Agenda item

This paper provides an update on primary care in the North Central London area during the Covid-19 pandemic.

Will Huxter, Clinical Commissioning Group (CCG) Director of Strategy, introduced the item and explained that he had oversight of ongoing programmes. He noted that Dr Katie Coleman, Islington GP and North Central London (NCL) Clinical Lead for Primary Care Network Development, and Keziah Insaidoo, Health and Care Close to Home Programme Manager, would present the item and answer questions.

Dr Katie Coleman noted that primary care had worked extremely hard during the Covid-19 pandemic to meet the needs of the local population. It was explained that there were some challenges for staff and patients and that some significant changes had been required to ensure safety. It was noted that the detail was provided in the report but that a major concern had been access to healthcare during the pandemic. Dr Katie Coleman explained that, initially, GP surgeries were not open and people were unsure how to access their GPs. There was now a digital approach to gain access to GPs and it was acknowledged that the digital approach had caused some problems for a small but significant portion of the population. It was added that it had been challenging to return to a ‘business as usual’ position, particularly for those with Long Term Conditions (LTCs), child immunisations, and cancer identification. It was commented that the responses of primary care were listed in the report and included creating a dedicated service to support the needs of people with Covid-19 and post-Covid syndrome. It was added that things were developing quickly which involved ongoing learning and responses to challenges.

It was noted that the Committee had been interested in assessing how services had changed for patients and their pathways, particularly in the case of diabetes as there had been some concerns that residents had not been able to access blood tests. Dr Katie Coleman noted that, at the early stage of the Covid-19 pandemic, those with LTCs were not able to access GPs. It was explained that there had been a great deal of fear for patients and staff; however, this had improved as more was learnt about the virus and about how to protect staff and patients.

In relation to those with LTCs, GPs were able to search their patient lists and actively identify those whose conditions were most poorly controlled and who were at the greatest risk of complications; this enabled GPs to stratify their populations. Therefore, someone with diabetes would be identified by a GP and would be contacted over the phone for an assessment. It was noted that this could be undertaken by a Healthcare Assistant or Pharmacist and that training for virtual support had been provided to staff. It was highlighted that a number of diabetes cases involved behavioural and lifestyle considerations, such as diet and exercise, which could be addressed virtually. After this initial assessment and identification of care needs, a patient would be offered an appointment for their annual blood tests; the GP or Pharmacist would generate and send a pre-filled form to the Phlebotomist. Afterwards, the results would be sent to the GP practice and any follow up or adjustments to medication could be made. Dr Katie Coleman explained that putting these changes in place had taken some time but that service delivery was now back to pre-Covid levels. It was acknowledged that not everything could be provided virtually but that having this option increased direct patient care; it was noted that about 50% of appointments were undertaken virtually.

Cllr Clarke stated that primary care had done well to recover but enquired why the Royal Free had suspended reporting on treatment waiting times. Will Huxter explained that there were national arrangements for reporting and that, due to data problems, the Royal Free had been unable to meet the national reporting standards. In these circumstances, it was agreed that the Trust ceased national reporting, although there was still local monitoring and national reporting was anticipated to resume at the end of March 2021. Cllr Clarke also noted that there were reports of increased suicide attempts and asked whether this was an issue locally. Dr Katie Coleman noted that there had been an increase in mental health issues across all age groups. Work was underway with mental health teams to ensure that there was sufficient support and funding and pathways had been changed to respond to children in crisis. It was added that there were some promising transitions underway to embed mental health care in local communities and primary care networks.

Cllr Smith enquired how GPs identified people with LTCs and whether the Clinical Commissioning Group (CCG) was monitoring whether all people with LTCs had been contacted. Dr Katie Coleman explained that all people with LTCs had codes and GP practices could undertake searches based on these codes. This database of codes was accessible to all GP practices and other providers. It was possible to monitor how GPs were achieving in the outcomes for people with LTCs using the Quality and Outcomes Framework; this was monitored annually. Some areas were also looking at enhanced services around outcomes; although this was primarily in Camden at present, this might be rolled out across NCL. In addition, there was a population health management platform used across NCL, Healthy Intent, which allowed outcomes across GPs and all providers to be monitored.

It was enquired when GPs were visiting care homes and how this workload was shared. Dr Katie Coleman explained that, at the start of the pandemic, no medical professionals were going into care homes and there were virtual ward rounds and assessments. It was noted that there had been existing plans to introduce a programme called Enhanced Health in Care Homes and this was brought forward; this meant that every care home in NCL had a dedicated clinical lead in charge of ensuring patients with concerns were identified and supported. This programme was introduced in May and then enhanced in October. It was added that the model of care for care homes was more community based with a multi-disciplinary team working in a collaborative way and reporting issues to GPs where necessary.

Cllr Das Neves stated that the most vulnerable and disadvantaged would be struggling to engage digitally and possibly even by phone; she asked how this was being monitored, whether there were clear processes, and what was being done to improve digital inclusion. Dr Katie Coleman acknowledged that the change in approach had not happened perfectly and there was always more that could be done to improve. She explained that she had raised digital inclusion as a significant risk at the NCL Digital Board recently and had been assured that this would be addressed. It was noted that there was no monitoring but that this was a known issue which needed to be addressed. It was explained that there was a project with Healthwatch that had recently begun in Haringey which tried to procure digital hardware and provide training to improve digital inclusion. Will Huxter noted that there was a plan to undertake an Equality Impact Assessment on digital inclusion which would set out what was being measured and possible ways to mitigate issues. It was added that input from the Committee would be welcomed.

It was also noted that some residents had received varying instructions and it was enquired whether there was a clear process for the delivery of care. Dr Katie Coleman noted that each GP was an independent provider and would undertake care processes which suited them best and, as such, it was acknowledged that there would be some differences. However, the CCG endeavoured to provide GPs with recommendations about the delivery of care. For example, in terms of risk stratification, it was recommended that certain patients were contacted on a regular basis, such as those with dementia. In addition, all GPs were currently working in a more joined up way with community providers to support those at greatest risk. Dr Katie Coleman noted that GPs were also monitored at the end of each year based on their achievement against the Quality and Outcomes Framework; this meant that any issues could be examined and addressed. It was added that, if there were consistent issues, a GP would come to the attention of the regulator which would lead to additional measures and reviews.

Cllr Freedman enquired whether there was any data on the uptake of the flu vaccination. Dr Katie Coleman explained that NCL was currently on the trajectory to achieve the 75% target vaccination rate for over 65s, high risk 18-25s, and children. The Healthy Intent platform was being used to understand any areas of need and it was noted that certain parts of the community were taking up the vaccination less. It was explained that some targeted work was underway with the Voluntary and Community Sector (VCS) to raise awareness about the importance of the flu vaccine, the Covid vaccine, and the risk of contracting both diseases. It was noted that the government had procured larger numbers of flu vaccinations and there was a central supply. It was noted that not all GP practices could administer the flu vaccine but that there was more collaborative work and mutual aid which would be useful for the upcoming Covid vaccination campaign.

It was also noted that, in the report, only four of the five Healthwatch organisations had been mentioned; it was enquired why Barnet Healthwatch was not included. Dr Katie Coleman noted that all five NCL Healthwatch organisations were now working closely and one area often led on a project. It was noted that investigation could be undertaken to see why Barnet was not mentioned in this section of the report. Post-meeting note: Healthwatch Barnet confirmed that they were also invited to participate in the survey but were unable to do so at the time as they were going through a contract change. Healthwatch Barnet had not done specific work on this but, in general surveys, their findings replicated those from the other Healthwatch organisations, namely a mixed picture in relation to patient feedback on digital access to primary care.

Cllr Cornelius noted that some care homes struggled to obtain flu vaccinations for staff; she suggested that it would be more efficient for staff to receive vaccinations at work or for the vouchers to be sent directly to the care home. Dr Katie Coleman noted that there was a team supporting care homes to get flu vaccinations for care home residents and staff and she would have to look into this. Post-meeting note: Care staff did not require a voucher to get a vaccine and could obtain one from the pharmacy when they showed their care worker identification. The biggest challenge with care staff take up of the flu vaccine this winter had been around inconsistent supplies of vaccines. However, national stock issues had been resolved and community pharmacies now had further access to vaccine stock. A range of actions had been undertaken in NCL to promote take up now that there was a good supply, including webinars and mythbusting sessions, calls to providers from their borough leads, and pop up sessions at care settings.

Cllr Revah enquired what was in place to inform people who were housebound and people with disabilities about changes to GP services. Dr Katie Coleman noted that there was a strategy for people who were housebound and they should receive the same level of care. She acknowledged that, at the start of the pandemic, there had been a lot of fear about the risk of transmission and there had been fewer home visits. However, there had been a lot of training for staff and most GPs were now undertaking home visits with PPE and additional measures. It was added that there were Rapid Response Teams in NCL for anyone who was acutely unwell but did not require hospital treatment; these were multi-disciplinary teams who were overseen by GPs and increased local capacity to respond during the pandemic. In relation to people with disabilities, Dr Katie Coleman noted that there were concerns and extensive communications campaigns had been undertaken. GPs were also expected to undertake annual learning disability health checks; these were not yet at pre-pandemic level but work was underway to address the shortfall.

Cllr Freedman noted that virtual certifications of death could be assuming that Covid-19 was a cause of death and it was enquired whether there were any face to face certifications. Dr Katie Coleman commented that certifications were initially undertaken with PPE but that processes were being developed to support certifications in nursing homes. It was explained that nursing home nurses were being trained to undertake certification of death with doctor oversight.

The Chair noted that a question had been received from a resident; it was enquired what was being done to reduce the risk of Covid-19 transmission at GP surgeries and hospitals. Dr Katie Coleman explained that robust infection prevention control procedures had been introduced which significantly reduced risks. She noted that she was a GP and could not provide the best information about hospitals but she was aware that patients with and without Covid were separated and there was regular staff testing. In GP surgeries, it was explained that there were more spaced out appointment times, waiting areas were regularly cleaned, windows were opened to increase ventilation, and Personal Protective Equipment (PPE) was worn and regularly changed.

The Chair noted that there was a framework for people with LTCs in the report which implied that people with medium or low risks would not have access to GPs. Dr Katie Coleman explained that a number of staff were qualified to deal with LTCs and the framework meant to demonstrate that those with medium or low risks could be seen by other medical professionals, not only GPs. It was highlighted that this was not a reduction in service but aimed to increase resilience.

The Chair stated that the Committee should receive a report explaining the Healthy Intent initiative and a report on the NCL Digital Board work on digital inclusion, including the Equalities Impact Assessment. It was added that it would be useful for the Committee to receive some information on the digital inclusion pilot in Haringey, even if this related to some initial findings. The Committee could then decide whether a full report would be required.

RESOLVED

1.    To note the report.

2.    To receive a report explaining the Healthy Intent initiative.

3.    To receive a report on the North Central London (NCL) Digital Board work on digital inclusion, including the Equalities Impact Assessment.