Draft REPORT for consultation

A DRAFT report prepared for consultation with

Health & Social Care Scrutiny

1.Introduction

1.1.Access to GPs is very much a topical issue and at the time of the general election came to the forefront of public concern when the Prime Minister was quizzed about the government’s target for access to GPs on the BBC1’s question time programme in April 2005.

1.2.In 2003/04 Access to a GP was the only Department of Health Performance Indicator where Salford Primary Care Trust (PCT) failed to meet the target.This was recognised by the PCT who have looked into the reasons why and have worked hard with GP practices to correct the failures

1.3.Concerned about national press coverage and the failure of Salford PCT to achieve the Access to GP performance indicator Community Health & Social Care Scrutiny decided to consider the issue closely. They decided to establish a sub group to consider the issue of access to primary care in some detail.

  1. Background

2.1.Access to primary care in Salford was an issue first considered by the Community, Health and Social Care Scrutiny in February 2005. It is such a complex and important issue, which impacts on the health of the people of Salford.

2.2.Considering the importance in line with the Council’s pledge “improving Health in Salford”it was decided, a sub group of the committee should consider the topic, as the problem needed closer consideration than could be achieved through its regular meetings. The sub group would find out the extent of the problems and what the City Council could do to improve the current situation in Salford. The members are listed appendix 1.

2.3.The first meeting of the subgroup sought to establish how to take forward the issue of Access to Primary Care in Salford. Tina Randall outlined the key issues, which had been raised in discussion with representatives of the PCT at the February meeting of the Community Health and Social Care Scrutiny. The Sub Group decided in the first instance that access to primary care is such a large topic area it should in the first instance look at a manageable piece of work.

  1. The focus!

3.1.The sub group decided that should focus on Access to GPs and agreed this with Community Health & Social Care Scrutiny. It should be a piece of work, time limited, but one which the members envisage may lead to further pieces of work covering other aspects Primary Care Services, for example dentists.

3.2.The Subgroup then drew up and agreed Terms of Reference for the investigation with the Health & Social Care Scrutiny – Appendix 2 and set out to define access and determine who should be approached for evidence / opinions, shared research.

  1. What is access to primary care?

4.1.Primary care is the first access point to the NHS and accounts for some 90 per cent of NHS activity. “Access to Primary Care “ Is as already mentioned a large complex area covering a range of services including General Practitioners (GPs), district nursing, dentists, chemists, and even alternative health providers. So we can appreciate that improving access to primary care has been a high priority for Primary Care Trusts and is a key measure by which patients judge improvements.

4.2.It is the aim of the Department of Health for patients to be able to access a GP or other health professional 24 hours a day 7 days a week, not necessarily at their practice but via perhaps a local out of hours service, an NHS walk-in centre, NHS direct or NHS online.

4.3.As well as quickly being able to see a health professional which meets their needs patients should also be able to make an appointment in advance if they wish at a time to suit, or with a GP of their choice.

  1. Access to GP’s - What is the 24/48 Hour target?

5.1.In 2004 the government introduced a National Target, a requirement for all PCTs to ensure the members of the public can make an appointment and see a health professional within 24 hours and a GP within 48 hours. Though introduced first as a guideline the target became one of the performance indicators on which a Primary Care Trust is inspected.

5.2.The financial rewards available to practices to hit the target, initially saw some GP practices across the country scrapping advance bookings, choosing instead to concentrate on making appointments available within the 48 hour period. This was thought to be almost 1 in 5 practices. This did serve its intended purpose and improved the percentage of patients being able to see a GP quickly.

5.3.However systems like this quickly gave rise to complaints from patients unable to obtain advance appointments for non-urgent conditions or follow up treatments, which is precisely the point raised with the Prime Minister. Complaints also came from GPs themselves who recognised the difficulties and increasing pressures on appointment systems.

5.4.This led to a clarification of the target

“all patients should be seen by a GP within two working days or a primary care professional within one working day if they wish to do so.”

5.4.1.The following definitions help to further clarify the target

  • ‘A GP’ - anygeneral practitioner. This is not a named GP, nor is it necessarily a GP at the registered practice, but is expected to be one who is convenient and easily accessible to patients.
  • ‘Within 48 hours’ - within two normal workingdays (i.e. not including Saturday or Sunday or Bank Holidays) following the day when a request by a patient was made. This does not include emergency appointments.
  • ‘A primary care professional’ - any health care professional including GPs, practice nurses, allied health professionals, other health care staff who is a member of the practice or wider local primary care team, a community pharmacist for instance. This is not a named PCP nor is it necessarily a PCP at the registered practice, but is expected to be one who is convenient and easily accessible to patients.
  • ‘Within 24 hours’ - by the end of the next normal working day (i.e. not including Saturday or Sunday or Bank Holidays). This does not include emergency appointments.
  • ‘Patients’ - patients registered with a general practitioner. It will be for the PCT to make sure there is appropriate access across their locality.
  • ‘To see’ - face to face personal contact. Telephone consultations can reduce the overall demand for appointments but they can not be counted for the purposes of this target.

5.5.In reality the imposition of the target seems to have been successful. In 2002, on average, 75% of patients, nationwide were hitting the access target and seeing a GP within 48 hours. By 2005 this had increased to 97%, an obvious improvement. (source letter of National Director for Primary Care and Head of Primary Care)

5.6.The target is measured by the PCT by telephone survey every month and reported to the PCT board and to the Department of Health.

5.7.The PCT recognise that this regular survey of the access target with its measurement occurs on roughly the same day each month and although it is prescribed by the Department of Health could be affected by the predictability of its measurement. The Sub group agree and would like to see someadditional source of measurement which may provide a more accurate assessment of the level of access.

  1. Access InSalford

6.1.The ability to obtain an appointment to see a GP within 48 hours and to see a primary health care professional within 24 hours are performance indicators which the PCT use to judge performance against their third pledge to “Provide better and more services locally”. The latest figures show both are achieving the 100% target.The PCT have worked hard and continue to work with individual practices to secure improvements.

6.2.There are 64 GP practices operating in Salford, with 153 doctors including 30 salaried GPs, though this is still around 20 short of the desired number for Salford, there are also123 practice nurses. In Salford it is estimated that there are 20,000 contacts with GPs each week.

6.3.In Salford, City Council Members. The PCT and the PPI are aware of some problems with access at some of the GP services in Salford. There exists a deal of evidence, both factual and anecdotal, that the residents of Salford have genuine concerns about the ease of access to general practitioners.

6.4.Restrictive appointments systems were a matter of most concern to Members of the group, it appeared anecdotally that some GP practices did not allow any advance appointments a difficult situation leading to congested phone lines first thing in the morning and was problematic for people trying to arrange their day around appointments received at short notice.

6.5.The Director of Modernisation was able to confirm that, currently no GP practices in Salford have such restrictive appointment systems – all offer the opportunity to book an appointment in advance, usually up to a month.

6.6.The PCT receive very few complaints about GP access and they are always acted upon.

  1. What has the PCT done to improve Access?

Members of the sub group met with Alison Dalley, Director of Modernisation Salford PCT and Brian Hope GP and Chair or the Professional Executive Committee (PEC) to discuss access and determine what actions have recently been put in place to improve access in Salford.

7.1.The PCT considered the problem closely in 2004 when this target was identified as the only key performance indicator that the PCT failed to meet in 2002/3 and 2003/4 though it had improved considerably.

7.2.An audit of appointment systems within the GP practices in Salford was carried out by the PCT in 2004.They found that GP practices had made significant improvements to improve access. Many have introduced the “Advanced Access” system as recommended by the National Primary Care Development Team, which involves the assessment of demand from patients in the locality and the available capacity within the practice, then the appointment system is developed to match one with the other. A toolkit is readily available for practices to assist implementation of the advanced access appointment system.

7.3.Well over half the GP practices in Salford are rated as “GOOD” by the PCT. The PCT primary care development team have worked closely with practices to overcome difficulties in understanding and implementing this system and continue to do so. All practices have in place development plans some of which include actions to improve their appointment systems. Should any practice be allowed by the PCT to close their list to new patients, and they can only do this under exceptional circumstances for 12 months, the PCT work closely with them to ensure any problems are quickly addressed and the list is opened up again as quickly as possible.

7.4.Complaints are monitored closely and if there are seen to be any problems,assessments of individual practices are carried out as required.The primary care development managers will then continue to work with every practice as appropriate, across Salford to improve access.

7.5.The Audit Commission’s Annual Auditand Inspection letter 2004/05 identified access as an issue, the only key Performance Indicator not met, though it was not a major problem it was a slight underachievement

The auditor’s comments read

“we can see there are steps being taken to improve the service but there remain inadequacies in the service.These however are, over time becoming smaller in number and Salford PCT is achieving 100% on a frequent basis.”

7.6.It must also be pointed out that Salford is again recognised as a Three Star PCT by the department of Health.

  1. Additional improvements in place.

8.1.GP Recruitment

8.1.1.There is an acknowledgment that there are not enough GP’S and they are difficult to attract to Salford, particularly in the inner city. The PCT is striving to improve recruitment and are looking at alternatives methods. A recent recruitment of Italian GPs has proved successful.

8.1.2.In addition to the GPs in Salford, there are 30 salaried GPs (22 FTE’s) paid by the PCT all are working in general practices.

8.1.3.The recruitment of suitably qualified and experienced locums has been a problem

8.2.Do Not Attends (DNAs)

8.2.1.DNAsare a serious issue – a report released in August 2005 found that more than 10 million GP appointments are being missed every year in the UK.
Appointments that could be available for others are wasted, little can be done other than to reinforce the message that patients need to cancel if they are not turning up. Practices cannot strike people from their list or charge for non attendance. Some practices display the DNA’s outlining the cost in terms of time.

8.2.2.In a small way the 48 hour target could be contributing to a reduction of DNA as patients are less likely to forget or ignore appointments booked only recently, but this will only impact at the margin. The group wondered if the council could possibly use the internet to reinforce this message.

8.3.Additional access improvements

8.3.1.In Salford the PCT have established walk-in centres at Little Hulton and at Hope A&E working closely with HopeHospital both are in their early days. – hence the decision to visit the established Walk-in centre in Bury, which is discussed later.

8.3.2.The Group agree that it is easier to see a health care practioner rather than a GP. This was also a point reinforced on the visit to the walk-in centre. Not all patients making an appointment to see a GP actually need to see a GP, there are many instances when problems could be resolved by a practice nurse.

8.3.3.The PCT has increased available capacity to help with this by increasing the number of nurse practioners by 2 fold since it was established.

8.3.4.There is therefore a need to educate members of the public and manage health expectations so they do not always need or expect to see a GP. Can the council play a role in this?

8.3.5.There is a training programme being developed by the PCT which covers customer care diversity and disability. This is being made available to staff in GP practices. Although it is acknowledged that the GP Surgery is a business, and there is a limit to impositions that can be pressed upon them. Reception staff are sometimes a source of unhappiness with health care as evidenced by the consultation results. Itmust be said that they are not employed by the PCT but by GPs themselves, they should be customer focussed, but are not always in receipt of any training for example in customer services,and they can face aggravation from angry or frustrated patients.

8.3.6.The Practice Managers in Salford have established their own Forum independent from PCT- is a forum where members can share good practice in workshop sessions

8.3.7.Out of hours. In Salford out of hours calls are handled by BDMS it is very well managed they take callers details and pass on to out of hours Doctor’sat weekend they deal with around 100 / 200 patients a day. In future it is expected that the out of hours system will also work closer with HopeHospital’s walk in centre when fully operational.

  1. PPI forum work

9.1.The PPI forum worked together with the subgroup bringing their experiences and skills and contacts to the meetings and playing a full part in the consideration of the issue. Anne and Annie shared details of the work that the PPI forum had undertaken in this area. This included a survey, looking at the difficulty of obtaining a doctors appointment on a Monday morning,and a research paper on which dentists in Salford are taking NHS patients.

9.2.The survey was carried out some time ago, a further follow up survey, would be perhaps be a useful further indicator. However at present indicators are very positive. The Group fully support the PPI and would like to continue to work together, particularly as they move on to look at other areas.

  1. Practice Visits.

10.1.The sub group hoped to visit a number of representative GP practices but found this difficult to arrange. This is understandable as the practices are very busy and could not justify taking up valuable time of GP when they could be meeting a need.The group was grateful to the practice managers who talked to us.

10.2.It was decided to contact the main medical centres in Salford and offer them an opportunity to contribute to this piece of work with any comments, observations they have. The result of this will be reported back to the sub group in June.

  1. People with learning difficulties

11.1.Sub Group members visited Cath Rotherham, Healthcare Facilitator - Learning Difficulties who is based at St James house with the PCT.

11.2.Accessing healthcare generally can be a very daunting and confusing process for a person with a learning difficulty. There is considerable evidence to show that people with learning difficulties do not always access the care they need, because either they do not recognise when they have a health problem or do not know how to obtain help or how to communicate easily with a health professional.

11.3.Members were extremely pleased to hear about and see examples of the work done to improve the health care of people with learning difficulties, particularly the work of “New Directions”, the joint learning difficulties team, which is a partnership between the PCT and Salford City Council, working with people with learning difficulties in Salford.