These measures call on NHSE/I (NHS England and NHS Improvement) and Government as we move into a second wave of the COVID-19 pandemic. As well as during the biggest flu programme ever delivered and on top of on-going workload and workforce pressures.
Our proposals are based on the Government’s ‘protecting the NHS to save lives’ campaign; and learning the lessons from the first wave. As well as what we’ve learnt from colleagues elsewhere.
Demand has increased
Practices have, as directed by NHSE/I in the phase 2 and phase 3 letters, increased their services to patients and therefore patient demand has increased.
Practices are also seeing increasing demand and workload from elsewhere in the NHS where services remain limited. The environment in which practices work is much changed from the norm, often with reduced staffing levels due to isolation and lack of access to testing.
Financial support from NHSE/I and government has been insufficient and has now ceased
Alongside this, the income protection and funding to cover practices’ additional costs, has not been sufficiently broad to fully cover all costs, and were only provided until 31 July 2020, with some, for example directed enhanced services, ending before that date, but only one measure (funding for additional capacity to assist care homes) being carried on past that date.
The additional costs for practices have continued beyond August, therefore impacting other services, and will undoubtedly increase again throughout the coming months.
As a result of these issues, as well as the changing government messaging around COVID-19, patient expectations are much increased and are often unable to be matched by what practices are realistically able to deliver.
Practices are reporting that they do not have the capacity to undertake all the work NHSE/I requires of them, on top of managing patients during this difficult period, while also managing system change and dealing with the fallout of other services not being available to patients.
This is the current situation and the starting point as we move into the second wave.
Practices and LMCs (local medical committees) across England are telling us that they will not be able to cope with a second wave (especially if this is worse than the initial wave) unless measures are put in place to support them, reduce their workload and reprioritise services.
It’s essential therefore that practices are provided with the resource and support they need as a matter of urgency.
Measures that must be taken
We have set out below a series of measures. This is in order for general practice to be supported to deliver the necessary services to patients and to protect those working within general practice.
These measures broadly fall into four categories:
- support for general practice workforce
- resources to support practices
- augmenting services to support patients
- minimising the impact from elsewhere.
We believe these measures would reduce risk to patients, to general practice and to other parts of the NHS, while protecting practices and patients.
These measures will be required until at least the end March 2021, possibly beyond, but will require flexibility to expand or reduce as the situation changes.
Support for general practice workforce
- NHSE/I and CCGs (clinical commissioning groups) must provide occupational health services to practices and staff, including locum GPs and GP trainees, or provide the funding for occupational health services to be accessed by these groups.
- Financial and non-financial support must be provided to practices to implement adjustments required following the outcomes of risk assessments of their staff members including adjustments for locum GPs and GP trainees. This is something which NHSEI has required practices to undertake but for which they have received little to no support.
- NHSE/I and DHSC (Department of Health and Social Care) must increase and prioritise access to COVID-19 swab tests for all NHS staff and their families.
- Going forward all PPE must be provided to practices without cost, and practices must be able to recoup the costs of any appropriate PPE already purchased throughout the pandemic period.
- NHSE/I must ensure all healthcare workers providing care through the CCAS (COVID Clinical Assessment Service), have appropriate terms and conditions.
- We must see continued cessation of all routine practice inspection by CQC (Care Quality Commission), halting the introduction of its Transitional Regulatory Approach for general practice and re-establishing its Emergency Support Framework so that practices can continue to fully focus on providing direct patient care.
- The new supportive framework for appraisals due to be implemented from October should be implemented such that those who don’t have capacity to undertake it can defer until next year.
- New emergency laws must be introduced to protect healthcare professionals from medicolegal disputes and investigations from their employer, regulator or the criminal justice system, for difficult clinical decisions made in good faith during the pandemic period.
- GP trainees working in primary care setting must not be redeployed into secondary care settings – to do so would impact on the training and experience of GP trainees as well as removing this resource required in primary care.
- GP trainees and GP trainers require flexibility over this period to make adjustments that work for training and service delivery purposes, including flexibility around the timing and delivery of assessments, including AKT (applied knowledge test) and RCA (recorded consultation assessment).
- Mandatory training requirements (for example basic life support, safeguarding) for all GPs and practice staff, must either be eased or be made available online or remotely.
- NHSE/I and CCGs must provide access for all appropriate practice staff, including locum GPs, to laptops and remote working solutions, as well as to VDI licences so that they can provide care to patients in a safe way.
- All healthcare workers must be provided with death in service benefits in line with the measures of the NHS pension scheme, as a security measure for those who are putting themselves at risk to work on the front line, providing services to patients.
- The government must provide support for staff who contract COVID (adjusted sickness provisions that do not affect usual sickness provision) and for those with long-term ongoing health concerns as a result of COVID.
Practices and PCNs (primary care networks) need complete flexibility to ensure they have the workforce they require to deliver services during this period.
The ARRS (additional roles reimbursement scheme) and PCN development funding must be permitted, for this period, to be spent on any staff requirements, as decided by the PCN and practices, including those not within the current scope of the ARRS.
This would provide support to practices without needing to increase the cost for the NHS, and would minimise any underspend of the existing funding.
Support for sessional GPs
Locum GPs should be prioritised to provide additional support to practices, as well as to the CCAS and NHS111, with protection against cancelled sessions.
Locum GPs income must be assured/protected so that these important members of the general practice workforce are protected in the same way as others have been protected through the furlough scheme, and so they are not lost to private providers.
A national locum-practice matching system would provide additional capacity for all practices that require it, thereby addressing the increased demand from patients while also ensuring practices’ existing staff are not overworked.
Resources to support practices
All practice income related to the provision of NHS services, including community contracts and ‘any qualified provider’ initiatives, must be protected.
- National core and non-core funding.
- Local funding from CCGs (local enhanced services/local incentive schemes and any other funding).
- Other sources (eg local authorities). This was very variable previously, but a clearer national direction is needed so that activities such as NHS health checks are stopped with income protection based on historic activity.
All additional costs must be covered, with the COVID support fund being extended in full to the end of March 2021.
The COVID support fund should also be expanded to ensure all additional costs will be covered (eg additional telephony costs, more stringent and more frequent cleaning regimes).
NHSE/I must be clear with CCGs that they must be as flexible as possible, to permit all legitimate additional costs.
These provisions at national and local level should recommence from the date they expired previously.
Premises and equipment
Provision of, or reimbursement for, equipment and infrastructure – including:
- medical equipment
- telephony systems
- other equipment required to facilitated home working and working in different settings, for example hubs, both hardware and software, and licences.
Funding for (major or minor) structural changes to premises, made available with minimum bureaucracy, to facilitate better patient flow and to implement social distancing measure further.
There must be increased guidance for premises on social distancing and infection prevention and control, along with the funding associated with implementing these.
Practice must have easy access to, and funding for, additional space within premises to enable them to provide their services in a safe way.
Augmented services to support practices and patients
Support for those shielding and in vulnerable groups
We must have clarity over how shielding/vulnerable groups will continue to be supported. This includes support for carers, home visiting and medicines delivery. We must ensure measures are in place to offset any workload impact of this for general practice and other patients.
Reduction in contractual requirements
While clinical services will always be provided to patients who need them (whether face to face or via virtual means), other contractual requirements must be deprioritised, for example proactive invitations for annual health check, reporting requirements. The requirements that were previously deprioritised must continue to be so until the end of March 2021 to free up GP and practice time so they can concentrate on the patients most in need.
Local quality schemes should be flexible and focused on cohorting of patients during COVID.
The services provided to care homes as part of the PCN DES from October onward should continue, to protect those that are most vulnerable, but the remaining two service specifications must be suspended, with practices and PCNs to make clinical and professional judgements about prioritisation of patients and services to patients.
Suspension of QOF (quality and outcomes framework)
QOF should be suspended with funding fully protected, while practices continue to prioritise patients in the most clinically appropriate way.
Extend the reduction of bureaucratic processes
During the first wave, practices saw a reduction in bureaucratic processes, for example reports and letters, being deprioritised. This should be extended for the second wave.
Providing care in a different way
NHSE/I and CCGs must support practices and sessional GPs to utilise digital triage and remote consultation processes (including ongoing funding for tools such as AccuRx).
NHSE/I and CCGs must provide resource for a flexible approach, including hot/cold sites, hub working and a home visiting service (as agreed and commissioned locally), with continued provision of face to face appointments where clinically appropriate.
Expanding CCCAS will assist general practice, and data/system updates should be made available at national, regional and local level to inform practices and other parts of the system.
Direct booking reduction
DHSC must reduce the number of appointments reserved for direct booking from NHS111 and CCAS into practices; these have not been used in full throughout the pandemic, and are potentially making access worse, impacting the provision of services to other patients presenting direct to practices.
Exceeding capacity safety measures
Practices must have a safety net for when capacity is exceeded in general practice, with the ability for practices to direct patients to elsewhere in the NHS, for example COVID related calls directed to CCAS, appropriate transfer to pharmacy, in the same way as NHS 111. These safety nets must be locally led, and agreed by local leaders.
Minimising impact from elsewhere
National and local systems working together
We must ensure that local and national systems work together to find mutually beneficial solutions to some of the problems being experienced, particularly the impact on each other due to not being able to operate in the usual way.
Urgent solutions must be backed with additional resources to follow any increased activity where it is redirected from elsewhere in the system.
Community diagnostic hubs
Introducing, and funding, community diagnostic hubs, which all parts of the system can rely on to provide investigations, would ease pressure in both primary and secondary care, and provide a clear and more convenient pathway of care for patients.
Staffing of these hubs must not detract from current services. Any redeployment to a hub is optional and should be conducted with full engagement of the healthcare workers that would staff them.
NHSEI must ensure all parts of the NHS are supported to deliver their contractual responsibilities. NHS providers must be held accountable for the duties they are contractually and legally required to carry out. Providers must find alternative ways of delivering care rather than transferring these responsibilities to other parts of the NHS, with additional funding provided where required for this.
NHSE/I initiatives must be suspended
NHSE/I initiatives, such as the planned contract disaggregation for digital first provision, must be suspended.
At this time, systems and those working for the NHS must focus on the situation at hand, and will not be able to engage with these reforms if pursued currently; equally these reforms will not be able to be implemented in the middle of a pandemic or in the recovery period.
COVID vaccination campaign clarity
Clarity is needed about how a COVID vaccination campaign would operate, and whether this might fall to general practice – and if so, what other workload would be removed, and what resource/support will be provided, to allow for this.
Whatever changes are made at local and national level, clear communications will be needed to ensure the public understands the pressures and changes that have been made to deal with the situation, with clear guidance about what they can do to ease pressure on general practice.
We believe these measures, learning the lessons of the last six months, and set in place at least until the end of March 2021, would support general practice to continue to deliver appropriate care to patients, while easing pressures and ensuring the workforce are protected during the second wave of the pandemic.
Looking to April 2021 and beyond, general practice and the wider NHS will need a sustained period of stability with minimal contractual change. This is to allow the system and staff to recover from arguably the busiest and most stressful year of sustained pressure that the NHS has ever seen.