Delivery plan for recovering access to primary care: Key points

May 23, 2023

NHS England’s ‘Delivery plan for recovering access to primary care, was unveiled on 9 May 2023, with two central ambitions:

• Tackle the 8am rush and reduce the number of people struggling to contact their practice.
• For patients to know on the day they contact their practice how their request will be managed.

The plan focuses on addressing the well-known challenges of access to primary care. This is seen as a prerequisite first step ahead of longer-term reforms that will deliver the vision set out in the Fuller Stocktake for the future of primary care.

GPs should be aware of the plan’s key points about how primary care practice will evolve in the next two years. Note that funding and transitional support is available for practices that sign up to implement changes by the relevant deadlines in 2023/24, as indicated below.

Roll-out of ‘Modern General Practice Access’

By the end of 2023, it is hoped that most practices will have adopted the ‘Modern General Practice Access’ approach, using online tools, digital telephony, and triage by trained care navigators to make it easier for patients to contact the practice and learn how their request will be handled. It will also make it easier for practices to receive, navigate, assess, and respond to requests.

The plans are aligned with NHS contract changes for 2023/24, requiring patients to be offered ‘an assessment of need, or signposted to an appropriate service, at first contact with the practice’ from May 2023.

In Modern General Practice Access, patients should be told how their request will be managed on the day they first contact the practice:

• Clinically urgent: same day assessment by telephone or face-to-face appointment (next-day assessment is allowed where clinically appropriate if the patient contacts the practice in the afternoon).
• Non-urgent: telephone or face-to-face appointments scheduled within two weeks.
• Where appropriate, patients will be signposted to self-care or other local services such as community pharmacy or self-referral services.

Dates to be aware of:

• From May 2023, training and transformation support will be available through a National General Practice Improvement Programme.
• Practices on analogue phone systems that commit by 1 July 2023 to adopt digital telephony will receive support and funding up to about £60,000 over two years.
• Funding will be available for practices that sign up by March 2025 to adopt digital tools and care navigation training.
• All analogue phone systems across the country will be switched off by December 2025.

A major communications campaign will explain to patients how primary care is evolving and how they can best use the NHS. The hope is that many patients will find it more convenient to make requests and receive responses online, freeing up phones for those who prefer to call.

Empowering patients, relieving pressure on GPs

The plan also aims to employ tools that people can use to manage their own care, to relieve pressure on GP practice teams. Self-referral pathways will be expanded by September 2023, and by March 2024, it is expected that >90% of practices will enable patients to use the NHS App to see their health records, read practice messages, book appointments and order repeat prescriptions.

Subject to consultation, the Department of Health and Social Care (DHSC) will also expand the role of community pharmacies in 2023, potentially saving 10 million GP appointments each year by:

• Increasing provision of oral contraception and blood pressure services.
• Launching the Pharmacy First programme, allowing pharmacies to supply prescription-only medicines for sinusitis, sore throat, earache, infected insect bite, impetigo, shingles, and uncomplicated urinary tract infections in women.

Increasing capacity and reducing bureaucracy

Within the plan is a commitment to publish the long-awaited NHS Long Term Workforce Plan, which will detail future GP training, recruitment, and retention plans. In the meantime, the plan intends to deliver more appointments with extra staff, with measures including:

• Larger multidisciplinary teams: increasing additional roles reimbursement (ARRS) funding and flexibility, to deliver on the commitment to fund more direct patient care staff.
• More new doctors: expanding GP specialty training; helping newly qualified GPs who require a visa to remain in England.
• Retention and return of experienced GPs: through pension reforms, and simplifying return to practice.
• Requiring higher priority for primary care in housing developments.

The plan also details how administrative workload in primary care will be eased, building on the Bureaucracy Busting Concordat published in 2022, by:

• Improving the interface between hospitals and primary care, including a reduction in inappropriate transfer of hospital administrative workload.
• Increasing self-certification to reduce medical evidence requests to GPs.
• Streamlining the Investment and Impact Fund and consulting on the Quality and Outcomes Framework clinical indicators.

Although the plans have been broadly welcomed, GP leaders in the British Medical Association and Royal College of General Practice remain concerned that more investment and support is crucial to deal with workforce and infrastructure problems, if the measures are to be implemented effectively. It remains to be seen how future long-term plans for reform will address these issues.

If you have questions or concerns about the NHS plans and how they will affect your practice, please contact us for advice at Medical Defense Society

Dealing with medicines shortages in general practice

May 3, 2023

Recent months have seen serious shortages of certain HRT products, antibiotics, antidepressants, and other essential medicines, due to a complex interplay of factors, including global supply and distribution issues, high demand, and longer prescription cycles.

Although the Department of Health and Social Care (DHSC) has processes in place to prevent and mitigate the issues, the MIMS live tracker shows that drug shortages have risen markedly during 2022–23.

The problems bring concerns about potential harms to patients: a risk of worsening symptoms, withdrawal symptoms and other complications, if access to treatments is delayed. They also add to the pressure on pharmacists and primary care teams, who report increasing workloads, stress, as well as abuse by frustrated patients.

Serious shortage protocols (SSPs) allow pharmacists to substitute prescription medicines in short supply

Community pharmacies and dispensing doctors receive regular updates and follow national guidance to implement management plans in case of drug supply issues. They should share information with prescribers and patients as appropriate, and work to obtain or locate stock from suppliers or at other pharmacies.

SSPs, first introduced in 2019, may be issued if the DHSC determines that there is a serious shortage of a specific medicine or appliance. The protocols allow community pharmacists to use their professional judgement to decide whether it is appropriate to substitute the patient’s prescribed order according to the protocol. They must obtain the patient’s valid consent for this, and check their allergy status and Summary Care Record, but they do not have to refer the patient back to the prescriber. This ought to help patients access treatment sooner and save time for clinicians.

SSPs are developed with advice from expert clinicians and specialist societies, and specify:

• Actions pharmacists can take to substitute the prescription with an alternative quantity, strength, or pharmaceutical form, a generic equivalent, a therapeutic equivalent, or an alternative device product.
• The appropriate circumstances, suitable patients, relevant dates, and geographic locations.

In the case of a therapeutic substitution, the pharmacist should inform the prescriber, ideally by the following working day. This information may need to be entered into patients’ records.

Dispensing doctors may also follow SSPs if necessary, but generally they can amend the FP10 prescription form to supply an available medicine.

The NHS Business Services Authority provides a list of currently active SSPs and SSP Operational Guidance.

When is referral back to the prescriber required?

Even where an SSP exists, there are situations in which the pharmacist must refer the patient back to their GP for an alternative prescription:

• If the patient does not consent to the substitution.
• In case of concerns regarding the patient’s medical history or individual circumstances.
• For patients with complex medical regimens or complex health needs.
• For patients with certain conditions, such as epilepsy, where generic or therapeutic substitution would not be appropriate.

Limitations of SSPs

A recent survey of UK pharmacists suggested that despite SSPs, medicines shortages are having a worsening impact on patient care. Not all drug shortages are subject to an SSP, and supply issues may occur before advice on alternative medications is available. Where SSPs exist, pharmacists report that they are bureaucratic and inflexible – leading to extra workload and financial risk.

The Royal Pharmaceutical Society has called for pharmacists across the UK to be allowed to make minor amendments (for example, changes to quantity, strength, formulation, or generic substitution) to allow the prescription to be dispensed in the absence of an SSP, without having to contact the prescriber. In Scotland, this is already the case.

The prescriber’s role in managing supply issues

GPs may be notified of shortages by local communication networks, or, in the case of high- or critical-impact shortages, by ‘Supply Disruption Alerts’ via the Central Alerting System. All nhs.net email users can also register to access the Specialist Pharmacy Service website to find communications from the DHSC about specific medicine shortages and their management.

Once GPs are aware of a supply issue, they may request suitable alternative drugs or formulations on prescriptions, thus reducing the pharmacist’s work and the need for prescription amendments.

For example, as shortages of HRT products continue to cause frustration for all concerned, prescribers should refer to the advice of the British Menopause Society (BMS) to find suitable alternatives. MIMS also provides an HRT comparison table for hormone doses, formulations and costs.

Note that from April 2023, GPs are required to write listed HRT items on separate prescriptions, to facilitate use of annual HRT Prescription Prepayment Certificates, which may help to ease supply pressures.

Please contact us at Medical Defense Society for advice if you have concerns about the impact of medicines shortages on your practice or the wellbeing of your patients.