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Health and Social Care Committee 

Oral evidence: The future of general practice, HC 113

Tuesday 28 June 2022

Ordered by the House of Commons to be published on 28 June 2022.

Watch the meeting 

Members present: Jeremy Hunt (Chair); Lucy Allan; Rosie Cooper; Luke Evans; Marco Longhi and Laura Trott.

Questions 182 - 226

Witnesses

I: Matthew Taylor, Chief Executive, NHS Confederation; Saffron Cordery, Interim Chief Executive, NHS Providers; and Sarah Sweeney, Head of Policy, National Voices.

II: Dr Claire Fuller, GP, Chief Executive-designate, Surrey Heartlands Integrated Care System; and Dr Hugh Porter, GP, Clinical Director, Nottingham City Integrated Care Partnership.


Examination of witnesses

Witnesses: Matthew Taylor, Saffron Cordery and Sarah Sweeney.

Q182       Chair: In our inquiry into the future of general practice today we are particularly focusing on the interface between general practice and the rest of the NHS, whether that is hospital care, community care or social care. We have a stellar cast list. Matthew Taylor is the chief executive of the NHS Confederation. Sarah Sweeney is the head of policy at National Voices. Thank you both for joining us. We will also have Saffron Cordery online in a moment. [Interruption.] Hi, Saffron, can you hear us?

Saffron Cordery: I can hear you. Hi. Nice to see you all.

Chair: How are you feeling?

Saffron Cordery: Not too bad, thank you. I had a little bout of the terrible covid and it is still lingering.

Q183       Chair: Well, thank you very much for braving it and joining us remotely; it is really appreciated.

Let us start with some general points. Matthew, first of all, congratulations on your new role and the impact you are having. At the NHS ConfedExpo, which you helped to organise, the Secretary of State said he did not think the current model of primary care was working and there needed to be a plan for change. Do you agree with that, and what would be top of your list in terms of the overall things that need to change? Our focus is on general practice, but obviously that is part of a bigger picture.

Matthew Taylor: I do not think it is particularly useful to generalise in the sense of saying primary care is broken. We need to recognise that, for example, we are now seeing more consultations than before covid11% more consultations, with 5% fewer staff, than five years agoso actually there have been productivity increases in primary care. If we only had productivity increases at that scale in the rest of the economy, we would be thriving. Most patients are satisfied with their experience of engagement with primary care, although levels of satisfaction are declining, so there are really big issues, but let us also recognise that this is still a system that is working for most people.

In terms of where we are, I have thought a lot about this, and I hope you do not mind if I use a metaphor for understanding where we are. Sometimes I think there is a false dichotomy between those who say the issue is demand and capacity, and who seem therefore not interested in reform, and those who say the answer is reform and seem not to be realistic about demand and capacity. My metaphor would be that, until I recently moved, I would spend a lot of time in the morning rush hour waiting to get on an underground train at Clapham South station, and I could not get on. I could not get on for fundamental reasons of demand and capacity: there were too many people and not enough trains, and if you did not recognise that, you were not recognising the truth. However, there are ways in which you can design trains to enable more people to get on them. The new Elizabeth Line trains, for example, are a single carriage—they have fewer seats. So you can do things that can help with the capacity issue.

Thirdly, the way the public behaves does matter. If people take off their rucksacks, if they are polite to each other, if they stand next to each other, we can also get more people on. Fourthly, the relationship of the underground to the rest of the transport system is also important: are there cycle routes, are there buses, do employers stagger peoples start times? That is the way I would understand primary care: as a fundamental issue of demand and capacity, but there are important things we could do with design, with public expectations and with the wider system that could improve things.

Q184       Chair: Let us just focus, if we may, on the reform bit of that false dichotomy. You will not necessarily know this, but we have spent a lot of time as a Committee talking about the capacity side and the need to recruit and retain more GPs. Putting all that to one side, what are the big reforms that could make a difference?

Matthew Taylor: I would identify two. The first is enabling and incentivising primary care to operate at scale. That is the big idea behind primary care networks. We at the confederation represent all parts of the system, so we represent primary care networks and primary care federations. But we also represent the rest of the system, so we think a lot about how primary care interacts with that system. Primary care operating at scale has real advantages in terms of efficiencies and in terms of the capacity for learning and for innovation. We have created primary care networks; I do not think we have invested in the right way in terms of management capacity, organisational development and the space for primary care networks to innovate, but I still think it is the right idea. The idea at the heart of Claire Fuller's work, and Claire is on after us, around primary care networks coming together to work at a locality basis, is also powerful.

The second thing I would say is improving the way in which we triage at scale. If we look at the 111 service as an example, we could find ways to better direct people to the service they need when they need it and, even better, enhance that with the capacity to actually understand where demand is in the rest of the system. If I could give you a vision of the future, it would be trained people working in 111 centres within localities who not only have the record of the patient who is ringing them up and a good set of skills to understand what their needs might be, but a dashboard that tells them how many people are waiting in A&E or other services, so they are able to direct that person to the service they need. That could make a big difference.

Q185       Chair: Let me ask you a follow-up on that and then one final question before I bring in your fellow panellists. Other witnesses have said that the system is just way too confusing for patients. Most people know that if it is an emergency, it is 999get to an A&Ebut if it is not at that scale, if you have something that is minor and not an emergency, do you use the out-of-hours service or 111, or do you call your GP surgery? It is very bewildering to know what to do. Do you think we need to make it much clearer for people to know what they should do in certain situations?

Matthew Taylor: I think so. The best service would be one where you knew where you had to go and where the person responding to your challenge understood you and your needs, as well as the capacity in the system, and was therefore, in the best possible world, able to give you choices and to say, Well, you could go to A&E, but you might be waiting several hours, or you could wait three days and see a GP, or you could see a physiotherapist tomorrow because you are complaining about musculoskeletal issues. If we can improve the signposting and even give patients a capacity for choice that empowers people, that would be a big step forward.

Q186       Chair: I will  bring in my colleagues shortly, but I just want to ask you about two specific reforms, and then I am going to ask Saffron and Sarah to comment on these two reforms as well. We have discussed them in earlier sessions, and we would be very interested in your insights.

One of these reforms is that we have heard from the Secretary of State a possible intention to scrap the partnership model. He wrote the foreword to a think-tank paper that suggested that the partnership model might be over by 2030 and that we should move to salaried GPs being employed by hospitals, as happens in some parts of the country already. We had a lot of evidence from GPs concerned about that, saying that the partnership model allowed independence and innovation, and that although there was an issue with the partnership model over premises, and the property risks were killing some partnerships in some places, we should try and solve that problem. So we would be interested in your view on that one.

The second one was on continuity of care. We are going to find out how much Claire Fuller agrees with this or not when we talk to her later, but there seems to be a view in the system that continuity of careseeing the same GP, or with the same GP responsible for your care over a long period of timeis the right thing for complex patients, but that normally fit adults just want to see a doctor as quickly as possible. We had a lot of people saying that was rubbish and that it is incredibly important with normally fit and healthy people that they too see a GP or have a GP who is responsible for their care, in order to stop them becoming a chronic patient or in order to spot that cancer. Not only that, but GPs who see the same patients regularly are much happier and it is much less stressful than seeing 30 or 40 brand-new people every day. Those are a couple of thoughts there that we have heard. Matthew, first of all, what do you feel about both those areas?

Matthew Taylor: On the partnership model, partnership brings many benefits, particularly in terms of the kind of commitment that general practitioners make to that model. I do not think the partnership model is in any way in tension with primary care networks or federations operating at scale. There does seem to be a trend away from the partnership model. I do not think that the major reforms we need to achieve are unachievable with the partnership model, so why would you want to take on something that a lot of people care about , that matters to them and that motivates them? The challenges are hard enough without having a battle we do not need to have. That would be my view.

In relation to continuity of care, we need to distinguish between different types of continuity. One of the bits of continuity failure that most annoys people is around continuity of information. It is not so much seeing the same person; it is having to repeat the same details again and again. There is continuity of information, there is continuity of care, and there is continuity of relationships, and these are different kinds of things.

I agree fundamentally, and, indeed, I will take a story from Charlotte, from National Voices. She gives an eloquent story of her own experience. She does not have multiple conditions or long-term conditions, but there is a history there, having lost her husband to cancer and having had mental health challenges in terms of members of her family. The idea of having to explain that history, which is quite a painful history, all over again to somebody is not nice.

So, yes, there are people for whom continuity of care matters who are not people who have long-term, multiple conditions. Therefore the principle should be signposts, not no entry signs. If patients say continuity matters to them, we should trust them that it does and try to enable them to have it.

Q187       Chair: Thank you. Saffron, are you getting continuity of care for your covid?

Saffron Cordery: Well, fortunately, I have not yet had to access a healthcare professional for it, so let us hope it stays that way.

In terms of the questions you ask here on partnership and continuity of care, the partnership one is really interesting. We have a number of our members who are, as trustsnot just hospital trusts, but mental health trusts and community trustsactually working with GP practices and running GP practices in some of their areas. It is not the only solution, and we should be really clear that we should not be jumping to a single solution to solve a big challenge here, because I do not think the partnership model is what is creating the challenges that exist in primary care and GP practices. It is actually a broader issue that we know runs across a whole host of the challenges we face across the NHS, and there is just as much that unites secondary care and primary care in those challenges. It is about the availability of workforce. It is about the levels of demand going up. It is about the availability of social care. And, to an extent, it is also about funding.

This is not a silver bullet, if you like, to solve the problem, but we have seen that it is working in some places. There is no evidence that simply being employed by another organisation will resolve the workforce challenges, for example, that we have across the NHS. We also know that there are not actually that many trusts at the moment who are running GP practices. There is no empirical evidence on that, but we think it is probably around a dozen or so, so it is not a widespread model at the moment.

On that basis, we should think really carefully before jumping to a solution that says all GPs should be salaried and that the partnership model is dead. It is about working out what local circumstances need, and working out within systems, and with trusts within systems, the best way to take these things forward. It is fundamentally about building that capacity. It is about having a supply of workforce. It is about a proper workforce plan for GPs. It is not about the model of running a particular service in this instance.

Q188       Chair: What about continuity of care?

Saffron Cordery: That is a really interesting one, and certainly what I take from reading the Fuller report, for example, and my own conversations with Claire and others is that we should start to think much more seriously about the functions of what we are trying to achieve with both primary care and secondary care, rather than about where that care takes place and how it is delivered, because that is the fundamental element. Are people able to access the type of care they need and want in the way that they need and want to? Sometimes that will be about having access to the same GPs, but at other times it will be about overcoming some of the real challenges that we seecertainly in the interface between secondary and primary carewhich are about flows of information. It is about chasing up referrals. It is about getting the right digital data interface in place, which we know is one of the big challenges facing primary care. Often, it is about sorting out thoseI was going to say hygiene factors, but they are way more than hygiene factorsfundamental infrastructure issues that would then create the space for GPs and other primary care professionals. We get very fixated on GPs, but it also goes beyond that.

Q189       Chair: Thank you. We will come back to you. Sarah, your thoughts on those two potential reforms?

Sarah Sweeney: It is quite difficult to comment on the partnership model in a way, because it is not that we speak to patients and they give us feedback on the types of models or what happens behind the scenes. From our perspective, the reality for people who either have long-term conditions or are occasionally or sporadically accessing health and care services, is that there is not necessarily an understanding of the difference between general practice, primary care, community care and all the different parts of the system. Each time we enter the system, we need to have effective signposting and then communication to understand what is happening. So it is not something where there would necessarily be a particular kind of patient

Q190       Chair: They probably do have views on whether they get to see the same person.

Sarah Sweeney: Yes. For continuity of care, I think this is really important and this is part of the reason why we are seeing low polling and low satisfaction with GP practices over a longer period of time. What we heard during the pandemic was that access had worsened, which a lot of people here will be aware of, but of course, notwithstanding the fact that there are more appointments than there have ever been, we see long telephone waits and websites that are hard to navigate. One of the things we hear from people is they feel they do not have a choice about the way they access care or when they access care.

There is, of course, a very obvious argument for why people with long-term conditions should be accessing health and care in a way that enables that continuity of care. There are lots of different reasons why people might want that; they might not want that as well. In a workshop that I took part in last week, I heard of a man who specifically picked his GP because he is from the same country and can speak the same language, so there are lots of different reasons why people might want continuity of care and to see a similar face. Also one of the things we have learned around health inequalities throughout the pandemic has been that there is also a large role within health and care in terms of winning back the trust of communities that have experienced inequalities and exclusion from health and care services. Sometimes a person who you recognise, who you know and who you trust acting as the front door to the whole of the health and care system can make a really big difference within that. It is not just for people with long-term conditions and mental health, although that is important, but there are lots of other reasons why that might be part of the mix. So it comes back to choice, from our perspective.

Q191       Laura Trott: Sarah, can I ask you first off whether you think that accountability mechanisms for GPs are adequate at the moment in terms of the service they provide and also the access?

Sarah Sweeney: That is a very good question. We are part of lots of conversations at the national level where we work with Confed, providers and other organisations, so you have a really good sense of how it feels to work in a GP practice. Broadly, the thing we hear there is around bureaucracy, red tape and wanting to remove that and wanting to give people as much time with patients as possible.

At the same time we hear about some really concerning issues on the ground, especially around access. One of our member organisations, Friends, Families and Travellers, for example, did a mystery shop of 100 GPs last year to see whether a nomadic patient could access registration through the services. Of those 100 GP practices across the country, 74 refused to register the mystery shopper because they were unable to provide proof of identity or proof of address or to register online.

To me, this speaks to a really basic thing that should be an expectation across health and care and indeed is part of NHS England guidance: that we should all be able to access general practice. This is also experienced by people experiencing homelessness, asylum seekers and refugees. For these issues, that fundamentally make a difference in terms of being able to access health and care in a country where everyone should be able to, of course there should be accountability within that.

But we also need to look at the full width and breadth of the support that is needed for GPs. I find it very difficult sometimes. We know that people are working incredibly hard, working really long hours and really want to serve the communities around them. Being human, lots of people get it wrong. To what degree you use carrot and stick is always going to be a very difficult thing. Broadly across the country, I see that people are keen to support and work with communities, but that mix is not always perfectly correct and that could be improved.

Around the access issue, that is a serious thing. It is unhelpfully played out in dialogues where you hear people say no one is getting access except through digital, which is not true. We have lots of people who either prefer to access health and care through digital means, but also lots of people who are given that choice. It is a really mixed bag, and we all need to look at the kind of full width and breadth of tools available to make sure we can all access health and care.

Q192       Laura Trott: Where you have identified the problems that you talked about here, do you feel there has been follow-up to address those?

Sarah Sweeney: With the access to registration for GPs for example?

Laura Trott: Yes.

Sarah Sweeney: Most people, when they hear that at every level of the system, are slightly horrified that that might be the case. There is not one of us that sits here and thinks this is acceptable, or even that it is happening, in lots of cases. I think there is a disempowerment within general practice of the reception team. Actually, the reception team are such a focal point for ensuring really good continuity of care for patients; they are the point of contact for all communications and for that kind of triage function, which involves a lot of the trust people have in health and care. It would be really good to see, as part of future reforms for general practice, a serious investment in the reception team. If people had more time to spend with people and explain why they were being triaged to a specific part of general practice or the wider health and care system, that would make a lot more sense to people and it would help to rebuild some of that trust.

There is also that investing in the website models for GPs. We know that during the pandemic lots of people very quickly responded to the fact that we could not all be together in a room and that it was not safe for a period of time by creating websites. We also hear from patients and other people that their experiences of accessing those was not good because, even with a long-term condition, they were having to repeat themselves constantly and fill out extensive forms, or just feeling that it is not possible to fill out a form either because of confidence using digital or lots of other things. Yes, it is a real mixed picture.

Q193       Laura Trott: Matthew, can I ask you the same original question? Do you think the accountability structures for GPs are adequate at the moment?

Matthew Taylor: Anybody who is publicly funded and providing an essential service to the public needs to be accountable. As Sarah said, the experience that GPs and primary care more broadly have is of a highly regulated environment. However, I would say, and this is a general issue for the health service actually, that accountability is too upwards. That is to say, accountability is around responding to the regulations sent down from the centre. What we need to see is stronger accountability laterally. Saffron talked about community, social care and mental health, so actually what we want to do is strengthen the accountability of primary care to the other organisations working within systems, and that is one of the strengths of Claire Fuller’s idea of locality-based working. You can bring together those people, who are often working a lot of the time for very similar peoplethe client group that you dedicate resource to in terms domiciliary social care, community services and primary care is very, very similar. So, we should have more accountability outwards and more accountability downwards into the community.

I do not wish to steal all Claire’s thunder, because she is coming on next, but one idea in terms of freeing primary care up to do more population health managementgetting out into the community, doing more preventive work—is that it means a model of primary care that is much more responsive to its local community and its needs. Let us try and get accountability better balanced, is what I would say.

The other thing is that, yes, performance does matter. One of the reasons why I think we want to see primary care at scale is that it means that smaller and more isolated practices get the opportunity to see how others are doing and to recognise that some of their practice may not be great. If you look at some of the best practices in federations, for example, they have that scale so that you can learn from colleagues. It becomes more difficult if you are not doing the right thing and people down the road are doing the right thing.

Q194       Laura Trott: You talked earlier about 111 and your idea for a better use of data, do you think that is also true in terms of looking at the performance of GPs across the boardfor their assessment within the primary care network, but also for them to compare themselves to other GPs nationwide?

Matthew Taylor: I am in favour of transparency to the public, but I do think we have to understand that if you were to compare the performance of primary care, you would have to say, Well, hold on. Some parts of the country are very under-served in terms of GP numbers. For example, some parts of the country deal with much more challenging populations. As Sarah said, some primary care groups will happily take on homeless people or other people. Should they be penalised for the fact that, in doing that, their performance in other areas may not be as strong? Yes, accountability and, yes, data, but let us not have a system that creates perverse incentives to, for example, not take on the most challenging patients.

Q195       Laura Trott: Saffron, can I ask you the same question, please, in terms of whether you think the accountability structure for GPs is adequate at the moment?

Saffron Cordery: Yes, thanks for asking. I put my hand up to come in, so that is great. We have to think about what we are looking at in terms of accountability. On a very micro level there is, of course, the accountability for individual performance. Being a GP is a highly regulated role and profession, and we should reflect and remember that that is in place in terms of the functioning of that individual role.

Where it gets more interesting, as Matthew said, is when we think about the overall role, function and impact of GP practices and primary care more generally. We should remember that prior to ICSs, and as ICSs have come into development, it is not that primary care, for example, was entirely without any kind of accountability or regulation. We have had things like health and wellbeing boards in place for a long time, which are run by local authorities and bring together hosts of local partner organisations to hold to account, and to input into, the level of service and the efficacy of that service. We have the overview and scrutiny committee and local authorities that are carrying out some of that role on behalf of communities, holding public services to account. I would see the ICS role here is as pulling together and creating more coherence around that sense of accountability.

At a higher level, we then need to look at whether primary care and its contribution, and GPs within that, actually meet the needs of the population as a whole. That would be the broad sense of whether the ICS itself is meeting its strategic function. Of course, NHS trusts play a key role within that. We already have some accountability structures in place. Should they be strengthened within a system context? Yes, but appropriately so. What we do not want to do is tie up the hands and feet of every GP practice in the land with a lot of red tape. What we want to do is make sure that outcomes and needs are being met.

Q196       Laura Trott: The point you just made there, Saffron, about outcomes is very important because, as Matthew said, there is a lot of regulationarguably too muchfor GPs. But in terms of monitoring of actual outcomes for patientswhether they are missing a lot of cancer diagnosis, for examplethat may be something where we could look at ICSs taking on a bigger role. Would that be something that you think is fair?

Saffron Cordery: I think we need to look at the role of ICS in terms of how they are meeting the overall population health needs of the patch they are there to serve. We will get into very difficult territory if we are starting to look at this on an individual condition-by-condition basis. We know that there are big chunks of conditions that do need particular scrutiny, but I do think that that will get us into quite challenging territory. We know different parts of the health system are already held very closely to account for cancer outcomes, and GPs will have a contribution to make to that, but whether we should be holding GPs, individually, severally, to account for whether or not they are missing cancer diagnoses, for example, would require further investigation before we went down that route. That would be my view.

Q197       Luke Evans: My question is to Matthew and Saffron. We have spent a lot of time hearing you say we need to sort this, we need to change design. Matthew, if I start with you, who is wewho is in charge of making these changes?

Matthew Taylor: We have a new architecture, of course, in terms of the health service, and again, to reiterate a point I made earlier, one of the strengths of primary care at scale and primary care networks, localities, federations, is that that gives primary care the scale to be able to engage with systems and with places. Generally, most problems that the health service have are systemic problems. If you takeI don’t knowthe issue of why ambulances are waiting at the front door of a hospital, that is in part to do with issues about the number of people who are in the community who have not been diagnosed during covid, but it is partly to do with whether people can get out of the back of the hospital, depending on whether or not there is social care provision or community provision. Given that most of the issues are systemic, you need to bring the system together. The voice of primary care has not been sufficiently heard because it does not have the scale to be able to engage in that conversation.

Claires suggestion around strengthening it at a neighbourhood level, the place level, really gives primary care an opportunity to act in concert with others in order to be able to achieve change. That would be my locus for that because otherwise what you end up with is a rather kind of brittle situation in which you have the national infrastructure seeking to determine the behaviour of thousands

Q198       Luke Evans: That is why I am really keen. If we go through NHS trusts, mental health trusts, NHS England, you had the CCGs, now on to the ICSs. We have not even got into the care sector that goes in with that, and the ambulance service as well. We can clearly see that all the joins in the NHS are the most difficult, and Saffron was talking about primary/secondary care interface.

Sitting here having crossed from being a GP into the politics side of things, my question is, who is responsible for making these changes? Because a dictate coming down from the centre gets that response immediately saying, You cant tell us what to do. Yet, we hear from the bottom end, “We dont have enough power to make that change. Which organisations is it that are doing this, and is it fundamentally one of the problems that we have that everyone is looking at each other, talking to each other, saying, We know those are the problems. We can identify streams and flows and things like that, but how do we actually sort it out?

Matthew Taylor: Yes, and that is why it is an incredibly positive thing that Claire, when she published her report, got every ICS to sign up to that report. That is really important. In my ConfedExpo speech, I advocated that as the Fuller principle, which we should apply in future: if we want to achieve major change in the health service, let us make sure those people who actually have to undertake the change are signed up to it.

So, yes, this is a responsibility of systems, but I also think, without wanting to go off on a tangent, that we have talked a lot about ICSs. What are ICSs there to do? A critical issue here is that ICSs should not see themselves as layers in the health service, where you have NHSE and then regions and then ICSs and then places and then localities. They should fundamentally see themselves as enablers. They are there to bring together the different parts of the system, to identify the problems that need to be solved and to get the system as a whole to work more effectively.

If you take something like the urgent and emergency pathway, again, to say what I said earlier, that is a systemic challenge. ICSs are there to bring the partners together at a system level, or sometimes at a place level, and to enable them to find solutions. The trick here is ICSs are responsiblenot responsible in the kind of old-fashioned sense, but in a much more enabling, almost ecological, sense of bringing the system together to function more effectively.

Q199       Luke Evans: You have really helped outline the issue because, effectively, I see the ICSs as a way of focusing on the joins in the health service to make sure it runs more smoothly, because it has been too far siloed.

Saffron, if I can bring that to you, and more so given that you represent the ICSs in pulling that together, do you think the practical sides come through? The classic one is secondary care effectively dumping on to primary care their requests for tests and vice versa, and inappropriate referrals going from primary care into secondary care. These are the bread and butter things that slow the system down. That, in turn, for patients, means they do not know why they are going for a test. They get bounced because the referral is rejected. They get lost over the communication pathways. We have identified now that there is a system at the top level to work out where these systems are, but how do we actually change that in practice? Is there enough emphasis on the managers to be able to make those decisions and be held accountable for the good that happens and also the bad that may happen?

Saffron Cordery: There is lots in there, isn’t there?

Luke Evans: There is.

Saffron Cordery: Just to pick our way through that, NHS Providers represents trust of all types, whether that is hospital, community, mental health or ambulance, and we are really focused on the role of trusts within systems. You are right that the interface between secondary and primary care can often be the bit that people experience as pretty bumpy. I would say there are a number of elements there.

To go back to your original question, which is around who is actually responsible for making change here, within the current situation that we have, we see lots of primary care practices, GP practices and secondary careso hospital trusts and othersusing their autonomy and their agency as far as they can to overcome these challenges at a local level within systems. Northumbria, for example, is doing quite a lot to overcome that issue around GPs needing access to consultants for advice and guidance. They are making their consultants available for that advice and guidance and following up and ensuring that unnecessary referrals are not made. That is one really practical, tangible step, and that is happening.

However, what is sitting around that we have to rememberand this is more the responsibility of Government than it is of the local organisations is the factors that influence the ability of organisations to do that. Do we have the workforce in place? No, we do not have the workforce in place. There are a number of reasons for that and we have spent the last year or so lobbying on a Bill to try and get a solution in place. We do not have that yet, but we are getting close to it.

Fundamentally, we need a long-term, funded and costed workforce plan for the NHS that includes things like GP numbers and supply of GPs; that would help immeasurably. That workforce supply issue would also help on the other side of the coin, which is with trusts and the supply of workforce there, because time constraints are often due to workforce constraints.

Another factor, and just one more factor that I will throw in

Chair: Briefly, if possible, Saffron.

Saffron Cordery: Another infrastructure issue that we have is around things like digital investment and whether we have the right digital interface; that is a Treasury issue because we need capital investment. We do not have that capital investment, so we need things done with the CDEL limit, which would help us with greater capital investment. Sometimes the solutions do actually sit with Government, but organisations locally, and systems, do their best within the parameters that are there.

Chair: Thank you. Our next panel is due to start at 12. I will bring Marco and Rosie in on the next panel, unless they have a burning question for this panel. If not, I will just bring in Lucy now, because I am sure you have some questions.

Q200     Lucy Allan: Thank you, yes. Just following up, Saffron, on what you were saying in your role as NHS Providers, do you ever get frustrated that the difficulty that patients have in accessing GPs puts intense pressure on A&E and other aspects of hospital trusts, when you really should be seeing those patients in primary care? Is that something that you find frustratingthat people are being directed by 111 or not being able to access their GPs and are then turning up at the front door of the trust?

Saffron Cordery: This is a really interesting question. Frustration exists, but it is frustration on behalf of the patient; it is not frustration with primary care. It is worth saying that there is actually no evidence that A&E is overrun because people cannot get a GP appointment. There is evidence that that A&E departments are suffering extreme demands because patients are turning up who are more unwell than they previously were, and that is the same for the level of acuity we see for primary care as well. We have to be really careful here about attributing a cause and effect, because we are not clear that that actually is the case.

What we do know is we have to find some satisfactory answers for how people access different services. If we talk about primary care as the front door of the NHS, it is not about whether that front door sits in A&E or that front door sits with the GP practice receptionist; it is about making sure that people can access that care when they need it.

We have some false distinctions going on at the moment that are really important to overcome. Acuity is incredibly high. People are sicker than they were before. People are not caught early. There are whole hosts of reasons, and I do not think we should lay blame—blame is the wrong wordat the door of primary care. It sits at the door of a whole host of issues, including lack of social engagement and not having the right community infrastructure in place, which typically picks people up when they have issues and suggests that they access care. All of that infrastructure has gradually faded away, not only during covid, but also before that, with the diminution in funding for local authorities.

There are a whole host of issues there. It is pressure across the whole system, it is increased acuity and it is a lack of time to focus on that anticipatory activity and that preventive care, rather than not being able to access a GP appointment.

Chair: Thank you. Rosie, Marco, did you have one?

Q201       Rosie Cooper: My question is, how do you practically make this work for patients? We have talked at a very high level, and I am sure everybody who is listening to this thinks, The words are all great, but when I cant see a GP, and I have to phone 111, it takes forever. I put the person in the car and go to A&E.” In my constituency, an old gentleman was in the road for five or six hours. It was going dark and eventually we got a GP to come and get him and he was taken to hospital by car. Really, how does all of this make a difference for patients? A real difference—not talk, not a lot of words. How does it make a difference? Because people will not be hearing that today. I am not hearing it, and that is my big problem.

Matthew Taylor: You are going to hear from Claire next, and I think Claire's vision for primary care is a vision that will have a remarkable degree of support, actually. The question is, as we were discussing last week at ConfedExpo, how do we get from where we are to where we want to be? I really do not think there is an enormous disagreement about how we need to change primary care for the future. I would say we represent primary care and we represent the wider system, and there would be a consensus about that. Chair, you have discouraged us from focusing on the resources issue, and I understand that because it can drown out everything else, but as Saffron eloquently described, and she is absolutely right, there is a fundamental capacity gap, and that, at the moment, is standing in the way of us giving patients the care they want.

Saffron is also absolutely right about the acuity which seems to exist out there in the community. What we have is a consensus about where we want to get to and a real challenge about where we are now. The question we therefore need to answer is, how do we manage getting from here to the kind of vision that you are going to hear from Claire in a moment? That is a very practical question and we cannot dodge it. As I said at the very beginning, let us not make a recognition of the capacity problem the enemy of the need for reform. They must both go together.

Rosie Cooper: I think you are absolutely right. The problem is, everybody has heard that same sentence every five years, or every 10 years, as every change comes along. It is all magic, but it never actually

Matthew Taylor: Sorry, Chair, but I should just say that things do improve. Outcomes do improve. GPs are seeing more people. Digital consultations were, unfortunately, subject to a, I thought, rather thoughtless attack a few months ago. Many, many patients are happy with digital consultations. They are happy with what they can get online. As the quote has it, “The future is out there, but it is unevenly distributed. Let us not forget the examples of good practice Saffron has given. There is a lot of good stuff out there but generally, in primary care right now, overwhelmed with demand.

The private sector suggests that on the whole you need about 20% of free time to really be able to innovate. Ask any GP in this country whether they have 20% of free time to think about doing things better.

Sarah Sweeney: Could I come in there?

Chair: Make this a final comment, but, yes, please do.

Sarah Sweeney: There is something that could make a big difference. Any system of this sizeany organisationprides itself on listening to user experience and customer experience, but actually I think there has not been enough listening or power attributed to how people and communities feelpeople and communities, and their diversity. For me it would look like primary care becoming more democratic and people having more of a right and an opportunity to input about what would actually make a difference to them. We spend a lot of time at the national level and in a lot of different meetings that we hold, talking about structures and systems, but actually it comes back to whether people feel listened to and whether what they say is acted uponwhether they feel supported to self-manage.

Also, we should look at the fact that only 20% of our health outcomes and conditions are influenced by what happens within the health and care system. It is about the wider communities in which people exist and the wider support. For me, that looks like a shift towards people and communities and their voices being more clearly heard in the decisions. We would have a very different health and care system if it was people living with ill health and disadvantage who were constantly making the decisions about how services are delivered.

There is also a huge role for the voluntary sector in holding prevention in the community and managing relationships and the trust that is needed as well. It is about a big shift towards people, communities and the voluntary sector, and learning from the kind of asset-based approach to community development that lots of voluntary sector organisations hold, because I think that has a lot to contribute to general practice. That would be my final say.

Chair: Thank you. It has been a very interesting session. It actually has been a bit sort of system-y this morning, Rosieabsolutely right. It has touched on a very important issue, which we will probably want to come back to as a Committee. We talked about the accountability of GPs. There is a much bigger question with the new structures, about the accountability of ICSs and how we make sure they are also accountable, downwards and laterally as well as upwards. We may well want to return to that and ask all of you back. Soto be continued.

Thank you very much indeed for your time this morning. Much appreciated. And thank you, Saffron, for dialling in as well, given your condition. Good luck with your recovery.

Examination of witnesses

Witnesses: Dr Claire Fuller and Dr Hugh Porter.

Q202       Chair: Like Banquo at the feast, Dr Claire Fuller has been listening to all of that. She is the architect of the NHS England report, which, as we have heard, has been signed up to by all the ICSs. She is also the chief executive-designate of Surrey Heartlands ICS which, in the interests of transparency, I should say covers my constituency. I know Claire very well and will be extremely careful not to get on the wrong side of her during this morning's session. Thank you for joining us, Claire.

Dr Hugh Porter, thank you for joining us. Hugh is the clinical director of Nottingham City ICP, so he is going to be right in the middle of these new structures.

I want to cut to the chase. I will let you weave in any general comments that you want to make. Could I start with you, Claire? I just want to ask you very directly the question that Matthew Taylor was talking about, which is how we make sure that there is accountability downwards to patients with our primary care structures and not just accountability upwards to NHS England. Is that actually possible without dismantling the millions of targets that are imposed by NHS England, whether directly in terms of national waiting time targets, or indirectly through things like the QOF system that GPs have to follow like a straitjacket if they are going to get paid for their services? Is there a risk that your vision of strengthening bonds at a local level is just pie in the sky unless we get rid of all those national targets?

Dr Fuller: At the same time as doing the stocktake, we also commissioned a review by the King’s Fund, which was a global literature search looking at how you bring about change within primary care. What it showed, which will not surprise any GPs that are here, was that, actually, in England more than anywhere else in the world we have relied upon centralist financial incentives to drive change, and there is very little evidence that it actually drives change. It does drive an increase in activity but does not necessarily drive change in outcomes.

I think we sometimes use primary care as being synonymous with general practice, which it is not, so we need to be careful, and most of the time we have been talking about general practice here. Actually, the way to drive changeand I am going to say in primary care because it is in primary careis to create teams, give them a clear remit, create the environment for them to succeed and leave them alone. It is to actually enable teams to work in high-trust environments. That would be my comment on the top-down accountability.

Q203       Chair: I think that is a nice way of saying we do need to get rid of some of these national financial targets and financial incentives. I appreciate you want to be diplomatic about how you say that, but I think we understand where you are coming from. Can I just ask you some very specific things? The partnership model: the Secretary of State is reputed to want to scrap it by 2030. Do you or do you not agree?

Dr Fuller: You will remember from the scope of the stocktake that the things that were out of scope were the partnership model, funding and contracting. I cannot talk from having done a national review looking at it, but if you want to ask me as somebody who has been a partner, and from a local point of view, the partnership model works very well where I currently work, and I am very much of the view that, if something is working, do not mess with it, but there are a lot of areas around the country where it is not working. We have talked about the inverse care law already this morning, and it is those areas where I think we need to look at doing something differently, because it is our most vulnerable people that are not served well by the current model.

Q204       Chair: Another quick one: in terms of the complexity of access for patientsshould you go for out-of-hours service or 111, call your GP surgery or go to a walk-in centreis that something you think needs to be simplified?

Dr Fuller: It should not be up to people to work out the severity of the condition they have. It should be up to us, and that us would be me as an ICS chief executive and us more globally as leaders of the health and care system. We need to actually make it as simple as possible, and that will actually be about co-ordination of points of access. For people, it should be whatever works for you; we should create a system that works for that individual. That is one of the other ways that you provide continuity. So it is continuity of a relationship, continuity of data and continuity of access. Those three things matter to people.

Q205       Chair: The third thing I wanted to just ask you about was on this issue of continuity of care. Your report is very carefully worded, I would say, in order to please everyone. I just want to quote what you say: Some people