Agenda item

Cheryl Rehal, Acting Head of Primary Care, Bromley – SEL CCG (“Acting Head of Primary Care”) provided an update on GP access in Bromley.

The Acting Head of Primary Care informed Members that there were 43 GP practices across Bromley (one virtual), which sat within one of the eight Primary Care Networks (PCNs). GP access prior to the pandemic had predominately been via face to face appointments (69%) due to other technology not necessarily being available. It was noted that other providers had come into the marketplace offering video consultations and promoting themselves as being highly convenient and accessible for working age adults. This had effectively “cherry picked” patients that were relatively healthy and left GP practices with the most complex and time-intensive patients, which was de-stabilising to General Practice. This had helped to drive change, and an aim of the NHS Long Term Plan was for every patient in England to have the option to access online and video consultations by 2021.

In spring 2020, GP practices had been required to rapidly switch to virtual consultations to protect both patients and staff due to the risks posed by the COVID-19 pandemic. Face to face appointments had been paused wherever possible and GP practices were instead required to operate ‘total triage’, assessing all patients remotely and restricting entry to surgeries for essential in-person care only. Moving through the pandemic, during summer and winter 2020, the focus had been on the restoration of services. Face to face care had been increased – patients were encouraged to seek help for ailments in a timely manner and contact their GP practice for overdue care and screening services. GPs had reported difficulties in reassuring anxious patients that it was safe to visit their surgery, with reluctance being particularly high amongst those who had been shielding and other more vulnerable patients. From spring 2021, General Practice had been “open for business”. The COVID-19 vaccination programme was the main drive and where most of the face to face care had been provided – as the majority of the adult population had now been vaccinated, there would be a multitude of delivery modes by which patients could access clinics. GP surgeries were now expected to permit visits to surgery receptions, and a lower threshold of in-person consultations, where safe to do so.

The Acting Head of Primary Care advised that the most recent data regarding GP access was currently on a South East London (SEL) level, however work was being undertaken to extract data directly from GP surgeries to view at a Bromley level. This included:

-  The total appointments in General Practice had risen - across SEL nearly 750,000 appointments were offered in March 2021 compared with 664,000 in March 2020;

-  Patients were receiving an appointment sooner - there were 440,000 same day/next day appointments in March 2021 across SEL (60% of total), compared to 350,000 in November 2019;

-  Face to face appointments had risen since the original lockdown - in March 2021t, 42% of appointments were face to face, compared to just 32% during April-May 2020;

-  Home visiting had returned to near pre-pandemic levels - home visits stood at around 3,000 per month across SEL; and

-  Online consultations had quadrupled since pre-pandemic levels - around 15,000 e-consults were now submitted to Bromley GP practices every month.

The Acting Head of Primary Care noted that patients had been accessing general practice via total triage. This required every patient contacting the practice to firstly provide some information on the reasons for contact to a member of trained staff, and this was then triaged to decide on the most suitable mode of care delivery, by the appropriate healthcare professional, at the right level of urgency. It was highlighted that around one third of the requests received were admin related, such as details about prescriptions, blood tests or changes to personal circumstances, which did not need to be dealt with by a clinician. This process also allowed urgent items to be flagged for clinicians who could then give patients direct access to a consultation (face to face or virtual) or referral to a specialist, or community pharmacist. The aim of total triage was to ensure that patients received treatment or onward referral in a timely manner.

With regards to online consultations, Members were advised that the highest user groups were those that were employed full time and those that were fully retired. The highest use was by patients living in the areas of Bromley and Beckenham, whilst the lowest usage was in Penge. The most prolific users were the 25 to 64 year-old age cohort and e-consults were mainly submitted at the beginning of the week, with Monday’s being the busiest. The Acting Head of Primary Care noted that although the number of online consultations were increasing, it was still unclear if this was reducing the demand on the healthcare system as a whole, as urgent and emergency care was still seeing a significant increase in demand.

In July 2020, a Bromley Patient Survey had been carried out in partnership with Healthwatch. Feedback had reflected that patients’ physical and mental health had been affected by: lockdown; delays in seeking help; being unaware that services were open; reluctance to burden the NHS further; being unwilling to visit the surgery; and the preference to wait for face to face contact. As a result primary care was now addressing a build-up of work due to:

-  workforce challenges reducing practice capacity;

-  increase in demand, both new and accumulated;

-  increase in acuity;

-  longer waiting lists for acute specialities; and

-  a backlog in routine check-ups, screening and immunisations.

The Acting Head of Primary Care highlighted that the pandemic had resulted in a decrease in people accessing NHS services for a range of conditions unrelated to COVID-19. Last summer, the NHS ‘Open for Business’ campaign sought to give people permission to access NHS services and reassure them that they would not be a burden on the NHS. The GP campaign had been accompanied by explanations about remote triage and consultations, and that face to face appointments were being offered alongside other ways of accessing GP services.

In addition to the feedback provided directly to practices from patients via Friends and Family Test, Patient Participation Groups and ad hoc contacts, there had been efforts locally and nationally to understand people’s experiences of accessing General Practice. Whilst some patients wished to return to face to face consultations and felt frustrated that they did not get enough time with their GP’s, others were pleased with the remote offer and preferred the new process, and therefore there was a need to provide a balance of both. There was a group of patients considered ‘under-served’ or otherwise less heard, as well as patients who experience ‘digital poverty’ or had difficulty conveying their requirements. These patients may not be accessing all the care they required and there needed to be a way to best identify and support digitally excluded patients effectively. Feedback had also been gathered from GP practices in Bromley and it was noted that:

-  many GPs and their staff had adopted new ways of working very effectively;

-  total triage had been beneficial as a way to keep patients and staff safe;

-  most GPs still preferred in-person consultations as a safe, reliable way to provide care but were balancing this alongside rising rates of COVID-19 and potential risks of visitors infecting other vulnerable patients and staff; and

-  practices were reporting an increase in the volume of contacts, and an increase in unhappiness amongst patients (who may be frustrated, worried, fatigued, etc.)

To help improve access in General Practice the SEL CCG had identified four areas of focus:

-  technology and estates (including investment in digital technology, staff training and improvements to premises);

-  workforce (including expanding and retaining the workforce, and proficient triage);

-  patient needs (providing a range or appointment options and flexible access); and

-  strategic planning (analysis of the demand in Bromley and effective communications).

A Member noted that she had been contacted by several constituents, and highlighted a number of issues that they had raised relating to the Orpington Health and Wellbeing Centre and online triage system. The Acting Head of Primary Care responded that they wanted to ensure that no one was excluded by virtual access. It was highlighted that residents could walk into their GP surgery and speak with the receptionist – if the practice used the online triage system, the receptionist could assist and support the patient through the process, and this could also be done via the telephone. With regards to what elements may not be detected through the virtual triage system, the Acting Head of Primary Care advised that this was a concern for GP practices. The initial triage of contacts was undertaken by reception teams, and also wider groups such as healthcare assistants, and the general rule was that if they were in any way unsure, the request should be put through. Some practices were using a RAG rating to flag the contacts that they were most unsure about, and those that required urgent attention – the benefit of this was that it ensured they were dealt with in a timely manner. This was reflected in the data, which indicated that more ‘same day’, ‘next day’, and ‘within the next seven days’ appointments were being made available across SEL than there had been previously. It was noted that this was still a learning process for both clinicians and patients. The Acting Head of Primary Care said that around two thirds of the contacts were transferred through to General Practice to be signposted on, and further details could be provided to Members following the meeting.

In response to further questions, the Acting Head of Primary Care advised that telephone calls were the most popular and easiest option for appointments – video consultations were possible, but practices were not using these as frequently. It was noted that there was also the possibility of uploading photos for the clinician to view. The Acting Head of Primary Care advised that patients were entitled to request to be seen by a named doctor, as continuity of care was extremely important, however the wait for an appointment with them may be slightly longer. The Bromley Borough Director noted that people with long-term conditions and the elderly were supposed to have a named GP who had an oversight of their conditions, but this was not a requirement for every individual.

(Post meeting note: Dr Bhan apologises for some inaccurate information given during the meeting, about named GPs, she was quoting from guidance that was not the latest. Current guidance states that all patients should be given a named GP within 20 days of registering with a practice, not just those with long term conditions. Patients should also be told who their named GP is.)

A Member enquired if there was any evidence as to the number of patients directed to the Accident and Emergency department rather than their local practice. The Bromley Borough Director advised that they had some basic data regarding how many people in attendance at Emergency departments had tried to access their GP services first. Current indications were that patients were generally able to see their GP if they wished to do so, but if the appointments given were late on in the day, they were not always convenient for patients. Further work would be undertaken around how, and when, patients could see their GP and it was suggested that an update could be provided to Members at a future meeting of the Sub-Committee. The Bromley Borough Director advised that if a surgery was extremely busy, they could ask a patient to use the 111 system. This system was geared to increasing access for patients, however when all parts of the system were pressurised with increased requests for consultations, there was difficulty in meeting the needs of everyone.

The Member further questioned if there were any financial sanctions for practices that were underperforming or not complying with instructions. The Acting Head of Primary Care confirmed that there was a contractual process which could be followed if any GP practices were not complying with the directions of their GP contracts. This would initially involve an informal conversation and visit to the surgery; issuing a remedial action notice; and finally they would move to formal contractual action if required.

In response to questions from a Co-opted Member, the Acting Head of Primary Care said that they wanted to educate patients to ensure they were aware of their access options. In SEL, part of this work would look at which patients were accessing primary care services, and how they were doing so – more information would be made available on the different routes, and the wider primary care specialists that patients may be signposted to. With regards to choice around virtual or face to face appointments, this was led by the clinician, but there was also input from the patient.

The Executive Assistant for Adult Care and Health noted that this appeared to be a good system going forward and enquired if this would be prescriptive on GP surgeries. The Acting Head of Primary Care said that they wanted to encourage patients to use online or telephone access routes, but they did not want to prevent them from coming into surgeries if they wished to do so. It was noted that there were 43 practices across Bromley, and some had premises that had been difficult to make COVID secure, but generally they wanted patients to be able to visit their GP reception. It was not prescriptive that surgeries must operate in a specific way, but it was highly recommended – the standard operating procedure for General Practice throughout the pandemic was that they were expected to comply with the guidance to maintain safe and secure operations.

In response to a question from the Chairman, the Acting Head of Primary Care said that if Members received complaints/feedback from constituents she was happy for them to be forwarded on to her confidentially.