Dr Dominic Slowie, Medical Director, NHS Newcastle Gateshead CCG will provide the Committee with a presentation on this matter.
Minutes:
Dr Dominic Slowie, Medical Director, NHS NewcastleGateshead CCG and Lynne Paterson, Portfolio Lead Gateshead System, NewcastleGateshead CCG provided the Committee with a presentation on this matter.
Dr Slowie advised the OSC that it was important to be aware that over the last twenty years there had been relative disinvestment in general practice and primary care. The Health Foundation had carried out a piece of work examining the expansion of the medical workforce across the NHS and found that there had been a doubling of the hospital workforce whilst the GP workforce had stood still. The explanation for this position was that this focus on increasing the hospital workforce had been to drive forward specific initiatives put in place to tackle waiting lists which had been successful.
Dr Slowie stated that post pandemic the priority was again about recovering performance in relation to waiting lists and incentives were being put in place to drive this forward but these were potentially at the expense of GP practices and mental health and community services.
Dr Slowie also advised that it was important to understand Gateshead’s position compared with that of the rest of the country. Dr Slowie indicated that the optimal doctor to patient ratio was 1 GP to 1800 patients who would be able to offer approx. 25 appointments per day. Dr Slowie confirmed that GP practices in Gateshead were able to offer this doctor to patient ratio whereas the national picture was 1 GP to 2000 patients which suggests that Gateshead is in a relatively good place.
However, Dr Slowie advised that over the last 20 years GP’s were being faced with much more complex care as a result of an increase in individuals long term conditions and more complex mental health needs. As a result, demand has increased. Therefore whilst the number of GP appointments in Gateshead has gone up this has been counterbalanced by the rise in demand.
Alongside this Dr Slowie advised that it was increasingly difficult to recruit into GP practice due to a range of complex reasons. Becoming a GP is currently not seen as an attractive career and he advised that there was increased burn out amongst GP’s many of whom were working late into the evenings. Other challenges were levels of sickness absence and levels of early retirement as a result of financial disincentives related to GP pensions.
Dr Slowie advised the Committee that it was important to remember that GPs have never been formally part of the NHS but are independent contractors. The positives of this position mean that GPs have the autonomy to make the necessary changes to respond to patient needs and go the extra mile when delivering care. Dr Slowie informed the Committee that a recent consultation paper “ At your Service…….? has argued to bring GP’s into the NHS and have a salaried service. However, Dr Slowie stated that the downside of such an approach might be that being a GP in such circumstances was seen as a job which finished at a particular time of day. Dr Slowie considered that there was evidence of a difference in culture amongst some salaried GPs and contracted GPs.
Dr Slowie advised that in Gateshead GP practices have always fared well in terms of feedback within the national patient survey. However, for the first time satisfaction is starting to tail off.
Dr Slowie considered that media attention seems to be focused in a positive way in relation to surgical interventions but appears to have a less positive focus in relation to general practice.
Lynn advised that Committee that her role within the CCG was new. Previously there had been one workforce lead for NewcastleGateshead CCG however, Lynn advised she had now been appointed to act as the workforce lead for Gateshead alone.
Lynn advised that there were a number of factors which had impacted on access to GP services in Gateshead and in relation to recruitment and retention of GPs.
Over the last 10 years there had been an increase of approximately 5000 patients who were older and required more complex care which is managed by primary care. There were also large pockets of deprivation within the population of Gateshead which has impacted on health and wellbeing and particularly mental health leading to large waiting lists for support. Alongside this there are large pockets which are more affluent. Therefore, GPs in Gateshead had been asked to look at the population health of the patients in their practice in order to tailor services to meet their needs
Covid had also had a major impact on the services GPs could provide as a result of
· Lack of testing for staff
· Home visiting – hot home visiting took twice as long having to change PPE at every visit
· Seeing hot patients in hot practices
· Delivering the vaccine programme and flu programme at the same time
· Staff sickness, shielding staff and staff burnout – restricting services offered
Lynn advised that in Gateshead the CCG is approximately 6 WTE GPs short across all their Primary Care Networks (PCNs), which equates to approx. 600 appointments each week and this was before the issues of Covid had an impact.
Lynn stated that work had also focused on maintaining key priorities such as looking after cancer patients and avoiding disruption to their services and in relation to management of patients with complex care and long term conditions as well as those with Learning Difficulties and other health check-ups for vulnerable and complex patient groups.
Lynn advised that GP practices were working towards getting back to ‘normal’ / ‘new normal’ but unfortunately were not there yet as practices are still having staffing problems that impact services.
Lynn stated that the CCG has been using OPEL scoring 0-4, to enable it to support practices with issues impacting on service deliv awaiting further info on ery via extra care appointments. Lynn indicated that practices are also
Covid Testing and IPC guidance and how this will impact on delivery. In the meantime the CCG has been listening to what staff have told them during the pandemic in relation to what has worked well and what could be better.
Lynn noted that during the pandemic staff had found that some patients who had been reluctant to access services had gone on line which was positive
Lynn indicated that she is working on a long - term programme for recruitment and retention of GPs in Gateshead. However. Lynn advised that in this regard the picture across the rest of the country was also not good as many young people studying medicine do not see, recognise or fully understand the role of primary care. Lynn indicated that this was a fundamental flaw which needed to change. Lynn stated that what was needed was to make primary care an attractive place to work and explore the perks of working in this area over secondary care or having a balance of both for fulfilment within an individual’s career.
Lynn noted that a Golden handshake scheme was currently in place for both new GPs and other staff as an incentive to working in areas where it was difficult to recruit such as primary care. Lynn advised that currently there were 12 healthcare professions which were eligible for the scheme, which is due to end in March 2023 - GPs, nurses, pharmacists, pharmacy technicians, physiotherapists, paramedics, midwives, dietitians, podiatrists, occupational therapists, mental health practitioners and physician associates.
In terms of making Gateshead an attractive place to work was being progressed in relation to
· An online induction platform for all those coming to work in Gateshead in primary care, voluntary organisations that support primary care and local authority staff. To ensure everyone in Gateshead is working together
· Work with current GPs to create specialities of interest which support that PCN and the wider system.
· Creating staff benefits for Gateshead Primary Care Staff, similar to other large NHS organisations.
· Creating a flexible workforce
Funding had been secured for a flexible workforce hub for the next 24 months plus which would assist all practices in the Gateshead to get support for GPs, nurses and admin staff vacancies. Consideration was also being given as to whether this could be expanded to support social care.
Lynn advised that the recruitment for the hub had been successful and they had several skilled staff that were part of the regional vaccination programme signed up to support current gaps in workforce.
The 5year plan would involve the recruitment of GPs and closer links with universities, placement programmes and work experience with two practice development nurses to support recruitment and retention. The CCG was also looking to upskill other roles within GP practices, such as non-clinical admin and HCA roles, Career start nurses and Advance Nurse Practitioner (ANP) programmes. The OSC was advised that there are currently 16 ANP in Gateshead. The OSC was informed that within primary care there were other highly skilled roles in Pharmacies and Practices, thanks to the Additional Role Reimbursement Scheme (ARRS) in Primary Care Networks all of which can help to alleviate pressures on the system.
In 2022/23 the CCG would continue to rise to the challenges of restoring services, meeting new care demands and reducing the care backlogs that are a direct consequence of the pandemic. The CCG would also accelerate plans to grow the substantive workforce and work differently as well as focusing on the health, wellbeing and safety of staff and use the learning from the pandemic to rapidly and consistently adopt new models of care that exploit the full potential of digital technologies.
Lynn advised that over the summer months they would be promoting the Pharmacy First programme and would be looking at care navigator roles to help support patients to navigate where they needed to be. The CCG had also received funding to work directly in schools to run master classes with staff in relation to epilepsy, asthma and diabetes so that they would be able to support children with these issues.
The Chair queried whether it was possible for the CCG to try and attract medical students to work in Gateshead whilst they were studying at University.
Lynn advised that it was possible and they used the Golden Handshake scheme to secure new people. The CCG was also working closely with Universities and schools to hold events/ job fayres where they could highlight the benefits of being in a GP practice in Gateshead.
The Chair queried whether this was just scratching the surface of the problem given the current level of demand from patients and consequent impact on GPs and other health colleagues.
Dr Slowie stated that in addition to the work outlined by Lynn it was worth noting that many GP practices were also teaching practices and take medical students and the hope was to expand this offer. The aim being that students have positive experiences within placements and are then more likely to consider a career in general practice within Gateshead.
The Chair considered that this was an excellent approach.
Lynn advised that the CCG was also working with the voluntary sector to support patients via social link prescribers in Edberts House. Within each GP practice social link prescribers would have referrals from GPs in relation to patients who needed support in relation to social support and wellbeing rather than medical issues.
The OSC noted that they had received a presentation from Sarah Gorman at Edberts House in relation to the work on social prescribing.
The OSC noted that reference had been made to patients attending A&E when they should be going to their GP. The OSC considered that there were probably examples of patients going to their GP when they should have gone to A&E and patients going to their GP instead of to a pharmacy etc The OSC queried if there were any figures in relation to the numbers of patients going to the wrong place? The OSC recalled a scheme where patients with minor illnesses were re-directed to pharmacies.
The OSC was advised that the Pharmacy scheme was still ongoing and patients were being advised to attend pharmacies for their repeat prescriptions and emergency medicines. The CCG was also looking to put together a patient group directive for Urinary Tract Infections (UTI’s) to be dealt with via pharmacies. The work with pharmacies was relieving the pressures on both secondary and primary care and had saved approximately 3000 appointments since Christmas.
Lynn advised that she would send more data through to the OSC after the meeting.
The Chair queried whether there was any reluctance on the part of patients to attend pharmacies due to having to pay for prescriptions.
Lynn advised that if patients have their medications reimbursed they would still receive these free if they went to a pharmacy.
The Chair queried if this was widely known.
Lynn advised that it wasn’t and this was one of the areas where they needed to improve.
The OSC noted that it had heard about the work to retain GPs in Gateshead and queried how this fit with the position across the rest of the country.
Dr Slowie stated that currently Gateshead was faring better than other parts of the country as there were not huge amounts of turnover and GP practices were fairly well established and had positive relationships with commissioners. In addition, the health and care system was well integrated and there were opportunities for GP practices to be involved in teaching and training. However, an area of difficulty related to GP pensions. Once GP pensions exceed a certain amount the levels of taxation are so heavy that GP’s in their mid 50’s are being advised to retire as if they don’t they will be penalised. This has been forcing an exodus of GP’s who could have continued to work for a further 10 years. Dr Slowie advised that the Government was looking into this issue.
Dr Slowie advised that one of the advantages of the Hub which Lynn had referred to was that it offered part – time remote work which might prove attractive to those who were retired etc. Dr Slowie advised that there had been quite a bit of interest in this.
The OSC noted that reference had been made to navigating the health and care systems and noted that these had changed rapidly in recent years making it more difficult for patients to know where to go and potentially leading to some patients withdrawing from the system. One member of the OSC also expressed concern that the government might be using the complexity of the system to cover a plan to privatise the NHS and move towards an American system where healthcare was paid for and requested further information on who were NHS GP’s and who private contractors.
Dr Slowie clarified that all GP’s are independent contractors and those who are employed rather than being partners at a practice are employed by the practice. Each practice has an NHS contract. The independent status of GP’s means that they have more autonomy over matters such as quality etc. However, GP practices are monitored and if it is considered that quality standards are being breached at any practice notices will be issued against the practice.
The OSC noted the focus on integration within the health and care system and asked what GP’s views as a profession were in relation to this contractual position and whether this was likely to create any barriers to attracting more people into general practice.
Dr Slowie stated older GP’s tended to be more protective of the position of GP’s as independent contractors and partners in a practice whereas some younger GP’s were more attracted to salaried positions as they have tended not to have the same level of responsibilities. Dr Slowie advised that the balance appears to be shifting in favour of the latter.
The OSC queried whether pharmacies were able to prescribe antibiotics to individuals. Dr Slowie advised that this would depend upon the condition of the person in question. Dr Slowie stated that a pharmacy would, with a patient’s permission be able to view a patient’s summary care record which would identify any repeat prescriptions and would be able to prescribe this medication. However, if a patient was seeking medication for a condition outside of that scenario then they would need to see their GP.
The OSC noted the position re care navigators but highlighted that patients may not always be confident that these individuals know what they are talking about.
Lynn advised that this another area where the CCG needs to carry out further work in terms of messaging to the general public as all care co-ordinators have received training for their role.
A representative from Healthwatch Gateshead noted that Gateshead along with other areas has a Pharmacy Needs Assessment and queried whether shifting more work to pharmacies was just a case of shifting a problem from one place to another and whether a study of capacity had been carried out with pharmacies.
Lynn advised that the local Pharmacy Board had identified that pharmacies in Gateshead have the capacity to deal with the work being referred to them. Lynn advised that the advantages of pharmacies are that recruitment takes less time and as a result of the extended opening hours pharmacies have the capacity to see more patients throughout a day and at weekends.
Dr Slowie stated that they were aiming for right care at right place first time and he advised that all PCN’s have a clinical pharmacist, first contact mental health worker and a physio.
The representative from Healthwatch Gateshead highlighted that in terms of messaging it was important to manage public expectations as not all pharmacies are equal and only some have additional services.
Lynn advised that referral pathways would take members of the public to the pharmacies that meet their needs.
The Chair on behalf of the OSC, thanked Dr Slowie and Lynn for an excellent presentation.