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'Disappointment in primary care demanded highlighting'

The Bristol, North Somerset, Somerset and South Gloucestershire area team wrote to all practices in the area suggesting they call in ‘off-duty’ staff and cancel ‘discretionary activities’ in order to boost capacity and provide more urgent care cover.

Email dated 7 January 2015 from area team to practices

Dear Colleague,


As you will know the urgent care system is under considerable pressure at present with all services over-subscribed despite additional capacity being created wherever possible.


We know that this is being felt in Primary Care too.


One of the particular features in the last week has been an unusually high number of frail elderly patients with acute respiratory infections. Work is being undertaken today to provide the most up to date advice regarding therapeutic and diagnostic interventions for treatment of these cases in order to enable more patients to be treated in community settings. We are also advising the acute trusts to provide increased accessibility to respiratory consultant support including hot clinic access. We hope to publish this and to send it to you later today.


In addition we seek your support over the following:


•To take all actions to maximise capacity in the surgery, calling on any ‘off-duty’ staff as appropriate


•To seek to cancelling discretionary activities in order to free up more urgent care slots if there is excess demand, in line with Acute and Community Trusts


•To triage home visit requests as soon as possible and to prioritise early visiting for those who may need community services response or hospital assessment. This may allow same day discharge


•To keep us informed of any particular issues, including surges in demand, specific presentations that may be amenable to a review of protocol, staff sickness etc.


We will be in further conversation with the LMC about this to settle on the full range of appropriate and pragmatic actions that primary care can offer in these circumstances. Meanwhile any feedback or ideas are welcome.


Email dated 14 January 2015 from area team to practices

Subject: Urgent Care System Pressures

To all GP partners, Practice Managers in Bristol, North Somerset and South Gloucestershire

Communication sent on behalf of Linda Prosser, Director of Commissioning, NHS England, BNSSSG Area team


Dear Colleague,

I want to correspond with all of you again in response to your comments and suggestions following my e mail of last week regarding Urgent Care system pressures. I also want to thank you for taking the time to respond to me, not surprisingly there were many impassioned views expressed. Whilst I may not fully appreciate exactly what it is like to be under the pressure that you all feel, I do not doubt it; your experiences are expressed to us consistently.

The fact that the system ensured that patients were managed safely and effectively of the holiday period is due in a large part to the number of additional patients that you have seen and hours that most of you have put in. You will appreciate from your peers working in other parts of the system, including acute trusts that their pressures have been intense too, such that any disappointments that they experienced in Primary Care responsiveness demanded highlighting.

Unfortunately only a generic approach was pragmatic, which I know was galling for those of you who really were pulling out all of the stops. Of course we never really know how many patients who are attending A&E and saying that they could not get in to their GP have really actually tried, but we want to have been able to accommodate them if at all possible where they did.

I think though that uncomfortable as this may have been, we have gleaned some suggestions and priorities for development which we will consider in detail and take up where possible. These include:

  • The need for a rigorous system wide analysis of this Christmas & New Year, including quantification where possible of ‘inappropriate’ demand, effect of NHS 111 etc.
  • Review of Community capacity and responsiveness including rapid response and social care – to ‘never say no’
  • Giving practices the resource to employ such community services and set their culture
  • Supporting GP’s in their management of high risk individuals around the clock
  • NHS commissioned nursing home capacity
  • Mechanisms to access funds as appropriate for costs of services over and above the norm, including additional winter clinics
  • More public communications re the purpose of A&E (national), also localised messages
  • Reduce the burden of QOF and prescribing schemes on practices
  • Planning for this and other post long holiday periods to suspend planned care (such as LTC clinics, contraception etc.) as far as can be caught up in future weeks, to focus resources on urgent care
  • Suspension of training / study leave in this period
  • Peripatetic day time home visiting service (Winter only or all year?)
  • Creation of a pool or bank of Primary Care staff, across the whole multi-disciplinary team that can be called upon at peak times, across groups of practices. This can include part time nursing staff
  • Enabling some tasks to be undertaken by ‘home-workers’ such as part-time GP’s processing incoming letters, results etc
  • The sharing of a range of resources across practices
  • Roll out primary care pressure reporting on the Almanac system
  • Increase clinical input in to NHS 111; triage is best done by experienced clinicians
  • Simplify the profusion of Care Plans

We will all be working now to pick up these issues and your local CCG meetings will be a place for further discussion. However if this doesn’t feel like sufficient attention we can arrange specific events, though we will do so only with care because of the need for a good return in taking up peoples valuable time. I wonder whether the reality though is that we are at the threshold of seeking more strategic and further reaching solutions to Primary Care sustainability, such as those trailed in NHS England’s Five Year Forward View, relating to new forms of organisation.   This will definitely need constructive time together.

Thank you for your continued commitment to your patients, which we fully recognise, whist we work together to seek creative ways forward to sustain effective services whilst protecting the whole workforce.

Kind regards,


Linda Prosser

Director of Commissioning

NHS England: Bristol, North Somerset, Somerset and South Gloucestershire Area Team





Readers' comments (9)

  • I suggest NHSE offer to suspend QOF nationally for the rest of the financial year and ask practices to switch all their focus onto acute care (fix on last year's out turn % points achievement adjusted to this years prices and points value) as an option for practices like happened in Devon last year. So much time at this time of year chasing non attenders but of course still vital to address those with Long term conditions like COPD where good elective care saves emergency admissions. Perhaps some trust in GPs to prioritise to the need rather than slavishly follow a series of tick boxes.

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  • We followed the advice and stopped booking HGV medicals etc. We then had complaints including threats of going to the press because patients said they would suffer loss of earnings! We can't win!

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  • I cannot believe the blatent cynicism - reduce current Quof activity to help the system at providor risk- that you will be able to put more routine through in March, despite the fact you cannot magic staff or time to do so.
    If this is a serious request to be able to convert scheduled capacity to unscheduled capacity the only fair solution is total suspension of quof promotion activity and payment of all attainment as per previous year.
    Can the hospitals in the area demonstrate cessation of elective payment by results cases to free capacity for unscheduled care?
    thought not -
    so why does the system expect GP surgeries to take the cash hit for the system?

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  • "Call in any off duty staff" especially those that are off duty to re-charge their batteries, so that they can add to the sickness tally due to being stressed out with over work.

    "Seek to cancel discretionary activities" I think we should seek to cancel discretionary CQC visits and discretionary erroneous returns to CCG, LAT, NHSE et al that should free up some time to organise discretionary practice activities that we can cancel in order to help.

    Marvelous!!!! You really couldn't make it up!!!

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  • review of community capacity? Where is the capacity?
    catheters and syringe drivers are left for OOH doctors to do.

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  • Can our public be given self responsibility, not to use doctors time for sick notes and housing letters, I want something done for sore throat, I want to see the ball rolling etc.

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  • Run for the hills the NHS is imploding................

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  • We are in BNNSSG - and have just received a letter from an MP as one of his constituents had complained that they had to wait 3 weeks for a routine appointment. We have responded along the vein that, in line with Secondary Care, we are having to prioritise urgent care over more routine work. We also detailed how many appointments we offer per 1000 patients (above the numbers recommended by NHSE), the number of home visits and telephone triage consultations. The patient wishes to remain anonymous and we also do not have any details as to whether the appointment he wanted was specific to a particular doctor at a particular time/day or just a routine appointment.
    We await his response with interest

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  • "We also detailed how many appointments we offer per 1000 patients (above the numbers recommended by NHSE), the number of home visits and telephone triage consultations"

    Why do you personally fund more appts then you are (contractually) meant to. If you have excess money please pass some along to a worthwhile charity

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