A representative of NHS Kent and Medway will be in attendance to respond to the committees questions.
The Chairman welcomed the attendance of representatives from the NHS to answer the questions submitted by Members on the matter of Local Primary and Community Care Services.
The following representatives were present:
· Sukh Singh - Director of Primary Care
· Natalie Davies - ICB Chief of Staff
· Vincent Badu - ICB Chief Strategy Officer
· Mike Gilbert - Executive Director of Corporate Governance
The key questions submitted by Members were as followed:
(1) Which services are directly commissioned by GP's and why?
(2) Please confirm to us which services GPs will be commissioning directly taking into account the difficulties in now getting GP appointments.
General Practice (GPs) do not directly commission services. GP providers are independent contractors who deliver the service requirements of the GP contract to their patient population. NHS Kent and Medway Integrated Care Board (ICB) has delegated responsibility from NHS England for commissioning GP services.
General practices themselves are commissioned at various levels to provide additional services (in addition to core GP services) to their patient populations, these services include:
· Minor surgery
· Vaccinations and Immunisations
· Enhanced GP access
· Enhanced Health in Care Homes
These services allow practices or primary care networks (PCN’s) to expand their workforce and deliver services to their local patient population.
Changes to Services
(3) What changes in local primary, community and hospital services are being considered now and, in the future, to achieve the goals set out in the long-term plan?
(4) Are any other changes in local primary, community and hospital services being made or considered as a result of pressures or priorities?
(5) The change to phlebotomy service provision at Deal Hospital has understandably raised concerns over the future of other services offered there. What are the plans for service provision at Deal Hospital over the next five years?
(6) With bus services being reduced public transport accessibility to major hospitals is becoming more difficult. What is the NHS doing to address this and are they looking at making more diagnostic tests more accessible locally?
Community diagnostics and developing integrated pathways
The development of a Community Diagnostics Centre (CDC) at Buckland Hospital will provide greater opportunities to deliver a more localised ‘one stop’ treatment and health promotion service for people living in east Kent. The Buckland site has benefits of integrating with existing outpatient and Urgent Treatment Centre services, which gives local residents quicker access to diagnostic imaging as well as the site becoming a focal point for the delivery of local, accessible health care. The Community Diagnostic Centre ‘hub and spoke’ model also enables residents the ability to access better integrated primary, secondary and community care services associated with diagnostic, community, and outpatient care.
The East Kent Health and Care Partnership, supports the development of a provider collaborative approach which will bring GPs and other clinicians together to jointly deliver end-to-end care pathways, making best use of clinical and professional resource, as well as maximising opportunities to diagnose and treat conditions without referral to an acute hospital site. Work to explore the benefits of this greater alliance model are ongoing.
Some examples of initiatives to increase local integration of services include:
· A flexible, digitally connected capacity model for CT and MRI scanning to service the wider east Kent population and target areas of low access, sub-optimal outcomes, and areas of high deprivation.
· Direct patient booking appointments.
· Rollout of targeted lung health checks as part of the lung cancer screening programme using the diagnostic capacity at Buckland, linked to outpatient and other services
· Opportunities to have more locally focussed and targeted health promotion programmes, linking healthy living initiatives, primary care, and community care engagement.
East Kent Hospitals
The hospitals in east Kent have been struggling for many years to provide quality services that meet all the national standards of care. There is widespread consensus that the way services are currently configured impacts directly on this, as does the quality of the hospital buildings and supporting infrastructure staff are required to work in and offer patient care from. In October 2021, East Kent Hospitals submitted an expression of interest to apply to be one of the 8 new hospital projects in the Government’s New Hospitals Programme. We are now waiting to hear whether the bid has been successful in making it onto the short list for possible future funding. If successful, this will provide East Kent Hospitals with a much needed and long awaited clear strategic direction for the future of acute hospital services and infrastructure.
We are in the process of creating three Hyper Acute Stroke Units across Kent and Medway. In East Kent, the HASU will be located at the William Harvey Hospital in Ashford. The implementation of HASUs through the centralisation of stroke services at a smaller number of hospitals will have numerous benefits including improved clinical and patient outcomes as well as financial savings.
We also have plans to centralise inpatient Vascular Surgery for Kent and Medway at Kent and Canterbury Hospital. These plans are in the final stages of approval.
Certain investigations and treatments, which could traditionally only be provided in hospital, will increasingly be available in primary care, enabled through the Primary Care Networks with wider skill mixes, more estate options, and extended hours.
Patients can get the care they need at home safely and conveniently, rather than being in hospital thanks to virtual wards, enabled by telemetry and wearable technology, support is delivered by a multi-disciplinary team at a distance.
We are bolstering our Urgent Community Response services that aim to see patients within 2 hours of referral in their own home.
Victoria Hospital, Deal
Local community hospitals like Deal are a vital part of the overall provision of NHS care and there are no plans to decommission services provided at the hospital.
Wider services at Victoria hospital were not affected by the change to phlebotomy services and Kent Community NHS Foundation Trust, as the owner of Victoria Hospital, has confirmed that it sees the site as an important local resource and has no plans to remove other services.
In addition, the former CCG contacted other providers of services at Victoria Hospital during the summer and they also confirmed they do not have any plans to change the services they operate from the site. There is no change to this position.
The provision of bus services is the responsibility of the local authority. However, the development of a Kent and Medway whole system integrated care strategy, will include for the first-time partnership arrangements that look to support and address wider determinant of well-being, such as transport, environment, education, sport, and leisure, etc.
(7) What are the statutory criteria for consulting with the public about changes in local primary, community, and hospital services?
(8) Is consultation ever undertaken about changes in local primary, community, and hospital services in circumstances where there is not a statutory requirement to do so?
The legal duties on public involvement as set out in the NHS Health and Care Act 2022 require NHS organisations to make arrangements to ensure people are appropriately ‘involved’ in planning, proposals, and decisions regarding NHS services. The guidance on this is detailedhere (https://www.england.nhs.uk/long-read/working-in-partnership-with-people-and-communities-statutory-guidance/).
NHS Kent and Medway Integrated Care Board is a new statutory organisation set up in July 2022 and its responsibilities include:
· Involving people and communities in the planning of services and proposal and decisions having an impact on services
· Demonstrating how legal duties have been met at different levels
· Developing integrated health plans with people and communities
· Creating strategy on how the ICB will work with people and communities.
There are different levels of engagement and activities vary widely depending on the change being considered.
Formal public consultation is different from public engagement. It is a mandatory process which NHS bodies have to go through when considering making significant, permanent changes to service configuration.
(9) District Councillors have an important role as community representatives in supporting local residents including those affected by changes to primary, community and hospital services. Is there a way in which district councillors can be kept regularly informed of these changes?
Yes, they can sign up for news alerts from our website, to receive our Community Bulletin, and become members of our ‘Have Your Say’ digital engagement platform. We also seek to actively engage local councillors on matters in their areas. You can find out more on the Get involved section of our website - Get involved :: NHS Kent and Medway (icb.nhs.uk).
Local GP Practices
(10) The Care Quality Commission (CQC) while providing the reassurance of good or better ratings for GP practices in the Dover District has found that one practice (The Cedars, Deal) that requires improvement in respect of safe and effective categories. What is the role of Kent and Medway NHS in supporting the improvement of practices that require improvement and overall seek to continuously improve the provision and quality of services?
We work closely as an ICB with the CQC. Specialist teams within the ICB including quality assurance and improvement; medicines management teams; safeguarding children and adults; Looked After Children (LAC) team; Infection Prevention and Control (IPC); patient safety and learning; etc. work with practices to ensure that patients continue to receive good, quality care and services, and where required work to improve these.
(11) Why are people requesting blood tests from Specialists referred to Ashford, Canterbury, or Margate rather than locally?
Blood tests requested by General Practice or where there is a shared care arrangement with the Acute Trust (specialists) will be completed by General Practice. All other blood tests requested by the acute trust will be completed by the hospital as part of the patient pathway with the acute provider (i.e., EKHUFT sites – Ashford, Canterbury, and Margate).
(12) Why can’t people book 4 or more weeks ahead for a blood test locally?
Blood tests are available to book up to 4 weeks ahead. For some practices this is up to 6 weeks ahead. Arrangements can be made in advance for chemotherapy patients to ensure that all blood tests are taken according to their schedule. General Practice determine how may days/weeks ahead they will release clinical appointments.
(13) There is currently a shortage of around 4,200 full-time equivalent (FTE) GPs in England, which is projected to rise to a shortage of around 8,900 FTE GPs in 2030/31, relative to the number required to meet the rising need for care. Please could you provide in a table, broken down for each GP practice in the Dover District, the following information:
· The population covered by each GP practice
· The current number of full-time equivalent (FTE) GPs at each practice
· The current number of other clinical staff at each GP practice (nurses, nurse practitioners, paramedics, etc.)
· The expected number of other clinical staff at each GP practice if full staffed
See the table below for the response to a number of the questions.
For the expected number of FTE GPs at each practice if full staffed, this information would need to be sought direct from practices as they are responsible for their staffing model
For the expected number of other clinical staff at each GP practice if full staffed, this would need to be sought direct from practices as they are responsible for their staffing model
· The projected required number of FTE GPs at each practice in 2030/31 based on projections for population growth and rising care needs for the population
· The projected actual number of FTE GPs at each practice in 2030/31 and what plans are in place to deal with any projected shortfall
Our business Intelligence lead in the primary care workforce team is currently doing some work looking at previous trends from NHS workforce data and future projections. This work has only just started, so will take a few weeks. It will be at Primary Care Network, Health and Care Partnership and GP practice level.
(14) The Nuffield Trust estimates that for the Southeast of England, there is a clinical staff shortfall of 8.2% for hospital and community health services. While accepting that the operational vacancy number will be lower due to agency staff cover, what is the current level of clinical staff vacancies for hospital services in East Kent and what is NHS Kent and Medway doing to support its hospital partners in ensuring safe levels, and longer term the desired levels, of clinical staffing is in place?
(15) The Committee has previously been advised of shortages in clinical staff, beyond that expected as a result of normal turnover, in primary, community and hospital care. Is this still the case and if so, what is being done to address these shortages in both the short and long-term?
(16) I understand that many, though not all, shortcomings in our local service are due to chronic understaffing, as recruitment fails to fill vacancies. What are we doing to bring in the right calibre of staff?
Written response to follow for secondary and community workforce
From a primary care perspective, the shortages of GPs and staff nationally is seen locally. The training hubs, in collaboration with the ICB and Health Education England, have developed several initiatives to highlight to potential health care professionals the wealth of benefits and opportunities of working locally. These include:
· Academic Fellowship development for both GPs and multi-professionals,
· New to Practice programmes for newly qualified GPs, as well as nurses and other professionals
· Supporting practices and PCNs to host students to highlight the benefits of working locally so that once qualified they will choose to work in practices
· Career development packages tailored to individual roles to enable practices to grow their own staff
· Opportunities to develop as educators to support trainees
· Attendance at GP trainee and nursing sessions raising the profile of benefits of working locally
· Recruitment campaign in planning stage to encourage nurses to consider a career in primary care
· Working with practices to achieve Tier 2 sponsor licences, which will enable them to recruit individuals on Tier 2 visas
· Working with practices to develop existing staff to support retention and to support recruitment processes to maximise potential
· Primary care recruitment workshop planned for early new year to support practices to maximise advertisement of posts
· Better supervision and wellbeing support for staff
(17) Patients’ experiences in hospitals and surgeries can be adversely affected when they have difficulty in understanding. What are you doing to improve the communication skills of staff (from consultants to health care assistants) who fail to communicate effectively?
From a general practice perspective:
· Customer Services skills development including communication skills available for all Reception staff
· Difficult conversations development package provided for staff
· Roll out of ‘A Kind Life’ development programme
· Telephone Triage and signposting development programmes which focus on effective communication
(18) Walk in A&E services were withdrawn from Deal hospital due Covid and are only available if an appointment is made after ringing 111. Taking into account the issues with 111 why cannot this not revert to walk in facility again to take the pressure off the major the Major hospital A&E hospitals?
Members were advised that a written response would be provided separately at a later date.
In addition to the key questions, Members raised the following matters:
· Whether GPs were resourced to take on the additional workload for blood tests following the withdrawal of the service from Deal Hospital? In response, it was stated that the change was due to the provider withdrawing the service and the ICB was working with GPs to ensure the service could be delivered. The service had been withdrawn on clinical safety grounds as the provider no longer had the capacity to deliver the service and primary care was seen as the best alternative as it already offered that service. There were more tests being offered than before but this was also balanced by an increased demand for the tests.
The ICB was responsible for commissioning a range of statutory and other services, but it needed a provider or it could not deliver the service. The intention was to deliver as many services at a local level as it could though not all these services needed to be delivered through a hospital. However, it was acknowledged that some services, such as stroke services, needed to be delivered centrally. The ICB was required to plan at “place” level and a place was considered to be 500,000 people. On this basis, East Kent was considered to be a “place”.
· Who was responsible for providing ear syringing? In response it was advised that this was not a statutory service and it would have to be investigated to find out who was providing the service.
· Members raised concerns over the consultation that had been undertaken in respect of the withdrawal of blood services at Deal Hospital and it was requested that a full consultation be undertaken in future even if the overall impact of a change seemed minor. In response it was stated that the ICB would ensure that any consultation undertaken was sufficient in future. This did not mean that the outcome of the consultation would satisfy everyone as the changes made were often intended to improve the service for the most people. Members requested that local councillors be more involved in consultations in the future.
· In respect of concerns over GP numbers, Members were advised that this was a matter for the individual practices to recruit staff but the ICB remained committed to help support practices where it could.
· What was the ICB doing to support the Cedars surgery and its 11,000 patients following its CQC report? In response, it was stated that the CQC report had been a surprise and the ICB was working with the practice to address the issues identified. The ICB would work with the practice to communicate the CQC report to the patients at the practice. The performance of surgeries was monitored through a range of metrics and CQC inspections.
· There were concerns raised over accessing specialist services. In response the ICB asked to be provided details of the specialists concerned and this would be investigated further.
· In response to a concern about the maximum number of patients per GP, Members were advised that no such limit existed. However, practices could close to new entries if they were unable to cope with patient numbers and locums could be used.
· What was being done to resolve the issues identified with maternity services at the QEQM? In response it was stated that the ICB was working with the hospital trust to address the issues raised, including tackling the culture and operational systems of the service through sustained improvements. The CQC was the regulator for maternity services and the ICB was the commissioner.
· What steps were being taken to plan for succession in GP practices due to retirements? In response it was stated that the ICB was working with practices on succession planning.
The Chairman thanked the representatives from the ICB who had attended and answered the committee’s questions. She emphasised the need for better communication with elected Members and communities particularly in respect of big changes and invited them to return in one year to meet with the committee again.
 The east Kent Health and Care Partnership is a partnership between, primary, community and secondary care providers and the local authority and voluntary care sector. Over time the Partnership will take on greater levels of responsibility for the commissioning and provision of health and care services for the residents of east Kent