Email sent by Wessex LMCs
Date sent: Thursday 16 June 2016
Email sent by Wessex LMCs
One could be forgiven in thinking that nothing changes in the NHS. I go into my surgery on a Monday and Friday and face the same clinical challenges and the demands of running a small business.
But in fact the NHS is going through some of the most significant reforms since its inception over 67 years ago.
The NHS has never stood still but has been evolving over time, the publication of the Five Year Forward View (5YFV) in October 2014 made a number of clear statements about the future plans for the NHS. (To read the document please click here).
Key issues from the 5YFV
There is recognition of the developments in the provision of health care which has led to better survival rates in cancer and cardiovascular disease, the shortening of waiting times and higher patient satisfaction.
There is a commitment to break down the barriers in how care is provided between GPs and hospitals, between physical and mental health, between health and social care.
There was also a recognition that "one size does not fit all" and therefore a new system whereby there was greater local determination of the priorities for the delivery of healthcare could be decided and creating the opportunity for new care delivery options. The included the Multispeciality Community Provider (MCP) and the Primary and Acute Care System (PACS).
There was a clear statement that the list-based system of general practice remains the foundation of the NHS and that GPs need a "new deal". The document goes on to state "over the next five years the NHS will invest more in primary care, while stabilising core funding for general practice nationally over the next two years. GP-led Clinical Commissioning Groups will have the option of more control over the wider NHS budget, enabling a shift in investment from acute to primary and community services".
Core funding for general practice was increased by £220m for 2016/7 and reflected some of the cost pressures associated with the rising costs of providing a general practice service and also specific expenses such as the rising costs of Indemnity cover.
The publication of the GP Forward View in April details a long list of commitments to invest £2.4bn more in primary care to support general practice.
In October 2013 there was an announcement of £50m being made available to improved access to general practice called the "Prime Minister's Challenge Fund", this has now become the Prime Minister's Access Fund. An additional £100m was made available for 2015/6 and the scheme expanded to cover about 1/3 of the population of England about 18,000,000 people. For existing sites funding has now been secured for the next 4 years and funding will be made available in 2017/8 for other areas to develop services to improved access in accordance with the requirements of the scheme.
There remain many questions about the introduction of a seven day service for general practice in terms of the available workforce, the need of such a service and the duplication with Out of Hours. (More below)
GP Forward View
The details of this are attached to the email. The LMC is determined to work closely with the CCGs and the Area Team to ensure that commitments that are made within this document at delivered and that we see general practice getting the resources and recognition it should have as the front door of the NHS and the major building block on which all other services in the NHS rely. Without general practice there would be no NHS.
Please see the attached letter which has been sent to all local hospitals and CCGs relating to workload in general practice.
Seven day services for general practice
I enter this debate with a fair degree of fear and trepidation as I know that it is an area that causes significant concern to all GPs.
It is worth pointing out that there is already a 7 day GP service, it is delivered by the 8,000 practices in the UK during the hours of 8am to 6.30pm Monday to Friday (except Bank Holidays) and at all other times by the GP out of Hours services.
The Government want to commission better access to general practice and this includes some routine appointments at a weekend.
So what does this means for GPs, their practices and primary care?
My view is that a 7 day GP service delivered from 8am to 8pm cannot be delivered within existing resources at practice level with an inadequate workforce.
So what could be delivered?
Practices continue to deliver services from 8am to 6.30pm Monday to Friday (except Bank Holidays).
Primary Care Access Hubs are created in "natural communities of care". These already exist in the areas that took on the challenge of delivering enhanced access through the Prime Minster's Access Fund. But instead of believing access should be just about GPs, these hubs should create a multidisciplinary focus and deliver additional services where there is a need for this to be delivered at scale rather than within each individual practice. This could include Advanced Nurse Practitioners, Extended Scope Practitioners (MSK for example), Mental Health Workers, Community Nurses, Specialist Nurses and Minor Injury Units. These Hubs could work closely with the OOHs service who could provide their non visiting services from the Hub.
A critical element of safe and effective services is the ability of these services to contribute to and share a common health record. Our electronic patient records need to be made more widely available for the benefit of patients taking into account a number of issues including appropriate access etc.
So in summary, the future for general practice is beginning to look more promising for some (we need to do more for those where the future looks bleak). General Practice needs more resources to support the delivery of core services.
The future is building on the registered list but also for practices to be part of a "natural community of care" (for me that is my locality of about 100,000). Practices need to be working together and with other providers such as community services and the local authority. The New Models of Care (PACS and MCPs) are developing new ways of working to deliver better and less fragmented services and aiming to make general practice a better place to work and therefore help to ensure its sustainability.
One important development that many GPs are not aware of is the creation of the Sustainability and Transformation Plans (STPs).
Sustainability and Transformation Plans (STPs)
Many have probably never heard of the STPs but these plans are vital to the future of general practice. These were announced in December 2015, the NHS shared planning guidance 16/17 – 20/21 outlined a new approach to help ensure that health and care services are built around the needs of local populations. To do this, every health and care system in England will produce a multi-year Sustainability and Transformation Plan (STP), showing how local services will evolve and become sustainable over the next five years – ultimately delivering the Five Year Forward View vision of better health, better patient care and improved NHS efficiency.
There are 44 health and care systems in England and in Wessex there are three:
2. Bath & NE Somerset, Swindon and Wiltshire.
3. Hampshire & IoW.
The health and care organisations in these 44 areas are working together to create a credible plan to deliver a sustainable local health care system and as part of that define the transformation that is require both within organisations and between organisations and providers. The plans have to have completed by the end of June and are a blue print for the next five years.
Those involved include NHS England, the CCGs, Acute Trusts, Community Trusts, Ambulance Trusts, Local Authorities, Health Education England, Public Health and General Practice.
It is well known that 90% of patient contacts occur in primary care, yet when providers are brought together, the one that is frequently missed out is general practice. All too often it is assumed that the CCG represents general practice, which of course it does not, it is a commissioner and does not have the mandate to represent GPs and practices in their provider role, that is the statutory role of the LMC.
Each area is at different stages of planning but are broadly developing similar plans. The LMC has negotiated a seat on each of the 3 local Boards.
What are the key messages?
1. Doing nothing is not an option - by doing this each local health system will face a significant financial gap.
2. Acute providers need to work together and collaborate in a way that many have not done before.
3. A greater proportion of patients need to be managed in the community rather than in hospital.
4. Social care has an important role in terms of the improvement in care for patients and also in terms of the efficient running of the NHS.
5. Prevention - in terms of lifestyle changes to stop people developing a specific disease and the early intervention in a long term condition to prevent the development of complications is critical to the health of the population and also to the sustainability of the NHS. Although the life expectance in England has been increasing recently, one factor often missed is that the population is spending more years in ill health as a result of the increase life expectancy as the prevalence of long term conditions is increasing and the age when they develop for individuals remains largely unchanged and for some such as diabetes are developing at younger ages.
6. General Practice - there is currently a 12% vacancy rate for GPs, if general practice fails then the NHS will fail, not my words but those of the Chief Executive of NHS England, Simon Stevens. So the STP also has to address the sustainability of general practice and ensure any transformation of work to be delivered in a community setting does not mean unresourced work is "dumped" on general practice.
Most agree the future is to build on the strengths of general practice and the registered list system but also there is a real need for primary care to be able to operate at scale with a much greater integration between general practice and community services. This must be underpinned by the technology to create a common health record with the appropriate sharing of information between providers.
The delivery at scale needs to have local ownership and can be delivered by individual practices working together, super practices, GP federations or in the future Accountable Care Organisation (ACO) that are being established in the Vanguard Areas.
You can see a common thread that exists between the Five Year Forward View, the GP Forward View, the STP. and much of the work that has been undertaken by the 3 Vanguard Areas in Hampshire.
All these are important to general practice today and in the future and this is the reason that the LMC has been very involved in all these plans, strategies and working with other relevant bodies to ensure the voice of general practice is heard.
Sessional GPs Newsletter
Here is the link to the latest Sessional GPs e-newsletter - click here.
The life expectancy for people with learning disabilities has increased significantly over the last 70 years. Yet people with learning disabilities are nearly 60 time more likely to die before the age of 50 than the rest of the population. For example a study showed that in the 1930's the life expectancy for someone with Down's Syndrome was 7 years and in 1998 it was nearly 60.
An important report was published in 2011 which identified that some of the health inequalities that is experienced by people with learning disabilities is avoidable - click here for the full report.
Challenging behaviour can also be a common feature and all too often this is treated with psychotropic medication and once started is often put on repeat medication without adequate consideration of stopping the medication after a short period of time. NHS England has recently highlighted this in a document called - "Stopping over-medication of people with learning disabilities" -click here for the document.
In 2004 when the new GMS contract was introduced a new enhanced service was introduce that funded practices to complete an annual review of the physical and mental health of patients with learning disabilities and produce a health action plan - for those practices that provide this service they are paid an annual fee of about £116. More details available by clicking here.
The Mental Capacity Act was introduced in 2005 and has had significant implications for GPs in terms of the management of patients who lack capacity. This is especially true for people with learning disabilities.
For more information on Mental Capacity - please click here.
The GMC has recently published a very useful flow chart about the assessment of mental capacity - the chart is attached to this email.
Anybody making ‘best interest' decisions on behalf of a person with profound and multiple learning disabilities must consult with the person's family and others who know the person well. Within the Mental Capacity Act the new legislation relating to Deprivation of Liberty (DOLs) was included and this also has significant implications for GPs especially for those with profound learning disabilities.
Following the death of a person in an Oxfordshire Learning disabilities unit, there has been much publicity and focus on the care provided for this vulnerable group.
There are a couple of national pilots looking in greater detail at the deaths of patients with learning disabilities who die between the ages of 4 - 70 to see if there were avoidable factors and to share any lessons learnt.
Although the raising of awareness is welcomed there is always a danger that this sort of investigation becomes the norm and rather than look for lessons that can be learnt it turns into looking to "blame" the clinician.
So the question that comes to my mind is, what can we as GPs do to help narrow the health inequalities for this vulnerable group of patients and how can we ensure that we protect ourselves and our practices from being exposed in an in depth review of an individual's care?
1. If your practice is signed up to the enhanced service ensure the annual review looks at the physical and mental health needs, produces a health action plan and records whether the person has capacity. In addition check where appropriate whether there is a DOLs in place and if so record this on the person's record.
2. If the practice has not signed up to the enhanced service consider doing so. In my practice the annual review is largely conducted by a practice nurse, although with the issues related to psychotropic medication and mental capacity may need a GP to review them.
3. Using templates allows the consistent recording of data and will add the appropriate code which ensures consistency and allows easier retival of data for reporting.
National Diabetes Audit
This is an annual audit and will take place over the next month. Each year when practices receive the email asking them to take part in the audit the LMC receives a flurry of emails asking where this is compulsory and what is the benefit of this.
There is not a contractual requirement to complete the audit but the LMC would strongly encourage you to complete the audit.
We all know the prevalence of diabetes is increasing, the latest estimate is that there are over 4m people with diabetes in the UK. About 3.5m who are diagnosed and 500,000 Type 2 diabetics who are undiagnosed. This is an increase of about 120,000 from the previous year.
It is estimated that diabetes costs the NHS about £10bn per year - that is more than the total budget for general practice. Most of this money is spent in secondary care and focused on managing complications.
There is a strong argument to invest more in the early detection and primary care management of this long term condition - so please help us to help you by completing this audit.
RCGP-led Fuel Poverty Referral pilot
Dr Tim Ballard, a GP from Great Bedwyn in Wiltshire and Vice Chairman of the RCGP, is spearheading a campaign to look at and address fuel poverty.
The pilot is testing primary care referral (practices and extended primary care teams) into the Warm and Safe Wiltshire energy and fuel poverty advice hub to get patients with conditions like COPD and asthma help with a cold/damp home.
The pilot has been live since March and they already have over 20 organisations registered (practices and extended primary care team). Similar interventions in the north east have had really impressive results in relation to decreased hospital and GP activity.
The LMC supports this initative and would encourage practices to sign up gain the benefits for the patients, the practice and the NHS that has been demonstrated.
Please see the attached document for more information.
Focus on GP funding changes - click here.
BMA's advice for practices - click here.
Dr Nigel Watson
Churchill House, 122-124 Hursley Rd
Chandler's Ford, Eastleigh
Hants. SO53 1JB (Registered Office)
Attached file: General-Practice-Forward-View-v3-NW-2.docx
Attached file: Mental-capacity-flowchart.pdf