Report: To provide an overview of the current access to GP appointments in East Sussex; the contractual mechanism by which these are delivered; and support for these services provided by East Sussex Clinical Commissioning Group[1]
To: East Sussex Health Overview and Scrutiny Committee
From: Amy Galea, Chief Primary Care Officer (designate) NHS Sussex (go live 1 July 2022); and Executive Director, Primary Care, NHS East Sussex CCG
Recommendations: The Committee is asked to note progress in restoring primary care medical services in East Sussex over the past months, particularly regarding access to appointments; and the current and planned support offered by East Sussex Clinical Commissioning Group (CCG) to further improve this.
Background
As of 1 April 2022, a total population in East Sussex of 567,500 people is served by 52 GP practices across our communities.
The number of practices has remained static over the past year, with only the closure of Eastbourne Station Health Centre.
The number of people in East Sussex is projected to grow by nearly 69,000 over the next 15 years, with an increase of 56,000 in the number of people aged 65+, compared with little change in younger age groups.
Currently the lowest patient list size for a GP practice in East Sussex is 2,991 and the highest is 28,227.
In terms of patient care, GPs are required to provide essential and urgent medical services to people registered with them between 8:00am and 6:30pm Monday to Friday.
Additional appointments outside these times are also offered under an “Improved Access” scheme that is currently commissioned by the CCG; and an “Extended Access” Directed Enhanced Service (DES) commissioned nationally by NHS England from Primary Care Networks (PCNs). PCNs are groups of general practices working together with a range of local providers, including across primary care, community services, social care and the voluntary sector, to offer more personalised, coordinated health and social care to their local populations. All practices are members of a PCN, of which there are 12 in East Sussex. Details of each PCN, and their member practices, are available on the CCG website. Each PCN then provides additional appointments across their group of GP practices in the evening and at weekends.
The Care Quality Commission (CQC) inspects and monitors GP practice services. Practices are given a rating for 5 domains (safe, effective, caring, responsive and well led) and an overall rating. Ratings range from outstanding to inadequate. Currently, over 94% of practices have a rating of ‘good’ or better and three practices require improvements.
Current position
Appointments offered
During the pandemic GPs changed their delivery model overnight to continue to offer care and support to people under lockdown and infection and prevention and control guidance. This was based on national guidance and temporary changes to the GP contract, that adopted a total triage model that managed patients care virtually wherever possible, whilst ensuring those patents who did need a face to face consultation received this with as little risk to their own safety and that of the practice staff. Since the lockdown measures ceased, there has been a noticeable rise in patient demand for general practice services. The number of appointments offered has increased to above pandemic levels in Sussex, i.e. 10,000 per day.
Table 1 shows the number of GP appointments offered in East Sussex from April 2019 to March 2022. It highlights an increased number of appointments available during 2021-22 compared to 2020-21 – an increase of 17.5% – and shows that the level of appointments available in 2021-22 is comparable to pre-pandemic levels.
Table 1: Number of GP appointments offered in East Sussex Apr 2019 to Mar 2022[2]
Table 2 indicates that the number of appointments, standardized for list size offered in East Sussex are above Sussex, Southeast, and national averages.
Table
2: appointments per 1000 list size[3]
These figures demonstrate that notable progress has been made in restoring services, but that is not to that there is equitable access across all GP practices for patients. All GP practices are reporting increasing demand, which is due to a range of factors, including a growing number of people with multi-morbidity; increasing complexity of physical and mental health needs; changing patient expectations; and workforce challenges.
Workforce profile
Workforce availability and increasing access are intrinsically linked. The committee will be aware of media campaigns in recent months relating to low GP – to – patient ratios reported across England. Some reports have specifically focussed on one practice in Hastings which featured due to erroneous data on the NHS digital website which has since been corrected. Nevertheless, across Sussex, and indeed nationally, the increase in appointments highlighted above has not been matched by a significant increase in the GP workforce which has grown by 0.79% over the past year. The slow growth in GP numbers has been mitigated to some extent by an increase in the number of other roles which are operating in general practice. Nurse numbers are up by 4.7% over the last year; and other roles employed in patient care are up by 35%. These roles include pharmacists, physiotherapists, paramedics and mental health practitioners, working across a group of practices in PCNs. These roles are funded nationally by the NHS under the Additional Roles Reimbursement Scheme (ARRS).
Across Sussex, over the last year, these ARRS roles have increased by 49.6% (to a total of 165 whole time equivalent staff (wte)); with most of the increases being in care co-ordinators, pharmacy technicians, paramedics and first contact physiotherapists. During the period April 2020 to April 2022 the increase in wte ARRS roles has increased in East Sussex by 1650% (from 9.54 wte to 165 wte).
This increase in staff inevitably requires, and indeed drives different ways of working to meet the needs of patients. The CCG is matching these enhanced numbers with an investment programme tailored to the needs of each area.
East Sussex CCG support for General Practice
The CCG continues to invest in General Practice to respond to create better resilience in these services, to respond to Care Quality Committee findings and in some cases to respond directly to concerns raised by patients. Over the past 12 months the East Sussex Primary Care Commissioning Committee approved an additional £604,264 to support practices in the county against the four key strategic aims:
· Access to primary care
· Increasing practice space
· Supporting primary care resilience
· Reducing health inequalities
· Supporting the vaccination programme
Examples of such investment have included additional locum staff and CCG wide improved access appointments to support practices during times of high pressure including the winter months and bank holidays; improvements to security and the overall practice environment; and the development of better signposting and patient information resources on practice websites.
A significant recent development is the implementation of eHubs. The CCG has commissioned shared hubs that use digital tools to support administrative and clinical working between practices. From 1 July 2022 there will be six eHubs will be operational in East Sussex covering 30 practices and 309,000 patients. The aim is to free up additional time by processing the online consultations in the hub rather than separately in each practice. This also offers benefits by ensuring the patient gets the most appropriate care for their needs and increases the availability online consultations through economies of scale.
We have an ongoing programme of work aimed at further improving access to primary care that includes:
· Improving communications – Co-designing materials with Healthwatch for practices to use on their websites and phone communication to help signpost people to the care they need
· Working with Health Education England to maintain a pipeline of future healthcare professionals in primary care with the promotion and expansion of training places in general practices across East Sussex
Future developments and estate
The Sussex Primary Care Estate strategy aligns to the national aim of developing a resilient estate. The fundamental principle is to protect a scarce resource (doctors and health staff) and facilitate a greater service provision at a site, so as to support population access and care.
Estates developments are discussed at the Strategic Property Asset Collaboration in East Sussex (SPACES). This is a partnership of a group of public bodies and third sector organisations, which was established in 2013. The work of the SPACES Programme is guided by a Board made up of representatives from each of the constituent organisations, with the Chair of the Board rotating each year between the partners.
The CCG recognises the estates pressures across the primary care footprint in East Sussex and is working to address these pressures with practices.
We have worked with a number of practices to develop new premises; St Leonards Medical Centre, Ice House, Warrior Square, Victoria Drive Medical Centre and the Beacon. A further 9 developments are currently underway.
Conclusion
This paper has described the current position about accessing GP appointments in East Sussex. Considerable progress has been made to restore service delivery to pre-pandemic levels, but further work is being done to continuously improve this. The CCG – and NHS Sussex from 1 July 2022 – is supporting practices to meet challenges they are facing and to continue to focus on delivering high quality care.