Agenda item

1.1.        The Committee considered a report on the state of access to GP practices in East Sussex.

1.2.        Dr David Warden, Chair, Hastings and Rother Clinical Commissioning Group (HR CCG); Amanda Philpott, Chief Officer, Eastbourne, Hailsham and Seaford Clinical Commissioning Group (EHS CCG) and HR CCG; Jessica Britton, Chief Operating Officer, EHS CCG/HR CCG; Ashley Scarff, Director of Commissioning/Deputy Chief Officer, High Weald Lewes Havens Clinical Commissioning Group (HWLH CCG)  Dr Peter Birtles, HWLH CCG; and Sally Smith, Director of Primary Care and Integration, HWLH CCG responded to questions from HOSC.

Extent of GP vacancies

1.3.        Amanda Philpott explained that the greatest number and highest proportion of GP vacancies are in the HR CCG area, where there are currently 16 vacancies out of 97 GP positions. In the EHS CCG area the vacancy rate is 11 out of 120. Sally Smith said that the greatest number of vacancies in the HWLH CCG area are in Newhaven and Peacehaven, but recent vacancies have arisen in Rotherfield, Crowborough, and Wadhurst.

Work to support individual GPs

1.4.        Amanda Philpott explained that newly qualified GPs are increasingly looking for a ‘portfolio career’ where working as a GP forms part of a wider clinical role. To accommodate this new working practice and to tackle GP shortages CCGs in the East Sussex Better Together (ESBT) area have implemented the following initiatives:

·         A GP portfolio fellowship scheme that allows junior doctors to work in a GP practice for 2-3 days alongside working, for example, in an acute hospital or within mental health services. This improves the variety of a GP’s working week and improves the spread of knowledge between primary and secondary care.

·         The availability of a GP bursary scheme for new GPs;

·         The employment of physician associates to reduce the administrative burden on GPs; and

·         The option for part-time, flexible mentoring work for older GPs who are otherwise planning to retire.

Amanda Philpott confirmed that work to support GPs had all begun to be put into practice and was either in a pilot stage, or in the process of being rolled out across the ESBT area.

Work to support GP practices

1.5.        Amanda Philpott and Dr David Warden outlined some of the initiatives established by the ESBT CCGs to help GP practices, including:

·         supporting the GP Federation to run a GP locum bank that administers requests for locum GPs centrally that would otherwise be made by individual GPs.

·         Encouraging pharmacists in the ESBT area to work with networks of 3-4 GP practices, or be employed directly by a GP practice. Pharmacists perform medication reviews of patients in consultation with the GPs and perform care home visits. Most practices that have used pharmacists have achieved considerable savings in their prescribing budget.

1.6.        Sally Smith outlined the initiatives established by HWLH CCG to help GP practices, including:

·         The Enhanced Help in Care Homes team, which is a GP-led multi-disciplinary team (including a pharmacist) that supports patients in care homes and nursing homes. The team was established in November 2017 to cover five nursing homes and will cover all nursing homes in the High Weald Lewes Havens area by the end of March 2018.

·         The Integrated Pharmacy Teams that work across several GP practices to improve their standard of prescribing. These teams have been in operation for the last 2 years in the Havens area and were rolled out to the Lewes, Uckfield and Crowborough areas during the last six months.

·         A community-based Frailty Service comprising 1.5 FTE consultant geriatricians and frailty nurses. The initial service has been in place for two years but in the last year the capacity has been increased.

Workforce Plan

1.7.        Amanda Philpott acknowledged that staff applying for jobs within the local system that they find more attractive and the fact that there are more specialist consultant trainees than GP trainees entering the system are both workforce issues. Ms Philpott explained that ESBT organisations have produced a Workforce Plan to help co-ordinate and plan the best use of available nursing and clinical staff.

Clinical Governance in GP Practices for non-GP staff

1.8.        Dr David Warden explained that strong clinical governance for non-GP staff should be in place for each GP practice in the ESBT area. He said that advanced nurse practitioners and paramedic practitioners have professional indemnity insurance and will perform clinical work that is within their own skill level. Amanda Philpott added that each practice has had a Care Quality Commission (CQC) inspection, and the CCGs’ Chief Nurse, alongside other team members, performs ‘quality visits’ to support practices.

1.9.        Dr Warden clarified that whether clinical pharmacists can prescribe medicine to patients or not depends on their license, which is not issued by the CCGs.

New housing developments

1.10.      Amanda Philpott explained that housing developments include section 106 monies that the developer provides to improve local services. CCGs can make a bid for section 106 funding for additional GP practices, or GP capacity in existing practices, if they are made aware of proposed housing developments sufficiently in advance, and the housing development is of sufficient size that a new practice would be necessary to accommodate the additional residents. She said that for this reason the CCGs’ Capital and Estates Team works with planning authorities to ensure that they proactively inform the CCGs of any proposed developments. Ms. Philpott cautioned that S.106 funding is also sought by other public organisations and there needs to be sufficient workforce available to be able to recruit to any new facilities.

1.11.      Amanda Philpott confirmed that the proposed new Hailsham Health Centre and the Beaconsfield practice in Hastings are two of 16 potential practice developments within the ESBT area. The construction of these facilities are contingent on other factors such as planning permission and capital funds, but there is a CCG officer focussed on capital works whose role is to ensure that the developments are supported as much as possible.

1.12.      Ashley Scarff explained that local authority housing teams inform HWLH CCG through their involvement in the Connecting 4 You programme of the demographics of people who may be moving in to new developments, i.e., younger or more elderly people, which helps to determine the necessity for new GP practices, as demand is based partly on age.

Effect of Brexit

1.13.      Amanda Philpott said that Brexit is a factor in the workforce recruitment difficulties facing the NHS locally, albeit one whose long term implications remain unknown until the terms of negotiations with the EU become clear. She explained that a significant percentage of the workforce in East Sussex – like the rest of the country – comes from Europe and many are taking the decision to leave early, or not come in the first place. Dr Peter Birtles added that the whole health and care system is going to be effected by Brexit, in particular the nursing and care home sector. He said this will have a knock-on effect on the willingness of trainees to specialise as GPs.

1.14.      Despite the uncertainties, Amanda Philpott said that the CCGs in East Sussex are preparing for Brexit by supporting the ongoing work of the Chief Executive of NHS England, Simon Stevens, to secure the ‘special status’ of NHS workforce post-Brexit. She said that the actions the CCGs can take directly are to retain the existing GP workforce and make the role more attractive, which is what they have been working on doing.

GP Federations

1.15.      Amanda Philpott explained that GP federations are voluntary and comprise GP practices that wish to become more resilient to crises by joining together. She said that there are currently four GP federations in ESBT but this could reduce to one or two in the future if they come together. She added that the introduction of Extended Hours will increase the likelihood of GP practices federating because the requirement to provide extended hours is based on localities and not individual GP Practices, so by federating GP practices can share the responsibility for providing the quota of extended hours.

1.16.      Dr Peter Birtles reminded HOSC that GP Practices are independent contractors whose contracts are held by NHS England and that GP federations are legally binding arrangements between individual GP practices. Guidelines call for CCGs to support federating but ultimately the decision is with individual practices themselves. Within the HWLH area there is not much appetite for federations, however, they are only one way of working co-operatively to improve sustainability, for example, the Lewes GP Practices have come together to form the Lewes Health Hub.

1.17.      Dr Birtles explained that the development of federations and other joint GP working has developed more slowly amongst GP practices in the HWLH area as the area has only been affected by GP shortages in the last year or so. Elsewhere in the country there have been shortages for much longer, so GP practices have had to band together earlier in order to increase resilience.

Responding to GP practice closures

1.18.       Amanda Philpott explained that NHS England provides best practice advice to CCGs on responding to the closure of a GP practice. She said that GP practices are funded on head count, so the money that would have gone to Cornwallis Plaza practice in Hastings will be redistributed to other practices that took its patients. The only additional funding is a small amount of transitional funding to provide capacity to those practices that take on a large tranche of patients in a short timescale to review patients’ medical records, as well as undertake medication reviews and referral reviews for certain patients.

Monitoring potential practice closures

1.19.      Amanda Philpott explained that there are always going to be vulnerable GP practices; not always because they are financially challenged but sometimes a GP has become unwell, or the practice is small and the GP is planning to retire. She said that CCGs always attempt to stay aware of the health of the GP practices in their areas and offer support where appropriate, for example, supporting GP practices with action plans to improve their standards where the CQC has inspected them and recommended that they make improvements.

Support for patients after a GP closure

1.20.      Jessica Britton said that the ESBT CCGs are confident that they do all they can reasonably do to contact vulnerable patients in the event of a practice closure. In the case of Cornwallis Plaza, HR CCG identified all patients flagged as ‘vulnerable’ by the former GP practice and specific actions were put in place to ensure that all, as far as possible, were contacted and re-registered. This included direct contact from someone in the CCGs’ team to assist them with the process of registering.

1.21.      Amanda Philpott explained that there are some patients with out of date information who would be uncontactable following a GP closure, although this amount is very small. In the case of Cornwallis Plaza it totalled about 50-80 out of 17,000 patients.

1.22.      Sally Smith said that there have been two closures in Peacehaven in the last four years, and in both cases a list dispersal process was undertaken by HWLH CCG in line with NHS England’s published process. Ms Smith said that GP practice boundaries tend to overlap, so there is an element of patient choice in which practice they can opt for and an appeals process that can be followed if needs be. She added that Practice Participation Groups assist with communicating with vulnerable patients, as can other NHS or care organisations that may be in contact with these patients.

Armed forces personnel recruitment into health and social care

1.23.      Amanda Philpott explained that HR CCG hosts the Armed Forces Network for the Kent, Surrey and Sussex area. The purpose of the Network is to ensure that a) armed forces personnel and their families receive rapid, priority access to appropriate health and care services; and b) provide appropriate job opportunities to people leaving the armed forces within the health and care sector. East Sussex is currently rated ‘silver’ for job opportunities and is working towards ‘gold’.

The use of digital technology in GP practices

1.24.      Sally Smith confirmed that HWLH CCG has not received any complaints from the public about the patient administration systems used by GP practices. Amanda Philpott said that there has been a lot of positive feedback from patients in the ESBT area about text reminders, particularly in relation to the reminder to request a repeat prescription, which is a common reason for contacting the Out Of Hours (OOH) team.

1.25.      Sally Smith said that issues with digital technology tend to arise where GPs are using different systems for the same purpose, for example, the 20 GP practices in the HWLH area are using two different the systems – EMIS Web and System One – to administer patient records. To help mitigate this issue the CCG is providing ICT and digital assistance to GP practices. She confirmed that the three GP Practices comprising the Lewes Health Hub are using the same system to share patient records.

1.26.        Dr David Warden said that digital technology has benefited GP practices by:

·         Significantly reducing the number of missed GP practice appointments, particularly nurse practitioner appointments.

·         Ensuring consistent templates are used by GPs to record patient data into a central system. All GP practices in the ESBT area use EMIS-Web and there is a central ICT team that designs the template.

·         Allowing GP practices in GP Federations to match demand from patients in one locality with available timeslots in another locality of the federation.

·         Allowing GPs to access patient records remotely through an iPad. GPs having remote access to clinical information makes a significant difference to decision making and caring for patients outside the GP practice.

1.27.      Amanda Philpott explained that the NHS Locally Commissioned Schemes provide individual CCGs with the opportunity to specifically commission a particular digital technology for a GP practice if it is beneficial to do so.

1.28.      Dr David Warden said that it would be a potential breach of data protection if a GP practice contacted a carer via text on an ad hoc basis and GP practices would not do this. However, it is possible to text the carer when it has been recorded that an individual has given them permission to do so.

1.29.      Amanda Philpott explained that online consultations are undertaken by an individual and are not automated. She said that Skype consultations are carried out by a GP as part of their core business as an alternative to a patient vising their practice; they are based on patient choice and used when appropriate.

Access for people not using digital technology

1.30.      Sally Smith explained that the purpose of digital technology is to increase the range of methods people can use to book their GP appointments, and people would still be able to access services using conventional methods such as the telephone. She added that the CCGs, in conjunction with the CQC, monitor and support GP practices with their response times to telephone calls and other methods patients use to contact them. 

Physical Access to GP Practices

1.31.      Dr Peter Birtles explained that CQC inspections take into account physical access to GP practices. Sally Smith added that the HWLH CCG Estates Strategy includes a survey of the condition, accessibility, and lease arrangements of the 20 GP practices in the area. Ms Smith said that some GP practices might not meet the requirements of the Disability Discrimination Act, but the CCG is working continually with them to identify opportunities to improve the premises or move to new ones.

1.32.       Ms Smith said that NHS England provides minor improvement grants that GP practices can apply for. There is also a national Estates and Technology Fund that HWLH CCG has submitted a bid for on behalf of its GP practices – as have the ESBT CCGs. This fund will support the move of the three GP practices in Lewes to the new building in the North Quarter development.

General Data Protection Regulations (GDPR)

1.33.      Dr David Warden confirmed that GP practices in the ESBT area have undergone considerable training in preparation for the introduction of the new GDPR. Sally Smith said that the HWLH area GP Practices are also prepared for GDPR because protecting and safeguarding individual patients’ records is an area that they take very seriously.

1.34.      The Committee RESOLVED to:

1) Note the report;

2) request to be provided with further details of the CCGs’ approach to workforce planning in primary care in relation to the impact of Brexit;

3) request a briefing on the use of digital technologies such as Skype, including the timelines for roll out, and what is done to ensure patients with disabilities can use the technology.