Three County LMC/HB Meeting

LMC/HB 10/03/11

Three County LMC/HB Meeting

10th March 2011

PRESENT

HB:

Jill Paterson, Assistant Director of Primary Care and Community

Dr Mark Barnard, Associate Medical Director for Primary Care

Rhian Bond, Head of Primary Care

David Eve, Assistant Director of Finance

Jenny Pugh-Jones, Head of Prescribing & Medicines Management – Ceredigion

Anna Evans, Primary Care Development Manager

LMC:

Dr David Roberts, GP, Meddygfa Teifi, Llandysul, Ceredigion

Dr Laurence Williams, GP, St Thomas Surgery, Haverfordwest, Pembrokeshire

Dr Heather Evans, GP, Meddygfa Tywi, Nantgaredig, Carmarthenshire

Janet Powell, Secretary, Dyfed-Powys LMC

Guests:

Carol Evans, Assistant Director of Corporate Services (Public and Patient Engagement)

Support:

Karen Hackett, Performance Officer, Primary Care

Agenda Item No: /

Subject

/

Action

Apologies for absence

Apologies were received from the following:
HB:
Bernadine Rees, Director of Primary, Community & Mental Health Services
Dr Sue Fish, Medical Director
LMC:
Helen Roberts, Practice Manager, Tenby Surgery, Pembrokeshire
JPat informed the group that Bernie Rees would no longer be a member of the group due to her recent appointment to Cwm Taf LHB and extended her thanks to Bernie for her past attendance and contribution to the discussions.
2. /

Minutes of the last meeting held on 13th January 2011

The minutes were agreed as a true and accurate record of the meeting.
It was noted that the majority of the papers were again sent out late for this meeting. The HB undertook to aim at getting all papers out 7 days prior to a meeting in future. / HB
3. / Matters arising not on the agenda
Leg Ulcers:
The HB reported that no update has been received on this issue. MB will chase Dr Fish for an update for the next meeting
Communication with Primary Care:
DR reflected that there is still some work needed to improve communications with GP practices. The LMC requested regular communication with the LMC administration office, to assist in the dissemination of information.
JPat informed the group that she did not attend the recent Ceredigion Practice Managers’ Forum as she hadn’t receive an invitation, but she fully intends to attend these meetings in the future.
Rheumatology Service:
It was reported that a consultant rheumatologist has been appointed and is due to start in April 2011. The new incumbent was a part of the previous ABMU HB’sservice and therefore it is expected there will be some continuity of service. The new Hywel Dda service is due to be modelled on the old ABMU / Carmarthenshire service.
It was noted that ABMU HB are intending to gradually repatriate patients who reside in the Hywel Dda region, so all will eventually be treated closer to home.
It was also noted that the rheumatology pilot is coming to an end. HE informed the group that her practice has not had a chance to make any use of this pilot due to the lack of communication about it and suspects this is the general experience across the region. She expressed concerns that the HB may consider this as a lack of interest and stressed the fact that the inability to participate in the pilot is no reflection on the need for the service. She requested that the HB take this into account when looking at the uptake figures.
The LMC requested the HB issue some clarity about the service model. It was agreed a letter would be drafted to all GPs, outlining the future model and clarifying what will happen to patients already in the system. The letter will be sent to the LMC for comments before posting.
LW expressed concerns about rheumatologists across the HDd region not working together or providing different levels of service. He predicted that if one area provides a ‘better’ service than another, this area will become inundated with referrals. JPat promised to feed these concerns back to the consultants involved.
Patient Transport:
LMC informed the HB that they had not received any notification of the dates of meetings yet. RB undertook to remind Peter Llewellyn to send these out.
GMS Budget:
DE will chase the minutes of the last LMC/HB Finance meeting. The group discussed the organisation of future meetings.
It was agreed that Finance should be a standing item on the agenda for future meetings.
DE advised that the global sum repayment is being delayed and practices will be contacted individually withadvice on amount and timescales.
JPat expressed concerns over plans to divide the GMS contract management into county levels, which would mean that Pembrokeshire would need to absorb the costs of high activity in certain areas by itself. She also expressed concerns that this would eventually lead to the region offering different services in the different areas. DR expressed surprise that the HB is able to find enough resources to fund the administration of such a split when it cannot find enough resources to afford fundamentally important GMS activity. DR confirmed that the LMC would not want to see the service fragment into counties.
DR advised the HB that Hywel Dda is not spending as much on ES’s by UK standards. The LMC will send the HB the UK figures for comparison. It was however noted that compared to the rest of Wales the position was comparable.
DR reminded the group that, when the nGMS contract was first introduced and GPs were asked to sign up, they were informed that the monies available would be increased by LHBs however this had never materialised.
Enhanced Services Accreditations:
MB advised that talks are still in progress around Minor Surgery accreditation criteria and process. RB will chase Dr Cuthill for an update.
MB suggested that the future process may involve a tick box protocol for use by the HB to assist with in-house assessments.
Wound Dressings:
JPJ confirmed that this work is still going ahead but implementation is not imminent.
LARC:
RB requested assistance from the LMC on the new wording for this LES
Treatment Room:
JPat outlined 2 options to go forward with this service; the first would be to send all activity back to the A&E department; the second would be to keep the current specification but lower the price for certain items. The LMC rejected both options as unfeasible. HE stressed the importance of considering the costs of patients returning to hospital. HE expressed her unhappiness at the reduction of the price paid for activity; DR warned that reducing the price would send out a negative signal to practices; LW noted that the price for all ES had already been eroded by inflation; JPow advised that the current price for Treatment Room activity is similar to the price paid by Powys HB for their Ancillary Services LES, which is an equivalent service.
LW reminded the group that the monies to resource this LES were initially supposed to come from secondary care.
The group discussed the significant problem in Hywel Dda in terms of both high activity and cost, especially in Pembrokeshire and Carmarthenshire. DR reminded the group of Trevor Purt’s explanation that this region needs to spend more on such services due to its rurality. DR stressed the need for increased investment in primary care services in recognition of this rurality.
MB noted that Treatment Room activity when aggregated was not particularly seasonal in nature.
JPat advised the LMC that the HB had a duty to assess whether or not overspending was due to appropriate and defendable activity. LW queried whether any inappropriate activity had been found. JPat confirmed that a small amount was identified and this had now been rectified.
JPat will flag these issues with the AMDs at their next meeting.
Pembrokeshire Boundary Issue:
JPat confirmed that a letter had been sent by her predecessor to Barlow House Surgery regarding their boundary issues. LW expressed the opinion that the letter had been inadequatelyphrased and had caused problems and confusion. DR noted that the wording of the letter was not recognised in law and that practice lists could either be open or closed, not both, and similarly there can only be one boundary area.
The group discussed the criteria for when a practice is able to deregister patients following proposed boundary changes. It was agreed that new patients moving into the disputed area from outside would not be entitled to register with the practice and the practice could therefore refuse to register these patients. Agreement could not be reached over how to deal with patients who move from within the practice’s agreed boundaries into the disputed area. The HB argued that such patients should not automatically be deregistered but the LMC argued that the practice would be within their rights to deregister these patients. LW advised the HB that it is unfeasible to have more than one boundary and practices should be allowed to only accept patients from within the formally agreed boundaries if they wish for the sake of fairness.
JPow noted that there is nothing in the regulations to say that a practice can’t accept patients from outside their agreed boundaries.
DR suggested that a system is put in place for deregistration of patients in stages over a long period of time in order to allow neighbouring practices to cope with the potential influx of patients.
DR commented that the original agreement with Barlow House Surgery should never have been made in the first place.
Consultant NPT Variations:
RB advised the group that she has spoken with PPV and informed them that if a practice is caring for a patient under the terms of the ES then they are still able to claim for that patient despite the conditions imposed by secondary care.
The LMC raised concerns about the PPV visiting team not using the specification to assess the appropriateness of claims. It was agreed that the PPV team should be invited to attend the next formal meeting in May.
Shared Care Protocols:
RB reported that Sarah Isaac is coming to the end of her work on the HDd protocols. SI has spoken with the consultants and has confirmed that they now understand the process. DR stressed the importance of the consultants communicating and liaising with primary care and working within the protocols.
The new protocols will be brought to a forthcoming meeting for sign off. / MB
HB
JPat
HB
MB
JPat
RB
DE
KH
LMC
RB
LMC
JPat
HB
KH
HB
4. / Last Informal Development Session: Anti-Coagulation (INR) Workshop – Outcome and Communication
JPat confirmed the outcomes of the informal development session on INR held in February.
The group discussed HB plans to introduce a new reduced rate for those practices providing level 1 but not in accordance with the Blue Book. It was agreed that 3 month’s notice would be required for this change.
JPow pointed out that the practice setting for level 1 phlebotomy is not mentioned in the Blue Book. RB explained that the HB has been guided by Richard Quirke’s correspondence supplementing the Blue Book. JPow noted that the HB never agreed the use Quirke’s guidance with the LMC. She stressed the importance of level 1 practices as a safety net for the hospital service.
The group debated the interpretation of the term “outreach” and whether this applied to the site or the patient.
It was noted that HDd and Powys are the only 2 health boards in Wales to commission level 1 INR.
The group discussed the provision of level 4. It was noted that the HB will expect practices to be able to demonstrate adequate IT software and equipment is in place before the HB agrees to the practice providing at this level. This will be equally true for existing level 4 practices, whose service is due for review. LW commented that no agreement had been reached that the IT software was best practice and the LMC noted that this software is not available to the secondary care service in Withybush hospital. MB reminded the LMC that Dr Grubb had informed the workshop that IT software was desirable.
It was agreed that JPat would draft a letter on proposed changes to the specification and pricing and would send it to DR for advice on wording and LMC agreement.
It was noted that within the next 2 years the NHS expects only about 10% of INR patients to be on Warfarin. It was agreed to include a reference to this in the letter JPat will draft. / HB
JPat
DR
JPat
5. / Enhanced Services Monitoring and Performance
RB explained that the aim of the paper was to highlight where the main expenditure is. It was noted that for some ES one county stands out from the others with much higher activity.
The group discussed the benefit to the HB of drilling down into Treatment Room activity in order to understand why it is so much higher in Pembrokeshire than the other 2 counties.
The group discussed the substance misuse review and spending. DR speculated that substance misuse would become more of a problem for the region in the coming months due to the effects of the current recession. It was agreed to keep this factor in mind when reviewing the current services.
DR stressed the importance of recognising county differences.
The LMC requested that the information is presented per 1,000 population for comparison. It was noted that an All Wales average would also aid comparison.
DR suggested the HB should look at hospital activity and identify what services could be provided within primary care instead in order to target inappropriate activity. / HB
KH
6. / Next Development Session: Federated Practices
The HB will follow up on the invitation issued to Dr Fernandes of the Croydon Federation to attend this session.
It was agreed that ideally there should be a presentation given by both Dr Fernandes and Dr Maureen Baker from RCGP.
The group discussed how widely they want the session opened up and whether there should be a workshop session after the presentations. DR stressed the need for more GPs at the workshop and suggested that the GP negotiators should be invited. Dr Ian Millington or Dr David Bailey were suggested. It was agreed that a letter of invitation should be sent to Dr David Bailey in the first instance. It was agreed to open up the session to all practices and GPs. The need for a speaker with rural experience was discussed and agreed.
It was agreed that the session’s main aims would be to identify what federated practices were and then consider how they could work in the HDd region.
The choice of venue was discussed and it was decided to look for an alternative to that booked. KH was asked to look into the cost of Carmarthen venues.
It was agreed to invite the county Heads of Primary Care and Community Services and the county AMDs. / KH
HB
HB
HB
KH
KH
7. / Diabetes Business Case
MB discussed with the LMC what had been happening with the diabetes business case paper that was circulated to LMC members of the group only.
The group discussed NICE’s proposed changes to the diabetes indicators in QOF which are due to be implemented in 2012-13. It was noted that these reflect the draft new HDd Diabetes LES and if implemented will make the LES obsolete since the HB is unable to pay practices twice for the same activity. RB will email the link to proposed QOF indicators to the group.
It is therefore proposed to introduce the new Diabetes LES for a short period of time, in preparation for the change in QOF indicators.
LMC members were asked to email any proposed changes to the business case to MB within the next 7 days.
MB discussed how the new service is aimed at slowing or reversing the onset of diabetes and thereby potentially reducing costs for the NHS.
There is one more meeting proposed to finalise the business case and then the paper will be presented to the Strategy and Planning Committee in April 2011 for a decision. JPat stressed the need for the LMC to see the finished document before it goes to this committee.
LW commented on the need for comparison figures on the cost of patients on dialysis etc so lay members of the committee can easily understand the benefits of the new service and the potential cost savings for the NHS.
MB informed the group that the HB is committed to meeting NOF targets by 2013.
There was a discussion about whether clinics should be held in practice or not.
The proposed drugs incorporated into the LES were discussed.
The group discussed the proposed plans for managing patients in the new LES.
JPow requested sight of the new ES specification in the near future. MB described what he envisages being in the new specification. LW commented that there is no point in spending time on drafting the new specification until the business case is agreed.