Agenda item

·  Vaccinations

·  GP Access

·  Long COVID (verbal update)

·  NHS patients referred to private health providers (verbal update)

Vaccinations

 

Cheryl Rehal, Acting Head of Primary Care, Bromley – SEL CCG (“Acting Head of Primary Care”) provided an update on vaccination uptake in Bromley. The Acting Head of Primary Care informed Members that the uptake of the COVID-19 vaccination (first dose) had commenced in December 2020 – uptake in Bromley had peaked in spring 2021, and the second doses had been delivered during a busy period in summer 2021. The uptake in the borough was high – the total percentage uptake for the first dose of the vaccine was over 80%, and just under 80% for the second dose. The vaccination of 12–15-year-olds had now commenced, and it was anticipated that vaccinations would have been provided to this cohort at all schools in the borough by the end of November 2021.

 

In relation to the COVID-19 booster programme, it was noted that this would help to improve the protection that people had from their first two doses of the vaccine, giving longer term protection against getting seriously ill from COVID-19. Those that were eligible would be offered a booster dose from six months after they had received their second dose. The booster dose offered to most people would be the Pfizer/BioNTech vaccine or Moderna vaccine. In response to a question from a Co-opted Member, the Acting Head of Primary Care said that the advice issued by the Joint Committee on Vaccination and Immunisation (JCVI) was for the Pfizer/BioNTech vaccine or Moderna vaccine to be given regardless of the vaccine used for a patients’ first or second doses. Dr Angela Bhan, Borough Based Director – SEL CCG (“Borough Based Director”) highlighted that this was general advice as the use of different vaccines showed a strong protective response. However it was recommended that anyone with a complicated medical history speak with their GP as some people may instead be offered a booster dose of the Oxford/AstraZeneca vaccine.

 

The Acting Head of Primary Care highlighted that the circulation of flu had been very limited in the 2020/21 season and as a result, a lower level of population immunity against flu was expected this winter. This was also expected to be the first winter when seasonal influenza virus (and other respiratory viruses) would cocirculate alongside COVID-19. To help mitigate the potential impact from flu, the NHS would vaccinate additional cohorts, and aim for a high uptake of the flu vaccine to maximise protection. As there was a high degree of overlap of those eligible for flu and COVID-19 boosters, the CCG was encouraging co-promotion to eligible individuals, and co-administration wherever possible. With regards to plans for the autumn, it was noted that the coinciding seasonal flu campaign and COVID-19 booster programme would bring additional workforce pressures – the preparation and administration of the COVID-19 booster vaccine was more time consuming than the flu vaccine, and the 15-minute post vaccination observation period for Pfizer currently remained a requirement. The volunteer workforce had been an essential part of the success of the vaccination programme, however since the easing of restrictions, and people returning to work and daily routines, the pool of volunteers had been affected.

 

In response to questions, the Acting Head of Primary Care said they were aware of some issues with the supply of the flu vaccination in early September, with a number of GP practices having their scheduled deliveries cancelled. This had now been resolved, and flu clinics were now well underway – it was noted that pharmacies were also administering the flu vaccination. Supply of the flu vaccination would continue to be monitored, and it was hoped that there would be no further impact on the campaign. With regards to co-administration of the vaccines, it was highlighted that the logistics were challenging as the Pfizer vaccine needed to be diluted and used within six hours. Some GP practices would send patients to get their flu vaccine following their COVID-19 jab – however some did not have the space or staff to deliver both at the same time, and uptake of the flu vaccination would therefore be promoted to these patients.

 

The Chairman considered that some GP surgeries were being more proactive than others at setting up flu vaccination clinics and asked if this was being monitored. The Acting Head of Primary Care confirmed that uptake in practices was monitored and highlighted that a core element of work for GP practices was to deliver the flu vaccination to their patients. In response to a further question from the Chairman, the Borough Based Director advised that it was difficult to measure the uptake of the flu vaccination by pharmacy as this information was sent to the patients GP practice.

 

The Chairman raised concerns that patients were experiencing issues with the availability of flu clinic appointments. If only one clinic was arranged, patients were being asked to ring back at a later date – this was not good customer service, especially when the aim was to encourage uptake. The Borough Based Director acknowledged that there had been some issues in relation to GP practices managing the flow of the flu vaccinations, which had partly been due to the initial messages on co-administration being unclear. In previous years, Bromley had been the most successful borough for vaccinating the over 65’s cohort which would not have been possible without the regular support and overview of the Acting Head of Primary Care and her team.

 

A Member enquired if walk-in flu clinics would be held in the borough. The Acting Head of Primary Care advised that these were not available in GP practices. It may be possible for pharmacies to provide a walk-in offer, however this would have initially been affected by the limited supplies received and lots of locations wanted appointments booked to help manage the flow of patients. There was currently a limited offer, but walk-in clinics had not been completely disregarded. The Co-opted Member representing Healthwatch Bromley advised that they would be happy to receive any patient feedback and would flag any issues with the Acting Head of Primary Care.

 

Sub-Committee Members were advised that mandatory vaccinations for care home staff would come into force from 11^th November 2021, and all visiting professionals would also be obliged to show their vaccination status. Work would continue with the care homes and their staff to encourage uptake of the vaccination, and an evergreen offer for staff wishing to receive their primary dose of the COVID-19 vaccine would remain in place. The COVID-19 booster and flu vaccinations would soon commence in care homes, for both residents and staff who consented to these vaccines – the CCG would monitor delivery and uptake of vaccines in the borough’s care homes, and work with OneBromley partners to promote and support uptake.

 

A Member enquired if staffing issues were anticipated in care homes following the mandatory vaccinations coming into force in November. The Assistant Director for Integrated Commissioning advised that by the third week of September, 94% of care home staff had received at least one dose of the COVID-19 vaccination which would allow a second dose to be administered by 11^th November. It was noted that of the remaining staff (around 120 individuals), some would be exempt from receiving the vaccine. Further work would continue with the care homes. Care homes were reporting that they were not anticipating an emergency shortage of staff, however this situation would be monitored closely.

 

In response to a question, the Acting Head of Primary Care advised that for any individual who was unvaccinated it was expected that their employer would undertake a risk assessment and provide Personal Protective Equipment (PPE) or redeploy them if required. People were encouraged to continue to have conversations regarding the vaccine if they were still unsure whether or not to get their jab. In relation to Bromley care home staff, the Assistant Director for Integrated Commissioning noted that advice and support continued to be provided and this could be better reported on as the 11^th November deadline approached.

A map was provided showing the COVID-19 vaccination sites across the borough. The Acting Head of Primary Care noted that the Hospital Hub would remain open to staff only during the winter period for them to receive vaccinations, and that additional pharmacies were now also deploying COVID-19 vaccinations.

 

 

GP Access

 

Dr Andrew Parson, GP Clinical Lead – SEL CCG (“GP Clinical Lead”) advised that General Practice had remained open, working hard to be both proactive and reactive. GP practices were currently dealing with the roll out of the flu vaccination programme and reaching out to those patients who had long-term health conditions prior to the pandemic – it was noted that there was an increased demand in terms of acute illness and mental health.

 

The GP Clinical Lead highlighted that infection control measures would not be lifted anytime soon as it helped reduce cross infection and stopped outbreaks. Some patients and practices had found the overnight changes to access at the beginning of the pandemic difficult, but others had found that digital and phone methods saved them time. These digital modes had been instigated without much build up and GP practices had faced major pressures.

 

The Acting Head of Primary Care informed Members that a National GP Patient Survey was completed each year, which measured views on patient access to: local GP services; making an appointment; last appointment; overall experience; and when the GP practice was closed. This year, a set of questions related to COVID-19 had also been included. Response rates in Bromley were high at 36% (the SEL average was 28%), however it was noted that the survey did not include qualitative data, which limited interpretation and insight.

 

Overall, Bromley had received positive responses, with 84.1% of patients describing the experience of their GP practice as “very good” or “fairly good”. Another area of strength was the high level of confidence and trust that patients had in the healthcare professional they were seen by. Areas for improvement included accessibility and the appointment times that were available to patients – it was noted that the percentage of positive responses for Bromley were above the SEL average, however there was more work to be done. In relation to the impact of the COVID-19 pandemic, Bromley patients had avoided making appointments and visiting their GP practices last year – it was considered that this may have contributed to the current high levels of demand for healthcare.

 

The Acting Head of Primary Care informed Members that the data from this survey would be used to inform changes to access and GP practices were being supported to:

-  Upgrade their telephone systems, to enable improved call waiting/queuing arrangements;

-  Review voicemail messages, to keep these succinct and relevant to their patients;

-  Train reception staff in customer service and customer management;

-  Publicise to patients that their doors were open, whilst maintaining ‘Covid safe’ measures;

-  Encourage patients to attend face to face appointments where clinically necessary; and

-  Offer additional face to face appointments, including ‘catch up’ clinics, overflow hub appointments and, as part of winter plans, extra ‘hot hub’ clinics.

 

It was noted that demand for all parts of the health system remained very high and further support was being provided for GP practices to:

-  Hold appointment slots for 111 to directly book in patients to their practice GP;

-  Directly refer self-care/pharmacy appropriate queries to a local pharmacy of choice; and

-  Bolster workforce gaps with a Bromley Locum Bank of experienced, qualified clinicians.

 

In relation to modernising primary care, the Acting Head of Primary Care advised that remote monitoring technology was being expanded. This included:

-  Oximetry@home to monitor oxygen saturation levels in the blood and ensure a timely escalation of care if required;

-  BP@home to monitor blood pressure for patients with diagnosed hypertension to ensure controls were maintained; and

-  ‘Arc’ technology in care homes, improving rapid, reliable and regular clinical assessments for care home residents.

 

As patients were increasingly using online services, GP practices were also being supported to:

-  Continue to upgrade and modernise their websites, reviewed by independent Healthwatch audits;

-  Gather timely feedback from their patients through a Healthwatch ‘widget’ tool; and

-  Work with the Clinical System provider to improve patient experience of e-Consults, the online consultation system.

 

The next steps would focus on three main areas:

-  Promoting public messages as part of a wider winter campaign:

GP practices were open, but the pandemic was not over; highlight positive stories that recognised the contribution of general practice; explain the different ways to access general practice services.

 

-  Improving through patient feedback:

targeting support to GP practices to use insights from national and local  feedback to inform improvements, and maintain regular feedback mechanisms through ongoing engagement, including with those who may be digitally excluded.

-  Reducing the gap:

determining current capacity (data analysis and audits), alongside demand within general practice, and where additional capacity could be further added into the local primary care system, processes streamlined, or back-office improvements made to increase efficiency.

 

The Vice-Chairman highlighted that it was concerning to see that 10% of patients had avoided making a GP appointment in the last year because they found it too difficult. The Acting Head of Primary Care advised that easy-read materials had been created as part of the winter campaign – this would promote how patients could use General Practice safely and appropriately, reducing the pressure on Urgent Care. More widely, it was acknowledged that it could be confusing for older people to know what to do and where to go, as lots of information was provided. Lessons had been learnt from the last year and communication would be slicker with clearer messages – it was anticipated that improving the websites of GP practices would help this further. The GP Clinical Lead noted that communications would be looked at collectively with partners. Primary Care Networks (PCNs) were being encouraged to get to know their local Councillors and MPs as they could help disseminate communications.

 

In response to a question, the GP Clinical Lead advised that pregnant women could make early self-referrals directly to the Maternity Unit and seek advice. The Acting Head of Primary Care noted that this self-referral service had been a benefit of the online consultation model. In response to a further question, the GP Clinical Lead said that webinars had been held relating to the delivery of care programmes, including vaccines, for pregnant women and their families and this would continue to be an area of focus.

 

In response to questions from the Portfolio Holder for Adult Care and Health, the GP Clinical Lead advised that a Physiotherapist would be in post at a GP surgery from the following week. Self-referrals could be made via the Vita Health website and would be heavily promoted. In response to a question from a Co-opted Member, the Acting Head of Primary Care said that Mental Health practitioners would be in post by the end of the financial year, funded by Oxleas NHS Foundation Trust. There would be one Mental Health practitioner per PCN, and they would work across the borough as a team to provide consistency. It was hoped that the team could be expanded in the future – these posts specialised in adult mental health, and children’s mental health was an area of growing concern. The GP Clinical Lead highlighted that once the new clinical practitioners were in place there would be learning required on both sides and the impact of the staff may take a while to bed in and show effect.

 

The Chairman considered that GP practices were not fully aware of how the population was feeling, and how angry they were becoming at the perceived inability to access the care that they wanted. It was noted that the telephony equipment being used in some GP practices was extremely out of date and the importance of getting the phone system and customer service right was emphasised, and the need for staff to undertake conflict resolution/avoidance training.

 

 

Long Covid

 

Mark Cheung, One Bromley Programme Director – SEL CCG (“One Bromley Programme Director”) provided an update on the development of Long Covid services in Bromley.

 

The One Bromley Programme Director advised that a post-COVID pathway had been developed which had four different elements, and patients could go back and forth to whichever was the most appropriate:

- GP / primary care (patient identification, assessment and investigation);

- self-management;

- community services; and

- acute services (specialist input, hospital services).

 

With regards to acute services, a specialist post-COVID syndrome assessment clinic had been established at the Princess Royal University Hospital (PRUH) from April 2021. The clinic was continuing to receive referrals and was extremely busy. Due to the pressures on this service, a community offer had since been developed for Long Covid patients which had a soft launch at the end of August 2021. Through this pathway, patients could access therapists, consultants, GPs, mental health services and third sector care co-ordination. Over the last month the service had seen 10-15 patients per week and was fully staffed – from the following week a notice would be included in the GP bulletin to advise that the service would now be taking referrals from GPs. It was noted that funding was currently unconfirmed – the service would continue to be provided, however capacity would need to be monitored closely.

 

The One Bromley Programme Director informed Members that the community service provided patients with an 8-week course covering symptoms such as breathlessness, fatigue and the impact that Long Covid could have on mental health. Those patients that were suitable for self-management would be signposted to resources within the community and could also access the Your COVID Recovery website, library resources and support groups delivered by Bromley Well. As services were developed, it provided data regarding the percentage of the population who were suffering from Long Covid. Some studies had previously estimated this to be around 10% of patients – however further studies now suggested this ranged between 2%-12%. The community service had been based on 6% of the population requiring access and it was anticipated that around 500 patients would be seen over the next six months.

 

A Member highlighted that Long Covid was a serious and significant issue. Thanks were extended to the One Bromley Programme Director and his team for the work undertaken – Bromley was leading the way with its Long Covid service, which would reduce the pressure on both GPs and the PRUH.

 

 

NHS patients referred to private health providers

 

The Chairman noted that the reference to NHS patients being referred to private health providers related to a letter received from a member of the public. It was emphasised that the both the PRUH and CCG were looking into this case in further detail.

 

In response to a question from the Chairman, the Borough Based Director advised that this complaint had related to a hospital outside of the SEL CCG, and King’s College Hospital NHS Foundation Trust and the PRUH had not been involved at any point in the process. For NHS patients referred to private hospitals a contract should be in place – at a minimum this should include a follow-up appointment, transportation, meals and a discharge summary, and aftercare if required. In this case these arrangements had not been followed up by the private hospital and the Borough Based Director would be taking this forward.

 

The Chairman thanked the representatives for their updates to the Sub-Committee.

 

RESOLVED that the updates be noted.