National Assembly for Wales

Okay, well, first of all, just to say that the information technology procurement exercise is held every four to five years and that has been the long-term case across the whole of UK, and that's to make sure that our systems do not become out of date. So, that is why the contracts are four to five years. The procurement exercise, because of the cost of the contract, meant that it had to be formal, following the procedures as laid out in the Official Journal of the European Union, with respect to a national procurement because of the cost or the value of the contract. 

The contract specification was drawn up by the NHS Wales Informatics Service based on the current contract that is being used by the two current providers, which are Vision and EMIS, and added to that were some additional items, based on a survey of GP practices as to what they wanted and needed for the future as well as being cognisant of the development at a national level with respect to the national architecture. It's safe to say that the significant majority of the contract procurement areas were actually the areas that the current contractors are currently providing.

Obviously, any system supplier could actually put forward a bid for the contract. Only three systems did, and they were EMIS, Vision and Microtest. All three suppliers put in on the first round, which I understand was a trial tender round but described to me as round 1, and they put in their bids, which were then assessed according to how they would be assessed in the formal bidding round. The make-up of those doing the assessment includes technical experts because I'm sure that, like a lot of people, I'm certainly no techie, but I know that when I switch on my IT I want it to work and I want it to interact properly. So, we had technical experts on there. There were also experts from GP practices as well in terms of practice managers using the systems as well to make sure that the bids that were being put forward were actually going to meet the requirements. There was feedback given to each of the three suppliers, and I understand that each of the three actually made it through the trial round, some by a larger distance than others, and individual feedback was given to each of those three bidders. It was made clear to them, I've been told very firmly, that each of them were made aware of the main areas in which they needed to meet the minimum requirement—the minimum, not the maximum; just the minimum—in order to be successful and to be awarded an offer of a contract.

So, they all had that feedback and, as I said, it was individually given to the individual companies. They were then asked to formally submit their tenders, and they did so. One of the companies, EMIS, chose—it clearly made a commercial decision to choose—not to meet some of the minimum standards required. Now, some of those are actually very important to practices. So, for example, if my practice fails, I would expect my system supplier to class that as an emergency or a priority to get it up and running again. But unfortunately, EMIS as a company, according to their tender document, would not class that as an emergency until maybe five practices had failed to work. So, that again is not acceptable. They also weren't willing for it to interact with Docman. Docman is a piece of software we have whereby we scan hospital letters. It's integral to the patient record. Currently, they provide that interaction free of charge. They were going to add charges for that. That in itself wouldn't have caused me much of a problem, but it was a whole series of areas within their tender document that was unacceptable. The other area that was of great concern, I understand, to the work streams looking at the tender document was around contract change. So, if there was a development within Wales, Wales-specific, they wouldn't necessarily change that on request.

So, there were a lot of issues there about the decision making of each of the companies in terms of what they put in the bid. If it had only, I believe, failed to meet one or two areas that weren't of concern, then I believe—I am told—that there probably would have been discretion in terms of allowing the award to go through, but there were significant concerns across significant areas, and it was felt that they couldn't be ignored. And if you've got a process in place, why on earth would you ignore it?

The end outcome was absolutely not what we expected. The end outcome was absolutely what we didn't want at this point in time, given the pressures on GP practices. At the time that the outcome of the review from the work stream group was brought to the executive board, it was clear that EMIS could not be awarded a contract. At that point, we said that this was absolutely catastrophic for practices in terms of the problems this was going to cause in terms of workload pressures, the issues about migration, interaction with other bits of software, other pieces of equipment they have bought to interact with the EMIS system, which probably would not work going forward and that loss of investment. And we highlighted all of this to the executive board and we were given a firm commitment that, whilst the decision had to be the decision—and, to be honest, I stand by that—there will be a comprehensive package of support given to practices before the migration to allow them to prepare, during the migration and after migration, because, of course, sometimes you get unexpected problems.

We went through migration in my own practice. We went from a system called Ganymede to EMIS. We knew it was going to be difficult; it was difficult and it took a few weeks to settle down and we are still learning the system today. So, we know what we're up against. I am an EMIS system. We would not have chosen for this to happen, and, actually, the practice managers who reviewed the bids were EMIS practices as well. This was not a choice—this was not a problem to do with NWIS, this was nothing to do with the specification, this was nothing to do with the actual board or the people looking at the tender document. This was purely a commercial decision by EMIS not to meet the requirements within Wales.

So, we are very saddened that that is the position that they took—in fact, very saddened that they didn't seem to value the contract and customer base that they have in Wales, in line with the rest of their customer base. But, going forward, I think we have to accept it is what it is, and we will work very, very hard to mitigate and minimise the effect on practices, and we will be strongly represented on the stakeholder board, which will have representation from practices across the board, because even those on Vision, who choose to stay with Vision—and all practices have to re-choose their platform—will need to migrate to the new Vision software as well. So, there will be issues for all practices across Wales. But I am assured that, with Rebecca's letter to the Minister, also the representations that we've had minuted on the board, and the discussions we've had with Welsh Government as part of our contract negotiations, there will be a comprehensive package of support put in place for practices, and I am confident that that will be the case, and we certainly will not allow there to be anything else.

We have taken a lot of flak at GPC Wales level for this. No doubt you've had a lot of communication; I understand the Minister has. We have taken a lot of personal flak, because, for some reason, people seem to think that we have personally decided this, and it is down to GPC Wales simply disregarding the wants and needs of practices. That's not the case. The personal flak has been completely unacceptable, to be perfectly honest, and we have made robust representations to practices to say that this is what it is, we will support and ensure that practices are supported, but, going forward, we have no choice but to follow the outcome of the review. And we're more than happy to take questions, but I'm very, very angry about some of the commentary that I have seen relating to this issue, both from within the profession and wider.

I'd like to speak a little bit more about the impact this is going to have on practices. So, I've had representation from GPs across Wales, and particularly in north Wales, where 80 per cent of practices currently use EMIS. Many of them went through a migration four years ago and found it a very difficult experience at the time. So, in terms of what it means for practices, for a lot of GPs who are on the verge of deciding whether to stay on or whether to retire, this, if it's not managed properly, runs the risk of being one of those tip-over moments, that says, 'No, enough is enough.' A lot of practices need to spend time looking at the alternative products available, and it's really important that they have resource time to do it—so, backfill in terms of locums and other support for the investigations they need to decide which ones to go to.

There's also a lot of equipment that practices and health boards have invested in that links in with the current EMIS system. So, for example, some of the automated check-ins, automated blood pressure machines, may not have the ability to transfer over. In fact, what I'm being told is that a lot of them won't. And if that is not recognised and that equipment replaced by health boards, it really sets a precedent that, 'Why bother as a practice investing in things that you know will help if, in four years' time, it could be redundant?' and you lose all that functionality, and all that investment.

There are also issues about what data transfers, and we're quite concerned about that. So, although the patient records should transfer over, actually there's a lot of other information contained within the notes—things like recalls for a patient to come back, things like extra notes that you put on their notes, saying, 'Patient has a big, scary dog', or, 'Lives alone, key safe number.' That sort of really useful information. We need assurance that that will transfer as part of the migration, because that isn't automatic.

There's also a particular issue in regard to locums. So, we need to make sure that the locums are trained up in the system, and later we're going to be talking about performers lists. In west Cheshire, immediately bordering on north Wales and the BCU health board area, 100 per cent of the practices are EMIS. Now, we would like people to be able to locum both sides of the border—performers lists issues not withstanding. And, historically, that's actually been where a lot of our workforce has come from—people working in north-west England who've locumed in north Wales, loved it and stayed. So, we need a wider offering, not just to people in the local area, but a bit wider, so that we can get that support and people being confident to move across the border and use the system.

We also need to make sure that the patients are being adequately supported through the time of the migration. I get accosted in the school yard about this issue—this is how much people are upset about it. Stories I hear in the schoolyard are about when the last migration happened. One senior partner had to be sent home because they were just so distraught about—it was just so, so difficult managing that changeover. So, we need people there to see patients while partners are learning new systems, and we need to make sure that support is in place.

We also need to make sure there is comprehensive training. One of the feedbacks I've had is that, last time, although a basic level of training was provided, that wasn't necessarily enough for people to really feel confident, and that, often, things crop up in the next few weeks, as Charlotte's already mentioned, after that migration, and you think, 'Oh, my goodness, I don't know how to do this'. So, making sure that that support is readily accessible, and not just for the couple of days after migration, but actually longer appointment times are provided with locum support to see patients, because you won't have the capacity while you're having those longer appointment times.

Another really big concern for us is about the timing of the migration. So, I understand that there's a phased roll-out plan, but what we want to ensure is that, while it's winter and practices are already under pressure, we're not having migrations at that time of year. Now, that's going to cause some severe logistical difficulties, but that's a key concern for us: that at vulnerable times of the year, no additional pressures are added. Then, if we add to that the impact, potentially, of several practices in a local area going over at once. That's something we feel needs to be avoided, and a real plan for just one practice in a cluster to go at a time, and looking at how we can use the cluster-working model to provide additional support.

So, those are just a few areas. Now, I believe you've got a copy of the letter I sent to the Cabinet Secretary for health, outlining all the mitigation we feel is needed. So, they are just a few examples of the very real impact this will have on our workforce and the support we need, going forward.

Finally, I've spoken to the Welsh Government about this and have been assured that the GMS information management and technology board will be responsible for identifying the needs for practices, going forward, as a result of this change. What I'm less sure about is where the resource is coming from in order to facilitate those changes, and I'm very much hoping that a budget will be identified and it will be very clear to health boards, or whoever else is providing it, just what the scale of their obligations is so that it is really clear that the support is there to help practices manage this very, very difficult transition.

Could I just come back on that? The stakeholder board will be the board that actually takes this forward, and the decisions of that board will come to the GMS IM&T, and that will have strong representation. It will be chaired by a GP, and co-chaired with a practice manager, probably from north Wales. It will have representatives from EMIS and Vision practices across Wales, as well as technical health board and Welsh Government representatives.

We have a commitment within the Welsh Government negotiations this year that any resource implications identified in-year—because you can't identify a budget ahead of time until you've actually worked out what resource you need—will be taken forward during the negotiating forum in the next year. We have that commitment, and that has been signed off by the Minister.

In addition, everything that we—

Before you move on, can I just ask one—? Obviously, at a fairly sort of simple level, I mean, for GP practices, this is a cost burden borne by GPs personally—some of it—and some of it is going to be health board, yes? Can you sort of spell out exactly the percentages?

Some of it will be a cost burden to practices in terms of if the equipment they've purchased before doesn't work, but we have identified that as something that needs to be scoped out and looked at and addressed. Secondly, there will be a cost burden to practices in terms of the time out for training, but also for sessional locum doctors as well. All of that has been identified and will be captured in the stakeholder reference board, and I would suggest that that board actually also gives progress back to this committee as well on the developments as they come. Because some things that sound very sensible and very simple to put in place often are technically quite difficult, but, rest assured, everything that Rebecca has said, the content of the letter mirrors exactly what we have been saying as well, and we will make sure that that is taken forward, and I suggest that it should report back here as well.

Yes. Right, we've got 10 minutes for some clarification, although, I've got to say, it's pretty clear anyway. I think we could come together and do also a letter to the Cabinet Secretary as well as reviewing the situation. Rhun first, then Julie.

Just some technical questions. This is all software—the application. There's no hardware involved in changing the system. Is that correct?

The systems are software. There's some hardware with some of the third party applications, but it's all software. The hardware applications, like printers and things, go through the GMS IM&T board anyhow.

Yes, and it's a PC-based system.

It's PC-based, yes.

But the hardware that I alluded to earlier are things like the automated check-in machine.

Yes, absolutely, the add-ons—

The actual system is a software system, yes.

We have identified that those practices that have invested in that additional add-on hardware need to have that scoped out and addressed as to how they can offer the same services to patients, going forward.

Okay. And the only other question I have is: what happened when you went back to EMIS and said, 'You're about to be told that you're not getting this contract; this is your last chance; the decision has been taken; there is one last opportunity for you to reconsider'?

Absolutely nothing. Whilst the announcement had to be made and there was a 10-day cool-off period, at that time EMIS had the opportunity to challenge it if they felt they wanted to come back or challenge the decision in any way. They chose not to. In fact, they actually sent a message out to practices, which was very clear, actually, that they were saddened by the decision, apparently. I can't say they would've been surprised, but they were saddened by that decision but would continue to support the software until such time as the migration happened. We were criticised, actually, for telling practices about the decision at the start of the 10-day period, but given that EMIS sent a message out to its practices straight away, you're damned if you do and you're damned if you don't, sometimes. 

And what was the value of it to EMIS in Wales every year?

The value of the contract is around £4 million and I think the value to EMIS was roughly a split of 55:45, so, just above £2 million.

Two million pounds per—?

Per year for the practices, yes.

And EMIS published a statement saying that they had lower margins on this contract compared to in England.

Okay. Julie next, then Caroline.

Yes. I had a lot of lobbying in Cardiff North from GP practices and very strong feelings. I just wondered whether what you've told us and the explanation there has managed to get through to GP practices now and whether there's been any change in attitude or understanding, because, certainly, they were very angry and very upset.

Yes, they were very angry. They levied that anger at the wrong people, and unfortunately, we were constrained in what could be said during that legal cool-off period. So, obviously, hares were set racing as to who was responsible, what was the reason, et cetera. The frequently-asked-questions document has answered quite a lot of the issues. Certainly, I've been very active on various GP sites and Twitter to try and address this, but really speaking, it comes down to the fact that EMIS made their own commercial decision not to want to have its Welsh customer base. And, I have to say, having been an EMIS practice for the last four years, it hasn't been without its challenges in trying to get things done.

So, do you think they know—? Are they accepting, the GPs, now, that—?

Whether they're accepting is down to them individually, but they have all the information, which they can read, to understand the decision. Whether that changes their minds or their anger, I can't possibly say. That's down to them, really, but as I say, very angry about the way in which some people have levied criticism about this when it should have been levied elsewhere.

Just building on your point, I think the anger is a measure of the vulnerability of practices at the moment, because we didn't see this level of anger four years ago when people were changing, like Charlotte's practice, off Ganymede. And, because a lot of practices are in such a vulnerable position at the moment, I think that makes it all seem even bigger and scarier than it already is. And, that is why we're getting such anger and upset from the profession.

If we could go further to address the underlying resource issues for general practice as a whole, increase the workforce, as we hope to in bringing in more multidisciplinary staff to support practices, and people felt there was more hope on the horizon, I think this would be easier to tolerate. But, actually, this feels to GPs like just one in a long chain of different events that are making it harder and harder to be a GP at the moment.

It is, but it's one in a whole chain of events that wasn't actually anticipated. EMIS were very well aware of what the red lines were with respect to the contract. So, it is a shame, but this time around, lessons have been learned from the previous migration, and also, this time around, there is the commitment to a comprehensive package before, during and after migration and that package covers financial, contractual and administrative support.

Good. Caroline, a quick question.

That leads on to my question, really, and that's on contingency plans should this happen again. Because it seems to me that the way EMIS has operated regarding Wales, they had us held over a barrel regarding particularly north Wales, where 80 per cent are still with EMIS. So, I am concerned at the plans, should this happen again, albeit with a different company. Surely there should be some recourse for the seemingly cavalier attitude that EMIS has had to Wales, really.

Well, I think they're allowed to have a choice, aren't they, as a commercial organisation? It's up to them whether or not—

But was there no real warning? What about the notice given and so on—the contract? How long does it hold them in to make sure that everything is left—the well-being of patients, then, is left in good order really, and the transition is going to be—

The current contract ties them in and they have confirmed separately, recently, that they will support the EMIS software until such time as the practice migrates, and so that's helpful. Unfortunately, we too have asked the question, 'Why aren't contracts longer?' but it's because of the systems becoming out of date. I don't see how we could in any way prevent something happening to another commercial supplier in the future. They are commercial. Unless we develop our own Wales-only system, really, and I don't know how feasible that is, but maybe that's something again for Wales to look at.

I think that's something to be looked at.

Maybe to look at.

Okay, final point from Rhun.

I think Dr Payne wanted to come in.

Yes, I just want to come back on that point, because I think you do raise a really important point: is Wales an attractive environment for the big software companies to do business? Because we only saw three companies bid in the first place, and I think that's a really important question that sits beyond the scope of this procurement, but with wider procurement issues. But obviously it's beyond—

Because three is a very low number to apply, isn't it? Is that because of the size of the country, do you think?

Possibly—the size of the contract. Unfortunately, it is thus. The suppliers that have been successful have been approved by the GP Systems of Choice process, and I note that there is a procurement going on in Scotland, so it will be interesting to see what happens there.

But nobody is suggesting that they're two systems that are useless anyway. You know, they're probably—

No, you know, it's a shame that other suppliers didn't put bids in as well, because if they'd been successful, the old contract could have gone to however many were successful and passed the bar, and then it would be down to practice choice. Unfortunately, practices are choosing from two systems, which perhaps they're surprised about, because the third one didn't meet the bar.

Were the red lines—the demands on the software companies—reasonable?

Oh yes—

No, just to Rebecca.

Yes, so the RCGP was one step back from this process. I'm not in a position to comment on that, but the BMA are the negotiating experts.

But your members were those that asked, 'Can we have these features in the system in future?' You're satisfied that EMIS and the others weren't being asked to do too much?

I've received assurances that it was a reasonable process to follow from people like Charlotte who've got expertise in the area. My concern is primarily about the impact on practices and how to mitigate that.

And those documents should be easily available from NWIS. As I say, they were primarily based on the current contract that is being provided, with additions for what practices had wanted, which NWIS did a survey for before developing the document, as well as including some of the national architecture changes, which it would have to operate with, such as the Welsh clinical communications gateway and things like that.

Okay. Thanks.

A very short point, Caroline, because you're in extra time now.

It was relating to the conflicting opinion on what was an emergency and what was not, between you and EMIS. Can you just elaborate a little more?

For me, if my practice system doesn't work, I want somebody sorting it ASAP, because that's got an impact on patient care and safety. From what I understand—as I say, I wasn't on the workstreams looking at this—EMIS would need other practices to have their system not working before it would be classed as a grade 1 emergency.

Thank you.

Okay. So, just to end this session, then, I think we can, with your agreement, Members, write to the Cabinet Secretary just noting the emerging themes from this—i.e., a commercial decision by EMIS. Because that's not automatically clear to lots of people in the field, plus also the maximum amount of mitigation that needs to happen. I know it's in train, but there's no harm in emphasising that point. So, are we happy with those themes to go in any letter to the Cabinet Secretary? Yes.

We'd be really grateful for any and every support. As I say, I think feedback to this committee is vital, really, given the level of concern raised.

Yes, thank you. Obviously, we'll keep the situation under review. Great. Right. 

We move on to the next item. Think of something different now, team.

Diolch, Chair. I wonder if you could outline for the committee the current process for applying for inclusion on the medical performers list in Wales, and how the system works in relation to having a separate list for England and Wales.

I understand you'll be taking evidence from the people that administer this, who will be able to give a more detailed answer. So, from my perspective as a GP, if I wanted to register in Wales I'd go to a website, click on a link and download a series of forms. I would then need to supply, face to face, some evidence, for example, my passport, degree certificates and other documents. A Disclosure and Barring Service check would then need to be completed and, crucially, if I was applying from England, evidence from my local area in England would need to be sought, which can add significant delay to the process. So, that is the procedure, in a nutshell.

However, for colleagues returning from overseas—and some of the case studies that we've sent to you—the procedure can become a bit more difficult because a decision then needs to be made about whether it's suitable to include them on the performers list. That's not a straightforward decision, as the system currently stands. So, for GPs who have trained overseas—and I have sent you an example of a Welsh girl who did her GP training in Australia and attempted to move back—there's a very complicated process involving the General Medical Council for equivalent recognition of qualifications, and I believe you're hearing more from the GMC about that process later.

Now, for people that trained in the UK as GPs and then moved overseas, we're back to the issue of: are they okay to go on a performers list? That is at the discretion of the local area assistant medical director, or ultimately reporting up to the responsible officer, I believe, for the area, but delegated to the AMD. In general, the guidance is that, if people have been out of practice in the UK for more than two years, generally, that isn't allowed to happen, but there is some discretion. Now, they can take advice from the deanery. The deanery—and again, this is what's been reported back to me, and I think it would be useful for you to have this conversation with them—they don't advise on whether somebody needs retraining, but they have a retraining programme that they can go through if the AMD feels that they need that retraining. So, that has resulted in a system where people are wanting to protect the Welsh population from doctors that may be out of date, or worked in very different systems, but that can cause some real barriers to returners re-joining the Welsh performers list.

When they're offered that returners programme, they have to do an exam first, and then there can be quite significant delays, as we've found, again, in these case studies. People report not being able to access retraining local to them. So, the girl from the Netherlands—well, a British girl who spent some period of time in the Netherlands—who tried to come back to Bangor, was initially offered practices in either Aberystwyth or Wrexham, which is not really a suitable daily commute from Bangor.

This is particularly concerning because of the current shortage of GPs and the length of time that it takes, as you said, if someone has been out of the country. Probably, we need to look at a system where it's more condensed, really, to get people through and not put them off coming to Wales, really. So, thank you.

Can I just come in on that?

Charlotte.

Just to say that the medical performers list was streamlined in 2016 to make it quicker. So, if somebody was on the English performers list, in theory they should be able to transfer those documents over and then work for up to three months while the people who administer the scheme actually check the validity of those documents. That's how it's supposed to work in theory, and we have examples where it has worked. We have examples where it hasn't worked. So, I think we need to be exploring those to make sure that the current streamlined process is working properly. There have been some barriers in terms of, I think, getting to the face-to-face appointments and some of the DBS checks.

With respect to the actual performers list within Wales, obviously, we would like to see a UK-wide or at least an England-Wales performers list, because many of our border areas rely on English doctors, particularly Shropdoc out-of-hours in Powys—they rely on English doctors to be able to cross borders. We have examples when the weather is very bad where some of the doctors who work on the other side of the north Wales border would happily come across, but they're experiencing difficulties getting onto the streamlined process for inclusion. But actually, more worryingly, we are finding that GPs within Wales are having difficulties moving on the performers list. So, for example, we have Bethan Roberts, who was our GP trainee representative—I think you've met her here before. It was quicker for her to change from a trainee GP to being a fully qualified GP on the medical performers list than it was for her to move from being a locum doctor to a salaried position between Gwent and Cardiff. So, we have to remove these barriers that mean that the system isn't working properly as it stands.

We do have to think about patient safety, and we do have to make sure that we have doctors who are up to date with their training. We need to make sure that, if we've got a robust appraisal system, like we have in Wales and there is in England—why can't that migration happen properly? And if we've got doctors in Australia who have trained in the UK and are over there for a period of time—can we keep them on an appraisal system so we know that they're safe to come back whenever they can and then streamline the process? So, that's what we're asking for: make sure the streamlining is working, make further improvements, remove that barrier across the borders, but actually make sure the system works within Wales as well. It's a nonsense that it doesn't.

Well, two comprehensive answers there that mostly answered most of the questions in this section. So, you can dovetail your questions in terms of relevance. Can I just reassure you that next on after you is the General Medical Council? And after that is the Wales Deanery and then the NHS Confederation. So, this is going to flow seamlessly this morning.

I think it is interesting. And the GMC process in terms of equivalence of training—are there ways that they could streamline their processes, maintaining patient safety? And, of course, with the Deanery and things like that—I think there's lots we can do. We've got a great opportunity in Wales, so let's make it work, really. 

Yes. It's all about streamlining and being sensible. Jayne, do you want to build on that? You can squash four questions into one.

I think you've made such a comprehensive start here in response to Caroline's first question. I think you've mentioned all the barriers that you see to recruitment. Is there anything else you'd like to add about how it specifically affects GP practices and GP organisations? Is there anything you want to add to what you've said in answer to Caroline?

I think really we need to sort things out very quickly in terms of enabling cross-border working. As I say, for Shropdoc, where the Shropdoc service provides services to patients in the daytime as well as the out-of-hours service, I believe 60 per cent of its workforce are English doctors. We need to sort that out and to enable people to help out across borders. I'm speaking at the LMC UK conference on Friday—and people often call Liverpool the unofficial capital of north Wales. So, if we've got the streamlined ways of engaging that workforce, that would be very helpful.

I do feel though that, at a practice level, if they've recruited somebody and then there is a challenge getting them onto the medical performers list—. We have heard examples such as where a Bristol GP wanted to work, had a job offer within Wales and it took so long for them to get on the performers list that they actually took a job within Bristol. So, it's a shame that this is actually slowing up the process for getting these GPs within Wales. So, we need to make it attractive. I think that, if we get the processes right, we can then highlight and promote that as a value to working in Wales: 'You will get into work quickly and we value you and want you in our workforce.'

I would agree with everything Charlotte's said, and just echo that point about value, because we know that Wales doesn't train enough GPs internally for our current needs. We need to bring GPs in from elsewhere. If the idea that's being promoted—not officially, but if social media word of mouth is that Wales is shut, it's too bureaucratic, it's too hard, go and look at Devon instead—that will act as a barrier to recruitment. And just bringing you back to my example from north Wales before, a lot of the GPs who settled along the north Wales coast did it having trained in Liverpool or Manchester. We need to make sure that it's not just in the 'too hard' box for doctors; it's not 'Well, I'll locum in Cheshire because it's easy, but crossing the border is too much hard work.' There's work everywhere. We need to fight harder to make it attractive to GPs. In a market where everybody wants them, we need to have a more attractive offer, and part of the way we can do that is by streamlining the process and making it simple, communicating value to them.

Just to say that as part of the return to work in Wales, we are looking at that scheme currently as part of the wider work of the contract review in order to look at how we can incentivise and encourage people to apply to that scheme, as well as make it easier to access and remove some of the hurdles and barriers there, and also looking at those who make tentative enquiries to enter that scheme but don't take it up—why is that? It may be personal reasons, but actually making sure that we can look at any potential hurdles—whether they're real or perceived—and addressing those.

Can I give a practical example of how that could work? We have the example here of a Welsh doctor who did her GP training in Australia. Actually, she wasn't even able to work as a doctor to start off with because of the GMC issue. Then she was able to work as a doctor but not as a GP, and, actually, we're small enough that we could find these people and say, 'Right, we'll give you a job, you can't see patients face to face, but there are other things you can do in the wider health economy, and then we'll support you through that. And then, when you can get on the register to work as a doctor, we can help you find a suitable job that uses your skills, keeps you up to date.' And really hold people's hands through the process and make them feel valued. That would be such an attractive offer because there are a lot of doctors who have moved particularly to Australia and New Zealand when they were younger, now parents' health is failing, they want to come back. If we can make it easy, make it streamlined, they will choose to come back to Wales rather than other parts of the UK. So, we have a real opportunity, if only we can grasp it.

And I think something for the deanery to look at, and maybe HEIW, when it comes out of shadow format, is something around the accreditation of those with equivalent training, because at the minute, when they need to have experience within Welsh general practice, they are competing, essentially, against GP specialty trainees as well for those places. There is capacity within the training network to expand the offer, so, again, I think we need to make sure that we're maximising the use of our GP trainers who are out there to train and support all GPs, as well as our allied healthcare professionals. It's not quite for this committee, but I thought I'd get it in there—that there is capacity in the training network, I feel, to enable these doctors to have the opportunity to do the training they need, as well as slowly expand our GP training numbers.

Well done, Charlotte; you're destroying our carefully prepared list of questions, having answered them all in the first 10 minutes.

I do my best. But the equivalent bit is an issue because of the capacity—they are going against GP specialty trainees, so sometimes they face a barrier in terms of getting the position or a training practice near where they live.

So, we're going to freewheel now; we've got Dawn and then Rhun.

I just wanted to pick up on the point of the—. You were talking about the length of time it takes to get a GP onto the MPL coming into Wales. Do GPs have the same barriers if they are applying to get on an MPL in England, or can they do that quicker? And if it is the latter, can't we look at using systems that they use in England to speed the process up?

Been there, done it. No, it's no easier in England.

So, this is a common problem, then.

Although this is a common problem—. I'll break that down. For a Welsh GP, such as myself, applying to the English performers list, it was no easier. So, that's point 1. When it comes to the returners issue, they have revamped that offer to returners—so, people who've worked overseas or taken time out of practice. That has been revamped in England to make it more attractive. And as Charlotte says, the work is being done in Wales to look at that.

Now, I think it is more of a problem for us, though, in Wales than it is in England—the fact that the process is bureaucratic. Because we actually need doctors who've trained in England to come and join us. And we see, particularly again in north Wales, that an awful lot of students will choose to go and study in universities in the north-west of England with an eventual aim of settling back in Wales. They're that really key group that we just need to make it easy for. Often they want to come home, but if you make it too hard, they'll settle elsewhere.

It should be quicker in Wales because of the streamline process, but it's not working as effectively as it should be for all applications.

Okay, that's fine. I was just wondering—

And maybe we need to tease out those individual applications where there is a problem.

Okay. Rhun.

The process that you described whereby somebody would come back home to Wales, have their hand held, re-introduced to the NHS slowly—who should do the hand holding? Who should be running that process, that touchy-feely process of welcoming people back to the fold?

I don't think it's my place to say who should do it. I can give you some suggestions, but I'm sure there are lots of people who would have an interest in it. First of all, we do have a single point of access now through the 'Train. Work. Live.' scheme, and that could be widely promoted and be the first point of contact. Now, when they reach that place, they're often connected with—I think they're called local champions—so, GPs in the local area who can provide a personal introduction. But I think we need somebody to hold the process. Now, should it be shared services, should it be HEIW, or do you want to do it another way? That's all up for discussion, but I think a national body needs to take responsibility for that process. I imagine HEIW would be the most natural place for it to sit.

I think HEIW, really, because we need to assure ourselves about the actual knowledge base—the understanding of the local area and working within the local population and the local systems. But I do believe that the training network is there to support that, and it would be ideal for that, really.

So, they would, in effect, perhaps, be given training placements by HEIW.

Well, somebody overseeing their patient management, getting education there to learn about local systems, the local IT—bringing it back to the IT today—and also promoting working in the local area as well. So, the advanced training network—. Apart from the training network, there's an advanced trainers network as well, so that sort of group would be absolutely ideal, really. The length of the placement, then, could be tailored to the individual. So, somebody who has worked here before, gone to Australia for a couple of years, and come back may only need a month's induction, overseeing and making sure they're inducted into the systems and integrated into the local systems. Others might need a lot longer, but tailor it to the individual, and I'm not sure there's really that tailoring that goes on as much as it could do.

If I can come back in, I think a really key element is the personal hand holding. So, a few years ago—well, many years ago—my husband and I looked at moving to Canada, and the recruitment agent was just so friendly: 'What are your children like? How old are they? What sort of schools would you like? What does your husband do?' and really talking us through the process. He had been prepared to send us house details, the lot. And in a world where medical professionals are really sought after and other countries are really walking people though the process of that, I think we need to do that as well, so, having a personal case manager, as it were, an individual who you can call or e-mail and ask your questions to. For a lot of people, it will be stuff as simple as 'What are the schools like?' For people who've educated their kids in Australia or New Zealand, they may have a lot of anxieties about then sending them to an area where the education is bilingual. You know, people who can answer those sorts of very practical, nitty-gritty questions that people will have.

I think that's very key, actually, having that person who you can go to and say, 'Well, okay, I'm thinking about going to work in north Wales. Which part of north Wales? My children don't speak Welsh, but I'd like them to learn, or I've got specific needs for my child'. But also, some of the work that we're doing around the recruitment of GPs at any stage in their careers is around some of these inducements that other professionals get—so, relocation expenses, personal navigators to help support them and know about schools, other spousal opportunities, childcare vouchers, things like that. Those are being teased through at the minute, but any support from this committee with respect to what could help incentivise and encourage people to come and then have a streamlined MPL on top would be fabulous. It really would make Wales stand out from the rest of the country, I think.

Can I come back in on that one more time? That's about the spouse opportunities, because that is a consistent theme that I'm getting fed. We know that 51 per cent of GPs are women. Among younger GPs, it's even higher. And from some of the examples of our case studies, they moved back, they left Wales—having failed to get on the performers list, but that's another story—because of their husbands' jobs, and until there are opportunities for spouses, we are going to struggle.

Things like the universities that we've got in Aberystwyth and Bangor, also in Wrexham—is there an ability to link in with those? Lots of doctors are married to social workers and teachers—professionals like that—so, how can we give a really personalised offer that would actually help us fill vacancies in other parts of the economy? But often, it is spouses' jobs that is a real stumbling factor.

Julie.

I can see that what you're saying would be absolutely fantastic, but how much of this exists now? Does any of it happen now?

The first part of it exists. The 'Train. Work. Live.' campaign has led to the creation of a phone number hosted by shared services. So, that exists. Then, people are linked in with local champions. What we need to do—

So, you've got the local champions.

But they're GPs working in the area. Actually, what I think we need to do is look at the linkage and, while still encouraging those relationships with people who are working in the area, actually have a next step of a formal relationship with a case manager, as it were, be that an advanced trainer, be that an administrator, but somebody local who then treats it like a health visitor holds their caseload—you know, checks up on people and that sort of thing—who actually then has an element of responsibility. Because the local champions will contact people, but it's more of a voluntary thing. We need a formalised process.

So, they're not paid extra, the local champions, for being a local champion.

No.

No. I think we're all in the situation whereby we all want to promote the wonder of working in Wales, so this is felt to be very much something that I think anybody would do when asked. What we do need to do, though, with the 'Train. Work. Live.' campaign, is to look at the recruitment campaigns that have been put on by them, both here and abroad, and see how successful they've been, and build on that. Because I'm still unclear as to the exact detail of the campaign and how successful it has been. Very good feedback where they've gone to royal college conferences et cetera. Very good feedback in terms of increasing the number of junior specialty trainees coming in in general practice, as well as other specialties, but I'm not quite so clear about recruitment wider than that. That's not to say it's not happening, just that it's not visible to me, and it's something I think that should be visible to all, really. 

It's segmenting out the impact it has had on juniors to actually talking about a different group here. We're talking about qualified, experienced GPs that we want to bring in. So, we can use the mechanism that's been created by that campaign and build on it.

Okay. Can you just confirm, just returning to the MPL situation for a bit, as someone who has only worked in one health board area, there's a complicated process, say, if I decided randomly to go and work in Betsi Cadwaladr, then? Is that what you're trying to tell us?

Yes, and that's the bit that shouldn't—

Because I don't understand why that should be in Wales.

And that shouldn't be the case. I believe, although there's a one-Wales MPL, actually, there's a series of five MPLs at individual health board level,FootnoteLink because you have to have the associate medical director actually sign off the person for coming to work for them, and sometimes the processes that the different health boards have for doing that can be a little different, and then they can ask for repeated information, or just there's a delay. So, as I say, we've got an example from Bethan Roberts, who found it quicker to change from being a trainee GP to a GP on the MPL versus being a sessional doctor in Gwent to becoming a salaried doctor in Cardiff. She found the process very bureaucratic and quite long, and it shouldn't be like that.

And it's for people who are moving permanently to an area. So, you can work in more than one health board, but say I was to move off the Cardiff list where I am to north Wales, and want to take up a partnership there, and not carry on as a locum in Cardiff, I'd have to go through this complicated process.

And yet we've got a one-Wales appraisal system, so that gives assurance that people are staying up to date. It shouldn't be like that, so whether or not there is another step being put in at the health board level, probably based on concerns about patient safety—but, actually, is that the right process that should be at the individual health board level? I'm not saying it's not the right process, but I'm saying that it does seem to be giving another extra level of delay. So, maybe, again, that's something to look at and tease out.

Because, obviously, as a committee we're looking at possible recommendations as regards what Government should do to improve the situation. So, potentially one as regards the—. I take on board everything you've said about attracting and enabling people to come back to Wales, but certainly within Wales there seems to be an issue. So, one would seem to be that all health boards are talking from the same hymn sheet, as it were, as regards medical performers lists. Would that be a fair enough assessment of what you're trying to say?

I think that's fair enough. I think there should be the same system everywhere, and it should be as quick as it can be. As I say, we've got an appraisal system for Wales. They've already gone through the various checks with the shared services partnership, who've checked they've got the GMC documents, the right certificates, the indemnity, et cetera. It should be a mobile population within Wales.

Yes, exactly. So, within that, we'll do the Wales-England bit: why should it get complicated going Wales-England, England-Wales, being as, granted, our appraisal revalidation system is ahead of the English system, but the poor darlings over there are catching up now, so it is fundamentally the same system? So, why should there be this huge barrier?

There shouldn't be any difference. There should be, ideally, an England-Wales list, or an all-UK list. That's probably a little complicated, but there should be an England-Wales list. I understand that, in the post-Shipman era when the medical performers list was first established, and then there was an issue, out-of-hours, with a German doctor who came over and worked in one part of England, and there was a disastrous incident there where a patient died because of a morphine overdose, that there was some concern about us accepting what an English area had done in other parts of England as well as in Wales. But those instances have gone, because I think that there's far more governance around the way we're working generally—in England and in Wales it's very similar. So, actually, those artificial barriers that were there for a purpose some time ago I don't think are being prioritised for review, and they do seem to be a bit of a nonsense, in my personal opinion, as to why they're even there. Some people have even questioned: do you need a medical performers list at all, particularly with the way that appraisal revalidation has come in, other than for checking you've got the necessary certificates? Do you actually need to have a medical performers list at all?

Otherwise, why have a GMC register? Rhun.

You've gone further there now than I thought necessary, in saying that what you need is one list. I would have thought that it might be useful to have separate performers lists for Wales, England and Scotland for all sorts of reasons—the fact that you have national health services as distinct entities and so on—but isn't what we need the complete harmonisation of those lists in the different parts of the UK? Does there need to be one list?  

So, I think there's a whole different series of ways this could be tackled. The first one is mutual recognition. So, if you're on an English performers list, we recognise you in Wales. If you're on a Northern Ireland performers list, we recognise you in Wales. So, that's the easy bit. That is doable. Then there is a question as to whether we have separate lists, but as a long-term strategy because there are benefits to it. That's a discussion we can have. But then there's a question as to, 'Well, do we solve this problem by a single list?' Now, my understanding is that that would need legislation in all four countries. I think that's probably in the 'too hard' box, given the amount of parliamentary time taken up by Brexit, and it would be better for us to concentrate on an achievable, which would be the mutual recognition.  

Especially if it's not absolutely necessary. If we have recognition, harmonisation, they work in the same ways, the movement is easy, you make an application—basically, 'Can I put my name on your list, please?', or whatever it might be. 

I don't even think we need harmonisation to get to that point, because the processes are very similar; there may be the odd difference. But, actually, we have confidence in the English system, and I hope that they have confidence in ours. So, if we could get to that mutual recognition and leave it there—

We would be absolutely fine with that. There is a question about whether you need a medical performers list at all, given the GMC register, the appraisal, the revalidation. I suspect that might be a step too far for those who are responsible for overseeing the ways in which we practice. I suspect that would be an anxiety that would keep them awake at night, maybe. 

But the Irish do that. Are you hearing from the Irish Medical Council? 

They have written to us, yes. 

So, there is an example of where it's administered at the Irish Medical Council level, but, again, that would need legislation. And while wanting a perfect solution, actually, a solution that ensures mutual recognition would be better. 

Actually, could you just explain the Irish situation for the benefit of Members here? 

Yes. This is not something I was planning to talk about in detail, but as part of my post-Brexit survival plan, being rather concerned about the impact of it, I've registered with the Irish Medical Council, and I cannot believe how easy it was. So, essentially, I sent them— 

Do you mean southern Ireland rather than Northern Ireland? 

Yes, the Republic of Ireland. So, I sent them some documents that were certified by a solicitor. I sent them a very large fee and, suddenly, I'm on the register and off I fly once a month or so to Dublin, locum there, and fly back again. 

Just to say, Northern Ireland, as part of the UK, actually follows the same as everyone else; it's not quite as—

This is the Republic of Ireland, yes. 

So, it shows what can be done, then. 

Interesting. Is there something—? Back to the question of whether you need a performers list at all, is there anything related to peculiarities in how we work in Wales, for example different EMIS vision systems? Is there anything here on the system in Wales—'You're okay, you tick the boxes for being up to speed on—?

No, it's about governance. So, if I do something really, really bad, it's clear who needs to haul me in and say, 'I've real concerns, Rebecca, about your fitness to practise', and that is the advantage of it. So, there is a nominated individual who will take action where GPs are not practising safely. 

A GMC kind of—

To be honest with you, at the health board level, if they've got the governance procedures right, then it shouldn't really need a medical performers list as well, particularly when you've got a mobile population as well with some of the ways in which GPs and other independent contractors work. So, it's making sure the governance is right. 

I understand why the MPL was brought in. I understand why they were different to start with, but I think a lot of those issues many years ago are now redundant, and, as I say, I do hear lots of people talk about the question, 'Do you need one at all?' Interesting. It's probably a little bit further on than this, though. 

And from my perspective, given the difficulties in getting legislative time, particularly in England, in the 'too hard' box, I think we need to concentrate on things that we can do now rather than a perfect situation for the future. 

So, the mutual recognition of MPLs. 

That would be great, but even if we can't do that because perhaps they don't wish to look at that in England as yet then, actually, just making our systems as streamlined and quick as we can, and the least bureaucratic as possible would be perfect, would be ideal. 

Excellent. Any other questions? 

Yes. [Laughter.] 

Rhun. 

I was down to ask some questions on equivalence, and you've addressed a lot of them. Is the equivalence issue a complete red herring in relation to what we're talking about here because, really, we're talking about what happens when somebody is registered within the UK? Equivalence is about our ability to recruit worldwide in general, isn't it?

I think it's a small issue at the moment in the grand scheme of things. I think, though, it may become a bigger issue. So, I think it is worth having the right processes in place to make it easy to do that equivalence recognition within Wales, certainly. At the minute, I think it is relatively small, but it could increase as time goes on. 

If we can sort of tease out the two bits. One is equivalence within the UK. UK training is set nationally, so I have every confidence an English doctor will be trained to the same standard as a Welsh one. 

I meant worldwide. 

Equivalence worldwide, as Charlotte says, is going to become a much bigger issue. So, we've seen about 50 per cent of junior doctors not choose to take up training posts in the UK. A lot of them are spending time particularly in Australia and New Zealand, and increasing numbers are doing their general practice training there. So, I think we need to make sure that we have a firm offer to those people who want to come back and practice here. So, we need to make sure that we've got our ducks in a row, as it were, now, and use the test cases we've got of people who have done it to make sure the system is fit for purpose for the future. 

I know that we've spoken to the deanery before about this, about particularly those working in an environment that is very similar to the UK GP environment, such as Australia, New Zealand, Canada, and that they have to go through almost like a set process of how they can be inducted and returned to the UK workforce, and there's a set process they have to apply for. And they usually have, I think it's between three and six months within a practice before they dot all the i's, cross all the t's, and are signed off for practising autonomously. I've often said 'Why is that a set three or six months?' And the responses that I've had from the deanery are, very often, if they tailor that programme to the individual or that environment, that could be open to legal challenge from others who have had to have a longer period. And I don't know—. I can understand from their perspective as an organisation that that would be a concern for them, but should that be a barrier? I'm not sure, but maybe it's something to discuss with the deanery. Have things moved on so that they can assure themselves of certain environments? Certainly, when doctors are going over to Australia, and I'm saying to them, 'If you're only going for one year or two, ask the deanery if you can still do your appraisal via Skype, and then you can return really quickly', because that is something that this committee has supported before. It is still not very well used and it has to be approved by the appraisal unit first, but I think that's something, again, we could advertise as Wales being different and unique. 

But that only supports doctors that have gone from Wales, whereas we may have that example of an Anglesey doctor trained in Liverpool, who went from Liverpool to Australia, and who would have never been on the Welsh performers list, so that offer wouldn't currently be open to them. 

So, that's where it ties in.

That's where it ties in with the induction and the returner scheme then, yes.

And one more point on that—so, even if our current processes would say to somebody, 'You're going to need a six-month induction when you come back. There are these practices locally, you can do it'—again, if people could come to a firm offer, that would be enormously helpful as well, because it's very difficult to uproot your family from the other side of the world. 

But they have a salary during it, and that kind of—

Absolutely. And that takes me back to the hand holding. Can we, as a Welsh NHS, actually find people a role somewhere, even if they can't work as a GP?

But do they need the six-month induction? I think that's a question that should be asked if they're working in an environment that is very similar to general practice here. Is it just a month to get them integrated and aware of the systems et cetera? Is it longer? I don't have the answer to that, but it's certainly something I think should be asked. 

The example I had in my constituency was a doctor who was trained here, who went to work in New Zealand, worked as a GP, came back to work here, got so fed up after six months that she still wasn't able to practise that she went back. 

It's sad, isn't it? And I've heard the same from small numbers, but enough that you think that, actually, that shouldn't happen for anybody.

If I can give you another example—it may actually be the same one—of the doctor who came back from New Zealand. Actually, she got in contact with me and I was working up in north Wales in out-of-hours at the time. And although she knew how desperate we were for doctors, she couldn't work in the out-of-hours, but we were able to link her up with the accident and emergency department, and she was able to work in A&E and brought huge benefits to them as a qualified GP. If it hadn't been for that connection, she would have been sat at home not able to work at all. So, there are ways we could employ these doctors if they're on a GMC register, even if they're not working as GPs, but we need make sure those routes are transparent and clear and people are able to access them, because it can be just so confusing.

Good. Any other issues before we wind up this session? No. Happy? Diolch yn fawr. Well done to you. Excellent. Excellent evidence session. So, that's the end of the first session on this. So, if I can say now that we'll have a natural break for 10 minutes. If we're back by 10.15 a.m., Members, that would be good. And with the General Medical Council then.

I wish I could stay and watch. Thank you.

Thanks a lot. Thank you.

Diolch, Cadeirydd. I wonder, please—good morning, Clare—could you outline specific issues with the current process for medical performers lists—having separate lists, for example, for each health board, separate lists for England and Wales? What impact do you think this has on individual GPs and organisations and also on recruitment, really, and people wanting to come back to this country, having trained here, been here, gone away, come back, and how that impacts on the current shortage of GPs situation, really, and recruitment?

Certainly. So, I should start off by saying that, of course, the GMC has no remit over the medical performers list. I'm obviously aware of how they operate and how they work, but management of them is something that is not under the GMC's auspices. So, as I understand it, to work as a GP in the UK, you firstly have to be on the GMC register and then you also have to be on the medical performers lists—different performers lists across the four countries and, in Wales, different performers lists within the local health boards. So, that inevitably will bring with it some challenges for people who want to work in multiple locations and who want to move swiftly between those locations. There are, understandably, certain processes to get onto the performers list that specifically ensure patient safety and ensure that those people going onto the list have the appropriate knowledge, skills and experience to work as a GP in the relevant country.

As we've heard this morning already, there can be challenges for people who want to move quickly, because there are different processes for getting onto the different lists, not only across Wales, but across the country. You have a border with England and there is movement between those two borders, and, therefore, the ideal situation, not only for those working, but also for those wanting to come and work in the UK, is that you would get onto those lists quickly and you would be able to move around with relative ease.

Okay. Dawn, do you want to pick up?

Yes. In your written evidence, you refer to the requirement for every doctor on the GMC's register to connect with a responsible officer for the purposes of governance. Could you provide the committee with a bit more information on the role of responsible officers and any issues there are around that, please?

Certainly. So, in 2010, there was a piece of legislation introduced called the responsible officer regulations. This was largely a forerunner to the introduction of revalidation and the idea behind the responsible officer regulations is that it establishes a form of clinical governance for all those working as doctors in the UK. So, there’s a distinct hierarchy that is set out in the responsible officer regulations that indicates that, if you are a doctor working in x location, you connect to y responsible officer. The responsible officer kind of does what it says on the tin—they are responsible for ensuring that an individual doctor has an appraisal, that, when they come to make a recommendation to the GMC about that doctor's revalidation, they take account of any clinical governance information that they might be aware of, any fitness-to-practice information that they might be aware of. If a doctor connected to the responsible officer has conditions or undertakings imposed by the GMC, that responsible officer, again, is responsible for ensuring that that individual practices within those conditions and within those undertakings. 

They also, when they come to make that recommendation about revalidation at the five-year point, would need to ensure that the doctor has provided information from their whole scope of practice. Now, what I mean by that is, these days, doctors have portfolio careers, they work in many locations, but they have one single connection to a responsible officer. So, to give you an example, a doctor could be a GP in England, but also working in Wales. Now, if the majority of their work is in England, their responsible officer will be in England. Now, ideally, there is information flow between the different locations where that doctor is working that feeds back to the responsible officer in England so they're aware of any issues before they make the recommendation to the GMC. That, if it's working properly, provides appropriate oversight and clinical governance for all the places that that doctor is working, so that you don't have an issue known in England that isn't necessarily known in Wales, and vice versa.

What we are seeing is that some of those information flows are very good, some of them aren't quite so good. We are about to issue a piece of guidance about information-sharing principles to ensure that anybody who is employing a doctor is aware of where else they're working and what else might be going on, so that there are appropriate information flows and that clinical governance piece is carried out. 

Now, actually, not all doctors have a connection to a responsible officer, but they still revalidate and they revalidate through a process the GMC takes care of. But that's the function of the responsible officer: it's that oversight, that clinical governance piece, and then making a recommendation to the GMC.

Thank you for that. So, is that then only potentially a difficulty if a doctor is working cross border or—? Because I fully understand that the role as you've explained it becomes slightly more complicated if they're working both in Wales and England. If they're only working in Wales and they only have a responsible officer that they report to or liaise with in Wales, maintaining the information flow shouldn't be a problem in those circumstances. 

Yes, absolutely. Obviously, the doctor has the obligation to declare to the responsible officer everywhere they're working, because they could be working in the NHS and also privately. And, again, it's important that that information share goes on from both locations, but it would go to just one single RO.

So, would there be any case for arguing for somebody then who works in both England and Wales to have a responsible officer in both? Or is that just being overly bureaucratic?

Well, that might be a level of bureaucracy too far. We're in discussions at the moment with the department of health about the responsible officer regulations. They're their regulations. They've been in force now for seven years—eight years. Are we 2018? Yes. And we're starting to see how they're actually working in reality. It may be that we need some changes to look at: is the connection where the majority of your practice is, is it where there are those difficulties between people who are working in different locations, should there be an absolute legislative requirement to share information or how do you ensure that those appropriate information-sharing pieces take place?

Okay, I understand. Just a couple of other questions, Chair, if I may. We've seen some changes to the current system, which was aimed at simplifying the process in terms of registering on the list. Have those changes had an impact, do you think, or—?

Not as far as I'm aware, but I did hear from the evidence given earlier that in some instances that streamlining process is working very, very well and it means people can move more quickly. But that's still not a uniform approach and there are still some people who are having difficulties in moving in different areas. The intention is absolutely appropriate, that people can move quickly, and that streamlining should help. It's about ensuring it works in practice.

Yes, absolutely. I understand. So, in terms of looking at reciprocal arrangements then as a potential way of streamlining that—because, presumably, if we didn't have to have people registered in four different countries, that might help—do you have any thoughts and views on that?

Yes. I think you could have one list for the entire country, but that brings with it challenges. So, that would need to be established on a legislative basis, and I think we all know that Brexit is the biggest legislative ticket in town at the moment. Having some form of reciprocity would make life so much easier, if people are recognised from one list to another. You would think as well that would also carry with it some information governance benefits, because again you can then check and see if there are conditions, if there are undertakings, if there are issues across different areas very, very quickly. So, you can see the benefit of having that reciprocity, definitely.

Sure. Okay, thank you. Thank you, Chair.

Julie, you have two questions.

Yes, thank you very much. Your written evidence says that any GPs who are off the medical performers list

'for more than two years must also complete the Deanery’s Induction and Refresher Scheme, which...places further time constraints, costs, and delays.'

So, could you outline—I know you've mentioned this to some extent already—what impact this has and any other issues that are faced by doctors returning to Wales?

If I can start with the GMC side of things, for someone to get back on the GP register—so, if they've relinquished either their registration or their licence, to get back onto the GP register is pretty straightforward. They need to give us evidence of their identity, evidence of good standing from any countries that they've been working in in the previous five years and evidence from any employers that they've been working with in the previous five years. So, that's pretty straightforward. To then get onto the medical performers list, there is a more intense process to ensure that their knowledge and skills are up to date. That's understandable from a patient safety point of view and it's understandable from a maintenance of standards point of view. But, with that, it means that a doctor could be registered and licensed with us and wanting to work as a GP but unable to until such time as they have completed that process to get back onto the medical performers list. So, there is an argument for making sure that that process is as efficient as it can be while still maintaining those standards. It's entirely understandable that those standards have to be there. I have heard anecdotal evidence from doctors who said it was very quick and very easy to get back onto the GMC register and get their licence back, but then they were sat twiddling their thumbs, not able to work as a GP, because they couldn't get onto the performers list. 

Right. Thank you. Now, you give us evidence about the work you're doing with NHS England and Health Education England to streamline applications to the GP induction refresher scheme, performers list and GMC register—could you give us more information about what you're doing on that? 

Certainly. So, we held a meeting between the relevant organisations: myself for the GMC, HEE and those looking at entry to GPIR scheme and the medical performers list. We very quickly identified that an applicant would be providing the same evidence and documents to all three bodies, and it seemed very burdensome and probably very frustrating for the individual applicant to, three times, have to give the documentation to three different bodies. So, what we suggested was that the GMC would check the documents first; we have a statutory obligation to ensure that, when we put people on the register, they are appropriately qualified and fit to practise. We would then provide information to those dealing with the medical performers list and those dealing with the I and R scheme about who we put onto the GP register and what documentation we had checked. Ideally, the other individuals would then not need to see those documents again. They would take our word for the fact that we had looked at that documentation, we had verified it and we had assured ourselves that everything was bona fide and genuine, and they wouldn't need to ask the applicant again for that information.

We're piloting this at the moment. I think it's fair to say we've run into some information governance issues in those organisations—you know, releasing that power to another organisation rather than holding it themselves and doing those checks themselves is something we're still working through. They, equally, seem to want to see the actual documents rather than take our word for it that we've looked at them and we've seen them, but we continue to work with them to see if we can rely on this process where the documents are checked once and once only and then they can be used multiple times. We're going to expand the pilot in England to see if we can get some more feedback and input from the people who are involved and then look, if it works, to roll it out across the four countries, because, again, providing the information once and it being used multiple times has got to be the best way forward. 

Thank you.

I think mine's been covered. 

Yours has been answered. Rhun. 

Just a couple of questions on the principle of equivalence. The royal college of GPs England tell us that they're working with the GMC to simplify the processes for applications from doctors from abroad. Could you just tell us a little bit about that work that has been ongoing and where you're at?

Certainly. So, you're correct. For international medical graduates, there is a, quite frankly, burdensome process that they have to go through and we have some very prescriptive legislation that goes down to even the particular types of evidence that we have to see. It specifies training logs—you know, all the rest of it—it specifies that they have to be authenticated. So, we're very constrained by the legislation that we have at the moment, which we would like to change and make more flexible, but as part of the GP international—

UK-wide legislation.

UK-wide legislation, yes, indeed. And not just for GPs—for all international medical graduates applying to get onto the specialist register or the GP register.  

Okay. Sorry to interrupt. 

That's fine. So, as part of the GP international recruitment programme that's being led within England—we know across the UK there are GP shortages—we've been working with the royal college of GPs to look at whether there is a streamlined process that can be undertaken that still maintains patient safety, the standards of the GPs coming through, and also protects the integrity of the GP register. The process that we've started with is looking at the curricula in place in Australia, comparing it to the curricula in place in the UK and seeing where there are similarities. Now, in the UK we have one royal college—the royal college of GPs. In Australia, they actually have royal colleges and therefore two GP curricula—one that's specifically focused on rural working, because I'm sure as you can image, in Australia, there's quite a lot of rural practice that goes on. So, the royal college of GPs have engaged the University of Exeter to carry out a programme to look at the two curricula to see where the similarities lie.

The idea will be, if there are similarities—. The normal application from a GP could have, let's say, 1,000 pages-worth of evidence—that is normally how big they are—but, where we've mapped the curricula and found equivalences, we could maybe reduce that requirement—I'm going to pick a number out of thin air—to 50 pages-worth of evidence that would cover elements that weren't included in the curricula.

What we've started—. We haven't received a final report from the royal college of GPs yet. What we're wanting to do is see if this practice could then be scaled up across all other countries. So, it's obviously not just Australia. There are some challenges with that—curricula don't stand still. We are updating our own curricula, so you would need to do this process on an ongoing basis. Somebody could be applying from a curriculum that was 10 years old, five years old, two years old, so it would require some ongoing effort. But the idea would be that if we could do that across all countries in the world, across all specialities—65 of them, and GPs—then we could streamline the process for applicants.

Whether it'll work in practice or not is another matter, because you do need there to be comparable approaches in the other countries, so you need to have an overarching body, like a royal college, you need to have a curriculum—not all countries have a curriculum, and you need to do that mapping process. But it's a starting point.

We're very much committed to ensuring that we can streamline the process and that's where we're starting off, and starting with Australia because there are some obvious similarities in terms of the way they approach things, the fact that we're first world, the way that healthcare is delivered. Whether it could be extended across the world is another matter, but that's a challenge for the GMC.

And this is what, a five-year, 10-year project?

Well, we're starting off because of the international GP recruitment. We need to see if it works, and then we'd think about how we would roll that out. Would we roll that out by shortage specialty? Would we roll that out by country? And think about where that goes.

We are working again—. We're stretching that legislation to its limits. Ideally, if we could get some legislative change to provide us with a more flexible approach to dealing with these applications, we could look at all manner of different ways for ensuring that people provide us with evidence that they are of a similar standard to a UK GP. But we're working within the confines that we have at the moment.

Thank you very much for that; that's really useful. Now, I need to know if that's relevant at all to what we're discussing here now and the performers list and the ease of movement across borders. Is there a relevance? Where would the relevance come in? It would be on how equivalence is gauged in Wales vis-à-vis England, I guess, would it?

Well, the equivalence process is four-country, as you say. There could be some benefits to us talking to the GP I and R scheme, those who manage that scheme, which is what doctors have to go through before they get on to the performers list, to say, 'Here's the assessment we've done; which elements of that assessment map across to what you're doing?', so they can also reduce what they're asking a GP to undertake.

But, once you have full recognition and respect about the processes that have been followed in one performers list, you resolve these issues, don't you?

Well, I'm talking about entry on to the GP register, which is different from entry on to the performers list.

Yes, of course.

But, yes, if there were reciprocity across the performers lists, once you're recognised in one area, you should be able to rely on that recognition elsewhere.

Fine, thanks.

Good. Last question, Lynne.

Thanks, Chair. Your written evidence says that there are implications for workforce recruitment, which could become worse because of Brexit, but you've also said Brexit could also provide an opportunity to amend legislation that might address some of those issues. Can you just tell us a bit more about that, please?

Certainly. For Europeans, they're currently recognised under European legislation, and that legislation recognises qualifications to a minimum standard, and that standard is based on, pretty much, time spent, rather than anything else. So, we have a list of all the specialties that are recognised across Europe, and we have a minimum number of years that somebody has to have trained in that specialty before that recognition can take place. The benefit, obviously, of the European legislation is that it's a very, very streamlined process. A couple of—. I'm exaggerating for effect, but a couple of pieces of paper and you demonstrate that you've got the relevant qualifications and we can register you with the GMC. The equivalence process is much more prescriptive; you're talking about 1,000 or so pages of evidence to cover the entirety of your curriculum. If Brexit were to disappear—. If Brexit means that the recognition of professional qualifications disappears tomorrow, 1,300 doctors a year who used to just wave a couple of bits of paper at us now have to end up in a process where they're talking about thousands of bits of paper instead. So, they go from a streamlined process, where they could get registration in a very short period of time, to a process that's quite burdensome, very, very paper heavy, very intensive, and takes much longer.

But, with Brexit, it gives us further opportunity to highlight these discrepancies between the two areas and push for legislative change so that we can ensure that the workforce supply is not impacted and we can get people onto the register as quickly as we can—of course, while still maintaining standards and patient safety. It also brings with it an opportunity for us to move to a process where, rather than looking at time spent, we're probably looking at competencies gained, which is the way we deliver education in the UK. We look at the outputs rather than just the specific timeline. That may mean—not necessarily for a GP, but for other specialties—people can be recognised quicker, we can recognise prior learning from elsewhere. So, it does bring with it some benefits to refresh the way we're looking at education in the UK and we're looking at recognition. And, if we can get that legislative change, it would also mean we could look at: can we say, 'We recognise this qualification from this country because it meets our standards; we've looked at the curriculum and it works the way we think it should do'? But the biggest—. The biggest, I think, impact will be on workforce, if we have from everybody in a very streamlined European process to everybody in the international medical graduate process, which takes much longer. So, hopefully, this is the lever that we can use to get change to the legislation to make it much easier for everybody.

Okay. Rhun, you had a supplementary.

It's not a supplementary; it's just out of interest, perhaps. This 1,000-page application, how much of that would be standard? So, if a doctor who's been trained in South Africa wants to come and work in the UK, would 400 pages of that be the same for everybody coming from South Africa, as in a copy of the South African curriculum, or would that be tailored for that individual?

Each application is assessed on its own merits, and what we tend to find—and the same can be true in the UK—is that training programmes are different for the individual. I mean, if you look at a UK process, a doctor can do some out-of-programme training, they can get some experience from overseas. So, actually, you have to look at each one on its own merits. So, it's difficult at the moment to say everybody—as you say—from South Africa who graduated between 1995 and 2000 will all be treated the same way, because they are inherently different.

Yes. And it must cost somebody a fortune as well.

It's not a cheap application process, no, this is true, and we rely very heavily on the royal colleges to provide the specialty input. It's a fairly fierce undertaking to go through that process, it has to be said. With the exception of GPs, if we look at specialists, by and large many of them are in the UK practising anyway because they've got full registration and they're working towards getting their specialist registration, so they gather their evidence while they're here. For GPs, it can be slightly different because of course you can't work in the UK as a GP unless you're on the GP register and on the performers list. So, they have to provide everything in one go, and, if that application fails, they equally don't get full registration so they can't be working at the same time. So, it is a little bit more challenging for GPs as well.

And one final, more relevant, question: whose heads need to be knocked together in order to ensure that we have the reciprocation and the recognition across current performers lists?

Well, I'm actually not sure who's in charge of the medical performers lists at the moment, but, whoever is in charge of running the medical performers lists, those will be the people who you need to get together in a room, I think.

Cheers. Thank you.

Diolch, Gadeirydd. Good morning. Could you tell me, please, due to the current process of having separate medical performers lists for each health board and a separate one for England and Wales, could you tell me what the current issues are facing GPs because of this?

The issues will be for people who work in more than one place, whether that's across the Welsh-English border or whether it's between the health boards in Wales. There's an irony in that the list is managed in Pontypool by shared services, and yet, if you move from north to south or east to west, or wherever it might be, or into Powys, the chances are that you will have to apply for additional inclusion on more than one site. That, to me, seems to be a nonsense, and I think that the sooner we can deal with that the better, because the standards of entry in Wales are identical wherever you work.

There may be some aspects of the legislative process that governs the performers list in England that are slightly different to Wales, Scotland and Northern Ireland, and in that context, if you were to move towards the obvious solution, which is to say, 'We have a UK performers list,' then you'd have to get the four departments of health within the UK to sit down and to iron out the differences and to agree on what concessions or additions might be made to those lists in order to make them identical, or, maybe, to tease out some issues that are so minor that they can be on some lists and not others but they don't fundamentally affect the standard of entry and remaining on the performers list.

Because of the current situation with our GPs—the shortage of GPs and so on—it does seem to be a stumbling block. So, are you as keen as other people, and us included, to overcome this? And how soon do you envisage looking at this?

The performers list is secondary legislation, so the regulations within the four countries do not require, as I understand it, primary legislative change. So, the Brexit argument wears a bit thinner on that point, and I've heard some reference to Brexit that will affect some of the debate today, but not necessarily all. So, it will depend on the will of the four nations to do this.

I think that our border, really, and our only real border, is between England and Wales, and particularly in the Marches. We have a lot of cross-cover and there are a number of people who work on both sides and are on both lists. The addition to that number on an annual basis is very, very small, so the number of people actually affected by this is not going to change the workforce dynamic in Wales or in England. So, the numbers that we're talking about are tiny. So, the will to create change will depend on the potential benefit, and if that benefit is perceived to be small on either side of the border, then the will is correspondingly not great. So, that would be as I imagine it. I've not spoken to many people in the department of health in England about this, but I know it's an issue that people are discussing in Wales and it's an important point for this committee to consider and provide recommendations on. But the will will be, I imagine, proportionate to the benefit.

Dawn, do you want to carry on there?

Yes. So, are you saying that you don't think that the current system is having a direct impact on GP recruitment in Wales?

I don't think it's having an impact on GP recruitment, no, because the people who come into GP training—the vast majority of people who become GPs in Wales—go through training programmes here, or they go through training programmes in England and move into Wales, and then they have to apply for a performers list anyway. So, they have to shift from being a trainee to an established GP on the list—what we used to call a 'principal', but, anyway, a qualified GP—once they get their certificate of completion of training and they get onto the GMC register, which I'll say something about later, I guess. So, I don't think it's a burden at that point in time. I think the only burden is for people who want, for the first time, to work cross border. And when it's done, it's no longer a burden.

Yes. And that one, you're saying, there are relatively few numbers involved in that?

There'll be, along the border, I'd imagine, fewer than 100, off the top of my head, GPs who are working on both sides. If you come from Newtown or from Welshpool down to Abergavenny, Hereford area, the number of GPs in that patch who are working on both sides is very, very small.

You also mentioned the need to apply to be on different lists in each health board within Wales, which I'd picked up in the evidence that we've had. Can you just explain a little bit more about how that works? Presumably, that's a much quicker process. Once you're on the list in Wales, moving between health boards, presumably, isn't a—

I think that that was streamlined, probably in about 2016, maybe a little bit earlier, but there is certainly a will to make that easier, and I think that some of the evidence that you hear will be anecdotal pre-change. So, I'm not sure that it such a problem now.

So, you think those changes have made a difference. 

I think the changes to make it more streamlined have happened, but the changes to create a single list for all haven't, and I think that I don't see any real hurdles. You know, if we have a concept of an NHS Wales, I don't really see that there are problems with the performers list being run in a single place and the governance of it in different health authorities. The governance is about individuals who are on the list, and the maintenance and management of the list is held in shared services. So, having one seems to me to be entirely logical, and having more, the opposite. 

Okay, that's fine. Okay, thank you, Chair.

Next questions—Julie.

Is there anything you would suggest as an improvement?

I think, in Wales, just to agree that we have one performers list and to get the chief execs of the five health boards to agree to that. Because there's no difference; the performers list regulations in Wales are universal across the five health boards, so it seems to me that to name the health board in which you want to work is, okay, maybe helpful for manpower issues, but, in terms of standards and governance, it's not at all. 

So, is there resistance from within the health boards?

I'm not aware of resistance. Certainly, I don't think there was any resistance in the shared services in terms of streamlining. I'm not aware of resistance in health boards, but it just seems to me that it's almost like a cat's eyes situation, isn't it? Why wouldn't you have it once you've thought of it? I'm just not sure whether people are actively thinking about it on a day-to-day basis. I think we lose sight of the fact that, within our integrated health boards, general practice remains, I think, largely disenfranchised because the big issues are around hospital and 90 per cent of the budget. So, I think that, unless there's a problem in general practice that someone has to sort out, it's pretty much left alone.

Thank you. Could you outline your involvement with the process of doctors who are applying to return to work in Wales?

Yes. I should say that I was on the General Medical Council for a 13-year period up until 2012, and, when I was on the council, there were a couple of things in Wales that we didn't have—nor did England, actually, although one of them, which is about medical appraisal, they were just kind of starting off with in a very piecemeal way and didn't have any structure around it.

So, the two things that we did in the deanery were to create a GP appraisal system, which is now a system for all doctors in Wales, which feeds into revalidation and responsible officers and so on. But the other issue that happened, in terms of people—largely people coming to the UK and getting onto the GMC's GP register, which, actually, is just a recognition of your legal right to work in general practice; it doesn't give you a job and it doesn't remove the need for health boards or whatever in England to ensure that the standard of working is right. If you like, you could say that (1) the GMC list—you could call it a legal fitness for practice, whereas the performers list is fitness for purpose. So, it first came to my attention on the GMC that people coming from abroad were going through what's now called the certificate of eligibility for GP registration route—the equivalence route—not having experience of general practice in the UK and failing to get onto that list, and the GMC saying, 'If you go and work in a GP practice for six months, get the skills, get some assessments, maybe do the college exam, then we'll reconsider your application and it shouldn't be a problem.' But, legally, they can't work in general practice. You heard from Clare Barton of the GMC earlier that you have to be on the GMC register as a GP, so you have to have completed training in Europe, in the European Economic Area, and that gives you UK, obviously, and EEA medical directive recognition, because of freedom of movement. Frankly, it doesn't ensure the standard, but it's a legal requirement—movement comes first. We were aware of people coming over to Liverpool and London. They had an initiative to appoint people, because of a GP shortage, from the EEA some 12 years ago, which ended in disaster in some places, and none of those people are left working in the UK now. 

In Wales, we set up an advisory piece for the old local health boards, whereby if they had a curriculum vitae that looked odd in that people hadn't worked here, or that they had been out of practice in the UK for—we used to say three years, but now that's become two—they might want to go through an induction or refresher programme. We set up a network of further training practices across Wales, which were established training practices that volunteered for this higher level engagement, and they looked after the inductees—mostly EEA and returner. The numbers are small, and let's not kid ourselves, if this was easy, we wouldn't have 100 people coming into Wales tomorrow or in the next two years who want to work in general practice in Wales.

The numbers reported in England recently are—I shouldn't say 'exaggerated', but there's an element of double-counting in that, in that they count people who've expressed an interest, and if all of the people who had expressed an interest in coming to Wales for the returner and induction scheme had been appointed as GPs, we'd probably have about 50 to 100 more than we have. At the moment on the returner scheme, we probably have no more than two or three. This was something that we set up in Wales because of an obvious need that was identified by these GMC processes. And the other process was the performance processes at the GMC, which basically might conclude that a doctor's performance was such that they needed additional training. There is no mechanism in the UK to do that, so again, in Wales, we set that up for the deanery in terms of a remedial process, linked to the health boards and the performers list after they came in in 2004.

We got ahead of the game on all of that, and England have caught up on the induction and returner programme. In fact, their numbers are such that they kind of dominate the piece, and in particular, and actually helpfully, around the assessments, because the number coming through in Wales for assessment is so small that we would not maintain the skill set of assessors or the expense of running it, actually, for that number. So, it's quite helpful to be linked up with the Wessex Deanery, as was—Health Education England Wessex, or HEE South West now, whatever the recent nomenclature is in England. So, they do a lot of the donkey work around that initial piece. I saw one of the submissions from Sophie to your committee about jumping between websites and I can understand that, to an extent, but that's only if you re-click on the wrong button. I did check it this morning.

That's the involvement of the deanery in that, and we still have—. Of the 12 advanced training practices that we initially set up, we get them together a couple of times a year for further training and to share experiences and so on, and we've put through, I don't know, maybe 20 or 30 people over a decade, I would say roughly that. So, again—

It's very small numbers.

It's very small numbers, but it ensures standards. I think you heard from Charlotte earlier of the BMA GPC that there was an incident in Cambridge where a German doctor came over to do a weekend shift and injected someone with 10 times the intended dose of morphine. That wouldn't have happened in Wales even then, because we already had this set up and this link between what the deanery can provide and what the health boards might recommend, so people go on to the performers list in a conditional way, so they have conditions on their entry to the list.

Fundamentally, it's a patient safety issue, but also—. Again, there's been some evidence submitted about people who are unhappy about the process and having to do a test and all the rest of it, but at the end of it I can tell you that the vast majority are very grateful to have gone through it, because it either exposes them to a system that they haven't worked in—because they've been in Australia for 12 years, and there are changes all the time in the NHS—or it allows them to regain confidence that their knowledge is up to speed and that their skill set is fine, and they come back in a graded and supported environment, and they're treated pretty much like trainees. So, they're on the GMC list, they're on the performers list, but with these conditions; and then they do what they need to do and after a variable period of time, depending on their skill set and how quickly they get up to speed, they're signed off and then they have full entry on the performers list, and they can go to work wherever they like in that health board, or in Wales.

So we think it's been helpful. In fact, one of the former health Ministers of this Welsh Government has been through the process and returned to work in general practice for a few years before finally retiring.

It's interesting, this example you give of the German doctor, which Charlotte gave as well, because surely that sort of mistake would be the sort of thing you would have thought that training anywhere would have militated against.

Yes, you would. I absolutely agree. But that particular event—I don't know whether it's a decimal point misplacement or whatever it might be, but these things happen on a daily basis in the NHS. Mistakes are made in prescribing, but they don't usually result in death because they're not usually with medication that is so fundamentally dangerous—potentially dangerous. And the reason that I say it wouldn't have happened here is that that doctor wouldn't have got onto the MPL in Wales, at least not initially. He might have done the same things a year later, who knows? But people do make mistakes.

So your view is that patient safety in Wales has been safeguarded by this.

Yes, patient safety, and—. I've been out of clinical practice for 18 months, and I think I'd need to go and sit in a little bit, even now. I wouldn't go back and do a locum tomorrow, even in my own practice. It's difficult after being out for a period of time.

Okay. Dawn, your questions—

I think some of it has been covered. I just wanted to ask briefly, on the point you've been talking about now, whether there's any difficulty in balancing the need to ensure that doctors returning to the UK are fit to practise and using a system that, from what we've heard from other witnesses, is actually quite cumbersome in terms of getting on the list. So, do you think there is any difficulty in that balance at the moment?

The first difficulties that people encounter are time difficulties, and that's partly because they're abroad, and they have to come back here to do some of the assessments, although they can do the knowledge test from abroad, and they can do it in various centres in the UK. But the clinical skills assessment happens in London. So, that's an issue, and that is a matter for the individual. There's not much you can do around a process that you run three or four times a year anyway, which is expensive; to run it for smaller numbers of people on a bespoke basis would really not be financially sound.

So that's one side of it—if you like, the procedural thing. Then there's the content that allows you to arrive at a decision as to where that individual sits within four or five different categories of skill set. This is relatively new, so this is in the past three or four years that people will say, 'Actually, this person is really very clever, they've done incredibly well in the knowledge test, and the skill set, and so they might just need a month or so, a brief period, two or three months, or whatever, to reacquaint with the new system, get used to IT, get used to how the NHS works, and so on'. Then you've got a couple of categories below that where they might need a little bit longer, and of course you have to have a category at the bottom that says, 'Did you go to medical school?' Seriously. You would be disappointed by some of the standard that comes through. Not the majority, obviously, but you have to do that, and that's the ultimate place where patient safety is crucial.

Rhun. 

After being on the GMC, I did a few jobs for the organisation afterwards. One was to chair the equivalence advisory group, and the purpose of this group—. It included representation from the Academy of Medical Royal Colleges, the RCGP, the BMA and various specialties, some lay representation and a BMA member who was a non-consultant grade—so, what's called an SAS doctor; a specialty and associate specialist doctor—in surgery. So, we looked at 12 or 13 recommendations that were made about two years previously by a review of that process, which are still not all in place. The majority are, but some of them remain conspicuously unenacted, and the main one relates to GPs.

It's the fact that the process of assessment from any country other than the EEA would be that you come to the UK and you do the relevant college exams, you have a period of time working in the UK in that specialty under supervision, where you have workplace assessments as well, and at the end of that period you can submit your application, or re-submit your application, to the GMC with college support, and you get on to the GP register. So, you get on the GMC register and the GP register at the same time through what's called the CEGPR or equivalence route—the certificate of eligibility for GP registration. 

So, the problem that all those specialties don't have is that you can work in psychiatry, dermatology, medicine, surgery—anything in the NHS—as a non-consultant grade and a non-training grade. But in general practice, the legislation—the Medical Act 1983 and the vocational training regulations—say you can only work in general practice if you have a certificate of completion of training. So, you've trained in the UK for a CCT, or equivalent in Europe, or you have a CEGPR, which you don't have because that's why they're telling you to go there—so it kind of defeats itself—or you're in a training programme. So, if you're in a training programme, fine, but these people don't want to come from Australia or wherever it might be and enter a three-year training programme, even though some of it might be able to cut short—actually, no, it couldn't be cut short because there's no recognition of training overseas.

If you have training in another speciality here, it will be recognised for up to six months at the moment, and you can transfer competencies, which is quite good, but we need to be careful that we're not shortening GP training too much. It's the biggest curriculum with the shortest training span. It's a three-year training programme and it is a massive curriculum. There's just about nothing that isn't on it. So, it's huge, and there's a dilemma over increasing the period of time in training, and the constraints are financial, essentially, because, educationally, it was approved seven years ago. But I'm digressing. So, coming back, this is the obstacle for creating a situation where people can be in a programme that isn't the formal training programme, but they can be in, if you like, a separate programme, which hasn't been created, that allows them to complete that programme. It would have to be for at least 12 months, and they would have to do the college assessments, and they would have to have a work-placed based assessment. So, it would be as close as equivalence can get, and it would be in a shorter period of time. 

And they're still not on a practising list after that.

Yes, they would be after that. 

They would be after that.

Yes. Well, they'd reapply to the GMC, and it would almost certainly get them on. 

Lynne, I think your question has just been answered, so that's the end of the questions. Any closing remarks? 

Diolch, Cadeirydd. Good morning, everyone. Bore da. I wonder please—. My question is: could you outline to the committee any amendments that have been made in relation to having separate medical performers lists for England and Wales and, for example, amendments to regulations and the application process that you follow? Thank you.

The first amendment was in October 2015. It was recognised that individuals applying for inclusion on the medical performers list felt that it was quite an onerous task, having to fill out voluminous amounts of paperwork. So, the application form was streamlined in October 2015 and it was reduced from a 25-page application form down to a four-page application form.

Further amendments were introduced in March 2016, and that included a provisional inclusion concept whereby, subject to submission of limited information and a DBS certificate, indemnity, an application form, and consent for shared services to contact the host health board, those performers who are already on the list of a PCO in England could come on provisionally, which meant they could practice for up to a period of three months whilst shared services undertook the remaining checks. 

One of the other amendments was to—. In the past, we would only accept a DBS if it was undertaken in the preceding six months. For those applicants already included in the list of another PCO, that was extended so that we could accept DBS certificates that had been issued in the preceding three years.

Right. Thank you.

There's no need for all five of you to answer every question; we'll just make that clear. [Laughter.] Dawn, do you want to come in?

Just to follow up from that, are you satisfied that those changes (a) have had a positive impact, and, secondly, whether you think they've gone far enough or whether there are further changes that are needed?

I think it's certainly less onerous for the applicant in terms of the bureaucratic process. I don't think it's opened the floodgates and allowed lots of other GPs, or more GPs, to come into Wales than would have anyway. But it's certainly helped from an administrative point of view as far as the applicant is concerned.

It's slightly less bureaucratic.

Yes. I think things could be improved. I think, perhaps with some IT improvements, things could be streamlined further.

Because I think from the LHBs' point of view, you were talking about having something akin to a locum passport or—. Do you want to say a bit more about that?

Yes. That was something that I was involved with way back in—I think it was 2006. It proved far, far too difficult. Again, part of it was because we didn't have the IT infrastructure at the time. You would have a locum who would be two or three days a week in, let's say, Tredegar and would be two or three days a week in Newport, and would then move on the next week and would be in Pembrokeshire. The IT infrastructure wasn't there to do it. It would have been very, very labour intensive and very, very paper heavy. So, it was actually shelved at the time. 

Okay, but that was specifically for GPs operating within Wales, that wasn't a cross-border—

Correct, yes.

In Wales, yes. I think, when you're looking at the performers list, you have to go back to the rationale for having a performers list. So, the rationale is to ensure that people are fit for purpose and continue to be fit for purpose. So, as the medical workforce changes, we're going to have more people working peripetetically here and there. So, there is a case for us to strengthen the governance by knowing where people work.

Okay.

Rhun, on this point.

Why are there any separate performers lists at all within Wales? Why is there any barrier at all between moving between health boards?

Okay. So, once you're included in any of the seven health boards' performers lists, you can work in the geography of the other six. So, in itself, it's not a barrier. It goes back to the legislative framework at the time. So, the performers lists were linked to the commissioning organisations, so basically, you know—and in England at that time there were lots of commissioning organisations, in excess of 100. Now there's a single commissioning organisation for primary care in England and a single performers list, whereas we've got seven health boards. So, historically, the performers lists aligned to the commissioning organisations for primary care, so that was the relationship. 

So, when we've heard examples of doctors finding it difficult to travel between different parts of Wales, that is historic—that cannot happen any more.

So, substantively, you can work—. So, you can be included in Cardiff's performers list and work in Gwent, for example, or anywhere in Wales, but we'd like people to be aligned to the health board and the performers list of where they predominantly work. That's because of the governance reasons. You want the governing organisation to be familiar with the performers in their patch.

Why do we—? I still don't get it. We have the same standards of governance throughout Wales, the same expectations of governance—why would not one reciprocal list that works exactly the same way across all health boards do? You could name a village in west Wales that has three county boundaries in it. I'm sure there are parts where there are three health board boundaries working in it. If you're working just as a locum, which is very common nowadays, you could be working in three areas. 

And that's what the reciprocal arrangements allow. So, we've got lots of GPs who live in Cardiff who are included on the Cardiff performers list who work in Gwent, who work in Cwm Taf, who work in Abertawe Bro Morgannwg. So, we do recognise that, but for the purpose of governance, they're linked to the health board where they predominantly practice. 

I think we're actually going in that direction. If you remember, back in 2009, we had 22 local health boards and we're now down to seven. So, there is actually progress towards that. 

Just following on, because there is—if I recall from the evidence here—something about if you work out of the area where you're on the list. So, say you're on the list in Cwm Taf and you work out of that area for more than 12 months, you have to re-register in the health board area.

Yes, that's right. Anybody who hasn't practised in the area of governance, the host health board can take steps to remove that practitioner from the list.  

From that list in that health board.

Yes. 

Okay. 

But just to clarify, it's not something we would do lightly. We would ask people whether they wish to be retained. If people wish to be retained, why would we chose to remove them, providing they can—?

I think, where they've not worked at all—but if they've worked in a different health board area in Wales, they have to then go to the governance of that health board area—

Yes.

Right, okay. 

We would encourage them to transfer areas, but there's nothing in the regulations as they currently stand to say that they must register in that different health board area. 

Okay. Lynne, you've got a couple of questions—some of them partially answered already. 

Yes. Can I ask the NHS Wales Shared Services Partnership about option 7, which you identified as being the most appropriate way forward in the Welsh Government's consultation—if you could expand of why that would be the best?

Yes. Each health board has its own medical performers list but all seven medical performers lists are administered on an all-Wales basis by the shared services partnership. So, from an administrative point of view, we didn't think there was an awful lot to gain by changing the process to any great extent as it currently stands. The one issue that we felt that could improve the situation, and certainly improve upon any delays that are currently in the system—at the moment, if an individual is currently registered in an area with an English primary care organisation and they're coming into Wales, they have to undergo various checks. The regulations say that we have to ask the consent of the applicant to go to their host PCO for information on the references, career history and qualifications.

Now, we tend to find that when we're approaching England, the English PCO, they have difficulty locating the information. That information may not be available because it predates the requirement for references, which means, then, we have to go back to the individual applicant, ask for them to give names of two referees. We have to contact those referees and all that adds a number of weeks into the process, so it delays it quite considerably. So, we felt that, subject to certain amendments, the system as it currently stands, from an administrative point of view, works quite well, and as I say, subject to those few amendments, we could improve it ever so slightly. But we feel that was the most appropriate way forward from a shared services perspective, because it also means that the checks and balances that we currently employ when a doctor is transferring from one health board list to another, or from a PCO list to another—it means that we're refreshing those checks on a regular basis, so it improves the governance of the process overall.

Can I just ask if there are any issues you want to bring to the committee's attention, specifically about doctors returning to Wales?

They're very few and far between. I think we've had about seven during 2016-2017. No, the process from an administrative point of view, I think, works fairly well. I can't think of anything that would improve the system greatly from our perspective. 

Okay. Dawn, do you want to have a run at things?

I think we're—. No, I think I'm done.

You're happy. Rhun.

Yes, I still don't quite understand—[Laughter.]—why things are so complicated, considering we have a centrally administered list. We have equal expectations of governance throughout Wales. We have a continuing process of ensuring that our general practitioners are up to the job. Any health board would know, or should know, if there's a problem with somebody within their health board area, therefore every GP, hopefully, in Wales should have a gold star next to his or her name at any point in time. Wouldn't the existence of that gold star mean that you shouldn't really need any kind of separate performers lists in different parts of Wales, that there should be a single Wales list, which means those practitioners can work wherever they want? Would that be an ideal situation, first of all?

Yes, and with technology being so advanced now, one would think that it could be fair to implement what Rhun is—.

I think it actually would be, but at the moment you actually have a de facto seven separate designated bodies under the responsible officer and revalidation regulations, so that would always remain there as GMC requirement for revalidation anyway. So, yes, you could have a single performers list for Wales with the accountability still with the responsible officer of the designated body, which, in the case of Wales, is the medical director of health boards.

Okay, you have a general practitioner who is predominantly recognised as working in one health board area, but he or she can move without filling any application forms whatsoever between one health board and the other?

Well, they could work in another health board area without any restriction.

Yes, but you still want them to register.

Well, I think it's—. That's just about aligning the governance, so that the person who's dealing with any issues is familiar with the person.

So, there's no form to fill, there's nothing—

No. So, you can get in your car and drive from Rogerstone to Penarth and can—.

Okay, right. How could that be replicated on a cross-border basis?

I think it would require UK legislation, I would guess, because—

Would it? Because if we accept that there is a standard accepted throughout the whole of Wales, and therefore that's why it's easy, in practice, of course, to move from one part of Wales to the other, would it not be possible to have a system whereby we in Wales officially stamp, recognise, the way they do things in England and therefore GPs from there can work in Wales and vice versa? 

I'm sure that we would all agree that that would make sense, but the issue is that you've got four legislative frameworks. So, there are four sets of performers list regulations that are broadly similar, but with some distinct differences. England, for example, revised all performers list regulations going back to 2004 with some amendments. England did a substantive revision of their performers list regulations in 2013. So, you'd probably need to align some of the regulations and how we operate the regulations. What's worth saying is that Wales is small enough that we all talk to each other—you know, if there's a performance issue, we'll speak to each other. We have a standard operating policy procedure for managing performance concerns, as do England and as do, presumably, the other two Celtic nations. So, I think if we could agree to align our policies and procedures, I don't think anybody would be resistant.

And it probably wouldn't need to be an alignment of everything—there could probably be an accommodation for detail in changes. How much work is going on to try to get to that point where alignment is close enough for you to have reciprocal arrangements and recognition both sides of the border?

Currently, we're reviewing our operating procedures in terms of how we manage performance concerns. One of the considerations when reviewing those is how we can make things more aligned so that we could do some of that without legislative changes. There will be a question—if there are specific legal parameters around things, such as suspension or applying conditions to a doctor's practice, then it's very difficult to do that in a reciprocated way without aligning those regulations. 

We're not hearing a big demand for legislation, really. Some have suggested that, maybe, a single UK list would be a way forward. I don't think we necessarily feel that that has to be necessary, but there's certainly an appetite from different directions for us to get to a point—

I don't think we need a single UK list, but if we had reciprocal recognition for being on any one of those four lists—that's what we need, really, isn't it?

Yes. Can it be done?

I think it would take all of the four countries, but I think—yes.

Who's blocking it? Clearly it's not you. [Laughter.]

It's not us, no. I think it probably needs the good officers of the civil service supporting the UK Government and the three devolved Governments, or the two and whatever's happening in Northern Ireland, to support that. [Laughter.]

Is it important enough to invest time in doing? Actually, we had a representative from the Wales Deanery earlier who said, 'I don't think it affects that many people.' We had the Royal College of General Practitioners saying, 'This is serious, and it stops us from being able to attract people easily across the border.' Where do you stand? Is it worth the bother?

In terms of huge numbers, the numbers aren't huge, but what we don't know is the unknown unknown—are people being put off? We don't know, because we only know about the people who have applied to go through the process. The minimum amount of impediment is what we want, isn't it, to free movement?

It varies, so if you spoke to GPs in Monmouthshire or in Wrexham, and both ways in the Wye valley, they might feel more strongly about it than someone further away from the border.

Frictionless borders.

Yes, it's been said before.

Harmonisation.

If we had one-way borders, I'd agree with you—bringing people into Wales.

Do you want me to ask the question that I'm meant to ask as well?

I thought you had meant to ask it.

Just on equivalence, really—we've been discussing this morning whether the issue of equivalence and seeking the right information, and whether somebody from abroad can work in the UK, has a relevance to this discussion on cross-border practising lists. Is there a relevance there, or once somebody's in the UK is it just the same for everybody? 

The absolute numbers are small. There are very few GPs who come directly having trained as a GP in the EU to start working as a GP in the UK—well, certainly in Wales; it will vary in England and Northern Ireland, for obvious reasons. I can't recall in 10 years at Aneurin Bevan someone coming straight from Germany or wherever to work here, so people—

Or outside the European Economic Area even?

Or outside. They tend to come in as junior doctors and train as GPs through our processes, so it's the same training process as for people who are born and educated here.

I think a lot of lessons were learned back in 2008. If you will remember, Dr Daniel Ubani, who was the German GP who was working in the out-of-hours service in Cambridgeshire, and who would fly in on a Friday, do a couple of out-of-hours shifts and head back off to Germany, hit the headlines when he prescribed 10 times the normal dose of morphine, sadly resulting in the death of a patient. That was the only one that hit the headlines. When he hit the GMC—and the fitness to practise hearing is on the GMC website if you want to read it—that was only one of a catalogue of errors. I think that concentrated the minds of everybody at the time, in that he was working in Cambridgeshire and he was on the performers list of Cornwall and the Isles of Scilly. Since that time and since the GMC case of 2010, I think lessons were learned and things were tightened up a lot.

Can I just make an additional point, if I may? General practice in the UK is a very broad-ranging, complex area of clinical work and, without wishing to appear derogatory in any shape or form, other countries have different expectations of their GPs. So, there isn't a direct equivalence, and it may well be that there is the requirement to familiarise people from elsewhere as to what happens within the UK and to provide the extra training and support to facilitate that.

And we've certainly taken some good evidence this morning on improvements to the system, and to make sure that people who do want to come here, having been trained elsewhere, are taken by the hand and what have you. Okay, thank you.

Lynne, yours has possibly been answered. Yes. So, that's the end of the session.