Agenda item

4.1  The Chair stated that most of this meeting would be devoted to this discussion and the purpose was to to gain a better insight into the strategic issues which are driving primary care locally and to look forward to what GP services might look like in five years’ time. There would be 8 short presentations and there would be a Q&A after the first 4. 

4.2  Members gave consideration 5 briefing papers:

4b Note from NEL CCG Primary Care (to follow from Richard)

4c Note from GP Confederation

4d Note from Office of PCNs

4e Note from Clinical Effectiveness Group at QMUL

4f  Note from Healthwatch Hackney (primary care section of draft strategy)

4.3  The Chair stated that unfortunately the current Chair of PCNs Dr Kathleen Wenaden had to give late apologies.  He welcomed to the meeting:

Dr Kirsten Brown (KB), Primary Care Clinical Lead for C&H Partner at Spring Hill Practice and The Lawson Practice

Laura Sharpe (LS), Chief Executive, GP Confederation

Dr Deborah Colvin (DC), Partner at Spring Hill Practice and The Lawson Practice

Dr John Robson (JR),  Clinical Reader in Primary Care Research and Development and Clinical Lead for the Clinical Effectiveness Group at the Queen Mary University of London

Malcolm Alexander (MA), Chair, Healthwatch Hackney

Richard Bull (RB), Programme Director Primary Care, NEL CCG

Dr Vinay Patel (VP), Clinical Director for Woodberry Wetlands and Springfield Park PCN and Chair of Local Medical Committee

Dr Ellie Jacob (EJ), Clinical Director, Hackney Downs PCN

Dr Haren Patel – joint Clinical Director for Hackney Marshes PCN

Caroline Millar, Chair, GP Confederation.

4.4  Dr Kirsten Brown, Primary Care Clinical Lead for C&H gave a presentation on how GPs are commissioned and the different types of contracts - GMS, PMS and APMS.  The majority are on GMS, 8 are on PMS and 5 are on APMS.  All new contracts are APMS contracts now.  She clarified that GMS and PMS are in perpetuity and are very similar. PMS contracts were being phased out as they had been equalised with GMS. The APMS contracts were just for 15 years and have to be re-procured. The majority of Practices are Partnerships but AT Medics runs Trowbridge and Hurley Group runs Allerton Rd Practice. She also detailed how the ‘core contract’ worked and the Carr-Hill funding formula. She also explained how Directly Enhanced Services and Local Enhanced Services operated. 

4.5  Richard Bull (NEL CCG) detailed how the CCG handled the contract management on behalf of NHS England.

4.6  Laura Sharpe(CE of GP Confederation) gave a presentation on local commissioning arrangements on top of the national arrangements. C&H has the greatest number of additional services in East London, delivered via the GP Confed, resulting in an additional £10m a year going into local Practices. She explained the switch from having a reactive to a more proactive model of service in supporting for example those with Long Term Conditions. She explained the principle of ‘total population coverage’ which underlines the Confed’s approach and the background to setting it up.  She described a model of ‘Protected Learning Time’ which they were now rolling out in Practices. She added that they have become a voice for Primary Care in the local system.

4.7  Dr Deborah Colvin (GP) gave a verbal update on the Partnership Model and on the  local ‘provider’ landscape which she stated was generally very turbulent at present. 32 of the 39 GP Practices were partnerships. She detailed how after two years of a lot of patients not going to the doctor sickness levels had therefore increased. There had also been a significant increase in mental health issues. The number of GPs, nurses and admin staff had fallen behind.  Many GPs were choosing to go into Locum work instead because of work-life balance and stress issues. This reduced the continuity of connection with a GP. It could also deskill GPs somewhat. Estates continued to be an issue with Practices running out of space. The push for more digital appointments ran the risk of deskilling doctors as they really needed to physically examine patients and this drive also hit the most vulnerable patients who are the most digitally excluded. On the Partnership Mode,l she stated that it was invaluable as it saved lives and saved resources and should not be discarded.  Salaried GPs in large APMS organisations often do not feel as valued, she added. One of the disadvantages of the Model however was that it was difficult to act effectively on poor performance. 

4.8  Dr Ellie Jacob, a PCN Clinical Director, gave a detailed presentation on PCNs (in place of current Chair, Dr Wenaden) it covered: national context, local provider landscape, general practice funding, commissioning.  She explained the structure, role and function of the 8 PCNs in City and Hackney.  She detailed the performance targets or QOFs for PCNs and the struggle with recruitment, which was a national issue.

4.9  The Chair commented that the two key PCN functions were performance management and additional services.  EJ concurred and replied that being a voice for Primary Care was a key part of the Clinical Director role in PCNs as well as collaborating with the Neighbourhoods System.

4.10  A Member asked about harmonising consistency of care across 8 PCNs and on what GP Mental Health Support was available and on the expanding use of First Responders and whether PCNs could better facilitate this. 

4.11  EJ replied on balancing quality across PCNs and role vis-a-vis the Confed. If NHSE decided that certain things come through PCNs rather than GP Confed then that might pose a problem.  Re paramedics and first responders, there was a clearly defined list of roles which they can recruit to it would have to be a paramedic. Dr Vinay Panel (Clinical Director of a PCN and LMC Chair) stated that the two organisations had different agendas and different roles. It was important to celebrate that Primary Care in City and Hackney had such a track record of close partnership working and close engagement with the Neighbourhoods Team. There was scope for the Confed to help the PCN achieve their joint targets even if it was not performance managing them. Capacity was a huge problem in primary care and NHSE plans were going ahead on the promise of additional GPs, which then weren’t secured. They need to help patients understand what GPs do but also what other primary care providers can do also.

4.12  The Chair asked about workforce issues and the Confed’s bespoke recruitment system. VP replied that it was a great proposal but many Practices hadn’t signed up yet as they’re over worked. Many GPs were reducing their stress and their hours and this was perpetuating the problem.

4.13  The Chair asked about Estates Development and how the Council might assist. Cllr Kennedy (Cabinet Member) explained how the Council had worked with the NHS on this in the past. He stated that it had taken a great effort and a very long time to get Lower Clapton and Spring Hill Practices into their new premises.

4.14  KB responded on the equality issues around access to GPs. The over emphasis on fast or convenient access as the main focus was not where our main priority should be, she stressed, as some people’s needs will be greater than others. The push for digital access had created inequality of access and a ‘digital inverse-care law’ so that those who might need the care more aren’t able to get it. We need to reframe this and there has to be continuity of care, she added..

4.15  LS replied that with the CCG-the Confed-the PCNs-the LMC there was a danger of fragmenting the strategic positioning of primary care locally.  These strands need to be pulled together so that we do not damage primary care even by accident.

4.16  Dr Mark Rickets commented on the investment put into primary care over the years and the number of patients per GP in City & Hackney vis-a-vis Barking & Dagenham.  An FTE GP in City & Hackney has 1550 patients whereas in Barking & Dagenham they have 2450.

4.17  A Member questioned how the additional roles under the PCNs are managed and supported. She also commented that GPs must spend so much time in meetings because of all these structures. EJ outlined the roles and how they’re managed e.g. Physios employed by the Homerton yet they work part time in a clinic in St Leonard’s and part time in the Practices.  Another model was Practices employing people via the PCNs e.g. pharmacists.  Nurse Associates and Physician Associates and Health and Wellbeing Coaches and Social Prescribers were new roles which exist as part of this very mixed model. 

4.18   The Chair commented that the digital divide issue affecting vulnerable/elderly patients was coming up frequently in councillors' case work and wondered whether a better system can be worked out locally to improve this.

4.19  Dr Jon Robson (Clinical Effectiveness Group at Queen Mary University of London) gave a detailed presentation on quality improvement in primary care and the work they do with City and Hackney Practices in particular.  It covered: How do we measure effectiveness; Hypertension care as an example; The right method; Inequality indicators; Greatest impact = numbers x effectiveness; the McKinsey hospital model is not an effective way forward.  He explained for example that prevalence will vary considerably depending on factors outside of Practices control so there will always be outliers, not because of failings in a Practice.  He added that inequality indicators need to be analysed at a CCG level not at practice level. He concluded that we need “to look under the light at what we need to do and choose wisely”. He added that there needs to be more done to identify and target renal failure in east London, that Childhood immunisation and control of blood pressure need to be the key deliverables and there was a need to prioritise the highest risk groups. Generally targets were crude measures and you need to incentivise behaviour change instead. 

4.20  Malcolm Alexander (Healthwatch Chair) gave a verbal presentation on what residents think of GP services. He outlined some key concerns such as the loss of face to face appointments and a rise in triaging by receptionists and non clinical staff.  The digital divide e.g. in Stamford Hill was a big challenge.  They would be doing Enter and Views to hear the voices of local people. He added that Southgate and Whiston Rd Practices has closed, with 6k patients being transferred, and impact on the Lawson Practice must be significant. Healthwatch wanted to see much stronger PPGs.  Most people have no knowledge of PCNs, he added, and patients won’t understand why they are being seen by people other than GPs. We have to make sure all Practices are registering all patients without demands for ID, he added. Some GP websites are not good enough and need to be improved and he asked that within a PCN area why can’t a patient register with any Practice in that area.  The Chair thanked Healthwatch for highlighting the access issue. MA added that a Complaints Charter will be available to patients at all Practices.

4.21  Richard Bull (CCG) gave a verbal presentation on the process of retendering or list dispersal when a Practice closes and he detailed the reasons for each recent closure.  They take each situation on its own merits and there is an established process however each case goes through a proper governance model. The decision to disperse or reprocure involves looking at a wide range of factors such as list size (raw and weighted), contract duration, type, reason for expiry, history of the practice and they complete a deep-dive into Practice performance. They do an analysis at an early stage of the capacity within a 1 mile radius of the closing practice and as well as a capacity audit they look at viability if the list size is below average.  Any Practice below 6K is not economically viable according to NHSE guidance. Premises considerations are also important so if there is no guarantee of a premises for the subsequent 15 years of an APMS contract, then it would be unlikely to get a successful reprocurement.

 4.22  A Member asked about the digital divide challenge with elderly and vulnerable people.  She also asked about the efforts to support the over 80s. JR replied that elderly patients deserved full support to the end of life and there was no judgement involved. His analysis was merely to highlight the proportion of care required by this cohort.

4.23  KB added that within the PCNs and GP Confed there were a number of additional contracts to provide proactive care for vulnerable patients and they set aside dedicated time for this. In response to Healthwatch, she added that there was a key need to improve communications with patients. EJ added that the advance of online access would actually serve to free up phone access for those who need that the most, and this was their intention.

4.24  The Chair concluded the item by thanking all the contributors and adding that Hackney was very fortunate with the high quality of its GP Practices and Members were very appreciative of all the work they do.  He stated that it was very helpful to get an overview and in a year’s time he would like the PCNs to provide an update on the progress they have made.

RESOLVED:

That the report and discussion be noted.