NHS England made £250m available for GPs to increase access during the winter, but with a number of caveats attached. How has the money been used across England?
When the £250m Winter Access Fund was announced last October, there was uproar over the plans to ‘name and shame’ practices deemed to be the worst-performing on face-to-face care. After months of media criticism and abuse from patients, NHS England’s plan felt far from supportive.
The access plan asked commissioners to identify the 20% of practices with the lowest levels of face-to-face GP appointments, those with the overall appointment numbers lower than in the equivalent pre-pandemic months, the 20% with the most significant levels of 111 calls from their patients during GP hours, and the 20% with the most significant rate of A&E attendances. Later guidance confirmed that some practices in need of access support would not get extra funding.
The data used to support this part of the plan has been heavily criticised. In November, our sister title Pulse exclusively revealed that it was based on a one-month ‘snapshot’ comparing August 2021 with August 2019 – although it remains unclear which of the above metrics this covered.
Another glaring issue with NHS England’s plan was how its solutions for improving access focused on using more staff – such as funding more sessions from existing staff, hiring locums, or employing other physicians – ignoring the fact that in many areas this extra workforce simply does not exist.
The list of practices – along with ICS plans for how to spend the money – were due by 28 October. Work around the fund remains ongoing, with NHS England confirming on 23 December that it had not been put on hold. GPs report that accessing the fund, however, has not been straightforward.
ICS plans for the Winter Access Fund have not been made publicly available yet, but Pulse spoke to LMC leads and PCN clinical directors in five different areas to get a taste of what has been agreed so far.
Dr Rob Barnett, Liverpool LMC’s medical director, describes the whole process of accessing the fund and collecting performance data on face-to-face appointments as a ‘disaster from start to finish’ and says plans put forward by his CCG were initially rejected by NHSE.
‘Some of that was related to the fact that 24 practices would not qualify for any winter access funding because of the data,’ he says.
He adds: ‘When you looked at those 24 practices, they were not the bottom 24, they just happened to be where they were because of the data. They weren’t bad or underperforming practices, they were just practices whose data didn’t meet a set of criteria.’
In Liverpool, the CCG has now agreed a ‘PCN approach’ to the fund where PCNs have put forward plans ‘based on an aggregate of what practices said they were going to do,’ Dr Barnett says. This includes some money being used on a city-wide basis for improving communication with patients and a locum chambers type approach.
But, following the agreement, the ‘vast majority’ of the funding is now being distributed by PCNs, Dr Barnett says.
‘From what I can see there will be an equitable distribution,’ he adds.
A spokesperson for NHS Liverpool CCG said that the plan was agreed with NHSE ‘following discussions with the city’s PCNs about how best to deliver activity locally’.
‘It involves a number of PCN-led activities and actions, including plans to increase the number appointments delivered by the existing workforce, alongside a planned increase in capacity in enhanced access services during the out of hours period,’ the spokesperson said.
‘In addition, we have developed some city-wide initiatives, including plans for additional service information for patients, and support with non-clinical staffing for practices.’
They added: ‘We recognise that delivery of plans is reliant on the primary care workforce, which is currently under considerable pressure because of the impact of Covid-19 and the ongoing vaccination programme, and we will be working closely with PCNs to look at how best we support our practices to improve access over the coming months.’
NHSE denied that any Winter Access Fund plans had been ‘rejected’ but said that some went through ‘different development stages and iterations as is to be expected in a process like this’.
Dr Faisal Bhutta, clinical director of Hyde PCN, says the face-to-face data approach was discussed locally but it was agreed that these practices ‘probably need more support rather than depriving them because they’re usually the ones suffering with workforce problems and so on’.
‘With the CCG we decided we weren’t going to do that because there would always be a bottom 20%, so we thought that wasn’t the right way,’ he says.
He adds that his only concern is that Tameside and Glossop CCG top-sliced some of the funding to go to urgent care – which is based in the hospital – ‘but it’s only a small proportion’ and the remaining £3 per patient has been distributed through PCNs to deliver three different schemes.
These include a putting in place a paediatric advanced nurse practitioner to see children who need urgent on-the-day appointments, employing a paramedic to expand the PCN’s acute home visiting service, and employing locums who are being allocated to practices based on list size – with practices getting one hour of locum time per 1,000 patients per week.
‘These three schemes have opened up 400 extra appointments per week across the PCN. Two of them started on 1 December and the nurse will be in place soon,’ Dr Bhutta says.
‘We offered locums £100 an hour, which is slightly above the going rate – but in a week we filled all rotas until 30 March.’
He adds: ‘We were concerned that smaller practices lose out with lots of these schemes, and we wanted to make it equitable and fair, so we did it based on list size.’
Peter Higgins, chief executive of Lancashire and Cumbria consortium of LMCs, says his area has some of the ‘worst workforce problems in the country’ and the money is ‘largely being used for general schemes to divert pressure away from individual practices to alternative services or hubs’.
‘There is no spare GP capacity up here so not much chance to put extra cash into practices that can’t access GP sessions, either from partners, sessional or locum doctors,’ he says.
He adds: ‘We did engage [with the plan] because it was only sensible we stayed talking, but we said we wouldn’t countenance anything that put any extra pressures on an already overstretched workforce.’
Mr Higgins explains that the local CCGs have ‘acknowledged the state of general practice in the North West’ and have come up with schemes that can divert patients or provide extra access that doesn’t impact on practices. Some money is going towards assisting with diverting patients to pharmacies, some to establishing locum banks, and some towards setting up hubs.
Practices were also not singled out over access data: ‘They [commissioners] have the data as that’s relatively easy to get hold of, but when they have put in bids they have just listed every practice and not singled out the bottom 20%,’ he says.
‘Our ICS is very supportive and since Covid when we have sat in the primary care meetings with CCG clinical leaders, we have all been singing from the same hymn sheet.’
In Dorset, Dr Simone Yule, clinical director for the Vale Network, says that PCN clinical directors felt that they couldn’t agree to the Winter Access Fund plan because ‘it is not about the money’.
‘We just do not have the workforce to do any more than we are doing already and that’s the bottom line – I think it’s about being creative about how else we support patients to access healthcare, but as clinical directors, GPs, primary care, we are doing everything we can,’ she says.
‘Our CCG have been incredibly supportive, and I think it was quite a difficult conversation for them with [the NHSE regional team] to actually say the GPs cannot do anymore than they are doing already.’
Levels of face-to-face appointments are also higher in Dorset than pre-Covid, Dr Yule says, and so commissioners have come up with a plan to support workforce planning locally instead. This includes looking at how they can recruit remote appointment capacity from the independent sector, ‘at both practice level and PCN level, and across Dorset’.
‘Some practices are already doing that as part of their resilience, because recruitment is just dire isn’t it – we’ve all got vacancies,’ says Dr Yule.
PCNs are also working with the CCG to look at how they recruit and retain practice admin staff, managing workflow so ‘it doesn’t all come to clinicians’, as well as increasing phlebotomy capacity across the patch to catch up on blood tests – if they can find the staff to do it, Dr Yule adds.
Dr Dan Bunstone, clinical director of Warrington Innovation PCN, tells Pulse that the list of practices in the ‘bottom’ 20% was submitted by commissioners and some GPs in his area have been told about the data – with those who worked hard to improve their digital access, as per NHS England strategy, now possibly finding themselves criticised for it.
‘There are practices who made the move in directions of remote care and signposting, getting patients in front of the clinician at the right time with their patients benefiting from that approach and they still find themselves in the bottom of the list, but for the wrong reasons,’ he says.
Dr Bunstone says there was a widely used but informal ratio of practices offering around 70 face-to-face appointments per 1,000 weighted patient population, so for a 5,000 patient surgery this would be 1,400 appointments per month as a target.
‘We need to consider what primary care is being commissioned to deliver and the incredible strain already being suffered, and that ‘reasonable access targets’ are already being significantly exceeded.
‘The 70/1000 figure does not take into account appropriate triage or patients being offered other services within primary care such as direct access physio as part of the PCN funding, which offers additional capacity.’
He adds that the comparison of August 2019 and August 2021 appointments data was such a crude measure as to be ‘worthless’ given how practices have adapted to operating in a pandemic.
‘There is not enough capacity for the system to meet “patient want” rather than “clinical need” which is why triage exists. The reason we started proactive remote signposting is because we were in a pandemic and having a lot of people in a waiting room where the virus could easily spread is just crazy – and none of this seems joined up.’
Discussions on how the funding will be allocated are actively ongoing, Dr Bunstone adds, with the practices that were on the list now taking part in a data validation exercise.
‘There is a recognition that the data [used by NHSE] may be incorrect and it may be pointing in the wrong direction, so the exercise is to check NHS England’s data against the data from the surgeries,’ he says.
As previously published in our sister title, Pulse.
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