On arrival at Dr Agnelo Fernandes’ surgery in Thornton Heath, south-east London, your eyes are drawn to the poster imploring patients to consider whether they really do need to attend A&E. The prominence of the poster is apt, as Dr Fernandes is perhaps the most influential GP in terms of the future direction of urgent and emergency care in the NHS in England.
Pulse met the RCGP’s lead on urgent care one year after the launch of the NHS 111 service, which was beset with problems, including patients having to wait hours for a call back and call abandonment rates in excess of 40% in some areas. Not surprisingly, since Dr Fernandes was one of the architects of the pathway used by NHS 111 call-handlers, he is anxious to present a more positive view of the service.
He says the problems in the North-West and the west Midlands – where NHS Direct gave up its NHS 111 contracts last year when they became financially unsustainable – has meant ‘a lot of people’s judgement is clouded about the service’.
He adds: ‘We need to move away from anecdote to facts. The facts at the moment are that there is nothing in the system that suggests NHS 111 is having an adverse effect. In fact, in many areas it is having a positive effect in terms of their urgent and emergency care strategy.’
Croydon is one of these areas, Dr Fernandes notes with pride. He is keen to emphasise that NHS Croydon CCG – where he is assistant clinical chair – has seen a reduction in activity at the urgent care centre situated in the Croydon University Hospital. At the same time, emergency department attendance has remained flat, while GP out-of-hours activity has fallen by 50% in two years.
NHS 111 progress
The CCG integrated NHS 111 into its urgent care system by launching it in April 2012 at the same time as procuring a new out-of-hours provider and establishing the urgent care centre.
He credits this approach with the success of the helpline in his area.
‘First, it is the initial point of contact for out-of-hours services. Second, we are using the original model, with call-handlers using NHS Pathways, with
a directory of services that is configured to ensure that out of hours is an option if patients want to see a GP.
‘Third, if a patient needs to see a GP, they are booked in directly by NHS 111, and if they need a home visit, they are booked directly in.’
Outside of NHS England, Dr Fernandes was almost a lone voice defending NHS 111 last year. Now, he confidently asserts that the service has been gradually improving.
For instance, the unwieldy nine-page call summaries previously sent to GP practices if one of their patients had called NHS 111 were revised just before Christmas last year. Dr Fernandes regards the updated version as an improvement, even though GPC still dismisses them as ‘useless’.
He says: ‘In areas that upgraded their Adastra IT systems, it should not really be an issue. I’m not coming across that as an issue on a pan-London basis.’
Dr Fernandes does not hesitate to speak his mind, and he made a highly effective defence of GPs last year when he challenged claims by health secretary Jeremy Hunt that the 2004 GP contract – which removed out-of-hours responsibility from GPs – was responsible for an increase in attendances at A&E departments.
We meet the day after the Prime Minister announced the successful bidders for the £50m ‘Challenge Fund’ to test seven-day GP access across the country. David Cameron originally indicated that this would help relieve the burden on A&E departments, although the emphasis later turned to the familiar Government mantra of ‘supporting hard-working families’.
While Dr Fernandes is happy to promote the RCGP line that any new funding for GPs is welcome, he is also keen to keep the pressure on the Government, stressing it is unlikely that wider GP access will relieve the situation in A&E departments. ‘The proportion of people who try to contact their GP before they go to A&E is actually very small,’ he says.
He points to factors that are far more relevant to improving urgent care. Chief among them are increasing the number of A&E consultants and removing the four-hour target, which compels A&E departments to admit patients needlessly thereby disrupting the flow of patients.
Dr Fernandes also highlights patient confusion surrounding the various emergency services available.
He says: ‘You have A&Es, urgent care centres, minor injuries units, walk-in centres, Darzi centres… not everyone knows which of these are in their local area, or what services they provide.
‘The majority of people use emergency services infrequently and the majority of people who are well generally do not use the health service much at all. So when they do have call to use the health service they know three things: 999, A&E and their GP.’
This puts pressure on emergency services as patients tend to migrate to the places they know best, he says.
But Dr Fernandes is clear that the performance of general practice in managing demand goes a long way to explaining why emergency attendance hasn’t gone up as much as it could have: ‘The demand is going up and resources in general practice are going down, so that is probably the biggest crisis at the moment.’
This good performance extends to out-of-hours services but these have to contend with even greater scrutiny than in-hours care, Dr Fernandes says.
‘GP out-of-hours services are probably the most micromanaged and monitored part of the NHS.’ Their consistent quality, he says, ‘is a testament to out-of-hours services rising to the challenge against all the negative press that it has had’.
Is there a crisis in urgent care?
It depends on what you describe as a crisis. We have an issue with A&E departments meeting the four-hour targets and with patients waiting too long in A&E. However, the issue is not increased numbers going to A&E – it is more about the flow in hospitals.
What should NHS England do with NHS 111?
We have to learn the lessons of NHS Direct. When it was a localised service, there was local ownership. When it got bigger, the local ownership was lost. When it became national, the local ownership was almost all gone.
Is the Government right to focus on GP access?
Access is a part of the solution but not the whole solution. The recent tranche of money has shown that GPs are interested in being innovative, finding solutions, working differently. It is a testament to how GPs inherently want to improve care and access. CCGs spent just 7% of winter funding on primary care.
Is this right?
If they just wanted to meet A&E targets, then the bulk of the money would have gone to secondary care. If they understood their urgent care system better, they would have spent it more appropriately in different parts of the system.
Propping up hospitals
Dr Fernandes is also a key adviser for the ongoing review into emergency care at NHS England, led by NHS medical director Professor Sir Bruce Keogh, and he is critical of the way the NHS funding system is used to prop up hospitals.
He says: ‘[The reason] is quite simple – part of spending money is that you have to understand the urgent and emergency care system.
‘If you don’t understand the issues about patient flow, you are going to spend it in the way that is not most effective, but will help you meet the targets. If you want sustainable change, you have to invest much more in general practice.’
On the whole, though, Dr Fernandes believes NHS England is moving in the right direction on urgent care. Sir Bruce’s review last year concluded that GPs should offer more same-day phone consultations and that A&E departments should be rebranded as ‘emergency centres’.
He says: ‘I’ve been involved in reviews for the past 20 years. What is different this time round is there is a genuine interest in terms of delivery. The NHS is full of strategies, but we are not very good at delivery.’
But he is clear that the only way out of the current stresses on the system are for local commissioners to seize hold of the issue immediately: ‘CCGs have to sort things now.’
Married with two children
Qualified in 1987 from Charing Cross and Westminster Medical School
GP at Parchmore Medical Centre, Thornton Heath, south-east London
1990-present: Out-of-hours GP
2003-present: Educational supervisor for out-of-hours trainees
RCGP lead on urgent care
2012-present: Assistant clinical chair of NHS Croydon CCG/shadow CCG
Being awarded an MBE in 2004 for services to medicine and healthcare
Playing and watching tennis; travel