Agenda item

Discussion around the availability of GP appointments for West Berkshire residents before, during and after the pandemic, and how this has affected Hospital Emergency Departments.

Richard Wood (CEO of Berkshire, Buckinghamshire and Oxfordshire Local Medical Council) gave a presentation on the Availability of GP Appointments (Agenda Item 11. Key points included:

·         GP numbers were falling, with 1 in 15 permanent salaried partners leaving or retiring since 2016.

·         In Berkshire, GP patient lists sizes had increased by 186% since 2014.

·         The list sizes were 150% above the threshold where it had been shown there was a decline in patient health outcomes.

·         At the same time as GP numbers were declining, patient demand was increasing.

·         Safe workloads were agreed to be 25 consultations per day for simple matters, or 15 per day for complex cases - within Berkshire, GPs were averaging 32 consultations per day.

·         Some GPs had had to deal with 76 consultations per day, which was neither sustainable nor safe.

·         Clinical encounters only comprised 20% of medical record entries in patient notes – the remainder included workflow around patient care (e.g. reading letters, processing lab reports, documenting discussions with colleagues, etc).

·         NHS England data only captured data in relation to booked appointments – it did not count the other 80%.

·         November 2020 was busier than the preceding year, but since November 2020, there had been a further 23% increase in activity. This had mostly been related to workflow around patient care. This may be attributable to transfer of work from hospitals and patients remaining on waiting lists for longer. Also, there was more administration (e.g. letters from patients).

·         Demand was outstripping supply across the whole health system, including A&E and Outpatients Departments.

·         Remote consultations were universal across the healthcare system and it was inappropriate to single out GPs for doing this.

·         General practice operated under an independent contractor model and partners had unlimited liability for their business.

·         GPs chose how they delivered their services to align best with their patient populations and the sustainability of their businesses.

·         Clinical triage was critical when demand outstripped supply in order to identify those most vulnerable and in need.

·         Telephone consultations were invaluable to identify who should be contacted first or seen face-to-face. They were also more convenient for patients, allowing them to get on with their day and minimising transport.

·         Messages about returning to face-to-face consultation undermined safety.

·         Practices were also using ‘bottom-slicing’ to allocate minor medical tasks to others such as paramedics, minor ailment practitioners, or pharmacists.

·         Patients were able to submit queries online rather than booking an appointment. Some practices got up to 700 letters / online messages on a Monday morning.

·         Telephone consulting was very efficient – 8 minutes vs 14 minutes for a face-to-face consultation for the same ailment. This freed up more time for dealing with the workflow around patient care.

·         More than 90% of diagnoses were made on the basis of history alone, including what the patient described – it was unusual that a face-to-face consultation changed the formulation or management plan.

·         It was accepted that a doctor’s touch may be considered part of the therapy.

·         Remote consultations were heavily pushed as part of GP contracts pre-pandemic, with the expectation that it would be increased over time.

·         If individual practices had particular issues with access, this was usually because there was a particular issue at the practice that needed support from the LMC and commissioners.

·         NHS England changed data capture in relation to consultations in Summer 2020, so pre- and post-pandemic data could not be compared.

·         GPs and receptionists were getting a lot of abuse from the media and a minority of patients and this must be challenged at every level.

·         GP practices must be supported to make their own decisions about how they managed access, which was their contractual right.

·         The public needed to be educated about hybrid models and new ways of working.

·         Hospital colleagues needed to stick to interface protocols so GPs did not end up doing their work as well as their own.

·         The long-term solution was to reallocate resource to core GP work of seeing patients.

Councillor Rick Jones asked what was being done in terms of GP recruitment. He also asked how Social Prescribers could help to manage demand.

Richard Wood noted that GP recruitment had been an issue for years and there was insufficient funding for retainer schemes. He stressed that it was important to for junior doctors to have more exposure to general practice as part of their training. He explained that the work demand had increase and the contract value had been squeezed to such an extent that it was no longer an attractive proposition – Dr Wood worked 12-14 hours per day, but was only paid for 8 hours. An audit of a busy city practice had shown that for every 4 hours of contracted time, GPs were logged onto medical notes for 6 hours 40 minutes.

Richard Wood indicated that he had found social prescribers useful for patients where he was unable to do anything. However, they did not help to address medical issues.

Councillor Lynne Doherty was sorry to hear about the abuse that GPs were facing. She suggested that residents were only hearing one side of the story from the media and asked what GP practices were doing on communications to aid public understanding about the issues GPs were facing. She also asked if there were any figures specifically for West Berkshire.

Richard Wood indicated that there were not enough practices contributing data to provide meaningful data for West Berkshire, and he did not want to expose individual practices to performance management.

Regarding communications, he had written to MPs to promote discussion, learning and understanding. He explained that each GP practice had its own access arrangement, but GPs struggled to find time to engage in communications. He was looking at how to support practices in educating people about their access policies. Elsewhere, there were media campaigns by the BMA and GP practices were putting up posters. He noted that press releases were not always picked up by the media.

Sean Murphy suggested that changes to triage and remote consultation coincided with the pandemic and the public were wrongly expecting things to return to pre-Covid conditions. He stressed the need for the public to understand that this was the ‘new normal’ and why new ways of working had been introduced.

Richard Wood agreed and while there was a need to protect against Covid, it was more about managing demand. He noted that the population was grieving for what had been lost and it was normal to lash out. Therefore it was a natural phase of recovery, but there was a need to limit the damage to the profession.

Councillor Jo Stewart indicated that she was an advocate of the hybrid model of working and recognised the benefits for her as a patient. She asked what the Board could do to help with the media issue.

Richard Wood indicated that this was a new area for him and he would be grateful for the views of Board Members on how best to tackle the issue.

Councillor Owen Jefferey noted that his daughter’s GP surgery in Burnham had used WhatsApp to disseminate information throughout the pandemic, which had been useful. He suggested that this could be template for others to use.

Richard Wood felt the most successful campaigns would be led by the practices. He noted that local media were more supportive than national outlets.

The Chairman indicated that his GP practice used Facebook to communicate with patients, which was good, but their online booking system allocated appointments two weeks out and failed to mention that urgent appointments were still available.

Andrew Sharp noted that there was perfect storm of conditions. He suggested that the board had levers to help and the health service should not be left on its own to cope. He indicated that the communications deficit was systemic across the NHS and it was not seen as a priority area for funding. Also, he highlighted that NHS campaigns repeatedly told people to visit their GP rather than their local health provider. He noted that the public had gone from clapping the NHS to giving them abuse. This needed comms professionals to address the issue and he advocated using Healthwatch services to talk to patients. He suggested that the NHS tended to make changes and just expected the public to know.

Richard Wood accepted that comms had to be refined, so people understood what GPs did / did not do. He concluded by suggesting that children needed education on how to self-manage minor conditions.

Katie Summers gave a separate presentation setting out the impact of Covid-19 on primary care:

·         Demand had increased with easing of restrictions.

·         Pressures were linked to a backlog in demand and extra secondary care work.

·         She showed a table setting out the change in monthly activity by GP surgery across Berkshire West since the start of the pandemic – this showed that the Kennet PCN had experienced a 17% increase vs a 149% increase for West Berkshire Rural PCN.

·         There had been an overall increase in the number of telephone and face-to-face consultations across Berkshire West.

·         The expectation was for more practices to triage consultations going forward.

·         The CCG was building up intelligence about Primary Care activity and report on activity other than consultations.

·         The access points to GPs had increased (e.g. 111 call handlers were now able to book into Primary Care).

·         Efforts were being made to standardise telephone messaging for GP practices.

·         An extra £1 million had been allocated to Berkshire West GPs to increase capacity by 170 appointments per day until March 2022, with 50% of these as face-to-face appointments. This was in response to requests from the PCNs themselves. Longer term, the public needed to be educated about what was happening in Primary Care and how it was changing.

·         There was a pilot with Royal Berkshire Foundation Trust’s Emergency Department to allow them to book GP appointments.

·         Community Pharmacy consultations were being established as an alternative to visiting GPs.

·         A poster had gone out to GP practices about the differences in how GPs were working and asked if this could be promoted by the Council and partners.

·         The CCG was concerned about the pressures that GPs were under and they were actively seeking to relieve these pressures.

Councillor Doherty noted that there were not enough GPs and asked how the additional 170 daily appointments would be delivered.

Katie Summers explained that the GP practices would be able to get in extra locum GPs. The PCNs had confirmed that the capacity was available. It was recognised that locums would not have historic knowledge of patients, so it was being seen as a ‘sticking plaster solution’. Longer-term, more medical students had to be encouraged to see general practice as a career.

Andrew Sharp advocated increased use of pharmacists to relieve pressures on GPs. They could make referrals as appropriate. He also highlighted the lack of comms within the CCG’s proposal and stressed that the Comms Team was very small. He stressed that comms were critical to counter national media outlets.

Katie Summers acknowledged that the Comms Team was depleted. She indicated that she would raise the matter with the Integrated Care Team.

Action: Katie Summers to raise the issue of comms with the ICP.