Patient Participation

Across the Black Country and West Birmingham there are extensive arrangements in place

to engage patients and the public in the way that services are developed, delivered and

evaluated. Each partner has mechanisms to involve our population in the way that services

are commissioned and provided; primary care is no different in this regard. Most of our

practices have Patient Participation Groups (PPG) and we have great examples of the

impact that these groups can have, not only on the way that GP practices operate but their

role in empowering local people and communities more widely.

Based on feedback from the 2017/18 GP practice survey, we know that:

In Dudley, patients overall experience of their GP practice was very good. Local people are

aware of online services that are offered at their GP practice, but many have not used them.

Mental health and long-term conditions are recognised and supported well.

In Sandwell and West Birmingham, most patients rate their overall experience as good.

Almost half surveyed were not aware of the online services offered at their practice and

therefore did not use them. Most patients get a choice in date or time when booking a GP

appointment.

In Walsall, the overall experience of GP practices is very good with most patients finding it

easy to get through to their GP practice on the phone. Most patients were aware of online

services, but a high proportion said they had not used these in the last 12 months. Their

confidence and trust in staff providing services when their GP practice is closed was high.

Wolverhampton, most patients describe their overall experience of their GP practice as very

good. There is a general awareness of online services locally, but most patients have not

used them. There are also high levels of satisfaction with receptionists in practices and

patients find it easy to use their GP practice website to look for information or access

services. Satisfaction with appointment types was also high.

We also use digital solutions to capture, on an ongoing basis, patient views of the services

we provide and the care they receive. An example of this is shown in the image below:

Patient Experience Measure – GP Patient Survey 2018

The information captured in this told us that across all our localities patients’ perceptions of

care received at their last GP offered room for improvement, with them feeling like they are

not treated with the right level of care or concern and that they are not given enough time.

Mechanisms like this are routinely employed and review by individual organisations and

within the STP structure so that we understand how we are performance and to help identify

any areas for improvement. These are then brought into the planning and programme

structure mentioned earlier.

It is also reasonable to say that whilst opinions expressed in the latest survey are consistent

across the STP and positive in terms of how we benchmark with national results, there is

some variation across results from practice to practice.

It is this variation that we want to tackle, so that people across the Black Country and West

Birmingham recognise the level of service they can expect, regardless of the practice they

visit.

We have used the knowledge from this national survey, ongoing place-based involvement

work by local CCGs and specific engagement events on this strategy development to ensure

that this strategy responds to the views of local populations.

As an STP, we also recognise that the needs and expectations of the public are changing.

We are living longer but we often require different, more complex care as a result. New

treatment options are emerging, and we rightly expect better care closer to home. Our

primary care services are there for people, often as the first port of call and when at its best,

general practice plays a valuable role of coordinating care for those most frail and

vulnerable.

Good access to general practice is something, which all patients and the public want. For

those living with long-term conditions they strive for not only good access but for continuity of

care and want to feel able to influence their own care planning.

We know that having a sustainable primary care service and using new models of care such

are networks, is very important for our population registering with a GP of choice, often for

life, and means that people grow strong relationships with their local practice. We know that

our patients have a strong and emotive reaction to any suggested reduction in the local

provision of primary care services.

Our population also recognises the challenges faced by primary care such as the issues with

recruitment, many GPs reaching retirement age and increasing complexity of an aging

patient population. From conversations we have had with our patients and service users we

know they are open to exploring other options such as online access and being cared for by

new types of workforce such as practice based pharmacists, paramedics in practice and

social prescribers to address some of these challenges.

There is wide recognition and ambition across the STP to create a future where our

residents have more choice and control over their own health. Care planning, which places

the individual and what matters to them at the centre, is something, which our residents

support too. It is also an area where our population have positive ideas on the role that they

can play in supporting their own health.

Local people still need more information on the way in which primary care services are

developing, they want to understand the new roles being introduced to primary care and to

understand the different ways that services can be accessed through, for example the new

network structures.

As this strategy is mobilised and more plans for implementation are developed there is

commitment across the STP to engage with patients and the public. We have structured this

at the following levels:

People – we will increase the choice and control that people have. Increasing opportunities

for people to influence their own care, to set personalised goals, participate in shared

decision-making and for individuals to be seen as equal partners in their care planning.

Practice – we will encourage each practice to have a Patient Participation Group and offer

support to those practices who do not have one or for those groups who need some support

to be the best they can be. This will offer all patients, registered with a practice in our STP, a

chance to have a voice about how the care is provided in their practice.

Place – each CCG has a forum for PPG leaders to come together at a PCN or Place level.

Theses forums are a great way to hear about health developments, share ideas and

influence commissioning decisions. Each CCG has a Primary Care Commissioning

Committee (PCCC) with patient / public representatives (including Healthwatch) and these

meetings are held in public. These are key to us being pen about the way in which decisions

are made in relation to planning and buying (commissioning) primary care services.

Partners – At an STP partnership level we will offer collective clarity about the direction of

travel for primary care, we will ensure that there is consistency in the opportunities for people

to be involved in decisions about that strategic direction and we will support this through the

introduction of ‘Black Country Voices’. A new citizens panel for the STP which will be in

place by April 2020 and will provide a mechanism for gathering insight and feedback on

health and care issues. It will help the STP to reach an unrepresented demographic from

across the five localities including those who are seldom heard and will complement existing

engagement methods used across the footprint.

As an STP we have also committed to communicate in a way that is:

- Open and transparent – our communication will be as open as we can be, ensuring

that when the information cannot be given or is unavailable, the reasons are

explained.

- Consistent – There are no contradictions in the messages given to different

stakeholder groups or individuals. The priority to those messages and the degree of

detail may differ, but they should never conflict.

- Two-way – There are opportunities for open and honest feedback and people have

the chance to contribute their ideas and opinions about issues and decisions.

- Clear – communication should be jargon free, to the point, easy to understand and

not open to interpretation.

- Planned – communications are planned and timely rather than ad-hoc and are

regularly reviewed to ensure effectiveness.

- Accessible – our communications are available in a range of formats to meet the

needs of the target audience.

- High quality – our communications are high quality in relation to structure, content

and presentation at all times.

We will also ensure that there will be no service changes without adequate involvement and

we will promote the ways in which local people can have their say.

Public Engagement on this Strategy

To help us identify what matters most to local people, we held four public engagement

events across the STP footprint. The events encouraged people to have their say on primary

care services and captured views and experiences based on a series of topical areas

covering access, the development of new roles within primary care, the use of online

services and the emergence of digital solutions.

The events led by primary care leads in each of the CCGs, highlighted the challenges faced

by primary care, the opportunities of partnership working and how CCGs were working

together to develop a system-wide Primary Care Strategy for how it will improve the care for

people living in the Black Country and West Birmingham over the next five years.

A graphic recorder was commissioned to create a visual representation of the conversations

that took place at each event. The visuals will be used to evidence the progress and

direction of conversations in each of our four localities and will support CCGs to understand

what matters most to local people.

Across the four events, 118 local people attended. Attendees were predominately white, of

retirement age and who were experiencing a number of long-term conditions. Some

localities did get representation from Black Minority and Ethnic (BME) communities including

a representative from the Refugee and Migrant Centre, which covers Birmingham, Walsall

and Wolverhampton and a representative from a mental health support group.

Generally, feedback we received from local people who attended the events was consistent

across our four localities. Overall patients would be happy to see a variety of health

professionals in primary care for minor ailments, provided they had the training required and

were able to make easy onward referrals to their GP or other services. Patients with multiple

long-term conditions were more hesitant to see alternative health professionals as they

thought it was important that the health professional understood their history and they valued

consistent, face-to-face care.

When discussing the digital agenda, most people felt they needed further education to

understand the solutions being investigated and what this would mean in practice. They also

felt that if results were made available electronically they may need support to understand

them. Concerns were raised regarding data security and the level of information being made

between groups, with a particular focus on voluntary sector organisations.

Representatives on behalf of refugee and migrant populations/mental health sector

highlighted the difficulties that would arise for patients if they were required to attend

alternative practices and see health professionals that they were not familiar with.

The following sections highlight the insights that we learned from each of our localities:

Dudley

Generally, people were positive about seeing a healthcare professional rather than their GP

however, some questioned the training and competency of these professionals, and raised

that it would be dependent on the urgency/nature of the enquiry. Some felt this option would

be helpful for people with specific issues, but not for someone with a long-term health

condition.

The role of receptionists in signposting patients to the right care was raised, along with

healthcare professionals having access to records and being conveniently located in the

community for patients to visit.

People were happy to visit another practice in their area if they could not get an

appointment, as long as patients with long-term conditions could have access to their named

GP.

For triage purposes, people would be happy to speak to a healthcare professional over the

phone when they are feeling unwell. However, equality of access would need to be

considered.

Overall people were happy with online services for booking appointments/seeing test results

online but concerns were raised with the lack of trust in the current system and whether

certain populations were making use of online services. Alongside this, questions were

raised about the interpretation of test results, compatibility with ‘Patient Access’ and the

face-to-face contact with receptionists which some people prefer.

When discussing the role of healthcare professional in GP practices, people were aware of

the different roles in place but felt more needed to be done to promote the competencies of

these professionals.

People supported the principle of sharing records between healthcare professionals as long

as data sharing agreements were in place, that information was shared on a need to know

basis and that due diligence was observed.

When thinking about digital solutions in primary care, people felt it was important to

introduce new technologies but emphasised that it should not be the be all and end all.

Significant promotion of existing technologies and Apps is needed, with a suggestion to

involve voluntary sector organisations to help with promotion. Some people are confused

with the volume of Apps available and suggest that some need to be combined to create a

clear route to services/support. Other comments made as part of the conversation were:

- Offer training sessions

- Video calls

- Security needs to be high

- What about self-monitoring pods in high footfall areas.

Generally, people felt that digital solutions should be tailored to individual needs and have

functionality for conversations with GPs, booking events, translation services, and skype

consultations. However, concerns were raised for vulnerable people and the need for them

to be protected from abuse.

Locally, people said they use online services for appointments, prescriptions, access to 111

and a test web chat. However, all agreed the need for input from different population groups

to develop digital solutions in primary care.

Challenges to the use of digital solutions were:

- software adaptable for people with dyslexia and other disabilities

- large proportion of population who are not good with technology

- needs to be easy to use and available in different languages

When asked what digital solutions would support patients, people said:

- Medical records access - Access to medication - Text message alerts from GP - Symptom checkers for reassurance - Care plans i.e. Cardiac/diabetes etc.

When thinking about opportunities for digital solutions people said:

- Video consultations - NHS organised directory - Tell ‘Alexa’ to give me a repeat prescription

Sandwell and West Birmingham

Mixed views were shared about seeing a healthcare professional, rather than a GP. Some

would rather see a nurse or pharmacist for minor ailments and felt they were best placed to

make the choice when it would be appropriate to see their GP or use an alternative service.

For those supportive of seeing a healthcare professional, questions were raised about the

qualification of these roles, the need for them to signpost to other services and whether they

would be able to administer prescriptions.

Again, views were varied about visiting another GP practice if you were unwell and could not

get an appointment at your own practice. Those that were against the option highlighted

travel times, access to records, continuity of care for people with long-term

conditions/complex needs. Those in support felt that continuity of care wasn’t always a given

with their named GP so would be happy to visit another GP practice if the distance wasn’t

too far, if they were worried about a health condition, if the treatment was effective and that

they had a choice.

Overall, people said they would be happy to speak to a healthcare professional on the

phone if they were feeling unwell albeit some people would prefer to speak to someone in

person. Training and access to records were raised as concerns, along with managing risks

(such as sepsis), supporting people with complex conditions and ensuring the professional

would call at appropriate times to suit the patent. Language barriers, staffing and logistics

were also raised as part of this conversation.

People’s opinions of online services such as booking appointments/access to

records/viewing test results were varied. Those supportive, felt they would be in control of

their health and would have easy access to records/consultant letters however, some

already using online services have experienced technical difficulties and are concerned

about data protection/ the sustainability of online services. Those not in support, felt that

online security was not safe enough and that many people would not have access to

computers to be able to use these types of services.

The majority of people said they did not understand the role of other healthcare

professionals in their GP practice and that more should be done to educate patients. Many

suggested the need for Patient Participation Groups (PPGs) to be involved in the promotion

of additional roles in GP practices. Other ideas that were shared were:

- Education leaflets - Posters in waiting room with description of roles - Notice board in the surgery - Practice leaflets, website - Send letter to inform patients - Word of mouth - Use My GP App - Text message.

When asked about the principle of sharing records and care plans, most people were happy

to have their information shared with health professionals but not voluntary sector

organisations. Concerns were raised about ensuring information was up to date, that

patients had choice in who views their record and what gets shared, patient confidentiality

and ensuring only medical professionals had access.

Many people viewed the role of digital solutions in primary care as a way to improve and

enhance access to existing services, as well as provide patients with more information about

their health. Education and training was highlighted as a way to support older populations to

use new technologies and free up time for more GP appointments.

Walsall

Most people agreed they would be happy to see a healthcare professional rather than a GP

however; every effort should be made for people to see their named GP especially those

with a long-term health condition so that continuity of care can be provided. Questions were

raised about a pharmacy option for advice, whether healthcare professionals would be able

to signpost to other professionals and the need for the service to be seamless and joined-up.

Overall people were happy to visit another GP practice (in their area) if they were unwell and

needed an urgent appointment but, there was a consensus on the need for people with long-

term conditions to go to their own GP practice. Concerns were raised about the impact to

low income families who may not be able to drive/travel. Suggestions were made to collate

information from patients on how far each person is willing to travel.

When discussing the option of speaking to a healthcare professional over the phone, people

thought it was a good idea and that it should be promoted to those who would benefit most

from it. Comments were made about the need for all practices to adopt this approach and

ensure that healthcare professionals were able to offer advice and support on social care

and signpost patients to alternative services. Some people did raise risks, in particular with

patients who find it difficult to communicate / have a hearing impairment / where English is

not their first language / have low confidence in healthcare professionals other than their GP.

Experience of this type of service was shared, however many said that most people who

speak to a healthcare professional over the phone end up having to come into the practice

anyway.

The majority of people were aware and used online services at their GP practice – such as

booking appointments and accessing test results. Many thought there should be more

support for people that do not use technology and they thought that the ambition of 25% of

online consultations might not be achievable for practices with an older population. Some

discussed support arrangements for people receiving test results so they understand what

the result means and do not have to wait too long after receiving a result to see their GP –

patients are likely to google results and as a result might self-diagnose.

When asked about the role of healthcare professionals in their GP practice, people

understood their roles but shared that these should be promoted more widely – in particular

the role of physician associates.

Overall people were supportive of their records and care plan being shared as long as

explicit consent was provided at the point of care. Some were unsure about voluntary

services having access and asked for these types of services to be clearly defined.

Comments were made about the ambulance service and out of hours services having

access to information, as well as the need for an agreement which releases information to

partners. Locally, people thought the Waldoc service worked well.

When discussing digital solutions there was a lot of local knowledge about the technologies

available to patients but people felt there was a need for a one-stop shop of NHS digital

solutions, with approved apps, online guidance and support for information sharing. The

importance of digital tools to monitor health was seen as a priority, especially for those with

diabetes, heart problems and those on weight management programmes. Video

consultations, telehealth and mood path for mental health were also mentioned.

Challenges and risks to using digital solutions were listed as:

- unapproved health advice being shared on social media - funding - disparity amongst people who are able to buy wearable technology - multiple digital systems/apps already in use - needs to be tested on ‘idiots’ to see if it is easy to use - people trusting it and using it - getting the software right - what if people don’t have access to broadband/Wi-Fi

Wolverhampton

People had mixed views about seeing a healthcare professional rather than their GP. Those

unsure of the option thought that it would be dependent on the complexity of the condition/

whether the health issue was undiagnosed. However, those in favour thought that continuity

of care was important when seeing a healthcare professional rather than a GP. Other

comments that were raised were:

- This is just to manage demand to support GPs - What about issues with patient/professional relationship - What about cross border patients A specific comment was made in relation to migrants and refugees – as it is a challenge to

get them to register at a GP practice as their previous experience of healthcare is to directly

see a consultant.

Again, people had varied opinions on visiting another GP practice if they could not get an

appointment. Those in favour said it would be dependent on their circumstance and whether

the practice had access to their health record. Some wanted to know the competencies of

GPs and healthcare professionals at other practices and many who had experience of

seeing other GPs/locums raised the following issues

- Trust– especially for mental health patients

- Not all surgeries are telling patients about extended hours (Duncan Street)

- GPs will not know the patient

- GPs can change medications of people they don’t normally see

- Pharmacist can refuse to dispense prescription

- Travel time/bus/transport links

- What about practices that don’t appear to be working together.

A separate risk was raised, as they would get used to the practice they are registered with.

When discussing if people would be happy to speak to a healthcare professional over the

phone, some said they would be happy to do so. However, questions were raised about the

definition of a healthcare professional. Some said if the professional was not known to them

then they would not want to speak to them over the phone. Other areas raised were

- body language is not readable on the telephone

- Dialect can be an issue/talking too quickly

- Depends on the condition

- Varied and difficult for refugee and migrant populations.

Varied views were given when talking about the use of online services such as booking

appointments, seeing test results and viewing health records. Some people said they were

happy without online services and others said they were already using online services to

book appointments and they liked it. Concerns were shared about:

- usage of the internet with older people

- data protection

- people being able to afford phones/computers

- anxiety if no one is around to assist

- more methods of booking creating inequalities

- Technology needs to work

- Refugee and migrant populations may worry that information will be shared with the

Home Office

The majority of people understood the role of other healthcare professionals in their GP

practice but they wanted to see more of a seamless process and highlighted that it was a

specific skill to determine what a patient needs. Some said the terminology of professionals

(voluntary sector link worker) could be an issue along with patient confidentiality if

professionals are not known. Feedback was shared on the positive use of social prescribers.

A comment was made about the difficulties to persuade refugees and migrants to register

with a GP. The perception of a healthcare professional is that they are not qualified enough

to deal with the current health issue.

People shared mixed views about having their records and care plans shared between

health professionals, with some asking for more information on what would be shared.

People were concerned about information being shared, especially with voluntary sector

organisations. Comments were made about receptionists being responsible for sharing

information which people were concerned about.

When thinking about the role of digital solutions in primary care, people said test results

should be available for those who want them as well as easy access to records. People

thought that booking appointments online was a good idea, but many that use this service

say appointment slots are usually full and the number of appointments available online are

not increasing.

Locally, people are aware of telecare but many do not access other forms of digital services

with a statement made about 30% of people not having access to Wi-Fi.

When thinking about the challenges of digital solutions in primary care people said:

Booking appointments were still very difficult with people struggling to get through on

the phone/availability of online appointments

Not all people can or want to use computers

Not all aware of online services

Concerns about security

However people did comment on the high proportion of people wanting to access digital

equipment to support/monitor their health.

For migrant and refugee populations nearly all clients have access to smart phones but

many do not have knowledge of online services and need to be education on the primary

care system, which third sector organisations could help with. It was noted that NHS 111 is

not always forthcoming with offering interpreters which is a problem for the 4,000 asylum

seekers living in the Black Country and West Birmingham (800 in the Wolverhampton area)

Additional comments shared in the session were:

- GPs only allow one issue during an appointment

- Still getting problems with access to appointments and registering with a GP for

asylum seekers

- Text message appointment reminders are brilliant

- People are not always comfortable about speaking about their health issues over the

phone

- Want to see more of a mixture of booked appointments and ‘walk in same day’

appointments

- Patients don’t know about the services available to them – there needs to be more

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- Branch practices are not working together.

1.1 Future involvement

Going forward we will continue to run events with our local population to present the work

that we are doing and to get input from public and patients on upcoming projects to ensure

that it meets their needs. The outputs of events will be collated and taken to the STP

Partnership Board for consideration.