This paper highlights the significant clinical and organisational challenges as GP practices restore core services to their patients. It argues that premature implementation of enhanced services will divert the resources and effort required to re-establish those core services and therefore should not take place until April 2021 at the earliest. It proposes that funding potentially available for existing schemes should instead be utilised as part of the support funding package necessary to restore those core primary care services safely and effectively.
The proposals have been produced by a special working group established by the Waltham Forest Tri-PCN Alliance and are designed to assist current planning.
Tri-PCN Alliance is a collaboration of three Waltham Forest primary care networks – Walthamstow West, Walthamstow Central, Forest 8 – who work together to share support and best practice to deliver the best possible quality services for over 130,000 Waltham Forest residents.
Re-setting primary care in Waltham Forest – Introduction
Great Britain ‘locked down’ to manage the threat of Covid-19 on 23 March 2020.
In the wake of the first Covid-19 lockdown, there are now expected to be waves of Covid-19 and continuing Covid-19 related illness in patients.
We believe that that current plans for ‘resetting General Practice’ miss key concerns that must be included in work being done on recovery.
Restoring resilient NHS services will need to be multi-faced, multi-agency and will rely on effective primary care delivery to get services right for the community. We know there is a backlog as in effect many acute services were put on hold including elective surgery and physicians’ appointments bar oncology. It is only now that primary care networks are recognising the scale of new work emerging for the ‘post Covid-19 project’ ahead of us. (For example: the additional levels of Acute Kidney Injury (AKI) and renal monitoring that will be required. The impact of scarring of the lungs and post-operative complications of Covid-19 are also now being realised as patients are discharged into the community.)
We recognise and support the need to restore services to patients as soon as possible. Our PCNs are dedicated to doing their utmost to deliver this. But we believe that any approach based on the priorities of minimising further Covid-19 outbreaks to save lives, and patient clinical need must first ensure core services are properly put back in place and demonstrated to function properly within a Covid-19 aware environment.
Without applying sufficient resources to support general practice to fully restore these core services, which requires deferment of extraneous work like PCN Directed Enhanced Services (DES) until at least April 2021, there is a real possibility that primary care could destabilise, putting already vulnerable patients at further and unnecessary risk.
Our warning may seem stark, but it is a measure of the concern we have for general practice and our patients and our belief that only when core services have been properly re-embedded and tested that desirable quality enhancements can then be delivered.
Understanding the immediate challenge We have categorised our areas of concern into short term and long term:
Short Term (6-9 months): Restoring disrupted essential services
The ending of remote working will reveal a tsunami of ‘catch up’ practice workload including:
1. A huge surge in patient demand for support and appointments as lock down is lifted.
2. A tsunami of practice workload
3. Essential service catch up – The update and resumption of services that have been put on hold because of Covid-19 outbreak, such as cancer care monitoring presently being carried out remotely, mental health support, immunisations and routine cervical cytology. For example –
a. Cervical Cytology was cancelled even in primary care and GPs were advised to only consider high risk cases.
b. Hospital Colposcopy services ceased with Covid-19.
c. Radiology, outpatients and other diagnostics appointments delayed or cancelled by hospitals adding a re-referral workload.
4. Safety-netting of patients, who may have been missed via the initial referral to secondary care from primary care.
5. Additional Referral workload, where referrals have been pushed back into or managed in the community to ease acute congestion.
6. Need for longer consultations to deal with accumulated problems.
7. Enormous backlog of CCG, CQRS, contractual and other institutional forms (such as fostering and disability), returns and other information requirements.
Additional Covid-related work pressures
The existence of Covid-19 and the importance of preventing future surges will require significant additional and wide-ranging changes in practice requiring additional input including:
1. Updating systems and processes within practices including social distancing, premises modifications and the time-tabling of consultations. This need alone will create a multitude of actions and costs.
2. Tsunami of workload responding to changing demands from CCG, NHSE and other PCN/practice related agencies and authorities to meet Covid-19 testing logistics and relay and interpretation of results.
3. Significant additional work managing mental health and post Covid-19 syndrome issues: The Royal College of Psychiatrists has already predicted a surge in mental health problems. In a London Borough we anticipate practices seeing a major surge in Covid-related mental health issues, including:
a. Psychological aspects of Covid-19 infection and post Covid-19 medical syndrome requiring change of lifestyle, referral and treatments.
b. Mental health issues for family units who have
i. suffered directly due to Covid-19 and post Covid-19 infection syndrome.
ii. Experienced unemployment of family members and financial crises in the home.
iii. Experienced death of family members due to Covid-19 with the enormous psychological overlay of such family events, particularly the inability to say goodbye to close relatives and to attend family funerals.
c. Survivors with new disabilities.
d. Psychological impact of lockdown on families and individuals causing anxiety and depression.
e. Monitoring and assessing other lockdown impacts including domestic violence
4. Chronic disease management: All aspect of chronic disease management will need to be enhanced to accommodate additional Covid-19 risks including appointment and contact modifications.
5. Covid-19 exposure systemic monitoring team: We anticipate ‘teams’ of primary care staff and community staff will be required to manage the community aspect of post Covid-19 infection management in areas such as renal function, lung function. There may also be other systemic checks that will take up a yet un-estimated amount of time
6. Testing and immunisation: Antigen and antibody testing capacity and the need for discussing results with patients. Uncertainty of the tests and their interpretation will require a vast amount of primary care capacity.
7. Immunisation programmes including any Covid-19 vaccination will have increased importance. In particular immunisation decliners will now need to be chased vigorously requiring greater administrative and nursing capacity
8. PPE – Ensuring appropriate access to and provision of PPE to protect staff and patients is vital. The need for hand gel, gloves, masks, eye protection, PPE is over and beyond the capacity required in regular GP work. Other work required will include:
a. Cleaning of GP premises: This will need to be stepped up, with deep cleans as required necessary.
b. Long term adaptations to practice premises: Alteration of waiting areas, distanced seating, Perspex screens for reception staff.
c. Other toileting modifications and cleaning strategy. Creating a safe work environment.
d. The extra demand must be met by the DOH and NHS suppliers providing this equipment of the correct standard through the NHS supplies ordering systems.
9. BAME staff and patient management and protection. Protection of all staff is crucial but additional support and provision may be required to meet any additional risks identified for BAME staff, clinicians and patients. More generally provision will need to be adapted to reflect known levels of Covid-19 risk.
10. Respecting the memory of those who lost their lives in the fight against Covid-19. Almost all GP practices have medical staff of all grades on their patient lists who will need the very best level of support possible, not least to ensure that the memory of those NHS and key workers who lost their lives is acknowledged and respected.
Short term funding and financial considerations
Additional estimated minimum funding need projections:
To accommodate the short term challenge we believe practices will need to concentrate their resources for at least the rest of this financial year on restoring and re-organising their essential services. To manage the immediate demands, we anticipate additional interim support for a minimum of three months and most likely a longer period will be necessary.
Our assessment is that an average practice will require the following additional resources to deal with additional post-Covid-19 demand and workload outlined briefly above
- 1.5 GP locums (or 3 sessions per day)
- Practice nurse – 20 hours per week
- Healthcare assistant – 20 hours per week
- Additional time practice manager- 15 hours per week
- Admin staff – 25 hours per week
Estimated additional cost per week = £5,875
The above additional manpower will be needed for at least 13 weeks at a cost of £76,375. Depending upon the progress, half of the above manpower may be required for a further period of up to 6 weeks at the additional cost of £17,675.
We estimate that the additional short term requirement could amount to £15 or more pounds per patient.
While PCNs will work with practices, other PCNs and other providers to share resources and minimise costs we believe this assessment may be optimistic given the overall scale of the work.
Funding the requirement
PCN DES – In view of the clear priorities to prevent a second Covid-19 spike, manage urgent clinical need and restore core practice services it will be practically impossible to undertake any PCN DES related tasks in this financial year. We strongly advocate that all the DES and LES implementation must be deferred to at least until 01/04/2021.
The 2020/21 funding that would have supported these programmes should be allocated to PCNs to support the additional staff requirements outlined above.
ARRS – Similarly the 2020/21 underspend on the Additional Roles Scheme (ARRS) should also support the interim workforce need. Where possible Additional Roles could and should form part of managing the additional workload.
Over the longer term this advisory group believes we will need additional funding above and beyond that available from other initiatives already in place to ease the financial pressures from general practice. Top slicing existing scheme budgets or delaying the onset of the initiatives beyond March 2021 simply defers the financial challenge to a later date while making the scheme improvements intended undeliverable.
Additionally, we would recommend a separate immediate fund to support a short term programme of works to enable practices, working with the STP Estates Team to speedily put in place improvements such as screens, signage and seating to facilitate daily practice working in a post-Covid-19 environment. This would assist in meeting the challenge outlined in Point 8 listed above.
The longer term (9 months+)
We believe the measures and funding sources outlined above will assist in meeting immediate challenges and re-setting the core practice services. But it is vital that longer term impacts are also acknowledged. These include:
1. Truly collaborative models of care need to be in place. Tri-PCN Alliance will be shortly producing a separate proposal on this subject.
2. ‘Back with basics’: Overall the priority for general practice should be with chronic disease management, cancer care, diagnosis and referral, immunisations and cervical cytology. We need to re-provide these core services fully effectively in the first place. All other target led activity should be placed for the next phase of reset.
3. Setting up of new clinics, facilitating a new way of working with social distancing, recognising this could prolong the patient journey and require new levels of patience on the part of anxious patients.
4. PPE: Funding the additional long term need for enhanced PPE outlined above will be essential. The extra demand must be met by the DOH and NHS suppliers providing this equipment at the necessary standard and reliability of access through the NHS supplies ordering systems.
5. IT upgrades and specification to keep in step with patient demand management, with different modes of consultation.
6. A separate fund for contingency management of staff sickness -Access to interim funding needs to be in place to ensure rapid access to extra and replacement staff where spikes in need or staff sickness occur.
7. Enhanced carer support: There is additional medical, psychiatric and psychology need for carers to manage Covid-19 exposure risk in their patient care.
8. Impacts of extended acute waiting list times. These will be longer than before. Extra administration resource will be required to deal with the referral review process.
9. Patient education: A major education programme, much like the national campaign about virus warnings is suggested as necessary to explain the back-log, disruptions and the reasons for the slow reset required and needed for all tiers of services within the NHS.
10. Building patient ownership and participation. A truly meaningful relationship is needed with local patients, where patients take ownership of their medical conditions and affect change. The mindset of ‘no news is good news’ must change. Patients who are able and have the tools must diarise a review of their conditions so that it is owned. Evidence indicates that to secure this behaviour change will be take time and resource.
11. CQC inspection approach and timetable: Whilst all GPs value the work of the CQC in encouraging quality, a very light touch review would be beneficial while the re-setting process in under way. This must be ‘a light touch’ that does not onerously take the lead clinician and lead practice manager away from their stations. Commencement of visits should take place only after the Covid-19 crisis is well and truly behind us. Ideally a year’s notice should be given after the crisis is over.
Tri PCN Alliance affirms the importance, post-Covid-19 of re-setting primary care and getting GP practices working to provide essential core services as quickly as possible.
However, based on its working group review it believes the scale of the challenges to be overcome is substantial and that even without taking a second surge and a worse than average flu cycle into account, it is likely to take the rest of the year as a minimum to put sustainably in place.
To achieve even this deadline additional workforce and premises resources will be required, with an overall additional spend of at least £15 per patient over the rest of the financial year.
Seeking to implement DES/LES and other schemes as originally planned prior to Covid-19 will be unlikely to succeed but will, by diverting resources and effort, undermine the core reset process, undermining NHS priorities and increasing risk to patients.
Deferring implementation of these schemes will assist the re-set process but will also enable some of the funding requirement to be provided in the short term, reducing the need for additional central emergency funding. It will also provide the necessary opportunity to develop the planning and funding of the additional measures required to meet the longer term impacts of Covid-19 on general practices and primary care more broadly.
The Tri-PCN Alliance therefore strongly recommends:
- The proposed DES/LES Schemes should be deferred to April 2021 at the earliest, releasing the funding for core service reset interim support
- That Commissioners should outline how they will work with PCNs and other primary care providers to quantify and acknowledge the challenges, and promote planning that addresses the key risks in a funded flexible and locally sensitive manner.
- That Commissioners support PCNs to develop longer term collaborative plans with their Integrated Care Systems such that primary care continues to be a key and fully integrated component of a sustainable and resilient health and social care system.
Dr Abdul Q Sheikh, chair, Tri-PCN Alliance – firstname.lastname@example.org
Dr Sanjoy Kumar, vice chair, Tri-PCN Alliance, and clinical director, Forest 8 PCN – email@example.com
Dr Naheed Khan-Lodhi, vice chair, Tri-PCN Alliance, and clinical director, Walthamstow West PCN – firstname.lastname@example.org
Dr Rishav Dhital, vice chair, Tri-PCN Alliance, and clinical director, Walthamstow Central PCN – email@example.com