Agenda item

To receive an update on NCL Primary Care Services including on previous JHOSC recommendations.

Sarah McDonnell-Davies, Executive Director of Places at NCL ICB, introduced the report for this item noting that the major themes included contracts, access, support for and retention of the workforce, and the integration agenda.

She added that NCL was a high performing primary care system and that the amount of activity in primary care had recently continued to rise, including in GP practices, as well as expanded work with community pharmacies and work with the voluntary sector on social prescribing. Approximately 60% of appointments were now being conducted face-to-face and around 51% were on-the-day appointments. There was also a greater use of data by commissioners to understand quality and performance in primary care - the Primary Care Contracts Committee (PCCC) met regularly in public and published a quality and performance report. As set out in the agenda pack, there had been an increase in NCL staffing levels overall including nurses, while the number of GPs was broadly steady.

Sarah McDonnell-Davies then responded to questions from the Committee with input also provided from Dr Peter Christian, Clinical Lead for Haringey, and Paul Sinden, Managing Director of a local General Practice Provider Alliance:

• Asked for further details about the role of community pharmacies by Cllr Cohen, Sarah McDonnell-Davies explained that community pharmacies were nationally commissioned and that their joint working with GP practices had grown during the Covid-19 pandemic with the vaccination programme. The opportunities for further joint working were being supported locally, such as through the community pharmacy consultation scheme which was being locally funded, and there were regular discussions with the local pharmaceutical committee which represented providers in this area. There was also now an Integrated Medicines Committee as part of the ICB which included representation for community pharmacists. Dr Peter Christian added that there was untapped expertise in the community pharmacy sector which was only recently being utilised. He commented that GP practices should not be seen as the default service for everything because primary care involved a complex team of people and so signposting was increasingly important. The increased use of in-house pharmacists in GP practices was also a potential cause of workforce pressures on community pharmacists due to the finite number of qualified staff in the sector.
• Cllr Cohen commented about the pressures on the primary care system and a shortage of GP practice receptionists in some areas. Sarah McDonnell-Davies acknowledged that there were difficulties in recruitment and retention for GP practice receptionists and other administrative roles and that there was typically a high turnover. There was not the level of training and experience required when compared to a Practice Manager and so there was an ongoing conversation with the NCL Training Hub about upskilling and professional development for receptionists and administrative staff. This included issues such as handling challenging patient behaviour because of the high levels of abuse experienced by staff. Dr Peter Christian added that the position of GP practice receptionist was an important and complex role requiring good people handling skills and a detailed understanding of processes and procedures which was why training was particularly important.
• Cllr Connor asked how consultations with community pharmacists were linked to patient records. Dr Peter Christian responded that, while there may not be formal direct links, there was often a flow of information back to GP practices by phone or email from pharmacists. In addition, more patients had access to their medical records and so could show this to pharmacists via a smartphone. He noted that electronic medical records were becoming larger and risked becoming unmanageable and that this situation could be exacerbated should pharmacists be able to add further entries. Paul Sinden, Managing Director of the GP Providers Alliance, added that GP practices and pharmacists often liaised over prescriptions for minor illnesses and that there were records of these transactions.
• Cllr Connor expressed concerns that, according to page 54 of the agenda pack, the training provided was without paid release and that this would not be the case in other healthcare professions. Sarah McDonnell-Davies said that clinical staff were allocated professional development time but that for non-clinical staff this was at the discretion of the individual practice and acknowledged that more could be done to encourage practices to release staff for development.
• Asked by Cllr Atolagbe for further details about primary care quality and performance data, Sarah McDonnell-Davies said that detailed data for every GP practice in NCL was available online and that a link could be provided to the Committee. (ACTION) She added that, with patient satisfaction in general decline nationally, the patient survey results of 70% describing their experience as very/fairly good was positive.
• In response to concerns raised by Cllr Atolagbe about the difficulties experienced by residents in getting access to face-to-face GP appointments, Sarah McDonnell-Davies said that, although the NCL figures on face-to-face appointments was a couple of points below the national average, the figures on obtaining same day appointments were one of the highest nationally. She added that a key consideration was whether people who needed it most were getting access to face-to-face appointments and this highlighted the importance of the work on digital exclusion. Modernisation of telephone systems at practices was also needed to enable better queuing at busy times. Dr Peter Christian added that there was not necessarily a correct ratio of face-to-face appointments, as this depended on the demographics of a particular area, so variation between practices was necessary. For example, those in full-time employment during office hours often found telephone appointments to be more suitable. Asked by Cllr Milne if there was any data around diagnosis rates with telephone/online appointments, Dr Peter Christian said that, while there had been some understandable anxiety about this issue, he had not seen any audit work in this area. Sarah McDonnell-Davies added that face-to-face was often better for certain demographic groups and that GPs may ask a patient to come into see them if a telephone diagnosis proved to be difficult. She added that the ICB would soon be able to access data on local GP appointments which had not previously been available including waiting times and the mode of appointments. Cllr Connor requested that the JHOSC be updated about this new data when it became available (ACTION) and noted that a key concern of the Committee was that all patients who wanted face-to-face appointments were able to obtain one. 
• Cllr Chowdhury expressed further concerns about the difficulties in obtaining GP appointments and Cllr Connor asked why more wasn’t being done to make patients aware of the out-of-hours hubs that they may be able to access. Dr Peter Christian agreed that the early morning scramble for appointments could be difficult and noted that some GP surgeries had tried different approaches such as releasing appointment slots at different times of the day. Sarah McDonnell-Davies said that the extended access model was in the process of changing which did not help patient awareness. As the new system was rolled out there was communications work that could be done, including by providing some standardised information which could be provided on all local GP practice websites, as well as information for reception/admin staff, though the high turnover of staff did make this challenging. It would also be necessary to monitor the utilisation of the extended access services over time to ensure that this was at an appropriate level.
• Asked by Cllr Chowdhury about the GP associate roles and their ability to prescribe to patients, Dr Peter Christian commented that there were good examples in the NHS of staff being able to widen their remit safely and that, in primary care, this could help to free up the time of GPs to do what they were most needed for which was diagnosis.
• Cllr Bevan noted that, according to the report, local engagement was undertaken in the procuring of APMS contracts but said that he had never been consulted as a local Councillor. Sarah McDonnell-Davies explained that there were only a limited number of new APMS contracts procured and that the engagement would include the lead Member for Health and the relevant Ward Councillors. However, this engagement could be extended to included JHOSC Members in future if requested.
• Asked by Cllr Hutton about the links between multiple pharmacies and GP practices, Paul Sinden said that there were usually around three or four pharmacies in a practice area and Sarah McDonnell-Davies added that patient choice was the main driver of where patients obtained pharmacy services.

The Committee recommended that there should be a formal pathway for career progression for GP practice receptionist and administrative staff and, acknowledging that work was already underway in this area, requested that the Committee be updated about this further at a later date. The Committee recommended that this should include staff being released from regular duties to allow for the allocation of professional development time where required. (ACTION)

Rod Wells then submitted the following questions on behalf of Haringey Keep Our NHS Public (KONP) as noted under item 5 (Deputations) of the agenda:

“In the context of the Alternative Provider Medical Services (APMS) contracts awarded to Operose/Centene:

• What changes have and will be made to ensure NHS Standard General Medical Services (GMS) contracts are favoured over APMS ones?
• What has happened to the previous Operose contracts – when do they run out, have any been reversed since they were originally awarded and on what grounds?”

Haringey KONP also added that “APMS contract holders are paid 14% more per patient than GMS contract holders which is another reason for favouring GMS over APMS contracts”.

Sarah McDonnell-Davies responded that any new primary care contract tended to be offered under the APMS contract model but acknowledged that there was work to do to ensure greater parity between the two types of contract. In terms of the extra cost, there were additional elements to the contracts such as performance monitoring, screening and extended targets which had to be met for the money to be paid. This was being reviewed ahead of the next round of APMS contracts with considerations about achieving best social value and meeting the concerns of local residents.

Sarah McDonnell-Davies explained that two AT Medics contracts in Islington had recently gone through the Primary Care Contracts Committee. A decision had been taken to re-procure the contract for Hanley Primary Care Centre while the contract for Mitchison Road Surgery had been extended for only one year while performance was monitored. Cllr Clarke emphasised opposition to the handing over of primary care contracts to Operose/Centene. Sarah McDonnell-Davies said that the Committee must make decisions based on the evidence and within the bounds of the law and to be clear with providers about what they were expected to deliver and what mattered to patients. With regard to Mitchison Road, the Committee had found that the performance levels were better than at Hanley Primary Care Centre but there was not sufficient evidence either to renew for the full three years or to re-procure. The evidence was documented in the Committee’s papers and minutes.

Asked by Rod Wells about the St Ann’s contract in Haringey, Sarah McDonnell-Davies confirmed that this would be coming up for renewal and so there would be a performance review to help determine next steps.

Cllr Connor then asked for further details to be provided on collaboration between primary care teams and social care teams, including with social prescribing and community navigators. (ACTION)

Cllr Connor noted that the papers for the October 2022 meeting of the NCL ICB Primary Care Contracting Committee Meeting stated that:

“The NCL Delegated Commissioning budget is currently forecast to overspend by £4.4m against the 9 month allocation of £197m. However, £4.4m is included within the Non-Delegated Primary Care budget earmarked for enhanced access. This gives a neutral adjusted forecast position.”

Cllr Connor requested that details be provided on a) whether this position would be sustainable if similar overspends occurred in subsequent years, and b) what other funds were reduced in order to reach this neutral position. (ACTION)

Cllr Connor then summarised the requests for additional information and recommendations of the Committee as follows:

• The Committee recommended that there should be a formal pathway for career progression for GP Practice reception staff.
• It was agreed that a link was to be provided to a webpage that provided data on appointments for every GP Practice in the NCL area.
• The Committee requested that an update be provided on how Primary Care teams work with community navigators in local authorities (such as Connected Communities).
• With regards to the overspend on the NCL Delegated Commissioning budget, the Committee requested that details be provided on a) whether this position would be sustainable if similar overspends occurred in subsequent years, and b) what other funds were reduced in order to reach this neutral position.