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The guidance covers: Drug switching Exemptions from prescription charges Excessive prescribing Medicines shortages Non-GP prescribing Prescribing numbers for GPs Prescribing incentive schemes Prescribing advice Working with pharmacists Community drug charts Prescription intervals Travel vaccinations Supplementary and independent prescribing Private prescriptions Charging patients Patient rights and responsibilities

This study from Manbinder Sidhu and Jack Pollard investigated: what specifically has led to hospitals and GP practices being run by the same organisation; how it is done; the expectations of the GPs and NHS managers who made it happen; whether those expectations are being fulfilled; and whether there are any other consequences. To do this, they have interviewed GPs, NHS managers and other staff, 52 people in all, at two locations in England and one in Wales. They have also observed management meetings and reviewed documents referred to by interviewees. They found that the dominant reason for hospitals to run GP practices was to enable some practices that would otherwise have closed to keep going. This has so far been successful. These practices are also increasingly able to offer patients the opportunity to consult a range of health care professionals at the local practice, not just GPs, but also staff with special training to provide specific types of health care, for example, for diabetes or for problems with joint pain. Various legal arrangements were developed in different places to enable hospitals to run GP practices, including setting up an NHS-owned company and making the practices part of an existing NHS organisation.

The analysis found that: only a minority of patient requests for care stated a preference for a face-to-face consultation – falling from 30% of requests before the pandemic to less than 4% at the start of the pandemic. While requests for face-to-face consultations did increase after that, they only accounted for 10% of requests by the end of the study period in September 2021.the increasing use of online consultations systems cause concern about the risk of digital tools creating inequalities by making it difficult for some patients to access care.digital exclusion can be overcome if GP services use a blended approach to booking and consultations.

The Public Accounts Committee made six conclusions and recommendations: The Department has overseen years of decline in the NHS’s cancer and elective care waiting time performance and, even before the pandemic, did not increase capacity sufficiently to meet growing demand. Recommendation: The Department must strengthen its arrangements for holding NHSE&I to account for its performance against waiting times standards for elective and cancer care. This should include specific expectations for improving waiting time performance in 2022–23. The Department should write to the Committee alongside its Treasury Minute response to set out the specific and measurable performance indicators for elective and cancer care it has put in its 2022–23 mandate to NHSE&I. At the Committee evidence session, the Department and NHSE&I appeared unwilling to make measurable commitments about what new funding for elective recovery would achieve in terms of additional NHS capacity and reduced patient waiting times. Recommendation: In implementing its elective recovery plan, NHSE&I should set out clearly: timeframes, costs and outputs of the components of the recovery plan, recovering elective care and cancer care to 2024–25; the longer-term investments and plans that are being made now to improve the resilience of elective care and cancer care beyond 2024–25; and the national performance levels expected in each year between now and 2024–25. The NHS will be less able to deal with backlogs if it does not address longstanding workforce issues and ensure the existing workforce, including in urgent and emergency care and general practice, is well supported. Recommendation: In implementing its recovery plan, NHSE&I’s should publish its assessment of how the size of the NHS workforce (GPs, hospital doctors and nurses) will change over the next three years, so that there is transparency about the human resources that the NHS has available to deal with backlogs. It will be very challenging for the NHS to focus sufficiently on the needs of patients when it comes to dealing with backlogs, both patients already on waiting lists and those who have avoided seeking or been unable to obtain healthcare in the pandemic. Recommendation: The Department and NHSE&I must ensure there is a strong focus on patient needs in all their recovery planning, including: measuring the success of all initiatives to encourage patients to return to the NHS for diagnosis and treatment; creating guidance and tools, and setting aside resources, for meaningful communication with patients who are waiting; and supporting NHS trusts through planning guidance and other means to prioritise patients fairly, so they are able to strike an appropriate balance between clinical urgency and absolute waiting time. Waiting times for elective and cancer treatment are too dependent on where people live and there is no national plan to address this postcode lottery. Recommendation: NHSE&I should investigate the causes of variations between its 42 geographic areas and provide additional support for recovery in those that face the biggest challenges. NHSE&I should write to the Committee in December 2022 on the actions it has taken to address geographical disparities in waiting times for cancer and elective care and include a summary of any analysis it has done on differences in health outcomes for elective and cancer care in different parts of the country since the start of the pandemic. For the next few years it is likely that waiting time performance for cancer and elective care will remain poor and the waiting list for elective care will continue to grow. Recommendation: The Department and NHSE&I must be realistic and transparent about what the NHS can achieve with the resources it has and the trade-offs that are needed to reduce waiting lists. In implementing its elective recovery plan, NHSE&I should set out clearly what patients can realistically expect in terms of waiting times for elective and cancer treatment. By the time of the next Spending Review at the latest, the Department and NHSE&I should have a fully costed plan to enable legally binding elective and cancer care performance standards to be met once more.

The key messages are: Screen all new entrants, including children, for tuberculosis (TB). (Due to low prevalence) look for hepatitis B risk factors that may indicate a need for screening. Consider screening for hepatitis C (considerably higher prevalence than the UK). There is a risk of typhoid infection. Consider nutritional and metabolic concerns. Work with a professional interpreter where language barriers are present. Consider the impacts of culture, religion and gender on health. Assess for mental health (and trauma) conditions. Support individuals and ensure that all patients, especially children, are up-to-date with the UK immunisation schedule, including making the offer of Covid vaccination (primary course, boosters, or completion of initial course if begun overseas) Refer pregnant women to antenatal care. Newly arrived individuals will need help on how to access the NHS, and this will include GP registration as the principle route for accessing services. Individuals may struggle to provide proof of ID, address or confirmation of immigration status and their registration requests should be managed sensitively. None of these documents are required for registration and the inability of any individual to provide them is no reason to refuse registration.

Key messages: Now is the time to reform general practice in England. Reform is not a distraction from tackling the biggest issues confronting the profession. A mixed economy should prevail, but with greater incentives for workforce, data and procurement to become coordinated through ‘layers of scale’ in cooperation with the NHS. Independent provision will continue to have a central role in primary care. The primary care pathway should be redesigned to improve access by creating a more coherent ‘first contact’. Ensure continuity of care is built into any new model. General practice should be the foundational layer for scaling digital healthcare in the NHS.