Primary care Contents

2The new models of care

Changing how we care

Findings of the Primary Care Workforce Commission

Background

79.Comprised of six commissioners and chaired by Professor Martin Roland, the Primary Care Workforce Commission (PCWC) was tasked by Health Education England in 2015 to “identify models of primary care that will meet the needs of the future NHS”.124 The PCWC’s final report described networks and federations of practices built on multi-disciplinary teams working collaboratively. The vision of the Commission was one of teams of professionals utilising their individual skills to meet the needs of patients much earlier in their journey through the NHS. They said primary care will be:

based around the GP practice holding responsibility for the care of its registered patients, but practices will have a stronger population focus and an expanded workforce. Many existing healthcare professionals will develop new roles, and patients will be seen more often by new types of healthcare professional such as physician associates. Clinical staff will have better administrative support and, when needed, healthcare professionals will be able to spend more time with their patients to discuss and plan their care. They will also be able to communicate with patients and with other health professionals by phone, email, electronic messaging and video-conference.

Individual general practices and community pharmacies will work more closely together through networks and federations in order to provide a wider range of services, and IT systems will become joined up across providers of primary care. Primary and community care staff will also work closely with secondary care and social services through some of the models outlined in the NHS Five Year Forward View. Premises will be upgraded, making better use of existing community facilities in order to support closer working with hospitals and with social services, and to provide a wider range of diagnostic facilities.125

Improving the patient experience

80.Improving the quality of care and the patient experience is central to the PCWC’s conclusions. National Voices, a coalition of national health and social care charities, is campaigning for fully integrated health and social care teams. In relation to general practice they argued that a multi-disciplinary team is necessary to achieve this aim:

Practices should recognise the role of nurses and administrative staff in supporting more person centred care. Primary care should be capable of collaborating with external teams, working closely with other health and care professionals, including specialists.126

Anna Bradley told us that patients do not want to be reliant on their GP and would like to be able to self-refer to other health professionals. Ms Bradley said that patients “would rather see someone who can help them with their problem than necessarily always see the same person.”127

81.The PCWC acknowledged that general practice built around 10 minute appointments where only one problem is addressed is insufficient for today’s patients.128 Healthwatch England described how unsatisfactory 10 minute appointments can be:

Local Healthwatch across the country have heard from people unhappy with fixed length appointment slots, reporting they feel rushed and unable to make themselves heard.129

82.Dr Chaand Nagpaul explained GPs cannot provide the best care for patients with multiple complex conditions within the confines of the traditional 10 minute appointment. Dr Nagpaul explained that GPs:

simply cannot see a patient with multiple morbidity, who is 80 years old, may have memory impairment, diabetes, heart disease, be arthritic and on 10 different drugs, and do it in 10 minutes. It just cannot be done safely, it is not being done humanely, and it is not being done with quality.130

Katherine Murphy echoed these remarks and observed that 10 minute appointments are particularly inappropriate for patients with mental health problems.131

83.Ten-minute appointments do not allow adequate time for safe practice or to address whole person care. Relentless time pressure from short appointments tends to restrict patients to discussing only one problem with their GP and clinicians to working in a reactive rather than proactive manner. Given the increasing complexity of the long term conditions that are managed in primary care, allowing time to provide safe and holistic care must be a priority. We agree with the Primary Care Workforce Commission that reshaping primary care to give patients sufficient time to discuss their conditions with health professionals should be a central aim of the new models of care.

The blueprint for a new model of care

84.The report of the Primary Care Workforce Commission represents a vital step in illustrating how a new model of care can be delivered. As Professor Roland told us, “there is nothing fantastically revolutionary or new”132 in the report of his commission, but what it did present was a practical blueprint for the future services on which we all rely. This is a blueprint that we welcome and on which we expect the Government to act.

Multi-disciplinary teams

85.The patient benefits and organisational efficiencies that can be achieved by restructuring primary care teams along these lines are quite clear. It was widely agreed amongst the witnesses we heard from that new models of care can only be delivered by teams of health professionals working in close collaboration as part of multi-disciplinary teams.

86.Professor Field illustrated the key patient benefits of working in this way and avoiding professional isolation:

There is a direct correlation between inadequate practices—on fewer nurses, fewer sessions—and outstanding practices, which have really good multiprofessional care, using nurses and therapists, and a few now are using physician associates and pharmacists.133

87.The PCWC envisaged a workforce made up of a broad range of professions which could go as far as incorporating non-health specialists that can assist with social problems, and medical assistants to relieve GPs of some administrative tasks. Along with GPs and nurses, the heart of the new workforce will be comprised of pharmacists, physiotherapists, mental health workers and, potentially, physician associates.

Nurses

88.Nurses are already an integral part of the primary care team, as acknowledged by Professor Roland in evidence.134 The PCWC outlined how the existing workforce could be better harnessed and nursing roles in primary care developed:

General practice nurses, supported by healthcare assistants, now take on a wide range of responsibilities which, depending on their training and experience, include management of the main long-term conditions such as diabetes and asthma, seeing vulnerable groups such as children, people with mental health problems and those with learning disability, as well as taking on generalist roles including the management of acute minor illness. We believe that nurses could take on substantially more care for both acute and chronic conditions.135

89.The Royal College of Nursing (RCN) cited evidence in support of redistributing work within primary care that was published in 2003, which reiterated the point made by Professor Roland that the principles espoused by the PCWC are not necessarily new. They argued that nurses can ease the burden on GPs by triaging patients and that this process can be made more efficient by harnessing new technology. 136

90.We believe that advancing the role of nurses in primary care should not just be seen in the context of easing workload pressures on GPs. This should be a priority because we were told consistently that integrated teams provide better care for patients.137

91.Evolution of responsibilities within the nursing workforce was highlighted by the Primary Care Workforce Commission, which observed in its report that the existing job titles for nurses do not particularly reflect or describe the work that they undertake:

We have chosen not to focus on individual nursing job titles or roles in our recommendations (such as specialist nurse, advanced nurse practitioner) as the actual tasks carried out by nurses often depend as much on experience and the supportive environment in which they are working as on formal qualifications.138

We did hear concerns, however, that more needs to be done to support training and continuing professional development for practice nurses as well as other health professionals within the multidisciplinary team.139

Pharmacists

92.Discussing the role of pharmacists, the PCWC said that the surplus of trained pharmacists should be exploited by deploying them in extended roles as part of the general practice team:

Pharmacists carry out a range of medicines optimisation tasks in general practices mostly linked to patients on long-term medication, including monitoring and rationalisation of repeat prescriptions, carrying out reviews for people on multiple medications, supporting adherence to medication, and advising on prescribing to care home residents, who are at particular risk of medication-related adverse events. Prescribing pharmacists can take increased responsibility in these roles.140

Sandra Gidley, Chair of the English Pharmacy Board at the Royal Pharmaceutical Society, said that the report of the PCWC complemented their own views regarding the role of pharmacists in general practice teams:

What the report had to say was very positive about the inclusion of pharmacists. In fact, it chimes with some of the work we have been doing at the Royal Pharmaceutical Society working with the Royal College of General Practitioners to develop a scheme whereby there will be a number of pharmacists based in GP surgeries taking on a more clinically focused role. That seems to me not only a good use of pharmacists but a benefit for the patients.141

Community pharmacy

93.Whilst the widespread deployment of pharmacists as core parts of the primary care team could represent a departure from traditional model of care, the PCWC also emphasised the role of community pharmacy. The report of the commission recommended that:

Wider use should be made of community pharmacists and pharmacy support staff in managing minor illness and advising people about optimising their medicines. There should be agreed protocols for treatment and referral between local organisations of pharmacists and GP practices.142

94.Pharmacy Voice, which represents community pharmacy providers, said that that up to 18% of general practice workload and 8% of Emergency Department consultations are estimated to relate to minor ailments.143 Likewise, the government’s evidence emphasised the ability of community pharmacy to relieve the burden of demand facing general practice teams:

Pharmacy already plays a vital role in supporting the health of people in their local communities, providing high quality care and support, improving people’s health and reducing health inequalities. As we move to more integrated care, there is real potential for community pharmacists and their teams to play an even greater role in the future, particularly in keeping people healthy, supporting those with long term conditions and helping make sure patients and the NHS get the best use from medicines.144

In particular the Government emphasised the benefits that can be achieved when community pharmacy is afforded access to summary care records (SCR):

We are investing up to £7.5 million to give community pharmacists the training and tools they need to access patients’ SCR. A pilot has already shown that as a result of this, as many as nine out of ten people can get the help they need from their pharmacist without having to be sent to another service.145

95.Given the potential offered by community pharmacy, we were disappointed that the Government has announced a 6.1 per cent cut in funding for community pharmacy.146 We note that the Department of Health has implied that this announcement may lead to a rationalisation of services as “40% of pharmacies are in a cluster where there are three or more pharmacies within ten minutes’ walk”.147 The Pharmaceutical Services Negotiating Committee has warned that as many as 3,000 community pharmacies could close.148 The Government must ensure that this does not leave communities without access to pharmacy.

Physiotherapists

96.Professor Karen Middleton, Chief Executive of the Chartered Society of Physiotherapy, made the case that incorporating physiotherapists into core general practice teams not only improves services for patients but could reduce (and in some places already is reducing) the workload faced by GPs. Professor Middleton argued that allowing patients to self-refer to a practice physiotherapist also reduced onward referrals and enhanced patient satisfaction:

30% of what a GP sees, according to the British Orthopaedic Association, is MSK [musculo-skeletal conditions]. Physiotherapists are ideal to see those patients first off. [ … ] I visited a practice in Suffolk during the summer where they provide physiotherapy as the first point of contact across 27 sites. They have not only taken 30% of the caseload that the GPs were seeing before but they have reduced referral to secondary care. Hip and knee replacement surgery has reduced by 40%. The conversion rate for surgery for orthopaedics has gone up to 100%, so all those referred to secondary care actually need surgery. [ … ]

We are finding that not only are patients very satisfied with that approach but we know from all the evidence that has been accumulated around patients selfreferring that they are seen quicker, outcomes are better, they return to work faster and it saves a considerable amount of money for the taxpayer when a physiotherapist sees the patient rather than a GP. [ … ] When I talk about 30% of a GP’s caseload being MSK, it is not 30% of the patients, it is actually many patients coming back again and again or then being referred unnecessarily to orthopaedics.149

Physician associates

97.Extending the recruitment of physician associates in primary care is a somewhat more challenging proposal from a purely clinical perspective than attempting to embed the presence of physiotherapists and pharmacists in general practice or extending the role of practice nurses. How physician associates fit in with the rest of the workforce was described by Professor Veronica Wilkie, Professor of Primary Care and Medical Director for the MSc Physician Associate Course at the University of Worcester. Professor Wilkie sought to illustrate the core benefits of including this profession in the primary care workforce:

All of the students are required to pass a national exit examination, and are required to re sit a re-certifying examination every 6 years. Physician Associates remain generalists for the whole of their careers, and as such become flexible clinicians working across an increasingly specialised health economy.

The physician associate course will cover about 40% of the undergraduate medical curriculum. The curriculum is very practical (so that they can take blood, put up IV lines, suture, as well as take a history and perform an examination).

Physician Associates work very well alongside doctors, they are trained in the medical model, understand a significant amount of pharmacology, and work very well to make up junior doctor posts in hospitals or as part of the primary healthcare team in General Practice.150

98.Research undertaken by Kingston University and St George’s University of London assessing the merits of physician associates and published in the British Journal of General Practice reported positive accounts regarding their role in primary care:

For patients attending for same-day or urgent appointments, PAs [physician associates] attended a younger patient group who present with less medically acute problems and fewer long-term conditions, compared to those attended by GPs. After adjusting for case mix, there was no difference between PA and GP consultations in the rate of investigations, referral to secondary care, prescriptions issued, or the rate of patient re-consultation for the same or a closely related problem within 14 days. Patients report high levels of satisfaction with PA and GP consultations. The average PA consultation was longer than with a GP, although costs per consultation with a PA were lower.151

99.The RCGP, on the other hand, has given the proposed expansion of the physician associate workforce a lukewarm reception and they appeared to be sceptical of the intention behind expanding the profession:

There is a need for more evaluation of the impact of new roles in primary care on outcomes for patients, and in particular for evaluation of the benefits of introducing particular roles, such as Physicians Associates, into general practice. It is important to be clear that whilst other professionals have an important role to play in supporting the delivery of patient care in general practice, these cannot replace GPs, and should not be considered an alternative solution to the GP workforce problems.152

100.There is limited evidence as to the effectiveness of physician associates in primary care and this is acknowledged by the authors of the St George’s research. Because of the limited evidence base the report of the PCWC exercised a degree of caution in its conclusions:

Physician associates [ … ] offer a relatively rapid way of attracting more healthcare professionals into the workforce to address current levels of need and demand, and it is much cheaper to train physician associates than additional GPs. However, more studies are needed to assess how effective and cost effective these roles are in the long term.

While we recognise considerable potential in developing these new roles, the governance of these new staff members will be of critical importance in ensuring the quality and safety of their work.153

101.The Commission’s report did, however, counter the implication that physician associates could be recruited to fulfil tasks that should be undertaken by GPs. Instead, they made the more subtle case that multi-disciplinary teams should take on responsibilities that have traditionally, but unnecessarily, rested with GPs.154 Professor Roland argued that GPs should have more opportunity to focus more on “the things which only they can do, particularly for the complex elderly.”155

102.Government policy assumes that the physician associate workforce in primary care will grow relatively rapidly. Professor Cumming, Chief Executive of Health Education England (HEE), said that HEE had “given an undertaking that by 2020 we will have trained into employment 1,000 physician associates working in primary care.”156 We note that the lack of professional regulation of physician associates has been identified as a barrier to the recruitment of this workforce and we explore this further in Chapter 3.

Multi-disciplinary teams: conclusion

103.There are clear benefits for patients in basic reforms such as enabling self-referral to physiotherapists and incorporating pharmacists and other health professionals into general practice teams. We welcome the PCWC’s emphasis on drawing aspects of secondary care into primary care. We note, however, that fundamental barriers exist that can actively prevent this from happening. We explore these barriers in Chapter 3.

104.New models of care should not be about trying to replace GPs, but should allow them to take on a more specialist role focused on leading care delivered by multi-disciplinary teams. The benefits of integration, providing care coordinators and a single point of contact for patients with complex needs have been emphasised by many of those giving evidence.157 Incorporating care coordination must be another feature of the new model of care.

105.Whilst the vision for a new model of primary care and the workforce to underpin it has been established, the challenge for the Government and NHS England is to overcome the barriers to building these new teams and to implement the necessary change at scale and pace. This is especially important given the existing and worsening workforce shortfall. We are concerned that basic reforms such as widening the responsibilities of nurses, self-referral to physiotherapy and the incorporation of pharmacists into general practice teams should be enabled and accelerated. In the response to this report we would like to see a clear plan and timetable for action.

106.We support the objective of training physician associates to work alongside GPs within multidisciplinary teams in primary care, but as their new roles and responsibilities develop they will need careful evaluation. Attention must also be paid to the continuing professional development needs and supervision of physician associates.

Specialists in primary care

107.The PCWC also made the case that secondary care specialists should be incorporated into primary care teams to support GPs and provide treatment for complex conditions in the community. Outlining how the new model should work the PCWC said:

Hospital doctors and nurses will increasingly work with others in community settings, for example, in care of the elderly. While hospital-based specialists may run clinics and see patients in the community, a major role will be to support clinicians in primary care.158

108.An essential recommendation of the PCWC’s report that we believe should be implemented with great urgency relates to mental health. The report recommended that:

Practices or groups of practices should have access to a named consultant psychiatrist and to a named mental health worker such as a primary care mental health worker or community psychiatric nurse.159

Healthwatch Lincolnshire illustrated why developing this type of collaborative working should be prioritised across primary care:

Across all areas limited or poor access to mental health services was seen as having a direct impact on people’s wellbeing in the county. It was generally felt that doctors were supportive; however, there were concerns raised about specific doctors who the respondents felt didn’t understand their mental health needs and as a result led to a patient’s condition worsening.160

109.These concerns have been reinforced by the recent findings of the Mental Health Taskforce, which concluded that there will have to be far greater collaboration between primary care and secondary care specialists to ensure that the physical health needs of people with mental health problems are not overlooked.161 The taskforce expressed concern that people with mental health problems are:

three times more likely to attend A&E with an urgent physical health need and almost five times more likely to be admitted as an emergency, suggesting deficiencies in the primary care they are receiving.162

110.Improving the relationship between primary care and mental health specialists is particularly vital for those primary care services dedicated to supporting vulnerable people such as those with drug and alcohol problems and the homeless. Meeting GPs during our visit to Sheffield, we heard how this patient population can be overlooked by traditional primary care commissioning processes.163

111.We note in this context the introduction of new waiting time standards for the Improving Access to Psychological Therapies (IAPT) programme. The standards mandate that “75% of people referred to the IAPT programme will be treated within six weeks of referral, and 95% will be treated within 18 weeks of referral”.164 The Government has said that £460 million was invested in IAPT between 2010 and 2015 and a further £80 million was realised out of NHS budgets in 2015–16 to help meet the standards.165

112.We endorse the recommendation of the Primary Care Workforce Commission that practices or groups of practices should have access to a named consultant psychiatrist and to a named mental health worker or community psychiatric nurse. We also welcome the improved access standards and additional funding for the Improving Access to Psychological Therapies programme as an opportunity to improve access for patients in primary care to mental health therapies.

Communication between primary and secondary care

113.Whilst Alistair Burt, Minister of State for Community and Social Care, identified technology as a driver of change in the long term,166 the evidence from the Government did not reassure us that a systematic approach has been established to meeting some very basic technological challenges facing primary care. This is despite the fact that the PCWC highlighted the basic failings in this area:

We regard it as outdated that GPs and specialists are unable to communicate freely by email or by electronic messaging. Although some areas have commissioned services that enable GPs to email specialists for advice, these remain the exception rather than the rule. Often people need to be referred to hospital just for a simple query to be answered. At a time when there is so much focus on integration of care, it seems bizarre to us that provision is not made within the job plans and contracts of both GPs and specialists to encourage this basic level of communication.167

The PCWC recommend that:

Email correspondence and electronic messaging should become routine between primary care healthcare professionals and hospital specialists, enabling both to seek advice and give guidance on patient care. While this may need protected time in the working day, there are significant potential cost savings in terms of reduced referrals to hospital.168

114.We are concerned that there has been little emphasis on improving communication between primary and secondary care clinicians despite such improved communication depending on little more than routine use of email. We note that the PCWC concluded that achieving this would require “only minimal cost investment.”169

115.New models of care will be built around multi-disciplinary working, including primary care clinicians working with secondary care specialists. In the response to this report we invite NHS England to explain how they will act on the Primary Care Workforce Commission’s recommendation that GPs should be able to communicate routinely with specialists in secondary care by email and messaging.

The role of federations

116.It was apparent from the conclusions of the Primary Care Workforce Commission that many of their recommendations are predicated on GP practices at least working in networks or more probably joining formal federations. The implication of the PCWC’s conclusions was that a new model of care to meet the needs of patients cannot realistically be delivered unless practices work collaboratively:

Federations and other collaborative networks are an important way of enabling primary care organisations such as GP practices to provide a wider range of services, while at the same time offering the benefits of a smaller organisation, such as convenient location and continuity of care. [ … ] Primary care providers working together can also help monitor and better understand variation in clinical performance by sharing comparative data. Working collaboratively and sharing ideas across federations and networks can also help new models of care and new staff roles to emerge.170

117.Professor Roland said in oral evidence that these structures would provide the headroom for general practice to find ways to change their models of care and professional teams:

we think that groupings and federations of practices are going to be key, because generally it is a real struggle for practices to work out exactly how they are going to do this sort of stuff, but groups of half a dozen practices, or sometimes more, can make a real difference. [ … ] It is very difficult to innovate when you are constantly trying to catch up.171

118.Dr Maureen Baker illustrated the problems GPs face in finding the opportunity to step away from their daily routines in order to reshape patient care and move away from inadequate ten minute appointments:

Increasingly, though, we are seeing practices look at different ways of operating with a view to trying to give people with multiple, complex or difficult or dangerous conditions longer periods of time. The difficulty with this, as in so much else at the moment, is all this planning, thinking, testing and making sure it is safe takes time and headspace, and most colleagues at the moment struggle to get through the day, never mind trying to plan to make things better.172

119.Building on these remarks, Professor Field illustrated how collaborative working is often at the heart of good patient care and poor quality stems from isolation:

we have a large number of smaller practices in inner cities that are failing and are inadequate. We think most of that is due to professional isolation—that they are not connecting with local practices. It is not really the size; it is the fact that they do not learn and share with others. [ … ]

the better practices link in with other practices, share their data, their performance improvement and services, but also link into community services very well.173

120.We heard concerns that some federations are forming out of financial necessity without a clear vision of how they can improve patient care. Dr Steve Kell, Chair of NHS Clinical Commissioners, warned that federation of practices driven by financial considerations could miss opportunities to improve care:

It is also important that we have a clear narrative as to why practices would be working together. It is important that that is hopefully done in a proactive way, which improves patient quality, access and sustainability. I am more concerned when I think it is because of the financial need to do so, because then we lose some of the benefit that might happen. If it is because of changes to funding and so on that forces practices into that, we will get less benefit as commissioners.174

121.The evidence we heard indicated that resources to support the development of federations are very limited. Although Clinical Commissioning Groups (CCGs) now have the freedom to co-commission general practice services with NHS England, the running cost allowance for CCGs has been reduced by 10 per cent to £22.07 per head for 2015/16,175 which will inevitably make it more difficult for CCGs to support transformation at a local level.

122.We heard that the only national financial support for practices seeking to federate has emerged through the Prime Minister’s Challenge Fund (PMCF).176 This was not the fund’s original or primary purpose. Rosamond Roughton, the National Director of Commissioning Development at NHS England, commented that the requirement for a minimum patient population to access resource from the PMCF “in effect” incentivised practices to work together,177 but this requirement does not equate to formal support and resource for those that have already chosen to network or formally federate. Ms Roughton also told us that NHS England’s local area teams, which are tasked with supporting the development of federations, work across large geographical areas.178 In our view, thinly resourced local area teams which cover large geographic areas will struggle to provide targeted support to embryonic federations, especially given the number of practices that will be required to federate in the next few years in order to deliver improvements to patient care.

123.Federations and networks should be formed with the primary purpose of improving care for patients. NHS England Local Area Teams, in conjunction with clinical commissioning groups, should directly support the development of new models of care envisioned by the Primary Care Workforce Commission.

124.There must be assurance that federations and networks are forming with robust structures and leadership and a clear picture of how patient care and experience can be improved. We recommend that clinical commissioning groups, federations and networks also involve patient-facing charities and community organisations to help them maintain a focus on quality and local priorities for improving care.

Guarding against conflicts of interest

125.Now that CCGs are able to commission local GP services, NHS England will have a crucial role to play in preventing conflicts of interests developing between CCGs and large federations. Any suggestion that conflicts of interests are influencing commissioning decisions would undermine the credibility of commissioners, providers and the new structures that have been established in local areas. We recognise that NHS England has provided CCGs with guidance and established new systems and training in recognition of this risk.179 We believe that continued vigilance is required at national and local level to guard against conflicts of interest influencing decisions taken by clinical commissioning groups in relation to general practice. The commissioning system must operate both fairly and transparently and be seen to be operating in this way.


124 Primary Care Workforce Commission, The future of primary care, Creating teams for tomorrow (July 2015), p 57

125 Ibid, p 7

126 National Voices (PRI 144) para 18

127 Q218 (Ms Bradley)

128 Primary Care Workforce Commission, July 2015, para 2.4.3

129 Healthwatch England (PRI 228) p 2

130 Q291

131 Q209

132 Q2

133 Q272

134 Q12

135 Royal College of Nursing (PRI 63) para 11.2

136 Ibid, para 11.1

137 Qq2, 168

139 Qq112, 124

141 Q101

143 Pharmacy Voice, (PRI 241)

144 Department of Health, NHS England and Health Education England (PRI 200) para 108

145 Department of Health, NHS England and Health Education England (PRI 200) para 118

146 Pharmacy Voice, (PRI 241)

147 Department of Health & NHS England, Letter to Sue Sharpe, Chief Executive of the PSNC, 17 December 2015

148 Pharmaceutical Services Negotiating Committee, PSNC Briefing 007/16: Campaign guidance for LPCs, February 2016

149 Q107

150 Professor Veronica Wilkie (PRI 236) p 1

151 British Journal of General Practice, Physician associates and GPs in primary care: a comparison (May 2015)

152 RCGP (PRI 174) para 19

154 Ibid, July 2015, para 15

156 Q38

157 Qq185 (Mr Redding), 204, 219 (Ms Bradley), 409 (Mr Burt)

159 Ibid, p 32

160 Healthwatch Lincolnshire (PRI 39) para 4

161 NHS England, The Five Year Forward View for Mental Health, (February 2016), p 39

162 Ibid, p 31

163 Note of Committee visit to Halifax & Sheffield

164 HC Deb, 30 June 2015, c 3511 [Commons written answer]

166 Q409

167 Primary Care Workforce Commission, July 2015, para 2.31

168 Ibid, p 7

169 Ibid, p 11

171 Q13

172 Q279

173 Q272

174 Q258

175 NHS Clinical Commissioners (PRI 157) para 5.7

176 Q258

177 Ibid

178 Q389

179 Q439




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20 April 2016