Agenda item

This report presents a briefing paper on the current state of primary care access across North West London following recent changes to GP contracts and plans to improve same day access to primary care for patients. The briefing paper was originally produced for the North West London Joint Health Overview Scrutiny Committee meeting on 14 March 2024 and is presented for information.

Representatives from NHS North West London will provide an updated presentation for discussion at the meeting.

Dr James Cavanagh (Medical Director for H&F) provided a verbal update on the same day access to primary care approach. Although the plan was devised with good intentions and aimed to enhance patients access and continuity of care, he highlighted the apprehensions felt by patients regarding its implementation. It was noted that various members of the Integrated Care Systems (ICS) had also expressed their apologies. Following the extensive and constructive feedback received from numerous individuals the position of the ICS had changed.

Many residents in Northwest London expressed dissatisfaction with their access to GP services, making it a top priority for the ICS. Addressing these issues required collaboration among residents, GP’s, and stakeholders in the area. This Committee would provide an opportunity to identify where the innovation fell short and to ascertain how the ICS could build on this for future improvements.

Dr James Cavanagh noted the lack of sufficient engagement at all stages of this initiative, highlighting the failure to take the appropriate steps to fully develop it. Going forward the ICS aimed to prioritise engagement at both practice and Primary Care Network (PCN) level, involving residents and other stakeholders interested in the discussions. Primary care teams within each borough would lead this initiative. Furthermore, funding for access remained available for those that who wished to participate.

Dr Kyla Cranmer (GP Chair of the H&F Local Medical Committee) gave an overview of her concerns regarding the access proposals. This included patient safety, the disruption to continuity of care and the possibility of widening health inequalities. She acknowledged that access was a key concern across the board. However, questioned whether further research had been conducted to determine if, in addition to access, it was equally important for patients to consult with a qualified doctor and to be seen at their own GP surgery.

Dr Kyla Cranmer highlighted that her practice had been striving to enhance access for its patients over the years, continuously evolving its model. Whilst she acknowledged the importance of triage in improving access to general practice, she disagreed with the proposed approach at scale, noting that there was a lack of evidence to support it. She also expressed disagreement with the model that separated simple straightforward care from chronic disease management / complex care, emphasising the importance of continuity of care for both types of cases. It was noted that maintaining care within GP surgeries was essential to uphold continuity of care. Concerns were raised about the impact on GP trainees, training opportunities if services were diverted to hubs and vulnerable patients having to navigate multiple steps to receive care. Finally, it was suggested that the ICS should provide resources to enhance the effectiveness of current operations within the GP surgeries.

Dr James Cavanagh pointed out that the ICS wasn’t mandating access at scale but rather encouraging practices and PCNs to engage in discussions with their patients to enhance access, considering evidence from the 10 sites across Northwest London. Practices were now given the choice to opt into these discussions. He empathised the importance of improving continuity of care for the most vulnerable patients and the difficulty in providing this service to everyone due to high demand and a declining workforce. Furthermore, he explained that the concept of triage was already embedded in the NHS system and recognised the challenges associated with digital inclusion, stressing the importance of addressing this issue.

Dr Kyla Cranmer enquired whether it would be possible if practices, following the discussions, chose to utilise the funding to improve access individually rather than at scale through hubs. In response Dr James Cavanagh noted that this approach would be acceptable.

Deborah Parkin (Assistant Director Primary Care H&F Borough) provided an overview of all the ongoing work with the patient reference group. The Integrated Care Board (ICB) were keen to work with residents and GPs to establish the most suitable approach for each surgery setting, ensuring fairness and equality. This entailed revisiting the proposal to gather data and make informed decisions for practices and PCNs throughout the borough.

Merril Hammer (H&F Save Our NHS) noted that the paper circulated with the agenda was over 10 days old, expressing concerns that while a verbal update had been provided at this Committee, nothing had been submitted in writing. This made it difficult to know exactly what to say or how to respond, especially since the information on the ICS website had remained unchanged for some time. As a result, there had been no updates for the members of the public regarding official information on the website.  She outlined her concerns that the ICS had not considered certain crucial factors in its current proposals, including the lack of continuity of care, the necessity for triage to be conducted by a senior GP, patient safety and the implementation of cloud telephony services. Furthermore, an equalities health impact assessment for this proposal had not been provided, prior to implementation by the ICS.

In response to a question asked by Merril Hammer, Dr James Cavanagh noted that data was being collected regarding the impact of the pilots on access to care and patient satisfaction across Northwest London. He assured that this information would be shared and discussed once it became available.

Jim Grealy (Co-opted Member) made several comments. Firstly, he noted that what was said by the ICB this evening was inconsistent with the last Northwest London Joint Overview and Scrutiny Committee (JOSC). Secondly during the JOSC meeting Dr Smalls clarified that there was no concrete evidence for the pilots and all information relating to access had been gathered anecdotally. Finally, he echoed Meril Hammer’s views noting that all patients needed to be seen by a trained GP at their surgery as opposed to the proposal of hubs.

Dr James Cavanagh noted that over the next year, the ICS would strive to demonstrate to the public its commitment to listening to the needs of patients and practices. He apologised on behalf of the ICS for any mistakes that had been made along the way and emphasised the importance of progressing discussions with residents and practices to address issues surrounding access.

Jim Grealy (Co-opted Member) enquired about the status of the proposal in its current form. Dr James Cavanagh explained that the proposal related to the single offer had been withdrawn. Instead, the ICS would now propose to practices with an opt in offer to participate in discussions at the local level regarding access. Within these discussions the evidence would be provided on what had improved access nationally and aimed to gather useful data from the pilot sites in Northwest London.

Councillor Amanda Lloyd-Harris expressed her dissatisfaction with the proposal, stating that it had been poorly presented without any supporting evidence. It was noted that these changes had caused anxiety among patients, which was unexpected from medical professionals. She noted the need to streamline the process for the most vulnerable patients to ensure they were directed to the appropriate place. She also expressed concern about the plans for those who chose not to opt in and the potential impact on service provision for them. Furthermore, it was felt that in its current form, the proposal was not feasible, especially without any evidence or data provided.

Councillor Ben Coleman (Deputy Leader and Cabinet Member for Health and Social Care) made several remarks. Firstly, he enquired whether the ICS planned to consult with all GPs about access at place or if they would need to make an opt-in commitment first. Secondly, he commented that proper evidence needed to be provided to demonstrate that access was an issue within Hammersmith and Fulham. Finally, he asked if the existing proposal would be withdrawn and if new proposals would be presented.

Dr James Cavanagh clarified that a sum of money would be offered to practices if they chose to engage in the quality improvement work regarding access in Northwest London. This involvement would entail discussions with their residents and stakeholder about access.

Deborah Parkin (Assistant Director Primary Care H&F Borough) agreed that the existing proposal had not been well thought through and acknowledged that it wasn’t successful. She explained that there was data available on this matter, but it had not been utilised in the most suitable format to accurately identify the issue. Therefore, the ICS aimed to put an end to the existing proposal and start again. This would involve listening to the needs of both residents and GPs to identify where the gaps lied.

Dr James Cavanagh further reiterated that the new offer proposed quality improvement discussions to be held at the local level regarding access with GP practices, which would involve their patient groups and any other interested parties. GP practices would be provided with funding if they chose to opt into these discussions. If at the end of these conversations, GPs and patients felt that there was no issue with access, there would be no obligation to adopt any processes requiring them to work at scale.

The Chair asked how the evidence would be captured and whether all practices had the same system in place. In response Deborah Parkin explained that there was a platform accessible to practices digitally through their appointment system. The platform provided information on how many patients had contacted their practice and in what form.

Merril Hammer commented that if there had been a change in the proposals, the ICS needed to immediately update the website and provide explicit information for the public, clarifying exactly what was being proposed instead. For instance, stating the original hub proposals had been withdrawn, that KPMG was no longer involved, and that GP practices and PCNs would work with their patients. Further clarity also needed to be provided on whether financial support would be provided to develop GP practices for improving patient access generally and not just same day access.

Members made a recommendation to formally withdraw the proposals in their current form and to update the website with clear proposals regarding access, including timelines and in line with the discussions held at this Committee.

Deborah Parkin noted that a letter had been sent to GP practices indicating that they were not obliged to participate in the existing proposals. She noted that the ICB  was committed to starting afresh and suggested that she would lead on a working group for Hammersmith and Fulham to involve different stakeholders to advance discussions regarding access and how improvements could be made.

Action: Deborah Parkin

Dr James Cavanagh noted that he would communicate the Committee’s recommendations back to the ICS regarding the communications on the website and its desire to explore effective ways to convey the message for the new plans on the website, including the suggestion for a public apology.

                                                                        Action: Dr James Cavanagh

The Chair read out a written statement submitted by Keith Mallinson, Healthwatch regarding KPMG, and their involvement in the programme (please refer to YouTube footage) Councillor Ben Coleman suggested to write to the Chair of the ICB to clarify the role of KPMG going forward, including details about the budget allocated for their involvement.

Action: Deborah Parkin

The Chair thanked representatives from NHS Northwest ICB for attending today’s Committee, participating in the discussions, and listening to the concerns of the Committee.

RESOLVED

The Committee reviewed and commented on the plans to improve primary care access.