Agenda item

To consider a submission on this scrutiny topic from the Cleveland Local Medical Committee (LMC).

This second evidence-gathering session for the Committee’s review of Access to GPs and Primary Medical Care focused on a submission from the Cleveland Local Medical Committee (LMC).  Introduced by the Interim CEO and Company Secretary of Cleveland LMC (who had been a GP for nearly 20 years), a presentation was given which covered the following:

•           What is General Practice?

•           Who are Cleveland LMC?

•           What do Cleveland LMC do?

•           National trends regarding GP access

•           General Practice capacity

•           Funding pressures

•           Care navigation

•           Views on Recovery Plan

•           What is needed?

•           Further reading

Fully recognising that GP access was currently a priority issue for the public, it was emphasised that the existing situation within Stockton-on-Tees was very much aligned to the national picture when it came to challenges associated with accessing services.  During an overview of the differing strands of the overarching general practice offer, it was noted that the digital GP option was not hugely popular locally (compared to take-up within bigger cities such as London and Birmingham), and that private GP use was also low within the Borough due to a lack of demand (perhaps reflective of it being a less affluent area).

As the representative body for all general practices and GPs within Tees, having the authority to speak and negotiate on behalf of so many can present its own challenges.  Cleveland LMC was funded solely by its practices on a voluntary basis and was independent of other organisations (there were no conflicts of interest) and any political party (though did take an interest in political developments).

Cleveland LMC supported its constituents in multiple ways, including the dissemination of formal guidance (e.g. another Local Authority area had experienced issues around people getting registered with practices), escalating concerns to national negotiators, and providing contract implementation advice.  It also assisted with dispute resolution (which was currently a frequent occurrence), fed into the British Medical Association (BMA), and was linked-in with national communications teams.  Cleveland LMC was well respected by the BMA, but its views were not as well received by the Government or NHS England – the imposition of contracts being a particular concern at present.

Also acting as a job advert service, it was normal to have more than 10 GP vacancies at any one time, with recruitment proving more challenging in Teesside than in other regions (young trainees had shown a tendency to want to work in Newcastle or York).  As such, access was not seen as a huge priority for practices – the focus was much more on workload, workforce capacity, reducing regulation, financial stability / sustainability, and ensuring patient safety.  Whilst it liaised with other LMCs across the country, Cleveland LMC would like to meet more frequently with regional / local stakeholders to ensure positive outcomes (not just for the sake of meeting).

National trends around GP access painted a very concerning picture.  Population growth and a reduction in GP numbers had combined to put significant pressure on the sector, and many GPs had resorted to working three-day weeks (though very long days) to control stress levels within the context of a tough working environment.  Retention of staff had also become a problem, and it was important to note that 18% of GPs were over the age of 55 – whilst some were working full-time into their 70s, a big gap was looming once they leave the profession, and though the ageing workforce issue had been known for some time, there remains no solution.

Awareness was raised around the national ‘Rebuild General Practice’ campaign which challenged the way things were sometimes portrayed in the media.  Several concerning statements around risks to patients, inadequate time available to spend with patients, and recruitment and retention issues were highlighted, though it was acknowledged that the statistics reflected a national survey, and local data was not yet available.  There was also a desire for more continuity regarding contact with patients (which the current contracting mechanism prohibited) as evidence suggested that better outcomes follow when people see the same GP each time they access services.

It was important to recognise that more appointments than ever were being delivered, with the average appointments per year for every registered patient (6) now 50% more than what the funding was intended for (4 per year).  Ultimately, it was not safe to deliver more appointments, hence the push for a greater focus on patient safety – the move to 15-minute slots (rather than 10-minute) was an attempt to assist in this regard, and also reflected the increasing complexity of cases that GPs were being approached about.  As previously noted, the existing problem was not about access – it was more to do with capacity and demand.  Expectations around GP capacity were not possible within the present funding envelope.

In terms of funding, media headlines tended to focus on primary care as opposed to general practice (which was only one part of the former).  That said, primary care received just 8% of the NHS budget, with a greater focus now on investment into hospital services.  Core GP funding did not take into account the increase in appointments, and overheads (which had been impacted by recent inflationary pressures) needed to be deducted from this income – this situation leads to workforce reductions as practices try to balance their books.  The limitations of the Additional Roles Reimbursement Scheme (ARRS) were outlined, with funding in relation to this initiative unable to be spent on core staff and any underspends being lost (this was a particular issue across Teesside).  Other funding issues concerned investment being focused on Primary Care Networks (PCNs) as opposed to individual practice needs (an arrangement which could see poor performance from a neighbouring practice impact on others), and the provision of enough computers to support additional staff.

Regarding care navigation, it was emphasised that call handlers did not like having to ask questions of those contacting services, and that it was hard for them to manage patient demand in light of existing capacity – indeed, this was causing problems in relation to the retention of reception staff who were seeking less stressful roles outside the sector.  In related matters, the need for more non-GP roles within practices also created increased supervisory requirements – this in turn further limited patient contact time.

With regards the national recovery plan for GP access, Cleveland LMC felt this would have limited impact as it failed to address the underlying issues around funding and workload.  Practices needed more staff but were prohibited from increasing their workforce due to financial restrictions (indeed, there were currently GPs seeking work / additional work within Teesside who practices could not afford to employ).  In addition, a greater focus on the interface with secondary care would be welcomed as much work was done in practices that should be undertaken by secondary providers (a recent audit of practices had shown that 170 hours per week were being lost across Teesside – this report could be shared if required).

Reflecting on the presentation, the Committee expressed unease about the gloomy picture being portrayed and was particularly concerned about the call for more frequent dialogue with stakeholders as this appeared to indicate a communications issue.  Cleveland LMC confirmed that other organisations had been cancelling planned meetings at short notice, with no meetings held with NHS Trusts for some time, and the North East and North Cumbria Integrated Care Board (NENC ICB) standing down previously scheduled engagements.  The NENC ICB representative in attendance commented that meetings may be affected due to workload clashes and that there was an ongoing organisational restructure which may be impacting upon capacity – this would be taken back to colleagues to ensure any cancelled meetings were rearranged.

Members probed the increase in dispute resolution cases being dealt with by Cleveland LMC (hearing that these involved not only GPs but also nursing and reception staff), as well as the composition of its elected Board in terms of how the Borough was represented (there was presence from each of the four Local Authority areas and Stockton-on-Tees was generally over-represented).

Focus shifted to the reported appointment statistics, with the Committee querying the reference to ‘more being delivered than ever before’.  It was explained that some of this increase could be attributed to an initial telephone appointment (which would be logged as one contact) being raised to a face-to-face consultation (which would be logged as another contact even though it concerned the same individual).  When it came to the type of contact with patients, practices had the scope to deliver services in whichever way they felt was best (this was very much supported by Cleveland LMC), though whilst telephone consultations were quicker, there was often more value in an in-person appointment (which remained the standard option).  The ICB would be interested in knowing if there was a gap in services at any practice, and it was noted by the Committee that phlebotomy was a real challenge within the Borough (staffing provided by NHS Trusts, but issues around the arrangement of appointments for when staff were available).

Continuing the theme of appointment types, the Committee was reminded that, prior to the COVID-19 pandemic, there was a strategy regarding a telephone-first approach.  Some practices had already adopted this option and therefore adapted to the impact of COVID more easily.  Members highlighted their awareness of residents receiving call-backs from practices which was widely welcomed – this did, however, require dedicated staff to return calls.

The current funding landscape led the Committee to query if decisions on financial support for practices was pushing provision towards privatisation.  It was acknowledged that some within the sector did indeed have that impression and felt that there was a policy to force GPs into a salaried role.  In response to a question on incentives for greater access, it was stated that practices received 70% of the capacity and access improvement funding up-front, with the remaining 30% given upon delivery of their agreed plan – this was allocated as part of a PCN arrangement rather than on an individual basis.

The Additional Roles Reimbursement Scheme (ARRS) was explored further, with particular attention focusing on the stated underspend in previous years.  Cleveland LMC noted that it was difficult to get clarity on spending as the funding for this initiative was held centrally rather than by the ICB.  The NENC ICB representative advised that around 75% of available ARRS funding for this year had been spent in Stockton-on-Tees, and there had been an attempt to incentivise PCNs in relation to this scheme.  It was acknowledged that some PCNs were more proactive than others with regards collective working and the sharing of best practice / learning, with Members reminded that practices were, ultimately, individual businesses.

Members concluded the session by discussing access to / visibility of practice managers.  It was stated that this role was one of the most pressurised within the sector and was the biggest pinch-point in terms of retention – as such, much resource was given to supporting them.  Two practice managers were on Cleveland LMCs elected Board, as well as PCN Clinical Directors (who the Committee would also be attempting to engage with as part of this ongoing review).

Finally, the Committee was reminded by the NENC ICB representative in attendance that, despite the references to risks to patient safety within the presentation, all of the Borough’s general practices were deemed safe by the Care Quality Commission (CQC).

AGREED that the Cleveland Local Medical Committee submission be noted.