Agenda item

Sharon Morrow, Barking and Dagenham Clinical Commissioning Group (CCG) Chief Operating Officer presented the report and explained that the CCG’s Draft Primary Care Transformation Strategy, which was attached to the report, had been developed in response to a number of drivers for change, such as the NHS Five Year Forward View and the challenges of changing demographics, the increasing number of patients with long-term and multiple-long-term conditions and the number of GP practices that were saying their workload would be unsustainable. 

Sharon explained that the emerging vision was of Primary Care led locality based services, which would be supported by other medical professional services such as pharmacies.  The CCG felt the integrated services would provide personalised, responsive, timely and accessible care that was both patient centred and co-ordinated, which would improve benefits for patients.  It would ensure that patients received a standard offer across all practices.  The Strategy would also encourage partnership working between GPs and would drive a better use of IT.  The King’s Fund framework would be used to develop place based care in Barking and Dagenham.  Sharon drew the Board’s attention to the timescale and the next steps set out in the report.

Dr John, Clinical Director Barking and Dagenham CCG, commented that the current GP model would not be sustainable and this vision was trying to improve longstanding problems and to improve patient outcomes.  The strategy would encourage partnership working, including with local authorities to integrate health and social care.  There was also the added pressure of the number of GPs retiring in the area and across London and the South generally. 

The Board raised a number of issues, including: 

-  Other Factors – Health and care provision alone was not the answer and other social impacts, such as jobs and quality housing all have an impact on long-term health outcomes.  Matthew Cole, Director of Public Health agreed to provide some wording on this issue to the CCG.

-  Delivery and Funding - How would this Strategy be aligned with other issues, such as the Better Care Fund and how would delivery be achieved?  How would it be resourced, bearing in mind the £400m funding gap that exists across the BHR health and social care system? 

Ambition 2020 and any proposals emanating from that would impact on social care services will be delivered in the future.  This had not been taken into account.

Preventative Health measures and better lifestyle choices may not have an impact for many years to come.  As a result there were still pressures that needed to be met both now and in the short to medium future.

-  Document Accuracy - The details in the document also needed to be accurate, for example one GP mentioned in it had already retired a few months ago.

-  Staffing Levels - LBBD was second from bottom for GP staff numbers per 1,000 population.  Why was Barking and Dagenham so low in the rating and why were other boroughs better staffed when they had less health issues?

There are recruitment issues across a whole range of health professionals in this area, which included GPs, Health Visitors, Physiotherapists and Dentists etc.  Difficulty in recruitment of qualified professionals was not unique to GPs, for example children’s social workers were difficult to recruit and also under pressure because of demand.

-  GP Referrals to Outpatients - The number of GP referrals to outpatients was significantly higher at 426 per 1,000 than the London Average or 312. The range across practices locally of 320 to 680 per 1,000 was unlikely to be as a result of population factors alone.  This needed to be further explored rather than just being anecdotal evidence.

-  Growth Borough - LBBD was a growth borough and the population would be increasing.  How were the CCG and GP services going to deal with that increase when Riverside Ward still had no GP Surgery?

-  Seven Day Primary Care Service - If a seven day Primary Care Service was to be available, how were GPs going to be able to cope with the extra workload?

-  Leadership of Local Health – What input would be provided both from and to other health professionals, for example collaboration between GPs and dentists?

-  Data and Statistics – Data was being used to drive the LBBD’s Ambition 2020 vision and decisions but there appears to be a lack of data to support the proposals and strategy. 

-  Implementation - Concern in regard to the implementation dates and felt that this was a little premature and was not as holistic as it should be.

Sharon Morrow responded:

-  In relation to the funding issue, the rationale was that if patients have access to wider primary care services there would be less demand for more costly hospital care services.

-  The CCG were aware that there were difficulties in recruiting GPs to this area and action was being taken to make it a more attractive option for them to choose to work here.

-  The graphs and data were primarily to illustrate some of the variation in health measures that CCG monitor.  As the Primary Care localities were progressed then the specific demographics and needs for an area would be addressed through the locality structure.

-  The CCG have already attended planning meetings in regards to Barking Riverside and were looking at recruiting GPs and other health professionals for the area as it grows.

-  It would be unlikely and impractical for all GPs to open and provide a 7 day service.  The expectation is that weekend service would be provided through hubs.

-  In regards to leadership, the proposed model recognises that GPs are the gate-keepers for healthcare services and community services are organised around their registered lists. The Localities discussions were being held through HCO/ACO to see how GP practices could work together and provide integrated services.

-  Performance management and monitoring would be undertaken and achievement levels would become part of the contract.

Anne Bristow, LBBD Strategic Director of Service Development and Integration, advised that the work around the Accountable Care Organisation (ACO) Business Case was looking at what a locality structure might consist of and at this point in time there had been no decision as to whether these would be led by GPs. 

The Chair commented that she had repeatedly pointed out that a one size fits all approach does not work in LBBD and she was disappointed about the lack of consultation.  Whilst the Council had signed up to Integrated Care that does not mean it just will hand over services without being absolutely certain those services would be improved and delivered for individuals.  The Council could not sign up to supporting the Strategy as it currently stands.

Dr John advised he had visited LB Tower Hamlets Locality model, which had turned their diabetes service around and it was now one of the best in England.  In his view the Strategy would involve a lot of work to co-ordinate health professionals but it could be achieved.  Dr John said that he felt that the locality groups would have the same outlook and aims and this would improve patient outcomes.  The Locality model was not just about GPs but a hub of shared providers.  GPs were currently swamped and something needed to be done in the near future to stop the system deteriorating into crisis.

The CCG indicated that doctors do work collaboratively with dentists and the locality model would make it easier for this to happen.

Helen Jenner, LBBD Director of Children’s Services, said that a strategy needs to identify what needs to change but that this does not come out clearly in this Strategy and it was also not clear what it was aiming for within the structures.  This Strategy had not been seen by most Board Partners before nor had there been any discussions on the principles and aims but the Strategy had now progressed to the point of a structure.  This was a concern as discussion and consultation with Partners should have occurred long before this point.

Conor Burke, Accountable Officer, Barking and Dagenham CCG, advised that there had been little change in Primary Care in the NHS in 68 years.  The NHS had to change to address the shifts in the healthcare market and demographics.  This was a provider strategy and its aim is for those providers to deliver a more efficient service and it also deals with some of the problems of multi-provider care.  Locality models were about how GPs deliver the provision between themselves and it could be a delivery vehicle for the Accountable Care Organisation (ACO).  The GPs had recognised that they need to reorganise and reform and this could converge with the ACO business case as that moved forward

The Chair welcomed the clarification and whilst noting Dr John’s understanding of the Locality model and the CCG view that it would improve service and patient outcomes, she and her colleagues were rather cynical that North East London was being dealt with as one area.  The Chair commented that the Draft Primary Care Transformation Strategy was clearly not new but it had not been talked about before and the Board were not happy with it being foisted upon it.  LBBD Board Members wanted the best model for LBBD residents and not the best model for other NE London boroughs.

The LBBD Board Members felt that they could not support this Strategy at the present time and that it required further consultation and consideration of the impact on services, Ambition 2020 and ACO changes.

The Board:

(i)  Reviewed the contents of the Primary Care Transformation Strategy and in view of the lack of earlier consultation and the issues raised at the Board agreed that further consultation and work needed to be undertaken before the Board could support the strategy and requested a further report on this issue for further consideration by the Board in due course.