Agenda item

Two reports are included under this item, the first being the NHS England report outlining the general services provided by GPs under different contract types and summarising the contractual arrangements with GPs in Brent and the differing levels of access available at different practices across Brent.  The second report outlines the aims of the former ACE programme undertaken in 2010/11, by the PCT, designed to improve GP access.

A number of appendices are attached to the reports and there are also two supplementary agenda packs containing other appendices. 

Julie Sands (Deputy Head of Primary Care, North West London NHS, NHS England) introduced the first report on access to primary medical services in Brent.  She informed the Committee that the national GP patient survey 2012-2013 had been analysed to identify what areas were in need of improvement.  In Brent’s case, there had been a considerable variation in GP practices across the borough in relation to patient access, both in terms of practice opening times and in how patients rated access. This was an issue that was mirrored across England and was of some concern.  Julie Sands advised that the national Assurance Framework, developed by NHS England, bought together a range of demographic and performance issues about practices, including reported patient satisfaction on accessing GP services, and this information would be used to identify and manages practices where there were concerns about the level of service provided.  NHS England would carry out an investigation into the underlying reasons for any concerns or dissatisfaction with a particular practice and depending on the circumstances of each case, the course of action to address this may involve encouraging best practice with other high performing practices in the locality, taking remedial action or in more serious situations or where the problems had continued in the longer term, using contractual levers such as breach notices and control sanctions. 

Referring to the Standard General Medical Services Contract in the second supplementary agenda, Julie Sands advised that this was nationally prescribed.  However, there was no specific criteria in respect of access provision.  Members noted that there was a range of different kinds of contracts that the provider may have with the NHS, however every effort was made to encourage practices to offer enhanced services, although this was optional.  Members noted the types of contract and the services offered by each practice in Brent as set out in the first supplementary agenda.

Jo Ohlson (Chief Operating Officer, Brent CCG) then presented the second report on supporting practice improvement and primary care development that detailed the outcome of the Access Choice and Experience (ACE) programme and the work of Brent CCG since April 2012.  An update on the outcome of patient satisfaction rates was also included, comparing results with 2009/2010, 2010/2011 and 2012/2013 respectively.  It was noted that the biggest improvement in Brent was satisfaction in being able to get through to a practice by phone.  Jo Ohlson advised that there had also been some improvement in being able to obtain an appointment reasonably quickly.  However, in respect of satisfaction with the opening hours of GP practices, this had seen a slight reduction and this mirrored the trend nationally. 

With regard to Brent CCG support to improving care, the following strategies had been developed to underpin this:-

·         Supporting development and implementation of practice improvement plans

·         Investing in additional primary care capacity

·         Transforming primary care as part of developing out of hospital services

Jo Ohlson explained that Brent CCG worked with practices to ensure that they were fully compliant with their improvement plans when they registered with the Care Quality Commission in April 2013.  The CCG had also invested £500,000 per annum for 2012/2013 and 2013/2014 to improve practice premises in areas such as control of infection and accessible premises for people with disabilities.  In order to increase capacity and patient satisfaction, Brent CCG was commissioning additional bookable appointments via a patient’s GP practice in five locality centres on a pilot basis for six months and involved GP and nurse appointments availability between 15:00 and 21:00 hours Monday to Friday and 09:00 to 21:00 on Saturdays.  In addition, members heard that there were a number of work streams to develop out  of hospital services, including identifying the need to create locality centres in Kingsbury and South Kilburn.  It was noted that NHS England had already approved funding for a locality centre in Kingsbury.  Jo Ohlson added that Brent CCG was working with the support of the North West London Strategy and Transformation Team to develop an outline business cases for Central Middlesex Hospital (CMH) to be a hub plus for primary and community services, including specialist diagnostic services, outpatients and GP services and for Wembley and Willesden Centres for Health to be hubs with extended community services.  The eight North West London CCGs were also developing outcomes and standards that all out of hospital providers would be required to meet and these would complement standards in the national contract. 

Members then discussed the item and raised a number of issues.  A member commented that although there had been some improvements in the most recent survey compared to previous surveys, there remained considerable variation in patient satisfaction of GP practices, including within a particular locality.  She sought further details as to what levers and sanctions could be used, including where there had been breaches of contract.  Another member commented that as hospital services were being reduced, GP practices should be offering more services and she asked for the most recent data on the uptake of the pilot scheme in some practices offering additional appointments with GPs and nurses.  Confirmation was sought that all Brent GP practices were subject to the Quality and Outcomes Framework and when would the Primary Care Assurances Framework apply.  In respect of performance, details were sought on the number of practices in Brent identified as poor performers and what action had been taken to date to address this.  Furthermore, it was enquired whether poor performance could often be attributed to poor leadership.  It was also asked whether single partner practices were more likely to be performing poorly than larger practices. A member asked how performance was being benchmarked with other local authorities.  In respect of the patient survey, it was asked how difficult it was to take resultant action because of the level of robustness of information that had been obtained from it.   

A member referred to appendix two of the report, covering additional enhances services being offered by GPs, and expressed concern on the lack of practices providing services for diabetes, especially as this condition was relatively high in Brent and she asked for an explanation as to why this was the case.  She also felt that the lack of practices making claims in respect of cardiology services was not encouraging. Another member noted the lack of practices offering psychological therapy services and enquired whether they were being encouraged to opt in to this service.  Another member commented that with the additional pressure on GP practices following changes to the NHS and the commissioning being undertaken and the reduction in budgets for services such as cardiology, what action was being taken to ensure improvements to services in such areas.  Confirmation was also sought in respect of the variation of charges for ECGs and the reasons for these, particularly as the fees for ECGs undertaken by hospitals was considerably higher than those done by GP practices. 

In reply to the issues raised by members, Julie Sands advised that the practice contracts does not specify particular targets but states that practices must meet the reasonable needs of patients and show evidence of this.  Where practices appear to be under performing, NHS England investigates the reasons for this and also draws on other information, which if revealing serious issues, provides it with greater leverage to take action.  Where practices have been identified as having some weaknesses, initially a remedial notice that would include an action plan would be issued. If this did not address the issue or it was more serious, then a breach of contract notice would be issued, or, in the most serious of situations, the contract could be terminated.  However, in the majority of cases, practices responded positively in working to address concerns and collaborate with NHS England to achieve desirable outcomes.  Practices were also encouraged to consider alternative ways of providing services in order to facilitate improvements, such as using other technologies to be accessible to patients, including e-mail.  Members noted that the programme of action for those practices identified as having some concerns had recently commenced and the first practice would be visited this week.  

Julie Sands advised that eight practices had been identified as first priority for the need for action, with a further six practices categorised as second priority.  In the past, there had been a correlation between poorer performing practices and smaller practices, however this was not so apparent now and indeed there were some larger practices in North West London that were having difficulties.  Julie Sands advised that there had been some changes to the patient survey since the initial one in 2009, with the language softened to encourage responses, although this sometimes led to more vague feedback.  She informed members that comparisons between practices in Brent and with other London boroughs could be provided, adding that sharing data between practices with similar demographics would be particularly useful.

Julia Sands confirmed that practices in Brent had been subject to the Quality and Outcomes Framework since 2004.  The Primary Care Assurances Framework had been published in May 2013 and was in the process of being rolled out across England. 

Jo Ohlson advised that the pilot scheme offering additional appointments had started in September and the data from the first week had shown an uptake of between 30% and 50%, although nurse consultations had a lower uptake that those with GPs.  As a result, the possibility of offering nurse consultation up to two weeks in advance and sharing nurses across practices was being looked at.  Jo Ohlson added that selected practices from Wembley and Kingsbury localities had commenced the pilot scheme this week and the initial data for this would be provided to Mark Burgin (Policy and Performance Officer, Strategy, Partnerships and Improvement).  The committee heard that the practices who were participating in the pilot scheme were not receiving additional funds, so it would be difficult for them to employ more staff to help them offer services for the extra hours provided.

Jo Ohlson advised that Brent CCG was working with the practices identified to seek improvements and the concerns raised were not generally attributable to weak management. Many practices also faced especially challenging circumstances and patient satisfaction with access did not necessarily correlate with the opening hours as some areas were more demanding than others.  Members noted that there were no shared patient records between practices and their hubs and there was also variation between how each locality transferred this information.  In respect of funding reductions for some specialist services such as cardiology, Jo Ohlson stated this may result in the reduction of follow up appointments in some cases, however she informed members that she would seek more information on this and respond to this query.  With regard to diabetes services, Jo Ohlson explained that the role of GP practices was primarily to identify the condition and refer accordingly, rather than provide on-going clinical support and a number of practices in Brent already provided this.  Diabetes services remained available in hospitals and because of the rise of this condition in Brent, consideration would be given to expanding the service in this setting.  Members heard that the claims submitted from practices as detailed in appendix two were from quarter one of 2013-2014 and a number of practices had submitted claims since then.  Whilst practices may want to offer particular services, sometimes this was not feasible due to capacity limitations and it was part of the commissioning teams’ role to provide practices the appropriate support.

Ethie Kong (Chair, Brent CCG) emphasised the importance of working with patients to improve access to services and of being sensitive to the needs of the local community.  She advised that some practices were unable to offer ECGs so would refer patients to a hospital whose fees are higher. However, investment and training to provide ECGs was available for practices and if they already had the necessary equipment, they were obliged to offer this service.  Ethie Kong added that practices’ uptake of ECG equipment in Brent was quite good.

Sarah Mansuralli (Brent CCG) advised that as some practices did not have sufficient space to provide certain services, arrangements were made to ensure that hubs within localities could provide these.