The Leicester City Clinical Commissioning Group submits a report on the Development of Primary Care Networks. Members are asked to consider and comment on the report as they see fit.
Minutes:
As agenda items 11, (“Introduction to the NHS Long Term Plan”) and 12, (“The Development of Primary Care Networks”), were considered together, the discussion on both items is recorded in this minute.
Sarah Prema, Director of Strategy and Implementation with Leicester City Clinical Commissioning Group presented a briefing paper setting out the key requirements of the NHS Long Term Plan (LTP).
Ms Prema reminded the Commission that the LTP contained a vision for how the NHS would develop over the next 5 – 10 years and what it would deliver. Previously, a commissioner and provider model had been used, creating contractual relationships, but the new model moved towards a partnership relationship. The key to this would be to consider services from a Neighbourhood, Place and Systems perspective. For example, Place would help in the consideration of services that could not be delivered economically at a Neighbourhood level and Systems would relate to sets of outcomes based on the health needs of the population under consideration.
MS Prema then drew attention to the following points:
· As part of the LTP, it was anticipated that Integrated Care Systems would be designed and in place nationally by 2021. These would be developed from Sustainability and Transformation Partnerships;
· The first thing that needed to be done under the LTP was to establish Primary Care Networks;
· The draft People Plan had already been published, giving some direction for national initiatives on how recruitment was to be undertaken; and
· In creased use of technology, (digitally enabled care), would be embraced in all aspects of care. For example, it was anticipated that patient follow-up appointments could be reduced by one-third through the use of technology. This would release resources for use in other areas.
Richard Morris, Director of Corporate Affairs, Leicester City Clinical Commissioning Group, then discussed the development of Primary Care Networks (PCNs), showing the presentation attached at the end of these minutes and making the following points:
o PCNs were an element of the Neighbourhood part of the LTP;
o PCNs required groups of GPs to work together, so were not a new idea;
o GPs had been asked to come together in groups of registered populations of between 30,000 and 50,000. The former was a minimum number that would be acceptable, but there was a small degree of flexibility regarding the upper number;
o PCNs were formal arrangements, which they had not been previously, having contracts from Clinical Commissioning Groups to provide primary care;
o All PCNs were required to appoint a Clinical Director and would receive funding for this and other specified roles. It was understood that the Clinical Directors all would be current GPs;
o A number of service specifications would be issued at a national level in April 2020; and
o Ten PCNs had been created across the city. All GP practices were participating.
Members expressed concern that GPs already were unable to cope with the demands being made on them and queried how these changes would improve that situation. In reply, Professor Farooqi, Co-Chair of the Leicester City Clinical Commissioning Group, explained that the aim was to reduce outpatient numbers by 30%. However, these people needed to be seen somewhere else, so PCNs were being designed to have organisational structures that would enable work now being done in hospitals to be done in the community instead. Some services, such as lifestyle services, (for example, smoking cessation), could be tailored to particular areas, as they could be delivered within distinct boundaries.
It was noted that patients would no longer be able to reorder prescriptions from pharmacies, but would have to go through a GP instead, raising concern that this would in crease the burden of work on GPs. In response, Professor Farooqi explained that ordering of repeat prescriptions from pharmacies had led to great wastage of drugs, as many pharmacies reissued every drug on the prescription, irrespective of whether it was needed or not, so this change should reduce costs. When someone’s medication was stable and there was no reason to change it, doctors also could consider prescribing six months’ medication.
Members also suggested that it would be beneficial to have more nurses in GP surgeries, but Professor Farooqi explained that very few nurses were being trained to go in to general practice, as most remained working in hospitals. Mark Whightman, Director of Marketing and Communications at University Hospitals of Leicester NHS Trust, confirmed this, noting that there currently were 600 vacancies for nurses at the Trust. This was a safe level to work at, but there was no capacity to share nurses outside of the hospitals.
Concern also was raised that there could be a risk of creating a market between PCNs if there was not equity between them in the services provided. However, Professor Farooqi advised Members that funding for specific roles wold not be given if there was no-one in the post(s) to which that funding related. The main problem was likely to be whether there were sufficient people available to fill those roles.
The Commission enquired how much it was estimated the requirements of the LTP would cost and where this funding would come from. It also was questioned who would safeguard community resources when health services were being separated in to distinct parts.
Professor Farooqi advised Members that the NHS had set out plans for a ten-year investment programme in PCNs. As PCNs developed and services moved out of hospital settings, it was anticipated that resources would follow, so that services in the community could develop. Patient Participation Groups would be very important in holding PCNs to account.
The whole system would change, as CCGs and PCNs would work more collaboratively through Care Alliances. These would not be a way to let the private sector take over NHS work, as the emphasis would be on collaboration, rather than testing the market. As funding would be directed to achieving health outcomes, greater levels of funding could be directed to where the greatest health inequalities existed. Many of the targets being set were for 5 – 10 years, which was felt to be helpful, but it also meant that the national expectation that the targets would be met was greater.
Under the LTP, CCGs would have a more statutory role than at present, overseeing the management of the system. As a result of this, discussions were being held to determine whether it was appropriate to continue to have three CCGs for Leicester, Leicestershire and Rutland. Engagement would be undertaken to determine the most appropriate future structure for these CCGs.
Some of the funding for the LTP would be from central government, towards running services locally. It had not yet been decided what proportions of this would be passed to the PCNs and Care Alliances, but care would be taken to ensure that health inequalities were addressed.
The Commission suggested that it could be useful for health service organisations to provide officers, or work with voluntary organisations, to liaise with the community. This could be particularly beneficial in ensuring that people recently arrived in the city did not miss out on health services. Professor Farooqi agreed that this could be beneficial, including instances where staff from a PCN had particular language skills. It was hoped that PCNs would liaise with Councillors, either speaking to them direct or through PPGs. This would be facilitated by the majority of PCNs being geographically continuous.
Work had been done with PCNs with a wider geographical spread to ensure that those networks would work and that patients would not have to travel a long way to access normal GP services during a normal working day. It was considered that if anyone had to travel it should be the GPs, not patients.
It was reported that patients already were asking how these changes would affect them and their care, especially regarding the changes scheduled to take place later. In reply, Mr Morris explained that it had not been possible to openly discuss PCNs while they were forming. The deadline for their formation had been 1 July 2019, so some restrictions had reduced and it now was possible to answer questions and provide other information.
Members noted that the summary of LTP requirements submitted with the reports were the minimum national requirements, so opportunities were available to add to it. Healthwatch had undertaken some engagement in order to inform the LTP and as this developed responses to the engagement would be incorporated in the schedule of requirements.
Some concern was expressed that dementia and older frailty were not mentioned in the summary, but it was explained that partners saw this as a key area for the city. Work on population health management was ongoing though, which included using data to understand the cohorts of patients who were intensive users of services.
In view of this, the Commission asked how it could help shape the LTP to towards local circumstances . Sue Lock, Managing Director of Leicester Clinical Commissioning Group, explained that there was a need for partners to work closely with Public Health officers to identify local health needs. This would then be reported through the Health and Wellbeing Board. However, consideration needed to be given to how wider input could be incorporated, as the draft requirements had to be ready by the end of September 2019, with the final version being completed by mid-November 2019.
AGREED:
That the Leicester City Clinical Commissioning Group be asked to submit a further report to the Commission, on a date to be agreed, on the NHS Long Term Plan, with particular focus on Primary Care Networks and Care Alliances, this report to include information on:
a) How funding for the Long Term Plan is to be calculated;
b) How Primary Care Networks will operate, (for example, how funding will be allocated and managed);
c) How the geographical spread of Primary Care Networks will be addressed to ensure that appropriate services for patients are provided;
d) How individuals and/or groups can contribute to Sustainability and Transformation Partnerships and Primary Care Networks;
e) How health inequalities will be addressed, especially through funding;
f) How existing plans and protocols, such as the Winter Care Plan, will be embedded in new systems; and
g) If possible, a graphical representation of the structure of health services, showing what it is in place now and what they will be in the future.
Supporting documents: