Agenda item

To receive a report from the Leicester City Clinical Commission Group (CCG) on the Blueprint for General Practice – Delivering the General Practice Five Year Forward View, that was jointly published on 24 February 2017 by all 3 CCGs in Leicester, Leicestershire and Rutland.    

The Board received a report from the Leicester City Clinical Commission Group (CCG) on the Blueprint for General Practice – Delivering the General Practice Five Year Forward View; that had been jointly published on 24 February 2017 by all 3 CCGs in Leicester, Leicestershire and Rutland.

 

The Chief Executive, Leicester City Clinical Commissioning Group introduced the report and commented that primary medical care was the foundation of a high performing health care system and was critical to the successful implementation of the LLR Sustainability and Transformation Plan.  Ensuring the development and resilience of Primary Care would assist in bringing about the system-wide transformation required to focus on prevention and the moderation of demand growth. 

 

The Plan had been prepared by the three separate CCGs in LLR each had  distinct geographical, political, social and economic environments, with very differing health needs.  All three CGGS were committed to the development of our response to the GP 5 Year Forward view as a collective, and consequently there was a focus in the plan on what brought them together and how they would jointly tackle the challenge, whilst also highlighting locally sensitive solutions to their own areas of responsibility.

 

GPs from each CCG Board had actively engaged in the development of the plan and fully supported it.  There were many challenges facing General Practice, including workforce, funding and rising demand.   All CCGs would work together to develop and co-design a resilient and sustainable model in which general practice could thrive and meet the challenges in the future.

 

The CCGs had a clear direction for the future of primary care in which general practice was the foundation of a strong, vibrant, joined up health and social care system. The new system was patient centred, engaging local people who use services as equal partners in planning and commissioning which results in the provision of accessible high quality, safe, needs-based care. This would be achieved through expanded, but integrated, primary and community health care teams; offering a wider range of services in the community with increased access to rapid diagnostic assessment and, crucially, patients taking increased responsibility for their own health.

 

The following points were noted in response to discussion and questions from Members of the Board:-

 

a)            Work on the strategy had been taking place for some time in what was a complex area.  There had been a difference in approach from NHS England who had acknowledged the level of investment and resources in primary care had been inadequate.  Many GPs had complained for a number of years that the lack of investment had not enabled primary care to keep on track with the rest of the health system.

 

b)            The three key issues locally were:-

 

·         Capacity - the ability to deliver in different parts of the workforce around the LLR area. 

·         The health needs challenge presented by the city arising from deprivation.

·         The level of investment.

 

c)            The Primary Care strategy was seen as an enabling document for larger strategies such as the STP to be delivered.  The focus in the strategy was on:

·         Providing support to patients for self care.

·         An appropriate and accessible primary care service.

·         Integrated care bringing health and social care teams together to care for patients.

·         A home first model aimed at keeping people at home as long as possible and getting patients out of hospital as soon as possible where it was safe to do so, to avoid people becoming institutionalised the longer they stay in hospitals; which then required them to have more support when they returned home. Primary care was integral to support this.

 

d)            The Primary Care Plan was a blue-print for the LLR and was a part of the STP.  Although it was a joint plan for the LLR area it was broken down to recognise the difference in populations, health needs, and the state of health care between the county and city.  Parts of the Plan looked at health care across the LLR in its entirety and parts looked at specific issues with the city.

 

e)            Primary care continued to be the corner stone of the NHS.  It was the part of the service most used by patients on regular basis and the part used to build relationships over long periods of time.  There were relatively high satisfaction levels with primary care although these were lower in the city.  There had been significant challenges of demand and funding over the last 15 years and recruitment and retention of GPs still remained a challenge.

 

f)             The key points in the CCGs vision for the next 5 years were that:-

 

·         GP practices remained at the heart of health care and central to the health service.

·         Named GPs would take on more responsibility for active treatment of acute conditions.  This may mean that patients attending with routine conditions and enquiries may not always see their named doctors, but may see a health professional who was qualified to provide the level of treatment required by the patient.

·         Practices would come together and collaborate more than they had in the past.  This might be through informal or formal collaboration arrangements.  The CCG wanted to provide an environment which would enable voluntary collaboration of GP practices without the CCG being prescriptive on the arrangements.

·         The Plan incorporated the national requirement to provide access to urgent on the day GP services, and built upon the developments that had been made in the city over the last 12-18 months.  The biggest development had been the opening of three GP hubs.  These had provided 180,000 additional GP appointments in the city per year and were open to any registered patient of a city GP practice.  They had been piloted for 18 months and the CCG had now secured funds from NHS England to continue them for the next 2 years.  The hubs would be developed to provide a wider range of services for patients and communities by providing both routine diagnostic tests such as blood, urine and ECGs, but also other services that currently required an outpatient appointment.  In addition to the £2.2m for continuing with the hubs, the CCGs were also making £600k available in each of next 2 years to deliver transformation measures to make the system more sustainable in the long term or engaging in collaborative working.

·         The vision for GP recruitment envisaged the need for a change of skill mix with more nurses, nurse practitioners and clinical pharmacists working in practices to support GPs in order to create capacity for GPs to focus on patients with more complex conditions who needed more time and support. 

·         Not every GP practice in the City experienced difficulty in recruitment and some had innovative working practices to recruit GPs which would be shared with others. This included a varied portfolio providing experience of working in other parts of health service, research opportunities, lecturing at the universities and working in hospital setting.   20 GPs had been recruited in the last year and the 3^rd phase of the local GP recruitment scheme had attracted 27 applications.

·         There would be more investment through changing the GPs contract by increasing the current payment of £78 per patient per year to £85 per patient per year.

·         There had been significant engagement with clinicians within the LLR and the Plan had been endorsed by city GPs.  The Plan also built upon public views expressed in the last 2 years and further engagement would be undertaken. 

·         The document was written in NHS technical language and a public facing document was being prepared to enable further public views to be expressed on whether the proposals in the Plan were appropriate and met the demands that were currently seen within the service.

 

NHS England had published the ‘Next steps on the NHS Five Year Forward View’ on 31 March 2017, which set out actions to deliver NHS care fit for the future. The implications of this were being considered to see if this impacted upon the Plan and whether any changes were required as a result. 

 

The Healthwatch representative referred to an ‘Enter and View’ inspection carried out at the Westcotes Health Centre which had provided positive patient feedback on the flexibility of the system and also that some patients were using the hub as an alternative to their own GP practice.  It was hoped that those GPs who needed extra help in operating their practices were not overlooked by the hubs masking an underlying issue.  It was also felt that the scale and risk associated with the culture change required for patients to take more responsibility for their own health was understated in the Plan.  The creation of the integrated team model was, however, a good way forward to help reshape services.

 

In response to the Chair’s comment that the Plan had little reference to the important role that community pharmacies could play in relation to access, prevention and the self-care agenda, it was noted that a member of Pharmacy Board had recently been invited to join the Programme Board.  It was also recognised that there were groups within the local population who had low levels of confidence in using pharmacies in their own countries and there would be a need to work with these communities to increase their awareness and confidence in using pharmacies.

 

It was also noted that NHS England, as the commissioners of pharmacy services, were in the process of launching a 5 year forward view for pharmacy services and embarking on a national campaign to promote the services pharmacies could provide.

 

The Chair observed that GPs had expressed views that the system was fragile and not resilient.  It felt that the focus in the document was primarily on structural governance arrangements when people wanted to feel assured that they could see a doctor or nurse and get good care at home when it was appropriate.  The public also wanted to have equality of access across all 3 CCG areas and for services to have equitable outcomes.  At present there were high variants of cancer detection between the 3 CCG areas.

 

In response, it was noted that some outcomes were affected by GPs individual contracts. Evidence was emerging that by forming federations small GP practices could come together and share skills which enabled them to extend their services.  GPs could choose to offer other services above their core contracts if they wished.  Sometimes the physical accommodation in the building itself could be a constraint to offering additional services.  A federation offered an opportunity to allow practices to work together and have a consistency of approach.  Currently 12 practices had indicated that they were not interested in forming a federation.  The variance in cancer outcomes for patients etc were being addressed through the STP process where system wide funds could be used by all 3 CCGs, in partnership, to provide a targeted approach to encourage people to come forward in those areas where there were low outcomes in cancer detection.

 

A member of the public asked a question relating to there being no reference to providing training for GPs in the strategic document and the importance of sharing examples of good innovative practices to promote consistent standards across all GP practices.  There were concerns that when GPs retired, these innovative services could be lost and thought should be given to training new GPs to ensure continuity of quality care in these instances.

 

In response it was stated that:-

 

• The CCG provided training and planned to provide training where specific health needs were identified.  One such area was diabetes where the CCG had invested significant sums in providing diabetes training for GPs and nurses and had offered enhanced payments to GPs to provide increased service provision.  Increased outputs in quality of care had been observed in last 2 years as a result.

 

• The importance of training in clinical governance and patient care was also recognised as being important for those patients with more complex health care needs in the future.

 

• There would be a separate work stream for training for the future and work was being undertaken on the training hub in the city in conjunction with medical students, Kings College and Nottingham University to improve training, coaching and mentoring to increase skills and share examples of best practice.

 

Following comments from Board Members it was noted that:-

 

a)         The CCG was investing time and effort in meeting GPs and it was encouraging that many younger GPs had already expressed interests in the 5 year view, forming federations and wanting to help shape future services. The CCG were encouraging young GPs and practice nurses to take on leadership roles in the future.

 

b)         The CCG had started dialogues with the PPG forum to encourage the participation of the individual PPGs and this had received a positive and productive response in the exciting opportunities the document gave them in going forward.

 

c)         The proposals for shared investment mentioned in the 5 Year Forward would be funded by a two thirds contribution from NHS funding sources and the remainder from individual GP practice funds.

 

d)         The STP was still awaiting approval from NHS England to enable it to proceed to the consultation stage.  The proposals for primary care would not in themselves meet the thresholds for the formal consultation process, but there would be public engagement on the proposals.  Once the formal consultation process had been approved it would enable more meaningful conversations with patients, carers and the public on the draft proposals.

 

e)         The CCG had a responsibility to ensure that patients did not travel too far to access services and this was taken into account when forming federations.  The CCG also had a responsibility to ensure that qualified staff delivered services commissioned by the CCG’s to their standards.  The CCG would be issuing protocols in practices so that practice nurses could see and provide treatment to patients where they were qualified to do so.  It was noted that these changes were being introduced nationally.

 

f)          The current healthcare service was not sustainable in the long term and these plans were required to ensure that all staff had the appropriate skills to provide safe treatment to patients at the appropriate level for the patient’s needs and health conditions.  Not all health conditions required treatment from a GP.

 

The Chair commented that he had concerns in relation to what the changes could mean for health services generally.  Introducing large structural changes required considerable amounts of existing capacity, time and resources, which could impact upon the ability to provide services during the planning and implementation period.  Where there was not a requirement for full formal consultation on proposals, there should still be good effective consultation with patients so that they could make informed judgements.  This was particularly important in instances where there was no opportunity to challenge an individual practice in joining a federation and to help the public to understand the reasons why self-care was important in reducing the demands upon health and social care services.

 

AGREED:-

 

That the report and update be noted and that elements of the proposals be submitted to future meetings and the Health and Wellbeing Scrutiny Commission to link in with discussions on the STP.

 

There was a need for the Board and the Scrutiny Commission to be informed of specific timescales and proposals and to understand how the proposals specifically impacted upon the city, especially the impact of establishing federations in a particular area of the city and what services they will provide and what outcomes were expected as a result.