Primary Care in East Sussex – update report
Context
This report provides members of the Committee with an update on further work being done to improve access to general practice in East Sussex, including further support being provided this winter. It also provides an overview of NHS Sussex’s new commissioning responsibilities in relation to pharmacy, optometry, and dental services, with a specific focus on dentistry.
· General practice update – page 1 to 6
· New commissioning responsibilities and an overview of dental services – page 7 to 15.
General Practice
Introduction
As of 1 October 2022, there are 52 GP Practices and one Primary Care hub across East Sussex covering the 567,500 population.
Currently the smallest list size for a GP practice in East Sussex is Sedlescombe House in Hastings with 2,918 patients and the largest is Victoria Medical Centre in Eastbourne with a registered list of 28,585 patients. The general medical services (GMS) contract funds practices on a weighted capitation basis. Practices therefore organise their operations according to this.
In terms of patient care, GP practices are required to provide essential medical services to people registered with them between 8:00am and 6:30pm Monday to Friday.
In addition, a Nurse led Primary Care Hub in Hastings has recently been reprocured and from 2023 this service will offer a mix of booked and walk in appointments. This service is open from 8am to 6.30pm Monday to Friday and 8am to 8pm on Saturday and Sunday.
Appointments in General Practice
Since lockdown ceased, 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.
Table 1 highlights the increased number of appointments available during 2022-23 compared to 2021 and shows that the level of appointments available in 2022-23 is comparable to pre-pandemic levels.
Table 1: Number of GP appointments offered in East Sussex April 2019 to September 2022
Table 2 indicates that the number of appointments per 1000 list size offered in East Sussex during the first six months of 2022-23 are above the average for Sussex, South East and England.
Table 2: Appointments per 1000 list size
These figures demonstrate that notable progress has been made in increasing availability of appointments, however work continues to drive improvement as detailed below.
Enhanced Access
From 1 October 2022, Primary Care Networks (PCNs) are required to provide Enhanced Access between the hours of 6.30pm and 8pm Monday to Friday and between 9am and 5pm on Saturday. This is known as Network Standard Hours under the PCN Directed Enhanced Service specification.
PCNs are groups of general practices working together with a range of local providers, including primary care, community services, social care and the voluntary sector, to offer more personalised, coordinated health and social care to their local populations. There are 12 PCNs in East Sussex. Each PCN provides additional appointments via enhanced access across their group of GP practices in the evening and at weekends. This is either provided by offering appointments at one or more surgeries within the PCN, sub-contracted to another provider or a hybrid model.
The Enhanced Access service is still in its infancy; however, we have observed a steady improvement over the weeks since the services commenced. Guidance and advice is offered to PCNs who are finding delivering this a challenge given digital interoperability issues, workforce gaps, coding issues and lack of space. We aim to address these by working closely with the relevant local and national teams, recognising that at times, there are national constraints. The NHS Sussex Primary Care team continue to monitor the situation closely and ensure that patient choice, safety and quality of service are at the heart of these new services.
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. Across Sussex, and indeed nationally, the increase in appointments highlighted above has not been matched by an increase in the whole time equivalent (WTE) GP workforce which has declined by 1.3% year-on-year but has increased by 6.6% since March 2019. The decline in GP Full Time Equivalent numbers has been mitigated to some extent by an increase in the number of other roles which are operating in general practice. Other direct patient care roles employed in practices are up by 8.3% year on year. There has also been a significant increase in clinical roles recruited by PCNs under the Additional Roles Reimbursement Scheme (ARRS) which is funded nationally by the NHS. These 14 new roles work across a group of practices in PCNs and include pharmacists, physiotherapists, paramedics, care coordinators, and nursing associates.
Across Sussex, over the last year, these ARRS roles have increased by 44.3% to a total of 516.3 WTE staff. During the period from April 2020 to September 2022 East Sussex PCNs have employed 142.4 WTE ARRS roles.
Further support for General Practice
NHS Sussex continues to invest in General Practice to support with creating better resilience in these services, to respond to Care Quality Committee findings and in some cases to respond directly to concerns raised by patients.
During 2021, additional winter funding was made available for practices and PCNs. Practices could apply for funding to support schemes to improve resilience, access, and patient experience. A second fund was made available to facilitate essential upgrades to practice security measures.
This winter, NHS Sussex has followed a similar approach and made available £3.3milion to support practices, PCNs and their GP Federations. Of the £3.3 million, £830,500 is available for East Sussex practices to bid against. GP Practices and PCNs were notified about this process on 10 November 2022, inviting them to submit bids for various winter projects and initiatives. Some examples of suitable bids we expect to receive are listed below:
· Additional clinical cover – Locum or additional staff working extra sessions
· Support with workflow, either short term 3rd party provision or support to develop the existing practice staff
· Additional administrative support to bolster patient response times or to review existing DNA policies and procedures
· Care Navigation/ Signposting training to better manage patient demand
· Equipment to aid access or to meet core DES requirements, for example vital signs Kiosks, provided they can be in place in time for winter.
· PCN led initiatives that focus on high-risk cohort patients seeking to keep patients out of hospital who have had two or more hospital admissions or attendances in the last 12 months.
Alongside this, we are also progressing several key areas to optimise capacity in practices. These are described in further detail in the paragraphs below.
GP Practice websites redevelopment
GP practice websites are critical sources of information for patients; they can offer advice online to encourage self-care, information to direct patients to appropriate services, and support patients to contact and use practices in the most appropriate way.
An idealised “gold standard” modular specification for GP websites across Sussex has been developed as stage one of the project. GP practices have been provided with a matrix and support to help score potential website suppliers against their ability to meet this specification. There is an opportunity for GP Websites across Sussex to present a more consistent NHS appearance and functionality (“Brand Identity”), additionally within individual PCNs.
Stage two will investigate NHS Sussex using a Content Management System (CMS) to further increase the quality and consistency of the patient experience across Sussex whilst also improving awareness and integration of Primary Care Networks (PCNs).
Across East Sussex, 24 practices have submitted an Expression of Interest to take part in this programme.
Cloud Telephony
Moving to a cloud-based system allows practices to respond to the increase in telephone calls with advanced functionality to improve practice staff and patient experience. This provides better resilience and flexibility to the practices and the opportunity to work at scale to support PCN collaborative working.
The Digital First Programme aims is to have 95% of Sussex practices using Advanced Telephony by 31 January 2023. Currently 73% of East Sussex practices are on a cloud telephony system. Most other practices are either in the process of changing to a new system or in discussion with the Digital First team. The remaining two practices are having difficulty upgrading due to high exit costs however the Digital First team is working with them to consider options.
E-hubs
E-Hubs are seen as being a key digital enabler to support the transformation of Primary Care and the development of a single point of access. The purpose of an e-Hub is to assist with demand and capacity issues experienced by practices within a PCN/locality by building a shared physical or virtual hub. The e-Hub will use digital tools to provide additional administrative or clinical capacity for those practices within an e-Hub in managing their online consultations or administrative functions, rather than separately in each practice.
Six e-Hubs are currently mobilising covering 32 East Sussex practices. These e-Hubs are now operational but not all practices are currently included. As each e-Hub develops over the next few months, other practices will come online. E-Hubs are currently operating as part of a 12-month pilot scheme across Sussex and run for a year from their start date (the last one went live in Oct 22 so will run until Oct 23). These will be evaluated and considered to ensure alignment with the longer-term strategic direction for Primary Care. The e-Hub operational model may develop as part of this, as a key area of learning.
Digital Ambassador Project
From November, the Digital Ambassador (DA) role is being piloted for six months (started in November 2022) in four PCNs across East Sussex – Eastbourne East, Foundry, Seaford and Victoria. The role will support local people on the registered list with training to improve the awareness and take-up of digital healthcare tools and services. This will be evaluated at end of March 2023 to assess the impact of the pilot and support further roll-out if successful.
GP - Community Pharmacist Consultation Service (CPCS)
NHS Sussex is encouraging practices to participate in the GP Community Pharmacist Consultation Service (GP CPCS). GP CPCS is a pathway that GP practices can use to refer patients with a minor illness for a same day consultation with a community pharmacist. A patient with minor illness symptoms contacts the practice requesting an appointment. Following a series of questions, they are referred for a consultation with a community pharmacist and with their consent, an electronic referral message is sent to the patient’s chosen pharmacy. The pharmacist sends back the patients GP a summary of the patient’s consultation by secure digital message. Currently, across East Sussex, 30 practices are using this service.
Future developments and estate
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.
NHS Sussex recognises the estates pressures across the primary care footprint in East Sussex and is continuing to work with practices to address these issues.
NHS Sussex is in the process of rolling out a programme to support PCNs to develop a clinical and estates strategy. Colleagues from the National Association of Primary Care (NAPC) are running clinical workshops with groups of PCNs across Sussex. These workshops are designed to help PCNs establish and pull together the information required to write up their clinical strategy.
An overview of dental commissioning in Sussex
Introduction
On 1 July 2022, the delegated commissioning responsibility for Pharmacy, Optometry and Dentistry transferred from NHS England to all Integrated Care Boards (ICBs) in the South East region. NHS Sussex along with the five other ICBs across the South-East region were identified to be part of the first tranche of systems to co-design and develop the delegation framework and approach for each of these three services.
ICBs have received the financial allocations for Dentistry and are responsible for provision of local dental services across the ICB geography however as part of the delegation agreement, NHS England has retained some of its functions in an agreed governance framework. The NHS England Dentistry team continues to be responsible for managing local dental contracting and the performance management of dental contracts on behalf of ICBs.
As delegated responsibility for Dentistry fully transitions to ICBs, they will be expected to develop and deliver a strategy and local commissioning priorities which will develop dental services in line with local population needs and demand, prioritising reduction of inequalities in dental access and outcomes.
This information presented in this report includes information provided by the NHS England South East regional dental commissioning and Dental Public Health consultants.
There are several partners across the NHS and Local Government and the Community and Voluntary sector who are involved in collating and providing information on dentistry (refer to annex A).
Dentistry – the national context
The National Health Service provides any clinically necessary treatment needed to keep an individual’s mouth, teeth and gums healthy and free of pain.[1] Decisions about which treatment is appropriate is based on a clinical assessment and clinical judgement. A dentist must make clear which treatments can be provided on the NHS and which can only be provided on a private basis, and the costs associated for each.
Individuals who are entitled to free NHS dental treatment in England include people who are:
· under 18, or under 19 and in full-time education
· pregnant or have had a baby in the last 12 months
· being treated in an NHS hospital and whose treatment is carried out by the hospital dentist (they may have to pay for any dentures or bridges)
· receiving low income benefits, or if they are under 20 and a dependent of someone receiving low income benefits
Most dentistry is provided by independent practitioners, some of whom also provide, on a commercial basis, services which the NHS does not provide (i.e. for cosmetic purposes).
All dental services are open to anyone from any area and people can receive care in any practice willing to offer them an appointment.
Dental surgeries will not always have the capacity to take on new NHS patients. People may have to join a waiting list, look for a different dentist who is taking on new NHS patients, or be seen privately.[2]
A practice is only responsible for a patient’s care while in treatment, but many will maintain a list of regular patients and will only take on new patients where they have capacity to do so, such as when patients do not return for scheduled check-ups or advise they are moving from the area.
Dental checks and recommended intervals between oral health reviews
Although many patients have historically had a dental check-up on a 6 monthly basis, the National Institute for Health and Care Excellence (NICE) evidence-based guidance on Dental checks: intervals between oral health reviews[3] recommends the interval between oral health reviews should be determined specifically for each patient and tailored to meet his or her needs, on the basis of an assessment of disease levels and risk of or from dental disease.
The recommended shortest and longest intervals between oral health reviews are as follows:
- The shortest interval between oral health reviews for all patients should be 3 months. A recall interval of less than 3 months is not normally needed for routine dental recall. A patient may need to be seen more frequently for specific reasons such as disease management, ongoing courses or treatment or emergency dental interventions
- The longest interval between oral health reviews for patients younger than 18 years should be 12 months
- The longest interval between oral health reviews for patients 18 years and older should be 24 months
Dental services – the delivery model
Dental services are delivered through:
· General dental practices (high-street practices) for most of the population
· Specialist dental services (may be delivered as part of GDP practices or standalone) for more advanced care such as oral surgery and complex restorative treatment
· Community dental services which deliver dental care for children and adults who have additional needs which means they need special skills and facilities to be treated safely
· Hospital dental services which act as referral centres for those patients who require access to secondary care skills and facilities, including for procedures which need to be carried out in an operating theatre.
NHS dental practices are paid and contracted to deliver an agreed number of Units of Dental Activity (UDAs). The various treatments patients receive from dentists attract different charges based on bands and are also assessed as representing different numbers of UDAs. There are four bands of charges for all NHS dental treatment. Each band of NHS dental treatment (Band 1, Band 2, Band 3, Urgent band) equates to a certain number of UDAs, which are based on the complexity of treatment.[4] Practices are commissioned to deliver a set number of UDAs, as a rough guide - 7,000 UDAs equate to 1 full time dentist.
Dental system reform
The Government are seeking to deliver better outcomes for patients and better support for dentists in a number of new dental system reforms announced on the 19 July 2022.[5] The first phase of dental system reform will:
- Introduce enhanced UDAs to support higher needs patients, recognising the range of different treatment options currently remunerated under Band 2
- Improve monitoring of and adherence to personalised recall intervals
- Establish a new minimum indicative UDA value
- Address misunderstandings around use of skill mix in NHS dental care, whilst removing some of the administrative barriers preventing dental care professionals from operating within their full scope of practice
- Take steps to maximise access from existing NHS resources, including through funding practices to deliver up to 10% more activity in year, where affordable and,
· Improve information for patients by requiring more regular updating of practice information through their nhs.uk profile and the 111 Directory of Services
Current position of dental access
Assessing what dental services to commission is a complex process and is dependent upon service availability, accessibility, the needs of the local population and the types of dental service required.
Many Sussex residents enjoy excellent oral health and access their first choice of NHS dentistry. The overall attendance figure for the percentage of the Sussex population accessing dental services is 41.4% compared with a South East average of 39.7% (October 2022). The number of unique dental patients seen in Sussex over the last 12 months is currently around 79% of pre-pandemic levels, which matches the SE average[6]. The data trend is increasing with 73,231 (11.5%) Sussex patients attending in October 2022 compared to February 2022. Like the rest of England, the picture is not perfect and there are inequalities in access to urgent, routine and specialist dental care.
During the pandemic all dental practices were required to close for face to face care on 25 March 2020 at the beginning of the first national lockdown. Dental practices continued to provide telephone advice to patients with an urgent need, including advice on pain relief and prescribing antibiotics where clinically appropriate. This resulted in significant backlogs in respect of routine dental treatment. After the requirement to close ended, NHS dental providers reopened but were required to operate in a Covid secure manner, with additional safety protocols. This reduced the appointment capacity dental providers have been able to offer, and whilst it is increasing residents are still reporting they are unable to be seen by an NHS dentist.
Dentistry in East Sussex
East Sussex has a varying degree of deprivation across the five lower tier local authorities (LTLAs) of Hastings, Eastbourne, Rother, Lewes and Wealden. There are 329 lower layer super output areas (LSOAs) in East Sussex of which 47 LSOAs are in the most deprived national quintile, with 61 LSOAs in the second. The map of deprivation below helps to visualise this, where the deeper purple colours indicate more deprived areas.
Table 1 indicates dental access in Sussex between July to December 2021 by the South East average, Sussex value and Lower Tier Local Authorities (LTLA) in East Sussex.
|
Access in total population (%) |
Access in 0-17 population (%) |
|
|
South East average |
31.6 |
|
|
Sussex value |
20.2 |
33.0 |
|
Hastings |
23.6 |
31.8 |
|
Eastbourne |
19.1 |
29.7 |
|
Rother |
20.9 |
28.7 |
|
Lewes |
19.5 |
30.9 |
|
Wealden |
20.9 |
31.7 |
Data source: NHS Business Service Authority
Current commissioned dental activity
The data in table 2 shows the contracted level of commissioned dental activity and the number of practices in each LTLA in East Sussex. LTLAs have been ordered by the most deprived LTLA to the least deprived LTLA. The figures are based on contracted UDAs earlier this year when we started the work on the commissioning intentions for Sussex. There is likely to be small recurrent reductions in contracted activity for practices which regularly underperform against the number of UDAs they are contracted to provide.
There are 73 dental practices in East Surrey contracted to provide 914,817 UDAs. This equates to approximately 131 whole time equivalent dentists. Since April 2020, there have been 3,487 UDAs from contracts handed back by dental practices.
Table 2: Contracted level of commissioned dental activity and the number of practices in each Local Tier Local Authorities in East Sussex
|
Number of dental practices |
Total UDAs commissioned |
UDAs per head of population |
|
|
Hastings |
13 |
205,941 |
2.22 |
|
Eastbourne |
13 |
162,213 |
1.56 |
|
Rother |
14 |
149,021 |
1.55 |
|
Lewes |
14 |
167,629 |
1.62 |
|
Wealden |
19 |
230,013 |
1.42 |
Data source: NHS Business Service Authority
In addition to the contracted dental activity, the ICB is also aware of an East Sussex County Council initiative to develop dental services for homeless residents. This has been commissioned from the charity DentAid who deliver dental care using a mobile service staffed with volunteer dental staff. Information is being collected which will be helpful in informing a more permanent solution for these vulnerable groups.
Improving access
Funding has been offered to all dental practices across the South East region to increase access by providing additional sessions outside of their normal contracted hours, for example in the evening or at weekends. These sessions are for: patients who do not have a regular dentist and have an urgent need but have experienced difficulty accessing this; have only been able to receive temporary care (such as a temporary filling or first stage root treatment) and require further treatment; Looked After Children; and patients with an urgent clinical need such as those that need to be dentally fit prior to undergoing cancer treatment or cardiac surgery.
There are two practices in East Sussex, one in Hastings and one in St. Leonards-on-Sea that currently have the staffing levels to safely undertake additional sessions. The offer of funding remains open so that should other practices subsequently determine they have the staffing levels to safely deliver additional NHS sessions, these will be established.
NHS England is currently undertaking a procurement exercise to increase the level of permanently contracted activity which will enable many more patients to access care. At the current time this is limited to West Sussex due to the large number of contracts that have been handed back in the county over recent years, however this will have a knock-on effect on residents of East Sussex due to the way patients move around to access care which will release capacity as patients choose to access care closer to home.
Conclusion
This report gives an overview of two key primary care medical services in East Sussex – general practice and dentistry.
NHS Sussex and NHSE are committed to ensuring that everyone across our communities have access to high quality health and care services when they need support. We recognise the importance of access to dental care and we are committed to working with NHSE and our Public Health leads to undertake further work to review all related dental performance data confirming a baseline position. It is only when all of the information combined that a ‘true picture’ of the service-need can be established to inform local commissioning. We are strengthening our collaboration with Kent, Surrey and Sussex Local Dental and Managed Clinical Networks, to identify local projects to address dental access and will continue to establish where further improvements can be made following the first phase of Dental System Reform.
Annex A:
NHS and Local Government and the Community and Voluntary sector partners involved in collating and providing information on dentistry
Kent, Surrey and Sussex Local Dental and Managed Clinical Networks
The Kent, Surrey and Sussex Local Dental Network is hosted and supported by NHS England South East. Clinical leadership for local commissioning is provided by the Local Dental Network and Managed Clinical Network. These networks include a range of local dental professionals working in primary, community and secondary care settings and understand the clinical needs of local patients.
Public Health
Responsibility for gathering information on the dental health needs of local populations and commissioning oral health promotion and oral health surveys was transferred to local authorities following the Health and Social Care Act 2012. Local authorities also have intelligence about their local populations which would be helpful in identifying local health needs, barriers and enabling factors for prioritisation of available resources. There are two dental public health consultants within NHSE SE Healthcare Public Health team working across the region to provide public health / dental public health support.
Health Education England
Health Education England (HEE) provides training and support to develop the dental workforce in local areas. HEE will be merging into NHS England in April 2023. Nationally, HEE is leading a programme, Dental Education Reform Programme (DERP), which aims to improve the skills of dental care professionals, (including dental nurses, therapists and hygienists) and provide non-traditional routes for dentists to develop. The DERP initiatives are aimed at improving recruitment and retention within the dental workforce to facilitate providing the best possible services for patients.
Healthwatch
As an independent and statutory body, Healthwatch have set out a position on NHS Dentistry and play an important role in their engagement with local communities on local issues offering insight to inform health and social care plans.[7]
Key relevant dental data sources
NHS England and Public Health data dental collection comprises the following datasets:
- National dental activity data on dental attendance and treatments delivered. This provides a snapshot of the services delivered locally. Generally, data is representative for patients residing in East Sussex or from outside who choose to attend dental practices in East Sussex. The data in table 1 of this report is bespoke data looking at access to dental services for residents who live in East Sussex.
- Deprivation indices. There is ample evidence that deprivation is linked to poorer health outcomes, including oral health outcomes. Data used in this paper includes deprivation data.
- Ethnicity data. There is evidence that residents from some ethnicities are less likely to attend for dental care and/ or experience poorer oral health outcomes. This may be a combination of barriers which affect their ability to live healthy lifestyles which promote health and oral health as well as the barriers they may experience in accessing care. Ethnicity data is captured on the FP17 forms submitted by dentists following completion of a course of treatment, however this data is often not sufficiently complete to provide reliable data. The 2021 Census data will be released soon, which will provide an understanding of ethnicity data by local level data which can be reviewed against other data such a deprivation.
- Other background factors: Some groups such as Looked-After-Children and migrant communities also experience poorer outcomes and face barriers in accessing dental care.
These datasets need to be supplemented with other local intelligence around local needs and demand, including from local authorities and patient groups. This includes the Health Watch East Sussex’ report on The Experiences of Dentistry in East Sussex since March 2020, reflecting the experiences of local people in terms of accessing dental services before and after the pandemic period based on the 296 survey responses.[8]