Primary care Contents

Annex: Visit to Halifax and Sheffield

The Committee visited the Calderdale vanguard in Halifax and Sheffield Page Hall Medical Centre on Monday 23 November 2015.

Committee members present: Dr Sarah Wollaston (Chair), Dr James Davies, Andrea Jenkyns, Emma Reynolds, Paula Sherriff, Maggie Throup, Helen Whately and Dr Philippa Whitford.

Calderdale Health & Social Care Economy

Representatives of the Calderdale Health and Social Care Economy vanguard project included Matt Walsh, Chief Executive of Calderdale Clinical Commissioning Group (CCG), & Ian Baines, Head of Safeguarding and Quality, Calderdale Metropolitan Borough Council. Louise Watson of NHS England also attended.

Introduction to the Calderdale vanguard project

Calderdale is a mixed urban and rural economy. The registered population is approximately 215,000 situated in a large geographical area. Health inequalities persist and there is a ten year mortality gap. Seven organisations including two foundation trusts, the CCG and the local authority are partners in the vanguard project.

The Committee heard that there is still much to change within the area. There had been lots of work on engagement, the public have been consulted and 4 top themes have emerged from that work: clear information; flexibility of services; services closer to home; and understand-ability.

Political engagement proved difficult because the early part of the process was about closing and reconfiguring services. A politically mandated independently chaired ‘people’s commission’ was established which integrated evidence received during conversations and made a series of recommendations.

Local consensus within the people’s commission was regarded as important. During the course of the consultation the public said that they do not want to have to repeat medical details and they want care closer to home. They want the first point of contact with all of their details and a single key worker for each client/patient. The Health & Wellbeing Board has taken responsibility for implementing the recommendations of the ‘people’s commission’.

National overview of the vanguard programme

The national vanguard programme is in charge of delivering the 5 year forward view, a shared vision across 7 national bodies. The focus of the vanguards is on delivering 5 models of care sustainably. 50 vanguards were selected. There is substantial cross-over of purpose between the various models of vanguards: for example, multi-community specialty providers (such as Calderdale) have a great focus on Care Home care even though there are separate vanguards operating with this specific purpose.

Examples of success include: Birmingham - 60% digital consulting rates taken over the ‘phone; Whitstable - paramedics are embedded in practices and have access to patient notes; Corby - mental health crisis teams linked back to practice teams and Stockport - 92% of people chose place of death.

Quest for quality in care homes

It was explained to the Committee that the vanguard incorporates a care home element in which 24 care homes in the local area volunteered to be in the two year scheme. The objective of the programme was described as supporting self-management and enhancing telehealth. Using technology to prevent the need for home visits was an objective but it was observed that staff have needed support to improve their skills. Interoperability of systems and allowing GPs to access patient records has been the priority, but rural locations can make connectivity to IT difficult. Variation in the quality of care was attributed to problems with training and a lack of leadership in care homes.

The programme is based around a multi-disciplinary team including pharmacists who have rationalised prescribing and consultant geriatricians’ ‘skilling up’ staff in care homes during visits. Anticipatory care planning is designed to prevent Accident and Emergency (A&E) admissions and it has been observed that that staff have had better informed discussions about residents’ conditions. It was emphasised that increasing the skills of staff is important because making a decision as to the best care a resident requires can be very difficult when staff don’t have quick access to a doctor.

The Committee then discussed elements of the care home programme with the leaders of the project. They explained that managing data exchange, consent and technology issues is an ongoing challenge, but this is something that all vanguards are grappling with and common shared practice can be developed.

Another challenge in the care home sector is retaining staff in what is a low pay environment. As well as implementing the Government’s national living wage the vanguard said it was looking to develop better career pathways for staff as turnover of staff in this sector had been high.

Discussing the purpose of the vanguard more broadly the Committee was told that being given the status as a vanguard acted as an ‘enabler’, and helped to formalise existing projects. Members were told that communication between different parts of the system has improved and there is backing to deliver collaborative working. Working as a vanguard means that the project has been externally validated but additional investment will be required to double run services as the process changes.

Development of the new community specialist respiratory service for Calderdale residents

The Committee heard about a specific project aimed at tackling chronic obstructive pulmonary disease. The service was disjointed so specialist teams were co-located as part of a programme to deliver 7 day care. Additional nurses were recruited to the team and moved into primary care rather than secondary care.

Other changes included facilitating same day access to consultants at the front end of the patient pathway. The overall ambition is to create an anticipatory care model, but the reactive elements can also be designed to work better. At the heart of the changes is the need to achieve quick and accurate diagnoses and engage patients in activity that will improve their conditions.

The Committee heard that problems had included an inability to capture data around GP usage and information about prescribing costs and patterns. However, technology has helped more patients to understand and manage their conditions without recourse to other NHS services such as A&E.

Children and young people with complex needs

The Committee was told that there had been huge increase in the number of children with autism and sensory impairment - this has partly been due to better early identification. The Committee heard that being part of the vanguard released some non-recurrent funding for this aspect of care. There had been concerns about a lack of funding to provide adequate care but investing significant additional resource to address a single problem was not seen to be a solution. Similarly, it was decided that reforming the whole system was not wise as this could take care in the wrong direction. The members were told that waiting times for Child and Adolescent Mental Health services were still too long and the problems were rooted in primary care.

Concluding discussion

A short question and answer session discussed key issues relating to payment systems and workforce. The members were told that it is essential that the Vanguard delivers a saving but, fundamentally, there is not enough investment in the system at a national level. The view expressed by the project leaders was that funding should move away from tariffs to a population health led model.

The issue of workforce is complex and the members were told that offering incentives to work in one area which effectively drains a neighbouring area of staff is not a sustainable option. This is particularly relevant in Calderdale as patients will often be referred for treatment to hospitals in larger cities outside of the vanguard area. The vanguard is not working on the assumption that there will be more GPs as there are not enough GPs training locally to deliver this.

Page Hall Medical Centre

Background

The Committee had a meeting with staff and patient representatives from the Page Hall Medical Centre (PHMC) in Sheffield, including a presentation by Dr Kate Bellingham, a partner at PHMC.

PHMC comprised a team of 7 doctors (4.5 full time), 5 nurses (3.4 full time) and 2 Health Care Assistants. It has 7321 patients—1627 patients per full time doctor. The nurses perform a role that is very similar to that of the physician associate. The members were told that the practice has strong links with local communities. It is part of a newly formed federation with 7 local practices. The federation will allow the sharing of capacity and back office staff.

Challenges facing the practice

PHMC argued that the payment mechanism within the existing funding formula weights inadequately and does not account for the heightened health needs of newly arrived migrants. This includes early onset of complex illnesses associated with deprivation and also many patients being illiterate in their native language as well as English. Consequently, they said, there is a huge unfunded workload.

The members heard that 83% of patients are BME and 32% of consultations require an interpreter, rising to 85% for new registrations. Appointments requiring an interpreter inevitably take a long time and a ten minute appointment slot is unrealistic for this population.

In discussion with the members of the Committee the practice staff said that they offer a bespoke service for a specific patient group but the formula does not recognise these patients or reward the innovation required to manage them. Deprivation has traditionally been measured by social housing occupancy and numbers of benefit claimants but the migrant populations in Page Hall live in private houses of multiple occupancy and do not routinely claim benefits.

The discussion revealed that GP retention has been good at the practice. This was attributed to the fact that it is a training practice and trainees have wanted to build their careers at PHMC. In addition, the practice has made use of a pharmacist that has reduced the time taken by a GP to manage care home prescriptions from 3 hours to 25 minutes.

The members were told that five Prime Minister’s Challenge Fund extended hours hubs are now in operation within Sheffield. The feedback from the GPs at PHMC was that the hubs had drawn doctors away from out of hours services because the hubs provide better remuneration, as a consequence out of hours had been undermined.

The members then heard patient testimonials which emphasised the importance of the practice to the local community and the fear that if the practice closed the detailed knowledge of the local community that PHMC enjoys could not be replaced by alternative provision. At least two petitions have been launched with the purpose of keeping PHMC open.

Meeting with GPs that submitted evidence to the inquiry

The Committee invited the GPs who had contributed written evidence to its primary care inquiry. 14 GPs drawn from across England were able to attend.

Recruitment & retention

The Committee was told that workload and consequent stress make it impossible to recruit partners in some areas. It was also noted that some training practices do not have trainees because of the poor perception of general practice. Trainees witness the environment that partners work in and prefer to take locum of salaried positions.

It was observed that the lack of trainees and resource dedicated to primary care should be a matter of public concern. The Committee was told that exhaustion amongst GPs should be a cause of great alarm to the public. It was observed that golden hellos had been successful in improving GP recruitment in the 1990s.

Recommendations to improve primary care

The problems associated with declining real terms funding and the failure of the formula to adequately recognise deprivation were emphasised. A reduction in administration and bureaucracy was regarded as a key mechanism for creating room for patient care. The GPs agreed that 10 minute appointments should be a thing of the past but patient expectations should be managed. The GPs said that as a profession they ‘feel bashed’ by the tabloid media narrative which is regarded as ‘outright hostility’.

Multi-disciplinary working

The GPs discussed how they would like to interact with other parts of the primary care team. It was said that the principle of multi-disciplinary working is good but other health professionals must be autonomous so that problems related to issues such as prescribing do not come back to GPs. The Committee heard that indemnity costs are a barrier to expanding the primary care team, but it was noted that some practices have found ways of utilising physician associates. Working collaboratively with other GPs in other practices was seen as a mechanism for enhancing quality and making much better use of pharmacists in medicines management was regarded as priority.

7-day NHS routine care

The point was made to the Committee that offering routine services through federations in rural areas will be of little use if two practices are ten miles apart. GPs agreed that patients will not travel that far on a Sunday to attend a routine appointment. The Committee was told that a seven day service already exists in out of hours and the Government’s proposals risk undermining current services and continuity of care. Concern was expressed that offering routine weekend care could create supply induced demand rather than meeting existing demand. The GPs said that local areas should be empowered to develop their own solutions.

Conclusions

The point was made that primary care extends beyond they typical practice. Vulnerable patients can get lost in the system without a skilled approach from commissioners. The Committee was told that changes to pensions and loss of seniority payments have changed incentives for older GPs–there need to be more mechanisms to create extended roles for GPs to keep GPs from retiring early. Creating routes back into primary care for registrars who leave is important. It was agreed that morale is very low and there is a crisis in primary care. The GPs said that patients are more challenging than ever. The systems cannot stand still and should focus on servicing patient needs as opposed to wants.





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20 April 2016