PCN clinical directors joined Pulse PCN editor Victoria Vaughan on Microsoft Teams to discuss the arrangements for enhanced access
Dr Emma Chapman, clinical director (CD) for North Dartmoor PCN, Mid Devon
Dr Bal Duper, CDfor Oldham East PCN, outer Manchester
Dr Farzana Hussain, GP in Newham, former CD at Newham Central 1 PCN, East London
Dr Seun Akande, CD for West of Waverly PCN, Surrey
Dr Shanika Sharma, CD for Barking and Dagenham PCN
Dr Roy Boodhun, CD Ivel Valley South, Central Bedford
Dr Sajid Nazir, CD for Viaduct Care Network, Stockport
Dr Sarit Ghosh, CD for Enfield Unity PCN, North London
Dr Geetha Chandrasekaran, North Halifax PCN
Dr Robin Harlow, CD for Gosport Central PCN, Hampshire
In practice
Victoria: How has your PCN responded to the enhanced access requirement in the new Network DES?
Sarit The key [thing to remember] is that we’re all starting from a slightly different baseline. We’ve had extended access services for a while in our borough, we’ve got the infrastructure, it won’t be a big ask to deliver it. We’re relatively positive about it, it’s just going to be a continuation of business as usual. We’ll still probably be offering services beyond the 9am to 5pm stipulated in the DES with locally commissioned incentives. From my perspective in London it’s not going to be a terrible departure from what we’re doing now. But I fully understand that there are places around the country where it may be much more challenging to deliver without the existing infrastructure.
Geetha We’re in a slightly similar or even better position than that, because our extended access now is delivered by the federation. But luckily, the staff who run it are mainly based in our PCN. So, like Sarit, we don’t see it as a big burden. We’ve been asking to deliver it as a PCN and to come out of the federation model from the CCG for quite a few months now. So we think it will be better for the patients. There is always the balance of how you do the day job and do this; that’s always going to be one of the considerations.
Emma We’re a very small semi-rural PCN. We’ve only got 25,000 patients – a larger practice and four smaller practices. We’re already providing this as part of the DES anyway. And it’s giving us more flexibility to use other healthcare professionals so it doesn’t have to be so GP heavy. [That] will be easier, and might be more beneficial to the patients. I guess I’ve not properly looked into the finer details about how much flexibility we’re going to have. Can we do more group work and things like that? I think there’s potential here, and I think some of my colleagues felt it was a burden, but when you go to the wider group, we’ve got quite good cover from the healthcare assistants and the nurses. We’ve got a lot of clinical pharmacists happy to do some later hours. And some of the GPs prefer doing really early mornings rather than evenings or weekends. I’m glad to see we don’t have to do Sundays, because actually patients don’t want to have input on a Sunday, I think they like a day off for normal life. [As for] the Saturday, if we have to cover 9am to 5pm, that could be a challenge, because most people would rather work for just the morning. But even on a small scale like ours, I think we can meet the hours because we’ve got flexibility with the workforce.
Shanika I’m in a similar situation to Sarit in terms of London and having extended access and GP hubs mobilised for eight years now, and providing services. It becomes challenging in areas that don’t have established federations, or the working relationships between federations and PCNs. The other thing is the maturity and structure of different PCNs. If you’ve got a smaller PCN with a few practices, it’s easier to design and deliver something. But some PCNs have more than 10 practices, which can be challenging. There are enablers that need to be looked into, such as estates, workforce and interoperability, which again, some PCNs are really struggling with. Having said that, overall I’m quite positive about it. We had an evening meeting at the end of April with our practices about the correspondence from the LMCs and BMA General Practitioners Committee (GPC) [which said] practices can opt out of the enhanced access and the PCN DES. As with everything, some PCNs are feeling positive about it, but some are worried because key enablers are not in place for them.
Roy We’re a semi-rural area, and we seem to be struggling to do extended hours anyway, so the thought of doing both has put a lot of people off. Until 28 April, two out of five practices were thinking about opting out. I’ve had lots of discussions with them about the pros and cons, about PCNs doing great work, so they did decide to opt in. Our plans are to discuss more with the federation, which is offering the service. The practices in my PCN don’t wish to contribute to it, we want someone else to do it – because everyone is concerned about burnout. And even the additional roles reimbursement scheme (ARRS) staff don’t seem to be keen to do anything. So, we’re very reliant on commissioning [this] to somebody else. But there seem to be a couple of options in my area that are quite credible.
Robin I feel like I’m an outlier, which is a surprise, hearing everyone’s positive comments about enhanced access. We have a federation that provides extended access for us at the moment, and we do our extended hours. We’re talking about the options in the PCNs in our area, about how we can deliver [enhanced access] and whether we’ll be able to do a fluid model and subcontract it to the federation to deliver. But to take that back in house and deliver it ourselves as a PCN in Gosport is going to be a real challenge. I think the federation also has challenges in getting GPs to deliver the extended hours [and] face-to-face appointments in Gosport as well. I know we’ve got lots of flexibility, but that is a challenge, and recruitment is also a challenge in my area, as I’m sure it is in many other areas. If we had to do this ourselves as a PCN we would really struggle – we struggle with the extended hours we’re providing at the moment. We are doing it, but it is a challenge.
Also, people have delivered the Covid vaccine programme over the last two years, and staff are tired. I’m less positive about [enhanced access], and whether we’ll have the flexibility to do early starts. Obviously, we need to get patient engagement and CCG support. Are we trying to stretch our teams and clinical staff too much to deliver something that we can deliver in core hours for the majority of people?
Bal The people in this discussion are signed up to PCNs – we are enablers. But I agree, Robin – there are real big challenges with recruitment and dilution of the concept of general practice and continuity of care, which nobody’s talked about. They are an unintended consequence of a lot of the stuff we’re doing. And the upshot of that is the aggravation our patients are venting to us. We’ve got challenges in Oldham with recruitment, [but we will do it]. However, I would echo what Robin says, that there are key concepts of general practice that we need to [consider] about continuity of care, about core hours.
Seun In West of Waverley, we’re semi-rural with 47,000 patients. We have what we’d call improved access here, which is run largely by our federation. We are looking at opportunities to improve on what we are offering, but there are challenges. We’ve talked about the GP IT systems, and workforce, and continuity. There is a challenge though, that large parts of the profession feel this has been imposed without adequate consultation. And because in primary care we’re doers, we will get about doing it. But this is damaging the trust between the profession and NHS England, [a trust that] continues to be undermined with time. That will be a big issue down the road, even if we get over this hump right now.
Sajid Our federation is delivering the extended access, but we’re going to change things as our PCN has decided we can deliver it better for our patients. And there’s good buy-in from the practices. We run the vaccination service in a similar way, using a number of staff who aren’t necessarily employed by the PCN, so we’ve developed a large bank of staff, both clinical and admin, who are all keen to carry on. So, we’re feeling positive. There are concerns about manning space, especially on a Saturday, for 52 weeks in a year. But we see it as an opportunity. We think the funding is fair for the work. And we’ve got some plans together.
Workforce
Victoria: How will you manage workforce issues where there are challenges?
Roy Certainly everyone in my member practices seems to think they can’t do any more. We’re trying to consolidate that as much as we can. We’ve had some meetings with the federation. It doesn’t currently provide extended access, but it has given us a plan of action about how it might. It has a large bank of staff in the Milton Keynes area, and we’re hopeful, with more discussions, to have some of those staff to cover our area. To be honest, in my PCN everyone’s scared about doing extra work, working a Saturday on top of Monday to Friday. [Perhaps] when we come to the nitty-gritty [of whether] one person can cover a Saturday [every couple of months], it might become less scary for some of the member practices.
Emma When we talk about the contract with partners and our PCN board members there’s reluctance – ‘I can’t do any more, I can’t.’ But when we put it out to our wider staff, it’s surprising how many people came forward saying they were happy to do it. We might have to pay them time and a half at the weekend but we have got the budget to do that because it is well remunerated. We found in our locality that we’ll try to portion out hours per practice on patient list size. Or if people want to do more, they can volunteer. The hours that are offered at individual practice sites are usually used by their own practice population. If we’re looking at doing one in six or one in eight [Saturdays] it doesn’t seem that terrible. And I think that it becomes even less [onerous] when [some people ask to do] a few more hours [because they’d like] a bit more money.’
Victoria: Why are some PCNs choosing to bring enhanced access in house from the federation?
Geetha Our federation has done a great job delivering it over the past few years, however we feel our population needs [are difficult to deliver at scale], because we’re quite a deprived area. We thought by bringing it into our PCN, we could serve our population better. Being able to complete a consultation on the day is one of the things we wanted to bring it back to our PCN for, because we felt some federation commissions weren’t completing that. [There’s also] the actual patient contact and patient care – we know as GPs that’s what we relish, having the one-to-one with our own patients. So smaller was better for us.
Shanika We’re a borough-wide model. Across Barking and Dagenham we’ve got six PCNs and we don’t want all six to go in different directions with enhanced access because it’s going to confuse the patients. So we’re trying to design a borough-wide offer. The federation has come forward with a proposal that the PCN and the practices are quite positive about. But as Geetha says, there are differences in the PCNs and the populations and the needs of the PCNs. We need a balance. We’re going for an economy of scale and are thinking about sharing a call centre with one of our neighbouring boroughs. But there are niches in a PCN that need flexibility. For example, our PCN has a very high diabetic population, so we might need some appointments to focus solely on diabetic reviews.
Sarit Our federation never delivered the extended access hubs. It was a lead practice model. The current architecture of the borough does not support much change. But I think Geetha’s raised a good point – what’s the main difference and the main opportunity for PCNs providing this? It is to reduce duplication and improve efficiency. This is a good opportunity to streamline pathways and give patients better access.
Seun Our plans are still at the initial stages; nothing’s been agreed. [We think] this will be done at place level across the four PCNs and are working with our federation on this. I don’t think there’s an appetite to bring this into the PCN. [It’s a big] ask in terms of providing the service and having to look after the clinical risk and governance issues. And our federation is already providing something quite good. But, again, even within the same patch, there are quite marked differences between the PCNs. Even if we’re thinking of a uniform approach, we’ll want to tailor to each PCN.
Imposition
Victoria: There is a sense that enhanced access has been imposed and this has created a negative atmosphere. How do you navigate that?
Bal There’s a sense of battle weariness at the moment in general practice. Yes, I think there is a sense that this has been imposed. I think many GPs can see the value of it. But there is also the other side of the coin, that it is imposition rather than collaboration. What we set out to do, three years ago as PCNs, was to try to help our practices to reduce their workload, and [the dynamic of] this is really interesting. [It’s been] pushed into a PCN contract without a conversation. And that produces [resistance] in the extreme. So, for example, we get the BMA saying: ‘Let’s cut core hours down.’ The LMC is saying: ‘Let’s resign from the PCNs, don’t sign up.’ And many of us who did the PCN stuff feel all that narrative starts to feed into negativity. I think that’s really wrong because enhanced access is a really positive thing. If it had been landed in a different way, we could have done it in a positive way. We could have looked at helping GPs to manage the workload.
The other issue I’ve got is with workforce. I’m the clinical officer for a small provider federation and this will cannibalise our staff. I understand what is being said, that people want to take extra hours on. They’ll do it for six months, or12 months, but I’ve been providing for services for over three years and people’s resilience starts to wane as time goes on. Then as a provider, you put your rates up. And federations and out-of-hours providers are already increasing their rates. It’s going to start cannibalising the workforce we need in general practice.
Seun Whether it’s us in primary care or the folks at the NHS, everyone means well. The concern is that communication seems to be breaking down and that’s not healthy for us, or for the patients we serve. There’s also a fundamental question here: is more access the solution to the problems in general practice? What data underpin this? Because what we may see in two years’ time is all these enhanced access appointments get saturated.
I think we need to be smarter. Do we know the people we see? What cohorts of patients do we see the most? We sit on a load of data in primary care that we don’t know about. And when we extract the data, we don’t have the head space to analyse it and use it to deploy care.
We need help with that, to improve care and work in a smarter way.
Farzana It’s obvious extended access is here to win political votes. Access is something the Government is crazy about and always has been. East London has had something called the GP co-op for nearly 30 years, [providing]urgent care. Our federation has been doing extended access for it. But Bal’s point is really important. I don’t think we’re going to cannibalise the workforce, I believe we already have. If I’m a GP, if I’m a mum, why wouldn’t I work a Saturday afternoon where I only have to see four patients at 15-minute intervals? Why would I be running my own practice of 5,000 [patients], having to go in when somebody’s sick, when somebody’s got Covid?
We have to implement this because it is the political narrative and it’s quite easy. In fact, the remuneration is generous. But this is a way to kill off general practice. And it’s a way to kill off PCNs because the only way we can deliver this is at scale and [Prime Minister] Boris Johnson will get lots of votes because we are access mad. But anybody who runs a smaller practice like mine will know patients want to see GPs. There’s no evidence that extended hours initiatives have reduced core hours work. This is not going to reduce work in general practice. We don’t have the GPs and we couldn’t afford it with GPs. We’ve got ARRS roles but who is going to do the DES if they’re all doing enhanced access?
Benefits
Victoria: What are the benefits and opportunities of enhanced access?
Bal The first few meetings for our PCN were antagonistic. As we’ve moved along, relationships and partnership are working. Stronger networks with other practices could be important. This may be mini-PCN federations or practices working together. There are lots of positives we could take from this because it’s going to give an opportunity to work with other clinicians in a less pressured environment than the Monday morning when there are 50 patients. If we can work it right, it might strengthen some aspects of general practice.
Sajid We piloted a winter hub, 5pm to 8pm from December until now, which was funded separately through the CCG – and it made a huge difference. Once practices were full they were allowed to spill over into that clinic. We’re just running the feedback. We learned lots of things in terms of prescribing and setting up an electronic prescription service and there were lots of teething issues but we’ve worked them out and it’s a big opportunity to do things at that scale. We’re looking at spirometry at PCN level because it’s becoming difficult to provide that at a practice level. We’re thinking about training some ARRS staff to provide some services. If you get it right it benefits patients, reduces waiting times and takes pressure away from practices. Of course there’s an agenda behind all of this that is putting increased pressure on all of us but there are opportunities.
Seun I see three opportunities. First, there is a great opportunity to co-produce this with patients and get the input from the people we serve on how to make this service even better. Second, it’s a great opportunity for collaboration between practices. I’m lucky to lead a PCN where the four practices have similar ideas. And third, it’s an opportunity to improve what we offer already and make sure not as much work goes back to the practices.
Shanika In terms of the positives, it’s patient choice. A lot of young patients with chronic conditions can’t attend reviews in core hours. It’s the same for screenings and immunisations. So we’re looking at this as an opportunity to work at a place level with our wider stakeholders, public health and the local authority. Also, we can design something that serves our population and provides more flexibility in terms of access. But it does need a lot of thinking and planning. But those are the things we’re hoping enhanced access will give us an opportunity to do.
Farzana The idea of more hours and access for patients is very positive. Obviously, I’m in an area where it’s not new. I particularly feel for places like Emma’s, where there is a massive geography, but I’m working in an area that’s a four-mile radius. If we’re going to make this successful we need to collaborate – and that’s not telling practices and PCNs what to do. There’s a lot of competition in the system – federations are a business, PCNs are a business and so are practices. I’m trying to find something positive – real collaboration rather than one trying to take over another because of size.
Also, we need to think about how it operates. Why is an extended hours appointment 15 minutes and a practice [appointment is] 10? We need to give patients a real uniform service. And taking Shanika’s point, yes, [our] area [has] a lot of inequalities, but is it just about hours? Because we’re dealing with human beings and the most important thing to change behaviour is a trusted relationship. So I leave that as a challenge for at-scale general practice – to build up that relationship, which GP practices have done for years. I believe that’s a challenge that [working] at scale cannot cope with.
