Agenda item

[To discuss Primary Care in Wolverhampton.  Report from Paul Tulley (Wolverhampton Management Director) of the Black Country and West Birmingham CCG, and Survey Report from Healthwatch Wolverhampton are attached]. 

 

 

The Chair thanked Healthwatch Wolverhampton and the Black Country and West Birmingham CCG for the reports they had provided on Primary Care, included with the agenda for the meeting.  She emphasised that Health Scrutiny was not about criticism it was rather about helping to find solutions. 

 

The Wolverhampton Managing Director of the Black Country and West Birmingham CCG commented that since the last meeting in October where Primary Care was discussed, there had been the national publication of the Winter Access Fund, which was intended to support Primary Care and the access offer.  Face-to-Face appointments had increased significantly in the most recent two-month period.  The situation in the Black Country was similar to the national position.  

 

The Wolverhampton Managing Director of the Black Country and West Birmingham CCG remarked that the report included some useful information about the social prescribing model within the Wolverhampton area, which was one of the alternatives to seeing the Primary Care Team.

 

The Chair asked about the percentage of appointments which had originated with an initial telephone consultation and then had to be escalated to a face-to-face appointment, which could potentially be classed as double counting. The Director of Primary Care of the Black Country and West Birmingham CCG responded that roughly speaking four out of ten telephone appointments ended up being converted to a face-to-face appointment.  He didn’t agree with the term double counting as many people preferred a virtual consultation to a face-to-face appointment.  Many people felt safer with a virtual appointment than having to attend a GP Surgery.  They therefore counted all the activity and it was clear they would be moving to a more blended model in the future. 

 

The Chair of the Black Country and West Birmingham CCG stated that as a GP if she had 18 telephone calls in the morning she normally converted 4-5 of them into face-to-face consultations for the same day.  These figures would vary from surgery to surgery depending on the demography for the area they served.  She had also noticed that when people did come into the surgery after a telephone appointment they tended to raise other medical issues in addition to the initial issue.  She did not class it as double counting, rather catering to a person’s needs.  Telephone triage was also a useful way of helping to keep people safe from Covid.  She thought the current system was the best at the present time. 

 

The Vice-Chair asked if there was any statistics for people that were particularly vulnerable to Covid and were therefore safer not coming into the surgery and speaking to them on the telephone would be a better option.  The Chair of the Black Country and West Birmingham CCG responded that the figures would vary from practice to practice depending on the demographics for the area.

 

A Panel Member commented that she was pleased that the report had highlighted that the access problem was not a unique one to Wolverhampton, that there was a national shortage of GPs and nationally there had been an increase in demand.  She thought it was important to consider how demand for GP Services could be controlled and making people aware how they could access treatments through other avenues than General Practices.  She asked what steps were being taken to make people aware of all the different services available, such as opticians and pharmacists. 

 

The Wolverhampton Managing Director of the Black Country and West Birmingham CCG responded that there were a number of different areas they were looking to improve in relation to alternative access.  He cited as an example the promotion of the pharmacy service, the appropriate use of NHS 111 and also different ways of contacting General Practice.  They were still working on implementing some areas which included a national scheme allowing a GP Practice to formally refer into a community pharmacy.  Encouraging patients, who were able to do so, to make repeat prescriptions online or via an App, would also help to reduce the pressure on GP practices. 

 

The Wolverhampton Managing Director of the Black Country and West Birmingham CCG commented it was important to ensure that the GP Practices had access to all the digital services available and that they supported patients to use them.  They were developing a communication program to support it.  They were also working with GP Practices and particularly their Patient Participation Groups so they could fully understand the different options and make use of them.  They were very keen on using the Patient Participation Groups to help support different access methods to services.

 

A Panel Member remarked that there was an issue in Wolverhampton where some people struggled to obtain a face-to-face appointment even if it was their preference and they were elderly, vulnerable and had multiple health conditions. 

 

A Panel Member referred to the immense pressure health staff were under due to the pandemic.  Clearly there were some national solutions required to recruit more people into the health service.  He thanked the NHS for their outstanding work in challenging times.  He asked about accessibility for people who had language barriers, those that struggled with technology and people with dementia.  Communication on the telephone or video call would be harder for them than a face-to-face consultation.  

 

The Chair of the Black Country and West Birmingham CCG responded that any service provision was never going to be a one size fits all scenario. This was due to the fact of the differing needs of patients such as language barriers, speech and hearing difficulties and digital literacy.  Some practices were now allowing people to walk into the practice to book an appointment as they had been permitted to in the past.  At the start of the Covid-19 pandemic some staff due to their own vulnerabilities to Covid had to work in a different way.  At the beginning of the pandemic and with the introduction of new ways of working a training session was conducted for GPs.  The training focussed on people with speaking and hearing problems and how they could make GP services more accessible to them.  This included pop ups on the surgery’s computer screen, if it was known the person had these difficulties, which would mean they would not be offered a telephone appointment.  She agreed that there may have been some practices which had not yet reached the standard expected.  There were mechanisms in place to identify them and address the issues.  This included patient satisfaction surveys and national surveys. 

 

A Panel Member commented that the general public sometimes did not appreciate the long working days GPs worked.  When they read that some of them only worked 3 days, they did not take into account the hours that they may have worked on each of those 3 days.  They raised a general point about the effectiveness of Patient Participant Groups and were of the view that it was rare to find one’s of high standard in the Wolverhampton area.  To increase the effectiveness of the CCG’s consultation with Patient Participation Groups, some Patient Participation Groups needed to improve their standards.  He also raised a concern that access to GP appointments would decline over the next few months due to the Government’s drive for booster Covid-19 vaccinations.  This would alter the statistics of face-to-face appointments offered and other appointments.

 

The Wolverhampton Managing Director of the Black Country and West Birmingham CCG responded that access was variable across the different GP Practices and how well developed the Patient Participation Groups were.  The Healthwatch report had set out very clearly the variability across the system.  A well-developed Patient Participation Group was an asset to the practice and to the patients.  Part of the work the CCG would be carrying out with Patient Participation Groups was to support their development where appropriate.  The GPs had played a very important role in the vaccination program in Wolverhampton.  The Government ask was to offer everybody eligible, a booster vaccination before the New Year.  GPs has therefore been told to prioritise vaccinations but this was only to the New Year.  Clearly vaccinations would continue after the New Year as well.

 

The Vice-Chair of the Local Commissioning Board referred to the excellent translation service which GP Practices could use.  The service could be accessed if the patient was using a telephone or if they were attending a face-to-face consultation.  At the start of the pandemic all initial consultations had taken place on the telephone.  As the pandemic progressed GP practices had adapted and were able to offer people a face-to-face appointment if requested.  They also offered direct face-to-face appointments to children and people who struggled to communicate on the telephone.  Peer reviews were carried out so GP practices could learn from other ones.

 

A Panel Member commented that some health staff were leaving the NHS to enter the private sector.  They felt this area needed to be addressed.  She acknowledged that it needed to be considered at national level.

 

The Director of Primary Care from the Black Country and West Birmingham CCG stated that 57-60% of all the appointments were face-to-face.  A Who’s, Who guide had been produced for Primary Care on all the different services available.  They were investing massively on additional roles in Primary Care.  He was of the view that 40% of patients who saw a GP did not really need to see them but someone else.  If this issue could be solved it would free up some GP time.  A Primary Care Summit had been held at the end of September and there was a will for a new Primary Care Operating Model across the system.  Learning from best practice and setting it as a standard for all GP Practices was the way forward.  There was a variation in practices across the system.  They had started to develop a Primary Care Dashboard to fully understand the variation and how they could work with practices to have a core standardised patient offer.  This would mean all patients would know what to expect from their GP Practice.  They would be working with Healthwatch, Patient Groups and the public in co-designing the new operating model. 

 

A Member of the Panel commented that expectations, many of which were based on previous experiences needed to be managed.  They asked how the triage process was best managed, as it was critical to ensure that patients were allocated to the correct Primary Care Practitioner.  They also did not wish to see the private sector creeping into the Primary Care Health Services.  They wondered how Primary Care would look when the Covid-19 pandemic was largely over.

 

The Director of Primary Care from the Black Country and West Birmingham CCG responded that how Primary Care would look after the pandemic was  really important.  They wanted to learn from the pandemic to improve the Primary Care service in the future.  The Chair of the Black Country and West Birmingham CCG stated the ideal scenario was to aim for a Primary Care Service that was better than it was two years ago.  It was however important to recognise that national input was required.

 

A Panel Member commented that the pandemic had stimulated faster change of digital options in Primary Care.  They saw two important areas, as being retention and recruitment of nurses and doctors.  The growth of the population in the UK and therefore demand on Primary Care Services was also a crucial factor in understanding the pressures on Primary Care.  Dealing appropriately with the 40% of patients who did not need to see a GP was important; solutions to this problem were what was required.

 

The Manager for Healthwatch Wolverhampton commented that access to GPs had been an issue for a number of years although Covid-19 had exasperated the issue.  Healthwatch Wolverhampton had contacted directly all 56 practices within Wolverhampton to conduct a survey over the period of 15 – 26 November 2021.  The Healthwatch report gave an overview of the findings of the survey at PCN level.  The report had been shared with the clinical directors of the PCNs.  Some of them had asked for further information which had been provided to them. 

 

The Manager for Healthwatch commented that some of the messages on GP Practices answerphones were long and would have not been accessible to people who were deaf, hard of hearing or if English wasn’t their first language.  For some practices, patients had to call the same number for repeat prescriptions and blood tests.  Some practices offered morning and afternoon appointments; she thought an important point to consider was how this information was relayed to patients.  For RWT PCN practices, there had been a struggle to speak to the surgeries on the telephone. 

 

The Healthwatch Board Member commented that she had phoned a select amount of GP practices over a defined period of time.  Some GP practices she had been unable to speak to over the telephone as they were just engaged constantly.  This was appliable to the morning and the afternoon.  At one Practice she had managed to speak to them at 8:15am only to be told that the appointment system was not open until 8:30am.  This was in contradiction to the surgery’s own website, which stated that appointments could be booked from 8am.  There was another GP Practice which opened their appointment booking system at 7:30am and they had six staff available to receive the calls. 

 

The Healthwatch Board Member commented that it was her view that a lot of the surgeries within each PCN did not work together, they did not appear to be following the same format.  There was no defined structure.  Some PCNs worked better than others.  There were some practices where if an appointment was not available at the surgery, the person could be offered an appointment at an alternative surgery within the PCN area.  Some surgeries utilised the NHS 111 appointment service whereas others did not.  Her view was that there needed to be a more united approach across all the GP practices in how they operated. 

 

A Panel Member commented that clearly one of the issues, which was highlighted in the Healthwatch report, were the problems in contacting a GP Practice via the telephone.  He asked what the CCG were doing to help alleviate the problem and to ensure GP Practices were consistent in their approach to answering calls from patients. 

 

The Director of Primary Care of the Black Country and West Birmingham CCG remarked that they had completed their own audit during the Summer and had found essentially the same results as Healthwatch.  There was a massive variation in patients’ ability to get through to the surgery and the information available on practice websites.  There were in fact four practices which did not have any sort of website.  When developing the standard Primary Care operating model they wanted to look at the very best GP Practices.  It was clear that the telephone infrastructure could be improved within some of the PCNs and that there needed to be sufficient staff to be able to answer the calls in a prompt manner.  Dr Reehana’s surgery had seen a doubling of telephone traffic in the last eighteen months.  They were looking at care navigation to allow people to call certain numbers for administrative matters such as the patient’s place in a hospital waiting list.  They were aiming to bring together a Primary Care Transformation Strategy in the New Year. 

 

The Chair of the Black Country and West Birmingham CCG remarked that the CCG were completing a significant piece of work on the variation in telephony systems amongst GP practices.  They were looking to see if some practices , particularly some of the smaller one’s could move to a better system and if not, establishing the reasons why.  As an example, one of the reasons could be contractual obligations with a particular company such as BT.  A good telephony system at a GP Practice was now more important than it had ever been.  Funding for new staff to answer calls and providing a confidential space for them also had to be factored into any considerations for new telephony systems. 

 

A Member of the Panel asked if there was a national framework model that GPs should be working to.  She praised the roll out of the booster jab in her ward.

 

The Vice-Chair commented that it would be useful to know from the CCG the exact issues relating to retention and recruitment of staff and GPs in the Primary Care system in Wolverhampton.  Given the increase in the volume of calls and how the Primary Care system’s way of working had changed it was all the more important to find effective telephony solutions.   The Managing Director of the Wolverhampton area of the Black Country and West Birmingham CCG agreed to include some information on retention and recruitment the next time Primary Care was discussed by the Panel.

 

A Panel Member commented that a framework for monitoring progress in Primary Care was important.  He was particularly pleased with the Healthwatch survey report on Primary Care as it had highlighted clearly where some of the issues were in the Primary Care System.       

 

The Director of Primary Care for the Black Country and West Birmingham CCG commented that the majority of GPs across the country were self-employed.  They were essentially based on a normal partnership structure and they held a national contract which was a General Medical Services (GMS) Contract.  The contract was negotiated nationally but there was also a Qualities and Outcome Framework, of which part was negotiated nationally and part locally.  The local framework was where the CCG could introduce some additional standards.  Unless mandated nationally, local negotiations took place with the GPs to reach an agreement.  In the New Year, over 6-9 months they hoped to put together a Transformation Strategy.  There were currently four different Primary Care frameworks in the Black Country and West Birmingham CCG because of the old four CCGs which had merged into one.  During 2022-2023 their aim was to standardise the frameworks and then they would have to consider the commissioning routes to commission the new service.

 

A Panel Member requested that for the next report on Primary Care that the statistics showing the number of residents allocated to each GP surgery be included and the number of GPs working at each surgery.  They also asked for the number of sessions each GP undertook each week.  The representatives from the CCG responded that the number of residents allocated to each surgery was possible to include.  They would need to explore further whether they could provide the answers on specific staffing matters.

 

The Vice-Chair of the Local Commissioning Board stated that each practice based on the population size they served were expected to provide a specific number of appointments.  This came from guidance from the Royal College.  All practices strived to achieve the ratio.  She considered this a better way of looking at the question of GP provision within the City of Wolverhampton.

 

A Panel Member requested a routine survey report from Healthwatch on Primary Care.  The Manager of Healthwatch Wolverhampton responded that this was possible and she suggested a report could be brought to the next meeting of the Panel where Primary Care was considered.  This would demonstrate if there had been any changes since it was last completed.  She suggested a report every 3-6 months which could be brought to the Panel. 

 

The Chair commented that she was aware the Royal Wolverhampton NHS Trust PCN were introducing a new telephone system.  She asked if there were any other PCNs considering a similar system.  The Managing Director of the Wolverhampton CCG confirmed that RWT PCN were introducing a new cloud based telephony system.  This meant people at different physical locations to that of the actual GP surgery could take calls on behalf of the surgery.  It meant the calls for all the GP practices within their PCN could be managed together in one system.   All practices were being encouraged to consider their telephony systems and go down a similar route.  The Director of Primary Care for the Black Country and West Birmingham CCG stated that they could bring a summary of the steps they were taking on the digital offer and initiatives in Primary Care at the next meeting on Primary Care.  They were currently reviewing all the GP practices telephone systems. 

 

A Panel Member requested that Phlebotomy services at GP Surgeries be considered at a future panel meeting.

 

 

Resolved:

 

1.     That the CCG and each PCN works with surgeries and develop a plan where appropriate: -

 

a)    To develop a consistent approach to messages left on answerphones, taking into account language barriers and accessibility.

 

b)    To develop and enhance staff signposting knowledge and triage skills, including the introduction of a training programme to standardise provision.

 

c)     To share with patients more information about the different times patients can contact the practice for urgent and non-urgent appointments.

 

d)    To ensure that the vulnerable (including new-borns and young children) and elderly are prioritised for appointments and that face-to-face consultations for this group are as readily available as appropriate.

 

e)    To communicate more with patients on the purpose of the 111, 999 service and the NHS App. 

 

2.     That all PCNs monitor the new telephony system being introduced in the RWT PCN, with a view to potentially introducing a new system, working with partners, in other PCNs should it greatly improve the patient experience.

 

3.     The CCG explore the possibility of introducing a specific role in each PCN to monitor access and quality across the surgeries and make recommendations where required. 

 

4.     That the CCG complete a facilities and technology audit of GP practices in Wolverhampton and facilitate improvements where necessary.

 

5.     With the increase use of digital services, the Panel seeks reassurances from the CCG on the safety of data such as images, audio and video files. 

 

6.     That a Special Health Scrutiny Panel Meeting be held on Primary Care in March 2022 to review progress.