Agenda item

This report provides accountability and transparency for quality standards and ratings in GP services in the borough as rated by the Care Quality Commission (CQC) and assurance that there are effective support arrangements for practices to improve.

Jonathan Turner (Borough Lead Director (Brent), CCG) introduced the report which provided information on standards and ratings in GP services in the Borough as rated by the CQC. The report covered the evolving landscape of primary care, the role of CQC, a summary of ratings in the Borough and how the CCG was working with practices to support them. He advised that satisfaction was generally good but there were variations and it was important as part of the work as an Integrated Care System (ICS) to address that variation. As well as GPs’ core role as consultants at the start of a patient’s NHS journey GPs also participated in extended primary care services such as screenings and vaccinations / immunisations, and co-ordinated with social care, the voluntary sector and the acute sector for referring and managing patients.

In relation to how the contracting mechanism worked for GPs, Jonathan Turner advised that generally the more patients a GP surgery had the more funding it would get. This was topped up through the quality and outcomes framework which had been a mainstay of general practice for 20 years. He advised that the key development in the last few years had been Primary Care Networks (PCNs) which had changed the way some practices came together as a group to support each other and consolidated some of the back office functions to standardise care. He pointed to page 44 of the report which set out the configuration of PCNs in Brent and which practices were within them, who was responsible and the clinical leads. Part of the CCGs role was to support the development of integrated care, the coming together as PCNs and the work with community nursing to ensure patients were being managed effectively as part of a whole system approach. The Committee heard that Brent was “underdoctored” in relation to GPs in the workforce with the workforce changing over time as more salaried roles become the norm and GPs took on more roles, with physios and pharmacists playing a bigger role for a more effective skills mix within practices. The additional roles and reimbursements scheme brought in by the NHS paid practices to bring in those additional roles to better support Musculoskeletal (MSK) conditions, aches and pains and those otherwise needing a referral so that they could be dealt with more quickly. A recruitment and retention programme was being introduced to ensure Brent got more qualified and experienced GPs. Jonathan Turner advised that there was a demographics challenge in Brent in relation to the number of people living in the Borough which had increased over the 20 year period and was concentrated in particular wards. As well as this the population was ageing with an increased number of people living for longer including in frail older people and people with complex comorbidities.

In relation to the CQC process, Jonathan Turner advised that every GP had an annual regulatory review which would inform how frequently that practice was reviewed depending on the rating of the annual review. Those rated inadequate or requiring improvement were therefore inspected more regularly. He advised that GPs were independent contractors not employed directly by the NHS therefore it was their responsibility to get into a better rating position but that there was a supporting role for the CCG such as running regular training workshops, conducting mock CQC inspections, supporting PCNs to provide dedicated support to individual practices and commissioning 1 to 1 support from external providers to address issues arising from CQC inspections. Part of the CCGs wider role within the ICS was addressing unwarranted variations so there was now a dashboard to look at a range of different care related metrics across practices and address unwarranted variation.

Fana Hussain (Assistant Director of Primary Care, CCG) advised the Committee that the report was a “moment in time” document and the situation changed regularly. The Committee heard that some very good practices on the list had been devastated to receive the report on CQC ratings but had taken the reports on board and made a lot of strides and changes. An area of development identified as a result of CQC ratings for PCNs in the Borough was the requirement to have documented policies that everybody was aware of. The CCG worked closely with the CQC and this enabled the CCG to have open discussions with GPs over where their practice was going in the future.

BethenieWoolfson (CQC) informed the Committee she had seen a positive improvement in the highest risk practices in Brent which had meant some ratings had gone up from inadequate to requires improvement. She advised that there was still a long way to go but the CQC were very pleased with that work. She mirrored comments that the CCG and CQC had a positive relationship and worked well together, engaging positively with practices. The Committee heard the CQC was moving towards a risk based approach as a regulator and at the moment were not conducting annual reviews but were using a transitional approach assessing the information held on a provider to decide whether to inspect, meaning frequency of inspection would not be used going forward.

Lesley Watts (Chief Executive for the North West London Integrated Care System) added that the ICS were trying to consolidate its oversight together with CQC in some sectors, which was already being done with major providers through oversight programs which the CQC sat on. The intention was to do that with primary care colleagues. She felt that there was a need to be more systematic within the system that assured the ICS that they were well sighted on issues which would allow for a programme of improvement.

The Chair thanked health colleagues for their introductions and invited members of the Committee to ask questions in relation to the report, with the following issues raised:

Members of the Committee highlighted that they had received complaints from constituents around changes in patient’s medication to cheaper alternatives, and there was concern this would result in less effective treatment. Lesley Watts assured the Committee that any medication prescribed by GPs were approved drugs, and usually the generic cheaper alternatives were exactly the same tablet and constitution but was the recommended medication regarding price. She advised that if there was a particular reason a patient needed a particular medication rather than the generic medication then the GP could prescribe that at their discretion if they had justification. She highlighted to the Committee that every penny spent on more expensive medications that did the exact same thing was money that could not then be spent on surgery or more GPs and nurses, and advised that the prescribing of generics was incredibly carefully controlled nationally. Dr M C Patel (NWL CCG) added that there was a Prescribing Committee which looked at papers and guidance from NHSE.

The Committee highlighted Table 1 of the report, in particular section 6.1 which stated Neasden Medical Centre and Greenhill Park Surgery had ratings of ‘requires improvement’, and queried whether there was any correlation between deprivation or affluence and the result of a CQC rating that mitigated or complemented the result. Lesley Watts acknowledged that the aim should be to ensure there was absolutely no correlation in ratings and deprivation and that people in the most deprived areas often needed the best services and in many deprived areas did get that. Bethenie Woolfson did not believe there was a correlation. She advised there were trends across the whole system in North West London which were often related to the governance of GPs and not the area or patients of the GP. She acknowledged there may be instances where fewer GPs were available in deprived areas but usually a poorer rating was linked to the clinical leadership and governance of the practice.

In relation to national studies of patient satisfaction, the Committee queried when the surveys took place in Brent and what the outcomes were. Fana Hussain advised that the national patient survey was conducted every year and was currently underway. Satisfaction in Brent currently was at 76%, and varied across practices, for example one practice had 94% satisfaction.

Regarding screenings and immunisations, the Committee heard that the immunisation programme was conducted through a core recall system operating nationally, as was breast cancer screening. All practices would have their own systems for calling patients due for immunisation. The immunisation rates had improved in Brent, but during the pandemic there had been less uptake of cervical sitology due to patients feeling reluctant to go into practices.

The Committee asked how much locally was spent on health services. Jonathan Turner advised that there was £550m allocated for Brent which included the whole acute system and all mental health providers, not just general practice. Sheik Auladin added that the delegated budget for primary care was £110m per year which gave an idea of the level of spending in the CCG compared to other areas.

Some concern was raised regarding employment practices due to the increased number of GPs employed by one partner. Jonathan Turner highlighted that GPs were independent contractors but also part of the NHS family. He explained that employment practices had changed over the years with an expansion of salaried posts which he expressed were perfectly legitimate ways of working, which some GPs preferred as it meant they did not have the same level of responsibility for the admin and running of the practice and could concentrate on clinical work. He advised the Committee that if there were concerns or issues around general practice and employment it would be for that individual practice to resolve, with the CCG becoming involved only where necessary. Dr MC Patel added that increasingly younger GPs were doing portfolio type work where they worked as GP and did a couple of other different sessions a week and a lot of younger GPs did not want to take on that additional responsibility so practices were relying on salaried staff and those who wanted to work part time. He felt that partnerships should be encouraged.

The Committee had concerns about access to GPs, including digital access and exclusion. Fana Hussain advised that GP access was monitored on a monthly basis. The NHSE website published a number of appointments available and the data for February 2021 had been reviewed which had shown Brent practices continued to provide GP access digitally, face to face and by appointment. Sheik Auladin (NWL CCG) advised that during the first wave of the pandemic there had been a lot of e-consultation but during the second wave GPs had seen patients through a mixture of e-consultation and on a face to face basis, therefore patients without access to IT were able to see their GP. A conversation was had regarding who councillors could contact in relation issues with residents accessing GPs, with the advice being to contact the GP in the first instance through their complaints procedure and let the CCG know. CCG colleagues agreed to provide a formalised contact for the specific purpose of giving councillors a place to go for resident GP concerns. The CQC added that from April 2021 they would be looking at GP access in Brent and encouraged anyone to share their experiences of access via the CQC website which could be done anonymously.

It was highlighted that due to COVID-19 relatives were not allowed to attend hospitals with patients, and the Committee queried what support was available from GPs for patients going for hospital treatments or urgent care who may rely on relatives to help them communicate, such as those with a language barrier. Lesley Watts advised that visiting was being looked at currently in all acute hospitals across London to put something in place, but there were always exceptional circumstances to consider, so if there were specific needs or a patient was end of life visiting was allowed.

Committee members highlighted that they had received information from residents that there had been a couple of incidences of “list cleansing” where patients had expected COVID-19 vaccination calls and had not received them as they had been removed from the list for not visiting their doctor for so long. Lesley Watts confirmed that any patient in the appropriate cohorts could be vaccinated whether they were referred by their GP or not and could book an appointment through one of the vaccination hubs. The Committee highlighted that this message could be better publicised to ensure people in the relevant cohorts were not waiting for their invitation from their GPs. Lesley Watts agreed to talk with the vaccination lead the following day regarding messaging on this and work with Council Officers for communications.

As there were no further questions, the Chair thanked Committee and invited recommendations, with the following recommendations RESOLVED:

i)              To note the contents of the reports and receive assurance on the management and support structures in place to improve standards of care in GPs in Brent.