Nigel Watson's Email Update - November 2016
Date sent: Tuesday 15 November 2016
Nigel Watson's Email Update - November 2016
Has General Practice got a future in the UK?
This sounds like a dramatic question but it is a subject that has been in my thoughts quite a lot lately. I am absolutely certain General Practice has a future but I suppose the question should be what does that future look like?
It would appear that everyone agrees on the problems that the NHS faces and more particularly those faced by General Practice, but what appears to be lacking to many is a cohesive plan on how we meet the growing patient demand, receive adequate funding and change the fortunes of the workforce so that once again General Practice gets more applicants than posts available rather than there being insufficient interest to fill the vacant posts.
We all work in a service industry that is publicly funded, but have you asked yourself "who is our customer?" Is it our patients, or in reality is it NHS England acting as a proxy for the Government?
NHS England commissions our services on behalf of the Government and therefore we need to understand the services they want to provide to the population as they fund the NHS and so in effect are the customer.
In October 2014 the NHS published the Five Year Forward View which should be considered as a roadmap for the next 5 years. This document details the "New Models of Care" that were to be developed and tested called Multi Specialty Community Providers (MCPs) and Primary and Acute Care Systems (PACs). Recently the GP Forward View was published and hailed as the "rescue package" for general practice. Finally, much publicity has been given to the Sustainability and Transformation Plans (STPs) which are being developed in defined geographical areas around the country.
These policies are not independent but are part of a broad policy of transformation that the NHS is undergoing. Whether we agree with the agenda or not it is vitally important that all GPs understand what is likely to happen over the next few months and years.
What does all this tell us?
At our recent LMC Annual Conference we tried to provide a programme that would start to address this important question with presentations covering all these areas. I know for some this seems like information that you have received before but much is changing and it is changing fast and this is why we are trying to keep you informed.
General Practice Forward View (GPFV)
The GP Forward view is beginning to get more publicity as we get more of the details of the 83 commitments. I do not intend to list each and every commitment but just highlight those most relevant at this point in time.
The GPFV has five key areas of commitments which are:
- Practice Infrastructure
- Care Redesign
The GPFV is committed to deliver an additional £2.4bn per year into GP services by 2020/21 (an increase of over 14%). It is important to recognise this is not money that will be added to practice baseline funding but will largely be use to invest in services to support General Practice.
The Prime Ministers Access Fund has already invested £150m into providing improved access and providing this at scale. These pilots currently cover a population of about 18m (which equates to about 1/3 of the population). A further £350m will be available to expand this programme.
It is important to recognise that this access, which was initially about providing access to General Practice from 8am to 8pm seven days a week, has evolved to recognise that this cannot be delivered at practice level and needs significant additional funding. To be effective these services need to support the provision of primary medical services at the level of the practice and need to evolve to be a flexible way of delivering a multi-professional primary care service at scale.
The additional funding will enable other areas to develop services to support General Practice.
This is a real issue in terms of the rising costs for the individuals and also for those GPs who may work part time and are put off undertaking additional sessions because of the additional cost of indemnity. The other problem practices are facing as they embrace a new workforce in terms of expanding their team to potentially include Pharmacists, Paramedics, Mental Health workers etc. is the costs and availability of indemnity.
Although having some additional funding to cover the rising costs with some of this to help out of hours over the winter months, a more comprehensive solution needs to be found because if it is not we will never address the workforce issue.
Practice Infrastructure, Resilience and Training
Practices in Wessex are starting to benefit from investment in these areas with additional commitments having been agreed and to be implemented in the near future (more details later).
The Vulnerable Practice Scheme
This scheme is being implemented, practices have been identified and help is being offered. Our concern is that all practices are vulnerable and we need a significant amount of help and not just a "sticking plaster". The LMC will continue to work with the commissioners to support these practices.
The GP Resilience Programme
This scheme is under development and we expect more details shortly. There is a sum of about £40m to be invested over the next 3 years and £10m will be used within this year.
Wessex Area Team has about £1.2m to invest this year and about 60 practices will benefit from substantial financial support. The investment is aimed at helping practices who have been put into special measures through CQC, those who are struggling to recruit or have problems with the workforce and practices who are trying to become more resilient by merging with other local practices.
There will be more funding available next year. The LMC is working closely with the CCGs and Area Team and will share more details about the support that will be more widely available.
Estates and Technology Transformation Fund (ETTF)
This fund was developed from the primary care premisis fund and has about £900m to invest over the next 4 years. In June 2016, local Clinical Commissioning Groups (CCGs) submitted recommendations to NHS England for Estates and Technology Transformation Fund, in line with their local estates and digital plans for investment in a range of GP premises and technology schemes.
The Estates and Technology Transformation Fund is a multi-million pound investment boost in GP premises and technology, to improve and expand out of hospital care for patients, a key commitment set out in the General Practice Forward View.
Nearly 300 new schemes across the country are set to be supported this year. A number of larger scale schemes are also planned for completion in future years.
A number of schemes in Wessex were amongst the successful bids.
The first stage of the delivery of expanded psychological therapies in primary care for patients with long term conditions including diabetes or COPD was announced in October. The GPFV commits to fund an extra 3,000 mental health therapists in GP practices.
NHS England awarded more than £11m in 2016/17 and over £24m in 2017/18 to fund 30 Clinical Commissioning Groups to improve mental health care for patients with long term conditions through 22 different psychological therapies schemes; they are expected to start seeing patients beginning within the next three months. Many people with anxiety disorders or depression also have a long term condition like diabetes or COPD. A pilot showed that treating people’s physical and mental health problems in an integrated way can lead to better outcomes improving both people’s mental health and management of their long term condition.
The LMC is seeking more details about which CCGs are receiving the funding and what the implications are for those working in the CCGs who have not been included.
£171m Practice Transformational Support
This is intended to:
- Stimulate development of at scale providers for extended access delivery.
- Stimulate implementation of 10 high impact changes.
- Secure sustainability of general practice to improve in-hours.
10 High Impact Actions to Release Time for Care
This is all about the use of resources, spreading existing innovations and a new audit tool to identify ways to reduce appointment demand.
Follow the link - click here.
Provide 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 as well as signposting to the most appropriate professional. Receptionists acting as Care Navigators can ensure the patient is booked with the right person first time. There are some excellent examples here from Wakefield and Leeds.
2. Different Consultation Types
Most practices find it difficult to provide enough surgery appointments to meet patient demand. Some practices phone triage all appointments and some focus on just urgent care appointments. There may be alternate ways of providing a service that could reduce demand. The use of phone follow ups rather than face to face (yes, I know you probably already do this but many don't), e-consultations (Web-GP now called e-consult). Where clinically appropriate, these can improve continuity and convenience for the patient, and reduce clinical time per contact. There are some excellent examples from practices who have introduced these. Web-GP is now being used by many practices in Hampshire. We are hoping one of the practices who have implemented this and seen a significant impact will produce a video clip to help show what can be achieved.
3. Reducing DNAs
Maximise the use of appointment slots and improve continuity by reducing DNAs. Changes may include redesigning the appointment system, encouraging patients to write appointment cards themselves, issuing appointment reminders by text message and making it quick for patients to cancel or rearrange an appointment.
4. Develop the Team
Broaden the workforce, to reduce demand for GP time and connect the patient more directly with the most appropriate professional. This may include training a senior nurse to provide a minor illness service, employing a pharmacist or providing direct access to physiotherapy, counselling or welfare rights advice.
Medical Assistants - the GPFV promises 1,000 of these - but who are they and what do they do? GPs doing phone consultations work alongside a specially trained member of the clerical team, who releases the GPs time by performing administrative tasks before and after the consultation, as well as connecting the patient to preventive and support services. This has created 33% more GP appointments per clinic for the practices.
Other examples detailed relate to Pharmacists in practice, Physiotherapists and Paramedics working as part of the practice team.
5. Productive Work Flows
Introduce new ways of working which enable staff to work smarter, not just harder. These can reduce wasted time, reduce queues, ensure more problems are dealt with first time and that uncomplicated follow-ups are less reliant on GPs consultations.
6. Partnership Working
Create partnerships and collaborations with other practices and other providers in the local health and social care system. This offers benefits in terms of improved organisational resilience and efficiency, and is essential for implementing many recent innovations in access and enhanced long term conditions care.
7. Social Prescribing
Use referral and signposting to non-medical services in the community which increase wellbeing and independence. Examples include leisure and social community activities, befriending, carer respite, dementia support, housing, debt management and benefits advice, one to one specialist advocacy and support, employment support and sensory impairment services.
8. Supporting Self -Care and Management
Take every opportunity to support people to play a greater role in their own health and care. This begins before the consultation, with methods of signposting patients to sources of information, advice and support in the community. Common examples include patient information websites, community pharmacies and patient support groups. For people with long-term conditions, this involves working in partnership to understand patients' mental and social needs as well as physical. Many patients will benefit from training in managing their condition, as well as connections to care and support services in the community.
There are some good examples that have been implemented from around the county.
It is expected that the Sustainability and Transformation Plans (STP) for our local areas will deliver many of these commitments.
This describes the move away from competition to the development of organisations working together in partnership and designing services to meet the needs of a defined population rather than an organisation. The commissioning of care will increasingly move from an organisational model to a population one that is built on the registered list system of General Practice.
Hampshire and the Isle of Wight have 3 Vanguards developing new models of care and additional work has been undertaken outside this programme in Dorset, Portsmouth and Southampton.
Developing General Practice - is a 3 year programme that is about to start which is backed by national funding amounting to £30m and can be accessed via your CCG. Click here for more details.
Changes to the Hospitals National Standard Contract
We are all too aware of the problems that General Practice faces at the current time. The GP Forward View has over 80 commitments to increase the resources that will be made available to support General Practice over the next 5 years.
The LMC is determined to work with CCGs, the Area Teams and others locally to maximise the benefits of these commitments.
It would be easy to be overwhelmed with the plethora of commitments and ultimately end up with few being delivered.
This email is the start of a stream of work to ensure the changes to the NHS Hospital contracts really does deliver the change that is intended and that General Practice is able to see the benefits in terms of workload in the near future.
What can practices do now?
1. Develop a practice policy on how to push back on inappropriate hospital requests that breach the standard contract. Perhaps use your next practice meeting to agree this.
2. Ensure all GPs in the practice are made aware of these new standards, and use the GPC’s templates (or any of your own), on each occasion that a hospital has failed to meet these new standards. Embed the template into your clinical system for automated use.
3. Ensure that the breach is notified to the CCG using the GPC’s CCG template.
4. Keep a practice record of all breaches, and the nature of the breach. Feedback the numbers and nature of any breaches to your LMC on at least a monthly basis.
The LMC would suggest we start with DNAs and onward referrals and then once systems are established practices embrace the other commitments that include:
- Follow-up of results and investigations
- Delayed discharge summaries
- Delayed clinic letters
- Provision of medication following discharge
1. DNAs - Contract reference SC6 states hospitals cannot adopt blanket policies under which patients who do not attend an outpatient clinic appointment are automatically discharged back to their GP for re-referral.
2. Onward referrals - Contract reference SC8 specifies that unless a CCG requests otherwise, for a non-urgent condition directly related to the complaint or condition which caused the original referral, onward referral to and treatment by another professional within the same provider is permitted, and there is no need to refer back to the GP. Re-referral for GP approval is only required for onward referral of non-urgent, unrelated conditions.
Please find below NHS Standard Contract letter templates for practice use:-
- Template response for missed appointment.
- Letter to Trust requesting that the hospital liaises directly with a patient who has missed an outpatient appointment, in order to book another one.
A - Template Response for Missed Appointment
Re: <<Patient Identifier Label>>
Your department has automatically discharged this patient from your service following a missed appointment. You have requested that we make a new GP referral for the patient to be seen.
You should be aware that this breaches new requirements in the standard hospital contract which came into force on 1 April 2016, to reduce inappropriate bureaucratic workload shift onto GP practices.
Contract reference SC6 states hospitals cannot adopt blanket policies under which patients who do not attend an outpatient clinic appointment are automatically discharged back to their GP for re-referral.
This was reiterated in a recent letter from NHS England to all Trusts.
In line with the national contract requirement, please liaise directly with the patient to organise another appointment as appropriate.
You will be aware that General Practice is under unprecedented workload pressures. It is not appropriate for GPs and staff to incur the additional bureaucracy and workload to re-refer patients after a single missed appointment. Additionally, several million GP appointments are wasted nationally due to patients seeing a GP for the sole administrative purpose of a re-referral, and which could instead have been offered to other patients.
Thank you for reviewing your Trust’s policy accordingly, and liaising directly with patients who miss a clinic appointment.
We have notified [insert] CCG as the commissioner of this breach in view of their responsibility to ensure delivery of the standard hospital contract.
B - Template Response for Onward Referral
Re: <<Patient Identifier Label>>
We write with reference to your request to make an onward referral regarding the above patient to [insert work requested].
You will be aware that changes to the standard hospital contract came into force on 1 April 2016, with new requirements to reduce inappropriate bureaucratic workload shift onto GP practices. This permits hospital clinicians to make an onward referral to another professional for a related condition as follows:
Contract reference SC8 specifies that unless a CCG requests otherwise, for a non-urgent condition directly related to the complaint or condition which caused the original referral, onward referral to and treatment by another professional within the same provider is permitted, and there is no need to refer back to the GP. Re-referral for GP approval is only required for onward referral of non-urgent, unrelated conditions.
This was reiterated in the recent letter from NHS England to all hospital providers.
We would be grateful if you would now make the onward referral accordingly for the above patient as you feel clinically necessary, without further delay.
You will be aware that General Practice is under unprecedented workload pressures. In order to not incur unnecessary additional bureaucracy on hard pressed GP surgeries, please organise to review your policy accordingly and ensure this is communicated to your team.
This arrangement will also have the added benefit of reducing unnecessary referral delay and waiting times for patients.
We have notified [insert] CCG, as the commissioner, of this breach in view of their responsibility to ensure delivery of the standard hospital contract
C - Template letter from Practice to CCG regarding New Standard Contract Breaches
Dear CCG Chair / Chief Executive,
Re: Implementation of changes to the Standard Hospital Contract
As you are aware, a new standard hospital contract came into force on 1 April 2016, with new requirements to reduce inappropriate bureaucratic workload shift onto GP practices. You will also have received a letter from NHS England reiterating the need for hospital providers to implement these new requirements.
I am writing to advise you that [insert trust] has breached the following requirement:
[Please tick as appropriate]
ð Stopping hospitals adopting blanket policies under which patients who do not attend an outpatient clinic appointment are automatically discharged back to their GP for re-referral (this wastes an estimated 15 million GP appointments per year).
ð Enabling hospital onward referral to and treatment by another professional within the same provider for a related condition, without the need to refer back to the GP. Re-referral for GP approval is only required for onward referral of non-urgent, unrelated conditions.
ð A requirement for hospitals to notify patients of the results of clinical investigations and treatments in an appropriate and cost-effective manner; for example, telephoning the patient. Therefore, GPs should not be inappropriately used to relay to patients results of tests generated by hospital clinicians.
ð Timely clinic letters to GP practices, no later than 14 days after the appointment, and with the intention of electronic transmission of clinic letters within 24 hours in the future.
ð A requirement to send discharge summaries by direct electronic or email transmission for inpatient, day case or A&E care within 24 hours.
ð Providers to supply patients with medication following discharge from inpatient or day case care for the period established in local practice or protocols.
I attach a copy of the letter which we sent to the trust on [insert date] in relation to this matter.
I would be grateful if you would advise what measures you will take in relation to this specific breach, as well as the measures which you, as the commissioner, are taking to ensure these new contract requirements are implemented to cease inappropriate bureaucratic burdens on GPs, at a time when most practices are struggling to cope with unsustainable demands.
I look forward to your response.
You can use the GPC's template letters in Quality First to reject such inappropriate transferred work. There are template letters for TPP and EMIS.
Free webinars are available for GP and other healthcare professionals.
Public Health England (PHE) and the British Society for Antimicrobial Chemotherapy (BSAC) have worked with primary care colleagues to develop a series of 7 free TARGET antibiotics webinars highlighting key easy actions you can take to help improve your antibiotic prescribing, and at the same time improve the patient experience and their self-care - click here.
I am about to have my appraisal and I am certainly going to include this in my PDP for next year.
For more information, please click here.
There is also an excellent Antibiotic App that was produced by the NHS locally and the LMC played a small part in the development of this - click here for more details or from your smart phone Apps - search for NHS Antibiotic Prescribing Guidelines SHIP By Blue Frontier.
GP Online Services
It does not need me to tell you how busy General Practice is. The demand for access to General Practice seems unstoppable. If you doubled your reception workforce you probably would still not have enough capacity to meet the demand from phone calls between 8 and 9am.
Do you promote the online booking of appointments?
Do you encourage patients to have online access to their clinical records and results?
Do you take advantage of patients ordering prescriptions online and moving to e-precribing?
Does your practice have a Facebook and Twitter Account? Do you know what they are?!
Here is some helpful information and templates that you might want to use - click here.
Adverse Comments on Websites and Social Media
As an LMC we frequently get calls from GPs and Practice Managers who are distressed because of adverse comments that members of the public or patients have made on Social Media. The BMA has recently produced some helpful guidance.
Please see the attached, which should help practices deal with the trolls!
Dr Nigel Watson
122-124 Hursley Road
Hampshire SO53 1JB (Registered Office)
Tel: 02380 253874
Mobile: 07825 173326
Attached file: unfair-comments-on-websites_1.pdf