or urinary Bence Jones Protein (BJP). Approximately 20% of myeloma cases are "Light Chain Only" and may be missed if only a paraprotein screen is performed. The current omission of SFLC/BJP as an option on the electronic test requesting platform in SBUHB creates a potential clinical risk.How can I request Serum Free Light Chains (SFLC) for my patients?SBUHB has advised that primary care clinicians can request SFLC using the following routes:Direct Request: If you have a patient with a strong clinical suspicion of myeloma but no paraprotein was identified on the initial screen, you can request SFLC using a paper request form. SBUHB state that Primary care sites were informed of this process when blood sciences stopped performing BJP testing.USC Referral: If you do not wish to use a paper request form for SFLC, you can refer the patient via the Urgent Suspected Cancer (USC) pathway on clinical grounds. The health board will then request the SFLC test.What happens if the initial paraprotein screen is positive?If a paraprotein is identified on the initial screen, the laboratory will reflexly perform SFLC testing to determine if the result indicates MGUS or light chain myeloma.

Question 56

Who do I speak to about issues with Electronic Test Request (ETR) forms?

Accepted Answer

We have sent the following our to practices on Tuesday, August 18Dear Practices The LMC have received reports about Pathology order delays. We have been advised that there are no further supply issues with ETR forms but have shared with the HB that if these reoccur, practices will switch to using plain A5 paper so that bloods can be processed in a timely fashion. The HB are aware that phlebotomy colleagues will unfortunately be responsible for printing out stickers in this scenario. We have received the following update from the department regarding all other stock delays: "We are sorry to hear that colleagues in primary care are still experiencing delays when requesting orders for Pathology stock.We recognise that the current process with a lack of visibility on the status and progress of orders is not ideal and can result in uncertainty and repeat ordering.Moreover, the Pathology Office has been operating with reduced staffing capacity for a sustained period, which has impacted the time taken to process orders. We will look to introduce an automated reply for the dedicated email account (SBU.PathologyOnlineShop@wales.nhs.uk) to confirm that an order has been received and will take up to 5 working days to process (reflecting current operational capacity).A further email will be sent to the requestor once the order has been processed and is available for transport to surgeries.We will liaise closely with the NHS Wales Health Courier Service (HCS) to ensure the orders are collected and delivered promptly. If practices have any future order queries Jenna Evans, Pathology Quality Manager, has kindly agreed to act as a contact : Jenna.Evans@wales.nhs.uk The department have asked that, where possible, it would be helpful if practices would consider sending a single email containing all stock requirements. If you continue to experience difficulties after these measures have been introduced, please let the LMC know so that we can investigate further. Many thanksMLMC Executive Team

Question 57

Are there any training resources for the All Wales General Practice and Health Board Clinical Interface Standards?

Accepted Answer

These standards have been designed to improve the safety and quality of patient care in NHS Wales and ensure that our patients have the best possible experience as they navigate their pathways. It is a consensus document that has been co-produced with Primary and Secondary Care Clinicians and endorsed by the All Wales Medical Directors.They apply to all NHS Wales clinicians communicating clinical information between General Practice and Health board run services. They also apply to clinicians working in the private sector who interface with General Practice.The All Wales General Practice and Health Board Clinical Interface Standards replace WHC (2018) WHC/2018/014 - All Wales Communication Standards between Primary and Secondary care (AWCS)Our Deputy chair has created some resources regarding these standards, including a video, for training staff on these Standards and are ideal for induction training or department training within a primary or secondary care setting. Slides are available here:Video of presentation available here:

Template letters & FAQs