Report of the Clinical Commissioning Group
Minutes:
The Director of Primary Care and Medicines Optimisation provided a detailed report and presentation relating to improving general practice access and the GP action plan, she also gave an update on expansion of the booster vaccination programme announced on 12 December 2021 and what that meant for general practice over the coming weeks.
Committee noted the main messages as follows:
· The activity in general practice over the last 4-5 months was compared data to 2019 levels, there had been a significant spike for demand on general practice.
· Staffordshire and Stoke on Trent area had demonstrated the most improved access to GP practices, 62% of appointments were face to face and work to improve access was having an impact.
· The majority of appointments were with GPs however practice nurses, advanced nurse practitioners and clinical pharmacists also had roles in practices.
· 180 staff had been appointed to new roles in the primary care workforce to increase the range of service and support new ways of working in practices, such as social prescribers, first contact physio’s and clinical pharmacists.
· Winter plans were robust, there were 4 programmes of work: (1) 3 respiratory hubs for paediatrics;(2) Additional capacity in primary care potentially creating up to 4000 additional appts per week; (3) Selfcare support – e.g., providing BP monitors for patients to use at home (4)111 been commissioned to provide additional support to free up general practice capacity.
· Levels of abuse, verbal and physical aggression against staff was having an impact and causing some to leave. The Together Against Abuse Campaign had been launched and could be accessed through the ‘Together We Are Better’ website. It aimed to inform public and staff to be patient and to have zero tolerance against abuse at work. There would be continued offer of support and training for staff.
· 359,000 booster vaccines to be delivered by 31 December, the majority of vaccines were provided in primary care. CCG had stepped down a number of enhanced services to make capacity to deliver this, including the Quality and Outcomes Framework (QOF) and the improvement programme for PCNs. The vaccinations programme and emergency care were priorities which meant delays to other services including routine operations until after Christmas.
· Communications were in place and additional help from Councillors was welcomed to get the message out to communities relating to the need to deliver the vaccinations, the pressure of the booster programme and need to have patience with GPs.
There followed a period of questioning. In response to Members questions and comments the following was noted:
Quality and Performance
· A member had concerns that the Quality and Outcomes Framework (QOF) guidelines were suspended and asked whether safeguards were in place and of the longer term position from January onwards. CCG advised that Government had stepped down QOF until the end of March but that it had not been completely paused, monitoring of the most vulnerable patients and those at risk would be maintained. Further guidance from Government was awaited. It was explained that a bigger issue related to long term condition reviews, a full data review was being undertaken to ascertain impact on QOF outcomes over the pandemic. CCG gave assurance that mitigation was in place and that the review should be complete by April 2022.
· Variation in GP performance – All but 2 general practices in Staffordshire were rated as good or outstanding. A 360-degree review would be carried out for every practice in 2022 and quality reporting for every practice would commence after Christmas to ensure practices including community pharmacies were maximising the whole of the primary care workforce.
Vaccinations
· The number of vaccinations walk in centres had been increased to take the stress off general practices and a vaccination plan was in place. A list of locations would be circulated. SCC had provided additional support to vaccination sites and there were a range of stakeholders involved to provide different levels of access to maximise capacity. GPs were on board to deliver the booster jabs by 31 December.
· Vaccine supply was not a problem, however availability of work force to deliver the jabs was of concern, everyone was committed to deliver them to prevent a Covid peak after Christmas.
· 6 million people were not immunised in the UK, there was an absolute understanding of numbers that need to be vaccinated in Staffordshire, 359,000 plus a number of people who need first or second jab. The numbers would be shared and passed on with Local Outbreak Control (LOC).
Access to GP Surgeries.
· The strategy for the model of care would contain detail about the way people access services moving forward.
· Currently 400,000 primary care appointments per month, the increased demand had led to additional surgeries per week to provide more access. There was the same level of capacity in practices but rising demand due to people catching up on prescriptions, meds reviews and matters delayed during lockdown. The data highlighted that the increase in demand started in April 2021, peaked in June, and had started to come down in October.
· To respond to 100,000 additional phone calls per a week CCG had deployed additional solutions. There were reports that people were waiting a long time on the phones and frustrations had been taken out on staff, verbally and physically, as a result some reception staff had left. The abuse was widespread across all practices and a plan was in place to address violence or aggression from public, including additional security, CCTV security alarms and panic buttons. There was a zero-tolerance policy in place and the Committee was very clear that it did not condone any violence or abuse against staff.
· CCG meet with all 146 practices annually and were working with the lower percentile 2%. Some practices were resistant to change. Practice contracts had been removed in the past working closely with CQC, but there must be specific reasons on quality and safety grounds - poor access was not a reason to remove a contract.
The Committee considered the 7 action areas in the Primary Care Action Plan in further detail and the following responses to questions were noted:
Communications
· Digital working and telephony improvements were being addressed and supported. It was suggested that online information should include how best to access the variety of services, the link into the NHS app and appointment booking and links to the most appropriate person to help them.
· A blend of remote and face to face access must be available. Each practice had a different operating model and software being used, there was a need to standardise and link them up. The majority of practices used EMIS, patient information was recorded on an integrated care record, joining up the NHS system. A system called accuBook was also used and could enable sharing when patient information was clinically required.
· There was concern that some patients have difficulty with digital. The access plan included tailoring contact with the individual with a range of access mechanisms and part of the training for receptionists was to recognise patient needs. Practices that were not performing were being supported.
· The standard offer - The Primary Care Strategy aims to develop universality and a consistent offer for patients and work to engage on the strategy which starts in the new year. The universal offer would be 15 service lines offered consistency across practices in Staffordshire.
· Members highlighted Patient Participation Groups PPG as a good way to communicate with patients about issues. CCG advised most practices have one, but it is not a requirement under their contract.
· It was clarified that there were 20 Physician Associate positions out of 600 GPs in Staffordshire. Numbers and location of other professional roles would be provided for information and confirmation was given that primary care level appointments were shared roles across practices.
Access improvement programme.
· Targets and objectives gave focus and direction to make the improvements, CCG had learned lessons from the use of data in vaccine programme to drive improvement and would use data to drive improvement in the programme for GP practices.
· CCG advised that a data validation process was underway to ensure data was consistent, open, and transparent and shared between practices and the public. Members highlighted the need for GP practices to recognise the need to share information to improve services. CCG confirmed there was a team of data quality assessors who have permission from GPs to work across all 146 practices to look at QOF indicators and other data.
· CCG were working closely with practices with greatest access challenges. Practices were also sharing and adopting best practice with each other and tailoring it to their practice.
· The whole of NHS was facing workforce shortages and a challenge was to make sure staff were not moved around too much, this was also the case for community pharmacists and mental health MPFT practitioners. The ICS would be commissioning community pharmacists to deal with specific conditions from April 2022, this was currently commissioned by NHS England.
· Concern was raised that only 14 practices were engaged in the access improvement programme. CCG advised that when the ‘Time for Care’ programme commenced in September 2021 practices reacted well, but the unprecedented level of demand, pressures and additional workload had caused it to pause; practices would pick it up when there was capacity.
· A member questioned how unmet demand or unmet need would be identified, particularly from those most vulnerable and those who have difficulty accessing the system. CCG advised that this would be attained from the data, each practice had a register and should through mapping data be able to identify where there were usually high level of deprivation or hotspots, to ascertain where lower than expected levels of demand were.
Digital
· Committee welcomed digital access to appointments and the range of services, some of which had already been discussed under communications action. The concern was that some patients could not access or use digital services and wanted to see a GP because they did not know the alternatives. CCG acknowledged that when services changed to the new model, more could have been done to introduce the new practice team and how they could help people but that that this was being addressed and videos were now on social media, youtube and facebook to give advice on the range of alternatives.
· It was recognised that many people had phones and were able to use them, for those that did not, there were leaflets and communications could be tailored to meet individual need.
· It was confirmed that most practices had a facebook page and could share information and videos, but it was acknowledged that there was still more to do on communications.
Quality variation and resilience
· CCG was monitoring indicators closely and recognised that access was a sign of quality.
· It was not possible to identify and deal with all issues impacting on quality in the same way because each practice had different issues affecting it. The approach was to consider individual practice by practice issues and to use the data effectively to prioritise those of most importance.
· A member requested that members be advised of feedback from the health inequalities survey and an update considered at a future meeting.
· CCG advised that the review of the consultation dashboard had taken place and the national plan around winter access had taken findings into account. Members were advised that 61 indicators were monitored on a practice by practice basis, these were not in the public domain, however GPs did share between themselves and challenge their peers practice level data.
Training and development of staff
· The 2016 Government announcement of 5000 more trained and recruited GPs by 2021 had not been realised and there were now 1300 less than in 2016. In Staffordshire there were 100 fewer GPs than in 2016. The primary care strategy to address the shortage of GPs had been to optimise the practice footprint. 172 practices had been reduced to 146 with an increased patient base. Practices were getting bigger and moving away from single handed practices to ensure they were resilient.
· Concern was raised about population growth in some areas and the planning policy not to contact CCG unless more than 500 houses were being built. CCG advised that planning officers had recently been appointed to take a helicopter view of the area and to work with developers to consider health sites. It was confirmed that there was no demand for new health buildings but that it would be important to work with the planning system to optimise the practice footprint, for the practice to be more resilient and to manage a multi-disciplinary team amongst the practices on one site.
· It was confirmed that all 175 spaces on the first staff training course relating to conflict and de-escalation for practice staff had been taken and additional courses were planned for the new year. There was a positive response about the training from all GP practices.
· A member questioned how we would know if patients were being offered the most appropriate appointment for them. There was no formal mechanism for monitoring appropriateness of the appointment but there was a range of data to work through, such as the patient survey, satisfaction rates at the surgery and soft intelligence. CCG welcomed the question and agreed to take it into consideration. It was also thought to be a useful indicator for the practice 360-degree review work.
The Chairman thanked presenters for a clear presentation and welcomed the data and detail in the report. He summarised that the Committee supported zero tolerance of abuse on staff, appreciated the work being done to progress the action plan and the approach to let data drive and focus on the actions. He welcomed that the future plan and work on performance indicators was progressing and indicated that that the committee would continue to monitor progress. Also, that the Committee had highlighted a need to consider whether the estate was fit for purpose and had asked for the vaccine plan and Primary Care Strategy to be shared when ready. The Chairman thanked partners for all the work they were doing.
Resolved:
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