Exclusive The third-largest integrated care system (ICS) in England is effectively mandating the use of ‘same-day access hubs’, leaving GP practices with only ‘complex’ patient care.
From April, North West London integrated care board (ICB) is introducing the requirement as part of its ‘single offer’ local enhanced service, with practices obliged to sign up to all services to access the funding – effectively mandating the hubs.
The same-day access (SDA) hub model will ‘deliver a single point of triage for same-day, low complexity’ demand for all patients in the ICS, and has already been trialled with ten PCNs in the area.
In documents seen by Pulse, the ICB has said it is ‘now a priority to support the remaining 35 PCNs’ to also implement the model so that there is ‘an equitable offer to patients across NW London’.
The ICB has commissioned management consultancy KPMG to help practices make the transition over the coming weeks.
Single or groups of PCNs can come together to form the hubs, which will be located at one of the participating practices or at suitable alternative premises.
They will be staffed with a multidisciplinary team consisting of ARRS staff from practices and as well as at least one GP who will hold overall clinical accountability.
An example of staffing, provided by NWL ICB, included one care coordinator to manage triage, one senior supervising GP, three prescribing ANPs or PAs, one pharmacist and one social prescriber.
Patients will be directed to the hub if they select ‘same day’ when phoning their GP practice, after which the care coordinator, with support of the GP, will assess whether the patient requires same-day care.
The ICB’s plan stipulates that practices and hubs must have shared record access so that if required, staff at the hub can book a patient directly back into the GP practice appointment list.
In its letter to clinical directors, the ICB said there is a ‘recognised issue with capacity across the NHS’ and all parts of the system ‘need to re-think the way they work’.
Local health leaders wrote: ‘Building on everything it has already achieved through working together at scale, NWL is asking practices to prioritise working with their colleagues (at PCN or borough-level, as determined appropriate) to scale up any total triage practice-based models they have in place, to deliver a single point of triage for a same day, low complexity access model, at scale.
‘This should be done with a view to addressing the balance of provision so that there is greater parity between a place’s ability to deliver reactive, same day care on the one hand, and manage preventative, proactive, complex care, on the other.’
In its assessment of the current state of general practice, the ICB said some practices are ‘still operating a first come first served approach to appointments’ and ‘switch their phone to answerphone when their on-the day lists are full’.
‘Enhanced access is not being fully executed or utilised: some practices are not delivering on the contractual requirements to deliver enhanced access. Efficiencies are limited due to poor interoperability and access to diagnostics,’ the report added.
This year’s GP contract included an obligation for practices to offer patients an assessment or signpost them to other services on first contact, meaning they can no longer ask patients to call back another time.
In January, Pulse reported that NWL ICB, among others, had paid for management consultants to help design GP strategies and improve access.
The local commissioner has built on this work with KPMG to develop a model which will form the basis of a specification for the ‘Enhanced Services single offer’, to be launched from April.
Unlike other specifications in the single offer, such as hypertension or coil fitting, the funding will not be allocated to PCNs based on activity, but rather to support practices to ‘transform the way they work’.
Over the next two months, GP practices are expected to work with KPMG to design their same day access hubs, and are expected to use existing access funding through the IIF and QOF to support this.
Pulse has contacted NWL ICB for comment.
In November, LMC leaders emphatically rejected the notion of separating acute on-the-day care from planned general practice care.
Last year, the Fuller stocktake – a landmark review on how to integrate primary care with other NHS services – recommended that urgent same-day appointments should be dealt with by ‘single, urgent care teams’ across larger populations rather than the patient’s own GP practice.
When you thought things couldn’t get more ARRS. I won’t be doing this as I’ll be in Canada.
Does this mean that other GP practices in that ICB area will be unable to access any funding for continuity payments?
I suppose all that continuity payment part of the GMS fund would be going spare then, so it could be used to fund the ICB’s same-day services !
Not sure if this is opportunity or threat!
A lot depends in how much money ICB throw at it
But GMS is GMS and PCNDES is a DES so ICB cannot effectively “mandate it” , practices can keep to terms of GMS and PCN DES
Practices can always say no! ( and should until the “price is right”
Beware that this is not funded per contact , and most schemes that make it easier for patients to access services just end up stoking demand
Maybe tie KPMG into payment based on them reducing demand !
Also a high proportion of urgent same day care is amongst those with complex pre-existing medical conditions , whom it sounds will be excluded from this scheme
Oh and I would not want to be the single accountable GP who gets the blame if anything goes wrong ! ( note not KPMG accountable)
1/12 ago, my mother attended a “GP” appointment for a cough that had lasted 10/52 despite 2 courses abx. She met criteria for a CXR +- sputum sample. Her GP practice could not accommodate her on the day so arranged for her to be seen at the local “overflow hub/same day GP appts service”. I accompanied her…
We were first asked to sit in a waiting area (directed by a sign – no human receptionist, leaving us wondering if iwe were even in the right place). We then saw a PA; he spent 35 minutes taking a lengthy (tick box) history, conducted an over-thorough examination and incorrectly diagnosed ‘tonsillitis’. We were then directed back outside to said waiting area; 10 mins later we were seen by a clinical pharmacist. She reviewed PA notes, undertook a brief exam (throat and chest); confirmed the absence of tonsilits (!) and then agreed mum met criteria for CXR. Unfortunately – for some unknown reason – on this particular day, the system was not allowing her to request the CXR / sputum sample herself; she made several unsuccessful attempts and eventually conceded that she would write to the GP and suggest that GP place the CXR & sputum sample requests. She then prescribed difflam and sent us on our merry way.
The entire process took around 1 hour and 10 minutes; mum had to then wait till the following week to contact her GP and chase up Ix requests.
The whole process was prolonged and inefficient and left me pondering how exactly this is saving the NHS money?! Ultimately the GP had to process the Ix request and will undertake f/u; what most GPs could have achieved in than 10 mins took 2 members of NHS staff over an hour to complete.
Having read this article today – I am left perplexed at how exactly all these ARRS staff save time, money, resources? I do hope these proposed changes are not enforced nor rolled out nationally … it would be the beginning of the end of efficient, quality care, not to mention where is the continuity ?!?
Mind blowing.
Completely agree. I’ve experienced this myself and also heard countless anecdotes from colleagues and patients about incomplete episodes of care involving fragmented care systems/non-doctors that generate unnecessary healthcare activity and create patient inconvenience. The data may show the system is offering ‘more appointments’ for cheaper but it misses the point completely. I think Jeff Bezos (Amazon boss) said “The thing I have noticed is when the anecdotes and the data disagree, the anecdotes are usually right. There’s something wrong with the way you are measuring it.”
More Trademarked London Fuckwittery.
This is awful. This is not general practice. Why are we sleepwalking into this shit show?
Sounds like they have invented a new “patient ping pong” game. Single risk holding GP has to decide whether to stick or twist 😩
KPMG now designing General Practice; previously a Centene model (both USA), described by Sam Everington as : “A massive risk to patient safety” in its Panorama GP undercover investigation, https://youtu.be/vmcrmRyBB3s
Massive implications for safety and training. How will future GPs learn? Talk about silos, whilst calling it ‘integration’.
How this service is different from Darzi centres or Walk in centres? Other than staffed by more ARRS? What about every one gets redirected to this service and start a game of ping pong from this service to that service?
Are any practicing GP on the boards that make these decisions? A whole day every day dealing with complex cases? No easy rapport building simple things to unwind and catch up? Where will ‘trainees be it student or registrar get experience in dealing with whole patient care from cystitis to prostate cancer an urti to lung cancer.
the skill and enjoyment of being a GP is managing the trivia tot he major. Those perhaps who dont enjoy this become those what is ‘best ‘ for others
the solution is to make the day job for GP better. 15 minute appointments , semi personal lists and perhaps a giant hub dealing with mental illness needing ongoing listening till things improve though this used to be part of being a GP until it was deemed that talking therapies and others can solve the mental health avalanche rather than looking at the societal causes of it
Having read the comments there would appear to be some anecdotal concern that ARRS noctors are out if their depth and are having problems dealing with undifferentiated presentations. It’s not their fault if they lack the aptitude or they haven’t received the appropriate level of training. They identify as fully trained and highly skilled health professionals and that’s all that matters. I don’t think we should be unduly critical. It’s not like they’re killing or maiming people is it? Is anyone measuring this metric in the Notional health service? Best not to.
In a situation where poor rates of GP pay lead to too few people willing to do the job leading to stress from overwork in those remaining we should be grateful for all the help we can get before we hit early retirement or book our flights to emigrate to a better health system. We could pay GPs better to resolve the situation but no we’re committed to not improving pay and conditions. How hard is it for top civil servants to get jobs at KPMG after they retire? A director ship maybe?
I’m not accusing anyone of anything but just wondering if I should push my kids towards getting jobs in the civil service instead of medicine.
Filtering “same day low complexity” cases for “hidden” complexity and potential underlying serious illness is the biggest challenge GP.s face every day. The prospect of hiving it off to a Noctor Hub might have some superficial attraction for some GPs, but it will be a disaster for patient care.
Anyone else think this is the end of General Practice?
What seems incredulous is that we know whatever is offered will get used, demand for healthcare is insatiable and unless it is controlled it will always be so. So offering new services is not the answer and certainly if this happens in my ICB resignation will not be far away.
There is a world of difference between managing your own patients as a practice, with staff whose competencies and training you know (and this includes ST1-ST3 trainees, clinical pharmacists, Physician Associates with different experiences, GPs with different sub interests, support admin staff with knowledge of local families and knowledge of those with health anxiety, drug seeking behaviour and personality disorders) and a remote hub where the level of risk tolerance will default to 111 levels.
Any NW London GPs care to comment on how this works or doesn’t. How much money is in the bundled LES?
From a distance I’d just keep the capacity and access monies and sack off the bundled LES
What a seismic change. Definitely looking forward to hearing how it works out.
This raises lots of issues.
Firstly, by bundlng all LCSs into one package and adding the new Urgent Care Hub requirement in, the ICB is essentially holding a financial gun to the head of practices: ‘do this or you will lose all LCS funding’. This is not negotiation, and it is not partnership working. It is bullying and coercion.
Secondly, the point of LCSs was that practices that had the expertise and capacity to take on extra work, and that work was being properly funded, could choose to take on that work. By bundling them all together, all practices have no choice about what non-core work they take on (or at what level of funding): it is all – or nothing. Again, this is bullying and coercion.
Thirdly, this is clearly an attempt to impose the Fuller Plan. In this, the future of general practice appears to be Emergency Care hubs run by the cheapest staff possible, with a single GP taking legal and clinical responsibility for the actions of a larger number of staff who are not medically trained or qualified. It would obviously be madness for a GP to accept that role, and even if they did I suspect they would burn out in weeks. The other part of general practice would be routine care and long term conditions clinics.
This approach is obviously madness. I have never heard a single GP – who is not employed by an ICB or NHSE – say positive things about it. There is no evidence it works, or is as safe or effective or efficient or productive as the current grossly underfunded model. It effectively reverses the last 50 years of progress and development in the practice of family medicine. It destroys continuity and holistic care. In return for what, exactly? What problem does it solve?
Should they attempt to implement it, the urgent care hubs will quickly be overrun, and the commissioner will insist that GMS resources are used to prop it up. What will happen to practices then?
This vandalism is being proposed by unelected bureaucrats. Surely a redesign/destruction of general practice at this scale should be put to a public vote? Let’s see a political party run on a platform of ‘vote for me and I will remove your right to see a family doctor’.
This proposal is an existential threat on the same scale as the recent real-terms funding cut proposed in the new contract offer. Agree to the implementation of this and there won’t be meaningful general practice within the NHS in 5 years. GPs will be considered a luxury good, and most of the population will not be able to afford to see a private family doctor.
No doubt similar ideas will be proposed elswhere shortly: I am sure NWL is just a test bed. Wherever this happens, I think we should:
– refuse to sign up, en masse. How can they implement it without us? How can they deliver the LCS care without us?
– explain to our PPGs what is planned, and what it means for them.
– contact Healthwatch and explain it to them.
– contact our local MPs and ask them to stop this madness.
– consider a public vote of no confidence in the ICB Chair and CEO (we can’t get rid of them like we could in CCGs, alas, but it would send a strong public message).
The worse the NHS gets, the more willing the punters will be to pay bo see an adult, and the more opportunity for doctors to escape the ghastly NHS.
We have had UTC/ EA/ EH hubs, for over 5 years. Some since Cameron’s PM challenge fund and the Vanguard Project. And A Home Visiting Service (paramedic and nurse led). They have had a big, even vital, impact.
Like our PCN Care Home Team, Frailty team, Acute Repsonse Team, PCN Pharmacist, Minor injuries and OOH they are important and even vital. However they need to be run by local clinicians. They have been counter productive when run for a politician who needs a soundbite at any cost.
Care in walk-in-centres and out of hours hubs is nearly always terrible. I very frequently have to re-sort out patients who are misdiagnosed and mismanaged by the clowns working in these places (usually non doctors). I am astonished at this wholesale reimagining of what a GP service actually is. My retirement plans are accelerating as a consequence. I can only hope that my small traditional practice (providing outstanding care) can fly under the radar long enough for me to eventually get out. Appalling.
The motto of this new Hub?
“Abandon all hope, ye who enter”.
Healthcare designed by management consultants isn’t healthcare, its management consultancy.
The same type of individuals who have destroyed the NHS continue to destroy the NHS yet ignore their long and ongoing record of failure and we are forced to absorb this nonsense of another group with associated further fragmentation and discord.
Those who have worked in walk in centres will know they offer no continuity, changing staff and are often are crammed with patients from the surgery they are based in or those nearest to the centre worsening health inequality for those who cannot access these centres but provide a grand visual disguise to the underlying chaos within the NHS.
The leadership solution for the failure of NHSE /HMG is not to use ARRS where they may have value but to implement a lower quality service by replacing doctors with non-doctors yet leaving the risks/accountability/potential GMC erasure for single GPs in large centres deliberately misleading the public who are not aware that this is not the higher quality service of the past and that supervision may be minimal and inconsistent.
Via relentless years of poor NHSE /CCG /RCGP and ICB and government leadership and decisions they have driven qualified medical professions away from Primary Care by policy moves and then sort to profess they are using ARRs due to resolve a need they have intentionally created through gross mismanagement.
Once more there is a role for ARRs but not in the current form where the hidden agenda is an overall worsening of quality by a reduction in role for GPs.
As a partner, seeing the vast numbers of repeat consultations for various reasons sometimes totalling an hour for ARRs on £50 to £70k for a simple medication query that required 1 minute of GP time is an outrageous abuse of public money/ difficult to control and occurs in multiple surgeries.
There is an advantage for partners to manipulate this crisis for their own personal gain and it is difficult to resist in some practices supported by the same CCG/ICB/NHSE/RCGP leadership names who have driven this catastrophic NHS failure in the first place and who have annihilated the NHS and Primary care yet we continue to read headlines from the same group.
The public should be made aware of the actual qualifications and educational background of those they are seeing and their suitability and supervision for the role they are assigned and the nature of the profits being siphoned off by those partners and some PCN members who have sort to use this PCN fiasco for personal benefit rather than admit the introduction of a non-medical level of variably supervised staff who are currently present unknowingly to many patients on the pretence that a short debrief can mitigate this scurrilous subterfuge.
This has to stop . Maybe late for GP careers in 50s but for younger generation. If all easy case are dealt by Noctors then 10 minutes appointments do not work as as time taken with complex patients is more. But the worse is time taken clearing the BS these Noctors do and hearing patient to be abusive when they approach GP after 2-3 previous consultations. I think lot of patients are already paying a costly price for NHS cutting corners.for GP but using wasteful management consultants.
Has anyone submitted an FOI request to this ICB to ask what happened to continuity-of-care metrics when they piloted this scheme?
Join the BMA
Does the BMA have a view ?
If so let’s hear it .
So.. more dumping by non accountable practitioners coz the safety netting will always be “ See YOUR GP If xyz..” as there will be No continuity. More chance of missing sinister diagnosis if present as ‘single symptoms’ multiple times but seeing different non-doctors. Also probably more referrals by inexperienced practitioners, over diagnosing, overprescribing. Good luck to the supervising GP! More litigation your way as’ the buck stops with you!’ So if another PA misdiagnose a DVT for panic attack, probably the Gp will be accountable. Plus it will feel like an on call where you will be dragged left right and centre for advice when others have taken a history and examined but ‘just want you to check’ to protect themselves, meaning more mistakes by stressed GP. And existing Gps, alongside seeing complex patients, will enjoy being dumped more work by those incompetent practitioners as they do not have the same 10 year experience of medical education and training. Which means patients will probably need another appointment with their own GP practice… Yes! This will in fact double the work load.. requiring more GPs…but there won’t be any…
This plan is barmy and shows a complete lack of understanding of what general practice is about. The pitfalls are obvious. Was there any Re GP input here or was it all managers in ICB with KPMG? Has there been any challenge from GPC BMA RCGP ? This is in effect a change of GP contract without consent.