Hebden Royd Town Councillors quiz Dr Nigel Taylor about Hebden Bridge Group Practice problems

  • The Hebden Royd Town Council meeting on 25thSept was a good start to the public discussion of Hebden Bridge Group Practice’s problems and how to solve them. It came up with three proposed changes. But it raised more questions than it answered, and left several unanswered. Councillors will feed follow-up questions to the Group Practice – so send your Councillor any questions you’d like answers to.
  • The first section of this blog post is a more or less verbatim report on Dr Nigel Taylor’s presentation to the Council.
  • The second section lists the Councillors’ questions that the meeting didn’t answer or only partially answered.
  • The final section lists questions that the meeting raised and that now need answers.

Dr Nigel Taylor’s presentation

Reasons for Hebden Bridge Group Practice problems

Dr Taylor explained that Hebden Bridge Group practice had had to make “difficult decisions” as a result of years of underfunding of GP practices, while the number of patient appointments had increased.

He called this “growing demand”, caused by an aging population with complex needs and the fact that GPs are now dealing with things that would formerly have been dealt with in hospitals.

We object to the use of the word “demand” in this context. It is a word economists use to describe the purchase of goods or services. The NHS is not a business. And patients don’t “demand” appointments, we need to see our GP when we are ill.

We’ve learned from attending many NHS organisations’ meetings, that “difficult decisions” is code for cuts to services.

Staffing

Dr Nigel Taylor said that their “difficult decisions” had included “diversified staffing”.

He did not explain that this ‘diversified staffing’ is driven by the government’s plan to turn the NHS into a version of the USA’s Obamacare, and is part of the West Yorkshire and Harrogate Integrated Care System‘s workforce plan – such as it is.

West Yorks and Harrogate Integrated Care System Workforce Strategy, April 2018

Dr Taylor said the Practice had engaged alternative staff – 3 Advanced Nurse Practitioners and 2 Pharmacy Practitioners, amounting to 4.25 Full Time Equivalent. These Practitioners were providing patient contact, and the Practice was having to work in a new way as a result.

This meant they now had 9.5 Full Time Equivalent GPs/GP equivalents for 18K patients.

There were pros and cons of the new system but the Practice had lost GPs for personal reasons and haven’t been able to recruit to replace them.

So they can’t provide same service as they used to

They can’t do GP triage and same day appointments. They tried non-GP triage, but it didn’t work well.

So they changed to the walk in clinic, located in Mytholmroyd because of better parking and because it is the centre of their 65 square mile patch.

Clinicians are doing the walk in clinic at Mytholmroyd and booked services at Hebden Bridge and Luddenden Foot.

The walk in service is not an end point – but an attempt to provide a service in trying times.

It’s not ideal but it does let people have same day services. This takes 50% of their clinical capacity.

So they only have 50% clinical capacity for the book-ahead service.

Their Receptionists are now “Care navigators”. This is part of the government’s plans for GP practices.

Care navigators have been trained to ask questions to identify patients’ needs and where they should go for consultation.

The Practice is open to any suggestions about better ways to do things. They will work with the Patient Representation Group.

According to the government’s plan, GP numbers in the UK should have increased by 5K over 5 yrs – but 4 years into that plan, GP numbers have fallen by 1K.

There are problems recruiting and retaining Hebden Bridge and Todmorden GPs.

Hebden Bridge Group Practice has been trying to recruit GPs continuously over the last 2 years.

The Practice has been through a “difficult stressful time”. In Feb 2018 they had 12 GPs. They now have 7. Of these, 5 are GP partners, 2 are salaried GPs. They amount to 5.25 Full Time Equivalent GPs

They have had 3 long term locums and one has become a new partner. She is one of the 7.

They are desperate to recruit more GPs, they are advertising continuously.

So have had to take difficult decisions.

Funding

Dr Taylor pointed out that flat funding for GPs hasn’t kept pace with inflation.

About 7% of NHS funding is on GPs but 90% of contacts with patients are through GP practices.

The GPs’ trade union, the British Medical Association wants 10-11% NHS funding spent on primary care.

New Primary Care Network funding and staffing

A new GP contract came in in April 2019. This is the Primary Care Network contract and Dr Taylor said this is just beginning to address some issues. All the extra funding for GP practices will come in through Primary Care Networks.

As already reported, Hebden Bridge Group Practice is part of the Upper Calder Valley Primary Care Network – along with Todmorden GP practice. Together they have 34K patients and Dr Taylor is the Clinical Director.

Dr Taylor explained that being a member of a Primary Care Network is now part of the GP contract, and Clinical Commissioning Groups have had to make sure all GP Practices are part of one.

In a Primary Care Network, GP practices come together. New funding streams are trickling in to engage new members of staff. 1 Social Prescriber has been funded for the Upper Calder Valley Primary Care Network. They started work on 1 Sept, and are split 50:50 Tod and HB.

The Primary Care Network are also recruiting a clinical pharmacist to review patients’ long term medication.

There is no plan to reconfigure GP practices or the buildings they’re based in.

The Primary Care Network is a way of linking between traditional primary care and traditional community health services.

Dr Taylor fully accepts the Practice could improve communications with patients.

Thanks and summary from Mayor

Cllr Stowe thanked the Practice team and said that Hebden Royd Town Council have set up a communication link with the Practice that they will use. They will feed follow up questions to them after the meeting. So let the Councillors know any that you have.

Here is where you can read about the outcomes of the Hebden Royd Town Council discussion of Hebden Bridge Group Practice problems at the 25th September meeting.

Councillors’ questions that the meeting didn’t answer or only partially answered

Why Hebden Bridge Group Practice has longer than average waiting times for non-urgent GP appointments

  • This was not really answered. Dr Nigel Taylor explained that the Practice was understaffed and that only 50% of clinical capacity was available for routine appointments, because the other 50% went on urgent appointments.
  • But he didn’t explain why Hebden Bridge Group Practice suffers in comparison with the national average – or with other Calderdale Group Practices, which, anecdotally, seem to provide far quicker access to routine appointments.

Issues for people with mental health problems and special needs who have to attend the walk in clinic

  • Councillors had asked in writing, how the Practice addressed public health concerns that people with co-morbidities (ie various health problems), mental health problems and special needs are required to attend the walk in clinic for urgent conditions, where they are exposed to overcrowding and others with acute infections for up to 2 hours.
  • Dr Nigel Taylor didn’t address this question.
  • In a related follow up question after his presentation, Cllr Courtney said that she was worried that the walk-in discriminates against people with disabilities who can’t access it.
  • Dr Taylor replied that when patients ring and say they’re unwell and can’t get to the walk in, they try and accommodate it.
  • At the end of the walk in, the duty doctor remains on duty till 1pm and will let patients come in after the official end time of 10am. In the afternoon, the Practice has has one doctor who does nothing but deal with urgent calls via the care navigators/receptionists.

He added,

“When something comes in that doesn’t fit in the box, we try and accommodate it.”

Recognising, prioritising and helping vulnerable people at the walk in clinic

The Councillors’ written question of how the Practice could do this was not answered.

Booked appointments

In response to a comment from Cllr Harvey, that it was off-putting to see a notice in the surgery saying patients could only raise one issue, when they’ve waited three weeks for an appointment, Dr Taylor said that most GP practices try and let patients know they can’t deal with lots of issues in one short consultation. They try and encourage people not to come with a long list, but they have to be sensible about the fact that people might need to talk more than one health problem.He added that booked appointments are generally 15 minutes.

What is the recommended GP:patient ratio?

  • Councillors had asked in writing, whether the Practice’s current number of whole time equivalent GPs was enough and what is the recommended GP: patient ratio
  • Dr Nigel Taylor told the meeting that they have 9.5 FTE GPs /GP equivalents for 18K patients.
  • This figure breaks down as 5.25 FTE GPs and 4.25 FTE GP Equivalents (3 Advanced Nurse Practitioners and 2 Pharmacy Practitioners)
  • He said this is not enough to provide same service as they used to.
  • Dr Nigel Taylor didn’t say what the recommended GP: patient ratio is.

What ck999 dug out after the meeting about GP:patient ratios

  • We found that there doesn’t seem to be a recommended GP:patient ratio – but there is Clinical Commissioning Group-level info about actual GP:patient ratios. And The Practice Index, that supports GP practice managers in England, gives the average staff:patient ratio across GP practices as a “ballpark figure” for practices to work towards.
  • On both these measures, Hebden Bridge Group Practice seems to be understaffed.
  • These are the Practice Index average figures for a Practice with 15,000 patients (the closest to Hebden Bridge Group Practice’s 18,000 patients)
    • GPs – 9.5
    • Nurses – 3.75
    • Admin staff – 16.25
  • A GP Online article reports that the best performing GPs in terms of access to GP appointments within a week are in City and Hackney Clinical Commissioning Group. In that area, there are 1,691 patients per FTE, fully-qualified GP.
  • That compares with 3,428 patients per FTE, fully qualified GP in Hebden Bridge Group Practice- more than twice the number in City and Hackney.

Unanswered questions

Questions that the meeting raised

How many hours/week does Dr Nigel Taylor work as the Practice’s rep on Calderdale Clinical Commissioning Group Governing Body and as Upper Calder Valley Primary Care Network Clinical Director?

  • Is that work taken into account in the Practice figure of 5.25 Full Time Equivalent GPs? What proportion of a Full Time Equivalent GP does Dr Nigel Taylor’s work with patients amount to?
  • How many Full Time Equivalent admin staff are there and do receptionists/care navigators count as admin or clinical staff?

Why has the Practice created the new role for receptionists as ‘care navigators’, when a previous trial of non-clinicians’ triage of patients didn’t work?

  • Dr Nigel Taylor told the meeting the new care navigators’ role for receptionists is part of the government’s plans for GP practices. Care navigators have been trained to ask patients questions to identify their needs and where they should go for consultation.
  • Dr Nigel Taylor also told the meeting that the Practice had previously tried non-clinicians’ triage of patients and found it didn’t work, which was one reason why they set up the walk in clinic.
  • In response to a question from Cllr Courtney, he said that in the afternoons a doctor is on duty to respond to patients’ urgent calls, via the care navigators/receptionist.

Is the current move to shift even more hospital services into primary and community services appropriate, given GP underfunding and shortages of GPs/GP equivalents and community health staff?

  • Particularly since Dr Nigel Taylor told the meeting that part of the reason for the increased ‘demand’ for GP appointments, that the Practice is unable to meet, is that GPs are already delivering services previously provided in hospital.
  • What is going to happen if/when the Calderdale and Huddersfield hospitals cuts and centralisation plan goes ahead and GPs/Primary Care Networks have to deliver even more hospital services?
  • What is Hebden Royd Town Council doing about the Health section of the Calderdale Local Plan, that promotes this shift?
  • How is the Town Council liaising with Calderdale Councillors Steve Sweeney and Jane Scullion, who are on the Upper Calder Valley Primary Care Network Board?

Doesn’t experience show that there is something wrong with the government’s GP Forward View model of GP services?

  • The shift of services out of hospital gained momentum with the GP Forward View 2015-2020. (NHS England’s 5 year plan for GP Practices)
  • This is part of the wider NHS England Forward View 2015-2020. The Plan was designed to cut NHS spending by £22bn over 5 years (through major changes to the way NHS services are provided), compared to what the spending levels would be if things went on as they were.
  • Dr Taylor told the meeting that over those 5 years, the government had planned to recruit 5K more GPs, but in the four years since then, 1k GPs have left.
  • What is the GPs’ trade union, the British Medical Association, doing nationally and locally to fight the government’s underfunding of GP practices? Dr Nigel Taylor said GP Practices currently receive around 7% of NHS spending – the British Medical Association says it needs to be 10-11%.
  • Is a local British Medical Association rep attending the West Yorkshire County Association of Trades Council’s meeting in Leeds tonight? (Update: They didn’t)

Is continuing the GP Forward View model – now with the addition of the new Primary Care Networks – going to solve the problems of GP Practice underfunding and recruitment and retention problems, that have built up since the government quango NHS England introduced the GP Forward View?

  • Or are the Primary Care Networks at best a sticking plaster solution and at worst, a continuation of the disastrous policy that’s been in place for the last four years?
  • What is the evidence that employing a social prescriber is going to improve patients’ access to the clinical care that they need from Hebden Bridge GP Practice?
  • Why is it a good idea to spend money on employing a Clinical Pharmacist to review patients’ long term medication? Is this a full time position?
  • Isn’t it the case that the problems in meeting patients’ needs that Hebden Bridge Group Practice is experiencing, are the predictable outcome of a government policy to run down the NHS to the point where people lose faith in it? And those who can afford to, turn to private health care?

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