National Assembly for Wales

Well, good afternoon, everybody, and welcome to the Health and Social Care Committee meeting this afternoon. Just to note, this meeting will be bilingual and will have simultaneous translation from Welsh to English. Members, can I ask if there are any declarations of interest at this point? I don’t see any. Members, if you find one as you go through, please speak up, and we’ll record that appropriately.

So, welcome to our first formal inquiry evidence session for our look at general practice in Wales. And I know some of us have been involved in sessions today already. This formal one is a fundamental start to the inquiry, and I’m really pleased to welcome Dr James Pink, a GP partner in Cardiff, Dr Richard Stratton, GP partner in Powys, Dr Elin McCarthy, GP partner in Swansea, John Williams, a practice manager in Flintshire, and Kirsty Brookes, a pharmacist from Anglesey. Thank you so much for giving up your time today. We’re joined by two elected Members in the room, and there’ll be three elected Members online. And we will have a set of questions to go through with you. This is a really important inquiry, and we thank you for what you’re going to share with us.

Where have my questions gone? Right. So, we will—. [Interruption.] Oh, sorry, yes, I forgot straight away. We’re going to be starting today with a video. Now, this video is something that Members have had access to for a while prior to this meeting. The full video is quite long, but we’re going to concentrate on about nine minutes of it, which are really important, because they focus on the opportunities for GP practices into the future. Some people might be recognised on the video. So, on that point, we’ll get stuck straight in, and can I ask for the video to start, please?

Thank you to those who took part in that video. I think that that outlines some of the key opportunities for the future. So, I hope that people watching in also found that interesting. We're going to lead now into some formal questions. Can I ask those of you who are online not to use the 'hands up' function but to put your hand up manually if you want to come in? It interferes with the technology otherwise. We've got a lot of questions here. Don't feel that everyone has to talk on everything, but you're more than welcome to come in if you wish. We have a fair lot of things to go through, and if there are some key bits we don't get to, we may ask you if you want to submit anything in writing to answer those. 

So, I'll kick off, if I may, around funding and contracts. Now, I know that there are concerns about the allocation of funding to general practice, including the sufficiency of overall funding and the distribution of funding under the Carr-Hill formula. Could I open it up and ask for your formal views on the Carr-Hill formula? Is this system fit for purpose for what we need in Wales? Can I come to you first, James?

Yes, I would love to talk on this. My colleagues and I—sorry, I'm going to take this off—got the data for all 370 practices in Wales. We got their Carr-Hill ratios, we got their age/sex distribution and we looked at their Welsh index of multiple deprivation scores as well, because we realised that, clearly, we do need to allocate the funds to where they're needed. As a general rule, we would expect that the practices who are in the deprived areas or who had the most elderly populations would have more funding than other places. Sadly, the funding just doesn't follow those correlations. There's almost no correlation between funding and deprivation, which beggars belief, and the correlation between age and sex and funding isn't as clear cut as you'd think. Basically, there's a variation between 0.65 and 1.34 in Carr-Hill formulas across Wales. So, if you looked at an average practice of 10,000 patients, that would be £862,000 difference for a practice looking after the same number of patients.

Now, I don't think anyone in this room will argue that there needs to be a difference in some patches, but the size of that difference has to be very much justified, and we therefore have to say, 'What's the funding formula we're using and is it up to date, robust and evidence based?' Currently, the one we're using was designed in the late 1990s for an English population, based on data that hasn't often been updated. PANI, which is the practice additional needs index, has not been updated since 2002 and, even at the start, was based on a lot of patient-provided data from their health survey, and other things that haven't really been updated since.

So, we haven't got an up-to-date formula, there's no question about that. It doesn't seem to map very well to areas of deprivation, and doesn't map all that well to areas of frailty either, and it seems, therefore, that we need to just update it, because it doesn't look fair, and I suspect it's not fair for lots of people for lots of different reasons. So, I think that it's probably not fair for deprived practices, it's probably not fair for rural practices, and it's probably not fair for practices with older patients. But, essentially, it needs looking at again, based on the data we now have. If it was fair and transparent and up to date and evidence based, there will be winners and losers, but at least we will be able to accept that and then plan accordingly. So, that's my view on Carr-Hill.

Thank you. Richard.

Thank you very much, James. If I could build on that just for a moment. Updating the formula is, without doubt, necessary. The formula will still be a blunt tool because of the wide variety. I think what we also need to factor in is the supplementary services that general practices participate in, on top of the core contract, and these are offered either at a national level or at a local level. And in the case of extreme deprivation or various local needs that are specific to that area, it's the role of commissioners to identify what those additional needs are, how they can be met in collaboration with providers, and then to fund that difference. I think the combination of a revised formula plus better use of local services, recognising need, delivering population health, would take us forward enormously. At the moment, both feel hamstrung by budgetary constraints.

Thank you for that. I can't see anybody else who wants to come in at the moment, so I'll just move us on then to the current system of annual contract negotiations and the extent to which these impact on longer term planning and service development. So, what's the view on the annual contract negotiations? Could things be done better? Who wants to come in first on that? Richard, and then I'll come to John.

I'll speak again. Thank you very much indeed, Peter. Running the way that we are at the moment on single-year budgets, not just in primary care, but in secondary care as well, is really debilitating. People are not making investment decisions. Particularly in general practice, the decision as to whether to recruit more doctors, additional team members, is really, really difficult. It was pointed out in the video that, not only are we in a single-year situation, but often it's month 9 or 10 before we actually know what we're going to get for the year that we've already delivered. Without that ability to plan, everything is crisis management, and that's where we find ourselves today.

So, two things would need to go hand in hand: first would be a vision for health provision in Wales, and then a contract that supports the delivery over what I would suggest would be a minimum of five years. And regularly updated over those five years as well, so we would know what years 6, 7 and 8 would look like, and we could plan and deliver to that. It would give us far more confidence.

Yes. John, would you like to come in on this?

Apologies; I was stuck on mute. Yes, to echo what Richard said, absolutely, a multi-year contract would better enable planning, but I think another issue with the current contract process is it's piecemeal. So, we have a sum of money, relatively small, something like £120 a year, for all of the patients' basic medical needs over a year, but we also get piecemeal chunks that feel tokenistic and they don't feel to me as if they're based on a relationship of trust between the Government, health board and GP practice. So, last year, we had a relatively small, few thousand pounds, in my practice for making a poster about acute kidney injuries and uploading a picture of that in our waiting room. And there does seem to be a sense that we can't be trusted to deliver the best for our patients with a sum of money, that there has to be some sort of tokenistic work around it, which is not very grown up, and because of the late nature of it arriving weeks before year end, it's always very rushed.

Thank you, John. James.

I would like to continue on that point. Actually, the one thing that matters is how many appointments we offer. I mean, that's the one thing that really will cut through all the headlines and be the thing that our patients care about, is how many appointments are there. How many appointments are there in this surgery for a doctor or a nurse? And actually, the one thing that we don't ever get attached to a sum of money is, 'If you provide this many appointments, we'll give you this much money', and that would really help us plan as well. No-one's ever been brave enough to say, 'All right, we'll give you £100,000 and this equals 1,000 appointments,' because we could then say, 'Okay, we'll work with that.' And so I think this is about trust again. If they are going to not trust us, then don't trust us in the right way. So, say, 'Okay, we do want you to show value for this money, and this is what we want you to show.' And you're right, the quality improvement projects where we produce a poster, I think are just completely out of proportion. The amount of work I put into doing a poster and got several thousand pounds compared to the amount of work I have to do to look after several hundred patients is just ridiculous.

Can I bring you, Mabon, in? Diolch.

Do you want to come back, James?

Yes, it is absolutely possible. And I'm not actually suggesting we do that, and I'm not suggesting that we do get paid for an appointment. I think that would be a really bad thing for our patients, a really bad thing for the NHS in general. The principle I was raising is that we are asked to jump through lots of hoops for the cash, and the one hoop that would seem most meaningful is how many appointments we offer, but that's not one we're asked to jump through. We're asked instead to make a poster or to come up with a project. And like I said, if we are being asked to jump through hoops, at least make it sensible. At the moment, we're just being asked to jump through things that don't seem to have as much clinical meaning. But I don't actually agree—. Personally, I don't want us to ever get to the point where we're paid per patient. I think that would be bad for our patients and it would be bad for the NHS as a whole.

Great. Thanks, James. I'll move us on. In the written evidence, we had one practice that told us that.

'Not infrequently we are offered money for things we don’t need but not for things we do need...We may be told that there is money available to buy a piece of kit that we already have but that we can’t use the money for anything else.'

I just wondered what your view might be about that, your concerns about the process of applying for money and funding and the inflexibility around that. James.

Yes, so this is again about the five-year contract or the five-year funding. This happens most frequently, in my experience, with cluster funds. Cluster funds are allocated on an annual basis and every year that I've been involved in clusters, at about February, one of the items on the agenda is, 'How are we going to spend this remaining money?' It's not enough normally to do anything meaningful, so we're talking maybe £10,000, £20,000. 'How are we going to spend £20,000 over the next two months?' And it's like, 'This is ridiculous. Can we not just put this into next year's budget and actually fund a nurse or a pharmacist or some project?' But this is very much in the same sphere.

If you give yearly budgets and you lose it unless you use it, then you're always going to get this situation where people go out and buy loads of laptops that they don't perhaps need or a load of blood pressure machines that they don't need. Whereas if you said, 'Well, actually, this money can go into next year's budget to invest in something more meaningful', then you've got a chance of using it.

Yes. Thanks, James. John.

Yes. It's inevitable in any system that, at year end, you have that sort of slush of dumping things. But I think your question points to a wider problem, which is the lack of involvement of primary care and GP practices strategically at a higher level in health boards in allocating money or deciding on funding. So, from our focus group this morning, I think we discovered that, of the health boards in Wales, only two have executive directors for primary care at board level, and it often feels as if there's an imposition of ideas on primary care, rather than asking us what would work best for our areas. We know our patients very well; we know, locally, what's needed. We're not, or very rarely, asked at the outset, 'What would work for your area? How best could funding or resources be allocated in your area for your patients?' We are seen quite often as something very separate to the health board.

Thank you for that. Joyce.

So, it raises a question for me as to how this is arrived at. How is it that you get money to deliver x, y or z, whatever that is? Where's that coming from?

Yes. Who dictates that?

Well, exactly.

Perhaps, Richard, would you like to—?

Many of these initiatives come out of NHS Wales, in particular the so-called executive, who have the task of making things better, and they may come across an initiative in a single practice where they've bought a blood pressure machine and therefore the big idea is that every practice needs a blood pressure machine, without surveying, without finding out, without—. Because project managers need to do something. Project managers need to create new work, need to do something innovative. But because something works in one place doesn't mean you need to do it everywhere, and it's a product of corporate thinking, it's a product of, 'Everything must be the same.' And, of course, what we know in healthcare is that everything is the same, but it's locally nuanced and general practice is very, very nuanced.

So, back to the point that John made, if we're involved in the decision making, we can influence those ideas and it's often said that when you work at a more senior level, you stop more things than you progress. There is unfortunately a machine of people wanting to bring new stuff in, and these projects happen on a very frequent basis, and it's an instruction to do it, not an option to do it. 

So, very rarely are you asked your opinion on what you might need.

No.

No, okay. Does anybody else want to come in on that before I move us on? Okay, I'm going to move to Mabon now who's going to take the next set of questions. Mabon.

Who'd like to have a stab at that one first? Okay, Richard.

Happy to jump in there. I had a rather unusual journey in that I first qualified as a pharmacist and I worked for Boots for 15 years, reached a senior management position and decided that no longer did I want to work for shareholders, but I wanted to do something for the better good, and I was persuaded that medicine would be a good choice. I went into it always wanting to be a GP, but every specialty that I worked in, I thought that was fantastic and I could have trained as a consultant. So, the decision to stick with generalism was because I'd enjoyed learning as much as possible, I'd enjoyed experiencing as much as possible and I wanted to put it into practice. The idea of becoming one of 80 medical specialties and forgetting all the stuff that I'd ever learned about everything else simply didn't appeal. So, it's the challenge of dealing with whatever comes in, whatever question I'm asked, we're expected to have something at our fingertips and that joy of exploring, learning all the time and never knowing enough keeps me on my toes.

The other thing is that that Boots experience gave me leadership qualities, it gave me skills, and it gave me an awareness of working in teams as well. That, of course, is something that we do in general practice, not only within our practice but outside, in the wider teams of primary care. It's led me into health board work and other opportunities as well, so I wouldn't change a single thing about it.

Mabon, do you want to carry on?

Who would like to kick off? Does anybody online want to have a go first? No? Okay, we have got Kirsty and then Elin. 

I'm not a GP by background but I just wanted to come in on schemes and attractions. Certainly, in my area, there are a lot of managed practices. What I've seen is a lot of the GPs from GMS practices actually working within managed practice, as salaried, because the working conditions are better. There's not that overhead of having to worry from a business perspective either. It just gives them the freedom to do the job and look after patients and then leave at the end of the day.

Certainly, from another workforce point of view, we have a really strong pharmacy team in north Wales in primary care. Part of that is being health board funded. We have the same pay and working conditions as colleagues in secondary care. I think that that really helps to both recruit and retain people in primary care.

I would echo that. We've got lots of enthusiastic young trainees and students wanting to go into general practice, but when they understand the details and the complications and the long days, their enthusiasm quickly withers away. I agree that we do need parity between pay in primary and secondary care, but that may not be achievable in the short term. But I think that we just need recognition.

Recruitment is one problem, and retention is another problem. I think that lots of GPs have been struggling, and that's why they've incorporated allied professionals. Through doing that, we can't recruit any more GPs because we wouldn't want to get rid of our current staff. That would be totally unfair. So, after years and years of poor recruitment, now we're in a position where we really have to look after retention.

I'm near retirement, and I fear whether my practice would be able to get more trainees, but that has changed as well over the last 12 months. One reason is because a lot of GP positions are now taken up by other professionals. But you need GPs in general practice to be able to do the whole running of the business side, as well as the clinical issues, and teaching and training of students, registrars and allied professionals as well.

An interesting question. I think that you could look at allocating GPs to practices that need more doctors—for example, practices that are working in deprived areas, or have a high proportion of frail patients. Or you could look at practices that are teaching and training and are able to come in and facilitate that teaching and training for the current partners. So, there are quite a few there.

Again, I spoke in the meeting earlier about looking at interface services between primary and secondary care. A lot of work has shifted onto primary care, whereas we need a more robust system for things like heart failure clinics, or contraceptive services, rheumatology—they are endless, probably, in all the specialities. So, there are plenty of options to incorporate those newly qualified GPs, or GPs who have done lots of locum work but now need more stable work. There are lots of options out there, and there's an opportunity for the Government to look at how they can be incorporated in a worthwhile manner.

Thank you. James and then Richard and John.

We touched on this earlier in our session. In Cardiff, we can't afford to employ new doctors. We haven't got enough funding to employ new doctors. So, that's the problem there. But I think that, in other parts of Wales, they may have that problem, but they've also got the problem that doctors don't want to work there. We do need to incentivise doctors to work in less popular areas of Wales.

One way that we could do this is with the scheme we've already got, which is the partnership premium payment. There's no reason at all why, with some clever maths, we couldn't weight that so that you get £1,000 per session to be a GP in Cardiff, let's say, or a GP partner in Cardiff, but you get £3,000 a session to be a GP somewhere less popular. That would be a very small investment on the bigger picture, to get people to commit to surgeries outside of the popular areas, and within our schemes already.

The other thing we talked about earlier was preferentially sending GP trainees to places where there are bigger problems with recruitment. That could be addressed with policy changes at the education level. Forgive me, but I've forgotten the acronym. It's HEIW. They might say, 'Well, actually, we're not going to send lots of GP trainees to Cardiff, where they've already got plenty. We're going to send lots to Powys, perhaps, which is rural.' So, those things are both very low cost, actually.

Clearly, we'd need to look at all the funding as a separate issue. But actually, to fix the recruitment problems in difficult areas, those two things would potentially be a low-cost solution to that. That's an idea.

Building on what has already been said, there is an NHS Wales workforce strategy, which was written more than 12 months ago now and took more than 12 months to prepare. That strategy says, 'We're going to come up with a plan'. But there isn't a plan. A plan means doing things. There hasn't been an increase in the number of university places for doctors and nurses in Wales. There haven't been recruitment campaigns, and there hasn't been any direct involvement.

I think that one of the barriers that is felt is that, as independent contractors, we are responsible for our own recruitment and our own retention. Therefore, the idea of a joined-up plan across Wales—one that would service both secondary and primary care, that would assess the needs of general practice, not now, but over the next 10 to 20 years, and put something in place to deliver that—isn't right.

So, we feel left adrift, when the big opportunity is to find those doctors who haven't got work, who tend to be in and around university towns, and encourage them to relocate elsewhere—whether it be for 12 months, two years—to go and get a variety of experiences in different practices, and to find that career that they're going to settle on eventually. We could do that in Wales. Wales is very attractive.

On GP recruitment, I think one big thing—we've already mentioned it, really—is just making the contracting period longer than a year, because it's expensive to recruit a GP and if you're a practice, you want to build a relationship with someone and you need to be confident in your forward planning that you can do that over a number of years, and extending that contracting period would be fundamental to that.

But I also wanted to move a little bit towards recruitment and retention of other staff, particularly administrative staff, whom I look after a lot more. They are a hugely important part of the general practice workforce, often overlooked, and recruiting and retaining those staff is enormously difficult as well. I think there are two elements to that. One is, simply, that general practice funding hasn't kept pace and is not sufficient for practices to offer the salaries I think they ought to be paying, rather than the ones that we can afford, particularly with the changes in national insurance, and how GP practices are particularly hit badly by that. For example, in my own practice in north Wrexham, our recruitment was hit quite badly when Aldi opened across the road, and they can offer £2 an hour more plus a discount on your shopping. If you're on a minimum wage or close to minimum wage job, you can't sniff at that.

The other part of the funding, so it's salary-apart, is the image of general practice, which has really taken a bashing, I think unfairly—I think really unfairly—since the pandemic, and an image bashing that's, sadly, often perpetuated by politicians as well as the media, which means that we're not often seen as an attractive place to work.

Hugely. With national insurance, for example, we've got a double whammy in that as not officially NHS but private contractors of NHS contracts, we were not exempted, so we don't get that covered. But, also, we get a double whammy in that for the Treasury, we're also seen as public sector, so we don't get the NI allowance of £10,500, I think it is, that all private businesses get. So, we get a double whammy there, and with the national living wage increases, in my own practice, which is reasonably large, with 13,000 patients, we're looking at an increase of £70,000 or so—20 per cent of our wage bill—overnight.

I'm happy to take that. I think the first thing to say is that multidisciplinary teams have existed for a very long time, and they're simply a description of more than one profession talking to another profession. So, they take place in hospitals, they take place in general practice and they take place across primary care and in the community. So, today, I think one of the things that is clear is that we are working in multidisciplinary teams within our own practices, where we have a combination of nurses, physician associates, pharmacists and physiotherapists, all kinds of other non-medical professionals, which we, as doctors, lead.

But we also network with all of the other professionals, such as district nurses, palliative care nurses and social care workers—lots and lots of people. There are some formal environments in which we do that, called the virtual ward, which is a daily check-in around patients with complex needs, and there are, of course, the informal—the chats in the corridor, the occasional conversation on the telephone, a video conference when somebody's out in a patient's home and needs to discuss with a GP.

Multidisciplinary team working is a bedrock of medicine. I think we all recognise that it can be better, and in different areas it works to different extents, and the needs are different around patient expectation and needs. One of the things that we need is to provide the facilities for data sharing so that we're all looking at the same information about the same patient at the same time, in real time, and then access. Can a district nurse get hold of the on-call GP within a reasonable amount of time? Can a paramedic who's out at a patient's home? They've fallen on the floor, they don't know the patient, it would be useful to talk to the GP, get a bit of background and decide whether they need to go to hospital or not. Making that access routine and standard is a challenge for us.

Can I bring Kirsty in? Kirsty.

I was just going to comment on both retention and then the role of the MDTs. So, up where I work on Ynys Môn, the actual number of GPs isn't great. It is one of those areas that struggles to recruit GPs, and what saw a fair few of the practices become managed practices was the lack of GPs. And whilst managed practices have a great deal of their own problems, one of the things I've seen really well, working within a managed practice, is actually the way that other members of the MDT take work from the GPs, so the GPs can focus on the complex cases that they have—so, advanced nurse practitioners taking the simple infections. Pharmacists in the managed practice that I've worked in take on the majority of the routine preventative work: blood pressure, diabetes, anticoagulants. There's even a pharmacist who handles a lot of the chronic pain patients, and is a prescriber in pain medication, which is a huge workload from the GPs, because these are often long consultations, and quite difficult consultations.

So, I think if we can get workforce into GP surgeries other than GPs—. I have seen in another GMS practice where they have, actually, quite a great number of GPs, they handle the acute work really well, but they have no admin staff to handle calling people in for routine bloods, and no other healthcare professionals to deal with stuff, so that they're not getting through their NOAC reviews, because they can't hire a nurse to do them, because all of that money is going towards GPs. And because GPs are more expensive, they're then sent off to do all the acute stuff. So, I think it's a case of working together, especially in areas where GPs aren't hugely populous.

And in terms of recruitment and retention, which I've already spoken on, a lot of it is to do with working conditions. Certainly, in my area, primary care pharmacy recruitment and retention is actually really, really good—better than secondary care, I would argue, who often struggle for staffing—in part because they've made sure that the working conditions are good, that the contract matches secondary care contracts.

Thank you, Kirsty. James. 

I love the idea of the MDT model, particularly when it's based in primary care. I guess the only thing we need to consider is the governance. Most of the models that I know, we still as the GP will take ultimate responsibility for when there's a problem. The nurse will knock on a door and say, 'Could you have a look this? It's a bit more complicated.' And I think that's fine. That makes us a little bit more like primary care consultants, and, I think, perhaps, if we are going to develop this MDT model, we need to make sure that we're training the GPs who are going to be part of that model in a slightly different role. And we were discussing this over lunch. I think it's a very exciting role, but it's certainly not one that we're all familiar with at the moment. So, if you're supervising a team of other professionals, whether they be doctors or otherwise, it's a different skill set to just managing your own list and seeing who's in front of you. So, I think it's great, but I think there's almost a pathway to go through, to say, 'This is what a good model looks like, but it does involve a GP somewhere along the spine', and that's in a leadership, management and governance role. 

Thank you. John.

John, do you want to come in on that?

I'll think about your last point, Mabon, as I'm saying my first one, to see if I can get an answer for you. I think, just on MDTs, obviously, allied health professionals are a really important part now of twenty-first century healthcare, of a multiskilled and financially efficient workforce. I think we have to be careful that they are additions, they're not substitutions for GPs, and often you see in the press Government schemes that say, ‘We're going to relieve pressure on GP services by investing more in community pharmacy’. That’s not to say those things aren’t valuable, but they can't be at the expense of proper funding for GP practices. It doesn't just take that workload and move it to other places in the same way.

The other point I want to make with MDT working, particularly intra-practice, or practices and other teams like community nursing, is there are governance issues, particularly information governance and IT issues, which are really hampering that working. Often, as the holders of the medical record, while we as GP practices are data controllers, and responsible to the patients and to the Information Commissioner’s Office for that, that's a big risk. And we're often asked to share data or give access to our systems, and completely unredacted access to other normally health board-run community services, which is a huge risk, because you're granting access to departments, and people are very anxious, justifiably, about that.

There are some solutions that exist. So, now that Wales is all moving to a single supplier for primary care data systems, EMIS, there’s a version of EMIS called EMIS Community where we could grant limited access to district nursing, for example, so they could only see what they needed to see, and that would probably satisfy the information governance requirements better. That's a significant cost that needs to be picked up probably centrally by Digital Health and Care Wales. But it's quite a basic thing to sort out, and it would probably transform a lot of MDT working in the community overnight.

Okay. Does anybody want to reflect further on Mabon's final point? No. Okay. Mabon.

So, I'll go to Kirsty and then to John.

I think one thing is probably making sure that the right person goes to the right place. I think a lot of patient frustration comes from lack of communication or knowledge as to who needs to see what, and so people get sent to community pharmacy where, actually, the community pharmacist can't deal with that condition and everybody involved is frustrated. The GP surgery is frustrated that they now have to deal with this much later in the day, the patient's frustrated they've been passed from pillar to post, and the community pharmacist is frustrated that they've been sent something inappropriate and then had to redirect the patient elsewhere. So, in part, it's being crystal clear who goes where and that it's appropriate, because people are usually happy to see a pharmacist if they're being dealt with appropriately, but if they're sent to see a pharmacist who can only go, 'I'm sorry, I can't help. This is actually too complex', then they're going to get really frustrated. I think a lot of that experience is that patients just go, 'I want a GP because I know they can handle what problem I have.'

Yes. Thank you. John. 

I think it's a GP practice’s responsibility to educate them. It can't come nationally. There are national educational resources—you don't need to see a GP, but, really, patients trust their local GP, and if their local GP tells them, 'Actually an ANP, a pharmacist, can see you, a physio can see you', they will trust them. In my own practice, we employ a patient engagement co-ordinator who manages our patient comms and social media and waiting rooms, and making videos with GPs—the GPs the patients know—saying to them, 'You can see a pharmacist for this, you can see an ANP for this', and gradually over time we've shifted that. But that's where it has to come from. It has to come from that patient-doctor relationship, ultimately.

Yes, thank you. Richard.

I was just going to build this into the question about access, and my own observation is that politicians over the years have promised improved access to general practitioners and even made incredible claims about how soon you should be able to see a GP. Of course, the reality is that most patients don't need to see a GP;  they do need to see a team member. And so, in my own practice, we introduced a triage system 16 months ago where patients request an appointment with the practice, and we as GPs triage that request and determine the best person to see them, as well as when to see them. So, patients will often perceive that their need is urgent, but we might think otherwise, and patients very often think that their need is routine and we want to see them that day, because their symptoms are more concerning than they've realised.

This approach has gone down really well. We allocate patients into various members of the multidisciplinary team, including each other as doctors, and, to date, we haven't had a single patient complaint about the service. The way that patients access it is they can use it digitally via their own phones or laptops, or, if they're unable to use technology, they phone into the surgery in the usual way and one of our receptionists takes down the information from them. We ask them for information and we say to them, or our reception team says to them, 'It really helps a doctor if—', and they provide the information for us. So, there are ways through this. It helps patients to see that care can be accessed, and what, of course, they were doing before was waiting four or five weeks to see a GP when they really didn't need to and their care could have been provided sooner. So, they're getting a better service as well.

Thank you, Richard. Thank you, Mabon. I'll move on and pick up the next section because one of my colleagues can't be here this afternoon. We just want to have a look at the interface between general practice and secondary care. In written and video evidence, we've heard concerns about increased demands on general practice from secondary care. You're being asked to do things that you wouldn't have normally done, or would have been previously done in secondary care. I'm just wondering if you can expand on this as practitioners and give us a view of what is appropriate to ask general practice to do, and perhaps what isn't. James.

The best example of this was ear wax. Back in the day, we always used to do dewaxing and the nurses would do it in their treatment room, and then our local medical committee five or six years ago said, 'Do you realise we're not getting paid to do this?' And then everyone stopped doing it. Now people have to wait six months to go and have their ears dewaxed in the hospital, or they spend £40 an ear to have it done in a pharmacy. At the time, I thought, 'Well, I'll go with the flow here because everyone else is saying we shouldn't do it, but where in our contract does it say what we should and shouldn't do?' And I think it comes back to the boundaries of our contract. Our contract says we should do everything. It's really, really broad, but that's clearly unrealistic and unfair. So, I think that when we are talking about this, we just need to say 'Okay, we would expect a GP surgery to be able to provide these services and, to provide these services, we are going to give them this funding and we would hope that they are going to use that funding as efficiently and as sensibly as they can. But we wouldn't necessarily expect this GP surgery to be able to do this, but if they want to do it, there is an enhanced service that we are happy to pay' because it is a lot cheaper to get the GPs to do it than the hospitals to do it.

They've done it really successfully with direct oral anticoagulants, they've done it quite successfully with diabetes. These things used to be hospital only, or hospital things. Now we do them quite efficiently. We get a few hundred quid a year to do it. It employs our nurse. Patients are happy. It's safe. It's efficient. And I think we just need to say, 'This is core, this is what the global sum covers, and if you want us to do anything else because the hospital hasn't got a service for it or because it's easier, then we should have a whole load of columns', which, as Richard was saying, can very much be dictated to our need. If we are a practice where everything is miles away, like in your area, then clearly we are going to have a lot more of the traditional hospital stuff being done in the community, whereas, in my practice, we're a mile away from the nearest hospital. We don't necessarily need to do everything in our practice because it's really only a few minutes' drive to get to the hospital. It should be a menu of options that everyone can opt into. But we need to make sure that we don't expect GPs to do everything just because hospitals don't want to do it.

Richard and then to Elin.

I think there are two aspects to this. There is work that is undertaken in secondary care, such as routine follow-ups with consultants that really could happen by video or in our own surgeries, bringing the consultant closer to the patient. And, again, in a rural environment, that would be fantastic. So, there is a real scope for a planned shift of care closer to home. But what we've seen is an unplanned shift, which is a request on the discharge form, 'Please follow up the blood tests.' The responsibility for following up on tests that you've organised remains with that clinician. There is an ethical and professional boundary here that is constantly being breached at the moment—requests for prescribing of medicines that were unsuitable, all kinds of stuff—which is, unfortunately, just a symptom of stress in secondary care and a lack of supervision over more junior colleagues, who are writing these things down in a hurry and sending it off. Because it no longer means, 'I need to follow up on that'; someone else can do it.

So, I think we need to be clear about whether we're talking about the planned shift of work, which we could do if we have the resources that come with it and which can be massively more cost effective in primary care, versus the unplanned shift, which is what we really have to push back against and make it clear—. Hospital contracts are very specific: they tell the hospital what they should be doing, the length of time that they should prescribe medication for et cetera, but it's constantly breached at the moment through—. I don't think it's intentional; I think it's a lack of control. 

Thank you, Richard. Elin. Oh, you're muted, Elin. Oh, there you are. You're on now. No, you're off again. Now you're okay. Good.

Okay. Sorry. I think it's a lack of understanding as well. I could give you lots of examples about primary-secondary interface. For years, GPs had been fitting pessaries, then, out of the blue, they decided it would be an enhanced service and that the GPs would then have to train or retrain to do something they'd been doing for years. So, lots of GPs then said, 'Well, it's not worthwhile us doing it', and secondary care were being paid a lot more, so these poor women, and they were usually elderly, would have to take a bus trip or depend on a lift to get into hospital. That's one aspect.

Something huge and major like diabetes, they want to put more on primary care, but we don't have the other resources, like nurses, podiatry, so there's no joined-up thinking there. There's a real major one now with chronic kidney disease, where they're expecting us to do a huge amount of work. But the one I want to focus on is heart failure clinics. There's a real ambiguity as to who should be funding the heart failure clinics. These clinics are, essentially, worked by specialist nurses, with secondary care consultants overseeing it. But any tests that are done are put in the name of the GP, and by default those patients in those clinics are very elderly, complex and more susceptible to really serious illness. So, often, these blood tests come back abnormal, and it's the GP who has to read it, the GP who has to action it, and the GP who has to ensure the patient's safety. So, when you say, 'Well, why is this happening?', everyone goes quiet, because we don't know. Is it primary care or secondary care, and how does the funding—? If things like that could be clear cut, or money specifically for interface where primary and secondary care are working together, that would really benefit patients and it would really benefit the clinicians as well.

Talking about the primary and secondary care interface, I know this might be a big subject, but it's things like ambulance delays. Patients are dying now because they're waiting for an ambulance. Patients are insisting, 'I'm staying at home' and refusing hospital admission, because the hospitals are like war zones, and patients are being discharged early. And that increases our risk management, and that is something that we have to—. As GPs, the buck ends with us, and we're having to really adapt our practice in order to keep those patients safe and to keep on trusting in us and our management. So, there are lots of facets when you're looking at the primary-secondary care interface. It's really quite complicated. But I do feel that there are ways around it to improve the current system.

Thank you, Elin. That was really helpful. I've got John and then Kirsty. John.

I just want to agree with what all my colleagues have said, particularly Elin. There are examples locally in north Wales of secondary care departments being set up—continence is a good one, as an example—where there's no medical oversight or no prescribers in the team. So, when they see patients and then decide medication is necessary, that's been set up with no way for that to be actually prescribed, administered, without defaulting to a GP, who has had no involvement. And for me, it just strikes back to my point at the beginning, that primary care is often not involved or consulted, and there's no strategic mechanism for our input into service design at higher levels in the health board. And if there was some way of more formally consulting us, or some really meaningful way, some of these issues could be sorted out much more easily. 

Yes. Thank you, John. Kirsty.

So, I wanted to agree with both John and Elin for really, really good points, and follow on a bit from what Elin was saying about patients being completely reluctant to go to A&E. You see a lot more patients now being treated in primary care for things that, to be quite honest, they should go to secondary care for, but you can't make the patient attend secondary care when they do not want to, especially within my patient demographic, which is primarily frail patients. For an extremely frail, multimorbid patient to go and spend a day in A&E and then end up probably spending months in hospital, it's really bad for them, it deconditions them, and they know what they're going to get at the other end as well. 

But, on a positive from the interface between secondary and primary care, part of my role is following up frail patients discharged from primary care or secondary care where there are concerns about their medicines management and where colleagues in—. There's a tech who works in SDEC who routinely sends patients to me where there are concerns that maybe they're not compliant with their Parkinson's meds or they're not sure that they understand the new blood thinner that they've been started on. When that gets referred to me, it actually works quite well, because then I can follow them up in the community and make sure they're not going to go straight back into hospital, which is what can happen.

Yes. Thanks, Kirsty. Well, moving on, on a similar theme, recognising that there seems to be sometimes a lack of understanding between secondary and primary care—perhaps that's a lack of communication—what do you all believe could be done to improve communication and referral processes, for example? Anybody want to have a stab at improved communications with secondary care? James.

Yes. We talked about this earlier. We used to have opportunities to meet with our consultant colleagues in educational meetings, which were protected, and we had protected time once a quarter. It wasn't a lot of protected time, but each surgery could close, the out of hours would cover that, and we could all get into a room together. We'd get a room together with our primary care colleagues, our nursing colleagues as well, and then a selection of people from the secondary care team. And over time, you get to shake a few hands, you get to know who's the person who's interested in knees and who's the person who's interested in heart failure, and when you then come to pick up the phone or write an e-mail or write a new referral, you've got some sort of engagement. I think we're—. This is soft stuff, but it's really the bedrock of what we do. We're all about communication. General practice is absolutely a communication game, and the more people we know, the more hands we've shaken, and the more people we've looked in the eyes, that really—. We can't measure it. It's one of the many, many things we do that adds quality, but it's not measurable. But a simple mechanism for us to sit around together, much like we've done this morning—. It's been nice to have a conversation with six or seven other GPs where we've shared ideas about the future. We just don't get this opportunity, and having that opportunity with our secondary care colleagues: 'Let's bash out what heart failure clinics should look like', 'What impact is that going to have on you, and you?', 'Oh, maybe we could do it like this'—. We just don't get it often enough. I'm sure that would help more than so many other things we're doing.

No, good point. Richard and then Elin.

Everything runs on relationships, doesn't it, really, at the end of the day, and the environment in which a GP can phone up a consultant and seek advice about a patient in real time is the best in the world. We develop that relationship, we develop trust in each other, and we're much less likely to dump on each other when that's the case. Unfortunately, in many areas, we've seen the introduction of clinical triage systems or interfaces, where I now speak to a clerk who takes down the information about a patient and arranges admission. It may not have been necessary. The consultant could have given me advice or discussed another option or given me a prescription idea that I hadn't thought about, and being able to clinically chew over problems in real time is invaluable. And it's not just about being able to do it via some online platform with somebody somewhere. It's about your local hospital, your local network, and building up those relationships that we've spoken about, because out of that comes the idea that, 'Oh, Rich is the guy for ENT; I'll get in touch with him—I've got an idea about running a clinic in the community.' Ideas always come from the bottom up, not from the top down.

Thank you, Richard. Elin.

Can you hear me?

Yes.

Lots of the consultants are running around like headless chickens in the hospital anyway, so I have some sympathy. However, they do have admin time. If GPs had admin time, maybe we could sit and reflect as well. So, having admin time in a GP's life would be brilliant.

But I just wanted to highlight—. You asked how things could be improved. Although it's taken years and years and years—about 10, 15, 20 years—from my humble experience, it's things like the antimicrobial stewardship and medicines management generally. I can see now there's a lot more thinking across the board, across primary and secondary care, whereas before it was a great big stick to bat the GPs with if we prescribed too many particular antibiotics or too many expensive medications. But none of the doctors on the wards were accountable for that, whereas now there is a lot more accountability, and doctors in secondary and primary care both looking at, 'Is this the most appropriate antibiotic? Let's get the microbiologists involved. Let's get the pharmacists involved.' So, I have seen progress with prescribing, particularly in antibiotics.

That brings me on to another point. Lots of GPs don't get recognition for good prescribing. We ourselves have reduced our opioids and our gabapentinoids, which is better for the patient; it's better for society. And we've had to work really, really hard to do that, whereas, in a more affluent area, to get the same percentage, they've only had to see like five or six patients, whereas we've had to see 50 or 60. So, that's an example of how there's inequality in how we're being assessed as well, as well as being provided for.

Thank you, Elin. I'll bring Kirsty in, and then I'll move on to Joyce for her questions. Kirsty.

I just wanted to touch on what Elin was saying about the discrepancy between areas when it comes to that kind of funding. So, up in the north, we have a LES, local enhanced services, where practices will get financed depending on how much they're prescribing of 4Cs or total antibiotics or gabapentinoids or opioids; there's a whole bunch of different criteria for it. But depending on practice size, again, that can be a much smaller workload for some practices than others. Also, if you're a practice that's doing really well, oftentimes you have to show improvement, and you can get one new patient—. You can be a really good practice on your opioid prescribing, and then you get one new patient to your area who is very much a victim of other GP practices, on a really high dose of opioids, and then that kind of ruins your funding. So, the funding isn't always looked at particularly fairly, I think.

Thank you, Kirsty. Can I move over to Joyce now? I know you've got some questions you'd like to ask.

On the estates and digital technology. We did touch on this this morning, but I want, for the record, to hear from you about the general practice and primary care estate across Wales, and what impact outdated or inadequate premises is having on patients, staff and service provision.

Anybody want to start off on that one? Richard.

Well, I'll have a dig from Powys, because the vast majority of the health board-owned property in Powys predates the NHS, and there's been very little maintenance of that over the last 20 to 30 years. In general practice, we're expected to provide our own premises. That can be through our own funding, we might own it, we might lease it off somebody else and, in some cases, the health board own and lease the premises. So, there are various states of general practice property, premises, depending on the motivations of the partners or the occupants within that.

One of the real challenges that we face is that our workforce numbers have grown to meet population demand, but our premises haven't, and the planning processes, the amount of money available to bid for for expansion or additional rooms is limited—very limited. And so we go through a cycle of money being made available, we have to make bids, we get turned down and we wait. This has serious consequences for being able to train additional practitioners or deliver new services in communities. So, overall, the state of our property in Wales—and I know that there has been a survey of all premises recently—will need a massive overhaul to be fit for the future. 

Yes. Anybody else?

They're all nodding, so they all agree. 

Elin, I could see you smiling through that. Did you want to add something?

Yes. I think that the public need to understand that we have to pay for our practices. I think that there needs to be a greater understanding as well that some practices are health-board funded. I've heard some stories from some GPs where they haven't had a boiler for 12 months, so they've had no hot water, they have to sit in a consultation in their coat, bring in their own heaters and things. They can't get their light bulbs fixed. And likewise, when we can see that there's some funding available, you really have to fight and fight your cause. There are so many obstacles and it's really restrictive. It's basic things, like having a new door that locks properly, having a new carpet because the current flooring is 20 years old and you have thousands of people traipsing on it every week; it's things like chairs. And that's before we get on to things like equipment—getting a new electrocardiogram machine that's compatible with your IT. I'm just seeing now, our guttering is awful, our car park and steps need to be fixed, and we have to have new fridges. So, we really have to prioritise. And it looks awful from the outside, and that can't be doing patients any good, but we simply can't afford it without everybody in the building, from the cleaner up to the senior partner and managers, having pay cuts. So, it's not just an appearance thing, it really is—. You need new couches, you need to have hot running water. But that is the state of affairs, and it's heartbreaking. And you haven't got space then to train your students or your registrars, so it's a vicious circle. You lose that opportunity to attract people into general practice.

Yes. That's really helpful, really powerful. Joyce, back to you.

John has got a—

John, sorry. John wanted to come in.

I'm not going to add to my colleagues' issues on the physical estate, because I agree completely, but digitally, the environment in primary care has come on leaps and bounds with the pandemic. It really transformed it. I think that one of the good things on the future for us is that there are lots of new technologies that could really help us to become more efficient, particularly in AI. I'm not necessarily talking about things like Heidi, which do digital transcription, because I think that there are some issues with that, but certainly with scanning and coding, a lot of that I'm quite excited about and it will really be transformative for our practice admin costs. It has been held up a lot because the technical coding infrastructure that Wales uses is unlike a lot of the rest of the world, and so a lot of off-the-shelf solutions have not been available to us. Certainly when I recorded my video they weren't. Since then, Digital Health and Care Wales have announced that we should all be switching over to this same coding mechanism called SNOMED by September. So, I'm hopeful that that could be really good for us. 

Yes. Thanks, John.

I'm going on to ask, and I know that you're obviously very keen on this, John, about the adoption of technology in general practice—others might not be so keen—and their views on the barriers to the roll-out of some of those digital solutions across Wales. So, over to you, John, to start with, and then the others can follow, I think.

I think technology helps, but it isn't a panacea, is my big answer, and also crucially, I think you have to make sure that whatever tech you use helps all your patients and doesn't therefore create inequalities with some of them—and some of them can. And that's a challenge, but as I just said, there are enormous benefits to that. What we really need, I think, for that to work properly, is a good working relationship with DHCW, which I don't really think we do have. So, I'll give you an example, which is a small one, but I was approached by a start-up company in London who did digital patient registrations, so if a patient wanted to register online with a practice, they could do it. They would fill in the form, they would code it, it would send them health information, it was saving the notes. It would take what takes a person half an hour, maybe 30 seconds, and they wanted to charge us 50p for a patient. I thought, 'That's fine. It will save so much money, that's great.' They were willing to work in Wales, and the barrier was that, in Wales, we still need a wet signature on a patient registration form. I spent eight months trying to find out if that was really the case—why did we need that—and eventually, I spoke to someone in NHS Wales registrations who said, 'When we get those paper forms with the paper signatures on, we just put them in a box and they go into storage. No-one ever looks at them.' 

Okay.

And I said, 'How do we change that, or ask someone to change it?' 'Oh, we can't.' So, that ended. By that point, the English company had been taken up by NHS England and had been given contracts to work with lots of practices in England and they were no longer interested in working with us. It's just a small example of, I think, all mechanisms in the NHS needing to be open to what could be delivered sometimes by just making small changes or questioning why we do things the way we do.

James.

Yes, we discussed something similar this morning, and my conclusion is that this is about leadership of the IT; this is about someone who is really IT literate who can also make decisions. Because we've got loads of people who are really keen on IT, and none of them seem to find themselves in positions where they can actually influence policy and make it happen. Because there are boundaries and barriers that you will need to overcome, but someone should be able to overcome them. I mean, you basically need to get people just knocking other people's heads together and saying, ‘Listen, this is ridiculous.’ This fact that you need a wet signature is hampering so many things, and they need to know the impact of that, because, clearly, 10 minutes or half an hour of your clerk’s time is multiplied by 370 practices per patient that's registered. And every little inefficiency is—.

The e-prescribing inefficiency is the one. I can honestly say the amount of hours that my receptionists spend each week trying to find lost prescriptions—. And if we'd had e-prescribing introduced five years ago, prior to the pandemic, it is almost impossible to put a number on how many thousands of pounds this has wasted, just in our surgery. If you magnify that by all of Wales, it's phenomenal. We would be able to employ thousands more doctors if we just sorted out these things. And the reason they haven't been able to get e-prescribing out is not because the technology’s not been there—because they've been using it in England for 20 years—it's because they haven't managed to bash the right heads together to say to the pharmacist, ‘No, actually, you need to invest in this system so it talks to this system,’ and we need to get someone who really cares about making this happen quickly.

And so, leadership: the IT is out there; someone needs to actually take control and actually be given that authority by NHS Wales to actually make the decisions that need to be made. I don't know why that's not happened.

No, no, good point. Kirsty? Kirsty wants to come in, and Elin, I think.

I 100 per cent agree, and I think having somebody who is actually in charge can make decisions happen a lot quicker, because it feels like any progress with technology in the Welsh NHS takes years and years and years to get in place. And I think there are some risks in that. Again, my cohort of patients is primarily frail, and a lot of those are elderly and not technologically competent, so I think with the roll-out of any systems, it's making sure that, at the end of it, we don't create problems for those elderly patients. I've had a lot of people complain about practices that mandate an electronic screening system or triaging system, where elderly patients just can't use it at all.

But, also, there are particular benefits for those patients. So, what John was describing earlier about wet signatures being an issue, I had a patient who was almost out of gabapentin as an epileptic, without it risking status epilepticus and going into hospital, and the GP surgery that he needed to register at was insisting that he needed to come in, in person, with a form, and he's housebound; he can't do that. So, the social worker had come to me in a kind of last-ditch effort to be like, 'Okay, please help.' So, I think changing the requirement on that is a big deal, in that for patients who are housebound in particular, we still have a lot of paper or face-to-face requirements that we need to overcome. We've got to be careful how we do it, but for those patients in particular, more use of technology makes a huge difference to their lives.

Thank you, Kirsty. Elin, did you want to come in?

Yes, it was just to say that, digitally, we just have to be a little bit careful because if we open up access it becomes unsustainable. You can get—. If you go to any practice, I think most practices now are able to look at their stats. If there are six doctors in a practice, you cannot deal with 200 requests adequately or safely. So, I think patient expectation needs to be reined in a bit, with no false promises that you get an appointment within a week or whatever.

Secondly, we do have to be mindful of an elderly population, particularly when they're sick, they can't suddenly put an app on their phone. It is very complicated for them. We've got some patients who are illiterate as well, so we've got to look after those patients as well. And then, sticking with IT a little bit, we've just had a new phone system installed. We weren't given any funding or support for that, but that's made a big difference. So, it's not just the IT; it's the IT communications part of it as well that's important to consider. 

Thank you, Elin. Joyce, anything further you want to—?

John's got his hand back up. 

Sorry, John. 

Just to add quickly, I think NHS England does this quite well. So, they have digital funds for practices to apply for, or integrated care boards as they are there, to apply for tools that both are aimed at patient access or at practice sustainability and workforce. And then they have a list of approved suppliers who have been through all of the information governance checks that the NHS wants them to have, so practices have confidence in working with people that they have been properly vetted. It feels like a much more grown up and supported way of working for those practices compared with what we have. 

Thanks, John. 

And Richard.

Richard. 

The opportunity in Wales, due to our size, is to have the same system that we would all use together and integrate. What we'd have to give up as GPs is that local choice of not wanting to do something or wanting to do something different. Personally, I'd really welcome that—make it work for us rather than choosing to be out of the loop. But there's definitely something to be tackled here about central procurement and decision making. 

Thank you. Joyce, anything further? 

I think we've covered off the estates and the technology, and I'm also going to have to leave soon. 

Right, yes. Thank you, Joyce. I'm going to move on to John Griffiths now to talk a little bit about or ask some questions about prevention. John. 

Diolch, Cadeirydd. I think one thing that would be hugely beneficial for our health and social care systems would be to be much better on prevention. It would ease pressure on the acute sector, primary care and health and social care generally. So, on that prevention agenda, early intervention, disease prevention, promoting healthier lifestyles for that benefit to population health, what do we need to do differently as far as general practice is concerned to be more preventative, and also, in doing that, to help tackle health inequalities far more effectively?

Thank you, John. Kirsty.

I think, honestly, it needs consistent funding, because if GPs are busy firefighting all of the acute cases, they're not going to have the capacity to do the routine preventative work, which, in turn, means that they've got more acute cases they need to deal with, which then blocks the door to secondary care. It does need some specific funding. It is definitely an area that I think allied healthcare professionals are really good at and could make a big difference to in primary care. We're often less expensive than GPs, and we often have more capacity to spend more time with patients who need it, and do that preventative work. For instance, within my role, I work with the community resource team. They have advanced therapy practitioners, physiotherapists, occupational therapists who do a lot of preventative work as well as rehabilitation. And a lot of my work is with polypharmacy, multimorbid patients who are at huge risk of going into hospital, and then trying to prevent that, and, oftentimes, some of it's lifestyle, some of it's medication. It kind of varies.

Yes. Thank you, Kirsty. Would anybody else like to come in on that? James.

Yes, this is my real area of interest. I think, on a one-to-one basis, we can do an awful lot for patients preventatively, but I am really, really concerned that we don't get lumbered with the responsibility for preventative healthcare, because, actually, health inequalities are based on poverty and based on housing and based on employment, and based on lots and lots of environmental factors, over which we, as GPs, have no control. I absolutely want to be part of the solution. When I have my patients in front of me, I absolutely steer it towards a preventative agenda, but we really, really need to make sure that, as a profession, we don't get charged with fixing what is an unfixable problem. It's a problem of society, it's a problem of very, very central Government, not even at a Welsh level, and it's a problem of tax, and how you tackle the power of the multinational fast-food chains, et cetera. I think, great, let's do what we can in practice, but let's also make sure that we hold our politicians responsible for, actually, the big issues, because the big issues are the things that are going to really make a difference here, and the small issues that we can do, great.

Yes. Thank you. Richard.

I think it's existential for the NHS. The NHS was set up to treat illness and injury and return people to normal life. We are in a very, very different world now. The quality and outcomes framework incentivised us to gather data and, from that data, we identified that patients may have diseases that we hadn't previously diagnosed them with. We made a diagnosis. When you make a diagnosis, you need to treat them. We treated them, and when you've done that, you need to review them and monitor them. So, we've created a big industry of maintenance of relatively low-level illnesses that we now need to carry on, because otherwise we're seen to be neglectful.

We need to become very, very smart about how we do that review process, how we assess whether or not patients need an intervention. We do it on an annual basis for most. Who's to say that a year is needed? Why not two or three or five? It's always been the role of public health to do prevention, but public health is not funded very well and has a very indistinct role within our current system. So, I think there's an opportunity to redefine what the NHS does, what screening and other preventative programmes do, and how we manage and run those. Unfortunately, one of my colleagues once described general practice as a skip—if you don't know what to do with it, put it in general practice. And much of it has flowed downhill in our direction, and we don't know what to do with it either.

I will pass back to John—. Elin, do you want to come in on that, and then I will go back to John to finish?

Yes. There are a few things. I think we need to improve social care—of course, that's another topic for a bigger debate. There are some examples in general practice, like the pre-diabetes service, which is an enhanced service in some areas. That has been shown to be beneficial, but it churns up as much work as it does for a diabetic clinic. It is quite time consuming, as you've to get your recalls—. It does need the resources to follow it.

There are some other things, I think, in primary care that we do well, but that we could do better—things like flu and COVID vaccinations. If we were properly funded and allocated enough time to do it, and with recognition of that, we could implement that, particularly for the housebound, and things. At the moment, we're governed by quite a few rules as to who we can and can't do as a housebound person, or the health board want to do it in their particular way and GPs have to stand on the sideline thinking, 'Oh, we could do that a little bit more efficiently.' But there are so many different aspects to it—I agree with the points raised earlier.

Thank you, Elin. I'll hand back to you, John. We've only got about five minutes left, though, so—. 

Okay, very quickly, Cadeirydd, obviously, many factors do come into play in terms of what would prevent ill health and what would tackle health inequalities. But, you know, we do have examples in Wales, don't we—the work of Dr Julian Tudor Hart in Abergwynfi, for example, I think, when he reached out to the community as part of a health effort, as a GP, to tackle that problem of people in poorer communities presenting late, for example, with symptoms of serious illness. He took testing and his primary care model out into the community, which I think was seen by many to be very effective. So, I'm sure there is a role for primary care in all of this, in a wider sense than what happens in the GP surgeries. John.

I feel like a broken record, honestly, but a lot of it goes back to trusting GP practices, who know their patients, and giving them power. So, the danger in designing or asking the NHS to design systems is that they tend to be imposed and uniform, and Wales, for all of its size, is immensely complex. Nobody knows individual patient cohorts and their groups better than GP practices, and I think giving practices, in some form or another, some commissioning input into funds might tackle the issue that you're talking about.

Cadeirydd, if there's time, perhaps I might just go on to that issue, really, of how primary care works with the health boards on prevention issues. We've heard, haven't we, I think, quite consistently that primary care doesn't feel that it's engaged enough by health boards or that it has a strong enough voice on health boards in general. Could some of these issues around population health benefit from a greater involvement of primary care at that health board level? 

Any takers?

Yes.

James—'Yes', he says.

I've recently been working with the health board in Cardiff in trying to set up a clinic to prescribe the GLP-1 weight-loss medication—clearly very, very topical. We now have a waiting list in our secondary care service of more than four years. Lots of people are eligible, lots of people meet the National Institute for Health and Care Excellence criteria and lots of people want this drug. I'm enthusiastic about this; as I said in the video, I'm into lifestyle medicine, so I thought, 'Well, I'm going to do what I can.' I attended a meeting, with the right people. There were 18 people there and I was the only actual GP—I was the only actual GP and I wasn't being paid. I've attended 10 meetings to talk about something that is really topical and really difficult, and I haven't been funded or, indeed, really respected in any of them.

So, the engagement from—. You know, there's no-one who is really employed to do this work. The people who might be interested get kind of, you know, a little bit of a back seat. Of course, the reason they're not interested is because, actually, there's no money to pay for it anyway. You know, 'This particular intervention is very, very expensive and there's no money, so what's the point in talking about it?'—that’s the impression I got.

Mabon, did you want to come in?

Yes, we've got about 50 seconds.

Has anyone got a quick-fire answer to that? Richard.

Yes. People are more complex, the situations are more complex. Everyone is multifactorial, so it's very difficult to separate the time spent on various different components of our work. We are no longer medics; we are generalists in every sense of the word and working with everybody around us.

I think you captured that really well. I'm afraid I'm going to have to draw us to a close. I would have finished with one quick-fire question, which would have asked for one longer term and one short-term recommendation to make general practice fit for the future, but I would imagine we could go on for quite some while on that, so perhaps I'd better not. Unless anybody's got a quick-fire one, if you want to fly in with a long-term or short-term recommendation that would make things better. James is up first.

Trust GPs.

Trust GPs. That's a powerful one. Elin's nodding. Elin, do you want add to that?

Yes. Listen to GPs. 

Trust and listen to GPs. Any advance on that? Richard.

Clinically led, management supported. 

Clinically led, management supported. Thank you. Can I draw it to a close and just thank you so much for your time today? There will be a transcript available for you to check whatever was said, and you can challenge that if we've misinterpreted or whatever. Thanks again for the time you've put in this morning and the time this afternoon. It's very, very welcome and invaluable to what we're going to do. So, thank you once again.

Okay, Members, we need to now move, under Standing Order 17.42, to resolve to exclude the public from the remainder of this meeting. Are Members happy to do that? They are. So, we will close the public meeting.