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\'02\'08.;}{\levelnumbers\'01;}\rtlch\fcs1 \af0 \ltrch\fcs0 \fi-180\li6480\jclisttab\tx6480\lin6480 }{\listname ;}\listid1874951229}}{\*\listoverridetable{\listoverride\listid1874951229\listoverridecount0\ls1}}{\*\rsidtbl \rsid272785\rsid468744\rsid745132 \rsid1773478\rsid2313565\rsid2696674\rsid2757186\rsid3043352\rsid3371419\rsid3411792\rsid3680152\rsid3894592\rsid3952659\rsid4526216\rsid4670358\rsid4676682\rsid5112302\rsid5251386\rsid6311058\rsid6645226\rsid7500086\rsid7687440\rsid7740654\rsid7828933 \rsid8074354\rsid8534840\rsid8547634\rsid9050623\rsid9126178\rsid9452075\rsid9512445\rsid9729744\rsid9906161\rsid10160742\rsid11280127\rsid11356785\rsid11536148\rsid11557787\rsid11825646\rsid12220809\rsid12615571\rsid12929052\rsid13522391\rsid13766561 \rsid14297028\rsid14572701\rsid15076219\rsid15539684\rsid15683163\rsid16140630}{\*\generator Microsoft Word 11.0.0000;}{\info{\title WEST SOMERSET GP FEDERATION MEETING}{\author Primary Care Staff}{\operator Primary Care Staff} {\creatim\yr2011\mo10\dy14\hr16\min47}{\revtim\yr2011\mo10\dy20\hr14\min41}{\printim\yr2011\mo10\dy17\hr11\min31}{\version15}{\edmins242}{\nofpages7}{\nofwords2541}{\nofchars14487}{\*\company Somerset Health Informatics}{\nofcharsws16995} {\vern24615}{\*\password 00000000}}{\*\xmlnstbl {\xmlns1 http://schemas.microsoft.com/office/word/2003/wordml}{\xmlns2 urn:schemas-microsoft-com:office:smarttags}}\paperw11906\paperh16838\margl1800\margr1800\margt1440\margb1440\gutter0\ltrsect \widowctrl\ftnbj\aenddoc\donotembedsysfont1\donotembedlingdata0\grfdocevents0\validatexml1\showplaceholdtext0\ignoremixedcontent0\saveinvalidxml0\showxmlerrors1\noxlattoyen\expshrtn\noultrlspc\dntblnsbdb\nospaceforul\formshade\horzdoc\dgmargin\dghspace180 \dgvspace180\dghorigin1800\dgvorigin1440\dghshow1\dgvshow1 \jexpand\viewkind1\viewscale100\pgbrdrhead\pgbrdrfoot\splytwnine\ftnlytwnine\htmautsp\nolnhtadjtbl\useltbaln\alntblind\lytcalctblwd\lyttblrtgr\lnbrkrule\nobrkwrptbl\snaptogridincell\allowfieldendsel\wrppunct \asianbrkrule\rsidroot16140630\newtblstyruls\nogrowautofit \fet0{\*\wgrffmtfilter 013f}\ilfomacatclnup0\ltrpar \sectd \ltrsect\linex0\headery708\footery708\colsx708\endnhere\sectlinegrid360\sectdefaultcl\sftnbj {\*\pnseclvl1 \pnucrm\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl2\pnucltr\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl3\pndec\pnstart1\pnindent720\pnhang {\pntxta .}}{\*\pnseclvl4\pnlcltr\pnstart1\pnindent720\pnhang {\pntxta )}}{\*\pnseclvl5 \pndec\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl6\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl7\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl8\pnlcltr\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}{\*\pnseclvl9\pnlcrm\pnstart1\pnindent720\pnhang {\pntxtb (}{\pntxta )}}\pard\plain \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16140630 \rtlch\fcs1 \af0\afs24\alang1025 \ltrch\fcs0 \fs24\lang2057\langfe2057\cgrid\langnp2057\langfenp2057 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 {\*\xmlopen\xmlns2{\factoidname place}}WEST SOMERSET{\*\xmlclose} GP FEDERATION MEETING \par \par MINUTES \par \par TUESDAY 11 OCTOBER 2011 \par PORLOCK MEDICAL CENTRE \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par }\pard \ltrpar\qj \fi-1440\li1440\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin1440\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 Present:\tab Dr {\*\xmlopen\xmlns2{\factoidname PersonName}}Ed Ford {\*\xmlclose}, Dr Ian Kelham, Dr David Davies, Dr Phil Wilson, Dr Simon Vale, Kathryn Kyle, Janet Hewlett, Sharon Rowe, Tina Pyman}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid15683163 , Dr Aimee Palace}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8534840 (GP registrar Porlock)}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid4670358 \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630\charrsid4670358 Guest Speaker \endash {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose} Barnes, Shepton Mallet Treatment Centre \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid16140630 \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose} explained that he had been able to combine his }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid4670358 trip today with a visit \par }\pard \ltrpar\qj \fi-1440\li1440\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin1440\itap0\pararsid4670358 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid4670358 to the new hospital which he thought was an impressive facility.}{ \rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9050623 He realised \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid4670358 that a barrier to patients attending the SMTC was }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9050623 the lengthy journey. An aim \par of their contract renewal had been to try and bring services out into the \par community to include areas such as pre-op assessments to reduce patient \par journeys. {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose} explained that he had wanted to see the facilities available \par at {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Minehead{\*\xmlclose} {\*\xmlopen\xmlns2{\factoidname PlaceType}}Hospital{\*\xmlclose}{\*\xmlclose}{\*\xmlclose} to answer the question what can SMTC provide on a \par treatment only or on a see and treat basis at {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Minehead{\*\xmlclose} {\*\xmlopen\xmlns2{\factoidname PlaceType}}Hospital {\*\xmlclose}{\*\xmlclose}{\*\xmlclose}.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid4670358 \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9050623 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid9050623 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9050623 {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}} Chester{\*\xmlclose}{\*\xmlclose} said that his initial thoughts were that they could consider ar}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 eas such as flexi-sigmoidoscopy and }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9050623 gastroscopy which were no longer performed at MHH. Carpal tunnels may be worth considering. Demand would be a factor and {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose} asked the GPs to provide him with their thoughts. \par \par Ian said that surgery at the hospital was now conducted by Dr Charlie Pascal who is already drawing his pension and his practice may not be sustainable much further into the future. This would mean that we would not have anyone to re move hernias and other lumps and bumps under local anaesthetic. Ian said that a lot of elderly patients may require treatment which would be referred to Charlie at MHH but GPs would probably not refer them to MPH. Cataract removal used to be performed a t MHH }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid745132 and }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 Ian }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid745132 questioned if this could be done locally again to save patients having to travel long distances.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid11536148 Simon pointed out that at the time patients undergoing cataract surgery were getting a very second rate service in Minehead and the proper equipment was not available. Ian said that we would need the right machinery. {\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose} explained that he had not mentioned cataracts because the equipment was not present at MHH and he understood that this had gone back to {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}} Taunton{\*\xmlclose}{\*\xmlclose} when the procedures ceased to be conducted locally. Ed explained that the League of Friends had agreed in principal to the purchase of equipment for cataracts but full details need to be confirmed. {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose} said that if comparable equipment to that available at S MTC was available in Minehead then it may be possible to sustain a whole service in Minehead although analysis would need to be conducted. Ian said that there would be significant numbers. Ed said that he thought it would be in the region of 800 per yea r and {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose} replied that the numbers did not surprise him. He added that some anaesthetist support would be needed on site and SMTC would need to look into how to provide that but this was not insurmountable.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid15076219 {\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose} asked how to move this forward and Ed asked {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose} to contact him so that he could liaise with Sue Meade and the League of Friends. {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose} said that we could start to put together some kind of proposal and advised that it was likely to take 6 months before anything was put in place.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid11536148 \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid15076219 \par Ed said that having scopes performed locally would be extremely useful and that MPH had blocked any further discussions with the PCT about providing community services. Ed said that {\*\xmlopen\xmlns2{\factoidname PlaceType}}David Slack{\*\xmlclose} was intending to talk to private gastro consultants regarding the possibility of providing services. MPH do not wand to release consultants into the community hospitals. {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose} said that SMTC was providing a service under a direct access basis rather than an outpatient appointment and then a scope. Ed said that we had not had access to this. He said that Dr {\*\xmlopen\xmlns2{\factoidname PlaceType}}Huw Thomas{\*\xmlclose} had performed endoscopy locally but was not doing enough. Ed said that he did not know if there would be enough dem and for carpal tunnels to justify a list per week and queried if Dr Charlie Pascal was doing a list every fortnight. He added that it would be good to keep a service for vasectomies, hernias etc}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9126178 when Dr Pascal retires. {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose} said that SMTC had no interest in duplication but if a service was already being provided out here, the speed and responsiveness in developing replacement services would be better and the lead time could be cut down. }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid15076219 \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9126178 \par Ed queried if it would be possible to consider minor orthopaedic procedures such as hammer toes etc. {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose} replied that as he was not a clinician he could not comment on what could be done under local anaesthetic and he would have to ask a lot more questions. Ed said it would be worth asking the SMTC consultants what they would look to do under local anaesthetic. He said that we had probably covered most of what we think is appropriate to our local population. He said that the League of Friends would want an ongoing provision of service if they were funding any kit. {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose} replied that the cont}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 r}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9126178 act would continue until the end of March 2014 and longer if the Clinical Commissioning Group (CCG) wanted it to continue. \par \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3043352 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9126178 Everyone thanked {\*\xmlopen\xmlns2{\factoidname PlaceType}} {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Chester{\*\xmlclose}{\*\xmlclose}{\*\xmlclose} for travelling to the meeting and he left.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par }\pard \ltrpar\qj \fi-1440\li1440\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin1440\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid16140630 Agenda \par \par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid16140630 \hich\af1\dbch\af0\loch\f1 1.\tab}}\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar \jclisttab\tx720\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 Apologies \par }\pard \ltrpar\qj \li360\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par }\pard \ltrpar\qj \li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 All practices were represented. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid16140630 \hich\af1\dbch\af0\loch\f1 2.\tab}}\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar \jclisttab\tx720\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 Minutes of the Last Meeting \endash The minutes of the last meeting on Tuesday 5 July were agreed and signed off by the chairman. \par }\pard \ltrpar\qj \li360\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid16140630 \hich\af1\dbch\af0\loch\f1 3.\tab}}\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar \jclisttab\tx720\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 Matters Arising \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par }\pard \ltrpar\qj \li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 QP indicators \endash Sharon reported tha t Yvonne Vigar has agreed that she can send one template on behalf of all Federation members as regards the peer review aspects of the QP QOF indicators. Practices therefore need only send in the templates outlining the details of their practice meeting. \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3043352 \par Other matters arising have been included as agenda items. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid16140630 \hich\af1\dbch\af0\loch\f1 4.\tab}}\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar \jclisttab\tx720\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 Update Re {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}} {\*\xmlopen\xmlns2{\factoidname PlaceType}}Minehead{\*\xmlclose} {\*\xmlopen\xmlns2{\factoidname PlaceType}}Hospital{\*\xmlclose}{\*\xmlclose}{\*\xmlclose} }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3680152 \endash }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3680152 Ed reported that the pilot project was due to go live on 7 November 2011. He said that the message was flexibility and if anyone has any questions please pick up the phone and ask. Ed met with John Tipping and a MPH manager of the stroke department and t hey had an idea which they would like to pilot alongside our project. Ed said that if patients fitted the criteria they were taken straight to MPH. They could come to MHH for an assessment and the GP could refer them directly into the stroke unit and fo r a CT scan. We could then cut out A&E and the MAU and the patient would go directly on to the stroke unit. }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3680152 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3680152 \par }\pard \ltrpar\qj \li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid9452075 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3680152 Phil said that patients were usually admitted to a general ward. Ed said that }{ \rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9452075 if the patient was a barn door case then we could fast track them and anyone else could be sent to the MAU. If we have any doubt then MAU could be more appropriate but the patient still wouldn\rquote t have to go to A&E. \par \par Ed explained}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 that they had decided that it}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9452075 would be better to base the GP on the ward rather than MIU for the pilot. This would enable the GP to focus on their own work rather than getting drawn into helping the Emergency Nurse Practitioners in MIU. \par \par Simon said that if a GP were on a home visit for example, there would be no point in him sending a patient to MHH and that he should have the ability to book on to the ward and for }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8074354 a CT scan. Ed said that there was no reason why any GP could not do this and the whole point is that this is a pilot and there will be teething problems. We need to feedback to enable changes to be made and iron out anything which does not work. It will not work from day one but we need to try and work with it. If we want it to work we need to be aware that there will be hiccups.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9452075 \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8074354 \par Ian said that he and David had discussed it and Ian h ad talked to Judith Brown to say that Harley House and Irnham Lodge would be looking after the Porlock and Dunster patients in the hospital. Ed said that there should be improvements to continuity of care and there should be better care plans and better management of the patients.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid6645226 Ian said that some patients required a review every day and Porlock GPs could be back and forth to Minehead which to some extent dilutes services.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8074354 \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid6645226 \par Ian said that it would be interesting to see how the pilot does with regards to admissions as he did not have a clue what the impact would be. \par \par Phil asked who GPs should ring. Ed replied that there will be a leaflet circulated with a number which would connect you directly to a GP. The GP would be on duty from 8.45am until 6pm. Ed said it was about being flexible and giving it time to work. He said that the pilot would include dealing with query DVT patients. The GP would do a D.Dimer and follow up with Clexane. The patient may then only need to go to MPH for a venogram. Phil s aid that these patients would not usually be an admission and Ed replied that they were counted as an adm}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7687440 ission because they went to MAU.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid6645226 \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7687440 \par David said that it was a shame that ultrasounds could not be done at MHH. Ed said that if there were enough we could but he thought that this was probably a lost cause. \par \par Ed said that IV antibiotics could be done at MHH and patients could be set up as either in-patients or ambulatory. Ed outlined the equipment which was being provided for the GP and the {\*\xmlopen\xmlns2{\factoidname PlaceType}} {\*\xmlopen\xmlns2{\factoidname PlaceType}}test{\*\xmlclose}{\*\xmlclose}s which could be performed. \par \par }\pard \ltrpar\qj \li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid468744 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7687440 Ed said that if anyone was thinking of sending a patient to {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Taunton{\*\xmlclose}{\*\xmlclose}{\*\xmlclose} , it was worth having a think about whether or not they could be dealt with at Minehead.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid8074354 \par }\pard \ltrpar\qj \li360\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid7828933 \hich\af1\dbch\af0\loch\f1 5.\tab}}\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar \jclisttab\tx720\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid7828933 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7828933 Update re GP Commissioning \endash }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid468744 Ed said that the Clinical Commissioning Group was meeting regularly and taking over more contracts from the PCT. He said }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 that interestingly }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid468744 the Somerset Pa}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 rtnership contract was the next}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid468744 which the CCG was undertaking}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 . }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid468744 The medicines management budget had already been moved across and the CCG was working on a proposal for a prescribing incentive scheme. Incentives would operate at a federation rather than a practice level. If the federation has underspent by over 50% there will be 50p per patient availab le for the federation to re-invest in patient care in {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}West Somerset{\*\xmlclose}{\*\xmlclose}. }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12929052 Ed said that we could have \'a324k which could go towards the cataract equipment if the League of Friends did not want to pay for it. Ed said there were fairly big figures involved. At a practice level, the savings would not buy much. }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid2313565 Ian said that this year Porlock and Dunster had \'a33,600 across 2 practices which does not buy much. Ed said that this was why the CCG thought that it would be better at a federation level. For example, ambulatory b/p monitors would be expensive for practices to buy but it may be more viable for the federation to purchase them. Ed said that equipment was getting expensive. Simon asked if the budgets were historic and Ed replied yes, quarter 4 }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 figures }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid2313565 had been compared }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 like for like and }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid2313565 as the Government change their approach every year it makes it very difficult. Ed said that the QP indicators of QOF already targeted particular areas so the CCG thought the best approach would be for the incenti ve to look at overall costs. Phil said this took away any practice incentive and questioned how this would be managed. Ed said that the only individual practice which was currently of concern was Frome }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5112302 who are the entirety of their federation. Ed said that there was not a particular concern and that the scheme had been proposed so that everyone wins even if they have over-spent}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 ; as}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5112302 long as }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 practices}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5112302 }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 have reduced their }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5112302 spend they will still achieve something. Federations will need to put peer pressure on practices not participating. Ian said that our federation was way down on our budgeted spend. Ed said that there was no other form of scheme proposed this year and if they did not introduce something people will not bother as much and we will get more e xpensive }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 which we cannot afford}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5112302 . Ed clarified that the incentive did not include red drugs. }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12615571 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid5112302 \hich\af1\dbch\af0\loch\f1 6.\tab}}\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar \jclisttab\tx720\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid3411792 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5112302 Tina Pyman\rquote s Role \endash Tina explained that she had worked for Wyvern but with the}{ \rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 ir}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5112302 demise she had now been asked to do two days a week for the West Somerset Federation and was also doing 2 days a week for NHS Somerset. Her work for the PCT was focused on the }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 controversial }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5112302 Any Qualified Provider project}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 . }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid5112302 She was also doing a review}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid2696674 of physio services}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid11280127 and said that the direct access service would probably be stopped as they did not have the capacity. David Rooke had been asked to identify someone with an interest in physio and }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 Tina }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid11280127 explained that they could not proceed with a review until a GP was on the working party. In terms of her work for the federation, Tina said that we may want her to work on management type things. She said that she was very glad to be working in {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}West Somerset {\*\xmlclose}{\*\xmlclose}. She said that she had worked with most of the federation members in the past and was aware of the experience of commissioning, particularly in terms of the days of fund-holding. Tina explained that so far she had been working on end of life care and had been contacted by Matthew Hibbert from the Drug and Alcohol Action Team (DAAT ) who is interested in developing an alcohol pilot in {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}West Somerset{\*\xmlclose}{\*\xmlclose}. Tina said that apparently {\*\xmlopen\xmlns2{\factoidname PlaceType}} {\*\xmlopen\xmlns2{\factoidname PlaceType}}West Somerset{\*\xmlclose}{\*\xmlclose} had the highest rate }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid14572701 of alcohol related admissions. {\*\xmlopen\xmlns2{\factoidname PlaceType}} {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Sharon{\*\xmlclose}{\*\xmlclose}{\*\xmlclose} explained that Matthew had already been out to Minehead to meet with Simon and Dr {\*\xmlopen\xmlns2{\factoidname PlaceType }}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Paul Slade{\*\xmlclose}{\*\xmlclose} and we were now awaiting the details of the specification for the pilot. Ian asked if there was a tool available on EMIS or similar that would calculate the alcohol aud it questionnaires given to patients but no one was aware of anything. Tina said that she was meeting Alf Collins on Friday afternoon who was offering free training for anyone interested in care planning for long term conditions. Ed said that the interes t in end of life care had come about because of the funding available to Ian to make improvements. He said to remember that GP and practice manager time can be reimbursed for any work done on investigating potential federation projects. The funding was a vailable at \'a3300 for a GP session and \'a3 150 for a practice manager. Tina said that as regards dermatology, the flexible healthcare team were looking into this and non-urgent patients could be referred to Martin Richards, a GPwSI in Yeovil. Ed said that a G P in Wiviliscombe was being investigated as a potential provider for {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}West Somerset{\*\xmlclose}{\*\xmlclose}. Tina queried if practices had dermatoscopes and s}{ \rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid13766561 aid that training was available.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid14572701 Ian replied that Porlock and Dunster had them already. Ed said that th e PCT may fund Damian Price to come out to train GPs and that sessions were coming up soon in Bridgwater and Ilminster. }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3411792 Ed said that the PCT had agreed to fund the training of a GP who has previously worked in dermatology so if anyone has a desire to get accreditation there is funding available for backfill. Ian said that this was becoming increasingly difficult and registrars were no longer doing dermatology. He said that if you send Damian a photograph he will provide advice. Ed said that a GP would }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid9512445 have had to have done 6 months dermatology training}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3411792 .}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3411792 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3411792 \par }\pard \ltrpar\qj \li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid3411792 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3411792 Tina said that she was happy to get involved in anything which we needed help with. Phil said that {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}} {\*\xmlopen\xmlns2{\factoidname PlaceType}}Brendon{\*\xmlclose}{\*\xmlclose} {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Hills{\*\xmlclose}{\*\xmlclose}{\*\xmlclose}{\*\xmlclose} struggle with templates and Tina said that she would be able to help with this. \par \par Ian said that it would be helpful if referral guidelines were all in one place for GPs to reference when necessary. }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12615571 Ed said that Kevin Hudson was working on creating a system whereby there would be an icon on your desktop which would be the source of this information. Hopefully this will also be available to secondary care clinicians so that they too are aware of the guidelines GPs follow. Tina asked what had happened to the map of medicine. David said that he looked at this yesterday. He said that this was a national tool and often directs to local guidance, linking it in with local patient care would be much better.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3411792 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12615571 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12615571 \par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid12615571 \hich\af1\dbch\af0\loch\f1 7.\tab}}\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar \jclisttab\tx720\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid12615571 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12615571 Adastra \endash Ian gave a demonstration of the Adastra software which is available for GPs t o upload end of life care information about their patients. The system is available to SWAST and aims to provide a single point of information. It is hoped that this will help prevent patients from being taken up to MPH unnecessarily. Passwords need to be requested in order for access to be given. \par }\pard \ltrpar\qj \li360\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid12615571 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12615571 \par {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}{\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid12615571 \hich\af1\dbch\af0\loch\f1 8.\tab}}\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar \jclisttab\tx720\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid7828933 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12615571 West{\*\xmlclose}{\*\xmlclose} {\*\xmlopen\xmlns2{\factoidname PlaceType}} {\*\xmlopen\xmlns2{\factoidname PlaceType}}Somerset{\*\xmlclose}{\*\xmlclose} {\*\xmlopen\xmlns2{\factoidname PlaceType}}Community College{\*\xmlclose} Liaison \endash {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}} {\*\xmlopen\xmlns2{\factoidname PlaceType}}Sharon{\*\xmlclose}{\*\xmlclose}{\*\xmlclose} reported that Irnham }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7828933 Lodge\rquote s access project was based around communication with our y oung population. Because of this {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Sharon{\*\xmlclose}{\*\xmlclose}{\*\xmlclose} had met with the college\rquote s deputy principal to discuss how to engage more effectively with young people. This was a helpful meeting and it is hoped that this will be the start of a longer-term relationship. {\*\xmlopen\xmlns2{\factoidname PlaceType}} {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}Sharon{\*\xmlclose}{\*\xmlclose}{\*\xmlclose} said that it may be that moving forward the engagement takes place at a federation level as every practice will have patients at the college. }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid12615571 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7828933 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7828933 \par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid7828933 \hich\af1\dbch\af0\loch\f1 9.\tab}}\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar \jclisttab\tx720\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid7828933 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7828933 Any Other Business \endash Ed updated on the last West Some rset Health Forum meeting. He said that a review would be conducted with regards to the availability of beds at {\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}}{\*\xmlopen\xmlns2{\factoidname PlaceType}} {\*\xmlopen\xmlns2{\factoidname PlaceType}}Williton{\*\xmlclose}{\*\xmlclose} {\*\xmlopen\xmlns2{\factoidname PlaceType}}Hospital{\*\xmlclose}{\*\xmlclose}{\*\xmlclose} and that Dr Andrew Dayani was involved in that process. \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7828933 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7828933 \par }\pard \ltrpar\qj \li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid7828933 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3371419 Ed }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7828933 put himself forward as}{ \rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3371419 the prescribing lead on PAAM \endash approved unanimously.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7828933 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af0 \ltrch\fcs0 \f1\insrsid16140630 \hich\af1\dbch\af0\loch\f1 10.\tab}}\pard \ltrpar\qj \fi-360\li720\ri0\widctlpar \jclisttab\tx720\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0\pararsid7828933 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 Date of Next Meeting & Venue \endash }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7828933 Tuesday 10 January 2012 at Irnham Lodge Surgery.}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par }\pard \ltrpar\qj \li360\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid7828933 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid7828933 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3371419 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3371419 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 Minutes confirmed and agreed: \par }\pard \ltrpar\qj \li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 \par }\pard \ltrpar\qj \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630 Signed: \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85\'85 Date: \'85\'85 \'85\'85\'85\'85\'85\'85\'85\'85\'85\'85. \par }\pard \ltrpar\qj \li360\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin360\itap0\pararsid16140630 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16140630\charrsid11356785 \par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1773478 \par }}