Agenda item

Cllr Kober arrived at the meeting and assumed the role of Chair.

The Board received a presentation, from Ms Cassie Williams, Assistant Director of Primary Care Quality and Development for Haringey CCG giving an overview of primary care. Following the presentation the Board discussed the findings.

It was noted that NHS England had put out an offer for Co-Commissioning of Primary Care with local Clinical Commissioning Groups (CCG’s). The aim of which was to create a joined-up clinically led commissioning system delivering integrated routine and unplanned primary care services based on the needs of local people. There were three types of co-commissioning offered: Greater involvement; joint commissioning or delegated responsibility. North Central London opted for a joint commissioning approach. Ms Williams noted that this process was still ongoing and that Haringey CCG was submitting a further bid to provide joint commissioning at the end of January.

The three main elements of the strategic  commissioning framework were:

• Proactive Care: Promoting self-care, health literacy and helping people to stay healthy.
• Accessible Care: Providing a personalised, responsive, timely and accessible service.
• Co-ordinated Care: Patient centred, co-ordinated care with GP-patient continuity.

Ms Williams outlined NHS England’s 5 year forward view. The three main areas were noted as:

• Prevention
• Restructure how care is provided
• Invest into Primary Care

In response to this the Government had agreed to give an additional £1.95 billion to the NHS for 2015/16.

Haringey CCG’s Primary Care Strategy was currently being redrafted. The key objectives of which were noted as:

• Make primary care more accessible
• Coordinate care around the needs of our patients
• Make care more proactive
• Support practices to work at scale 
• Develop our workforce, recruit & retain the best staff
• Ensure our premises are of the highest possible quality
• Improve our technology and information systems

Ms Williams advised that one of the most significant technological improvements was the development of interoperable IT databases so that GP’s etc would be able to see each other’s records. The acute care and community providers would shortly have the capacity to do this as well.

Dr Helen Pelendrides commented that as a GP, the ability to access a patient’s records across different surgeries and IT systems was “revolutionary”. Every GP in Haringey had agreed to the data sharing protocols, not just among themselves but with other partners externally. This would have a significant impact on health and care integration. The next stage was to complete the join up with synthesis in A&E and Out of Hours services.

The Chair asked Dr Pelendrides what the impact of this change would be on her as a GP in 5 years time. Dr Pelendrides responded that this would positively impact on both the quality of patient care as well as deliver financial savings as the number of duplicate referrals and wasted appointments should dramatically decrease, with patients being able to access services with fewer delays. It was noted that, by way of an information safeguard, patient consent to share these records was required every time a clinician accessed their personal records. Dr Pelendrides also commented that this process would be likely to encourage greater prioritisation of work flow and in the longer term it should be possible to hold “virtual” clinics.

Ms Price commented that the provision should have a particular impact on being able to see people that a GP may not have been able to see previously as it would open up access to more specialised clinics, especially where patients were assigned to smaller practices. Dr Pelendrides commented that although the Prime Minister had stated that access to services would be opened up and patients would not necessarily have to wait to see their own GP, there may be a significant amount of education involved in this as many people may prefer to wait to see their own GP. 

Ms Herman asked whether the new service would really enable the NHS to offer more flexibility in its primary care services as, she noted, the current service offer was very much one size fits all. Dr Sherry Tang commented that bringing secondary care up to the same standard of digitalisation and information sharing would be a key challenge, though overall the process of bringing about greater interoperability should further increase flexibility and give people greater choice. For example, choice in terms of what types of consultations they would like to receive i.e. virtual or non-virtual.

The Deputy Chief Executive, Zina Etheridge commented that the co-commissioning proposal presented some significant opportunities, but also some significant challenges. For instance, co-commissioning brings about some issues around conflicts of interest particularly in terms of public perception. Ms Etheridge also asked colleagues from Haringey CCG what support they would require from those around the table to assist in the implementation process and that sharing access to the system with partners around the table might help tackle some of those concerns early on. Ms Etheridge also sought clarification with regard to governance arrangements for the project and whether progress would continue to be monitored by the HWB.

Ms Etheridge further enquired what the project would mean for the system as a whole, particularly around the points raised on specialisation. In particular how were colleagues from Haringey CCG going to ensure that those benefits were realised across the system and used to drive further reforms, as well as implications for the integration of primary care and the acute care sector and whether these services would remain separate.

 Ms Williams responded to a number of points of clarification by advising that part of the governance arrangements for co-commissioning would involve the creation of a joint commissioning board at the North Central London level, including representations from; all of the CCGs, GPs, lay member representation, NHS England and Healthwatch organisations. Final arrangements about the specific make up and voting rights were still to be determined as were whether there would be representation from all 5 Health and Wellbeing Boards at the joint commissioning board.

In terms of specialisation, Ms Williams agreed that the CCG could be more intentional about how we share the specialisms and the different services available. Ms Price added that in terms of federations developing in the borough and groups of GPs working together, the CCG as commissioners could commission services to work better at a local level across primary, acute and community services. This would encourage and foster the creation of specialist services as groups of GPs look to take advantage of those development opportunities.

Sharon Grant, from Healthwatch Haringey, commented that increasing access to primary care on its own would not engender the required outcomes; the challenge was to do it strategically, looking at prevention and looking at different models of care. Otherwise the danger was that the Strategic Commissioning Framework would just create a lot of new appointments across different formats and media but no real change to the delivery services would be realised. The key was to focus on the enablers for this change. Dr Tang responded that the ability to review other records and the wider drive towards interoperability would hopefully mitigate any potential capacity for duplication and limit any negative consequences of expansion of access. 

In terms of any potential support required from the wider HWB, it was noted that there would be a number of discussions with partners required about what kind of models would be required. For example, as Tottenham developed discussion was needed about the services offered to residents and the local demand needing to be met. Dr Tang commented that one of the key challenges faced was around workforce, as it was difficult to find and retain local staff and to keep the skill set of the workforce up. It was noted that if there was anything partners can do to help retain a specialised workforce, then that would have a significant impact on the efficacy of these proposals. 

The Chair commented that the physical regeneration of the borough and the desire of the CCG to play its part in this would create something that could be quite exciting. Particularly in terms of creating a compelling offer to Haringey’s workforce and ensuring that residents had access to the highest quality well motivated staff. The Board should keep this in mind as a key challenge going forward.

Ms Grant noted three main issues for patients:

• Communication – a lot of work would be needed to be invested in this to explain the changes and explain what they meant to people.
• Impact on the continuity of care – would someone still retain responsibility for a particular person’s care and would patients still be able to make appointments to see the same GP regularly?
• Confidentiality – Clearly this was going to open up people’s health records to a far wider array of staff working across an array of health and social wellbeing groups. There was a risk that just a few cases where confidentiality was breached could seriously undermine the proposals.

The Chair asked Ms Grant whether she had any sense of what residents had to say about continuity of care versus a demand for greater flexibility. Ms Grant responded that this may be something that Healthwatch could undertake as a piece of work.

Ms Williams responded, noting that she shared concerns around the need for communications and engaging far and wide with residents. Similarly, it was agreed that confidentiality was a risk and a challenge but that the GP’s would not have signed up to this agreement if they did not feel that the protections etc were not in place. It was also noted that people could choose to opt of the new system in the first instance and nobody would be able to share their confidential records. In addition, as mentioned earlier, the clinician would be required to ask the patient for permission to access their records each time. There were therefore a number of checks in place to guard confidentiality issues but no system was 100% foolproof.

Dr Pelendrides responded that in terms of continuity of care, her perception was that younger people and those who worked full time or worked unsociable hours would prefer additional flexibility to speak to or see a clinician when they wanted. However people with complicated conditions would be far more inclined to utilise the same services and the information sharing process should help reduce patients needing to explain the details of their case to numerous health care workers.   Dr Pelendrides also added that there were no proposals to prevent people seeing the same GP if that was their wish. The example of the over 75’s project was noted and the use of care coordinators to supervise the care of the top 2% most vulnerable patients.

The Director of Public Health – Dr Jeanelle de Gruchy asked for further clarification on the model of primary care development and integration with secondary care that Haringey was exploring. Dr Jeanelle de Gruchy also asked for more detail on plans to improve the physical infrastructure, developing new premises, built to a high standard. Ms Williams responded that in terms of primary and secondary care specific details of the Haringey model were to be developed.

Ms Price noted that NHS England were going to begin work on the range of models acceptable for integration. The challenge for the CCG is to be ambitious and to be ready to act when integration options were released. 

Ms Price also noted that in the Claire Gerrarda work that was undertaken, the conclusions were that it would be very difficult to bring the standard of primary care up to the level of acute care as the cost of investing in facilities would be prohibitive. Money (c. £1billion) was made available by the Government in the Autumn Statement for improving the standards of facilities. NHS England would be communicating with GPs on how to potentially access some of these additional funds.

The Interim Director of Children’s Services – Mr Abbey noted that the rationale and link to Early Help was really reassuring. Despite concerns around confidentiality, information sharing protocols did already exist with child protection agencies etc.  In addition, the flexibility of offering a universal standard whilst also being able to tailor access to services to suit different needs would be a real positive. 

Ms Grant noted that in terms of confidentiality, what people would be concerned about was how much their personal details would be accessed by Local Authority services and this would require a significant programme of communications and one that might raise a number of questions.

The Chair then summarised and it was:

RESOLVED:

That the information outlined in the presentation relating to the future of primary care be noted.