Agenda item

10:45

Representatives from NHS England, (Thames Valley Team) Ginny Hope; and the Oxfordshire Clinical Commissioning Group, Dr Joe McManners and Rosie Rowe will present an overview of primary medical services within Oxfordshire.

Representative(s) of the Local Medical Committee (Paul Roblin), the City Federation and Primary Medical Limited will also attend to give a provider perspective.

The Committee will discuss challenges and service development. A briefing which has been prepared by NHS England (Thames Valley) team and the Oxfordshire Clinical Commissioning Group is attached at JHO7.

Ginny Hope from NHS England (Thames Valley Team) and Dr Joe McManners, and Rosie Rowe from the Oxfordshire Clinical Commissioning Group attended the meeting to present an overview of primary medical services and to discuss future challenges and service development within Oxfordshire. Dr Paul Roblin (Local Medical Committee), Dr Ben Riley (Oxford City Federation), and Dr John Harrison (Principal Medical Limited) also attended to give a provider perspective to the discussion.

A briefing which had been prepared by NHS England (Thames Valley team) and the Oxfordshire Clinical Commissioning Group was before the Committee at JHO7.

Dr McManners, Clinical Chair, OCCG, commented that the local Health and Social Care system was dependent on a high quality and well performing primary care system, which, if done well, could play its part in improving the quality of the whole system, including that of secondary care. Whilst Oxfordshire had been recognised as producing a high quality primary care, the role and function of the GP had changed gradually over the years and had reached crisis point. Reasons cited were increased demand for urgent appointments and more and more complex care combined with the expansion of the numbers of people aged 85 and over, less care taking place in hospital, and more preventative care being undertaken with patients. With the amount of resource as a proportion of the Health spend reducing, primary care is trying to do more for less. Dr McManners added that whilst there was much that worked well in primary care, there was a need to cluster groups of practices and integrate work with social care (and communities in local areas) in order to meet these changing needs. Thirdly he highlighted the need for more work to be done on recruitment and retention practices to meet the issues faced by a GP practice in the modern age.

Ginny Hope, Head of Primary Care, NHS England (Thames Valley team) commented that, following the recent reorganisation, NHS England held the legal commissioning contracts with all 80 GP practices across Oxfordshire and the whole of the Thames Valley region (240 GP practices in all, 10 CCGs). She added that the delivery of a high quality health service was being undertaken via co-commissioning with the CCGs and via close working with GPs and providers. NHS England was working with CCGs on different models of working and the transformation of primary care. They were also working with them on a demographic approach, looking to produce a mapping exercise across all counties. In addition, NHS England was also working with CCGs on questions for the new strategy based on expansion prospects and commissioning.  She informed the Committee that new funding was available via NHS England from a Primary Care Infrastructure Fund, undertaking to send officers the link to it for circulation to members.

Regarding the link between NHS England and CCGs who are unable to fund the transformation of practices into federations, or did not have the capacity to do so, Ginny Hope explained that NHS England would take forward the major commissioning, but in time (approximately 12 months). There would be opportunities for CCGs to be able to move from joint-commissioning to delegated commissioning. Dr Harrison commented that it would be possible to work in a larger scale and to operate extended services, but retain traditional primary care services within it, as demonstrated by the Banbury Health Centre.

Dr Ben Riley explained that the Oxford City Federation was a new organisation which had only just formed, representing 22 practices in the City locality. Its aim was to strengthen and support services which could be offered, partly to sustain the skills already in place and also to build on and expand them. Each practice would own a share and it would be run on a not for profit basis.

When questioned about why only 68 out of 80 practices in the County had agreed to follow the federation route, Dr Harrison explained that primary care had remained unchanged in Oxfordshire for many years and some areas were very conservative in nature and felt differently about federation. He made reference to the Prime Minister’s Challenge Fund (£4.5m), the aim of which was to fund interventions at a much earlier stage. For example it would fund an elderly visiting service to the frail and elderly at a much earlier stage before their health deteriorated, resulting in visits to A & E. The federation would also be responsible for delivering health checks within primary care and they would be delivered via quality assurance methods. There would also be opportunities to bid for monies from the Prime Minister’s Transformational Fund. There were also plans to introduce care navigators which would assist patients to link up with the right services and roll out care plans for patients with complex needs. There would be some linkage of services and sharing of responsibility – and other services such as Oxford Health working alongside. Different components were being piloted as part of a future vision.

Dr Paul Roblin addressed the challenges facing primary care focusing on resourcing to make the transformational changes, gaps in GP entry into the service, and stress levels within the GP service. The Local Medical Committee were keen for services to remain close to where patients live, that the national NHS contract would not be tinkered with, and that there be an integrated, seamless service put in place (to include secondary care), and, as circumstances change, for money and resources to move as appropriate.

Rosie Rowe emphasised that the OCCG and NHS England would be going out to consult on a detailed Strategy and that there were plans to form another cluster of practices covering the Abingdon area.

Dr McWilliam commented that there were several trends that could be expected from GPs in the future which would result in a different patient experience. Surgeries would be grouped into bigger units, would be more commercial, managed more centrally and uniformly and more GPs would be salaried rather than independent.

In response to a question about whether funding from the Better Care Fund would be used for this purpose, Dr McManners and Ginny Hope responded that this would not be the case but there were other pots of money available such as the Funds referred to above. They commented that Oxfordshire was relatively well served for premises. More investment would be coming and there would also be a focus on working with providers in this context. Dr Roblin added that the national contract (per capita) would not increase and the Government was looking to CCGs to fund the changes.

Dr McManners was asked whether the cut in nurse and nurse practitioners was an issue. He responded that he understood that there was a problem with recruiting sufficient numbers of nurses, however, a number of universities were now training post graduate nurses to work alongside doctors to undertake some of their work. With regard to the recruitment and retention of GPs, Ginny Hope and Dr Roblin referred to a 10 Point Plan which had recently been launched to address this and included incentives for existing GPs not to retire, or to assist GPs to return to the profession more easily. This Plan and federalisation would also make the profession more popular to prospective GPs.

When asked if there was any research on improving access to GPs. Rosie Rowe responded that the answer was closer linkage between health and social care. The Prime Minister’s Challenge Fund would provide the resources to ease the interface between staff and encourage closer working. The CCG were working with Oxford Health on the integration of Health and Social Care teams in the localities. Oxford University had been asked to undertake an evaluation of the new ways of working from a patient perspective.  Dr McManners commented that there was evidence that continuity of care reduces hospital admissions, though the outcomes were not so strong in urgent cases.

Dr Harrison was asked if the professional ethos which all doctors follow would be affected in a not for profit environment. Both he and Dr Riley responded that the current NHS ethos would be captured in the new organisation.

In response to a question asking where the incentives were to undertake regular visits from GPs to care homes if they were to become salaried, Dr Roblin stated that a scheme would be introduced within the next few months whereby GPs would be given incentives to visit care homes, amounting to £200 per bed.

When asked what arrangements had been made for the provision of new surgeries in new areas of housing growth, Ginny Hope explained that the CCG were trying to map that growth, adding that it needed to balance the long-term sustainability of the small GP practice. Small practices would not be the model, practices with 8,000 – 10,000 patients would be more sustainable.

Ginny Hope was asked about how NHS England planned for its future commissioning of new surgeries. She explained that NHS England was not a statutory consultee in the local authority planning process, but was often included as part of good practice. A more robust process was needed. It was also working with organisations such as Community Health Partnerships and NHS Estates to identify under - utilised, existing estate to ensure that assets were used.

A member asked if GPs would continue to provide a holistic approach to patient care, to which Dr Roblin responded that GPs are imbibed with a holistic ethos and they would hope to provide holistic, whole person medicine.

When asked who would be carrying out the visiting service and what training would be given, Dr Riley responded that the visiting service would remain a GP responsibility. Practices would be engaging emergency care practitioners and senior nurse practitioners who would undertake the visits, supervised by a named GP. Training would be given. All of this would have to be worked through. Doctors were already undertaking out-of-hour services and initial feedback had indicated that it had been successful.

In response to a question about patient information available to those undertaking the visiting service, Dr Harrison stated that the CCG was in the process of building the capability for summarised notes to be included on all patient records.

Dr McWilliam and Dr McManners were asked if systematic preventative care would also be developed as part of primary care going forward, or was it destined for the commercial high street. Dr McManners responded that a substantial amount of work was already undertaken in this sphere, in the early detection of cardio vascular problems for example, but a suitable approach was required and it needed to be worked out. Dr Roblin added that primary prevention had still to be resourced, analysed for its financial benefit and thought given to how primary care may be utilised to the patient’s best advantage. A member pointed out that the Banbury Regeneration Programme was an example of good prevention work, to which Dr McManners responded that a team at the CCG gave focus to it and went out to practices and groups with the aim of improving their practices in preventative work and breaking down any existing barriers.

A member asked about whether the use of physiotherapists would be included within primary care, Dr Harrison and Dr McManners responded that this would be included within a forthcoming review of musculo-skeletal services. The proposals included patient self-referral to physiotherapy services, with no filtering taking place. Dr McManners confirmed that it had been proposed that these services would be embedded into GP practices. He suggested that the Committee might wish to feed into the review.

At the conclusion of the discussion, the Committee AGREED to:

(a)  ask the CCG and NHS England to circulate the consultation document on Primary Care to members of the Committee for comment prior to it going out to the wider public; and

(b)  that a recommendation be sent to all the appropriate bodies that NHS England be considered as a statutory consultee partner when housing growth (large and small planning applications) is considered by Councils.