Written evidence submitted by the Department of Health, NHS England and Health Education England (PRI0200)

 

Introduction and summary

  1. This evidence has been prepared jointly by the Department of Health (the Department), NHS England and Health Education England.

 

  1. The term ‘primary care’ has traditionally been used to describe four sets of ‘first contact’ services provided largely by independent contractors: general practice; community pharmacy services; dental services; optical services. These services form part of a wider set of community-based services, including community nursing services, community mental health services, services provided by allied health professionals (e.g. physiotherapy, occupational therapy), and services provided by voluntary and charitable organisations.

 

  1. Primary care services, particularly GP services, are facing increasing demand from an ageing population with increased morbidity. They are also facing workforce pressures, with an ageing workforce in practice nursing and difficulties in recruiting GPs in some parts of the country.

 

  1. One of the key strategic aims set out by the NHS Five Year Forward View is to break down the traditional barriers between different primary care services and wider out of hospital care services, as well as other sectors such as social care. It sets out new care models that will deliver a more cohesive, joined-up set of community-based services, focused on keeping people healthy and helping people manage long-term health conditions.

 

  1. Our shared vision, in line with the Forward View, is for a transformation in primary care and out of hospital care more widely. The Forward View envisages primary care services built on the traditional strengths of general practice and GPs as ‘expert generalists’, particularly in targeting services at people with complex ongoing needs, such as frail older people or those with chronic conditions, as well as a greater focus on prevention.

 

  1. This written evidence therefore focuses on GP services, within the context of wider primary care and out of hospital care more generally.

 

Five Year Forward View and New Deal for General Practice

 

  1. The NHS Five Year Forward View explained the vital importance of strengthening primary and ‘out of hospital’ care.  It also set out some immediate steps to stabilise and strengthen general practice services by:
     
  1. On 19 June 2015, the Secretary of State for Health set out further details of a ‘New Deal for General Practice’ to help go further in transforming the quality of services and access to care. As part of that New Deal, we want to transform access to GP services - and give GPs greater responsibility and greater opportunities to help coordinate the care and support given to their registered patients, building on the principle of the named, accountable GP now embedded in the GP contract. For its part, the Government, NHS England and Health Education England are investing in general practice infrastructure, building the primary care workforce, and identifying ways to reduce workload pressures on general practice.

 

  1. Patients are reporting increasing concerns about access to GP services. The Government is committed to transforming access so that people who need to see or speak to a GP urgently can do so at any time – through new integrated NHS111/GP out-of-hours services – and, at the same time, making available a greater range of weekend and evening consultations for routine (planned) care. By March 2016 the Prime Minister’s GP Access Fund will have benefitted over 18 million patients, through GP practices coming together in networks or federations to provide weekend and evening consultations and to make much better use of technology to improve people’s interaction with services.

 

  1. At the same time, we need to strengthen wider systems of out-of-hospital care, so that GPs can work more effectively with wider multi-disciplinary teams to ensure patients get access to high-quality joined-up care. NHS England is launching new models of care that bring together general practice services with wider community-based services and/or hospital services, with the aim of delivering services more efficiently and more in line with patients’ needs and wishes.

 

  1. To support the overall transformation in primary care and wider out of hospital care, the Government has committed to increasing the primary and community care workforce by at least 10,000, including an estimated 5,000 more doctors working in general practice by 2020.Health Education England is leading work on developing the primary care workforce, including helping primary care introduce new workforce models that maximise the contribution of a range of other health and care professionals.

 

Contents

 

  1. This evidence is organised into the below sections, covering the bullet points given in the inquiry Terms of Reference. As set out in the introduction, this evidence is focused primarily on general practice but we would be happy to provide further evidence to the Committee as required.
  1. The quality and standards of care for patients
  2. Demand and access (including out-of-hours access and proposals for 7 day access)
  3. Funding (including local and national distribution of resourcing)
  4. Commissioning
  5. Future models of care as launched by the Five Year Forward View Vanguards
  6. Workforce: current and future challenges (including recruitment, retention, training, skill mix, contractual models, workload and pay).
  7. Dental, optical and community pharmacy services

 

 

 

 

  1. Background on General Practice[1]

•         There are 7,875 GP practices in England.

 

•         Practice size has increased over the last ten years, as GPs have chosen to work in larger partnerships (8,542 practices in 2004).

 

•         The average number of patients registered per practice is 7,171.

 

•         This number has been rising over the last ten years, from 6,149 in 2004. This is an increase of 16.6%.

 

•         54% of GP services (based on population) are provided under the national General Medical Services (GMS) contract. 44% are through Personal Medical Services (PMS) agreements which are usually similar in many respects to GMS, but are designed to reflect particular local needs or priorities. 2% are through Alternative Provider Medical Services (APMS) contracts, which are fixed contract length and can be owned by independent, voluntary or social enterprise providers.

 

 

  1. QUALITY AND STANDARDS OF CARE FOR PATIENTS

 

Quality of Care

 

  1. Quality of care is defined in the Health and Social Care Act 2012 as clinical effectiveness, patient experience and safety. International comparisons have shown that primary care across the UK performs well on many aspects of quality. The Five Year Forward View sets out the need to raise quality further across all healthcare services by reshaping care delivery, harnessing technology and driving down variations in quality and safety of care.

 

Quality and Outcomes Framework

 

  1. The Quality and Outcomes Framework (QOF) was introduced in the UK in 2004 as part of the new general medical services contract, with the central aim of tying a proportion of general practice income to demonstrating high standards of quality, particularly in relation to the care and support given to people with long-term health conditions like diabetes or coronary heart disease. However, there have been growing concerns that the QOF has become overly bureaucratic and rigid and may in some cases detract from providing holistic care for people with multiple health conditions and complex needs. In 2014/15, the Government reduced the size of QOF by more than a third and transferred the corresponding resources to core practice funding.

 

 

Care Quality Commission

  1. GP services are regulated by the Care Quality Commission (CQC). Since 1 October 2014, over 1,200 GP practices have so far been inspected and rated by the CQC. Of these, 3% have been rated outstanding, 81% good, 12% as requiring improvement, and 4% inadequate. Those practices with an inadequate rating have been entered into a new ‘special measures’ programme to help them address the problems identified.

 

  1. The introduction of the CQC inspection regime has highlighted a number of practices in difficulty and the importance of practices being well-led. With the nature of general practice operating as small independent units, there is a risk that even high performing practices can quickly fall into difficulty e.g. with the loss of one or two critical personnel.

 

  1. The Department of Health and NHS England have commissioned the Royal College of General Practitioners (RCGP) to provide a pilot programme offering expert peer advice and support for GP practices that enter special measures following inspection by the CQC.
  2. As part of the New Deal for General Practice, NHS England has identified funds of £10 million from the 2015/16 Primary Care Infrastructure Fund (PCIF) (see section on Funding below) to develop a support programme for struggling practices.

 

  1. Quality Surveillance Groups (QSG) have been established across NHS England at local team level, to share information and concerns relating to services, including within primary care. QSGs ensure that relevant agencies share appropriate information on risk and service delivery.

 

Patient feedback on services

  1. NHS England commissions the GP Patient Survey. This survey is conducted twice a year, and covers around 1 million people a year. This provides feedback on a range of areas. The latest results, published in July 2015, show that 85.2% of patients reported a good overall experience of their GP surgery.

 

  1. In addition to the GP Patient Survey from December 2014 it became a contractual requirement for GP practices to offer the “Friends and Family test” (FFT). The FFT works by asking a simple, standard question about whether patients would recommend the service to their friends and family, coupled with a free-text comment opportunity for patients to provide feedback. The latest publication of results for May 2015 shows that 88% of patients would recommend their GP practice to their friends and family.

 

GP Metrics

  1. NHS England uses a range of data to support its work in commissioning general practice services and holding GP practices to account for the quality of care they provide. Given the increasing role of CCGs in supporting the commissioning of GP services and improving quality of services, these data are shared with CCGs through a primary care web tool.
     
  2. The Government is committed to improving measures of quality and outcomes, with a strong focus on transparency as means of driving quality improvement.

 

  1. As part of the New Deal for General Practice, the Department has asked the Health Foundation to work with NHS England to carry out a stocktake of all current metrics, involving a range of stakeholders including NHS England, the CQC, RCGP, BMA and representatives of patients and the public. This stocktake will review where we are now, and how we can collect and publish better outcomes-based assessments of the quality of care for different patient groups. This will support the important progress made by Professor Steve Field in establishing the new CQC inspection regime but also address the concerns expressed by many about the shortcomings of some of the data being published.

 

  1. DEMAND AND ACCESS

Demand

  1. GP services are facing increasing demand from an ageing population with increasing levels of long-term health conditions and co-morbidity.

 

  1. GPs are reporting increasing workload pressures. NHS England is currently looking at how to release capacity in general practice.

 

  1. Broadening skill mix in a general practice has the potential to free up time for GPs and NHS England and Health Education England are developing skill mix initiatives, such as a pilot for clinical pharmacists working in general practice. Further detail is given in the sections on Workforce and Community Pharmacy below.

 

  1. Increased use of technology has the potential to improve the quality of support for patients and help manage demand for services by enabling patients to have a more active role in managing their own heath and care. Online patient access to summary medical records through primary care rose from 3% to 98% over the last year. By 2016, all patients will be able to access their own GP electronic record online in full, seeing not just a summary of their allergies and medication, but blood test results and appointment records.

 

  1. Additionally, initiatives such as the ability of pharmacists to access the Summary Care Record (see section on Community Pharmacy below) are important steps in realising the need, as identified in the Five Year Forward View, to build the public’s understanding that pharmacies and on-line resources can help deal with minor ailments without the need for a GP appointment.

 

Access

 

  1. The Government is committed to transforming access to GP services, including ensuring a much greater range of weekend and evening consultations.

 

  1. According to the GP Patient Survey, in 2014, 85% of patients reported they could get an appointment to see or speak to someone at their surgery when they last tried and 73% rated the experience of getting the appointment as good.

 

  1. The diagram below illustrates below illustrates the wide CCG level variation in the proportion of patients who say they have difficulty getting an appointment; results range between 6% and 20%.

Figure 1: Proportion of patients who say they have difficulty getting an appointment – CCG level (211 CCGs)

 

 

  1. Of those people responding to the 2014 GP Patient Survey, 11% of patients said they could not get an appointment and 8% of patients felt they were offered an inconvenient appointment. Of the people who said they were unable to get an appointment, or unable to get a convenient appointment, the survey indicates that  patients took the following course of action:

 

    1. 37% went to the offered appointment             
    2. 21% got an appointment for a different day             
    3. 6% had a consultation over the phone             
    4. 10% went to A&E or a walk-in centre             
    5. 3% saw a pharmacist             
    6. 13% decided to contact the surgery another time             
    7. 13% didn’t see or speak to anyone.

 

  1. In tackling concerns about access, NHS England is developing new ways of building on the pre-existing Direct Enhanced Service (DES) for extended hours. The DES was introduced in 2008, with the intention that practices should offer appointments outside core opening hours of 8.00am to 6.30 pm, Monday to Friday, in order to meet the needs of those patients for whom attending the surgery during core hours was inconvenient or impossible. 

 

  1. The Extended Hours Access Scheme was revised in 2014/15 to allow NHS England and practices more flexibility in providing arrangements which reflect the needs of the practice population. The specification for this service now allows GP practices to network together to offer extended hours access. Practices can deliver this service for their own patients alone, or choose to offer as a group of practices.

 

  1. Appointments can be offered with all practice staff, including health care assistants and may be provided through face-to-face, telephone consultations, using other technology or a mixture of these methods. Opening hours must be in line with patient expressed preferences, either through the GP Patient Survey or through preferences expressed through patient participation groups, the Friends and Family Test or other feedback.

 

  1. In 2013/14, 5,747 practices (71%) offered extended hours access, with total expenditure under the DES of £84 million.

 

  1. In October 2013, the Prime Minister announced a new £50 million GP Access Fund to help improve access to general practice and stimulate innovative ways of providing primary care services. This includes extending access to evening and weekend hours – but also different ways of accessing services, for example telephone, email and video consultations. Some schemes involve practices working together and making use of a broader skill mix to reduce workload on GPs and to offer services to a larger population. The Government asked NHS England to lead the process of inviting practices to submit innovative bids and oversee the pilot schemes.

 

  1. Twenty pilot schemes were selected covering over seven million patients across more than 1,100 practices spread across the country. Delivery of these schemes has been supported by a national development programme. NHS England has commissioned an independent evaluation from Mott MacDonald and their report will be published in September.

 

  1. In March 2015, a second wave of schemes was announced, with 37 pilots involving 1,417 practices and covering 10.6 million patients. This was backed by investment of over £100 million. The due diligence phase for these schemes has now concluded, and they are in the process of mobilisation.

 

  1. Taken together a total of 18 million patients in 2,500 practices will have benefited from improved access to general practice through this Fund.

 

  1. Out-of-hours GP services provide urgent primary care between 6.30 pm and 8.00 am on weekdays and all day at weekends and bank holidays. In 2013/14, these services in England handled around 5.8 million cases at an estimated cost of £400 million. Since 2004, GPs have been able to opt out of providing these services and most have done so. In these cases CCGs commission services on behalf of NHS England. Around 10% of GPs have retained responsibility for urgent out-of-hours services, but in the vast majority of cases contract the services out to out-of-hours providers.
     
  2. NHS England is working with CCGs to roll out a new integrated approach to NHS111 and GP out-of-hours services, so that patients can be confident that if they need to see or speak to a GP or another primary care professional urgently, they can do so regardless of the time of day and that there is a single consistent means of accessing urgent care through NHS111. Taken together with a major expansion in planned appointments at weekends and evenings, using the approaches tested through the Prime Minister’s GP Access Fund, this will provide a fundamentally new approach to GP access, seven days a week.

 

 

  1. Funding

 

  1. The Five Year Forward View sets out clearly the need for more investment in primary care. This is the biggest opportunity for new investment in general practice in a generation.

 

  1. A detailed breakdown of the totality of expenditure on primary medical care (general practice services), including that from NHS England, CCGs and local authorities, is published annually in the Investment in General Practice by the Health and Social Care Information Centre (HSCIC). The most recent HSCIC publication at the time of writing shows total spend on general practice services was £8,753 million in 2013/14, a 3.5% cash increase on 2012/13[2].

 

  1. Overall however, there has been a decrease in investment in general practice of around 0.8% per cent in real terms since 2008/09 relative to an increase in overall NHS investment in hospital and general and acute services of around 12.3%.

 

  1. The 2014/15 edition of Investment in General Practice is scheduled for publication by the HSCIC on 17 September 2015.

 

  1. About 82% of General Medical Services expenditure is linked to the number and profile of patients, through payments for:

The remaining 18% of current expenditure includes:

 

MPIG payments and seniority payments are due to be phased out altogether by 2020, with the savings reinvested in primary care.

  1. The Government is investing in primary care infrastructure as part of the New Deal for General Practice. At the autumn statement, the Government announced the Primary Care Infrastructure Fund, a £1 billion fund over four years, to accelerate improvements in GP premises and infrastructure like Information Technology. In January 2015, NHS England invited general practices to submit proposals for investment in 2015/16 and bids were approved where they would enable improved access to clinical services and support the delivery of new services to reduce emergency admissions. Investment of £750 million over the next three years will support a more strategic approach to premises development, including dedicated support for national IT projects, helping practices come together and link to other services.

 

  1. £25 million from the Primary Care Infrastructure Fund for 2015/16 is being invested in the GP Access Fund, as part of total funding of £175 million across the two waves of schemes.

 

  1. Additionally, the Five Year Forward View vanguards (see section below) have access to a £200 million Transformation Fund.

 

  1. Average income before tax for GP partners in England was £105,100 in 2012/13[3]. To provide greater transparency, practices have to publish by the end of 2015/16 the average earnings derived from the GP contract for GPs working in the practice.
     
  2. The average earnings for GPs have come down in real terms in recent years. Between 2004/05 and 2012/13 there has been an annual average percentage decrease of 2.1 per cent per year.

 

  1. COMMISSIONING

 

  1. The Health and Social Care Act 2012 amended the NHS Act 2006 (“the Act”) to establish a revised legal framework for commissioning NHS services in England. Planning and purchasing healthcare services for local populations had previously been performed by England's 152 primary care trusts (PCTs). The Act replaced PCTs with clinical commissioning groups (CCGs), and the NHS Commissioning Board (now known as NHS England). There are now 209 CCGs.
     
  2. Under the amended Act, NHS England became responsible for commissioning primary care services. The Act also places a duty on CCGs to assist and support the Board in discharging its duty in relation to continuous improvement of quality of primary medical services.
     
  3. CCGs can commission services from practices where they go beyond the scope of services commissioned by NHS England. NHS England has published statutory guidance on conflicts of interest guidance for CCGs when commissioning services from practices.
     
  4. NHS England is responsible for:

 

  1. Over the last year, NHS England has taken significant steps to enable CCGs to play a lead or joint role in commissioning general practice services, with the aim of supporting integration with other local health services and helping develop services so that they are more responsive to local needs and priorities. This is an important step towards expanding and strengthening primary care and should help to drive up quality, reduce health inequalities and put the NHS on a more sustainable path for the future. 
     
  2. There are three levels of ‘co-commissioning’ of general practice services, as set out in the ‘Next steps towards primary care co-commissioning document’.

 

  1. As set out in the Five Year Forward View, this option of increased control for CCGs of the wider NHS budget will help to enable a shift in investment from acute to primary and community services.

 

  1. On 1 April 2015, 63 CCGs assumed delegated responsibility for the commissioning of general practice services and 87 CCGs have now taken forward joint commissioning arrangements with NHS England.
     
  2. NHS England delegated the commissioning of GP out-of-hours services to CCGs in 2013.

 

 

  1. Five year forward view new care models
     
  1. The Five Year Forward View sets out a number of new care models that can meet the changing needs of patients, capitalise on the opportunities presented by new technologies and treatments, and unleash system efficiencies. NHS England is, through its New Care Models programme, supporting and stimulating the creation of those care models in a number of vanguard sites who can access a £200 million Transformation Fund.

 

  1. The vanguards for the first three new care models, launched in March 2015, are developing plans to reshape health and care in their local areas so that care is designed and delivered around the whole needs of patients. Primary care is at the heart of all those care models.
     
  2. As part of the Five Year Forward View, all seven national bodies that oversee health services in England are committed to enabling the delivery of new care models locally and the replication of new care models nationally. This is being supported through a national support package, published on 31 July, covering eight enablers:

 

  1. The national support package is supporting local health systems to challenge the status quo, remove national barriers to transformation and deliver the right care model for their local communities based on population health.
     
  2. The support package is being taken forward through ten dedicated work streams, each led by a vanguard leader and national subject matter expert, to co-produce the support that the vanguards have said they need.
     
  3. Multispecialty Community Providers (MCPs) will move specialist care out of hospitals into the community so that patients can access the care they need close to home. MCP vanguard sites are at different stages in the design of their model, but common characteristics include enhanced primary care, community integrated teams, specialist care in the community, improved access to specialist care and personalisation of care. We are supporting vanguard sites to redesign their workforce, create new roles and enable multi-disciplinary teams with professionals working together around the needs of patients.
     
  4. Integrated Primary and Acute Care Systems (PACS) will join up GP, hospital, community and mental health services. PACS sites all have community based multi-disciplinary teams focused on both physical and mental health. They all have strategies that are focused on either keeping people out of hospital when it is not medically necessary or improving discharge from hospital. All intend to create a single care record to facilitate integration, self-care and population health.

 

  1. Enhanced Health in Care Homes (EHCH) are designed to break the mould for older people in care homes, tackling social isolation and shifting from fragmented to connected care. To do this the vanguards have practical strategies to improve quality of life for current and potential care home residents and improve care planning so that care is more coordinated across different agencies. This will have a real impact on the interaction with, and access to, the primary care services upon which these patients often rely.
     
  2. Vanguards recognise the benefits for patients and local communities of integrating core general practice with other services currently separated by organisational boundaries.
     
  3. As a key enabler of that, we are supporting MCP and PACS vanguards to move towards capitated payments for a whole population. The MCP model, based on a GP registered list, will build in additional community and mental health services and social care as appropriate, converting these into an amount per patient that can be combined with core general practice funding. Some GPs have indicated a desire to migrate from GMS contracts to be part of a larger organisation. Through the implementation of the national support package, the vanguards are working with the New Care Models Programme to explore the different options, including ‘rights of return’.
     
  4. Given the significance of primary care for the delivery of new care models, from autumn 2015 the National Association of Primary Care (NAPC) and NHS Alliance (as well as other key primary care leadership bodies such as the Royal Colleges) will develop a learning community for primary care and community professionals, where participants can share insights and concerns with peers.
     
  5. Of the overall vanguard population, 14 vanguards are already developing new approaches to extended access to primary care, through the Prime Minister’s GP Access Fund. The New Care Models programme is working with all vanguards to explore whether similar approaches could be taken in their local health systems and is working closely with the Prime Minister’s GP Access Fund to make this a reality.
     
  6. Implementing new care models will in many cases require a different approach to the use of NHS assets and other estates. For example, moving care out of hospitals needs modern and suitable local primary and community care facilities. We are supporting vanguards to take a view across the local health system about how to manage, develop and rationalise estates and assets, aligned closely to the Primary Care Infrastructure Fund.

 

  1. workforce
     
  1. To support the overall transformation in primary care and wider out of hospital care, as part of the New Deal for General Practice, the Government has committed to increasing the primary and community care workforce by at least 10,000, including an estimated 5,000 more doctors working in general practice by 2020. Health Education England (HEE) is playing a central role in taking forward initiatives to meet this commitment, within the context of challenges within the GP workforce, alongside NHS England and other partners.

 

  1. To tackle immediate pressures in the GP and general practice workforce, HEE and NHS England have published a plan alongside the Royal College of General Practitioners (RCGP) and the BMA General Practitioners Committee (GPC), to attract more training doctors into general practice, make better use of the wider clinical workforce in primary care, target measures to support retention, and support the return of clinicians who have left general practice. The ten-point plan, Building the Workforce, is available on NHS England’s website: http://www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/01/building-the-workforce-new-deal-gp.pdf

 

  1. There are three key strands to this work:

 

  1. HEE and NHS England are also working together to promote and support new workforce models, drawing on the recommendations of the recent Primary Care Workforce Commission.

 

Improving recruitment into general practice

  1. Recruitment to GP training places is a UK coordinated process delivered via the GP National Recruitment Office, hosted by HEE.
  2. HEE has been increasing the number of training posts since 2013 with the aim of reaching its mandate objective of 3,250 trainees entering GP training each year by August 2016. Based on posts advertised this equates to a 12% increase. Although the numbers of applicants have dropped since 2013, the number of applicants being appointed to GP training has remained broadly consistent over the same period. Therefore the drop in fill rates for GP training is a result in a greater number of posts being advertised rather than a significant drop in GP acceptances.

 

 

 

 

 

 

 

Comparison between 2009-2014 (England Data) Source: GP National Recruitment Office

 

Year

Posts

Filled posts

Fill rate

2009

2719

2626

96.6%

2010

2732

2788

102.1%

2011

2665

2658

99.7%

2012

2778

2668

96.0%

2013

2761

2738

99.2%

2014

3067

2688

87.6%

 

  1. 2015 recruitment to date has resulted in a fill rate of 82%. To increase this, a further round of GP recruitment has been established to recruit for posts starting in February 2016. Currently 611 vacancies are being advertised in England in those LETBs that did not receive 100% fill rate. This recruitment round is supported by recruitment events in each area in partnership with the RCGP.
     
  2. 2015 specialty recruitment was evaluated through a recruit survey which was sent to 12,500 applicants from Round 1. 3,800 responses were received, creating a 30% return. The survey indicated factors that had an impact on applicants either choosing general practice or being successful through the application process:

 

 

 

 

 

  1. In view of survey results and other considerations, HEE is undertaking a number of initiatives to support improved fill rates and applications for 2016 recruitment:

 

 

 

 

 

 

Promoting general practice as a career

  1. HEE managed a series of 15 GP regional roadshow events in conjunction with the RCGP, targeted at medical graduates, prior to the second round of recruitment for 2015/16. Over 400 junior doctors and medical students attended the events which were held throughout England in February and March 2015.

 

  1. To support the opening of 2016 Medical Specialty Recruitment, all 13 LETBs across England are running GP specific recruitment events from September to early November, which will emphasise the range of opportunities that general practice can offer and that general practice is an excellent career choice.
     
  2. HEE, along with NHS England, RCGP and GPC, will be launching a campaign in week commencing 21 September that will focus on promoting the benefits of selecting GP as a specialty, using various communication channels and media. The strapline for the campaign will be ‘There’s nothing general about general practice’.

 

  1. Pre-Specialty Training (GP) provides the opportunity for career development and support for those interested in general practice or uncertain about their future career. It provides a one off opportunity for those doctors unsuccessful at GP Selection Centre to work for a year in one area of the country while receiving regular teaching and clinical exposure that will help to improve the skills they need for a GP career, and thus increase their chances of admission to specialty training through the national selection process. To date, 82% of trainees on the pilot scheme have been successful in a future GP application.
    Evidence suggests that this would also be attractive to some trainees who rejected GP offers, and to others who didn’t apply, because of a lack of understanding about what the GP career offered.

 

Improving the breadth of training

 

  1. With an increasing emphasis on the role of GPs in helping reduce avoidable hospital admissions and improve step-down care, additional skills training is necessary to meet service requirements.

 

  1. Posts created include Acute and Emergency Medicine, Quality Improvement, Leadership, Commissioning and Global Health. These are co-funded with CCGs and/or providers. In one area, an increased number of trainees have confirmed that they will stay in their area.

 

  1. The new post-CCT (Certificate of Completion of Training) fellowship in urgent and acute care will support the retention of generalist skills and the development of specific and enhanced skills, tailored to suit new settings of urgent care.

 

  1. Given the success of such pilots, HEE is scoping the use of an additional year of post-CCT training for GPs candidates seeking to work in geographies which historically have had difficulties recruiting trainees. The aim is to encourage new GP trainees to work in these areas.

 

Training hubs
 

  1. Work is underway to consider how to establish a number of hubs/networks providing new education and training models for the whole workforce within community and primary care settings.
     
  2. By creating a learning environment across the community and primary care providers and increasing the number of the workforce who are capable and competent to treat and manage people closer to home, we aim to improve recruitment, retention and develop skills of the workforce.
     
  3. Through the ten point plan, investment will be made to support LETBs and providers to continue to develop hub/networks across England.
     

Supporting those who wish to return to general practice

 

  1. HEE identified a need for a national Induction and Refresher Scheme which was launched in March 2015 and is administered through the GP National Recruitment Office (GPNRO). Candidates now have a standardised entry point to help speed up the time it takes to process individuals through the scheme and also making it easier for candidates to access relevant information. Further information on the scheme is available on NHS England’s website: http://www.england.nhs.uk/commissioning/primary-care-comm/gp-action-plan/gp-induction

 

  1. Next steps will be to develop information and sign posting materials and to place an advert overseas to encourage doctors to come back into England.

 

Retaining doctors within general practice

  1. There is a slight trend upwards in the numbers of GP leavers each year. NHS England is conducting a series of focus groups with existing GPs to inform work on retaining GPs in the workforce. This is happening alongside a systematic review of literature and research relating to the retention of GPs in England. Additional incentives may include clinical mentorship and coaching.

 

  1. NHS England will refresh the Statement of Financial Entitlements to enable the implementation of an improved retained doctor scheme to help keep experienced GPs in the workforce.

 

  1. NHS England is developing a pilot programme of investment in other parts of the workforce to support practices.  Whilst these will not directly increase the number of GPs, it should help improve workload issues, whilst signalling a move to new models of care for the longer term. 

 

Promoting new workforce models

 

  1. To consider the longer term requirements for the primary care workforce, HEE established an independent Primary Care Workforce Commission, chaired by Professor Martin Roland, Professor of Health Services Research, University of Cambridge. Its report was published in July: http://hee.nhs.uk/wp-content/blogs.dir/321/files/2015/07/The-future-of-primary-care.pdf

 

  1. HEE has welcomed the report and its emphasis on a multi-professional workforce in primary care to support the delivery of general practice. It is developing work on the use of Physician Associates in primary care, looking at a single approach to advanced practice, piloting the new role of the Medical Assistant and exploring the use of Health and Social Care Navigators.

 

  1. The community and district nursing work programme is launching a competency framework for practice nursing and following the paramedic review work it is anticipated that pace of recruitment of paramedics in primary care will increase significantly.

 

  1. HEE is considering the recommendations that the report has outlined and a formal response will go to the HEE Board on 20 October 2015.

 

  1. As part of exploring new ways of working and skill mix in general practice, in July 2015, NHS England launched a pilot for clinical pharmacists working in general practice (see section on Community Pharmacy below).

 

  1. WIDER PRIMARY CARE

 

Community pharmacy

 

  1. Community pharmacy is commissioned to:

 

  1. Pharmacy already plays a vital role in supporting the health of people in their local communities, providing high quality care and support, improving people’s health and reducing health inequalities.  As we move to more integrated care, there is real potential for community pharmacists and their teams to play an even greater role in the future, particularly in keeping people healthy, supporting those with long term conditions and helping make sure patients and the NHS get the best use from medicines.

 

  1. The Five Year Forward View stated that there should be far greater use of community pharmacies: in prevention of ill health; support for healthy living; support to self-care for minor ailments and long term conditions medication review in care homes; and as part of more integrated local care models. For example, many community pharmacies are being commissioned to provide seasonal flu vaccinations, helping to reduce pressure on GPs.

 

  1. The General Pharmaceutical Council (GPhC) is the independent regulator for pharmacists, pharmacy technicians and pharmacy premises in Great Britain. Its job is to protect, promote and maintain the health, safety and wellbeing of members of the public by upholding standards and public trust in pharmacy. Work is underway to deliver a modern approach to regulation, strengthening the regulatory framework as required, while facilitating and reducing the barriers to responsible development of practice, innovation and promoting a systematic approach to quality in pharmacy.

 

  1. NHS England monitors performance against Terms of Service set out in the NHS (Pharmaceutical Services and Local Pharmaceutical Services) Regulations, which outline contractual requirements of pharmacies providing NHS services.

 

  1. Prescribing and dispensing of medications is a core activity of primary care. The NHS Business Services Authority Portal provides comparative prescribing indicators which are extensively used by CCG medicines optimisation teams to challenge unwarranted variation in prescribing practice.

 

  1. NHS England has published a medicines optimisation dashboard to help CCGs understand how well their local populations are being supported, to optimise medicines use and inform local planning with data being refreshed every six months.

 

  1. Experience has shown that where pharmacists have been working in NHS 111 contact centres they can make a significant contribution to the efficiency and quality of care handling a specific case mix of calls including:

 

 

  1. A significant number of pharmacies are open seven days a week. Predominantly these are the contractors who are on the pharmaceutical list as part of the former 100 hours per week exemption. In 2015/16 there are 1,126 pharmacies providing services 100 hours per week. Some of these pharmacies will be sited next to walk in centres, minor injuries units and other services that provide out-of-hours services.

 

  1. The summary care record (SCR) provides key clinical information (medicines, allergies and adverse reactions) about a patient, sourced from GP records. It is used by authorised healthcare professionals, with the patient's consent, to support their care and treatment. More than 96% of the population have an SCR and it is already being successfully used in many settings across the NHS, such as A&E departments, hospital pharmacies, NHS 111 and GP out-of-hours services and walk in centres.

 

  1. We are investing up to £7.5 million to give community pharmacists the training and tools they need to access patients’ SCR. A pilot has already shown that as a result of this, as many as nine out of ten people can get the help they need from their pharmacist without having to be sent to another service.
     
  2. A report assessing the effectiveness of the proof of concept found that SCR access in community pharmacies delivered benefits to patients, pharmacy and general practice, including:

 

  1. Pharmacy professionals and community pharmacies have to meet the General Pharmaceutical Council's standards when accessing patient records. These standards make clear their responsibilities, including in relation to holding patients’ information securely, obtaining patients’ consent before accessing their information and respecting their privacy.

 

 

 

Clinical pharmacists working in general practice

 

  1. In July NHS England announced £15 million investment in a new patient-facing role.  These clinical pharmacists will be independent prescribers and will deliver a wide range of services based on local need, which may include supporting patients with long-term conditions to manage their own health and care more effectively.  We intend to invest about £15 million over three years in the pilot and anticipate that roughly 250 clinical pharmacists will be involved over this period, with the ambition of supporting over one million patients.

 

  1. The pilot builds on experience of some general practices in England who now include clinical pharmacists in their multi-disciplinary teams. Experience suggests that there have often been significant benefits for patients and for the wider practice teams. The purpose of this pilot is to encourage more practices to consider similar new ways of working.

 

  1. Two of the key objectives of this work are to:

 

 

 

  1. The key outcome of this work will be improved care and health outcomes for patients with improved access to care in general practice. Pharmacists will support patients to play a greater role in managing their own health and well-being and long term conditions, through optimising medicines, and  improving medicine related communication between general practice, hospital and community pharmacy for instance on admission and discharge and at other interfaces of care.

 

  1. The pilot is designed to allow for flexibility and innovation but is based on the principle that each pilot site would include an experienced clinical pharmacist who can train and mentor up to five less experienced clinical pharmacists. The role would include in the longer term: management of difficult conditions, facilitation of communication across the whole patient pathway, more effective and efficient use of medicines with a shift to best value rather than lower cost, and bespoke integrated pharmaceutical care plans for individual patients.

 

  1. Intended benefits could include an increase in the time available to GPs to undertake more complex or chronic care; improved access to GPs and the wider workforce, such as additional appointments and availability, decreased waiting times, and increased patient satisfaction. Specific benefits could occur for people with conditions such as those with chronic obstructive pulmonary disease, coronary heart disease, frail older people and people with diabetes.

 

Primary dental services

 

  1. The Government is committed to continue to improve access to NHS dentistry, and to improve the oral health of the population (with a particular focus on children).  NHS England is working in conjunction with the Department of Health to test a prototype new dental contract with a greater emphasis on the delivery of a preventative dental care pathway, customised to meet the needs of the presenting patient.

 

  1. NHS England has a duty to commission primary dental services to meet need throughout England. In addition, NHS England commissions community dental services (e.g. for people with special needs) and hospital services (for more specialist treatment). NHS England is responsible for ensuring that NHS primary dental services are accessible, and that they contribute to the prevention of dental disease, in addition to its treatment. 

 

  1. Oral health is an important part of an individual’s overall general health and wellbeing and has been steadily improving in since England the 1970s, among children and the overall population, although significant inequalities remain.  Public Health England provides overall leadership for oral health improvement across health and social care. This includes supporting local authorities to fulfil their public health responsibilities, including oral health, and supporting NHS England’s commissioning of dental services.

 

  1. General Dental Services (GDS) provide mandatory services such as fillings, crowns, bridges and regular check-ups. In addition non-mandatory services, such as orthodontics (tooth straightening) and minor oral surgery (complex dental extractions), may be provided.

 

  1. NHS England also retains responsibility for the commissioning of dental out-of -hours services. This service is designed to address urgent and emergency care requirements and is operational from normal practice close until late evening and weekends and bank holidays.

 

  1. NHS England work in collaboration with the NHS Business Services Authority to collect quantitative data to manage and monitor the quality of delivery of NHS dental services.

 

  1. The latest published access figure below shows a rise in the number of new patients accessing primary care dental services across England.

 

 

 

Patients seen in the most recent 24 months

 

 

June 2014

 

 

June 2015

 

National position

 

29,915,894

 

 

30,024,456

 

 

 

Primary eye care services

 

  1. NHS primary eye care services provide sight tests for eligible groups,  serving both to correct refractive error for people who need glasses and to support the early detection of a range of serious eye conditions such as age-related macular degeneration (AMD), glaucoma, diabetic retinopathy and cataract.

 

  1. The quality of service provision is maintained via a programme of self- assessment by practices backed by a targeted practice visiting programme by NHS England.

 

  1. Future plans include the phasing out of the current paper based system and its replacement with electronic links between NHS England and optical practices. This will improve the data quality available to both NHS England and sector and improve efficiency.

 

 

8 September 2015

 

 

[1] Health and Social Care Information Centre, General and Personal Medical Services: England 2004-14: http://www.hscic.gov.uk/catalogue/PUB16934/nhs-staf-2004-2014-gene-prac-rep.pdf 

[2] http://www.hscic.gov.uk/catalogue/PUB14900

[3] http://www.hscic.gov.uk/catalogue/PUB1492