London GP leaders have raised ‘immense concern’ around an ICB plan to effectively mandate the use of ‘same-day access hubs’.
North West London (NWL) ICB, the third largest in England, is introducing the requirement from April, as part of its enhanced services ‘single offer’, with practices obliged to sign up to all 25 services to access the funding.
Pulse has learned that for 2024/25, the single offer will be worth £75.4m, with £6.6m specifically allocated for the same-day access 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, meaning GP practices will be left with ‘complex’, longer term care.
Londonwide LMCs, which represents GPs within NWL, said it is in ‘active dialogue’ with the ICB about ‘ongoing reservations’ with the proposal, and requested a response from the ICB by today to a series of concerns, including patient safety, quality of care and logistics.
In an email to members, seen by Pulse, deputy chief executive Dr Lisa Harrod-Rothwell said: ‘It is clear from feedback we have received that there is immense concern regarding this model, with unrest heightened by: the proposed timescales; the desire to mandate this as part of the single offer which is being seen as an enforcement; the lack of outcomes as yet from a reliable, valid, comprehensive, fair and ethically conducted pilot programme.’
She also highlighted that the ‘ultimate limiting factor’ for patient access is the ‘gross mismatch between demand and capacity’.
‘Significant concerns’ raised by NWL GPs
- Patient safety
- Clinical triage
- Limits of clinical competency
- Unsafe clinical supervision arrangements
- Meeting the needs of unregistered patients
- Clinical quality and effectiveness of care
- Impact of loss of personalised care and continuity of care
- Widening health inequalities
- Driving up demand for clinical advice and care for self-limiting conditions
- Logistic concerns
- IT functionality
- Patient experience and public consultation
- Patient experience
- Public engagement and consultation
- Impact on staff and retention
- Impact of implementing change
- Staff experience
- Perception of ‘enforcement’ despite immense concern
- Inflexible contracting approach
- Appropriate use of funds
Source: Londonwide LMCs
While the hub model was piloted with 10 PCNs last year, the ICB notified the remaining 35 PCNs of a wider rollout at the end of January, leaving practices with only 13 weeks to prepare.
The ICB has commissioned management consultancy KPMG to help them make the transition.
GPs told Pulse the new model is being pushed through with little consultation, with one GP, who wished to remain anonymous, saying they are ‘livid’.
They said: ‘As a patient, parent and carer I am aghast. If I was ARRS, I would equally be unwilling to work within this model.
‘Non-evidenced and no mandate – who on earth is driving this? Continuity of care saves lives. Many of our surgeries have ease of access despite the narrative in the popular press.
‘This defunding and carving up of primary care is clearly about private profit and not about patient safety.’
A PCN clinical director in the area, who also wished to remain anonymous, said ‘there is no doubt’ that general practice could improve in some ways, but ‘you simply can’t do grassroots change in the way NWL [ICB] is attempting’.
They added: ‘It takes time, support, knowledge of change skills and commitment, and “you can’t impose anything on anyone and expect them to be committed to it”.
‘If the people in the ICB who are responsible for this proposal understood this, then they’d realise that what they are doing and the way they are doing it won’t give them what they want, it will simply widen disparities, across postcodes, and widen the divide between them and their GP practices.’
‘We want to improve things for our patients but we need the right support to be able to do this – not management consultants,’ the clinical director added.
Dr Selvaseelan Selvarajah, a GP in East London, told Pulse that a model like this ‘siphons away care from GP practices’ and will end up ‘increasing workload’.
‘It’s really hard to segregate acute care from routine care, especially for patients you know well. If it’s a patient I’ve known for ages, it’s much easier for me to manage them if they have a cough or a cold rather than a new doctor,’ he added.
Dr Selvarajah said he is not aware of a similar plan in his own ICB area, North East London, but that most ICBs will be looking at implementing the model since it is part of the influential Fuller stocktake.
However, Londonwide LMCs has pointed out that the Fuller stocktake ‘does not mandate this model as the necessary solution’ to same-day demand, and indeed promotes a ‘personalised care approach’.
Professor Azeem Majeed, head of the department of primary care and public health at Imperial College London, told Pulse he is ‘not a supporter of the hub model’.
He said: ‘I see it as a short-term solution to primary care workload and staffing problems; but which in the longer term results in fragmentation of service delivery and a loss of continuity of care.
‘Internationally-supported models of primary care – such as those endorsed by the World Health Organisation – emphasise the importance of a holistic approach to delivery of primary healthcare services, the promotion of continuity of care, and primary care providing comprehensive health services for all sections of the population and for prevention and the management of acute and long-term conditions.’
Director of primary care at the ICB Javina Sehgal told Pulse that ‘conversations are happening’ with LMCs and that the ICB hopes people will see the model ‘as intended’.
But she said the enhanced services single offer will continue because it ‘actually safeguards income for general practice’ and they ‘wouldn’t want to jeopardise that’.
‘The access element is part of the single offer, and has always been part of the single offer,’ Ms Sehgal added.
She also told Pulse that the ICB is ‘working in an open and transparent way’ and that the proposals ‘haven’t just come out of anywhere’ but are a ‘culmination of five years’ work’.
‘We’re very proud of what we’re doing. This is very innovative work, we need to be brave. At the end of the day, change is difficult, but in the end it will be for the benefit of everybody.’
Meanwhile, patients have also raised serious concerns with NWL’s plans to roll out same-day access hubs as part of the enhanced services single offer.
In a letter seen by Pulse, Brent Patient Voice chair Robin Sharp told the ICB CEO Rob Hurd that the initial pilot had sparked ‘surprise and dismay’ due to its potential to ‘undermine the patient/doctor relationship’.
Mr Sharp continued: ‘Our dismay has turned to alarm in that we have just learned from a package sent to PCN Clinical Directors on 29 January that this initiative involving a plan from KPMG consultants radically affecting how all patients in NW London (over 2 million people) will (or will not) be able to access their GP from 1 April onwards is being driven through without public scrutiny.’
He also said their local GP practices did not seem to know about the proposals, and that among patients, there will be ‘active opposition to this fundamental and precipitate change’ to general practice.
In response to concerns about the lack of consultation, Dr Vijay Tailor, a GP and ICB borough medical director, told Pulse that there has been a ‘lengthy consultation’ on the future of primary care ‘in general’.
He said: ‘When NWL decided to offer an enhanced services single offer, access was always part of it. We made that decision right from the outset three years ago. […] And every practice, every GP, every PCN in NWL had been aware of that right from the outset.’
When asked about the potential impact on continuity of care, Dr Tailor said it is an ‘essential component’ of how they deliver general practice, and that it has started to ‘break down’ and ‘erode’ over recent years.
He told Pulse: ‘The low complexity, same-day activity is for those individuals who have a single, episodic, reactive presentation which has a definitive end point that requires an intervention from a clinician to manage.
‘They don’t require continuity of care for that single episode. They may require continuity of care for other parts of their care that they receive, which will continue at their own practice who knows that patient best.’
The proposed hubs will bring together single or groups of PCNs into a hub which is located at one of the member practices and staffed with ARRS staff as well as at least one GP who will hold overall clinical responsibility.
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.
In January, Pulse reported that NWL ICB, among others, had paid for management consultants to help design GP strategies and improve access.