Agenda item

Cheryl Rehal, Associate Director of Primary and Community Care, Bromley – SEL ICS (“Associate Director”) and Dr Andrew Parson, Co-Chair and GP Clinical Lead – One Bromley Local Care Partnership (“GP Clinical Lead”) delivered a presentation outlining the challenges and contribution of General Practice to meeting the health and care needs of Bromley residents. Changes in the way these challenges were met were also highlighted, as well as acknowledging areas for improvement and future intentions.

The GP Clinical Lead advised that some of the challenges faced in Bromley included it being the largest, and least densely populated London borough. It had the greatest number of people aged 65 years and older, and residents had a higher life expectancy than the average Londoner. There was also a higher prevalence of complex health conditions compared to neighbouring boroughs in South East London – a greater proportion of people in the borough had long-term conditions, requiring additional care compared to those people with routine and same day needs. This resulted in more GP referrals into secondary care and increased spend on prescribing to support long-term conditions. A Member noted that there was a high prevalence of depression in the borough, compared to neighbouring borough, and enquired if the reasons for this were known. The GP Clinical Lead advised that depression was a condition that increased in prevalence with age, which could account for some of the figure. It was important to note that the data was extracted from GP systems – the data needed to be accurately recorded in order to plan any work to be undertaken. Within PCNs they had developed the role of mental health practitioners to support practices in addressing the needed of patients, the challenge of which had increased since the pandemic. A Member considered that depression could also be related to social circumstances, such as deprivation or loneliness, not just an ageing population.

The Associate Director advised Members that there were 43 GP practices across the borough, which formed 8 Primary Care Networks (PCNs) – they worked alongside the GP federation and community pharmacies to provide primary care services to Bromley residents. Practices ranged from small to large in size – some were formed of bigger partnerships of GPs, whilst others were single-handed practices. By collaborating in PCNs, they were able to develop a shared workforce of healthcare professionals, working alongside the GP and practice nurses. As PCNs, general practice was delivering a wider range of clinical care to patients, supporting the out of hospital strategy to better manage acute demand.

During the pandemic, GP practices, alongside the wider NHS, had temporarily adjusted how patients accessed its services – since the easing of restrictions, patients could access care in more ways than ever before:

-  GP surgery doors were open for making appointments and seeing clinicians;

-  remote consultations were available, where this suited the patient’s needs; and,

-  online services offered convenience for administrative matters and self-referrals.

However, general practice was experiencing continued high demand. This was experienced as delayed presentations, overdue routine screening and care, and increased contacts. Overall, population health and wellbeing had also been negatively affected by the pandemic, adding further pressures on practices. It was highlighted that total appointments were returning to pre-pandemic levels, and a greater proportion were now offered as remote options. Increased access to primary care services included:

-  Online consultations portal – around 17,000 eConsults were submitted every month. It was noted that this service had been introduced at pace and they were looking to review it to ensure it worked efficiently;

-  Text messaging services – direct to mobile appointment bookings and health monitoring;

-  Website service – 34 out of 43 practices were now using a professional web hosting platform; and,

-  Electronic repeat prescriptions – now offered by all Bromley GP practices and were easily accessible via the NHS App.

The Associate Director advised that there was a national drive to increase the number of additional roles in general practice. To help maintain the necessary capacity, the NHS was recruiting a wider group of clinicians and healthcare professionals to work alongside GPs and practice nurses. These roles were shared between practices in their primary care network groupings and were designed to provide care to all the patients within a PCN. From 1^st October 2022, practices had become responsible for providing Enhanced Access services for their patients, working jointly with local GP surgeries as part of PCNs. This had resulted in the following:

-  More flexible appointments at convenient times for patients – as well as the core opening hours, Enhanced Access offered routine and same day appointments on weekday evenings (6.30pm-8.00pm) and Saturdays (9.00am-5.00pm);

-  Local, convenient locations – appointments may be face-to-face (at a patient’s own surgery, or other local surgery within the PCN), by phone or video;

-  Enhanced access for all patients – the service was for all patients registered with the GP surgery;

-  Appointments with a wider range of clinicians – depending on the patient’s needs, the appointment may be with a GP, practice nurse, physiotherapist, clinical pharmacist, mental health practitioner or other suitable professional; and,

-  Easy to book – patients could contact the surgery in the usual way to book their appointment.

A Member considered that the Enhanced Access services did not reflect the experiences of residents in the borough, who were having difficulties in getting GP appointments. It was noted that the recently appointed Health Minister had stated that patients should be able to get an appointment within 2 weeks, and enquired if this was viable in Bromley. The GP Clinical Lead said that a recent review had been undertaken at his practice in terms of what they wanted to try and do. Discussions had been held with staff, before the recent announcement, about patients not wanting to wait longer than 2 weeks for an appointment – this was a challenge shared by practices, who wanted to be able to do this. They were aware that the delivery of appointments was high, but they were provided in a variety of ways – face-to-face, online, eConsult, texting and telephone calls. All of these appointments took time. The same ambitions were shared, and they hoped to target resources in the right area to achieve this. The Associate Director said that PCN operations would provide additional capacity into general practice. Some practices had managed the same day need by encouraging patients with non-urgent needs to use other routes, such as eConsult or self-referral. It was noted that expansion of general practice was limited as there were difficulties in recruiting GPs, and therefore they needed to maximise the use of the wider workforce. The GP Clinical Lead noted that this was a national trend – trying to restore regular care for long-term conditions and manage same day needs created difficulties which they were working to improve.

A Member enquired how a decisions was made as to whether an appointment was held face-to-face, online or via telephone call, and what the average time was for each. The GP Clinical Lead advised that during the pandemic, telephone appointments had been used due to infection control. They had now moved away from this need, and face-to-face appointments were used for those patients that needed to be examined. The average time for all appointments was 10 minutes.

Members were advised that an extensive programme of transformation was underway to help free up clinical time in general practice in order to offer more time for clinicians to see patients. Changes delivered, and others in train, included:

-  Investments in expertise to optimise the workflow of clinical documents from secondary care to the GP for clinical review and follow up care;

-  Analysis of clinical outcomes and trends to give GPs insights, guidance and tools to improve clinical effectiveness in their practice;

-  Introducing demand and capacity tools to help practice management teams with planning clinic types and staffing needs, matching to peaks in demand;

-  Working jointly as PCNs, operating e-Hubs to handle and respond to online consultation requests in a timely manner;

-  Setting up systems to support remote and self-monitoring of long-term conditions; and,

-  Undertaking process improvements to make practice-level operational and organisational systems more efficient.

With regards to improving the experiences of patients in Bromley, the Associate Director noted that the National GP Patient Survey results indicated that patient satisfaction was lower compared to last year. This trend was broadly reflected across South East London and nationally. Bromley was undertaking a deep dive into the appointment times offered, as this appeared to be an outlier area, and would take action. Members had been provided with copies of posters for five key messages – ‘Who’s who in the GP surgery’; ‘Appointment options’; ‘Community pharmacy’; ‘Self-referral to local services’; and ‘Social Prescribing’. These messages would be shared with the public and reinforced in the winter newsletter.

The Associate Director said that work to continue to further improve access included:

-  scoping with practices was underway to identify and prioritise cloud-based telephony needs in anticipation of funding following recent national announcements;

-  procurement of a new website service for GP practices and PCNs to provide easy-to-use online services and more functions through the website;

-  a recruitment campaign was being prepared to attract new people to health and care roles in the borough, including in Bromley primary care; and,

-  refreshed programme of professionally designed training and development by a dedicated Training Hub to maintain a qualified and professional workforce.

A Member noted that there appeared to be disparities between GP practices, specifically in terms of difficulties getting an appointment and the time spend on hold trying to speak to someone. It was questioned if these type of statistics were recorded by practice. The Associate Director confirmed that this data was available on a practice level, and they would continue to speak with individual practices that were seen as outliers. It was noted that smaller practices had less flexibility in terms of staffing phones during peak times. In some practices it had been identified that their telephony systems were outdated, which did not allow the patients calling to queue, and others were tied into long contracts. All practices had been advised that if they were coming to the end of a contract they should get in contact as support could be provided to help them take advantage of the tools available. During the spring, a couple of practices had completed major upgrades to their telephone systems, and it was hoped that their feedback scores would improve. A mystery shopping exercise was also planned, where practices would be called a number of times a day, over several days, to identify any particular issues.

In response to questions, the GP Clinical Lead said that telephone queues were a sign of the high demand for appointments. Appointments could be booked online, through 111 and the NHS App. In terms of a robotic phone system, it was noted that small practices would not be able to do this at scale, and older or vulnerable patients often wanted to speak with an actual person. The length of telephone calls was also increasing, which reflected the complexity of the conversations. An important part of the work of GP practices was informing patients of hospital results, as well as providing support to those waiting for hospital appointments.

The GP Clinical Lead said that the Associate Director had outlined the huge amount of improvement work that was being delivered and actioned within primary care. It was noted that the diversification of the workforce was happening at speed – these role would need time to be embedded into the workforce and it was hoped that the benefits would be seen over the coming years. Work at PCN level to feedback data was important for the delivery of care – there was a variable level of need across the borough, and they were working to provide a consistent delivery of care.

The Chairman thanked the Associate Director and GP Clinical Lead for their update to the Sub-Committee, and requested that GP Access be added as a standing agenda item at future meetings.

RESOLVED that the update be noted.