Agenda item

To receive the draft Leicester, Leicestershire and Rutland Sustainability and Transformation Plan which was published on 21^st November 2016.  The Commission is asked to comment upon the proposals during the current engagement period.  These comments will then be considered to determine whether any elements of the draft Plan need amendment prior to the formal consultation on those elements of the Plan which require it in early 2017.   

 

At the Leicestershire, Leicester and Rutland Joint Health Scrutiny Committee on 14 December 2016 it was agreed that this Commission would take the lead on the scrutiny the new model of care for the primary care sector and the services reconfigurations for UHL acute hospital sites and Mental Health aspects.

 

Members are asked to focus on the new model for primary care at this meeting, as the other two aspects will be considered at separate meetings.   

The Commission received the draft Leicester, Leicestershire and Rutland Sustainability and Transformation Plan which was published on 21st November 2016.  The Commission was asked to comment upon the proposals during the current engagement period.  These comments would then be considered to determine whether any elements of the draft Plan needed amendment prior to the formal consultation on those elements of the Plan which required it in early 2017.   

 

At the Leicestershire, Leicester and Rutland Joint Health Scrutiny Committee on 14 December 2016, it was agreed that this Commission would take the lead on the scrutiny of the new model of care for the primary care sector and the service reconfigurations for UHL acute hospital sites and Mental Health aspects.

 

Members were asked to focus on the new model for primary care at this meeting, as the other two aspects would be considered at separate meetings. 

 

Prof Azhar Farooqi, Co-Chair Leicester City Clinical Commissioning Group (CCG) and Tim Sacks Chief Operating Officer East Leicestershire and Rutland Clinical Commissioning Group.

 

Prof Farooqi introduced the report and stated that he would be happy to submit further progress reports in the future.  Although expenditure on health care services was expected to increase in future years, the continuing rise in population, coupled with an increase demand from the ageing population on health services and fast developing technology, clearly indicated that the increased funding would not keep pace with the projected costs.  If nothing was done there was a projected deficit of £350m by 2020.  This represented finding savings of approximately £80m per year (approximately 4% of the budget per year).  It was important, however, that changes were clinically and not financially driven.  It was accepted that were some areas where improvements were needed.

 

Primary Care services had been subjected to 10 years of static funding; a number of practices had closed, and existing practices faced pressures from, the inadequate infrastructure of many existing buildings (which were unsuitable to deliver high quality care), increased care in the community, increased emphasis on secondary prevention to stop people with conditions developing more complications and changes in prescribing.

 

Most GPs were currently employed on a national contract, although this may change in the future to allow commissioners to make the changes that may be needed to provide future health services in the primary care sector.  There were, however, a number of areas where the CCG could work with GPs to deliver workforce recruitment and development. For example, many GPs had received training to deliver advanced levels of diabetes treatment over recent years.  There was still a need for more GPs, advanced practitioners and pharmacists.

 

New models for GP working, such as federations, were being developed to deliver enhanced patient services and to meet the challenges being faced by primary care.  This may mean that if patients required a specific service or specialism that was not available in their own particular practice, they may need to go to another practice within the federation that was able to deliver that service or specialism.  Federations also allowed GPs to work collaboratively in order to provide sustainable out of hours service delivery.

 

In order to achieve a sustainable health service in the future, it would be necessary to change the public’s perception of the NHS and to get them to use the NHS differently.  For example, patients generally expected to see a GP for all their treatment requirements, but specialist trained nurses can provide many services and patient treatments safely and effectively; which frees time for GPs to spend with patients who have more acute and complex illnesses.  The challenge of changing the public perception of what the NHS is used for should not be underestimated, as currently 25% of ambulance requests were for people who didn’t need one and people attended A&E Departments with minor conditions that could be treated elsewhere in the health system.

 

The STP envisaged the following changes and pressures on GP services in the future:-

 

·         More care will be provided in community in next 2-5 years.

·         GPs would work more in a team approach to expand services available to patients.  

·         GPs would be taking a more focused lead and approach on complex patient care.

·         There would be more locality based care rather than hospital based care.

·         There would be more hub based patient care when GPs practices where not open.

·         There would be more patient diagnostic services provided in the in community.

·         There would be more demands upon social care services and carers and the primary care sector would need to be more involved in prevention measures.

 

The national contract for GPs meant that CCG’s couldn’t currently commission specifically designed services for each local area.  CCGs could, however, provide information, resources and access to the workforce to enable them to provide specific patient care.  A new model of GP working had been issued before Christmas based upon a multi-community provider approach which envisaged a far closer relationship between groups of practices, social care services and community services with pooled budgets to provide more joined up care for patients.  Elements of the model were already being seen with GP federations.  There was a clear national view for providing 7 day patient access to health services in the future and the CCG was providing support wherever possible to those affected by the changes to services that were required as a result of national guidance.

 

Members made the following comments during discussion:-

 

a)         It would be helpful to have more information on the work already undertaken on workforce planning.

 

b)         The financial details of the STP had not yet been published and details of the governance arrangements were still unknown. There were still concerns over some aspects of ‘red tape’ and the financial uncertainty of the STP.

 

c)         Some of the mechanisms for getting prescriptions from pharmacies were not working and some pharmacies in the City had closed down. There was anecdotal evidence of patient hubs experiencing difficulties.

 

d)         Any pubic engagement and consultation material should be easily understood and the public should have sufficient time in which to discuss it and put forward their views.  There should be adequate publicity on the process.

 

 

The following responses were received in response to Members comments:-

 

a)         The new models of working by GP practices would need full engagement with public as a ‘one size fits all’ approach would not work. 

 

b)         Health Education East Midlands were aware of the workforce ‘time bomb’ and newly trained staff would barely cover the number of expected retirements over next 5 years.   It was also important to train staff with the skills required to delivery services in the future. CCGs were required to allocate a minimum of 10.3% of their budgets into core services and all CCGs in LLR exceeded this requirement.

 

c)         ‘Push Dr’ app was an independent service that had recently been launched.  Patients entered details of their symptoms ect and, for a fee of £25-£40, could get advice or a private prescription.  The service could not refer patients to a secondary care service and more often than not referred the patient back to their own doctor

 

d)         GP’s have not always needed to ask for public views to make minor changes in service provision.   Healthwatch and PPGs were often consulted and provided useful feedback on proposals.

 

e)         Any fundamental change in service provision would require public consultation.  However, changes to the model of service provision would not require formal public consultation; but there would be an engagement process to discuss the proposals.

 

f)          The CCG had produced a document which would be made public soon to engage with patients within all 59 GP practices in city.  There was a huge variety of views and a number of PPGs wanted to protect the traditional forms of primary care; which reflected the view that ‘one size does not fit all’.  The CCG were also planning a major engagement exercise in city in February and details would be confirmed soon.

 

g)         The concerns surrounding ‘home first’ were understood.  It was essential as part of the process to have a robust clinical assessment of a patient to determine whether the patient’s condition was suitable for home care and to ensure that, when a patient was discharged from hospital, the assessment was robust to ensure that there was no likelihood of the patient being readmitted.

 

h)        The CCGs worked with the local universities on the appropriateness and need for specific courses.   Further work was progressing on enhancing skills for the existing workforce as it was important that everyone worked at the top of their competence levels and upskilling was used to maximum effect in providing health care service to patients.

 

i)          Consideration was being given to ways of making the role of GPs more attractive to encourage recruitment and retention.  For example, giving GPs a portfolio of experience involving not only working in a GP surgery but also offering opportunities to gain experience of working in A&E and specialist clinics etc.

 

j)          Status quo was not an option for the future as waiting 3-5 weeks to see GP was not appropriate and there was clearly a need to change the model, given the finite staff and financial resources.  The STP was a mechanism for providing services that patients needed within the resources available. 

 

k)         If the overwhelming view from the engagement/consultation process indicated that patients did not want change and wanted to have a GP consultation for all their health needs, then the response would be that it could continue to be provided but the likelihood would be that it would take up to 4-5 weeks to get an appointment and other patients with more complex care needs may not have care they need.

 

l)          There was a requirement to produce an Equality Impact Assessment for every element of STP.  These were in draft form at the moment but they would be made public when they were finalised.  There was also an overarching Equality Impact Assessment for the overall STP.

 

In response to a Member’s question concerning the ‘Push Dr’ app, the Deputy City Mayor commented that is was not appropriate for the Health and Wellbeing Board to look at one provider of a service, but it would be appropriate to have a broader discussion on the use of technology in patient care services.  He personally would not like to see patients being charged to use tele-care services.

 

The Healthwatch representative stated that they were concerned at the level of public engagement and had written to the CCGs offering their help in working with the public on STP.   It was also recognised that the STP required capital investment in some areas of the STP to bring about the changes required.

 

In response, Prof Farooqi stated that the proposals for primary care within the STP were not considered in isolation but were linked to everything else in the STP.   Transformation funding was needed to bring about change but currently these were unknown and NHS finances were constantly under review.  There was also a need to have resilience in primary care regardless of the STP process and the focus was to ensure that patients get the quality primary care at the right time.

 

The Chair commented that whilst the details currently known about the proposals in the STP sounded good in principle, there were concerns that they would not work in practice.   The proposals involved a high level of cultural change for staff and patients.  Also, it would not be easy to have twin tracking of services when it was being proposed to make financial savings at same time.   There were also challenges in bringing about a consistent cultural change for GPs, who were self-employed.

 

In response, it was stated that qualified nurses currently saw and treated 1,000s of patients in a safe and effective manner.  There were not enough GPs to offer patients an appointment for all health conditions.  Nurses have additional training to provide advanced treatments to patients and most people with multiple conditions were not getting appropriate care at moment, through lack of GP resources.

 

Patient safety was paramount and health professionals would not wish to see beds taken out of UHL until replacement beds were in place within community and home settings.  The City already had the lowest number of beds to population ratio.  There were twin tracking elements in the overall in STP.  There were currently 256 virtual beds in LLR and patients were seen 4-5 times a day by health staff.  

 

AGREED:

 

1)         That the Co-Chair Leicester City Clinical Commissioning Group (CCG) and the Chief Operating Officer East Leicestershire and Rutland Clinical Commissioning Group be thanked for presenting the report and answering members questions.

 

2)         That the CCG be asked to provide the overarching Equality Impact Assessment for the overall STP and that each individual Equality Impact Assessment be provided to the Commission as they are finalised.