Brighton and Hove HOSC Primary Care Briefing
General Practice
Introduction
As of 1 February 2023, there are 31 GP Practices in Brighton and Hove, delivering services across 39 locations (including eight branch surgeries) for a practice population of 331,831.
Practices are typically owned and managed by an individual GP or group of GPs, or sometimes alternative providers, who hold a contract to provide services to the NHS.
The General Medical Services (GMS) contract does not set absolute requirements on access to services but does require Practices to provide routine services within core hours (Monday – Friday 8:00am till 6:30pm excluding bank holidays). Out-of-hours care is usually provided through separate contracts with other providers, although some Practices do offer this themselves.
Practices regularly work with Primary Care Support England (PCSE) to ensure that their patient lists are as up to date and as accurate as possible. This is particularly relevant for practices such as the University of Sussex, as the patient cohorts are subject to regular change.
In terms of patient care, GP practices are required to provide essential medical services to people registered with them between 8:00am and 6:30pm Monday to Friday.
In Brighton, a walk-in centre is also available to both registered and non-registered residents from Brighton and Hove based at Aspect House by Brighton Train Station. It offers treatment, information, and advice for a range of minor illnesses and injuries and is open seven days a week from 8am to 8pm, including Bank Holidays. The walk-in centre is available to people who are registered with a GP practice in addition to those who are not. It is a particularly useful resource for people who have a health need but may not be able to access their own practice for a variety of reasons, such as people travelling to and from the city and students who may be residing in the city during termtime but are still registered at their home.
Appointments in General Practice
The total volume of appointments in the 31 Practices across Brighton and Hove averaged 130,000 for the first nine months of 2022-23, and per 1000 population is consistently below the Southeast regional and National average. In December 2022 on average 42.8% of appointments took place on the same day as booking, 16.5% within two to seven days, and 13.9% within 8 to 14 days. Both latter percentages are higher than the National average. 63.9% of these appointments were held face to face at the surgery or as a home visit.
Appointment data is published by NHS Digital, and although still experimental and non-standardised, it gives NHS Sussex an indication of performance against this trajectory utilising a consistent methodology. The number of appointments now exceeds those offered in 2019, before the pandemic, as illustrated in table one:
Table One: total number of GP appointments in Brighton and Hove April 2019 to March 2023
Source. NHS Digital, available at https://digital.nhs.uk/data-and-information/publications/statistical/appointments-in-general-practice/december-2022
To ensure that practice lists are as accurate as possible, practices regularly work with Primary Care Support England (PCSE) to make sure that the people on the lists reflect the population living in the area. This is especially important for practices where there may be a high turnover of people living in the area and registering with a practice, then moving on within a short period of time, such as areas around a university for example. In these situations, the practices work with PCSE to regularly refresh their patient list.
As a response to the winter pressures, particularly Strep A in children, GP practices reported increased demand over the winter period, predominantly from adults and children with respiratory illnesses. The ICB with the support from the federations and general practice set up respiratory hubs across Sussex with the increased demand peaking in December/ early January.
To manage this increased and unexpected demand, a respiratory hub for Brighton and Hove was set up in December 2022 and delivered by a local primary care provider, HERE with the aim of supporting GP practices with the high number of respiratory cases. It is situated at Aspect House which is next to Brighton Station and offers face to face appointments across the week to all practices in Brighton and Hove. The hub enabled practices to direct appropriate children and adults to the service to been seen quickly by a GP or appropriate clinician. As of 2nd February, 260 additional appointments were made available to Brighton patients, booked in through their own GP. The intervention will continue until mid-April then will be evaluated.
Table 2 indicates that the number of appointments per 1000 list size offered in Brighton and Hove during the first nine months of 2022-23
Table 2: Appointments per 1000 list size
|
Appointments Per 1000 List Size |
||||||||||
|
|
||||||||||
|
Apr-22 |
May-22 |
Jun-22 |
Jul-22 |
Aug-22 |
Sep-22 |
Oct-22 |
Nov-22 |
Dec-22 |
|
|
|
Brighton & Hove |
346 |
406 |
373 |
375 |
382 |
401 |
454 |
439 |
374 |
|
|
West Sussex |
396 |
446 |
422 |
420 |
444 |
480 |
531 |
532 |
450 |
|
|
East Sussex |
429 |
492 |
461 |
461 |
469 |
506 |
599 |
562 |
461 |
|
|
Sussex Total |
397 |
453 |
425 |
425 |
440 |
474 |
538 |
525 |
440 |
|
|
South East |
382 |
438 |
411 |
412 |
422 |
449 |
515 |
501 |
429 |
|
|
England |
389 |
448 |
420 |
421 |
429 |
457 |
517 |
504 |
431 |
|
It should be noted that the number of appointments per 1000 list reduced in all areas in December. This is due to the bank holidays, and although figures demonstrate that notable progress has been made in increasing availability of appointments, work continues to drive improvement as detailed below.
Workforce
On 1 December 2022, there were around 147.3 full time equivalent (FTE) doctors employed in GP Practices in Brighton and Hove. General Practitioners (GPs) also work with nurses and other professionals to treat and advise on a range of illnesses, manage patients’ conditions in the community and refer patients for hospital treatment or social care where appropriate.
These other staff groups total a further 85.1 FTE nurses, and 82.6 direct patient contact (DPC) clinicians. Collectively, they are providing care to the c.315, 979 (weighted population) of patients registered at GP Practices in Brighton and Hove.
The Brighton and Hove Primary Care workforce increased by 79.2 FTE (or 11.8%) compared to December 2021. Clinical staff in FTE increased by 15.2%, non-Clinical staff showed a +7.8% change.
A primary care workforce report is produced by the Sussex Training Hub monthly. The tables below show primary care workforce across Brighton and Hove in December 2022 compared to December 2021.
The GP workforce (in FTE) has increased by 1.6% compared to staff levels in December 2021. Since March 2019 (purple line) the GP workforce has increased by 13.5% (17.5 FTE).
The number of GPs in Training Grades has increased by 24.4% (+4.5 FTE) compared to December 2021 staff levels. In Brighton and Hove 15.5% of GPs are GP trainees compared to 25.4% in England.
The Nursing workforce (in FTE) has increased by 1.0% compared to staff levels in December 2021. Since March 2019 (purple line) Nursing staff levels have increased by 3.5% (2.8 FTE).
Direct Patient Care (DPC) staff employed by GP practices has increased by 34.7% compared to December 2021. From March 2019 (purple line) staff levels have increased by 100.4% (40.9 FTE).
The Non-clinical workforce (in FTE) has increased by 7.8% compared to staff levels in December 2021. Since March 2019 (purple line) non-clinical staff levels have increased by 6.0% (19.0 FTE).
GP trainees - to encourage new GPs into the city, the Training Hub team are working with practices in the city to inspire established GPs to become GP trainers. This helps to share the expertise of proven GPs at practice with newly qualified doctors wanting to become GPs and directly benefits the patients. Often GP trainees stay with their practice or within the city when they qualify, thereby expanding the number of GPs in the city.
GP recruitment - most practices that wanted to expand their workforce and employ either salaried GPs or GP Partners have struggled to recruit over the last year. However more recently, several practices have now shared with the ICB that they have successfully recruited or are in the process of recruiting GPs and other clinical staff to their practices. This means that the ratio between GPs and patients at some practices is improving.
The Primary Care Workforce Bank Platform delivered by Brighton and Hove GP Federation went live in January 2023. This platform aims to meet the resilience issues and demands of general practice by providing both clinical and administrative staff towards practices that are experiencing urgent workforce issues. The intention, once the service gets going is to have a repository of staff whereby people from across primary care can deposit their ‘spare’ hours. These will then be drawn on from PCNs and practices that need additional workforce to enable the delivery of specific clinics.
Primary Care Networks (PCNs)
Primary Care Networks (PCNs) were introduced in July 2019 to improve access to primary care and expand the range of services available, through better integration with community services and greater involvement of a wider, integrated primary care team. They are comprised of groups of neighbouring general practices, with additional national funding being made available to employ Additional Roles Reimbursement staff (ARRS) to deliver services to patients across the member practices. PCNs are not statutory bodies in themselves. All practices in Brighton are members of one of the six 6 PCNs (see Annex A for an overview).
PCNs are based on GP registered patient lists, typically serving communities of between 30,000 to 50,000 people. The largest Primary Care Network (PCN) in Brighton and Hove is Goldstone PCN. This is made up of three GP practices and has 78,346 registered patients, followed closely behind by East and Central PCN which is made up of nine practices and has 74, 620 registered patients.
The smallest PCN is Dean’s and Central PCN which has four practices and 27, 722 registered patients. Brighton Station Health Centre will join this PCN on the 3 April 2023, bringing a further 9,948 registered patients into that PCN. Details of each PCN, and their member practices, are shown at Annex A, and PCN maps in Annex B.
PCNs are being actively supported to recruit additional staff, including new GP Assistant and digital and transformation roles, to ensure patients see the right clinician at the right time. To date around 540 FTE “additional roles” have been recruited across Sussex, 103.3 in Brighton and Hove, including Physiotherapists, Physician Associates, Mental Health Practitioners and Social Prescribers.
Enhanced Access
From 1 October 2022, PCNs have been offering a national Enhanced Access service which aims to remove variability by putting in place a more standardised offer for patients. This replaces the Improved Access Service previously commissioned by the CCG and subsequently NHS Sussex. The new service provides appointments between the hours of 6.30pm to 8pm Mondays to Fridays and between 9am and 5pm on Saturdays. There may also be further additional appointment slots available e.g., on Sundays and early mornings on weekdays. Exact arrangements have been informed by patient preferences following engagement by PCNs with their local patient participation groups or other means of patient consultation.
In Brighton and Hove the enhanced access delivers an additional 12,000 minutes or 200 hours of appointments per week beyond core hours, which includes the following:
· a mixture of face-to-face and remote (telephone, video or online) appointments.
· appointments delivered by a multi-disciplinary team of healthcare professionals, including GPs, nurses and other “additional roles” such as mental health practitioners, physician associates, physiotherapists, and Social Prescribers.
· a blend of appointments offered on the same day or pre-booked for a future day.
These flexibilities enable patients to offer targeted interventions in addition to regular appointments, such as specific screening clinics; support for particular patients’ groups such as people experiencing the menopause; and support for the system in times of surge demand, for example in response to the recent surge in respiratory presentations in December and January.
The development of the enhanced access offer across PCNs has provided additional support for practices within the PCNs, and has been provided by HERE since the inception of EA. From April 2023 this offer will move across and be provided by the Brighton and Hove Federation.
Personalised care
Each PCN is producing a personalised care plan. Personalised care is one of the five major, practical changes to the NHS that will take place over the next five years, as set out the recently published Long Term Plan. Working closely with partners, the NHS will roll out personalised care to reach 2.5 million people by 2023/24 and then aim to double that again within a decade.
Personalised care means people have choice and control over the way their care is planned and delivered. It is based on ‘what matters’ to them and their individual strengths and needs. This happens within a system that makes the most of the expertise, capacity and potential of people, families, and communities in delivering better outcomes and experiences. As part of a broader social prescribing service, a PCN and commissioner jointly work with stakeholders including local authority commissioners, voluntary and community partners and local clinical leaders, to design, agree and put in place a targeted programme to proactively offer and improve access to social prescribing to an identified cohort with unmet needs. This plan must take into account views of people with lived experience.
Tackling Neighbourhood Health Inequalities (TNHI)
Following a recent stocktake by the Primary Care Directorate between December 2022 and February 2023 progress has been made to date across Sussex PCNs with some examples highlighted below:
· Chronic Respiratory Disease/Chronic Obstructive Pulmonary Disease (COPD) – Improving awareness and access to available screening services through targeting specific patient cohorts with a view to increasing uptake of screening services and early diagnosis. Example of cohorts targeted include carers, people with long term conditions such as cardiovascular disease, people with mental health conditions and or learning disabilities.
· Early Cancer diagnosis - Increasing uptake of cancer screening programmes and supporting people in accessing services as well as working to address and remove barriers. Example of patient cohorts targeted in this area include those from ethnic minorities, males over 60 years old and those with Learning Disabilities and/or Mental Health conditions as well as carers and those with a high Body Mass Index (BMI).
· Increasing hypertension awareness and monitoring through educational sessions and case finding, aimed at various cohorts of people.
· Annual Health Checks - Increasing engagement and uptake, with targeted support aimed at hard-to-reach groups. For example, rough sleepers, those in temporary accommodation, Asylum Seekers and veterans.
· People who are Housebound - Focusing on housebound patients with long term conditions, or those who struggle to access onsite practice/PCN level services due to poverty and or poor connections.
· Diabetes control - Initiatives aimed at people who are housebound, frail and/or living in Care Homes
All Brighton and Hove PCNs have plans in place for tackling local health inequalities using data sources that range from public health and practice profiles, Joint Strategic Needs Assessments (JSNA), NHS digital data dashboards, GP surveys, voluntary sector feedback, and national Health Inequalities dashboard.
PCNs within Brighton and Hove have reported a range of forms of engagement with their selected population. All the PCNs are effectively engaging with their system partners and local stakeholders, which has helped to achieve a range of successful interventions and initiatives that include: -
· North and Central PCN are effectively using their ARRs (Additional Roles) staff to increase hypertension awareness and involve patients in the ICB BP@Home project as well as increasing engagement with patients with serious mental illness, resulting in an increased number of SMI reviews. Their initiatives have also seen increased engagement between social prescribing link workers and patients with Learning Disabilities, resulting in increased uptake of annual health checks.
· Deans and Central PCN are increasing both quality and uptake of the pneumococcal vaccination programme, as well as expanding education around of hypertension awareness. They have seen an increase of 332 patients on their hypertension register in the past twelve months.
· West Hove PCN are targeting cohorts of people in the most deprived parts of the PCN’s geography, with initiatives focused on chronic respiratory disease, early cancer diagnosis and hypertension. Their initiatives have resulted in improved monitoring and management of blood pressure; increased diagnosis of lung conditions, identifying undiagnosed cancers through targeted lung checks.
Supporting our homeless, migrant and asylum seeker populations
Brighton & Hove has a specialist surgery for patients that are homeless, rough sleeping, in temporary or emergency accommodation, sofa surfing or a traveller. Since 1998 when, in response to rising numbers of people experiencing homelessness in the city, a pioneering health facility in the School Clinic on Morley Street was opened. Arch Health Community Interest Company (CIC) was established to address the health needs of people experiencing homelessness and housing insecurity in the city. In 2016 Arch took over the running of the Morley Street GP surgery and the homeless health engagement service for Brighton & Hove. They are rated ‘outstanding’ across all domains by the Care Quality Commission (CQC) in March 2019. The service has been recently reprocured with the new contract now in place until 2030.
Arch offer a range of innovations for the homeless cohort, including an extended outreach service for people who are hard to reach or are reluctant to leave their belongings and come to the practice building. This enables clinicians to go out to where people are and offer direct medical care, thereby building trust and engaging with this cohort, so reducing the likelihood of exacerbations or conditions going untreated leading to an emergency admission.
Brighton and Hove have several migrant and asylum seeker accommodation locations for people who are living in Brighton and Hove and are not signed up to a GP practice. Several local GP practices have signed up to directly support the residents, enabling them to access primary care services.
In addition to this, across the city there are now seven safe surgeries (Safe Surgeries - Doctors of the World). A Safe Surgery can be any GP practice which commits to taking steps to tackle the barriers faced by many migrants in accessing healthcare. At a minimum, this means the practice declares a ‘Safe Surgery’ for everyone and ensures that lack of ID or proof of address, immigration status or language are not barriers to patient registration. Safe Surgeries recognise the difficulties to healthcare access that exist, particularly for migrants in vulnerable circumstances, and believe that small changes in practice can make a difference. They are willing to lead by example and work to ensure that nobody in their community is excluded.
This report will now go on to outline some key areas of focus that support patients and practices.
Optimising Capacity
From 2023/2024 same day data from GP Practices will be automatically extracted to highlight where there are pressures in the system and offer support as soon as possible to ensure they can continue to meet patient needs. Improved Business Intelligence systems will be commissioned for Practices so they can identify those patients most in need and plan their appointments and workforce rotas accordingly.
Recognising the problems patients have reported having in contacting their Practice, as reported in the patient satisfaction survey, all Practices will be supported to purchase advanced cloud telephony systems which will improve the patient experience, ensuring patients are informed on progress throughout the call and linked with the right healthcare professional. Currently 26 of the 31 GP Practices in Brighton and Hove are now live or going live with the new service and will be live before the end of March. Two practices have been delayed for a variety of reasons, however with the support of NHS England (NHSE) are progressing and are expected to go live by the end of March.
Digital support
The new Integrated Care System will encourage PCNs to integrate more fully with Community/Mental Health providers, Local Pharmacies, Adult Social Care, and the voluntary sector, working together across Brighton and Hove.
NHS Sussex will continue to work with Sussex Healthwatch across all three places, patients, and Practices to codesign website ‘good practice’ templates and offer funding to those Practices whose websites have identified as being the most 'in need of improvement’, based on self-selection, Healthwatch ‘Mystery Shopper’ surveys, and a review by the Digital First team.
We continue to work with our GP Practices to ensure their websites are helpful, easy for patients to navigate and that they support patients to contact and use the practice in the most appropriate way.
Across Sussex 84 practices were offered funding to upgrade their websites – these were chosen by a combination of 1) the lowest scoring on the Healthwatch survey 2) Previously submitted an expression of Interest (EOI) and/or 3) Being in a Core20+5 area.
For Brighton and Hove 11 B&H practices were invited to apply for funding, and 10 practices accepted the offer.
Digitally Excluded Groups will be supported to learn how to better use digital health technologies, but promoting use of the NHS App, online consultations and NHS 111 Online where digital exclusion is recognised issue.
GP - Community Pharmacist Consultation Service (CPCS)
The NHS Community Pharmacist Consultation Service (CPCS) was launched by NHS England on the 29 October 2019, to facilitate patients having a same day appointment with their community pharmacist for minor illness or an urgent supply of a regular medicine, improving access to services and providing more convenient treatment closer to patients’ homes.
The service is helping to alleviate pressure on GP appointments and emergency departments, in addition to harnessing the skills and medicines knowledge of pharmacists. Should the patient need to be escalated or referred to an alternative service, the pharmacist can arrange this.
Currently 26 of the 31 GP Practices in Brighton and Hove are either live with this service or engaging in training to begin.
Additional services provided by the HERE and the Federation to support patients and practices:
Supporting patient flow
Other local improvement projects include the Primary Care redirection service at the front door of the UTC at the Royal County Hospital Trust. This service supports the system by triaging and redirecting appropriate patients that attend the hospital towards a GP service at the front door provided by HERE. This service is particularly flexible at times of high demand such as Brighton Pride and other key events that take place in the city.
Supporting people to access targeted Lung screening
Brighton and Hove and Crawley are the first places in Sussex to take advantage of the Cancer Alliance Targeted Lung Health Checks Programme. The intention of the programme is to pick up patients that are at the early stages of cancer and to liaise with secondary care for the onward treatment of the patient. This means that Brighton and Hove patients are identified and invited forward by letter and supported with a wide variety of resources such as a website setting out details of the programme, including patient and clinician led videos prior to the lung scan which is situated in a mobile unit. The individual patient letters are organised by a partner (InHealth) and any booking queries are managed by them to support general practice and expedite patients. For practices who prefer that all community actionable incidental findings are managed outside the practice, their patients can be directed to HERE in the CT results letters. HERE then support patients with any queries they may have and organise follow-up or clinical support, if required.
Supporting people to receive their covid vaccination
Covid-19 Vaccination clinics– the autumn Covid-19 booster delivery campaign in Brighton and Hove has now concluded and we are now preparing for a Spring booster campaign to commence. As per last spring, the following groups will be eligible for a vaccination:
• adults aged 75 years and over
• residents in a care home for older adults
• individuals aged 5 years and over who are immunosuppressed.
The current delivery model in Brighton and Hove consists of:
· The Racecourse as the main site led by HERE the provider
· Mobile vaccination units deployed to communities facing the greatest challenges in relation to vaccine uptake
· Six community pharmacies in central and outskirts of Brighton
In addition to the above, outreach activity has consistently been an ongoing theme from the start of the vaccination campaigns. The targeted areas were led by local data intelligence from public health partners and NHS data sources. As part ongoing plans to decrease inequity, vaccine champions are actively engaged with the key demographic groups in targeted areas to understand and support local community needs, while highlighting the importance of the vaccinations and address any vaccine hesitancy.
To maximise vaccination uptake in all priority groups and reduce inequalities equity of uptake for all Covid-19 vaccinations, additional equity plans were submitted to the Brighton and Hove Cell for approval, which targeted specific underserved groups for vaccination in Q4 and aimed to drive active communications and engagement initiatives in preparation for the Spring.
Primary care premises improvements
Work continues with Local Authority, NHS organisations, and other partners to invest in premises where primary care services are delivered, to ensure opportunities to improve the capacity and quality of these are maximised. NHS Sussex has a strategy for population support regarding premises, including close working with all Borough, District and City Councils around known or anticipated areas of housing growth, which includes:
· Building new premises at scale and combining with other services where an opportunity arises – for example the new University of Sussex health, and Preston Barracks development.
· Consolidation of premises even if no integration opportunity arises, but the quality, capacity and resilience of services can be improved – for example the rebuild of the St Peter’s Medical Centre.
· Developing existing sites where opportunities arise for extensions, refurbishments, and the conversion of additional rooms into clinical space or offices for staff – for example work with surgeries across Brighton and Hove.
Conclusion
Since the recovery and restoration programme described in the paper to HOSC in September 2021, NHS Sussex commissioners have worked with primary care providers, the Voluntary Community Sector, and the Community to ensure the best possible service is delivered to patients. Nevertheless, General Practice continues to face significant pressures upon its capacity, including increased patient demand and workforce shortages. The maintenance and expansion of access for patients in Brighton and Hove to primary care services remains a high priority for NHS Sussex, and will feature prominently in local work with Practices, PCNs, the GP Federation, HERE and working with partners across the Brighton and Hove health and care system.
