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Acting GPC chair Dr Richard Vautrey
Analysis by the King's Fund, based on data from the Department of Communities and Local Government, shows that councils in England will spend £2.52bn on public health services in 2017/18 compared to £2.60bn the previous year, on a like-for-like basis.
Once inflation is factored in, the think tank estimates that planned public health spending will be more than 5% lower in 2017/18 than it was in 2013/14.
GP leaders condemned the cuts as a 'national scandal' and warned that they could see money diverted away from practices and create short- and long-term workload problems for GPs.
Public health cuts
The £85m reduction in spending comes on top of cuts worth £200m made to public health in 2015/16. Funding for sexual health services has dropped 10% over the last four years.
Sexual health services are set to be slashed by £30m as part of the cuts, a 5% reduction on last year’s budget, the King's Fund report said.
This comes alongside a projected 5.5% cut to tackling drug misuse in adults – equivalent to £22m – and a 15% cut worth £16m to smoking services.
Most services are facing cuts, it warned, bar a few – including promoting physical activity and some children’s services.
Acting GPC chairman Dr Richard Vautrey said: ‘It’s a national scandal that the government is allowing such significant cuts to public at a time when we need investment far more than ever before.
‘We will pay the consequences in the long term if we cut funding now – it’s completely foolish to cut these services at this stage.
‘These cuts could take money away from GP services – many practices are reliant on money that comes from public health sources, doing important work around smoking cessation and reducing alcohol. Sexual health and contraceptive services are also funded through public health sources from local government.
‘In terms of GP workload – in the short term, there's always the risk practices will try to maintain services even though they have funding, which will impact on the services they can provide.'
GPonline reported earlier this year that GP practices deliver services that should attract enhanced services payments worth millions of pounds a year for free.
Dr Vautrey added: ‘And if we’re not offering basic services now, it is bound to increase workload pressures on GPs and community-based healthcare in the long term.’
Frontline GP services
RCGP chair Professor Helen Stokes-Lampard described the cuts as ‘incredibly concerning’.
She added: ‘We know that difficult financial decisions need to be made but it makes no sense to make cuts to these frontline services, and other valuable services for patients, that will only be to the detriment of the wellbeing of so many and could adversely impact on the health and wellbeing of some of our most vulnerable patients in society.’
Shirley Cramer, chief executive of the Royal Society for Public Health, said: ‘Short-sighted cuts to sexual health, drug misuse and stop smoking services are a false economy – saving money in the short term but costing far more over coming decades, while jeopardising precious gains we have made to cut the number of smokers and efforts to tackle our growing crisis of drug-related deaths.’
Izzi Seccombe, chair of the Local Government Association's community wellbeing board, said: ‘Councils are clear – the government needs to look to prevention, not cure, for delivering long-term savings and better services.
‘To take vital money away from the services which can be used to prevent illness and the need for treatment later down the line is counterproductive.’
A DH spokesman said: ‘We have a strong track record on public health – cancer survival and dementia diagnosis are at a record high whilst smoking rates and teen pregnancies are at an all-time low.
‘Over the current spending period we will invest more than £16bn in local government public health services. Moreover, we have shown that we are willing to take tough action to protect the public's health – introducing standardised packaging of cigarettes, a soft drinks industry levy and a world leading childhood obesity plan.’
Paramedics with advanced training can reduce the number of patients admitted to hospital unnecessarily, says NICE.
NICE is recommending the NHS provides more advanced paramedic practitioners (APPs) to relieve pressure on emergency departments, in new draft guidance.
Evidence reviewed by NICE shows that using APPs can reduce hospital admissions by 13% compared with standard paramedics.
APPs are able to treat patients in the community, refer them to a GP or decide if they should go to hospital. They can administer stronger pain relief compared with standard paramedics and are able to assess if a wound need stitches.
A previous British Medical Journal study suggests that for each APP, the NHS can save up to £72,000 a year. They can be used on the ground or by sharing their expertise over the phone.
Professor Julian Bion, consultant in intensive care medicine at Queen Elizabeth Hospital and chair of the NICE guideline committee, said: “It is essential we spend what money we have wisely, investing in areas where we’ll see a real improvement in care for everyone.
“Increasing the number of advanced paramedics we have working across the country is one way we can achieve this. Their skills and expertise can help to ease pressure on emergency departments and ensure patients are cared for in the most appropriate location.”
The draft guidance also makes wider recommendations about emergency and acute medical services to standardise care across the NHS. It supports NHS England’s Five Year Forward View for the future of emergency medical services.
These include providing nurse-led support within the community for people who are at risk of hospital admission, for example, if they have recently suffered a stroke or been diagnosed with heart failure.
Hospitals should consider daily consultant review of patients admitted with a medical emergency including weekends and bank holidays, the draft guidance says.
These patients should also get automatic, seven-day access to physiotherapy and occupational therapy if they need it, the document says.
Professor Mark Baker, director of the centre for guidelines at NICE, said: “This draft guidance features recommendations that seek to standardise best practice across our emergency and acute medical services. It also highlights where we need more evidence to properly assess what should be done to get the most from the limited resources we have.”
In total, there are 23 practice recommendations and 17 recommendations for more research, such as whether having GPs working in or near emergency departments can help reduce hospital admissions.
NICE will be consulting on the draft guidance until 14 August.
Original post: 04/07/2017 https://www.nice.org.uk/news/article/nhs-needs-more-advanced-paramedics-to-ease-a-e-pressure-says-nice
By Dr Mark Spencer on the 25 May 2016
Dr Mark Spencer, co-chair of the New NHS Alliance, employs a paramedic in his practice. He explains what the role involves and how it benefits the practice.
Paramedics are fleetingly mentioned within Dr Arvin Madan’s introduction to the recently published GP Forward View. They are also included again in the ‘Ten High Impact Actions’. Blink, though, and you would miss those references.
So, what is their role and what are they currently doing within day-to-day general practice?
At FCMS, the healthcare provider of which I am medical director, we have had paramedics filling urgent care shifts for over a decade. Way back in 2002 we were awarded the Health and Social Care Award in the emergency care category for our development of a multidisciplinary team in the GP out-of-hours setting. The team included GPs, primary care nurses, mental health nurses, pharmacists, dentists, social workers and paramedics.
So, what about ‘in-hours’ GP practices?
The past two years has seen my own practice move from predominantly GP dominated provision of day-to-day appointments, to a more multidisciplinary approach. Practices nurses have stepped up the mark for the provision of care for patients with long-term conditions, but seeing patients who request an appointment has, until recently, pretty much remained the domain of the GP.
Our change came out of adversity and need. In the past two years we have lost two whole-time equivalent GPs as four part-time partners either retired or moved on. This meant we were only left with four whole-time equivalent GPs for over 12,000 patients in an area of high deprivation and high demand. Failure to recruit new GPs left us with no alternative but to think differently.
We developed a strategy that includes an acute access team, led by an on-call GP, but with the bulk of face-to-face delivery being undertaken by a full-time nurse practitioner, a full-time clinical pharmacist and a full-time paramedic.
Our paramedic has three basic elements to his job. First, he carries out a morning minor ailments surgery, working alongside, and being supported by, the other members of the acute access team. Late morning he then sets off on home visits, covering the vast majority of acute visits that would otherwise have been undertaken by a GP.
Use of technology
The use of telephone support, but more importantly, video support between the paramedic and the on-call GP, has significantly broadened the range of conditions that can safely be managed by the paramedic, with the on-call GP remaining back at surgery. The live video link allows the GP to see the patient, and also allows the patient and carers to interact directly with the GP as if they were in the room.
To date, the feedback from patients and carers has been excellent. To cover information governance, the patient signs a written consent form prior to, and immediately after, the video consultation. We have also had written confirmation from our local coroner that they would accept a death certificate from the GP following a video consultation should the patient pass away, in exactly the same way as they would if the GP had visited in person.
Releasing the GP from having to undertake acute visits has not only freed up a considerable amount of GP time, but has had a substantial effect on reducing GP stress levels.
Thie post was originally aired here:
Paramedics can work as part of a multidisciplinary team to help practices manage their workload, but what does the role involve and what skills should you look for?
Skill mix in primary care is not a new concept. Nursing roles have expanded significantly in recent years and practices are also starting to embrace the idea of employing pharamcists as part of the practice team. However, there has been growing recognition that other professions could also help to address the GP workload and recruitment crisis.
One of these professions is paramedics. Broadening the skill mix of GP practices to include paramedics was proposed by the Primary Care Workforce Commission last year in its report The future of primary care, Creating teams for tomorrow, and NHS England’s General Practice Forward View, which was published earlier this year.
What can paramedics do in general practice?
The Mount View Practice in Fleetwood, Lancashire, which has 12,000 patients, recruited a paramedic to join its team in January.
‘We have worked with paramedics in our local out-of-hours service for 20 years now. It has been a success and made us question why we couldn’t make that arrangement work for working hours well,’ explains GP partner Dr Mark Spencer who is also co-chair of the New NHS Alliance.
At Mount View the paramedic spends the morning working in a minor ailments surgery as part of an acute access team. The team is led by an on-call GP, but the bulk of face-to-face delivery is undertaken by a nurse practitioner, pharmacist and the paramedic.
Following this, the paramedic then does home visits, covering the vast majority of acute visits that would otherwise have been undertaken by a GP. ‘This has freed up an enormous amount of GP time and had a huge impact,’ Dr Spencer says.
While GPs still carry out home visits for patients showing new symptoms, where a diagnosis hasn’t been made and for end-of-life care, the paramedic now takes on the bulk of visits for patients, where, for example, there has been a worsening of a pre-existing condition. It tends to be mainly elderly, or housebound patients or those in a residential home, Dr Spencer says.
‘Seeing patients at home is something paramedics would normally do,’ says Dr Spencer. ‘It is their bread and butter so this seems a natural step.’
The paramedic at Mount View has full access to patient clinical records but isn’t working absolutely autonomously. ‘Once at the patient’s home the paramedic will phone the on-call GP or set up a video link using their laptop. A three-way consultation is carried out between the patient, paramedic and GP back at the practice so the paramedic is fully supported,’ says Dr Spencer.
Benefits of employing a paramedic
The benefit of this is the amount of travel time saved for the GP - around 30 minutes per visit. ‘With anything between 8 and 16 visits per day depending on the season, this is a significant amount of time saved for doctors. But it’s also about improving the skill mix within a multidisciplinary team and making more efficient use of the workforce available,’ Dr Spencer says.
‘Some people would say they would prefer a GP but the fact is there just aren’t any. Paramedics are not a replacement for GPs but have a range of skills that are very useful in a multidisciplinary team.’
Paramedic Kevin Reid is employed at the six-partner Maryhill Practice in Elgin, Scotland and has been working in primary care for 12 years – six were spent with the local GP out-of-hours service and the past six at Maryhill.
Mr Reid’s role as an emergency care practitioner also sees him take prime responsibility for handling acute home visits. A key difference is that he works largely autonomously.
‘I was recruited by the practice to help with unplanned and unscheduled care. It was a very unusual decision then and was a risk but it has paid off,’ he says.
'The six years spent in out of hours gave me vital primary care experience so I am able to close most of the calls myself, either by admitting the patient to hospital or putting in place an appropriate management plan for care at home by community nurses and a multi-disciplinary team.
‘Obviously some patients have multiple co-morbidities and there is always a GP on duty with whom I can discuss the patient’s case if I need to.’
Mr Reid emphasises that it is working as part of a multidisciplinary team that makes the arrangement successful. However, he adds: ‘The real beauty of the single paramedic practitioner doing house calls is that they are seeing the patient day-to-day and can very quickly identify if there is any deterioration.’
Mr Reid also works with the practice team to deliver a telephone triage service. And like the paramedic at Mount View holds planned acute or minor ailment clinics. At Mount View, Dr Spencer says the paramedic role has also significantly reduced stress levels for GPs and had a positive effect on recruitment and retention. ‘Having a paramedic has made the working day for GPs much more manageable because they no longer have to worry so much about visits after the afternoon clinic,’ he explains.
‘One GP who left the practice because of stress levels actually returned to the job because they could see the working environment had improved so much.’
But how do patients respond to being treated by a paramedic when they expect to see a GP?
Dr Spencer says his practice hasn’t collected formal feedback from patients as yet but anecdotally they welcome the speed of access (the paramedic can get to home visits quicker). ‘Some patients call up specifically requesting to see the paramedic now,’ he says.
Skills and training needs
However, a crucial drawback to employing a paramedic is they are currently not allowed to prescribe. Dr Spencer admits this remains a hurdle.
As is the case for any practitioner, training and CPD is also essential. Regular courses and mentorship sessions play an important role. For paramedics used to dealing with emergency medicine honing consultation skills is key, explains Dr Spencer. ‘Our paramedic regularly sits in on the GP or nurse clinics.’
Beyond his paramedic training Mr Reid holds degree-level modules in minor injuries, acute illness, minor illness and the advanced clinical examination among many others.
He says: ‘Practices should look for paramedics with some sort of background in an extended role but who know their limitations. I’m happy to work at the top end of my licence and work with a high level of autonomy and risk but, at the same time, I absolutely understand when to ask for help.’
He adds: ‘Practices are struggling to recruit GPs. We are not the equivalent to them, of course, but we can be part of the answer to help fill the gap.’
The New NHS Alliance is now looking to create a primary care network for paramedics so they can link up and share best practice.
Recruiting a paramedic
- Be clear about the role you want a paramedic to do.
- Look for experience of working in primary care (for example, working in GP out-of-hours services).
- Ensure they have relevant qualifications.
- Look for communication and listening skills.
- Make sure your medical indemnity provider knows that you are employing a paramedic. Medical indemnity cover can be arranged in the same way as for other primary care clinicians such as nurse practitioners.
If you think that Paramedic Finders can help you then give us a call now on 01872 885450
Dr Mary McCarthy: (Photo: JH Lancy)
A GPonline survey of more than 500 GPs has revealed that 51% believe the number of patient consultations they provide each day is in excess of what they consider to be safe. More than 80% of GPs said the GPC should negotiate a maximum safe limit to the number of patient contacts they can undertake per day.
LMC representatives voted at their annual conference last month for GP leaders to negotiate a maximum safe limit on daily contacts with patients. Proposing the motion, GPC member Dr Mary McCarthy said GPs were seeing more patients than ever.
She told the conference that GPs in the UK had more daily patients contacts than any other country in Europe other than Turkey, where the health service is dealing with 6m refugees from Syria.
Safe GP workload
GPs in other European countries had fewer than 25 contacts a day compared with 40 to 50 a day in the UK, said Dr McCarthy. GPonline reported earlier this year that GPs in England provide around 1m appointments per week over the level the BMA considers safe.
‘We need to give ourselves some sort of guideline as to the workload we undertake,' she said. ‘Routinely seeing more than 25 patients a day may not be safe for patients or their doctors.’
Other LMC representatives opposed the limit and warned there was little evidence base for determining how to quantify a safe workload.
The special LMCs conference in January 2016 voted for the GPC to negotiate restrictions on the number of patient contacts allowed each day per GP to 'a level comparable to other EU countries'.
The BMA’s annual conference later this month will debate a call for a GP ‘black alert’ system to be set up, with or without government recognition, for practices to indicate maximum safe capacity has been reached.
GPC’s Urgent Prescription for general practice calls for ‘a national standard for a maximum number of patients that GPs, nurses and other primary care professionals can reasonably deal with within a working day.’
Research cited previously by the RCGP suggests more than half of GPs carry out 40-60 consultations per day.
BMA guidance on safe working published in 2016 makes the case that 115 appointments per week should be seen as the 'quantified commissioned activity of an NHS GP'.
Responding to the GPonline survey a Devon GP said: ‘I often work flat out for 11 hours, making a complex clinical decision every 1-2 minutes.'
A Bristol GP said: ‘The main problem is the intensity of sessions not necessarily patient numbers. Because of six-week wait for routine appointments patients demand multiple problems within appointment which simply cannot be achieved safely.’
A Kent GP added: ‘Having to see almost 40 patients face-to-face plus half of dozen of phone calls plus all the admin work on a daily basis, I thinks that is a maximum overstretch with safe consequences. I have no time to think and most of the time I can only react. My job is to think and I am not allowed to do so.’
Another Bristol GP said safe working limits should be for practices to decide, not regulation, but added: ‘Problem is that senior partners are not always good managers of people. Practices need to be flexible and pay scale adjusted accordingly.’
A GP in Edinburgh said safe contact numbers depended on the types of cases. ‘Depends on quality as well as quantity - 20 snotty kids are easier than two suicidal patients back to back.’
A Greater Manchester GP supported a limit, but added: ‘Who is going to see all the other patients [and] meet the rest of the demand?’
Original story publish on GP Online - &th June 2017
A new model of care being introduced in East Kent is seeing a reduction in the number of patients being taken to hospital.
South East Coast Ambulance Service NHS Foundation Trust’s, check (SECAmb) new Community Paramedic Programme which went live this month in Whitstable, Canterbury, Faversham and Deal is helping to keep, on average, 15 patients per day out of hospital and treated closer to home.
The reduction in the number of patients being taken to hospital is being achieved through closer working with GP surgeries in the area.
The programme sees teams of paramedics and paramedic practitioners (PPs) undertaking some of the GP home visits on behalf of surgeries while also being responsible for most of the 999 emergency calls in the area.
The GPs will determine which patients are suitable for a paramedic visit, allowing the patient to receive a quicker response and GPs to focus on seeing patients in their surgeries.
If seen at home by a paramedic or a PP, patients will also have access to additional clinical investigations, including 12-lead ECGs, which would not be available with a GP home visit.
Whitstable Paramedic Practitioner Steve Hulks, who has been involved with the programme since its inception said: “Working alongside our GP and community service teams in this way, you feel part of a whole team working together for the benefit of the patient.
“A really good example of this approach working well was when we received a 999 call involving an elderly man who had suffered a fall. As I had already seen him previously on a GP home visit, I was fully aware of the patient’s previous medical history, which we have access to, and was then able to make an informed decision. This meant the patient could be kept at home and referred back to the GP the following day.”
Related article: - Pioneering Service Treats 100 Patients A Week At Home
The Community Paramedic teams will also respond to almost all 999 calls from their communities. Being locally-based, will allow the teams to build closer relationships with patients, local community teams and GP practices, as well as providing a more responsive and effective service.
This new model builds on a pilot which took place in Whitstable, one of the NHS Vanguard sites which received central funding.
Whitstable Medical Practice at Estuary Park was one of the practices involved in the Vanguard programme.
Senior partner Dr John Ribchester said it was a very important step and fully in tune with its model of care under the Vanguard scheme which aims to transform how care is delivered locally.
“The figures have been impressive and we expect it will prove very successful,” he said.
“In our first week we referred 32 patients to be assessed and 20 of them were dealt with by the SECAmb paramedic practitioners, 10 were dealt with at home in liaison with the doctor and only two needed to be referred on for admission.”
“The team also dealt with the referred 999 calls in the area and the transfer to A&E was also down so it has been an excellent start.”
Regional Operations Manager Chris Stamp added: “We’re really pleased with the early stages of this new way of working which ensures better levels of care for our patients and means that where possible more patients are treated in their own homes without the need for hospital treatment.
“We’re looking forward to the further roll out of the scheme across our region as SECAmb is committed to innovation to improve care and experience for our patients and to increase local ties with GPs and other local community services.”
Similar models are already being trialled in other areas of Kent. Plans are being developed to roll these out across the whole region from later this year.