Primary care Contents

Conclusions and recommendations

Improving access to primary care

1.We believe that it is vital that patients have timely access to primary care services. This includes both access to urgent appointments and the ability to book routine appointments in advance. (Paragraph 25)

2.Evidence from the National Audit Office shows that people who work during the week would like to make use of extended hours at weekends. We welcome the principle of improving access for people whose working lives make it very difficult to obtain appointments during the week and recognise that this was one of the Government’s manifesto commitments. The Government should, however, bear in mind evidence that there may be more demand for access to GPs in the evenings or on Saturdays than on Sundays. (Paragraph 26)

3.There should be a full evaluation of the pilot programmes testing the provision of routine weekend appointments before any new system is rolled out around the country. The Government’s approach should be evidence based, learn from best practice and avoid unintended consequences such as damaging weekday services, continuity of care or existing urgent out-of-hours primary care services. (Paragraph 27)

4.An essential component of extending primary care services to weekends should be making those patients currently disenfranchised by the existing model of care aware of improved access. Ongoing evaluation of Prime Minister’s Challenge Fund backed projects should, at a local level, incorporate an analysis of patient awareness of weekend services. (Paragraph 29)

5.Continuity of care demands continuity of record keeping. Patient safety is compromised by inadequate access to patient records. There is greater risk of medical errors as well as the unnecessary costs of increased bureaucracy where patient records cannot be accessed and electronically updated at every point of contact. Routine appointments, especially for complex patients, without access to patient records give rise to an avoidable risk. (Paragraph 32)

6.It is essential, both for patient safety and to reduce bureaucracy, for patient records, accessed with their consent, to be directly accessible by all the health professionals seeing patients registered with any practice within a federation, network or out-of-hours provider. The response to this report should lay out a clear timetable for these arrangements to be in place including for shared access between primary and secondary care. Efforts should be made to ensure that such arrangements apply UK wide. (Paragraph 33)

7.We recommend that clinical commissioning groups, federations and networks be given the flexibility to develop local solutions for weekend access to meet the needs of those who cannot attend routine services between Monday and Friday. Clear and consistent statements affirming the Government’s commitment to local flexibility are required to assist both implementation and public comprehension of the policy. Implementation of new weekend routine services must also take account of the impact on local provision of existing out of hours services for urgent primary care. We recommend that locally led design underpinned by adequate funding and resource from the centre should form the basis of the Government’s implementation of its manifesto commitment to 7-day primary care services. (Paragraph 38)

8.In 2013 our predecessor committee recommended in its report on urgent and emergency services that urgent care centres providing out of hours GP services should be co-located on hospital sites where appropriate for the local population. The future location of extended primary care provision should take this recommendation into account as part of a process of simplifying and concentrating the confusing array of urgent primary care services. Local demographics and the location of hospitals will not always make this possible, therefore local input is vital to determine the optimum locations for patient access. (Paragraph 39)

Utilising information technology

9.We firmly believe that harnessing the opportunities presented by IT could improve access and quality of care. Patients expect to be able to book appointments online and practice websites should facilitate that. Whilst many patients will prefer or require a face to face consultation, for those who do not, primary care providers should facilitate telephone and eventually online consultations. (Paragraph 51)

10.NHS England must offer support by sharing and promoting best practice on the use of IT to facilitate remote consultations. Practice partners and managers would benefit from clear guidance and support in helping them to understand how technology can be harnessed to improve access and clinical standards of care in the most cost effective manner. We recommend that NHS England undertake research to support this objective with the aim of formally assessing demand, risk and potential benefits. (Paragraph 52)

Variable quality

11.We welcome Care Quality Commission (CQC) inspection of GP practices and the benefit which it has brought for patients. Independent regulation supported by robust inspection is a useful tool in driving improvement, ensuring quality and giving the public confidence in the services they pay for. Since the CQC’s remit was extended to primary care it has played an important role in identifying failing and underperforming practices, closing some down and ensuring others improve. (Paragraph 73)

12.We reject the calls from the British Medical Association and the Royal College of General Practitioners to scrap the current regulatory regime. We urge them to work constructively with the Care Quality Commission to protect the public from the small minority of dangerous practitioners and to help to turn around underperforming practices. (Paragraph 74)

13.We heard evidence of duplication of data requests resulting from the Care Quality Commission’s (CQC) primary care inspection methodology. Like all good regulators the CQC should constantly examine its procedures and methods to avoid or minimise unnecessary burdens or duplication. NHS England, the CQC, the General Medical Council and Local Education and Training Boards must work together to agree a common framework and data set to reduce bureaucracy and unnecessary duplication. It is essential that time which should be devoted to patient care is not eroded by an excessive bureaucratic burden. (Paragraph 76)

Improving the patient experience

14.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. (Paragraph 83)

Multi-disciplinary teams

15.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. (Paragraph 105)

16.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. (Paragraph 106)

17.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. (Paragraph 112)

18.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. (Paragraph 115)

The role of federations

19.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. (Paragraph 123)

20.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. (Paragraph 124)

Guarding against conflicts of interest

21.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. (Paragraph 125)

Workforce planning

22.Ensuring there are 5,000 additional doctors in primary care by 2020 is dependent in part on attracting people to return to the profession. The induction and refresher scheme is a vital component of the efforts to do so. It should be subject to annual review to ensure that it is facilitating the return of qualified professionals as quickly as possible. (Paragraph 131)

23.The Government should publish an analysis of the trends in doctors leaving the profession. This analysis should encompass their age, experience, specialism, the length of time for which doctors work abroad, the reasons for leaving the profession, and rates of return. (Paragraph 137)

Selection of undergraduates

24.Medical schools should recognise that they have a responsibility to patients to educate and prepare half of all graduates for careers in general practice. Much greater emphasis should be placed on the teaching and promotion of general practice as a career which is as professionally and intellectually rewarding as any other specialism. Those medical schools that do not adequately teach primary care as a subject or fall behind in the number of graduates choosing GP training should be held to account by the General Medical Council. (Paragraph 144)

25.Medical school entry requirements should look beyond pure scientific qualifications and actively to seek out candidates who not only possess academic ability, but can also demonstrate a commitment to providing care within their own community. (Paragraph 145)

Tackling local shortages

26.We note that a limited scheme is already in operation whereby a bursary of £20,000 will be made to trainees who agree to work in one of 119 locations that have historically struggled to attract trainees. The success of this scheme should be kept under review to build an evidence base for the use of financial incentives in workforce planning. We recommend that the Government should assess the merits of supporting student loan repayments for newly qualified GPs and nurses working in primary care especially in areas with acute recruitment challenges, over a concurrent period of obligated service to the NHS. (Paragraph 154)

27.In light of the current workforce crisis we recommend that in response to this report the Government should provide a comprehensive assessment of the full range of incentives that are available to attract young primary care professionals into general practice and to encourage returners and retention in areas where the need is greatest. (Paragraph 155)

Nursing

28.We recommend that Health Education England, NHS England and the Royal College of Nursing develop a plan for primary care nursing akin to the 10 point plan agreed for general practice. This should include proposals to attract trainees, reform undergraduate training and ongoing professional development, establish recommended pay and conditions, and outline examples of different types of careers that can be accomplished in primary care. As well as focusing on retention of the existing workforce, greater attention should be paid to incentivising qualified nurses to return to primary care after taking career breaks or working abroad. (Paragraph 163)

Training and education

29.We recommend that the Nursing and Midwifery Council urgently review nurse training curriculums with a view to increasing the exposure to primary care for healthcare professionals in training. The same principle should apply across the wider primary care team including physiotherapists and pharmacists. The education and training programme for physician associates should also be tailored in this fashion given their potential contribution to primary care and the developing nature of the profession. (Paragraph 166)

30.We recommend that the Government accelerate their work to create a payment mechanism which reflects the true cost to GP practices of teaching medical students. The objective of this work should be to ensure that reimbursement of the costs of training is not a barrier to undergraduates being able to access training in general practice. With this in mind, new proposals to replace the existing SIFT arrangements should be in place by the beginning of the 2016–17 academic year. (Paragraph 172)

Workforce and federations

31.Co-commissioning of general practice services by clinical commissioning groups presents an opportunity to tailor services to patient needs by making best use of local knowledge and experience. Allied with NHS England local area teams, Clinical Commissioning Groups should use their co-commissioning powers to oversee and guide the development of federations so that patient care is central to their ambitions. We recommend that a principal element of this oversight should be a requirement for federations to develop multi-disciplinary teams focused on enhancing access to primary care and improving the quality and range of services available. (Paragraph 175)

32.In order to accelerate the development of nursing roles in primary care we recommend that federations appoint a lead nurse to design and implement career pathways and continuing professional development for nurses. Health Education England should assist in setting standards and supporting federations and networks to meet them. (Paragraph 176)

Regulation

33.We welcome the fact that the Royal College of Physicians now hosts a faculty which will operate the re-certifying process for physician associates, but this is not an adequate substitute for professional regulation. Regulatory change is required for the statutory regulation of physician associates to be made possible. Within 12 months we expect the Government to have drafted proposals that will achieve the objective of professionally regulating physician associates. It is unacceptable to encourage new graduates to train as physician associates without giving the public or these new members of the primary care workforce the assurance that they will be a regulated professional group. (Paragraph 185)

GP leadership

34.GP leaders have a key role to play in helping to mobilise professional support for implementing the recommendations of the Primary Care Workforce Commission, for example by emphasising the benefits not only for patients but for professional colleagues. We would welcome the RCGP and BMA taking a greater role in helping to promote and drive forward multidisciplinary working and new models of care. (Paragraph 186)

Changing incentives in the system

35.The Government should, as a priority, evaluate the experimental projects involving capitated payment systems, with a view to extending them to primary care federations. As the vanguard projects begin to mature we expect NHS England to identify good practice and provide clinical commissioning groups with clear guidance on redesigning financial incentives to move care out of hospital, better coordinate care and, ultimately, reduce hospital admissions. (Paragraph 193)

36.We believe that primary care should receive a larger proportion of overall NHS spending. (Paragraph 197)

Investing in primary care

37.It is unacceptable that financial mechanisms and a failure to coordinate health and social care continue to divert too many patients to inappropriate and more expensive secondary care. We recommend that the Government set out a clear timetable and framework for delivering the practical financial tools by which local commissioners and providers can work together to improve patient care and to reduce demand and costs elsewhere in the system. (Paragraph 199)

Future funding

38.We recommend that by April 2017 NHS England present to Parliament a report outlining the achievements of the vanguards to date and identifying models of payment systems which produce better care for patients which can be replicated elsewhere across England. (Paragraph 202)

39.The costs of developing a new workforce, establishing the necessary technology and building new premises to allow for new models of care to flourish have yet to be established. By the end of 2016 we expect the Government to provide us with a full indicative costing in order for a full evaluation of the scale of this challenge to be available to the public. (Paragraph 214)

40.We endorse the recommendations of the Primary Care Workforce Commission and believe the process of implementing a new model of primary care is a vital step in ensuring the long-term sustainability of the NHS. It is now the Government’s responsibility to illustrate how it will provide the necessary investment to meet the cost of developing multi-disciplinary teams that will better meet the needs of patients. (Paragraph 215)





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20 April 2016