Agenda item

The Leicester City Clinical Commissioning Group (CCG) to submit a report providing an update on the development and delivery of the CCG’s Primary Care Strategy and how it links with the General Practice Forward View delivery across the Sustainability and Transformation Planning footprint of Leicester, Leicestershire and Rutland.

Leicester City Clinical Commissioning Group submitted a report providing an update on the development and delivery of the Leicester City CCG Primary Care Strategy and how it linked with the General Practice Forward View (GPFV) delivery across the Sustainability and Transformation Planning (STP) footprint of Leicester, Leicestershire and Rutland (LLR). The paper focused on reporting against delivery of key milestones for Q1 and Q2, and described some of the links between national and local approaches to supporting and sustaining primary care in Leicester City.

The Chair stated that Members had already received to briefing to better understand the process and reasons for the Five Year General Practice Forward View and the Primary Care Strategy in the context of the STP.  It was likely that this issue would be re-visited as part of subsequent discussions on the STP.

The Director of Operations and Corporate Affairs, Leicester City Clinical Commissioning Group stated that:-

a)         The Five Year General Practice Forward View was a national directive to address the primary care challenge across the country.  The review covered issues of access to GP services, workforce of GPs and other practice staff and funding of primary care.  The CCGs were required to prepare a plan across the LLR footprint on the delivery of services in the next 5 years.

b)         The initiative included practical and funding actions against five key areas, investment, workforce, workload, infrastructure and care re-design.  A key element was the ‘Releasing Time for Patients programme which included support to accelerate change either within individual practices and federations of practices.  There were 10 high impact areas to support this initiative but it was not expected that all practices and federations would implement all 10 areas but it was expected that practices would develop at least 2 or 3 of them. There would be some limited funding per patient to support practices.

c)         Access to GP services in Leicester had traditionally been amongst the worst performing nationally in the last 10–15 years.  Leicester had regularly been in the bottom 5% percentile.  The CCG had attempted to improve access by investing in hubs to give as much opportunity as possible to access GP services.  The 3 hubs provided 1,300 additional appointments per week.  The hubs had full access to all patients’ records and were therefore able to take into account the patient’s history and current medication during the consultation and treat the patient as though they were consulting their own GP.  The hubs had been successful and were utilisation rate of 95%.  They were busy during the day and on Saturday’s but demand dropped significantly after 1.30pm on Sunday’s.  The CCG was in the process of procuring the hubs on a permanent basis.

d)         The CCG had operated a Golden Hello scheme to attract GPs to work in the City.  This had been successful in recruiting 11 GPs in the first 2 phases, with a third phase open to all practice staff currently ongoing.  The CCG was also now involved in an international recruitment exercise.  The CCG were also trialling 9 pharmacists working in GP practices to review patients’ repeat prescriptions and their future treatment. 

e)         Primary care had been underfunded historically and there were also inequalities between those GP practices funded at the highest and lowest levels.  The CCG had re-invested more than £500k from existing funds to bring GP practices in Leicester up to and above the national minimum level of funding of £85 per patient.  It had also recycled approximately £2m of funding from within its existing budgets to provide additional funding for primary care services in Leicester.

Members of the Commission made the following observations:-

a)         There was a danger in the move to a federated model for GP services that a drift to larger contacts could lead to decisions being made at corporate levels outside of the City and the autonomy of local people could be reduced and compromised. 

b)         A number of low level mental health issues  could be improved by patients engaging in physical and community activities such as gyms/outdoor gyms, gardening  clubs, local health clubs and other community groups such as arts clubs etc. It was important that GPs had extensive knowledge of the local non-medical support that was available in the community. 

c)         With the advent of federations delivering health services there was a possibility that a different levels of primary care could develop over a wider area of the city if a federation decided not to provide some services, such as the 10 high impact actions.

d)         The reliance on transferring more care to the social care sector was of concern given the current budgetary pressures already faced by that sector.  Questions were raised at the long term sustainability of the element of the government’s vision for the STP.  

e)         Concerns were expressed that the pubic were not being consulted on these proposals and they need to be involved and understand the reasons for the changes in order that their perceptions of access to health services changed to support the models being proposed.  If, not then this could give rise to disappointed patient experiences.

h)        The model should also incorporate provisions for mental health as well as physical health.  Continuity of care was also important and patients should be allowed priority for subsequent appointments.

i)          It would be helpful in social prescribing if IT systems could include flags to enable GPs to engage with none medical solutions to arrange adaptations to houses for patients with mobility issues.

Following discussion of the report the Director of Operations and Corporate Affairs responded to Member’s questions as follows:-

a)         The CCG were not proposing to issue guidance on how a federation should work or operate, but wanted to work with federations collaboratively to ensure they addressed primary care challenges in the City.  There were currently 2 federations in the City that were providing a range of services.  These included providing the City’s GPs hubs to help practices share back office functions.  There was no limit on the size of a federation and it did not appear that a single federation across Leicester City would be likely at the present time.   At present just over half of the GP practices in the City were part of a federation.

b)         Most GPs were of the view that that the current model was not sustainable in the long term and the present system needs to change.  GPs considered that they should still be at the centre of patient care but with other professionals such as pharmacies, nurses and paramedics taking on more responsibility for appropriate patient contacts, allowing GPs to focus on patients with the greatest need such as the elderly and those with several long term health conditions.   Changing to this model of health care would need a shift in the expectations of patients and it would be essential to engage patients to explain the proposals and to seek their views.

c)         The CCG were considering the practicalities of one of the three hubs offering appointments for Sunday afternoons, rather than all three hubs being open and resources not being used to the best effect.   

d)         The CCG commissioned Inclusion Healthcare to provide medical services to homeless and asylum seekers and they carried out outreach work for the homeless, asylum seekers and other hard to reach communities. They provided good services and the CCG felt that the current model provided a robust service delivery.  Inclusion Healthcare could choose if they wished work with a federation if they needed to provide services at scale.  A homeless patient does not have to register in the City Centre with the Inclusion Healthcare practice as they can register with any GP practice.

e)         GP services were funded through the current core contracts and if GPs failed to meet the standards of delivery required then the CCG had powers to take action under the provision of the contract.  Services other than the core services, such as some sexual health services, were provided by local payments to GPs who wished to provide them.  Some practices chose not to offer these services and they often don’t feel they have the capacity to offer them.

f)          The CCG were in the process of working with practices to provide training which would equip reception staff with knowledge for all services that are currently available in the primary care system, so that if a particular GP practice had no available appointments they would have the ability to book the patient an appointment with one of the three hubs, direct the patient to a walk in centre or refer the patient to the NHS 111 service.

g)         One reason for the apparent disparity between the population of the City and the number of patients registered with city GPs was that the number of patients registered with city GP practices tends to be 30k or 40k more than city population because of people living outside the city boundary but choosing to access city GP practices, often because they worked in the city.

h)        Although these proposals were being included in the engagement arrangements for the STP it did not require statutory consultation under the STP itself.

i)          There had been patient and public involvement in discussing the proposals for the Hubs and the feedback had been used to develop the way in which the hubs were provided.  The provision of GPs services is determined by the primary care contracts that are issued by NHS England and the CCGs. Some practices are already working in the way described, as this is permitted by the contract.  However, it was considered important to inform patients about the kind of changes they might see in their own practice and listen to their views.  A programme to this was scheduled to begin in October.   Some GP practices have been operating many of the current proposals for some years and some feedback from patient and public groups have questions why the changes had not already been implanted earlier.

j)          The CCG were producing a public friendly facing document that would be used for public engagement purposes to clearly communicate what the proposals meant for patients.  The CCG would look for opportunities to meet communities at outreach events and areas of high footfall.

The Chair commented that whilst the changes to GP services are understood many of the changes are happening already without a widespread public debate and many of the changes rely on the public taking more responsibility for their own health and health education.  For example accessing cold cures at pharmacies and knowing that minor ailments such as coughs and colds can be treated through self-administration by the patient and do not always require a GP consultation.  Part of the reason that more people are accessing A&E services is due to this as often patients cannot get GP appointments.

The Chair also felt it was important for the Commission to look at joint areas of interest with the Health and Wellbeing Board and for the Commission to make its views known.

AGREED:

            That the report be received and that Members’ comments be taken into      consideration as part of the public engagement process.