1. Assurance of General Practice Access and ‘Reasonable Needs’ Test
Rachel Dillon
West Locality Manager Sheffield CCG

2. Background
Last October, contractual changes in the directly enhanced service for extended access meant that practices could not regularly close for half a day a week
There was a significant positive shift in Sheffield that saw 47 practices move to an open position in order to provide the DES
Nov 2017, operational guidance was issued to assist commissioners in coming to a judgement about whether a practice’s access arrangements met the reasonable needs of its patients. This included a definition of the latter which is not detailed in the contract
In November, practices submitted their E-Dec data which sought access information from all practices in England
David Geddes wrote to all Primary Care commissioners in April 2018 stating that E-Dec data indicated that there were a number of practices in England which still intended to close for half a day, closed for an extended period (over 4 hours) a day or closed for over 7.5 hours across the week.
32 of the 1210 (2.6%) are in Sheffield

3. David Geddes letter
In the letter, it states that NHS England expects Commissioners to:
Undertake KLOEs to ensure that the reasonable needs of patients are being met, which also includes services subcontracted
Pursue contractual action with those practices that cannot demonstrate they are meeting the reasonable needs of their patients during core hours

4. What is ‘meeting the reasonable needs of patients’
It also included a revised guidance on GP access; expectations in respect of extended and core-hours, national standards and guidance for commissioners.
The following represent in broad terms the types of services that NHS England expect will form the basis of discussions with practices:
Ability to attend a pre-bookable appointment (face to face)
Ability to book/cancel appointments
Ability to collect/order a prescription
Access urgent appointments/advice as clinically necessary
Home visit (where clinically necessary) ring for telephone advice
Ability to be referred to other service where clinically urgent (including for example suspected cancer)
Ability to access urgent diagnostics and take action in relation to urgent results

5. Subcontracted arrangements
In Sheffield, there is only one provider who is subcontracted by practices to provide a service during core hours: Sheffield Teaching Hospitals
The CCG also uses this provider when city wide learning events are held
In the guidance, NHS England expect:
Practices to consult patients on the arrangements
Patients should know in advance of the closure
Patients need to be able to speak to a receptionist or clinician over the phone, not an answering machine message
Patients should not have to redial another number
The responder should treat these patients as they would their own
The subcontractor must be able to have access to the patients clinical record
The service should be local or easily accessible

6. To date:
Virtual paper 31st May went to PCCC seeking approval on CCG’s response and approach to the ask outlined in David Geddes’ paper
The approach being:
to ask those practices to describe their access arrangements
the story behind their current position
identify whether they have engaged with their PPGs on practices’ opening arrangements and
seek evidence on their engagement
Whilst there was approval, there were some comments

7. Comments from PCCC A number of operational issues
Manage impact and operational delivery
Use our knowledge of the state of play of PPGs in the city to help with this work
That those who are closed have adequate access to deputising services
Interested in seeing the data from the WIC/OOH/Hubs
Are there any neighbourhood clusters where it is difficult for patients to access their own GP and use other services.
Further information regarding E-Dec data being correct.
Contradiction in the paper regarding the impact of a firm line
Definition of reasonable needs within the contract
Does not make clear how CCG will determine whether the arrangements meet the reasonable needs of patients and any next steps
LMC happy for the paper to be used as a basis for the response, however specific concerns about ongoing debate around practice opening, definition of reasonableness
The comments are picked up through the rest of the presentation.

8. CCG next steps
Issued KLOE template to those practices identified by NHS England seeking information about patient impact and engagement on access
The KLOEs were a shortened version of those recommended by NHS England because:
In order to reduce burden already stressed practices, some of the information is centrally collected
Time to complete
Unreasonably ask questions of those practices identified which are common across all practices in Sheffield.
Checked practice website data with E-Dec data
Assessed data from Walk in centre, A&E and Hubs

9. For noting This has been a short exercise in a short space of time.
The information should be treated with caution as it has not been triangulated with other factors related to practices – shortage of staff/quality of service/numbers of sessions provided/size of practice.
The committee has not considered in detail the definition of reasonableness provided by NHS England and whether any action should be based on this without consideration of impact on all practices in Sheffield.

10. Summary
Locally
In most responses practices have stated no negative patient feedback on their opening hours
Some practices have updated their opening hours as a response to patient feedback
However, not all practices had engaged with their patients about opening hours recently or at all Local hubs are not used any more on a Thursday afternoon than any other day
Citywide
There is no significant impact on services (WIC, A&E) in the times when the citywide GP collaborative is in operation in core hours e.g. Thursdays, compared to other days of the week
There is no notable trend in negative patient feedback in the National GP Patient survey for this group of practices overall
However, there are three practices which have attracted significant feedback via Care Opinion/NHS Choices

11. Overall summary
Overall, the Committee should be assured that there are no large scale problems with opening hours in the city based on the information gathered
There may be more work to support a small number of practices in regards to opening hours and engagement with their patients
Further work to triangulate practices’ information with other sources of data and knowledge may be useful
The Committee may want to look further into the service provided by the Collaborative, but should do so within the context of the Urgent Primary Care developments

12. Recommendations
PCCC is asked to approve the following response to NHS England before the 30th June.
Assured with the following key themes.
E-Dec submissions and PPG engagement have been verified.
Patient behaviour and impact on non primary care services has been considered and reviewed.
Patient complaints related to practices have been reviewed.
In relation to the key themes around opening arrangements in meeting the reasonable needs of patients, for practice and subcontracted arrangements, we need to understand more what the definition means and work with practices and partners on this within realistic timelines and within the context of our overall strategy of at scale working and the urgent primary care proposals.
In relation to themes around PPG representation and patient engagement, we have received information from practices regarding PPGs, which is assuring, we do further work to support practices in this area as part of the wider programme of work around patient engagement.
In relation to the theme on review of all complaints, we do further work to consider and review more fully.
Taking account of all above, we will be confirming to NHS England that we haven’t taken any contractual action to date, and will confirm whether any is needed on completion of the above.