Agenda item

PRESENTATION ON PRIMARY CARE WORK (CCG)

Minutes:

Dr Agnes Marossy, Consultant in Public Health, Bromley Clinical Commissioning Group, attended to present the findings of the Bromley Primary Care Needs Assessment. Dr Marossy had been seconded to the CCG to carry out a Primary Care Needs Assessment.

 

The aim of the Primary Care Needs Assessment was to describe both the need for primary care, and the needs of those delivering primary care, in order to inform the development of a sustainable model of primary care in Bromley. The Primary Care Needs Assessment had been informed by a Steering Group and a Clinical Reference Group. The Steering Group had consisted of GP Clinical Directors, the Bromley GP Alliance, the CCG Primary Care Team, the CCG Nurse Lead and the Director of Organisational Development, and the Clinical Reference Group had included GP’s (Partners, Salaried, Locums and Trainees), Practice Nurses and Practice Managers.

 

The Consultant in Public Health had undertaken a number of tasks, including workforce analysis and workforce surveys which identified trends, but the bulk of her time had been spent carrying out public engagement. This had included attending the Practice Nurse Forum, which was attended by around fifty Practice Nurses, and visiting and spending time at forty two of the forty five Practices in the Borough, to get an understanding of how they operated. The work also included engagement with patients and public, including vulnerable groups, and some of this was commissioned out to Healthwatch Bromley.

 

The results of the public engagement had found that patients were now more accustomed to not seeing the same person each time they visited their Practice. Patients did not feel this was an issue, acknowledging the positive impact of being ‘known’ at the Practice by clinical and non-clinical members of the team, and that a person’s job title was not important as long as they sorted out the patient’s problem. However, certain vulnerable groups, such as those with mental health issues and those with learning difficulties, benefitted from having continuity with one GP. A fundamental issue raised was the length of consultations, as neither doctors nor patients were happy about the ten-minute consultation time. Ten minutes was perceived to be too short. It was highlighted that an older patient may take longer to reach the consultation room, and then may need time to sit and compose themselves before speaking to the GP, would find most of the appointment time had already been used up. Patients also particularly objected to the ‘one appointment, one problem’ policy where it was being implemented.

 

There had been a number of questions asked when visiting Practices, and one key area of focus had been resilience and how they would continue to manage to provide care if a Partner went on long-term sick leave or retired; if a neighbouring Practice closed; or a new housing development was built close by. Other issues regarding how the Practices recruited and retained their workforce had been highlighted. There had been a number of key outputs, but the main ones to be addressed had been 'workforce' and 'workload'. With regards to workforce, it was stated that in order for Bromley to reach the same ratio as London, an additional 2.7 whole time equivalent GP's were needed in Bromley, and to reach the same ratio as England, an additional 13.4 whole time equivalent GP's were needed. Bromley had a higher nurse to patient ratio than London, but an additional 18 whole time equivalent nurses, of all types, were needed to reach the same ratio as England. In order to keep up with population growth, an additional 1.5 GP's per year were needed in Bromley. The annual workforce survey had shown that Bromley had lost 1.85 whole time equivalent GP's the previous year, which highlighted that the gap was getting wider.

 

Views had been gathered on recruiting to Partnerships, and the responses received had included "as a Partner it was not possible to control your workload", and that "there was a feeling of uncertainty about the future of General Practice as a whole which discouraged commitment to Partnerships". It was also considered that it was "not clear what incentive there was in 'slaving to death' and not being adequately remunerated". Recruiting salaried GP's took on average six months, from the post being advertised to being filled, and there were too few applicants. This was due to a combination of Practices not knowing how to access the trainee cohort, there being high indemnity fees and competition from higher paid posts at access hubs and Urgent Care Centres. There were also difficulties in retaining salaried GP's once they were recruited, due to excessive workloads which caused them to resign. Views had also been gathered on the recruitment of Locums, a number of which the Consultant had found worrying. The feedback received included statements that Locums did not do any admin; did not deal with difficult issues; did not follow up results; were unwilling to do home visits; and referred excessively because they were risk adverse. This indicated that the work life balance and caring responsibilities or life choices had created a shift in thinking about how doctors wanted to work. The evidence suggested that the negotiation of contracts between Locums and Practices was not always done well; and that there was imperfect understanding between the three distinct groups of GP's (Partners, Salaried and Locums). It was also evident that young doctors were making very different career choices.

 

With regards to the recruitment of Nurses, the annual workforce survey had shown that in the previous year, Bromley had lost 1.13 whole time equivalent Adult Nurse Practitioners, whilst gaining 2.95 whole time equivalent Practice nurses, which related to an overall increase of 1.83 whole time equivalent Nurses. Alongside this, there was a loss of 1.37 whole time equivalent Health Care Assistants. When the Consultant in Public Health had met with around fifty Nurses and Nurse Practitioners, they had highlighted that they felt they were not valued enough, and that they were tired, so a number of longstanding experienced nurses would choose to retire on a full pension at the age of 55. Newly recruited Nurses would not gain experience instantly - it took ten to fifteen years to 'grow' a good Nurse, and it was highlighted that there were a lack of training courses available, which needed to be addressed. Key issues that this underlined for the workforce were: that there was an insufficient number of GPs and Nurses; a lack of skill mix; competition between local services for GPs and Nurses; and an undesirable workload and work life balance.

 

With regards to workload, it was noted that under the GP Contract, GPs must provide a service to manage a registered list of patients. This included consultation, treatment, onward referral for investigation and extended primary care services such as prevention, screening, immunisations and some diagnostic services. GPs also helped to ensure effective coordination of care for their patients with other NHS services, social care and health services outside the NHS. Analysis had been undertaken to quantify the workload of GP's in Bromley. On average, they had 103 face to face appointments with patients, issued 513 prescriptions, provided 97 sets of results to patients, dealt with 107 items of incoming correspondence and made 27 referrals, per week. There had also been an increase of 55.7% in the number of home visits made in Bromley (from 11,596 in 2015 to 18,052 in 2017), which was in contrast to the national trend which had seen a decrease. Nearly 28% of these visits were to patients living in care homes, and it was noted that for some Practices, this represented 80% of their total home visits. An analysis of administrative workload filtering, looking at how non clinical staff could help filter the administrative workload of the GPs, had found that 28 Practices diverted a proportion of the GP's administrative workload, but it was largely ineffective. The findings of the assessment were that they were at the point where the issues of insufficient capacity and overwhelming workload were creating an unsustainable future for Primary Care in Bromley, and therefore something transformational was needed.

 

The traditional model of a Practice had five elements - GP Partner, Salaried and Locum GPs, Practice Manager, Practice Nurse and Receptionist / other admin roles, to which new roles of Physician Associate, Clinical Pharmacist, Medical Assistant and Health Care Assistant had been added. A 'first draft' of a new model had been provided, however it was noted that this may cover more than one Practice, and that the new roles would need to be wrapped around with training and support. Following further refining, a new conceptual model for Bromley had been created, based on five to six Practices working with a population of between 30,000 to 50,000 patients. The principles of the model were that it included sustainable ways of working; utilised a wider skill mix, including new roles; ensured all staff worked to the top of their skill set; refocused the role of the GP as an expert medical generalist; improved the quality of care; maintained continuity of care; and met the needs of the population.

 

On 31st January 2019, the NHS Long Term Plan and GP Contract Reforms had been published, which agreed with the findings of the Bromley Primary Care Needs Assessment, and also included Network Directed Enhanced Service (DES) and the expansion of digital access for patients. NHS England and committed to the implementation of a number of additional new roles over the next two years, with a 70% reimbursement for five years, and 100% for social prescribing link workers. Digital improvements included access to online and video consultation for all patients by April 2021; online access to full medical records by April 2020; electronic ordering of repeat prescriptions and electronic repeat dispensing from April 2019; 25% of appointments to be bookable online by July 2019; and up to date and informative online presence for Practices by April 2020, although it was hoped that this would happen sooner.

 

In response to a question from a Co-opted Member, the Consultant in Public Health said that as Practices adopted the new way of working they would be encouraged to strategically engage with Patient Participation Groups (PPG), to involve PPGs in the plans for new ways of working, e.g. active signposting, and consideration was being given to the PPGs also joining in networks.

 

The Portfolio Holder for Adult Care and Health highlighted the Borough’s older people demographic, and enquired if Occupational Therapists and Physiotherapists would be included in Practices to reduce the workload of GPs as part of a preventative agenda. The Consultant in Public Health responded that patients could self-refer to the Crystal Palace Physio Group, and that this would form part of the signposting role of Practice Receptionists. It was hoped that this would deliver faster treatment of common conditions. It was noted that preventative services were likely to be around cardiac rehabilitation and other chronic conditions, not just bones and joints.

 

In response to a question, the Consultant in Public Health said that the enhanced Care Home Service was intended to be a virtual Practice for around 1,800 patients. It was considered that the service would be more proactive if dedicated to them. It was noted that the home visits in general were largely reactive, and that pro-active care for the housebound was a matter of concern.

 

The Chairman queried if the proposal of 25% of appointments being bookable online by July 2019 was feasible. The Consultant in Public Health responded that most patients in the Borough should already be able to book appointments online, and that Practices had targets for signing patients up to use this service. There were two main apps that patients could use, Patient Access and My GP, and an NHS app would also be launching shortly. Online consultations were quicker than face to face consultations, and took place via eConsult, which allowed patients to describe their symptoms and navigate through a questionnaire. A report of the results was then created and provided to the patient’s GP, and a response would be received in 24 to 48 hours. The response could be for the Practice to call the patient advising them to book a face to face or a telephone consultation, or to provide them with a prescription of further information. Video consultations were aimed at improving access for certain groups or patients, such as those with a disability or mental health issue, and were not intended to save time.

 

A Member considered what could be done in terms of attracting entry level practitioners to the Borough and suggested that a recruitment campaign could be helpful to sell the benefits of locating to Bromley. The Consultant in Public Health agreed, and said that this was something that would be discussed at the steering group and could be fed back to Members.

 

The Chairman led Members in thanking Dr Agnes Marossy for her excellent presentation which was attached to the minutes at Appendix B.

 

RESOLVED that the presentation be noted.