Extended Access to General Practice Services Anna Hargrave, Chief Transformation Officer Hannah Willetts, Head of Planning and Policy NHS South Warwickshire CCG Patient and Public Participation Group, 25 January 2018

What do we want to do today? We want to use today as an opportunity to: Tell you about ‘extended access’ – what is it and why is the CCG planning to commission a new ‘extended access’ service?; Give you an overview of the overarching requirements for the new service; Give you an overview of the current state of the CCG’s planning Give you the opportunity to give us feedback regarding the opportunities and challenges that you feel the CCG should take into consideration within its delivery plan; and Give you the opportunity to ask us questions.

Background: National context

General Practice Forward View Background General Practice Forward View Published 21 April 2016; Signalled NHS England’s intention to roll out extended access to general practice nationally: “NHS England will provide additional funding, on top of current primary medical care allocations – over £500 million by 2020/21 – to enable CCGs to commission and fund extra capacity across England to ensure that by 2020, everyone has access to [general practice] services, including sufficient routine appointments at evenings and weekends to meet locally determined demand, alongside effective access to out of hours and urgent care services”. https://www.england.nhs.uk/gp/gpfv/

Why extend access? Background National GP Patient Survey “Overall, how would you describe your experience of making an appointment?” Good 2012; 79.3% →→ 2017; 72.7% National range at CCG level from 57.6% to 85.7%. “Generally, how easy is it to get through to someone at your GP surgery on the phone?” Easy 2012; 77.9% →→ 2017; 68% YouGov Survey (July 2015): https://yougov.co.uk

Why extend access? Background National Centre for Social Research’s British Social Attitudes (BSA) survey, 2016: http://www.bsa.natcen.ac.uk/

Why extend access? Background Ipsos MORI poll, 2015: https://www.ipsos.com/ipsos-mori/en-uk/motivation-nhs-seven-day-services-misunderstood-many

Why extend access? Background Ipsos MORI poll, 2015: https://www.ipsos.com/ipsos-mori/en-uk/motivation-nhs-seven-day-services-misunderstood-many

Why extend access? Background “An estimated 5.77 million (99.9% confidence interval = 5.49 to 6.05 million) A&E attendances were preceded by the attending patient being unable to obtain a general practice appointment or a convenient appointment, comprising 26.5% of unplanned A&E attendances in England in 2012–2013. The sensitivity analysis produced values between 17.5% and 37.2% of unplanned A&E attendances.” Access to general practice and visits to accident and emergency departments in England: cross-sectional analysis of a national patient survey, 2014 http://bjgp.org/content/64/624/e434?ijkey=fc5501f2ff3f49d3b066da35321934800ecb3a86&keytype2=tf_ipsecsha “Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for “minor” problems.” Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis, 2016 http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1002113

Patient perceptions of access: national GP Patient Survey & Local Patient Survey

Overview National GP Patient Survey Annual survey of patients’ experience of healthcare services provided by GP practices; Conducted by Ipsos MORI on behalf of NHS England; Results date back to 2007; Circa. 800,000 responses received each year; Covers all GP practices in England and produces statistically reliable data at both practice and CCG level; Addresses a number of different areas including: Experience of access to GP surgeries; Satisfaction with opening hours; Awareness and use of online services; and Experience of out-of-hours NHS services.

Headline Findings at CCG level National GP Patient Survey Headline Findings at CCG level Recent GP Patient Survey results show that residents in south Warwickshire are consistently satisfied with the services provided by our 35 GP practices. 4,043 south Warwickshire patients completed the survey in spring 2017. (This represents a local response rate of 47% versus a national response rate of 37.5%) 91% rated their overall experience of their GP practice as good. (The national average was 85%) 91% were able to get the appointment they needed. (The national average was 84%) 76% of patients were satisfied with the out of hours services. (The national average was 66%) The full results at CCG level can be seen here: https://www.gp-patient.co.uk/slidepacks2017

Headline Findings at CCG level National GP Patient Survey Headline Findings at CCG level In south Warwickshire, eight out of ten patients are satisfied with their GP practice’s opening hours. However, different age groups did respond differently. And performance does vary across the CCG’s Member Practices. Nine in ten patients managed to get an appointment when they wanted one. The majority said that the appointment they were able to get was convenient. Again though, there are differences by age group and performance varies across practices. And, for those who could not get a convenient appointment, what happened next varied. Most people’s experience of making an appointment at their GP practice was good. However, getting through to the practice on the phone does seem to be problematic for some. Issues identified in relation to phone access would be less concerning if more people were using online services, but this is not the case.

Performance across Relevant Indicators National GP Patient Survey Performance across Relevant Indicators CCG Average National Lowest Performing Highest Performing (-) Result Satisfaction with GP practice opening hours 80% (satisfied) 76% (satisfied) 66% 93% 7% (dissatisfied) Success in getting an appointment 91% (yes) 84% (yes) 77% 100% 6% (no) Convenience of appointment 95% (convenient) 92% (convenient) 87% 100% 5% (not convenient) Overall experience of making an appointment 83% (good) 73% (good) 67% 99% 7% (poor) Ease of getting through to GP surgery on the phone 78% (easy) 68% (easy) 6o% 99% 19% (not easy)

Convenience of appointment National GP Patient Survey Convenience of appointment And for those who could not get a convenient appointment, what happened next varied. In the case that you were unable to get an appointment/were offered an inconvenient appointment, what did you do?

Online Services National GP Patient Survey Issues identified in relation to phone access would be less concerning if more people were using online services, but this is not the case. In the past 6 months, which of the following online services have you used at your GP surgery?

7 Day Services Local Primary Care Survey “Findings do not seem to justify the need for seven day care, neither patients nor staff are particularly keen on these suggestions. Instead, patients would most welcome extended weekday hours (evenings). Again, this option is particularly appealing to the younger population, while older patients feel that they can attend appointments during normal working hours”. Source: South Warwickshire Public and Patient Survey, 23rd March –1 May 2017.

Making an Appointment Local Primary Care Survey Appointment booking receives mixed reviews, whilst for some the process seems seamless, others face difficulties particularly with availability and waiting times. “It is often very difficult to get an appointment with a Doctor less than 2 weeks in advance and not always at a convenient time.” “Getting appointments is a nightmare. The process is painful and long and when you do eventually get though often there are no appointments so you have to endure the same again the next morning.” “They do a great job under pressure but struggle to book routine appointments within 2 weeks or spend enough time per appointment.”

Opening Hours Local Primary Care Survey Opening hours should reflect the needs of the local population – whilst for some groups, traditional hours are acceptable, others, particularly younger age groups would appreciate flexibility and increased availability on weekday evenings or weekends. “If you work away from home it is important that more flexible hours are available.” “I would not normally seek to make an appointment at weekends, early mornings or late afternoons when other people who are at work all week need them. However, it would obviously be handy to have that option if there was some reason I couldn't attend during "normal" hours.” “If weekend hours and evenings were offered I think they should be for working people or school children so they do not lose time. Retired people like me should go either early or during the working day.”

Extended Access Preferences Local Primary Care Survey Extended Access Preferences Source: South Warwickshire Public and Patient Survey, 23rd March –1 May 2017. Q24. How likely would you be to book an appointment in advance to see a GP or healthcare professional at your own GP practice at the following times? Q25. Imagine you could drop in on the day to see a GP or healthcare professional at your own GP practice, how useful would the following time slots be to you? Base: All respondents (2489-2503)

Local Primary Care Survey Pathway Preferences

New Extended Access service

What do we know so far? New Extended Access Service The CCG is required to commission a new extended access service during 2018/19; We will receive a funding allocation of £3.34 per head of population (weighted) in 2018/19, increasing to at least £6 per head from 2019/20, to do this; This means that the annual value of the new contract will be circa £1.7m from 2019/20; The minimum criteria for the new service are the 7 national core criteria; Survey results (national and local) show that, in south Warwickshire, we don’t have a strong need to simply extend a ‘traditional’ in-hours model to more days and evenings; We know that the pilot (GP Access Fund) sites have developed a range of innovative service responses as part of their extended access offer.

Our ‘Triple Aim’ New Extended Access Service So, the question we are now asking ourselves, is how can we use the national requirement to create the maximum benefit for patients, our GP practices and the system?

Timing of Appointments New Extended Access Service 7 Core Requirements Timing of Appointments Commission weekday provision of access to pre-bookable and same day appointments to general practice services in evenings (after 6:30pm) – to provide an additional 1.5 hours a day; Commission weekend provision of access to pre-bookable and same day appointments on both Saturdays and Sundays to meet local population needs; Provide robust evidence, based on utilisation rates, for the proposed disposition of services throughout the week; Appointments can be provided on a hub basis. Capacity Commission a minimum additional 30 minutes consultation capacity per 1000 population, rising to 45 minutes per 1000 population. Measurement Ensure usage of a nationally commissioned new tool to automatically measure appointment activity by all participating practices, both in-hours and in extended hours. Digital Use of digital approaches to support new models of care in general practice. Inequalities Issues of inequalities in patients’ experience of accessing general practice identified by local evidence and actions to resolve in place.

7 Core Requirements New Extended Access Service Effective access to wider whole system services Effective connection to other system services enabling patients to receive the right care from the right professional, including access from and to other primary care and general practice services such as urgent care services. Advertising & Ease of Access Ensure services are advertised to patients, including notification on practice websites, notices in local urgent care services and publicity that into the community, so that it is clear to patients how they can access these appointments and associated service; All practices able to direct patients to the service and offer appointments to extended hours service on the same basis as appointments to non-extended hours service; Patients should be offered a choice of evening or weekend appointments on an equal footing to core hours appointments.

Key Attributes New Extended Access Service Integration with other providers in order to maximise the use of existing infrastructure, minimise set up costs and ensure that opportunities to take collaborative approaches are exploited; Provision of routine (pre-bookable) and urgent (same day) appointments for all patients registered with an CCG Member Practice (34 practices in total) during weekday evenings (after 6.30pm) and at weekends (Saturdays and Sundays); Direct booking available to all CCG Member Practices, NHS 111 and the Out of Hours service provider (other organisations may be added); A range of services to meet the needs of the local population; A range of appointment types and clinical staffing (not all appointments need to be GP face to face consultations); Ease of access for patients; Being operational 365 days a year.

delivery plan

Timeline Delivery Plan PHASE 1 PHASE 2 PHASE 3 Engagement planning; Q3 17/18 Q4 17/18 Q1 18/19 Q2 18/19 Q3 18/19 Engagement planning; Public and Patient engagement; Stakeholder engagement; Market engagement; Development of service model; Define procurement strategy. Procurement phase. Contract mobilisation; Contract start date. PHASE 1 PHASE 2 PHASE 3

Progress to Date Delivery Plan Programme Board established and meeting regularly; Full project delivery plan in place and being overseen by the Programme Board; NHS England assurance process on-going – CCG status is assured at the current time; Data review work on-going – looking at the implications of activity in other services (e.g. A&E, the Out of Hours service, etc.); Links with other local CCGs via the NHS England regional Extended Access Group and agreement with other Coventry and Warwickshire CCGs to take opportunities to collaborate where possible; Engaged with CCG Member Practices through the regular Members’ Council meeting; Engaged with CCG’s Gateway Group to define public engagement requirements.

Next Steps Delivery Plan Further public engagement (building on the engagement conducted during the spring of 2017) across February and March; Market engagement event planned for 30 January 2018; Outputs of stakeholder, public and market engagement will feed into the development of our service specification; Outputs of the market engagement will assist to define our procurement strategy; Plan to keep stakeholders updated via our regular stakeholder newsletter and a dedicated section of the CCG website.