This paper from Hammersmith and Fulham CCG looks at the urgent care and out of hours primary care provision in the borough and makes proposals about the hours of those services. This includes the case for change, the current usage of the two urgent care centres and the out of hours services as well as the public and stakeholder engagement to date and plans for consultation.
Councillor Richardson welcomed Janet Cree, Dr James Cavanagh, Rory Hegarty and Vanessa Andreae, who would jointly speak to the report. Ms Cree explained that that the report outlined primary care and urgent care centre (UCC) proposed changes. It also addressed the implementation of digital plans, the offer of increased choice, responding to patients to match demand. Ms Cree referred to details in the report about UCC, focusing on Hammersmith Care Centre, where just under 8% of usage occurred between midnight and 8am. Commonly, five people attended the centre overnight, most of whom were discharged without further treatment. Routine data indicated that around six patients would be discharged, and one transferred to A&E. Clinically, only two patients per night were treated. There was no proposal to change the UCC at Charing Cross Hospital.
In H&F, 765 additional GP appointments were currently commissioned weekly through two schemes, extended hours and weekend plus. Demand was met across the 29 practices in total; 19 practices were locally commissioned and 5 delivered in accordance with the national criteria. The CCG had met with NHS London Clinical Senate on 20 November 2018, and had outlined proposals and presented the clinical data that they hoped to consult upon. The Clinical Senate had sought further details about the transfer of patients to Charing Cross and about how consultation would take place. The Clinical Senate had confirmed that the proposals were clinically safe, compared to the current model, and that changes would not impact on the provision of primary care services. Chapter 5 set out an overview of the consultation and presented feedback, responding to some of the questions raised.
ACTION: CCG to provide information about patient transfers to Charing Cross, and, how the consultation would take place. CCG to forward this information to the Strategic Director of ASC and PSR.
Lisa Redfern expressed concern, and contextualised the impact of the proposed changes on residents. The commentary provided, in her view, a complex and inadequate narrative and appeared to be trying to achieve too much, in a short period. The intention to reduce services and, simultaneously introduce changes, was hugely challenging and would have a major impact. Ms Redfern recognised that there was logic in the proposals for reducing UCC services, but there was no compelling argument for the parallel reduction in GP out of hours provision. This, together with the reduction in practice hubs, held little logic. The introduction of digital based services such as GP at Hand, was also difficult to understand. Drawing a comparison with mobile banking services, Ms Redfern cautioned that the CCG were trying to phase in a significant change over a short timeframe, against a backdrop of additional, significant primary care service variations. The process also failed to recognise that while part of the population would be able to adapt, other groups would need longer to adjust. Any consultation questions would need to be set in this context. A final concern was the fact that these reductions in services had all been introduced at the same time, within the same setting.
Councillor Caleb-Landy echoed Ms Redfern’s comments and expressed similar concerns. The report was complex and needed to be understood in the context of the CCG financial report (Agenda Item 8). He questioned if the changes were motivated by the financial difficulties that the CCG were experiencing. Ms Cree responded that the changes were about matching availability of demand, while at the same time meeting a duty of care to provide efficient services. Current provision was underutilised and clinical resources needed to be used effectively. Feedback from patients had indicated that it had been complicated to navigate UCC care pathways. The aim of the proposals was to try and achieve greater clarity, maintain clinical safety, and improve patient pathways. These were not financially driven; although it was accepted that this was conjoined with ensuring efficiencies.
Ms Cree continued that they had consulted with the provider, who had joined them at the Clinical Senate. One of the difficulties was that Hammersmith UCC was not situated in a co-located facility, which was frustrating. The proposed changes would help move provision towards co-located services. Councillor Caleb-Landy welcomed this approach but expressed concern that residents had not been consulted about the options that they would like to see and to decide for themselves as to what they wanted. In his view, this constituted an important part of the consultation. Ms Cree responded that feedback from the Committee was helpful, as part of the consultation. It was explained that one of the key factors driving the need for change was that the Hammersmith UCC contract was due to end and would need to be re-contracted. The CCG had tried to be clear about the proposal, without predetermining the outcome.
Councillor Kwon observed that the CCG report appeared to be an amalgamation of three different reports. It was hard to envisage what services would be available, following the implementation of the changes. The proposals offered a reduction in services, however, Councillor Kwon commented that she would have welcomed more solutions being offered in the report. Councillor Richardson supported Councillor Kwon’s comments, and added that it was difficult to see the logic in reducing out of hours appointments, at the same time as reducing UCC provision. Ms Andreae responded that the digital offer addressed some of these concerns and would ensure that provision was future proofed. Broad consultation on all the proposals was necessary to ensure transparency and openness. Ms Andreae acknowledged that some of the changes were financially driven, however, if residents indicated that this was not wanted, then some uncomfortable financial decisions would need to be made. Ms Cree reiterated her earlier point in response to Councillor Kwon’s comments, that out of hours practice appointments had been underutilised and that there was an urgent need to match need to resource.
Co-optee Jen Nightingale asked about how successful the digital offer was expected to be and Ms Cree explained that this was difficult to report. There was a cohort of patients that would benefit from this type of access. The vision was that H&F residents would all have access to a GP. Ms Andreae expanded that there were different tiers within digital care and that the level of this kind of service would vary in different practices. They hoped to mirror the NHS 111 offer, in addition to offering an appointment. It was important to identify what would work well for residents, according to individual practice requirements.
Co-optee Jim Grealy commented that the changes were cuts. Referencing previous CCG communications which informed residents about A&E services moving to UCCs, Mr Grealy pointed out that people had not been properly signposted. He suggested that the CCG reviewed current provision and reconsidered their approach. The CCG needed to be honest, open and upfront up about having a cost-cutting agenda. The key point to note was that out of hours care was being reduced, with fewer GP appointments being offered. He added that it was not the responsibility of members of the Committee to endorse a cuts agenda. Ms Andreae admitted that this was partly about finance, particularly given the UCC contract renewal. H&F CCG was the only CCG that offered this level of out of hours service, which was outstanding compared to the national offer. Ms Cree added that the report set out proposals for discussion and had not predetermined the outcome.
Mr Naylor said that it was nonsense to put the document forward as a consultative document, when it was clearly about cuts. It was implied that local, older people were aware of the local offer, however, most were confused, not knowing when to contact NHS 111, or go to the UCC. The assumption that residents were informed, was an error in judgement and it was suggested that the CCG needed to communicate the current offer, and how to access it, before they determined whether services should be reconfigured. The CCG welcomed the comments and reiterated that this was not the final consultation document.
Councillor Umeh endorsed comments made by Ms Redfern and pointed out that the Northern part of the Borough was not well served. To consider the closure of the Hammersmith UCC was a concern. Residents could access services at Charing Cross, if they could reach it, and that this lack of provision was unacceptable. It was also insulting to residents to imply that most did not understand the digital offer. In response, Ms Andreae said that most people would self-select in terms of how they accessed services, but those who sought the digital offer were largely older. Patient pathways could be confusing, if consulted on separately, which was why they had chosen to consult on all aspects.
Ms Redfern sought confirmation that an analysis of patients transferring to A&E would be included as part of the consultation process. The current data did not indicate whether the patient would be able to manage the journey. Ms Cree clarified that some patients were transferred to A&E, dependent on their condition and the treatment needed. Councillor Coleman described the report as confusing, and that it was not clear what questions were being consulted upon. The report offered little clarity about the questions being asked in the context of reconfiguring out of hours services.
That the meeting be extended for a further thirty minutes.
Ms Cree referred to the front page of the covering report, and chapter 4 of the report which outlined questions for the consultation. The bullet points were clear and specific, and the aim was to ensure proper scrutiny as to the quality of the consultation. The CCG sought feedback as to how this could be improved. Councillor Coleman referred to page 33 of the report and enquired if the policies were in line with Shaping a Healthier Future (SaHF) and how this could be married with the possible, increased burden to Charing Cross Hospital. Ms Cree responded that the CCG ensured that patients were provided the right care, in the right place, complying with clinical safety standards. The proposed overnight closure was endorsed by Imperial and would not impact on performance at Charing Cross.
Councillor Coleman sought confirmation about the information in the report and references made to information that would come out of the consultation. He asked if this was sufficient for further analysis or if more information would be required. Ms Cree confirmed that they had sufficient information on which to go out to consultation and receive feedback from residents.
Councillor Lloyd-Harris referenced the report and noted that 64% of patients could access alternative provision. She asked if there was a procedure in place to ensure that individuals could access a GP appointment. Ms Cree confirmed that more accurate information was available about the type of presentation that might be treated at UCC. If the proposals were accepted, the CCG would have to consider how to advertise them. At the same time, they would have to consider the how patients would navigate the digital offer. Finally, if Hammersmith UCC closed, they would also have to consider how patients could access Charing Cross UCC. Councillor Lloyd-Harris pointed out that groups with protected characteristics (Equalities Act 2010) might find it difficult to access services. Ms Cree replied that she was aware of this, and additionally, groups without protected characteristics, who are also less able to access services. Mr Hegarty confirmed that the CCG wanted to reach as many groups as possible, across the Borough and welcomed advice from the Borough on how to do so.
Ms Brignell commented that the out of hours offer suggested that the service was needed and used by the majority of patients. Ms Cree explained that the proposal was to change the way in which this service was commissioned, and not cease commissioning it. Some practices made additional provision under a local offer, and all practices delivered Direct Enhanced Services (DES) under a national scheme. Both were offered with different rates of pay. The proposal was that all practices moved from the local offer to the DES (national scheme). Ms Brignell understood the distinction but reiterated that patients valued the flexibility that the local offer provided.
Merrill Hammer, Save Our Hospitals, challenged the idea that the aim was to match the availability of services according to demand. Hammersmith UCC was in one of the most deprived parts of the Borough, with a high percentage of BAME (Black and Asian minority ethnicity) groups. Yet there was no data to indicate the attendance of groups within the protected characteristics cohort. The data was based on only one year’s attendance at A&E and there was little to indicate that information about UCC services had been given to residents. Ms Hammer questioned how well the CCG had communicated information. She suggested that the CCG needed information about how well residents knew what was on offer. Less deprived residents in the South of the Borough understood the local offer better and the CCG needed to address the imbalance. Ms Hammer also pointed out that formulated plans about the digital offer were not provided.
Councillor Caleb-Landy commented that it was difficult to perceive any consideration or thought behind the planned consultation and that a wider, strategic narrative would have been helpful. There was no indication as to the cost of the UCC, or, the possible back office savings. He was concerned that withdrawing the service could have an adverse impact on other services.
In summarising the key points of the discussion, Councillor Richardson highlighted the lack of information to patients and asked if it was possible to have data that extended further than a year, and in addition, what publicity had been provided by the CCG communicating details of the UCC local offer. The Committee requested further details about the viability of the proposals and the nature of the consultation and Councillor Richardson confirmed that she would be writing to the CCG to request further clarification.
ACTION: The Chair to write to the CCG, requesting information about the viability of the service change proposals and the nature of the consultation about the proposed changes
That the report be noted.