Agenda item

Tony Hoolaghan, Rebecca Kingsnorth and Imogen Bloor, Islington CCG, and Ian Sandford Public Health were present for discussion of this item and made a presentation to the Committee thereon. A draft Scrutiny Initiation Document (SID) was also laid round.

During consideration of the presentation and SID the following main points were made –

·         There are 33 GP practices in Islington, serving a registered population of 252,273 at June 18

·         The practices range in size from a registered list of over 1700 patients to a list of over 18000 patients

·         There are 4 practices with single handed GP’s, to 6 practices with over 4 GP partners

·         All practices are inspected by the CQC over the past 38 months, and 30 are rated as good, 2 are rated as requires improvement and 1 is rated as inadequate

·         The known challenges for primary care are growing demand for services, due to more complex health needs, population growth and people living longer

·         There is also a struggling workforce, and 25% of the NCL GP workforce is over 55, and likely to retire in the next 10 years. For Islington this is 19%, or 36 GP’s. Fewer GP’s are looking for partnerships and there are recruitment and retention challenges

·         There is an evolving care sector, and renewed importance on the role of general practice in providing care that is accessible, and all integrated across all parts of a complex health and care system. Patient expectations are challenging in line with social and technological advances

·         There are ageing premises, and general practice is provided from a range of different types of premises. This ranges from purpose built to converted premises, and with a range of ownership models

·         Action is being taken as follows – Targeted investment into general practice, focus on existing and new workforce, target estates to support need, investment into quality improvement teams, prioritising digital opportunities, support practices to respond flexibly to demand, enabling the Care and Health Integrated Model (CHIN), enable collaborative working across local healthcare systems, and social prescribing

·         In terms of investment the CCG investment into primary care includes – a nationally set funding for core primary medical services, including provision of service, quality and outcome framework payments, and premises. CCG funding of Locally Commissioned services, short term funding – the GP forward view mandated that £3 per head of population be allocated from CCG funds over 2017/18 and 2018/19. This is being used to support practices to look at internal process for demand management, GP forward view funding for specific initiatives, such as developing online consultation, and GP forward funding for extended primary care, topped up with CCG funds in Islington

·         In Islington additional funding over and above the nationally sent contract costs of core primary medical services is received, and this provides the ability to invest in primary care and there is an investment plan to support these initiatives

·         In terms of workforce NCL faces significant challenges for the future workforce, and a recent survey has indicated that 45% of responding practices are due to lose one or more GP’s to retirement in the next 3 years. This along with an ever growing diverse populations demonstrates the need to develop and grow the GP workforce significantly over the next few years. A recent survey of GP’s trainees demonstrated that there is a need to consider different employment models, and portfolio careers. The majority of GP trainees want a portfolio career, and involved in education and training and want a salaried role

·         There is a need to look at recruitment and retention, work/life balance is increasingly important, young GP’s are looking for variety and flexibility and young nurses for career development. New roles working in GP teams such as advanced care practitioners, clinical pharmacists based in practices, physician associates, nursing associates and new ways of working, from a focus on a Doctor to provision of care as a team

·         Starting in 2016/17 the CCG has supported practices to explore new ways of working via ‘Team around the Practice Pilots – this has included an MSK specialist in GP surgeries, super admin clinical coder, telephone triage, health coach and navigator, well- being site, and reception navigation – these have achieved positive results

·         Responding to local pressures and taking advantage of nationally available workforce schemes, the CCG is implementing the following posts in 2018/19 - practice based pharmacists, primary care clinical fellows and primary care mental health nurses

·         Quality improvement support teams (QIST), provide hands on practical help to develop – consistent standards and service to all patients, introducing and delivering with practices agreed new ways of working, innovation and more rigorous and systematic approaches to patient care. The local QIST has been operational since August 2917, and is made up of local GP’s, nurses pharmacists, practice managers and an analyst. Key achievements so far have been – data sharing introduced across all practices and the GP Federation, increasing the number of people vaccinated against flu before the end of October 2017, and the total number vaccinated during the last winter. In addition, the proportion of people with Atrial Fibrillation, has increased, which is a risk factor for stroke, who are on medication to prevent a stroke from 70% to 78%. In relation to diabetic patients, a review has been carried out as to how each practice manages their diabetic patients and suggesting process improvements using local evidence. Quality improvement methodology is used for project design and evaluation

·         There is also a need to develop digital technology to support new ways of working in primary care – currently in place there are EMIS web, a primary clinical system across Islington, which is cloud based, allowing record access from any location, Doc Man, a document management system that allows the electronic transfer of documents between provider organisations, as well as onward filing into clinical records. There is also iPLATO which is a text messaging service around appointments, which reduce DNA’s and also health campaigns run by practices. In development there are on line consultations, which is a web portal giving patients an additional path to access their GP practices, which allows triaging of patients, signposting and a symptom checker. The North Central London Health Information Exchange, is a portal providing clinical staff an integrated view of records from across all provider organisations

·         In terms of responding to demand improving access is a continual focus and the CCG is investing a multi-year Improving access service that has produced and implemented guidelines that mean recording of appointment data in practices is standardised and accurate. Starting in 2018/19 practices will be incentivised to increase the number of appointments offered during core hours (8.00am to 6.30pm)

·         Islington CCG has also commissioned an extended access service – iHUB, which allows urgent and routine general practice appointments in the evening, and at weekends, at one of 3 I HUB locations, enables access to NHS general practice from 8am-8pm 7 days a week, and ensures Islington patients can book via their normal GP surgery or by calling their own practice, when it is closed and the iHUB is open. The CCG are currently engaging with patients and the public, about the focus of investment in additional same day GP appointments

·         In terms of responding to demand – as part of the GP Forward review, NHS England has produced a suite of 10 high impact actions to release time for care, and the CCG is funding practices to implement these and encourage them to think collaboratively when doing this

·         There is collaborative working at different levels to build resilience – in Islington practices have a history of working together in networks to review, with a multi-professional team, the care of patients identified as having a particularly high level of need. This is being expanded to other areas – for example sharing a practice based pharmacist across a network of practices

·         Practices are also collaborating on a larger scale with partners across the system, in CHINS, focused on developing place based models of care

·         Practices across Islington have formed a GP Federation, and this currently provided the iHub service, a community gynaecology service, a community ENT service, and is leading the development of primary care networks, primary care participation in CHINS, and many primary care resilience initiatives

·         In terms of GP networks through a process of engagement, Islington practices have agreed to group together in 8 GP networks, covering populations of 30-35000 people, as the best model to deliver better, more consistent primary care. Practices remain independent entities, but will develop stronger relationships with the other practices in their network. These GP networks will form the building blocks for 3 care and health integrated networks, around which acute, community, social care and the voluntary sector can align their services

·         There is a need to further develop Care and Integrated Networks

·         North Islington has a population of 87025 residents (2016 estimate). and 94332, registered with 14 practices. In line with the rest of Islington, there is a higher number of young adults from 20-44, but also some who are frail and in poor health. The ethnic profile is generally very similar to the borough as a whole, although Finsbury Park has greater diversity. The locality has a significant number of residents not in work, and life expectancy is below the Islington average, particularly Holloway

·         Central Islington has a population of 87025 residents and 93247 registered with 12 practices. There are a high numbers of younger adults between 20-44, and lower numbers of children than the London average. Educational attainment is relatively high and unemployment is low, with an affluent working population

·         South Islington has a population of 60991, and 63942 residents registered with 7 practices. The key age group for the locality is 20-29 year olds, and there are distinct demographic differences with greater health needs in Bunhill and Caledonian. As with other wards, the demography is changing, due to housing developments, high housing costs and regeneration

·         There is a need to develop social prescribing, which is a process of linking people with a range of non-medical community based services, which can support wellbeing and develop skills, knowledge and confidence to self -manage. Evidence suggests that social prescribing builds capacity into the health and social care system, offering an alternative to traditional health care interventions. Patients who are more activated are better able to self-manage, and use traditional services more frequently

·         Islington Navigation service is open to all adults with an identified need and over 1000 people are supported each year. In place for 5 years the service offers signposting and more detailed one to one case management support for anyone referred. Onward referrals have been made to over 130 organisations, such as Alzheimers, Gardening clubs etc. and navigators are core members of integrated networks supporting more complex/high risk patients. There have been more than 350 referrals from GP practices in 2017/18. Data reports more than 80% are likely or highly likely to see a reduction in the use of primary and secondary services due to interventions. The service was re-procured in July 2018 for a 5 year contract

·         In terms of contractual consideration, the CCG aim to work proactively with practices facing challenge at an early stage, by offering informal support, peer support from Governing Body clinicians, routes to additional funding for practices experiencing difficulty, and the Local Medical Committee and GP Federation can also offer support

·         Practices can also apply to reduce their catchment area, or temporarily close their patient list. This application is not viewed in isolation, and NHS England assurance can be sought regarding continuity for patients and families, consider the likelihood of additional pressure for nearby practices, seek assurance that there is local capacity and choice for patients, and consider benchmarks that indicate how a practices is managing demand

·         Practices may consider that merging with another practice will strengthen their resilience, even if not co-located on a single site, as it allows both practices to strengthen back office functions. Information and support can be provided, through NHS England resilience programme, to practices interested in this option

·         The Islington GP Estates Strategy shows that in June 2018 there were 33 practices across 31 sites. 3 sites host 2 practices each, and one practice has 2 sites. Practice size ranges from 1733 to 18603 patients

·         The highest ward population increase has been 3000 residents, equivalent to 1.6 full time GP’s and there are 35 identified sites for new homes over 50 units. This is over an estimated 6500 new homes, and 13000 new residents. The largest redevelopment is 750 homes, which is over 1500 residents and equivalent to 0.8 GP fte

·         Some practices have extended opening hours and there are three practices that host iHUBS, which offer evening and Saturday/Sunday GP appointments to all patients registered with an Islington GP. Six practices offer some opening on Saturdays for their own patients

·         In terms of ownership of premises three sites are owned by Community Health Partnerships, which own and manage NHS PFI sites, four practices are owned and managed by Whittington Health, one site is owned by the NHS Property Company and the remaining sites are owned/leased commercially by a range of landlords, and include purpose built premises, as well as converted premises

·         In terms of impact of new developments, Public Health and Planning colleagues analyse practice registrations to understand the impact of new housing developments, which is shared with NHS colleagues

·         There is an area based analysis of GP registrations. This informs responses to consultation such as with the Roman Way practice proposals, and it was noted that there is a large concentration of social housing around the Roman Way medical centre. Ill health is more prevalent in areas with a large proportion of social housing and an analysis has shown that 22% of residents living in areas with high social housing, has a long term condition, compared to 9% in areas with no social housing

·         The CCG has identified a number of opportunities to modernise and increase primary care provision, which includes physical expansion of the premises, where feasible, relocation of existing practices to larger sites, and remodelling of existing premises to maximise clinical use

·         In response to a question it was stated that it was anticipated that there would be an additional 600 properties on the Holloway Prison site. However, there is a purpose built GP facility opposite the Prison site, that some years ago had been designed to expand

·         19% of GP’s in Islington were over 55, and there is a need to assess how these are distributed amongst GP practices across the borough and that figures could be provided on this

·         Reference was made to the fact that the model of GP practices is continually evolving and that there is a need to assess whether the partnership model is still fit for purpose

·         Members were of the view that social prescribing and its effectiveness and increased use should be added to the SID

·         In addition Members were of the view that there was a shortage of GP surgeries in Caledonian and Bunhill wards and that this needed to be looked at

·         Reference was made to accessing GP’s on line and that this tended to be used by younger patients. It was noted that there were opportunities to make more use of digital technology, however there is a need to take account of people who cannot access on line services, such as many elderly residents. However, increased use of digital technology should also be added to the SID

·         Members expressed the view that Islington is a vibrant, diverse community and that it is a great place to live and work, and this would hopefully encourage young GP’s to work in the borough and replace those GP’s intending to retire

·         The Chair also referred to the fact that some GP surgeries were also owned by the GP and that when they retired they sold the premises, resulting not only in the loss of a GP but the site for a surgery. Reference was made to the fact that the CCG did have an estates strategy, however it took lengthy negotiations with developers to develop new sites, and it needed to be assessed where there is increasing demographic demand and where GP’s are likely to be lost

·         It was noted that the CCG were seeking to ascertain the intentions of GP’s, however there is not an obligation on them to inform the CCG of their intentions

RESOLVED:

That the SID be amended as follows –

Delete existing objectives of the review and replace with –

·         To examine service developments and options for increasing the number of people, including children, that can benefit from this model

·         Interfaces with other services

·         To examine the key enablers of primary care –

Digital and technological advances

Planned developments in the primary care estate

Approaches to both attracting new workforce into Islington and supporting existing workforce

·         To assess contractual approaches to securing the required capacity in general practice

Types of evidence – the addition of the following -

·         Information on digital and technological advances that may be relevant for primary care

·         Information on workforce developments

·         Information on the current social prescribing service

Witness evidence – the addition of the following

·         Interface Community Services (e.g. practice based mental health, MSK)

·         Age UK (providers of care navigator – social prescribing service)

The Chair thanked Tony Hoolaghan, Rebecca Kingsnorth, Imogen Bloor and Ian Sandford for attending