OFFICIAL
Paper: PB.30.03.2017/xx
NHS ENGLAND – BOARD PAPER
Title:
General Practice services – programme update
Lead Director:
Rosamond Roughton, Director of NHS Commissioning
Purpose of Paper:
To update the Board on the further progress made, and the key next steps in implementing
the
General Practice Forward View
The Board invited to:
Note the update provided.
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General Practice services – programme update
Purpose
1.
To update the Board on the further progress made and the key next steps in
implementing the
General Practice Forward View.
Background
2.
General practice is the bedrock of the NHS, but it continues to be under pressure from
rising demand. Patient satisfaction remains high, with 85.2% of the public reporting a
good experience of general practice services in the most recent survey, but this
masks variation and difficulties in some parts of the country in accessing convenient
appointments. GPs and their staff have to deal with rising volume, and rising
complexity and expectations.
3.
The
General Practice Forward View, published on 21 April 2016, sets out our
investment and commitments to strengthen general practice in the short term and
support sustainable transformation of primary care for the future. It includes specific,
practical and funded actions in five areas – investment, workforce, workload,
infrastructure and care redesign. On investment, it sets out our ambition to invest a
further £2.4 billion a year by 2020/21 into supporting general practice services. This
represents a 14% real terms increase – almost double the 8% real terms increase for
the rest of the NHS. It increases the proportion of investment in general practice
services by 2020/21 to over 10%.
4.
The
General Practice Forward View is not just about sustaining general practice
however. It is about laying the foundations for the future, so that general practice can
play a pivotal role in the future as the hub of population-based health care as
envisaged in the New Models of Care and Primary Care Home. Through support for
working at scale, the high uptake of new technologies and using the breadth of skills
and capabilities across the medical and non-medical workforce, general practice will
be better geared to support prevention, to enable self-care and self-management as
part of creating a healthier population and a more sustainable NHS.
5.
Many of the actions in the
General Practice Forward View are for NHS England,
Health Education England and the Care Quality Commission to take forward.
However, strengthening and transforming general practice plays a crucial role in the
delivery of Sustainability and Transformation Plans (STPs) plans. The majority of
STPs set out plans to strengthen primary care in line with the
General Practice
Forward View. Those with the greatest focus set out new delivery mechanisms for
general practice and integrated primary and out of hospital care, such as primary care
hubs, ‘super practices’ and aggregation of practices working at 30-50k population
through New Models of Care. There remain, however, some areas that have more to
do. NHS England and NHS Improvement will work closely with STPs in 2017/18 to
harness the changes need in STP delivery to strengthen general practice.
6.
This month we have also published the
Next Steps on the NHS Five Year Forward
View that sets out what the NHS will deliver in the next two to three years, within the
resources available. The Delivery Plan explains the improvements we will achieve
including through our priority to strengthen general practice.
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7.
CCGs are also translating the aims and key local elements of the General Practice
Forward View into their more detailed local operational plans. Primary care was a
‘must do’ in the
NHS Operational Planning and Contracting Guidance 2017-2019 which explicitly set out the priorities that CCGs should consider as they developed
their local plans and also required CCGs to submit one
General Practice Forward
View plan to NHS England encompassing the areas in the guidance.
8.
CCG Plans were submitted on 23 December 2016. Regions are responsible for
oversight of the plans, which are being to ensure delivery of specific aspects of the
General Practice Forward View, including improved access, as part of the wider
ambition to sustain and transform general practice. Robust tracking of delivery plans
as part of NHS England’s assurance mechanisms will commence once plans are
assured.
Benefit for patients
9.
From general practices, patients want high quality care provided by a familiar team of
healthcare professionals who they know and trust and who know their medical history.
They also want to be able to receive care in a timely fashion when they need it. Some
patients want to be partners in their own care. They want the knowledge, skills and
confidence to take more responsibility for their health and to feel more in control of
their outcomes. The
General Practice Forward View provides the support for
practices to build the capacity and capabilities required to meet these needs, including
support to adopt new ways of working (at individual, practice and network or
federation level) and to develop different ways of managing clinical demand. In
addition to increasing self-care, this includes the use of different triage methods and
development of the broader workforce, or alternative services.
Summary of progress towards delivery of the General Practice Forward View
10.
In the eleven months since publication of the
General Practice Forward View there
have been achievements in all five areas, with many signs of progress and positive
outcomes. Annex A includes a detailed list of achievements, together with at Annex
B, a number of case studies illustrating the real impact being made at a local level.
11.
An external Oversight Group with membership including the RCGP, NHS Clinical
Commissioners and the BMA is overseeing progress. The RCGP’s Regional
Ambassadors are promoting the values of general practice, supporting delivery of the
General Practice Forward View and inputting into NHS decision-making. The BMA
reference group of LMCs from around the country is providing feedback and input into
making sure the changes set out in the
General Practice Forward View come to
fruition.
12.
Key highlights for 2016/17 include:
increased i
nvestment in general practice in 2016/17 – including funding for
core allocations, better access, workforce and estates;
commitments to fund rises in costs in indemnity for GPs, with an additional £30
million being issued at the end of this month;
measures to attract doctors back into the
workforce, with a significantly
improved return to work scheme – offering GPs financial support, streamlined
processes and a single point of contact – which have already reaped dividends
as the number of doctors seeking to return has increased;
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491 clinical pharmacists working in and across 658 practices, with co-funding
from NHS England;
as part of the programme of work to tackle
workload, we have established and
delivered the new Practice Resilience Programme – a four year programme to
support practices and their localities. As at the end of February, over 1000
practices had taken up the offer of support, and, together with the Vulnerable
Practice Programme, over £20 million has already been spent on support;
significant additional investment in the
infrastructure, with over 800 new
schemes identified during 2016-2019;
to support
care redesign, we have established a new national GP
development programme, focusing on spreading best practice, implementation
support, and building improvement capability for the future. There are 86
schemes in place, covering 107 CCGs, and
we have set out the requirements for commissioners to improve
access to
general practice, with a clear trajectory of additional funding.
Next steps for 2017/18
13.
The
General Practice Forward View is a five year programme. Delivery in 20161/7 has
focused principally on helping practices with the pressures they are facing. Whilst
there has been good early progress, there remains much more to do. We do not
underestimate the challenges that continue to lie ahead.
14.
Our key next steps for 2017/18 will be:
Continuing to increase
investment in general practice – this will include an
extra £301 million into core primary medical care allocations in 16/18; CCG
plans to invest £171 million over 17-18 and 18/19 for Practice Transformational
Support; and a range of other targeted investments to support improving
access, improving the infrastructure and building the workforce;
Fairer funding – through negotiation of changes to the Carr-Hill formula for
general practice; and discussions will begin with stakeholders about the
replacement to QOF;
Continuing to deliver
improved access across the country – by the end of
March 2018, we are aiming for 50% of the population to have access to GP
services, including sufficient routine appointments at evenings and weekends;
Expanding the
primary care workforce – we will shortly be announcing the
second wave of practices who will receive co-funding for clinical pharmacists;
there will be a national framework to support more extensive recruitment of
overseas doctors in the most challenged parts of the country; and there will be
additional support for practice nurses and non-clinical staff;
Improving practice resilience – we will continue to roll out the Practice
Resilience Programme and the national GP Development Programme so that,
over time, all practices can benefit from the latest thinking in ways to manage
workload, and improve patient experience; and
Investment in infrastructure – this is a multi-year programme and, now that
we have an established pipeline, this will begin to accelerate during 2017.
15.
These measures will help to create the foundations needed to enable general practice
to take its place at the heart of population-based health care, whether in a primary
care home or one of new models of care.
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Recommendation
16.
The Board is invited to note the progress so far.
Claire Aldiss, Head of Direct Commissioning Change Projects
March 2017
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ANNEX A
Detailed list of progress towards delivery of the
General Practice Forward View
Investment
1. In 2016/17, we allocated an additional £322 million in primary medical care
allocations, providing for an immediate increase in funding of 4.4%. On top of this, for
2017/18, we allocated an additional £301 million in primary medical care, providing for
a further increase of 3.9%. Our early estimate is that outturn for 20161/7 will be in the
range of £10 billion to £10.1 billion, which would be £0.5 billion more than 2015/16
outturn of £9.5 billion and £1 billion more than 2014/15 outturn of £9 billion. Final
outturn will be confirmed once the accounts have been audited and will be published
by NHS Digital in the 2016/17 edition of the Investment in General Practice Report.
2. Some non-recurrent funding has been held nationally to support
General Practice
Forward View commitments in a number of areas, including growing the general
practice workforce, premises, technology, support for struggling practices and the
national development programme.
3. In terms of future years, the
NHS Operational Planning and Contracting Guidance
2017-2019 set out the detail of funding from the Sustainability and Transformation
Package, included in the
General Practice Forward View, that is devolved to CCGs for
specific purposes, including:
at least £138 million in 2017/18 and £258 million in 2018/19 to improve access
to general practice services;
£8 million in 2017/18 and a further £8 million in 2018/19 for the General
Practice Resilience Programme, with £16 million already allocated in 20161/7;
£15 million in 2017/18 and £20 million in 2018/19 devolved to CCGs for
technology, and
£10 million in 2017/18 and £10 million in 2018/19 devolved to CCGs for training
reception and clerical staff to undertake document management and active
signposting, to free up GP time, with £5 million already allocated in 2016/17.
4. In July 2016, we announced that we would offset the rising costs of GP
indemnity
through a new GP Indemnity short term financial support scheme, starting in 2016/17
and providing a special payment to practices, linked to unweighted patient population,
to offset average indemnity inflation. The scheme will run for two years, with £30
million to be distributed to practices at the end of March 2017. We also ran another
Winter Indemnity Scheme from October 2016 until March 2017, to assist with the
additional indemnity costs of GPs who are able to carry out more out of hours
sessions, to specifically address winter pressures. We have also just extended the
Winter Indemnity Scheme to cover the Easter period, extending the Scheme until 30th
April 2017.
5. It was agreed as part of the outcome of the 2017/18 GMS contract negotiations, that
negotiations on changes to the Carr-Hill
funding formula (to ensure a fairer
distribution of funding) will begin shortly. Full implementation of any agreed changes
will be effective from 1st April 2018 at the earliest. This will be in discussion with the
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BMA’s General Practitioners’ Committee to ensure that the pace of change does not
destabilise practices.
6. It was also agreed that for 2017/18 there will be not change to the number of
QOF
points available, the clinical or public health domains and no changes to QOF
thresholds. However, the CPI will be adjusted to reflect the changes in list size and
growth in the overall registered population for one year from 1 January 2016 to 1
January 2017. We have also agreed that a working group will be set up immediately
following the negotiations to discuss the future of QOF after April 2017.
7. In addition, as part of the outcome of the 2017/18 GMS contract negotiations, it was
agreed that
CQC fees will be reimbursed directly. Practices will present their CQC
invoices to the CCG (where delegated powers exist) or the NHS England regional
team and they will be reimbursed as part of the practice’s next regular payment.
Workforce
8. The Government has set out an ambition to double the rate of growth of doctors
working in general practice, with an aim of securing an extra 5,000 doctors by the end
of 2020. Health Education England (HEE) are leading on the work to increase the
number of doctors going into general practice training, and in the
General Practice
Forward View we set out our plans to support this work with a focus on return to work,
and retention.
9. We have strengthened the package of support, including financial incentives and
development support, to help GPs who might otherwise leave the profession to
remain in clinical general practice. Under the interim
Retained Doctors Scheme
2016 we increased both the money for practices employing a retained GP and the
annual payment toward professional expenses for GPs on the scheme. This package
of support will continue from April 2017 under a
new GP retention scheme which
provides further clarity on who the scheme is aimed at, and clearer guidance around
the management and approval of GPs on the scheme.
10. A new twelve month pilot –
GP Career Plus – has been agreed to test the
effectiveness and the economic case for large scale providers to recruit pools of GPs
to work flexibly across a primary care system. The pilot will seek to recruit
approximately 80 experienced GPs at risk of leaving the profession across 11 areas in
2017/18.
11. Improvements have also been made to the national
GP Induction and Refresher
Scheme to make it easier and quicker for doctors to return to practice. This includes
increased financial support; increased practical and personal support and more
flexibility in the application process and streamlining processes including DBS checks.
On 27 February 2017, we also launched a ‘Return to General Practice’ marketing
campaign, including print and social medial adverts to promote the package of
financial and practical support now available to returning GPs.
12. 50 practices have been identified to take part in a
pilot scheme that offers support to
those GP practices that can evidence that they have historically encountered
difficulties in recruiting GPs. The support includes recruitment support for practices
alongside up to £8,000 in relocation allowances for GPs employed through the GP
Induction and Refresher Scheme, and up to £2,000 in an education bursary.
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13. Through the
Targeted Enhanced Recruitment Scheme, which is implemented by
Health Education England, we are offering a salary supplement of £20k to attract GP
trainees to work in areas of the country where GP training places have been unfilled
for a number of years. 105 out of 122 places offered have been filled for the first time
in many years. An expanded scheme offering 144 places has been agreed for the
2016/17 recruitment year, and promotion of these places is underway.
14. We are also supporting, with additional funding, pilots in Lincolnshire, Essex, Cumbria
and South Tees/Hartlepool to
attract doctors from overseas into general practice.
This will inform a more extensive recruitment of overseas doctors this year into the
most challenged parts of the country.
15. The success of general practice going forward also relies on the expansion of the
wider
non-medical workforce, and the General Practice Forward View set out our
ambition to expand the wider workforce by an additional 5,000 other staff also working
in general practice.
16. As part of the first phase of the
Clinical Pharmacists in General Practice pilot
scheme, we have already supported 658 practices in co-funding clinical pharmacy
posts, with 491 pharmacists now in post. Recruitment onto the second phase of the
scheme, aimed at supporting the employment of a further 1,500 clinical pharmacist in
general practice over the next three years, commences in April 2017.
17. Regional networking events for practice managers were held in December 2016 as
part of the
Practice Manager Development Programme. We are also supporting the
growth of local and online networks of practice managers to accelerate the sharing of
good ideas, action learning and peer support.
18. Funding has been devolved to CCGs to invest in the
training of current reception
and clerical staff to undertake enhanced roles on active signposting and
management of clinical correspondence. Active signposting by reception staff
provides patients with a first point of contact which directs them to the most
appropriate source of help. Web and app-based portals can provide self-help and self-
management resources. Receptionists acting as care navigators can also ensure that
patients are booked with the right person first time. This frees up GP time, releasing
about 5% of demand for GP consultations in most practices. It is then easier for
patients to get an appointment with the GP when they need it, and shortens their wait
to get help. Clinical correspondence by clerical staff has shown that 80-90% of letters
can be processed with the involvement of a GP, freeing up approximately 40 minutes
per day per GP. Practices report they are often able to take speedier action on some
issues. More detailed coding of clinical information in the GP record also results in
improved monitoring and management of certain conditions.
19. In terms of mental health therapists, from January 2017 the first phase of IAPT early
implementer sites across 30 CCG areas has been agreed to begin delivering
integrated psychological therapies for people with long term conditions and/or
persistent and distressing medical unexplained symptoms. Many of these areas are
working to integrate with general practice, with new mental health therapists co-
located there.
20.
Multi-disciplinary training hubs, designed to form a locus in an area for primary
care workforce planning, multi-professional training and development and clinical
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placements, are being established through HEE regional offices. This has benefitted
from £3.5 million investment from NHS England.
21. On 8 March 2017, HEE published the
General Practice Nursing (GPN) Workforce
Development Plan ‘Recognise, Rethink, Reform’. Coordinated by HEE, NHS England,
other ALB colleagues and professional bodies, it made clear the challenges facing the
GPN workforce and made a range of recommendations to support and develop the
GPN workforce for now and the future. Recommendations address areas such as
improving training capacity; raising the profile of general practice nursing; developing
GPN educator roles and a proposed nationwide standardised general practice nursing
‘return to practice’ education programme. In response to these recommendations,
CNO England is now overseeing the publication of a GPN
Ten Point Action Plan. This
plan sets out the partnership working and investments for progressing
recommendations and actions to ensure GPNs can play their full leadership role in the
transformation of primary care.
22. The vanguards have also developed and tested different
new care models. Common
to most Multispecialty Community Providers (MCP) and Primary and Acute Care
Systems (PACS) vanguards are the development of
multi-disciplinary teams. Early
evidence from the vanguards shows some encouraging indicators of progress and
impact in terms of emergency admissions growth and emergency bed days.
23. We have also focused on the promotion of health and well-being. The
new GP Health
Service was launched on 30 January 2017. It is a free, confidential service provided
by health professionals specialising in mental health support to doctors. The service
saw 150 new patients in its first month.
Workload
24. Workload is the single biggest concern to GPs and their staff. We are providing
support for general practice with the management of demand and diversion of
unnecessary work.
25. Further new NHS Standard Contract measures have been introduced into the 2017-
19 NHS Standard contract to improve the
interaction between practices and
hospitals. These include strengthened requirements on hospitals for handling queries
from GPs and patients and ensuring that shared care protocols are only initiated
where the patient’s GP is content to accept the transfer of responsibility. A new
Primary and Secondary Care Interface Working Group involving the BMA, RCGP,
RCP, NHS Clinical Commissioners, NAPP, NHS Improvement and NHS England has
been set up and is driving further action to improve this interface between general
practice and hospitals.
26. The new
Practice Resilience Programme was launched in July 2016 to support
practices and groups of practices become more sustainable and resilient, better
placed to meet the challenges they face now and into the future. The intent was to
build on the
Vulnerable Practice Programme we launched in December 2015 which
aimed to support practices identified as in difficulty. The key difference is that the
Resilience Programme allows support to even more GP practices, including practices
which would welcome help to build resilience but who may not themselves be
vulnerable or struggling.
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27. National guidance for both programmes is largely permissive, ensuring there is local
flexibility and ownership. Guidance sets out the criteria to ensure selection of
practices is managed consistently (including practices rated as inadequate or
requiring improvement by CQC) and describes a menu of support that should be
secured and offered subject to locally prioritised needs. For the Practice Resilience
Programme, practices could also self-refer. However many were unaware of this so
national deadlines were extended for this programme to give time to raise awareness
and provide the opportunity for practices to request support.
28. All funding has been allocated to NHS England’s local teams who are responsible for
determining the nature of support, securing this and selecting which practices are to
be offered support, working locally with CCGs and Local Medical Committees. This
support is in addition to (and to some degree analogous to) the turnaround support we
commission from the RCGP for practices in CQC Special Measures. We have
extended the support to ensure a consistent offer to GP practices during the first
round of CQC inspections.
29. NHS England committed to invest £10 million by December 2016 in support to
struggling practices through the Vulnerable Practice Programme. A further £40 million
was committed in July 2016 through the Practice Resilience Programme with £16
million available in 2016/17 and £8 million a year thereafter until March 2020. As at
the end of February 2017, local teams have reported investment of £9.2 million
supporting over 600 struggling practices through the Vulnerable Practice Programme
and investment of £11.9 million supporting a further 500 practices through the
Practice Resilience Programme. All funding is committed to be spent by the end of
this financial year.
Practice Infrastructure
30. Improvements in general practice infrastructure (premises and technology) are vital in
enabling the type of transformation envisaged.
31. Through the
Estates and Technology Transformation Fund, a multi-million pound,
multi-year investment fund, 560 schemes for practices have already been
implemented, over 200 are in progress, and over 800 further schemes have been
identified for the 2016-2019 pipeline. Support is being provided which will contribute
to improving extended access to effective care across local services; improve existing
facilities; increase flexibility to accommodate multi-disciplinary teams and to develop
the right infrastructure to expand the range of care for patients, add more training
facilities and enable greater use of technology. This will facilitate primary care at
scale and more joined up care in local communities.
32. In addition, other
business as usual capital continues to be invested in:
GP IT, to deliver the priorities set out in NHS England’s
Securing excellence in
GP IT services, and
Premises improvement and development grants funded under the Premises
Cost Directions, which are aimed at helping to ensure that general practice
services are delivered from quality premises.
33. Measures to support practices with undocumented tenancies have been agreed with
NHS Property Services (NHSPS) and Community Health Partnerships (CHP)
including making Stamp Duty Land tax reimbursable for the initial term (up to 15
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years) and reimbursement of VAT on the rent for the duration of the lease when
charged by NHSPS and CHC. To date there has been limited take up of this offer.
We will work with the profession and others to take this forward.
34. Greater use of technology is enhancing patient care and experience, as well
streamlining practice processes.
35. As part of an early adopter phase, 20 CCGs are implementing NHS
Wi-Fi services
across approximately 1,000 GP practices by 31st March 2017, with a potential reach
of in excess of 5 million patients. Wider rollout will commence on 1 April 2017. Each
CCG will receive funding to enable them to implement free Wi-Fi across practices for
use by professionals and patients by December 2017.
36. Funding is also being devolved to CCGs to support the purchase of
online
consultation systems. The funding will start to be deployed in 2017/18 in line with
rules and a specification.
37.
Interoperability of GP systems is a key enabler for clinicians to provide excellent
care for patients regardless of the underlying system used by the GP practice. NHS
Digital are developing core technology for a national service which will enable
enhanced two-way access to records across practices (operating within appropriate
controls). This service will be free to use and open to all suppliers but will need to be
integrated by federations and other collaboratives into the systems they use to
support services across multiple practices, for example out of hours service centres.
The initial ‘First of Type’ for this new service is planned for April 2017 using Leeds
Care Record (delivered by Leeds Teaching Hospitals Trust). Federated GP practices
in Kernow CCG are also under the ‘First of Type’ banner and will commence shortly
afterwards using the same access to records technology. Further functionality,
appointment booking and sending tasks between GP systems, is planned for delivery
by May 2017. Based on success with these sites, a further group of early adopters
are planned as the next wave for implementation over the coming months. It is
expected that functionality will be available to all practice groups from September
2017 but dependent on the ability of systems used by federations to make use of the
core functionality provided by NHS Digital. That will be a matter for each group of
practise to negotiate with their respective suppliers. The expectation is that a fully
scalable national solution will be available by March 2018 for viewing patient records,
booking appointments and sending tasks across practices and in other care settings.
38. Work is ongoing with the supplier market to create a wider and more innovative
choice of digital services for general practice. Feasibility, design and discovery
activity is underway for commercial and technology models to replace the current GP
System of Choice Framework has been tested with the supplier market, including
potential new entrants. Early testing with clinical users has commenced with further
research and testing planned in the coming months, including with general practice
and new care models.
39. We have made significant progress in the roll out of
access to the summary care
record to community pharmacy. Approximately 32,000 pharmacy professionals
received training in the use of the summary care record by 12 March 2017. 77% of
community pharmacies have accessed the summary care record and the rate of
uptake continues to increase. Access to the summary care record supports clinical
decision making by pharmacy teams as it enables them to better support patients with
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long term conditions; urgent care needs; resolving prescription queries and
understanding new medicine regimens on discharge from hospital.
Care Redesign
40. The
General Practice Forward View committed £500 million by 2020/21 to enable
CCGs to commission and fund additional capacity across England to ensure that, by
2020 everyone has
access to GP services including sufficient routine appointments at
evenings and weekends to meet locally determined demand, alongside effective
access to out of hours and urgent care services. The
NHS Operational Planning and
Contracting Guidance 2017-2019 set out our intent and requirements for CCGs to
improve access.
41. The service currently delivered in the General Practice Access Fund sites will expand
to transformation areas in 2017/18 so that 50% of the population is covered by March
2018, with CCGs in these localities being funded at £6 per head of population. By
March 2018, the Mandate requires that 40% of the country will benefit from extended
access to GP appointments at evenings and weekends, but we are aiming for 50%.
This will include London who will use funding across the capital to offer 8am-8pm to
over 9 million people by March 2018. In 2018/19 all remaining CCGs will receive
funding at £3.34 to ensure 100% coverage across England by March 2019. From
April 2019 all CCGs will be fully funded at £6 per head of population to continue to
deliver.
42. In order to receive funding CCGs will need to demonstrate 7 core requirements
through their commissioning. These include specifics on timings, an hour and a half in
the evenings and pre-bookable and same day appointments at weekends to meet
local population needs, and on additional capacity, a minimum additional 30 minutes
consultation capacity per 1000 population, rising to 45 minutes, and connection to the
wider NHS system, such as urgent care services.
43. In delivering this, we want to secure transformation in general practice, including a
step change in our use of digital technologies, to support for urgent care, as well as
changes in general practice services that lay the foundations for general practice
providers to move to a model of more integrated services. We would not expect CCGs
to invest the totality of funding in additional appointments in the evening and
weekends, but to support wider transformation.
44. NHS England would like to see more transparency about the ease of making an
appointment in general practice. This will also help us identify where the greatest
pressures are in the system, and give us a better starting point for making the case for
support in general practice. We have committed to provide better information on
general practice waiting times to the public and will be working on this during
2017. Collecting, analysing and interpreting information on general practice is
complex and we will work with the profession to look at this in more detail with a view
to sharing meaningful information with the public, which reflects the great care and
high levels of workload being undertaken in general practice.
45. In their
General Practice Forward View plans, CCGs were required to include plans to
deliver improved access at evenings and weekends and submit a trajectory to show
how the CCG will deliver improved access in 2017/18 and 2018/19. Regions have
provided a first view confirming CCGs showed that they would achieve the planning
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ambition of total coverage by March 2019. We are currently working to confirm the
detail of the plans and ensure delivery through NHS England assurance processes.
46. The Planning Guidance also set out how CCGs should plan to spend a total of £3 per
head as a one off non-recurrent investment commencing in 2017/8, for
practice
transformational support, equating to £171 million non-recurrent investment. This
investment commences in 2017/8 and can take place over two years as determined
by the CCG. The investment is to be used to stimulate development of at scale
providers for improved access, stimulate implementation of the 10 High Impact
Actions to free up GP time, and secure sustainability of general practice. CCG plans
show commitment to invest the £171 million over the two years.
47. The new £30 million national
General Practice Development Programme – Time for
Care – is providing tailored support for groups of practices to help release capacity
and work together at scale, enable self-care, introduce new technologies and make
best use of the wider workforce, so freeing up GP time and improving access to
services. The Programme focuses on three areas: sharing best practice;
implementation support, and building long-term capability for improvement in the
general practice workforce. National resources and expertise are helping groups of
practices plans their own Time for Care programme. To date, 86 schemes are
covering 107 CCGs.
48. The
General Practice Improvement Leaders programme is providing practical
training for clinicians and managers to lead service improvement through working
smarter, not harder through additional support for the leaders of at-scale primary care
collaborations, facilitating knowledge exchange, peer support and capability. We
have had 136 expressions of interest to date. The first two cohorts for 2017/18 are
fully booked.
49. Free
GP coaching sessions have also been offered to support practice redesign. At
least 327 GPs will have received 2 coaching sessions by the end of March 2017.
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Annex B
Case studies illustrating the local impact from
implementation of the General Practice Forward View
Increasing the number of doctors in general practice
NHS England and Health Education England’s revamped Induction and Refresher scheme
to attract family doctors back makes it easier than ever to return to the profession
The first time Dr Frances Clement tried to come back to general practice after a 10-year
break she was faced by a wall of bureaucracy and gave up in frustration. But thanks to the
revamped scheme to attract GPs back, she has returned to work as a salaried GP in
Derbyshire, having been supported and funded through retraining.
The 49-year-old, who now works seven sessions a week for Royal Primary Care in
Chesterfield, admitted: “I’m absolutely delighted by what I have achieved. It’s obviously the
right thing for me at my stage in life. But if you had asked me two years ago, I would not
have been able to imagine how I would be able to make this choice.”
The newly-simplified GP Induction and Refresher (I&R) scheme aims to make it easier for
GPs to return to practice after taking time to have children, work abroad or following a
change in profession. The hope is to attract an extra 500 doctors into the NHS through this
scheme by 2020-21.
Changes were made to the I&R system in November 2016 to boost financial support and
streamline the process.
In Frances’ case, her successful return to general practice - from gaining a place on the I&R
scheme to starting her current job - has taken 11 months. She had a bursary of £2,300 per
month to do it, and a supervised placement overseen by accredited GP trainer Dr Helen
Rainford.
Dr Rainford, who is passionate about training and being a GP, added: “I try to make a
purpose-built rota for people so that they can learn in an environment that is supportive – in
Clement’s case, as a working mother.”
Those coming onto the I&R scheme from November 2016 receive even more. Their bursary
has been increased to £3,500 per month during the scheme, with assistance with indemnity,
General Medical Council membership and Disclosure and Barring Service fees. Practical
support has been expanded to include a new national support team based in Liverpool, to
provide each returner GP with a dedicated account manager and contact point to support
them through the process.
Clinical pharmacists in Norwich
Summary
Clinical pharmacists working across GP practices to help patients stay well and out of
hospital as well as support GPs and practice nurses with demand.
Three clinical pharmacists are working across five GP practices in Norwich and are pro-
actively helping patients stay safe, well and out of hospital as well as support busy GPs and
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practice nurses. They began work in spring 2016 and have, according to one local GP
“added a whole new dimension to patient care.”
Many patients at the five ‘pilot’ practices are now able to see a clinical pharmacist rather than
a GP, because they have the specialist knowledge to help – in just the same way as many
patients will see a practice nurse. It means people see the right clinician in the right place at
the right time, a key ambition for Norwich’s new GP alliance called “OneNorwich”.
John Higgins, who works from Norwich Practices Health Centre, said
: “It has been a big
success so far. One of the major successes is that patients enjoy seeing us face-to-face,
they ring to thank us afterwards! If a GP is unsure about anything they can send me a note
and I will do the prescription via the electronic prescription service (EPS) within ten minutes.”
EPS was rolled out in Norwich last year. As well as prescribe, the clinical pharmacists
undertake medicine reviews, help manage discharge of people from hospitals to make sure
they are taking the right medicines in the right dose and identify patients who might need
ongoing support to stay safe and well.
John said: “Many people with long term conditions like asthma don’t understand the
importance of attending annual reviews, which can lead to them not using their medication
properly. Some end up going to hospital. We look for those who ‘do not attend’ and
telephone them to offer advice. We don’t want anyone going to hospital over winter, no-one
does. We are helping prevent admissions by keeping people safe and well.”
John’s clinical pharmacist colleagues in Norwich are Naomi Power, who works in Oak Street
and St Stevensgate Practices, and Graham Chapman who works in Woodcock Road and
Taverham practices. Both pro-actively reach out to patients who may benefit from additional
medicines management as well as supporting colleagues in practices. Naomi is also
developing a pain management clinic.
Naomi added: “I think having a clinical pharmacist to talk to directly, who has specialist
knowledge and can advise on the latest guidelines, makes all the difference.”
Graham said
: “We particularly help in discharge management, being able to identify patients
where additional care and support may be needed.”
The pilot is an important part of NHS Norwich Clinical Commissioning Group’s ‘new model of
care’ and is being watched very carefully by the interim leaders of Norwich’s new alliance of
GP practices called ‘OneNorwich’. Helping patients to see the right clinicians in primary care,
not just a GP, is a vital part of their planning. It is also a component of the proposed
Sustainability and Transformation Plan for Norfolk and Waveney.
GP Dr Chris Dent, who is on the governing body of NHS Norwich CCG, said:
“patient
feedback was largely positive. He said: “Clinical pharmacists have added a whole new
dimension to patient care by improving the quality and safety of prescribing and helping us to
make better use of resources.”
Improving access
Physio First, West Wakefield
Summary
Experience shows that 70% of presentations can be fully dealt with in a single 15 minute
appointment. This has reduced pressure on GP appointments and provided better care for
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patients, with a significant reduction in the wait for expert advice. Patient satisfaction has
been very high, with 100% rating their experience as ‘good’ or ‘very good’.
Patients contacting the practice with a new musculoskeletal problem are offered an
appointment directly with the physiotherapist, often on the same day, without needing to
consult a GP.
As part of the GP Access Fund, six practices in West Wakefield found that around 20% of
GP appointments were for musculoskeletal complaints. To release GP time, they arranged
physiotherapy sessions at one of the health centres, bookable directly using the GP clinical
system.
Receptionists, working as care navigators, ascertain the patient’s need when they first
contact the practice. Patients presenting with a new musculoskeletal problem from a pre-
determined list are offered an appointment with the physiotherapist rather than a GP. This is
also offered as part of the online consultation system being used by the practices.
The physiotherapist has 15 minute appointments with patients. They have full access to the
GP record, making it easier for them to make a safe and accurate assessment, and allowing
them to record the consultation in the notes. The appointment provides an assessment of the
problem and advice on exercises and self-management. Where appropriate, the
physiotherapist makes an onward referral for continuing therapy. They may also request a
prescription via reception or refer back to the GP. Receptionists ensure this is handled in the
most appropriate way.
Impact
Experience shows that 70% of presentations can be fully dealt with in a single 15 minute
appointment. This has reduced pressure on GP appointments and provided better care for
patients, with a significant reduction in the wait for expert advice. Patient satisfaction has
been very high, with 100% rating their experience as ‘good’ or ‘very good’. Practices
themselves are pleased, too, and the scheme expanded rapidly from one to all six practices
in the first few months.
Practice Resilience
Pioneer medical group
The Pioneer Medical Group was created as part of a merger between three practices in the
south west. Each of the practices faced different issues. Avonmouth practice was identified
as vulnerable due to the reliance on part time workers, meaning high locum costs, and the
prospect of losing funding. Ridingleaze had long term difficulties in recruiting replacement
partners for two which had retired and one which had gone on maternity leave. Bradgate
was looking to develop long term sustainability (there were 6 clinical partners but no salaried
GPs). All three practices were clear that they wanted to bring certainty, sustainability and
resilience to their practices whilst focusing on patient centred care.
Using funding available under the vulnerable practices fund, Pioneer Medical Group (PMG)
was formed on the 1st April 2016 and is the merger of Bradgate Surgery, The Medical Centre
Ridingleaze and Avonmouth Medical centre.
By merging, the practices have been able to maintain their long term sustainability while also
maintaining the continuity of care that their patients valued. All evidence supports that this
has a significant impact on hospital admissions and patient satisfaction.
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The practices were also able to expand the wider primary care team e.g. pharmacists,
physicians associates and social prescribers. Clinical expertise is shared across all sites via
internal referrals. If there are gaps in service at one site yet over-staffed at another the
partnership will ensure that patients are not disadvantaged by relocating clinical sessions
from one site to another. Locum costs should reduce significantly.
The merger has also allowed the practices to make better use of technology and new
systems of working. Patients are able to consult at any base with any clinician and IT is used
to expand the range of options available to patients. With a larger clinical workforce,
increased number of clinical bases, greater use of IT and working with our primary care
colleagues we are able to support the development of access to primary care at evenings
and weekends. We believe that this model is safe, sustainable, responsive, and can grow as
patient need and numbers dictate.
Not only are all three practices now in a much more sustainable position, they are now in a
position to support other vulnerable practices. The agreed plan with NHS England is that
Hotwells Surgery will merge with PMG on the 1st January 2017. Hotwells Surgery has a list
size of 3,300 and is currently identified as vulnerable. The practice is run by a single handed
GP who will be retiring in 2017. The service uses long and short-term GP and nurse locums
and has no employed management.
Estates and Technology Fund
New Brighton
St Georges Medical Centre wanted to provide a new model of personalised and co-ordinated
health care services for their registered patients by integrating local, community and
secondary care services in-house. The supported improvements saw three administrative
rooms totalling 137 square metres being renovated into six consulting rooms to support
delivery of primary medical services. The new rooms increase space utilisation for the
practice in order to increase patient contact time and help reduce emergency admissions of
the frail and elderly by offering more preventative care and support.
In line with the Five Year Forward View, the additional consulting space will also create
opportunities for the practices to host 8-8 working as part of a single organisation, federation
or network of practices, enhanced services to support patients manage their conditions in
community settings and host outpatient consultations.
Lincolnshire
Care Portal is a ground-breaking new IT system allowing doctors to see a patient’s complete
medical record for the first time. The new system, installed across Lincolnshire, will allow
instant access, if a patient gives permission, to a complete set of medical and care records,
helping health and care professionals make decisions quickly and appropriately. It will also
allow patients to access their own records online an enable them to choose to share their
records with others, such as family members and carers.
Care Portal is powered by InterSystems’ global leading health informatics platform
‘HealthShare’. The initiative was developed as part of the Lincolnshire Health and Care
(LHAC) programme – a partnership of 13 health and care organisations across the county
working together to find ways of transforming services.
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As part of this work, which has involved hundreds of clinicians and included engagement
with over 15,000 residents in the county, the lack of access to full medical records emerged
as a key problem. Medical and care professionals identified the issue as a crucial hurdle to
joined up services and a problem which currently wastes valuable staff time. Patients also
made it clear they were frustrated when they often had to repeat their story several times to
different people during their care.
LHAC has managed to secure nearly £1m of NHS funding to support the introduction of the
Care Portal and implementation will be phased over the next two years. As well as improving
the experience and treatment of patients it is believed the new Care Portal will make a real
difference to the over stretched finances of the local health community. For example:
It is believed the Care Portal would release time to devote to patient care,
saving nurses and doctors between 10 and 15 minutes a day by avoiding the
need to access several different systems a day. Multiplied across the hundreds
of staff across the county it will free up huge amounts of time.
Based on figures from other Trusts, ULHT estimates that the Portal may lead to
a reduction of 8% in the number of patients sent for imaging tests and result in
up to 27% less lab tests ordered.
It is estimated that reductions in the number of patients sent for tests could
save around £4m a year in Lincolnshire.
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