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Children and Young People Additional GP Appointments
Background
On 15 March 2024, ICB asked both Camden Federations if they were interested in offering additional time-limited booked face to face appointment capacity for children and young people. The intention was to enable hub providers to offer additional dedicated support to this cohort which is known to have greater need for GP services outside of core hours.
In other NCL boroughs, the additional capacity was offered and taken up by the Bridging Services managed by the Federations. In Camden, the bridging service is provided by AT Medics.
ICB required these appointments to be:
- Available to anyone under 18, noting that the biggest need with in this cohort is expected to be in children aged 0 to 4
- Face to face, with either a GP or nurse as determined by the provider
- Available at weekends and on bank holidays, and sensibly distributed across Saturday and Sunday opening hours based on provider understanding of likely need
- Bookable by practices and by 111 (and available for parents to book directly if this is offered as part of the core hub service)
Breakdown of costs / appointment numbers for Camden
Borough: Camden
- Weighted List Size: 341658.4457
- % NCL list size: 20%
- Funding available: £23,968.93
- Cost per appointment: £40.31
- Number of appointments: 595
Federation: CHP
- Funding available: £17,976.70
- Number of appointments: 446.25
Federation: CHE
- Funding available: £5,992.23
- Number of appointments: 148.75
Providers were asked to deliver the above within a realistic timeframe balancing the need to mobilise and deliver quickly with an achievable number of appointments per week.
The appointments were designed to be available for “urgent” short notice need (booked <48 hours) covering weekend operating hours where core General Practice is not open. As ringfenced appointments are not always utilised as planned and providers were asked to be flexible with their service offer to accommodate this and maximise utilisation:
- In the first instance where appointments haven’t been booked at least 2 hours in advance these can be freed up for telephone triage for all patients.
- Over time, providers are also asked to monitor utilisation of the appointments and make sensible adjustments to provision and availability to maximise uptake amongst the target population.
- Where data indicates it would be sensible to deviate from the detail of the specification above to offer a service in-keeping with its spirit, this will be encouraged but providers are asked to discuss this with commissioners.
CHP's Service
As CHE said they did not want to take up the offer, CHP provided a service to all Camden practices. We located the service alongside the GP walk in service we provide at Royal Free Hospital within the UTC as this was the only hub service we provide that coincided with the hours and days required. As a result, we limited our costs relating to premises and administrative support. The agreed service offer with the ICB was:
Location, hours of operation and number of appointments
- Royal Free Hospital, CHP GP UTC area
- 8 hours service daily, 9.00 am to 5.00 pm, Saturday and Sunday, offering 32 appointments a day for 9 weeks
- Total number of appointments: 576
- start date 27 April to allow sufficient time to recruit to rotas, train navigators, set up IT infrastructure and publicise service with 111 and practices to promote utilisation.
Service model
- Entirely separately managed from ED queue with patients directed by 111 to GP area of UTC where there is a separate reception we staff
- GP provided face to face only
- Open to direct booking by practices and 111 for all Camden practices; we are not able to offer direct booking by patients in the UTC setting in this pilot.
Service flexibility
- Under utilised appointments could be switched to adults and booking more than 48 hours in advance
- We would not be able to offer remote appointments at the RF due to connectivity issues at the RF site.
Cost
We provided the service within the budget of £23,969. The cost per appointment, £41.61, was slightly higher than the target cost. CHP did not charge any overheads to the service as strategically we were keen to provide a service across Camden open to all practices and 111. We believed this would be useful experience, were there an opportunity to bid for the Camden Bridging Service from October 2025.
Service experience
Location and IT
The Royal Free Hospital (RFH) were very supportive to CHP in providing this service. They vacated a room adjacent to GP rooms in the UTC and waived any additional costs (rent and services). The ICB had no additional funding for rental costs. RFH approved community EMIS to be uploaded on to their desktop computers. The option of using WIFI enabled CHP laptops was not a realistic option as WiFi connectivity is very poor in the UTC. These were used as a back-up a couple of times when the RFH system went down.
Staffing
We were able to recruit four very experienced GPs to staff all sessions within the budget. The service was largely provided by two GPs, one of whom worked at Barnet and Royal Free UTCs and the other within CHP's EAS. The UTC GPs and the two weekend navigators had to be inducted in the use of community EMIS.
CHP provides a patient navigator as part of the GP service at the Royal Free UTC. The navigator was able to book patients into the service on arrival. However, there was insufficient navigator capacity to send patient reminders of their appointment or call patients when they did not attend. Nor were they sufficiently knowledgeable of EMIS to action referrals arising from the GP appointment. CHP provides an extended access service (EAS) in an adjacent GP practice to the Royal Free, Hampstead Group Practice on Saturdays. The EAS administrator was able to undertake patient texting and referrals. On Sundays, the EAS manager or administrator worked extra hours to provide this support.
The EAS manager was also on site for the first few weekends to induct GPs and navigators into the service and provide support.
Without support from the manager and administrator, the service would not have run as smoothly e.g. contacting 111 in real time on making referrals, giving the patients appointment times, not booking in adults, contacting patients. The navigators did not have capacity to support fully two services. Additional administration costs were not included in the agreed budget.
Utilisation and flexing criteria
The service was set up for 0 to 17 year olds but it was anticipated criteria might need to be flexed in case there was under utilisation of the service.
Below is the utilisation rate for the 9 weeks. During this period there were two bank holiday Mondays (6 and 27 May) and half term (27 to 31 May), all of which had an impact on utilisation. Utilisation on 5 May was very low. The first two Sundays also had lower utilisation than Saturdays, a pattern that continued throughout the service running.
27 April: 38%
28 April: 34%
4 May: 69%
5 May: 13%
11 May: 91%
12 May: 72%
18 May: 59%
19 May: 66%
25 May: 88%
26 May: 75%
1 June: 81%
2 June: 88%
8 June: 97%
9 June: 56%
15 June: 97%
16 June: 78%
22 June: 97%
23 June: 81%
Total: 71.0%
Given the utilisation rate, we agreed a number of changes to the booking criteria with the ICB. From Sunday 12 May, the service took bookings for adults via 111 on Sundays.
For weekend 25 and 26 May, ICB agreed that practices could book more than 48 hours in advance for children and young people and adults from Friday. 111 bookings could be made for adults on Saturday as well as Sunday. We kept some appointments ringfenced for CYP for Friday and weekend booking (practices and 111).
For the last three weekends (8/9 June to 22/23 June), the service was open to booking for adults by practices and 111.
While these changes increased utilisation, Sundays continued to have lower utilisation than Saturdays.
Source of referrals and discharge destination
111 and practices
Below is the source of referral split by practice and 111. The overwhelming majority of referrals were from practices (82%) even on Sundays. We contacted 111 at regular intervals including weekends, reminding them of the service. Bookings did increase from 111 when the service extended to adults on 12 and 19 May but this level of activity was not sustained. On seeking information about why bookings were low, we were advised, there was insufficient demand for face to face appointments.
27 April:
NHS 111: 7
GP Practice: 5
Total: 12
28 April:
NHS 111: 7
GP Practice: 5
Total: 12
4 May:
NHS 111: 4
GP Practice: 18
Total: 22
5 May:
GP Practice: 4
Total: 4
11 May:
NHS 111: 8
GP Practice: 21
Total: 29
12 May:
NHS 111: 16
GP Practice: 7
Total: 23
18 May:
GP Practice: 19
Total: 19
19 May:
NHS 111: 14
GP Practice: 7
Total: 21
25 May:
GP Practice: 28
Total: 28
26 May:
NHS 111: 5
GP Practice: 19
Total: 24
1 June:
GP Practice: 26
Total: 26
2 June:
NHS 111: 2
GP Practice: 26
Total: 28
8 June:
GP Practice: 31
Total: 31
9 June:
NHS 111: 4
GP Practice: 14
Total: 18
15 June:
NHS 111: 1
GP Practice: 30
Total: 31
16 June:
NHS 111: 1
GP Practice: 24
Total: 25
22 June:
GP Practice: 31
Total: 31
23 June:
NHS 111: 3
GP Practice: 23
Total: 26
Total:
NHS 111: 75
GP Practice: 334
Total: 409
PCN utilisation
Not surprisingly, the PCN closest to the service location had greatest utilisation (North Camden PCN) and the PCN furthest away, South Camden, did not use the service at all. Interestingly, the second highest utilisation was by Kentish South PCN which is two practices run by the same team. Higher utilisation could be attributed to more effective communication about the service within the PCN.
Appointments by PCN & Practice
Central Camden PCN: 18 4%
Central Hampstead PCN: 11 3%
Kentish Town Central PCN: 34 8%
Kentish Town South PCN: 132 32%
North Camden PCN: 146 36%
South Camden PCN: 0 0%
West and Central PCN: 54 13%
West Camden PCN: 14 3%
Total: 409
Patient demographics
Noting the change to booking criteria over the 9 weeks, the average utilisation by age and gender split is set out below.
Appointments by Age Group
0 to 5: 76 19%
6 to 17: 127 31%
18 to 64: 176 43%
65 & Over: 30 7%
Total: 409
Appointments by Gender
Female: 240 59%
Male: 169 41%
Total: 409
Even though adults were included from 12 May (week 3), the largest age group was 0 to 17 years. The smallest group was 65 years and over. There was higher utilisation by females compared to males.
Outcomes
Appointments by Outcome
Discharged Home: 346 85%
Referred to Community Services: 4 1%
Referred to ED / Hospital: 10 2%
DNA: 49 12%
Total: 409
The majority of patients were discharged home and 3% were either referred to ED/hospital or community services. 12% of patients DNA. Six out of nine weeks, DNAs were higher on a Sunday. DNAs were higher from 111.
Patient experience and feedback
44% of patients provided feedback via a survey sent to the mobile number provided. Of those who responded, 93% were very satisfied/ satisfied with the service.
Insights and recommendations for future additional weekend capacity
Mobilisation
With the support of RFH and access to staff and GPs in CHP’s UTC and EAS, we were able to mobilise the service quickly and run all agreed hours
Appointment length
With less than 100% utilisation, GPs were able to keep to 15 minute appointments. Were the service better utilised, we would have had to have either designated every 5th appointment for administration or extended the session length to maintain the same number of appointments.
Patient demand
Had the service been put on during the winter months, there may have been more demand for CYP appointments and bookings from 111. Some Federations in NCL agreed with the ICB to delay putting on this capacity until the winter months. CHP had not appreciated this was an option. However, they were adding this capacity to an existing seven day service. CHP does not run a GP bookable service on Sundays so testing a new service in the winter months might have been challenging alongside an ED service. It was useful experience for CHP and 409 patients were booked into the service. CHP GPs commented that a bookable appointments in advance for CYP is not entirely appropriate as they need to be seen on the day. As this was a weekend service, on the day appointments could only be accessed via 111. This underlines the importance of ensuring 111 accessing bookable appointments on the day in winter months or other peaks in high paediatric activity e.g. respiratory.
Established service and links with 111 and practices
With the exception of three weekends, referrals from 111 were very low. It is possible that had the service run longer than nine weeks with a constant criterial for all ages, better links would have been made with 111 and practices and more referrals may have arisen. For future hub services, we should ensure the hub service is number 1 or 2 on the DOS. There was also a breakdown in communication in how the service worked in that some patients were booked into the service by 111 but were not told they had a booked appointment. Had the EAS manager not contacted patients to ask where they were, they would have missed their appointment and the service would not have run so smoothly.
Location of the service
Utilisation across the PCNs was very uneven. If we were to run a weekend service on an ongoing basis, to ensure equity in access we would need a two base site, one in the south of the borough near Euston Road and one either in the north or west of the borough. Co-location with UTC services has some merits in providing service resilience, for example the CYP GPs helped out with the UTC queue when no patients were booked. Patients who need to have diagnostics or be seen by a specialist, do not have to travel further. However, patients also sometimes experienced difficulty in finding the reception area within ED although details were included in the text reminder and the navigator checked patients were not joining the ED queue.
There are also merits in boosting capacity within an established service e.g. extended access/Bridging Service. Patients finding the service would also have been easier.
Keeping DNAs to a minimum
For a hub service, the overall DNA rate was quite low (12%). This is partly attributable to the EAS team texting patients their appointment and sending a reminder. However, there were five days when DNAs were higher between 16% and 24%. We have undertaken a more detailed analysis of the DNAs and could not identify any particular pattern. Some days DNAs were higher from higher referring practices and 111 referrals resulted in a slightly higher average DNA rate than practices, 13% compared to 11%.
Cost and Federation capacity
CHP did not charge for any costs for planning and setting up the service. Were CHP not funded by the ICB to support at scale projects through the GP Federation contract or wanted the experience of running a Camden wide service bookable by 111 and all Camden practices, we may not have expressed interest in providing this service. The EAS team worked Saturdays and Sundays to support the service. The CHP UTC navigator was too busy in the UTC service to provide the support required (booking appointments, texting reminders to patients, actioning discharges and onward referrals). Realistically, additional capacity can only economically be added to an existing service e.g. EAS on Saturdays or a Bridging Service.
Operational issues
- Discharges to practices would be quicker if Write Back was included in community EMIS, not currently funded by GPIT
- Equipment was purchased for the service but was not kept securely in the GP room at all times and was taken by other health professionals in the ED and not returned
- Workforce, contract variations were secured for the three GPs but took some chasing. The GPs who worked in the service were very good and known to us.
- We appreciate the additional time and effort our staff and doctors put into making this service go live quickly and be delivered effectively.
- We also appreciate the support from Royal Free Hospital without which the service would not have gone ahead.