THESE MINUTES ARE A PRIVILEGED DOCUMENT CONTAINING CONFIDENTIAL INFORMATION. THEY ARE INTENDED FOR THE GENERAL PRACTITIONERS IN THE PRACTICES THEY ARE SENT TO.  THEIR CONTENTS SHOULD NOT BE DIVULGED TO THIRD PARTIES.

MINUTES OF A MEETING OF THE SHROPSHIRE & TELFORD LOCAL MEDICAL COMMITTEE HELD IN THE EDUCATION & CONFERENCE CENTRE, ROYAL SHREWSBURY HOSPITAL, ON TUESDAY 5TH  NOVEMBER 2019.

PRESENT:

			Dr S Hodson				Dr T McDonnell
			Dr I F Rummens			Dr T G Parker
			Dr K McCormack			Dr A Rogers
			Dr S Tuft				Dr J Awad
			Dr A Pringle				Dr R McMurray
			Dr R Taylor				Dr F Hay
			Dr M Babu				Dr M McCarthy
			Dr A Hutchison			Dr L Houghton
			Dr Lumley				Dr S Eslava
			Dr G Cook

APOLOGIES:

			Dr S Imam				Dr M Staite
			Dr R Shore				Dr F Lynch

2.	The Minutes of the previous meeting were accepted with two alterations.  Dr Hay pointed out that the patient referred to in item 4 “referrals delays” had intracranial hypertension not a brain tumour.  At the bottom of page 8 ironizing was corrected to ionizing.

3.	Matters Arising

i.	Requests for Medical Reports

The Minutes of the last meeting advised that Subject Access Reports must be provided free of charge, including the cost of posting them to a Solicitor requesting disclosure of the medical record on the patients behalf.  Pulse has recently reported a recent court case in which the judge ruled that a practice only needs to make medical records available to patients at reception and could not be forced to post them.  The Judge said that this 

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complies with GDPR and the Solicitors acting on behalf of the patient cannot insist that practices incur the expense and additional risk of posting them.

It was not clear whether the Judge’s ruling would be subject to an appeal but, for now, the ruling does appear to establish a precedent and a clarification of the General Data Protection Regulations.

ii.	Locally Commissioned Services

The Secretary said that the planned meeting to discuss LCSs with the CCGs had not yet occurred pending issue of the national DES specifications.  Dr. Hodson said that a significant proportion of patients he had attempted to refer back to urology for PSA testing had been bounced back to him to follow up.  The issue of PSA testing had been discussed with Shropshire CCG.  Dr Povey’s advice was to refer the patient back to the urologist and to report this every time using Datix.  Dr Hodson said there was no clarity over what constituted a significant rise in PSA.  Dr Penney said that new regional guidelines had been issued but the evidence was not clear.  Dr McCormack said that some consultants discharge patients with 10 years blood forms so that the result of testing goes back to them.  He felt that as the guidance around PSA keeps changing it was important that GPs did not accept responsibility and continued to refer patients back to urology.

In discussion it had been suggested that Mr Elves appeared helpful add sympathetic to the GP perspective.  It was agreed that the Secretary would write to Mr Elves on behalf of the Committee to suggest setting up a meeting with Dr Hodson.  Dr Hodson said that having clarified the CCG position with Shropshire he would now speak to T & W to establish their views.

Discussion then turned to the recent announcement that both CCGs are withdrawing low risk diabetic foot screening by podiatrists, presumably on grounds of cost, which meant that this would now have to be undertaken by a member of the practice in order to meet the requirements of QOF.  The Committee felt that this was likely to generate considerable resentment amongst GPs and may harden resolve to cease provision of the significant amount of work practices continue to do that is not commissioned or resourced.

Dr McCormack pointed out that the relevant Contract wording is “record that it has been done” in the same way as retinopathy screening does not require the GP to have provided the service themselves to be eligible for payment.

Dr Pringle said that CCGs elsewhere in the country are not funding low risk diabetic foot screening and it is entirely up to practices if they choose to do it or not.  Dr Hodson wondered if this could be a false impression if the service was being provided in the practice but not necessarily by the practice themselves.

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Dr McCarthy said that withdrawal of podiatrists was due to lack of money.  She pointed out that diabetic foot problems can rapidly change from low risk to moderate or severe and that podiatrists are best placed to assess diabetic feet.  She added that podiatrists do more than just screen, they provide the patient with foot care education and advice.  The Committee noted that podiatrists performing foot screening have half hour appointments with each patient and bring additional kit that practices would neither possess nor have the expertise to use.

Dr Parker said that the CCG should be supporting general practice and that GPs in Shropshire and Telford are already being paid less than elsewhere despite the majority providing an extensive range of unfunded additional services.

The Committee agreed that this action by the CCGs was a retrograde step and needed to be challenged.  The Secretary to write to both CCGs.

iii.	Primary Care Networks

The Secretary reported that, since the last meeting he had been approached by a number of practices confused about extended hours and extended access.  There are currently two Extended Hours/Access schemes;

•	The Extended Hours Service incorporated into the PCN DES – in Shropshire this is funded at £1.45/head of population plus an addition £0.50/per head of population in Global Sum.  This replaced the Extended Hours DES that was originally commissioned by the PCT in 2010.
•	The GPFV Extended Access Service, commissioned locally by the CCG but under national guidance.  In Shropshire this is funded at £5.80/per head with an additional £0.20 going to fund the additional hours not covered by the delivery hubs.

The DES is the same in T & W.  The requirements of the GPFV LES appear to be different.

Many LMC Members commented on the pressure practices were under from Extended Hours/Enhanced Access, that this would be impossible to sustain and that practices were at risk of failing as a result, not least because of all the other pressures general practice was under.

Dr. Penney said that the Welsh GP Contract now defines a session as 4 hours 10 minutes.

Dr Cook said he understood that GPFV Extended Access would move into the PCN DES in 2021 and he wondered if this might make it easier for practices to withdraw from delivery of this service.

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Several T & W representatives were unhappy that the initial GPFV LES specification was changed after only 4 weeks so that a GP now needs to be available at all times for appointments over the weekends and that the use of HCAs/Practice Nurses has, effectively, now been banned (because of uptake of appointments with them was too low).  NHS England demand that a minimum of 75% of available appointments are used.  Many Telford GPs feel the original LES was not given long enough for levels of uptake to become established.  It was agreed that the Secretary would write to Jacqui Seaton about this and would explore the potential for practices to withdraw if they wished.

The Secretary said he thought practices would struggle with other elements of planned PCN development particularly the five requirements described in the NHS Long Term Plan which states that general practice will deliver significant improvements in the following;

•	Avoidable A & E attendances
•	Avoidable emergency admissions
•	Timely hospital discharge
•	Outpatient redesign
•	Prescribing costs

Better support for care homes and CVD case finding were also mentioned.  It appeared that additional funding would be available through the Investment and Impact Fund (which will be overseen by the Integrated Care System Network) but, not least because of work pressure and the major recruitment and retention issues, it was difficult to see how all this extra work could be delivered.

Dr McCarthy said that her impression was that the GPC agreed to the PCN package in return for the Government agreeing to pay for medical indemnity, but noted that GMS payments appear to have fallen as well.  Although supported by a majority of GPC members when voted on, she felt a significant minority were unhappy with the establishment of Primary Care Networks and what would be expected of them.

The Committee felt that practices would welcome further information on the planned development of Primary Care Networks.  It was agreed to hold an Open Meeting early in the New Year and to invite Dr Krishna Kasaraneni, GPC Lead on PCNs, to attend.

iv.	Referral Delays

Nothing further had been received from either CCG.

A letter of thanks had been sent to Dr Wilson.  The Secretary had also written to the Community Trust seeking reassurances about the future of the service and the appointment of a suitable replacement for Dr Wilson.  Jan Ditheridge, Shropshire CHT Chief Executive had replied.  Following Dr Wilson’s retirement the two respiratory 

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Services across Shropshire and Telford had been aligned so that they are both nurse led with medical support from SaTH Consultants (under a Service Level Agreement).  The service will be monitored to ensure that the same standards are maintained or improved and GPs will contribute to the monitoring and evaluation process.  Jan Ditheridge acknowledged Dr Wilson’s great legacy which should ensure that future patients enjoy good outcomes and GPs are supported.

v.	Pain Management Solutions

Dr Lynch was due to report on progress but was not able to attend today’s meeting.  To be included on the Agenda for the next meeting.

vi.	STP/ICS

Since the last LMC meeting Dr Rummens and Dr Hodson had met the Clinical Directors of the Shropshire and Telford PCNs.  There was apparently unanimous support for LMC representation on the STP/ICS Senior Leadership Group and beyond.  A meeting had been arranged with Mark Brandreth, Chief Executive, RJAH, who is leading on the establishment of an Integrated Care System in Shropshire and Telford, to explore the involvement and representation of general practice.

vii.	0-25 Prescribing

Following discussion at the last meeting the Secretary had contacted and then met Liz Walker, Head of Medicines Management, Shropshire CCG.  She felt that the Prescribing and Physical Health Monitoring template was specifically designed to identify and help with the large number of patients GPs will have picked up mental health prescribing for over the years because the CAMHS service has been so variable and inconsistent.  Telford and Shropshire CCG Medicines Management Teams are looking to establish an agreed process for referral of Children to Mental Health services.  This includes regularly updating shared care agreements to reflect the most up to date guidance and to ensure the responsibilities of the specialist service and GPs are clear.  It is hoped to have these completed and approved at the February Area Prescribing Committee meeting.  Capacity of metal health services remains an issue.

The latest update from the CCG made no mention of funding or resources  It seemed likely that referral of all patients in this group for whom practices had undertaken prescribing responsibility would flood the system.  The Committee were clear, and this point had been made repeatedly to the CCG, that GPs could not be expected to participate without provision of funding, ideally by the commissioning of a LES.  Practices were reminded to check that any Shared Care Agreement identified that physical health checks were the responsibility of the Mental Health Team.

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The Secretary said he thought the “no man’s land” between hospital care and non-core GP work is potentially huge and disputes about responsibility for delivery likely to increase.  He wondered if the CCGs view block contracts with Primary Care Networks for services as a potential solution.

viii.	LMC Meeting Dates 2020

These were agreed as follows:

•	Tuesday 7th January at SECC
•	Tuesday 10th March at SECC
•	Tuesday 5th May at SECC
•	Tuesday 30th June at PRH
•	Tuesday 8th September at PRH
•	Tuesday 3rd November at SECC

ix.	LMC England Conference

This takes place on November 22nd in London.  The Agenda had not yet been published.  Dr. Penney and Dr. McMurray were attending.

x.	 Quality Improvement/Support Visits

Julian Povey, Chair, Shropshire CCG, had confirmed that these are not mandatory and should occur by invitation.  The exception is in situations where there are concerns about the performance of a practice, in which case the CCG has a duty to intervene.  The Secretary had had a conversation with Corrine Ralph, Head of Primary Care Telford CCG.  They are trying to identify practices that may be struggling and how best to help.  It is not clear how much practical help the CCG can provide. For many practices in this situation it seems that increasing links with other practices may be an answer and, perhaps with time, the PCNs would have a part to play.

xi.	Shropshire & Telford CCG

The Committee understood that NHS England has decided not to approve proposals for a single CCG for Shropshire and Telford although it seems likely that this will happen eventually.

xii.	Cataract Referral

Two issues had been identified at the last meeting.  Firstly, a GP referral had been rejected because a recent optician’s report had not been included, even though the GP had included their own measurement of visual acuity.  It appears that “corrected” visual acuity is 

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required, although not clear whether corrected visual acuity measured by the GP would be acceptable.  The second issue was around the apparent ability of accredited opticians to 
refer cases of cataract directly while non accredited opticians have to direct referrals via the GP.  An answer was awaited on this point.

	xiii    	Winter Pressures Money

Both CCGs had confirmed that practice (and PCNs) have been asked to submit bids towards projects that would have a positive impact on relieving pressure on A & E, improving same day access to Primary Care and raising awareness to patients of self-care initiatives.  Bids will be assessed and approval provided to practices as soon as funding is released.           

	4.	LMC Accounts

Dr Hutchison, LMC Treasurer, reviewed the Voluntary and Statutory Levy accounts which had been circulated to Members prior to the meeting.  There had previously been a fall in Voluntary Levy income which had led to a percentage increase in contributions and the LMC stopping its annual donations to three medical charities (The Cameron Fund, the Royal Medical Benevolent Fund and the Sick Doctors Trust).  The major reason for the previous shortfall; amalgamation of several practices into a large new practice, had not been recognised by the system and their contributions had ceased.  These have now been restored.  Additionally, the GPDF has announced a (non-recurring) reimbursement of contributions.  Dr. Hutchison said it should now be possible to reduce the Voluntary Levy contribution again and it was agreed to reinstate donations of £1,000 per year each to the three medical charities.  There was discussion of possible alternative charities for the future.

Turning to the Statutory Levy, Dr Hutchison pointed out a current shortfall.  This, in part, had come about because of a reduction in the Levy, made in response to a significant surplus that had previously built up for this account.  The Statutory Levy would need to be adjusted again, with the aim of keeping the bank balance at round half annual turnover.

Dr Penney proposed that the accounts be accepted. This was seconded by Dr. Parker and approved by a show of hands.

	5.	Local Ophthalmic Committee

The Secretary had been contacted by Paul Cottrell, Chair, Shropshire LOC.  The LOC is keen to work more closely with the LMC and had instigated a standing invitation for a rep from the LMC to attend LOC meetings.  These take place six times a year.  Committee Members felt that attending every LOC meeting was perhaps excessive and that it would 

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be difficult to find a representative prepared to make this commitment.  It was felt better to suggest sending a representative to specific meetings where relevant issues were to be 
discussed.  To facilitate this, it was suggested asking for sight of the LOC Minutes after each meeting.

Dr Hodson said that he had been approached by representatives of the Local Pharmaceutical Committee who were also keen to discuss issues of common interest.  He was due to meet them later that month and would report back.

Dr McDonnell described issues with a community pharmacist who undertook flu vaccination for residents in a local nursing home even though the pharmacy did not fulfil any of the criteria that would allow them to do this and without notifying the practice that these patients had been vaccinated.  The matter was not with NHS England.

	6.	Housing Letters

An enquiry had been received regarding patients asking their GP for letters of support in connection with housing applications.  The Committee thought that a longstanding agreement was in place across Shropshire & Telford that housing departments will not ask patients to ask for letters of support, but several LMC representatives confirmed that this is still happening.  It was agreed that the Secretary would prepare a template letter for use by practices essentially stating that letters should not be done at the request of the patient but patients advised that requests needed to come directly from the Housing Department who would be charged a fee.  The Secretary said he was not sure if the Collaborative arrangements still applied or, if they did, whether practices actually received payment.  He was not aware that a fee for this work had been set locally and GPs are advised to set their own fees and, ideally, obtain confirmation beforehand that they will be paid .

There was then discussion of requests for letters around Universal Credit and Personal Allowance appeals and whether a fee should be charged.  It was clear that a fee could be charged in the circumstances but that, depending on circumstances, is often waived.  The Committee felt that practices will continue to do what they feel is appropriate.

	7.	Shropshire Orthopaedic Outreach Service Referrals

A letter had been received from a Whitchurch practice.  They note that an increasing number of SOOS referrals are rejected for reasons such as “not enough info around physio or analgesia” or “a patient BMI greater than 35”.  The letter notes that the patient is not been referred for surgery but for an opinion on best management.  The practice is unhappy as it does not feel that this is how SOOS is meant to work.  The letter also commented on a patient letter from SOOS which said that “if trigger point injections are the only things that help then she will have to see if she has a sympathetic GP who will do these for her on a 4 monthly basis.  They are technically not difficult but not something our service can 
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offer”.  The practice felt this comment sets the GP up as being unsympathetic if they do not comply (letters are copied to the patient) and ignores the fact that practices may also not have the capacity to carry this out.
The Committee agreed with the comments of the practice.  Dr. Pringle advised using the referral template and completing it fully which should help ensure that patients are seen but he would discuss the comments made with the new MSK lead.  The Committee were unhappy with the advice around trigger point injections.  The Secretary to write to the CCG.

	8.	Other Correspondence

There was none.

	9.	Reports from LMC Members on Other Bodies

Dr McCarthy reported from the GPC.  A recent review of GP earnings showed that partners average income is just over £100K.  The GPC has made clear to the Government the problems caused by current taxation rules around pension contributions and the detrimental effect this was having to the NHS.  The BMA has developed a calculator to help individual doctors assess the financial impact of undertaking additional work.  She noted that many Consultants have stopped doing waiting list initiative work because of the punitive taxation implications.  Dr McCormack commented on the potential impact of the reportedly two year delay in NHS Pensions attributing individual doctor’s contributions and the potential for this to produce an unexpectedly large tax bill.

Dr McCarthy commented on the Romney report on sexual harassment within the BMA and GPC.  She also commented on discussion on antibiotic resistance.  It appears that approximately 80% of all antibiotics are used on animal husbandry and an initiative has been launched to encourage farmers to change practise.  She also commented on GP  training.  It appears that the UK is starting to lag behind in the quality of its training and that GPs in the rest of Europe appears to have a much better quality of life than GPs working in the UK.

	10.	Shropshire CCG

   There was nothing further.

	11.	Telford & Wrekin CCG 
   
   Dr Pringle said the main focus of the CCG has been working towards a single CCG. They  now have a similar deficit to Shropshire. A gradual integration of management structures is evolving. The clinical issues and areas of concern are unchanged.
       
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	12.	Any Other Business

There was none.

	12.	The next meeting will take place on Tuesday 7th January 2020 in the Education & Conference Centre, Royal Shrewsbury Hospital.