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.