Agenda and minutes

To note that Councillor Matt Shannon has stood down from the Committee and that Councillor Farzanna Mahmood has been appointed to the vacancy.

The Committee noted that Councillor Farzanna Mahmood had replaced Councillor Matt Shannon as a member of the Committee.

Resolved to appoint Councillor Saj Ahmad and Councillor Maria Joannou as joint vice chairs for the municipal year 2023/24.

Councillor Farzanna Mahmood - personal

In the interests of transparency Councillor Saj Ahmad stated that she is employed by NHS England/ Department for Health and Social Care.

To confirm the Minutes of the meeting held on 23 March 2023

The minutes of the meeting held on 23 March 2023 were confirmed as an accurate record and signed by the Chair.

Report of the Statutory Scrutiny Officer

Resolved to note:

(1)  the Committee’s Terms of Reference for municipal year 2023/24;

(2)  that Article 11 (Overview and Scrutiny) of the Constitution sets out the rules within which the Committee must operate; and

(3)  that the Committee’s operation, and the approach of scrutiny councillors should be in line with the agreed Overview and Scrutiny Protocol

Report of the Statutory Scrutiny Officer

Sara Fleming, Programme Director for System Development, Nottingham and Nottinghamshire Integrated Care Board, Dr Hugh Porter, Clinical Director, Nottingham City Place Based Partnership and Dr Manik Arora, Deputy Medical Director, Nottingham and Nottinghamshire Place Based Partnership attended the meeting to discuss work taking place to recover and sustain General Practice in Nottingham City.  They highlighted the following information:

a)  There is recognition nationally of the challenges facing General Practice and in May 2023 NHS England published the ‘Delivery Plan for Recovering Access to Primary Care’.  This Plan focuses on four main areas: empowering patients to manage their own health; implementing modern general practice access to provide rapid assessment and response and tackle the ‘8am rush’; building capacity and tackling workforce challenges; and cutting bureaucracy particularly across the interface between primary and secondary care.

b)  The Nottingham and Nottinghamshire Integrated Care Board (ICB) has developed its own Primary Care Strategy to support primary care in addressing the challenges and tackle workforce pressures.  This Strategy will initially focus on General Practice and then broaden out to other areas of primary care.  A new public facing document will be published by the end of 2023.

c)  The Strategy Delivery Group is chaired by the ICB’s Chief Executive, who provides senior focus and leadership on this important issue.  The Group involves two clinical directors from the City, leads from each workforce area and involves the Local Medical Committee.  The Group has met twice and is still evolving, but has given a focus to this work and is actively developing implementation plans and performance metrics.

d)  There is a national requirement for all ICBs to develop a system level access recovery plan which sets out how the ICB will deliver on the national Delivery Plan.  The proposed plan will be going to the ICB Board meeting on 9 November 2023 for approval.

e)  90% of patient contacts with primary care are with General Practice so it is a really important area.  To give a sense of scale, there were 166,000 GP appointments in the City in July 2023, which was approximately 20,000 higher than the same period in the previous year.  47% of these were same day appointments and 77% were held face to face.

f)  A range of ICB-wide actions are taking place and, while lots is happening, it will take time for change to embed. 

g)  In relation to empowering patients, the national Delivery Plan has a focus on patients using the NHS App to manage their own health.  Locally work is taking place on how to support those with digital exclusion.  If the majority of patients use the App this will release capacity to support those unable to do so.  In many cases, individuals with long term conditions know what they need and they need to be supported to access that, which in many cases does not require the involvement of a GP.  If they can be effectively supported to access care without unnecessary involvement of a GP, GP capacity can be released to see patients who do require their direct involvement in a more timely way.  This might be through community pharmacies who can support individuals in accessing, for example, contraceptive services.

h)  In relation to implementing modern access and tackling the ‘8am rush’, the aim is to support practices to support patients in getting to the right place.  The traditional receptionist role will change, with individuals trained so that they can become clinical navigators that help patients get appointments with the most appropriate service rather than defaulting to seeing a GP, which may not be the most appropriate.  There will also be a focus on basic telephony issues to support practices to get to a good standard of response.

i)  The number of GPs has remained stagnant and numbers are not increasing at the rate desired.  One focus in relation to building capacity is diversifying roles so there are a range of skilled and specialist roles within a GP practice that patients can be triaged to for appropriate support.  Often patients think that anything less than seeing a GP is sub-standard and this is not the case, and in fact other specialists are often better able to meet a particular need than a GP.  This perception needs to be addressed to make better use of the whole workforce.  The ICB is also supporting practices to retain staff, particularly GPs and practice nurses, which has been a big challenge particularly post-pandemic.  A primary care staff survey was carried out recently and, while the response rate was relatively low, it gave a good indication of what needs to be done.

j)  The aim of cutting bureaucracy is to maximise the amount of time that GPs are using their clinical skills rather than completing administrative tasks, for example it may not necessary for a GP to give permission for a patient to access specialist care but requiring this to be route to access takes time for GPs and is frustrating for patients. 

k)  In addition to top-down change, the ICB is also encouraging a bottom-up approach.  The 46 practices in the City are being brought together to help solve common challenges collectively and ensure that they are able to respond cohesively to top-down requirements and changes.  For example, last year the Clinical Director led sessions on empowering practices to provide the best service that they can.  They have had sight of the draft Primary Care Strategy and have been consulted on what is important to them.  Areas that practices want to do work on include workforce, clinical delivery models, IT and digital issues and communications and engagement with citizens to help them navigate services.  They are being worked on now, for example the creation of an interface programme between General Practice and Nottingham University Hospitals NHS Trust to, for example, stop the default always being referral back to the GP.  There is also co-production work with citizens taking place on how GPs can work in their local communities and neighbourhoods to be more proactive and preventative.  The aim is to produce a consistent and sensible approach across all 46 practices.

l)  Integrated neighbourhood teams and integrated models of care are being trialled in the Bulwell and Top Valley Primary Care Network (PCN).  The intention is to roll out learning from this approach to all PCNs over the next 12 months.

m)  Feedback from frontline staff is that the approaches being taken are the right thing for citizens, empower staff and are supportive of well-being and retention of staff.

n)  The findings of the Fuller Stocktake sit alongside the Delivery Plan and are feeding into work to recover and sustain General Practice. 

During discussion and in response to questions from the Committee the following points were made:

o)  It is recognised that, while consultation did take place with frontline staff on the development of the Primary Care Strategy, this is not sufficient and the ICB is not doing as well as it could on this.  Work is taking place to understand reasons for the relatively low response rate to the staff survey, and one of the factors is time and capacity to engage.  Work is taking place with the Communications and Engagement Team to make improvements in staff engagement.

p)  It is accepted that, in addition to health inequalities in the provision of, and access to services, there are inequalities in trust of health systems.  Work is taking place to, for example, hear about the lived experience of people with severe multiple disadvantage and things are moving to a better place on this but it is not yet sufficient.

q)  While issuing prescriptions for a relatively short period and requiring repeat prescriptions to be requested and signed by GPs rather than issuing a single prescription for a longer period can create work for GPs and be frustrating for patients, there has to be a balance with reducing wastage that can result from prescriptions for a longer duration.

r)  While empowerment of patients is positive, it is important to recognise that some patients are better able to do this than others and there are differences in the extent, and way in which patients can access services.  Assurance was sought on the impact assessments carried out in relation to the changes being introduced.  The ICB confirmed that this is part of the strategy finalisation.

s)  Across the country, there is a mismatch between capacity to deliver and patient expectations about access.  In improving access, consideration needs to be given to whether proposals are addressing need or patient preference for who they want to see at an appointment.  In many cases, patients could be seen more appropriately by another professional following direction from a receptionist, but that is not currently what many patients expect.  A Committee member suggested that it would be helpful if there was a clearly articulated set of standards about what patients can expect in terms of access to care and by when.  They suggested that these standards should be consistent across all City PCNs so that patients can have the same expectations regardless of where they live.

t)  While some patients are happy to see any professional, patients with long term conditions often prioritise continuity of care with a specific care professional.  While practices can be encouraged to deliver continuity of care, this is not incentivised within the national contract and the national metric on the number of appointments within 2 weeks penalises practices who schedule appointments beyond that timeframe as a way of ensuring continuity of professional. 

u)  In response to examples highlighted by Committee of a lack of communication and engagement between primary and secondary care when changes are made to, for example, thresholds for access and in supporting people to wait well, ICB colleagues explained that there are now interface groups with Nottingham University Hospitals NHS Trust to facilitate clinician to clinician discussion about significant changes.  An interface group with Nottinghamshire Healthcare Trust is being refreshed.  The Committee was assured that there has been learning from the changes made to the neurology service to ensure that both sides are aware of changes, and ideally no change should be implemented without robust discussion.

Sarah Collis, Healthwatch Nottingham and Nottinghamshire, added that based on research carried out by Healthwatch in 2022 it had recommended that practices consider ways of improving booking systems, including telephony services; increase public awareness of the range of healthcare professionals and services that practices provide and how they are accessed; and increase choice over the type of appointment they want.  She commented that there is good practice in some practices and suggested that the ICB should be supporting PCNs to enable practices in change and innovate together.  In response to a question about sustainability of funding to address the issues, ICB colleagues responded that funding is available for transformation and system development and work is taking place with PCN Clinical Directors to identify the most important areas for them e.g. improving the experience of frontline workers and retaining staff.  Consideration is also being given to how other providers can support primary care, for example through provision of HR support.

Resolved to:

(1)  recommend that Nottingham and Nottinghamshire Integrated Care Board:

a.  consider how it can influence the priority that General Practices place on continuity of care and care professional when scheduling and booking appointments to increase the proportion of patients able to book subsequent appointments with the same care professional where they wish to do so;

b.  facilitate joint working between secondary care providers and General Practices to ensure patients on waiting lists for specialist care ‘wait well’

(2)  request that Nottingham and Nottinghamshire Integrated Care Board provide:

a.  a copy of impact assessment(s) carried out in relation to the Primary Care Strategy and System Level Access Recovery Plan to demonstrate the consideration given to these issues in development of new approaches;

b.  data on when City General Practice practices book appointments;

c.  a written briefing that can be circulated to all City Councillors about the pilot taking place in Bulwell and Top Valley Primary Care Network so that they understand the direction of travel in the City

Report of the Statutory Scrutiny Officer

Resolved to note the Comments submitted by the Committee to the following health providers for inclusion in their Quality Account 2022/23: Nottingham University Hospitals NHS Trust; Nottinghamshire Healthcare NHS Foundation Trust; East Midlands Ambulance Service NHS Trust; and Nottingham CityCare Partnership.

To agree to meet on the following Thursdays at 10am:

·  12 October 2023

·  16 November 2023

·  14 December 2023

·  11 January 2024

·  15 February 2024

·  14 March 2024

·  11 April 2024

Resolved to meet on the following Thursdays at 10am:

·  12 October 2023

·  16 November 2023

·  14 December 2023

·  11 January 2024

·  15 February 2024

·  14 March 2024

·  11 April 2024

Report of the Statutory Scrutiny Officer

The Chair, Councillor Georgia Power, reported that, in addition to the items listed on the work programme circulated with the agenda, the Nottingham and Nottinghamshire Integrated Care Board has asked to bring items about changes to the operation of the Urgent Treatment Centre on London Road and a new Community Diagnostics Centre to future meetings (dates to be confirmed).

Resolved to add items on the Urgent Treatment Centre and a Community Diagnostics Centre to the Committee’s current work programme.