Agenda item

(To receive a report from the Lincolnshire Medical Committee (LMC), which provides the Committee with an update on access to general practice services.  Dr Kieran Sharrock, Medical Director, Lincolnshire Local Medical Committee will be in attendance for this item)

The Committee gave consideration to a report from the Lincolnshire Local Medical Committee, which provided an update on General Practice services.

The Chairman invited Dr Kieran Sharrock, Medical Director, Lincolnshire Local Medical Committee, to present the item to the Committee.

Also present for this item to help with questions was: John Turner, Chief Executive Lincolnshire Clinical Commissioning Group and Sarah-Jane Mills, Chief Operating Officer (West Locality) Lincolnshire Clinical Commissioning Group.

The Committee was advised that general practice nationally was overstretched, due to an increasing workload before the pandemic, and that the pandemic pressure had then exacerbated the issue. Also, due to hospital trusts being under pressure with long waiting lists, general practice was seeing an increase in the number of patients seeking support for their increasing health needs, which were not being managed by secondary care.

It was reported that the number of GPs had been falling consistently, in March 2016 there had been 51.5 GPs for every 100,000 patients, and that now in March 2021 the figure had fallen to 46.3 for every 100,000 patients.  It was highlighted that since March 2021, the British Medical Association had seen a loss of a further 597 GPs and 920 general practice nurses.  In order to compensate for the loss of GPs, Primary Care Networks were now employing other health professionals to manage patient conditions such as: clinical pharmacists, paramedic practitioners, first contact physiotherapists, social prescribes and mental health practitioners. It was highlighted further that these professionals were qualified to manage conditions in their sphere, but did not have the holistic skills that a GP would have.

The Committee was advised that to help ease the situation, practices had moved to a 'Total Triage' model of providing services. This allowed practices to navigate the patient to the most appropriate professional to manage their condition.  Further details of relating to total triage was shown on page 100 of the report pack.

It was highlighted that Lincolnshire had always had difficulty recruiting and retaining clinical workforce.  The Lincoln Medical School and other development at the University of Lincoln would help with recruitment in the long-term, but was unable to offer support to the short-term shortages.  The report highlighted that by 2025 there would be a shortage of 220 "autonomous" practitioners.

In conclusion, as Lincolnshire's general practice were experiencing  increasing workload and workforce shortages, Lincolnshire and other health systems were considering moving to a Primary Care Home model, which would require public and stakeholder engagement.  It was also highlighted that self-care and prevention needed to be prioritised to alleviate further pressures on health and social care.

During discussion, the Committee raised the following points:

·       The number of face to face appointments figures on page 100.  The Committee was advised that the only figures that could be provided were those from the NHS Digital GP Appointment Data;

·       The need for better communication to the public of the changes that had been made to mitigate the workforce problems and the increased workload issues, particular reference was made 'total triage', if people were advised how the system worked then there would be less concern from patients not having their expectations met.  There was recognition that more communication needed to be done and that there needed to be a consistent message as to why the change had been made and why it was needed to continue.  It was also highlighted that there needed to be better communication between the GP and the hospitals.  One member confirmed that following a consultant visit, a copy letter was sent to the practice and the patient, which was extremely useful;

·       What plans were proposed for a recruitment campaign to fill the 220 practitioner gap.  The Committee was advised that GPs had done an outstanding job over the last 18 months; and primary care as a whole had seen a lot of change as they moved to total triage and digital access, which in itself had caused some problems, as some patients still had expectations that the GP was the person they needed to see.  It was recognised that there were challenges ahead with regard to recruitment and retention and that was an on-going discussion. The Committee noted that the workforce challenge was nationally as well as in Lincolnshire.  The Committee noted that progress was being made in LincoInshire; particular reference was made to retaining GPs who were nearing retirement; successful international recruitment, it was noted that over the last 12 months, 38 newly qualified doctors had been recruited; the presence of 15 Nurse Associates working in general practice; work was on going to secure paramedics to work in general practice; and the recruitment of 58 clinical pharmacists. There was recognition that there was still more to do. A  request was made for the People Plan to be future item for discussion for the Committee;

·       One member from personal experience agreed that the system was working for long-term conditions, ordering prescription etc., but concern was expressed to conditions that were not picked up or diagnosed correctly, for example cold/flu like symptoms, which actually in one instance had turned out to be meningitis.  The Committee was advised that systems were in place which allowed people to assess their own symptoms and to make contact if they were not getting any better; and 99 times out of a hundred assessments were correct, but unfortunately there would be rare occasions when symptoms were missed;

·       Some concerns were raised regarding the difficulty of contacting general practices by telephone, patients having to wait half an hour to get through, some not getting through at all; and some actually after numerous tries just giving up.  It was highlighted that there was a lot of variation across the county.  The Committee noted that at the moment there were 86 practices and they all ran their practices in slightly different ways, and that discussions were on going as to how the variation across practices could be reduced.  It was noted further that there were proposals for setting up a task force to promote good practice and offer support.  The Committee was advised that the frustrating thing for practices was that some phone calls, some patients with access to IT could have actually used on-line facilities, freeing up more time for those without access to IT.  It was highlighted that the two main problems attributed to telephones were: firstly infrastructure, it was highlighted that support was being given to a number of practices to replace their telephone systems; and secondly there was the issue of having enough workspace and workforce available to be able to answer calls.  Reference was also mentioned to investment through funding from Section 106 funding to developing a telephone hub;

·       The care navigation process, some concern was expressed that whether following training, care navigators would be able to pick up on serious illness.  It was felt that care navigators needed clear instructions as to what they could do and what they should not do; as it was felt that this was not happening at the moment.  The Committee was advised that the role of the care navigator was purely to navigate people to the right person to deal with their problem;

·       The Primary Care Home Model, the separating of long-term and short-term health management, which allowed for better management of each of the groups by focusing the skills of the professionals to the needs of the patients. The Committee noted that some parts of the country were already working to this model and that it was something that had been discussed, but it was just seeing how the model would work for the population of Lincolnshire.  It was highlighted that over the last 12 months Primary Care Networks (PCNs) had established an enhanced Care Homes project, where each PCN had identified the care homes that sit within their area, and that the PCN were responsible for working with all professionals to support patients living in their own homes and care homes.  The Committee was advised that at the moment care arrangements between general practice and community services were not as integrated as they could be, however, there were patches of great teamwork and proactive work, but there was not consistent integration in Lincolnshire; 

·       Thanks were extended  to Healthwatch Lincolnshire, for their patient feedback;

·       The regular referral by GPs for patients to visit the UTC. The Committee was advised that if patients were being sent inappropriately to the UTC, the CCG would receive feedback from the Lincolnshire Community Health NHS Trust.  The Committee was advised that there was some testing going on in both the Skegness and Lincoln City area whereby GP practices could actually book patients into the UTC to have a face to face appointment in that facility, where that was appropriate for their needs;

·       The need for better transport facilities in rural area;

·       The need to promote self-care and to ensure that more was done from a public health perspective with regard to prevention, as it was felt that this was an area that needed further consideration;

·       Whether there was a process of peer review between practices.  The Committee was advised that peer reviews did occur across primary care, but not for things like how long does it take to get through on the telephone.  It was hoped that the establishment of the task force would help share best practice;

·       The fantastic role undertaken by nurse practitioners; and

·       A member's personal experience of ringing three separate practices and that a different message and response was received from each one with regard to Covid-19, which highlighted the discrepancies across GP practices;

The Chairman on behalf of the Committee extended thanks to the representatives for their presentation.

RESOLVED

1.    That the challenges affecting General Practice in Lincolnshire, in particular the shortfall of 220 autonomous practitioners, be noted; and the Committee's strong support for a recruitment campaign to encourage practitioners to work in Lincolnshire be recorded.

2.    That the Committee's preference that as many in-person appointments as possible should be offered to patients, where there is a clinical need for them to be seen in person, be recorded.

3.    That a further update on General Practice Access be received by the Committee in six months.