Agenda item

4.1  The Chair stated that Members have been raising a number of concerns about GP access and quality and these are summarised on pp.12-14 of the agenda pack, and NHS NEL was invited to the meeting to address these.

4.2  He welcomed: Dr Kirsten Brown (KB), GP partner at Spring Hill Practice and The Lawson Practice and Primary Care Clinical Lead for City and Hackney, NHS NEl and Richard Bull (RB), Commissioner for Primary Care at NHS NEL, formerly at City and Hackney CCG

4.3  Members gave consideration to 2 reports: Local GP Services - access and quality’ and Patient feedback from Care Opinion, both from NHS NEL Primary Care Commissioning.

4.3  KB took members through the report. She focused on workforce issues and the crisis in General Practice adding that the complexity of presentations at GPs was now much greater and that people were now living longer with Long Term Conditions, there were more mental health issues and high levels of deprivation such that people don’t know where to turn for help.  She noted how heart disease and diabetes for example wee now looked after in General Practice whereas they used to be in hospitals.  In addition A&E was bursting at the seams and so there was a knock-on effect on primary care.  She explained how Hackney had one of the highest GPs-Patient ratios in London. She explained that a key part of their response to this challenge was the recruiting of Additional Roles so that she now works as part of a multi disciplinary team, rather than a sole practitioner, which she found much better. On Patient Experience data, Hackney performs very highly vis a vis London and England and there were more GP consultations and Hackney has one of the highest rates of Face to Face appointments.  On telephone triage there is no perfect system but they work continually to improve it.  City and Hackney has very low levels of calls to NHS 111 within standard GP practice hours which is testament to high performance. She explained the Duty Doctor contract which is not universally available but a major part of the mix in Hackney. 

4.4  Members asked Questions and the following was noted in the responses:

KB explained that Triage refers to all patients contacting primary care and the need to direct them to the right service.  ‘Duty Doctor’ relates to urgent on-the-same-day care. Patients get called back within 2 hours as do paramedics or other professionals who require quick responses.

RB explained that the Duty Doctor was funded through the GP Confederation and they get extra money to ensure they can employ additional doctors to fulfil that role.

KB explained that there is a need to increase the understanding and awareness in the community about these additional roles and a need to continue to work with patients to make things as easy as possible.

RB explained that another indicator of high performance was not having any closures as a result of CQC inspections (unlike elsewhere) and additional investment has been put into PCNs and more communications were needed with the general public to help them understand the new model of care which is wider than just seeing a GP. The Chair commented that GPs in C&H have been able to receive  up to 40% more funding on top of their core contract because of additional local investment.

RB explained about the Patient Volunteers Pilot (Together Better) run with Volunteer Centre Hackney which integrates Practices more into the community.

Cllr Adams detailed his personal experience with a local GP Practice where the performance on transferring him to a new Practice and on registration and on repeat prescriptions had been very poor.  KB expressed regret about this but added that there would alway be a degree of variability in the way Practices are run and the important thing was for them to learn from each other.

On the prescription problems, KB explained that all GP Practices are now required to have Clinical Pharmacists working within them so there is no reason why there should have been problems with medication.

Members expressed concern about what having a Named Doctor actually means, and whether it was just a notional concept. KB explained that all Practices do it and the patient should also be informed of the name.  Members’ pursued if there was an issue about patient expectations here that needed closer attention. KB explained that she was passionate about continuity of care and while an individual won’t necessarily see their Named Doctor at every consultation this process still has value.  She also added that while she had initially been sceptical about the new roles in GP Practices she has been totally won over and sees they are now making a great contribution.

Members asked if GP:Patient ratio data could be seen by ward.  RB replied that they could map wards on top of PCN boundaries and you could get a sense of GP-Patient differentials across areas.

Cllr Goldberg expressed a concern that the data in the report was not reflective of what they were experiencing on the ground in the north east of the borough.  The rush to get through at 8.00 am, children taken to A&E because they couldn’t get a GP appointment for simple things and now the influx of 15 new private GPs moving into the area, illustrated this. The Chair asked why performance in Stamford Hill consistently rated worst across the indicators in the report and was there a particular issue in the NE in terms of Access. RB replied that GPs in Stamford Hill would admit they were struggling and this was also reflected in the survey responses.  Improvement plans were in place and the GP Confed had a Resilience and Sustainability Fund to help Practices at times of need e.g. with recruitment problems. He added the variabilities in performance are normal and the majority were on an even keel.  In that area they were under a lot of pressure from patient demographics. The number of children per family was high. The GP funding formula does not deal with the reality of large families (additional baby checks, immunisations etc).  He added that additional money was going in.

The Chair commented how digital solutions had helped improve accessibility at Lower Clapton Practice and asked whether the responsiveness of same day callback was the same across online and phone requests.  Cllr Goldberg added that most in Stamford Hill would not have digital access. KB responded that you need both and the key thing is to encourage those who can access digitally to do so which would free up phone lines for those who don’t. She also said that Practices need to improve their telephone system to better monitor data and regretted the influx of new private GPs.

The Chair asked how they were analysing the 8.00 am call data. RB replied that use of electronic monitoring tools was  common.  Demand is generally largely predictable and they have commissioned expertise to help them to understand demand and capacity and respond accordingly, a recent challenge had been a huge increase in, for example, respiratory disease and in those circumstances some Practices will inevitably struggle.

Members asked about how information is made accessible to the very diverse communities in the borough where there are c. 86 languages. RB explained the approach and illustrated work such as the Volunteers in Primary Care Project which was up and running in 7 of the 8 Pilot Practices and will shortly be in 16. Delivered by Volunteer Centre Hackney it uses volunteers to lead support programmes in the Practices working with residents on such things as cooking or exercise programmes which ties them into practical health promotion activity.

The Chair asked whether they have a strategic plan on culture and language barriers. KG explained that the GP Enabler Group had met the previous day to discuss this issue and in particular actions to improve health literacy, so it was in hand.

Members commented that it’s about more than language because diverse communities have different needs and will need assistance for example in understanding their health records. KB replied that online access is just one aspect and the aim is to use that to free up the practitioners to work with those who might struggle.

Members asked what more is being done on Prevention and on supporting newly arrived migrants. KB explained the Proactive Care Contracts via the GP Confederation. Patients are called for proactive appointments mainly face to face or have home visits e.g. for the housebound and also the work of health and wellbeing coaches helping with exercise, diet, improved social contact etc.

Sally Beavan (Healthwatch Hackney) commented that the trend in GP access is slowly and steadily improving.  RB detailed the work they did with Healthwatch and how appreciative they are of their input.

The Chair asked if there was a standard hold message across all 41 Practices or some IT support for patients who might just need a little assistance to get up and running using digital channels. Cllr Kennedy explained that the Practitioner Forum he’d just attended had announced the appointment of a new Digital Inclusion Specialist to focus on this aspect.

Members asked about surveying patients and a need for psychotherapy support in GP Practices. RB explains how GP patients are surveyed nationally and locally and the use of the ‘Friends and Families survey’ and ‘Care Opinion’ adding that there are a whole range of methods of collecting patients' views. On the issue of wrapping more mental health support around GP Practices, KB explained that there are mental health workers now in all PCNs, not psychotherapists but other mental health workers and they also form part of Neighbourhoods Teams.

Members asked how central govt policies were helping/hindering the current pressures; about the impact of Brexit on GP recruitment, and on GPs now dealing with issues previously dealt with in Acutes. RB commented that there were no real new policy solutions coming downstream from central government that would immediately ease current pressures and added that he envisaged perhaps another top down restructure.  KB explained that since Brexit, the schemes for overseas doctors require Practices to jump through even more hoops.

Members asked about funding flows and about patients having little confidence in using digital channels. KB replied that care closer to home is the right approach but waiting times for procedures for out patients are up.  Locally she stated that the Homerton was performing well compared to other trusts but those pressures have no doubt had an impact on GP Practices as they have to help patients on waiting lists manage pain and manage conditions for longer.

The Chair asked if there was in effect a levelling down since the ICB, also if the GP Confederation was at risk and could PCNs backfill the work of the GP Confed.  He asked further what staffing would Primary Care commissioning receive under the new structure. RB replied that GP Confeds do continue to have a future and NHS NEL would likely commission more directly from them in future adding that there still remains a space for Confeds working jointly with the PCNs. The Chair added that he would like this to be a future item on the work programme.

KB added that residents do require better education/information on where, when, and from whom to seek care at any time.  She reiterated her optimism about the greater opportunities that the newly created roles in GP Practices will provide.

4.5  The Chair stated that the data on NHS 111 calls and the patient survey analyses are   testament to the excellent GPs Practices we have in Hackney and he thanked KB and RB for their excellent and detailed report and for their attendance.  He added that he would like the Commission to revisit the issue of how PCNs are bedding down and how we can continue to protect the model we’ve got.

ACTION:

To return to the issues of GP Access challenges specifically in the NE of the borough as well as the PCN-GP Confederation alignment at a future meeting.

RESOLVED:

That the report and discussion be noted.