Health Committee
Oral evidence: Primary care, HC 408
Tuesday 8 December 2015
Ordered by the House of Commons to be published 8 December 2015.
Written evidence from witnesses:
- Department of Health, NHS England and Health Education England
Members present: Dr Sarah Wollaston (Chair); Mr Ben Bradshaw; Julie Cooper; Dr James Davies; Andrea Jenkyns; Andrew Percy; Paula Sherriff; Maggie Throup; Helen Whately; Dr Philippa Whitford.
Questions 183 - 267
Witness: Anna Bradley, Chair, Healthwatch England, Don Redding, Director of Policy, National Voices, and Katherine Murphy, Chief Executive, The Patients Association; Rosamond Roughton, National Director of Commissioning Development, NHS England, Professor Sir Bruce Keogh, National Medical Director, NHS England, Julie Wood, Chief Executive, NHS Clinical Commissioners, and Dr Steve Kell OBE, Co-chair, NHS Clinicial Commissioners and Chair, NHS Bassetlaw CCG, gave evidence.
Q183 Chair: Good afternoon. Thank you very much for coming to this session of the Health Committee. Would you introduce yourselves to those following this at home?
Katherine Murphy: I am Katherine Murphy, chief executive of the Patients Association, a national independent health and social care charity.
Anna Bradley: I am Anna Bradley, chair of Healthwatch England, the statutory consumer champion in health and care.
Don Redding: I am Don Redding. I am a director of policy for National Voices, which is a coalition of 140 health and social care charities.
Q184 Chair: Thank you very much. We are going to hand straight over to Dr James Davies.
Q185 Dr Davies: Thank you for joining us today and for the work you do for patients. Can I kick off by asking each of you what your impression is of the quality of primary care available in this country? We will start at that end.
Katherine Murphy: Thank you very much. From the Patients Association’s point of view, what we hear on our national helpline is from patients, relatives and carers, and there is huge variability. In some places there is excellent provision of primary care, but in others—especially in places where there are small practices—there is huge variation in the quality of care. Also, it depends on how big the primary care team is. There are some excellent practices providing really outstanding care with practice nurses, pharmacists and physiotherapists—not just the GP—but there is variation. Very often, the public find it difficult to get access to services. The public are sometimes quite confused about what primary care means: do they really need to see the doctor or could they be seen by one of the other primary care team? From the public’s point of view, it is difficult because, to them, primary care is the GP. I know that is changing, but it needs to change pretty quickly. Also, the public need to be made more aware of who else in primary care can provide the same service as the GP. Certainly at the Patients Association, we feel that it would probably be quite productive for GPs to look at who they are seeing, why they are seeing the patients they are seeing, and whether their time could be spent more usefully if other people within the primary care team were to see patients as well as the GP.
Dr Davies: Thank you.
Anna Bradley: You will be very well aware that, if you ask patients in the public about the quality of primary care, you get very high levels of satisfaction. That is undoubtedly the way most people talk about primary care. It has been our experience very clearly that, if you scratch the surface and have a bit more of a conversation with people about perhaps their latest episode of care or their experience most recently, it is very varied, as Katherine has said. We have been doing some work in the healthwatch network up and down the country. This has been an absolute priority for over half the network, and 50 of the local healthwatches have pooled their work together and have spoken to 11,000 people during the course of the last year. They have been into over 550 primary care services of one sort or another.
Two sets of things have emerged from that. One is that there are some quite basic things that get between them and the quality of care that they would expect, including things like issues around staff attitudes, certainly surgery hours, translation services, access for people with disabilities, and information to help them find their way through the system and get to the right place for what it is they need.
The other thing we have found out from the work with local healthwatch and some deliberative research we have done is that people have an appetite for much more substantial change to primary care. Although they report this general satisfaction, their feeling is that much more could be done, possibly with less. The great news from the research that we have done is that they stand willing to play their part in that. They want to help to shape services and take more responsibility for their own health and care, and they have some quite radical ideas about the whole primary care team. They really like pharmacists; they have incredible difficulty with dentists; there are significant issues with access to GPs. They recognise that the pressure on access to the most highly qualified clinicians is a premium service, if you like, and they have a great appetite for meeting with and receiving care from a host of other people as yet unidentified—different sorts of service. There is an opportunity to improve quality but through change as well as incrementally.
Don Redding: Building from that, National Voices would look at this in terms of the model of care and whether that model is still an appropriate one for changing needs and demands. Two thirds of consultations are for people with long‑term conditions and a third of consultations are for people with multiple conditions. The core customer has changed but the model has not. The model remains reactive, in that it waits for people to turn up with an exacerbation or a symptom. It is episodic. Although GPs try their best to provide continuity, the way that they work is not geared to providing continuous support. It deals with one issue or symptom per consultation. If people have conditions that are lasting over time or fluctuating, it is possible to plan the way that care and support is provided for them, but we do not do that particularly well.
We would say that you have a core customer who has changed and you have a legacy model of care that needs redesign. That redesign would be to more planned, proactive, co‑ordinated care with others who work close to home, whether in social care or allied health professionals in community health services. Particular constellations should follow identification of local populations and needs. We talk about that as person‑centred care.
One interesting finding that Anna was alluding to is that people want to be supported in the way they manage their lives and their health conditions. That is one of the things that they do not find easily, either at GP level or necessarily from other parts of the system.
Q186 Dr Davies: Between you, you have outlined a number of concerns and opportunities in primary care, but, as has been mentioned, patient satisfaction levels, as measured, appear to be high. How would you explain the discrepancy there?
Don Redding: If you take large datasets from patient surveys and run a statistical correlation between the questions and items in them, you find that the strongest correlation with satisfaction is for the way that health professionals communicate with people: listen, talk back in language you can understand, provide usable information and involve you in decisions about their care. All those things are very much strengths of the general practitioner. Satisfaction in your interaction with the clinician is likely to be high, even when there are very big strains on the service and, as we have mentioned, there are things that you can easily identify you would rather have that are not currently there.
Anna Bradley: There is another dimension that we have rehearsed well from the research we have done over the last three years, which is that people are ultimately truly grateful for the national health service and see it as a treasure that they want to protect, and throwing brickbats at it for not doing quite what they want is not, in their view, necessarily the right way to behave. There is something about the quality of conversation that you have with people and the fact that people feel safe to have that conversation.
One thing that has emerged in all the research we have done is that people feel quite vulnerable when they are using health and care services and are quite reticent to say if their experience has not been that good because they think it may have ramifications for their future service, and there have been occasions where indeed it has. Although that is not the general picture, it is something that makes people quite fearful and perhaps slightly less than honest. It is that quality of conversation that you need to have that provides people with a safe space.
Katherine Murphy: To add to that, the vast majority of the population are very happy with the service. There is a lot of stoicism and people are incredibly grateful to have the NHS. It is difficult sometimes in primary care for people to raise a concern or make a complaint about the quality of services because they do not always have another choice. They cannot easily leave a practice and hope that a practice down the road is going to take them on as a patient. I also think that, as a quality of the satisfaction, surely we should be asking patients and the public whether they saw the healthcare professional of their choice and whether they were happy with the outcome, and give them supportive information to enable them to make that decision.
Q187 Dr Davies: Do you think we are asking the right selection of people out there— the right patient groups through the national survey, for instance, which assesses the views of a million people a year, does it not? Is that looking at the right patient groups?
Katherine Murphy: Certainly we believe at the Patients Association that there is a huge number of people who never get asked about their experiences. There are lots of reasons for that. Certainly mental health patients, drug and alcohol abusers and homeless people never get asked about their experiences. We feel that is a huge gap.
Anna Bradley: We concur. People of all descriptions will crop up in small numbers in the national survey, but the vulnerability of certain groups of the population and the particular needs that they have mean that they are absolutely worthy of more detailed exploration. One thing that local healthwatch has done up and down the country is exactly that. For instance, in east London and Luton it has focused particularly on talking to immigrant communities about their ability to access and discovered that translation services were a particular issue that was blocking access. Of course, as often happens with these things, it then discovered that the problem was that it was no longer clear—post-PCT, after the 2012 changes—who was responsible for paying GPs for these services when they commissioned them so the GPs had stopped commissioning them. There was a very practical solution. A number of local healthwatches have also done a lot of work with groups of people in their communities who are deaf or have partial hearing, and again found a whole series of issues that are specific to that group. You do not get that unless you have what I was describing earlier as the right quality of conversation in a safe environment. The advantage of local healthwatch is that it is embedded in communities and it has access to people to have that kind of discussion, which gives you a different thing from a national survey, which is also very valuable but does not give you the whole story.
Don Redding: Briefly, I agree with much of what has been said. It is clear that, whatever future paths different parts of the country take, this question of getting a better handle on your population information has to be part of what CCGs and their GP practices do. It is talked about in terms of identification, stratification, segmentation and so on. That means trying to tailor the way you provide services to particular segments of that population, and that means you then need to have a conversation tailored to that group that involves them in saying how this could be designed in such a way that it is right first time for them.
Q188 Helen Whately: Do you think patients are able to make an accurate assessment of the quality of clinical care that they receive from their GP?
Anna Bradley: Many patients think they are capable of making that assessment. I will pick up the point that Don was making earlier about groups of patients who are living with very long‑term conditions. They are the greatest experts in their own state of health and wellbeing and know what difference clinical interventions are making to their state of health and wellbeing. It is much more difficult if you are a first‑time patient with a new condition. That group of people is increasing in number, and by its nature is engaging with a much larger number of different clinicians. As the patient, you are the only person who brings all that together in one piece and knows what all the different bits do or do not add up to—so for that group of people, absolutely.
Katherine Murphy: Patients have to feel comfortable and confident about their relationship with their primary care professional. It is difficult for patients because they very often do not get that meaningful information to know whether their interaction was of high quality or not and it depends on their expectations of the consultation. Some patients will look to perhaps having diagnostics—an x‑ray or blood tests—and if they do not get the request for that, they may well see that as a poor outcome for them. From a patient’s point of view, it can be quite difficult to know whether they have had a good quality consultation or not.
Don Redding: In a previous post I worked with Picker Institute Europe, which has done the bulk of the development of patient experience surveys in the UK. The guiding rule there was not to expect patients to assess the clinical skills of the clinician but only to report on what they could objectively report on in terms of their experience.
We can go a little further than that because they can report on people’s listening and communication skills, and ability to share decisions, explain risks, benefits and options for treatment—shared decision making. Traditionally, they are not treated as clinical skills. Clinical skills are seen as hard, scientific technical things, which are impenetrable to outsiders, but if you cannot listen well, how do you diagnose properly? If you are not good at sharing decisions with people or giving them the chance to do that, how do you know that a treatment decision is the appropriate one for them in their circumstances? While I would not argue that patients can assess clinicians’ in‑depth knowledge of an evidence base, for instance, I would say that the things they can report on are very important to clinical practice and not just soft or woolly stuff that is of no interest to doctors.
Anna Bradley: I want to qualify that in case there is a misunderstanding. I am not suggesting that patients can make a judgment about clinical skills or the skills of those people who are treating them, but very often they are in a position to comment on the clinical outcomes because they experience them, and that is a different matter.
Q189 Helen Whately: I have one follow‑up question along these lines, to do with the CQC inspection of GPs and whether you think that is a helpful guide to patients as to the quality of their GP. Are patients aware of the CQC inspecting GPs? Could they be aware and should it be used differently?
Katherine Murphy: At the Patients Association we have worked with 230 GP practices in the south of England working with patient participation groups. We have certainly talked to all of them about the importance of their involvement during the CQC inspections. From the public’s point of view, the CQC inspections are a very positive thing to happen, but I know in some parts of the country a lot of people are not aware that the inspections are happening or what the CQC is looking for.
Anna Bradley: You may not know, but I am also on the CQC board. As the chair of Healthwatch England, I have to be a member of the CQC board; I am saying that because it is important that you know. From the healthwatch point of view, local healthwatch play what I think is a very important part in feeding in intelligence to the CQC inspection process, but they have another role, which is to provide signposting and information to the public about services in their local area. They would certainly look at CQC inspection reports across the board as part of what they tell people or point people to. It may not be something that the general public knows about, but it is something that local healthwatch would identify for them in that context.
Don Redding: I am not going to add a lot, except that I am unsure that the current CQC model of having distinct inspectorates for distinct settings of care and really ramping up the numbers and level of inspections is going to survive for very much longer. Both in terms of funding and as a way of approaching care, as we increasingly move towards trying to achieve integrated care in local health and care economies, they will need to be looking across the piece at some of the outcomes of care for people rather than at micro level, at GP practice level.
Q190 Chair: Could I ask a supplementary based on Helen’s previous question? Very topically today is the rating that patients give practices. They give them lower ratings if they are lower prescribers of antibiotics, yet the rest of us are trying to use lower prescribing of antibiotics as a quality marker. Is that potentially an issue in trying to improve quality?
Katherine Murphy: That is one thing I was trying to mention earlier. Very often patients in primary care unfortunately do visit their primary care, with certain conditions, and expect to get a prescription for antibiotics. There needs to be a lot more awareness in the public around the resistance to and overuse of antibiotics. Looking at prescribing within practices is very good, but that information needs to be given to patients so that they can use it in a meaningful way.
Q191 Chair: Thank you. Can I come on to a group of questions about variation in quality? One thing that was striking from the CQC’s recent report was—I think it was the quote that Steve Field used—that the poor is very, very poor. Can you give your thoughts on why there can be such huge discrepancies even within quite narrow geographical areas? Have you identified what the reasons are for that?
Anna Bradley: From the work that local healthwatch have done, there is nothing that emerges as an explanation for why there is such a discrepancy. I am not sure I can shine any light on that, to be honest, Sarah.
Katherine Murphy: Sometimes it is to do with the local community—the socioeconomic group, the people using the services. It is difficult to give any one explanation for why there should be such a variation and that in some parts of the country the service is so poor.
Don Redding: It is not an explanation, but one aspect of this is how quality improvement works for general practice. Since the PCT days people have gradually been trying to drive single‑handed practice out of the picture in many local areas because a lone operator does not receive as much peer‑to‑peer scrutiny, practice review, looking at data patterns and so on. It may be that a part of the variation is to do with how people fit into local networks and how good the scrutiny of the particular local commissioners is, and so on, to spot variation and raise quality in a local patch. The emphasis that think‑tanks and others are now putting on the potential to federate or scale up is driven partly by the sense that, if practices are members of bigger communities of practice, that will better expose and act upon variation. I am not fully convinced of that, but that is one track of thought.
Q192 Chair: Sometimes patients are very attached to single‑handed or very small personal practices, which again is not always reflected in the quality of care they provide. Is that your impression?
Anna Bradley: It is, but in a way this goes back to “Better what you know than something you don’t,” unless you are comfortable with what is going to come next. People are grateful for what they have and often have very personal relationships. They are worried that it will just be taken away and what it is replaced with will not be qualitatively better or at least the same. The work that local healthwatch has been doing around, for instance, the vanguards and new models of care speaks to the importance of that strong engagement with the public and communities when you are thinking about changing services so that people can feel that they are part of the co‑creation of something different and feel comfortable with what it is that is proposed, and generally then do. It is the difference between feeling grateful for what you have and feeling empowered to be part of the solution.
Q193 Mr Bradshaw: Given that the introduction of student university fees has arguably led to students and their families making much heavier demands and having higher expectations of the quality of their education, do any of you think there may be an argument for the introduction of GP charging—to do the same for GPs?
Anna Bradley: We have had some conversation with the public in the deliberative work we have done in two different contexts because people have raised this question. I do not have a view. We do not have a corporate view, but the view that has emerged very strongly in the public that we have been talking with is the huge value that they attach to free‑at‑the‑point‑of‑demand services. It is probably the thing that is most central to people’s sense of what the NHS is about. That is not to say that it would be right or wrong, but it is clearly an absolutely central tenet and it would be a very challenging thing to change because it is the one that the public perhaps hold most dear.
Q194 Mr Bradshaw: Even though, arguably, it leads to this mentality of people feeling grateful for what they get rather than having higher expectations for a service they pay for.
Anna Bradley: As you said, that is an argument and it is a philosophical argument as much as anything else, is it not, in terms of which way you think delivers the greatest empowerment?
Katherine Murphy: Many of the public that we have spoken to would fear a two‑tier NHS. As Anna just talked about, being free at the point of need is very important to people.
Don Redding: National Voices is a coalition of charities, so we do not directly represent patients and I cannot answer on that, but I would universally expect our member charities to oppose the introduction of charging. There are some real issues if you do start to introduce charging. We have opposed the introduction of charging recent migrants for services, for instance, because it is a deterrent for people to seek treatment, and that means you are going to increase public health risks and the incidence of disease that is not detected and identified in the population. We already have trouble—
Q195 Chair: Thank you. That is taking us off into other territory. Can we return to primary care? Given, Anna, that people do not have a choice often within an area to move to another practice—in other words, having CQC ratings might not be able to drive behaviour change if there is not the choice to go elsewhere—where do you see the CQC ratings fitting in as helping to co‑create something better?
Anna Bradley: Local healthwatch is working very closely with the planners through the health and wellbeing board, with the commissioners through the CCG, and now the new co‑commissioning and delegated commissioning arrangements for GP services, and with providers of service. It would be fair to say that they consider themselves to be agents of change in a number of respects. Healthwatch England wants to help them to do that in a number of ways. If there are issues that emerge in a CQC inspection, for instance, they would want to understand more about how the local population might like to see that changed. They might work with a GP practice and they might also work with the commissioners to bring about some of that change. They certainly are doing that where they have already identified an issue for themselves. For instance, in Bradford, they did a lot of work going into GP practices and talking with patients about some of the issues. They spoke to 600 people and established that one of the primary issues for those users of service was staff attitudes that were getting in the way of them and their access to clinicians. They have had a conversation with the CCG, and as a result there is a new training programme that has been developed in Bradford for staff across the GP practices in the area. That is the kind of thing we would like to see more of.
Q196 Chair: That is the kind of thing you would like to see more of, something coming out as a result of an inspection where healthwatch is involved locally as agents of change.
Anna Bradley: Exactly. That arose because it found that issue, but it could just as well be a CQC inspection that had found that issue and it would then see it as part of its role to help.
Q197 Chair: I have one final point before we move on. It is the controversy about whether or not we should publish individual GP data around variation—some GPs feel that that would be very damaging and exposing—or whether it should be individually fed to them to improve their quality. Would you be in favour of publishing individual data, or do you think that would be a step too far?
Anna Bradley: This is not a Healthwatch England view; it is not something we have explored. But, as a long‑standing consumer advocate, I would say this is what happens in a whole host of other areas and it has served to improve services. I would point to some other clinicians, some of the consultant groups, for instance, who have been publishing their own rates through their colleges for some time. There is a certain amount of courage already being shown in this space and I am not sure that it has been a bad thing. On the whole, people think it has been a positive thing, but, if it achieves anything, it drives peer‑led improvement rather than the public so much changing their behaviour. The extent to which this is information that is used by you or I is quite limited, but it certainly makes a difference to the clinicians. For that reason, perhaps it is worth exploring.
Chair: I do not know whether Katherine or Don would like to add to that.
Don Redding: I agree with everything that was just said.
Katherine Murphy: From a transparency point of view, it is important that that individual information is publicised, but the individual clinician needs the support to raise the bar, basically, and to improve the quality.
Q198 Mr Bradshaw: From a patient’s point of view, how meaningful is it if there is no practical GP choice?
Katherine Murphy: That is where the difficulty comes.
Anna Bradley: That is the issue. Is the information that is supplied about the individual practitioner there in order to create the opportunity for choice for consumers or patients, or is it to drive up improvement across the profession? You have to be really honest when you do these things about why you are doing them. Where it has been successful, it has been more about professional development and quality improvement—and not about patient choice.
Q199 Chair: The view from clinicians is often that it is best to feed that to them without it being in the public domain, but your view, I am hearing, Anna—tell me if I have got that wrong—is that you think it needs to be in the public domain.
Anna Bradley: There is something about it being in the public domain that is exposing and perhaps that also then drives quality improvement, but that is not the same as expecting the public to act on it.
Chair: Thank you. We come on to Maggie.
Q200 Maggie Throup: We have already touched a bit on managing patients’ expectations and them understanding responsibility. Do you believe it is necessary to manage patients’ expectations more and to educate them as to their responsibilities, for example, being on time for appointments, not going to GPs for trivial issues, and we have already touched on the prescribing of antibiotics? What are your thoughts on that?
Katherine Murphy: Patients are well aware that they have rights but they also have responsibilities. We hear this a lot on our national helpline with regard to attending appointments and cancelling appointments. It is difficult sometimes for patients to get an appointment, but if they get an appointment for a couple of days’ time and then their condition improves it can be very difficult for them to cancel the appointment.
Q201 Maggie Throup: Why is that?
Katherine Murphy: Because it is almost impossible for them to get through to the GP’s surgery.
Q202 Maggie Throup: That is through the telephone system.
Katherine Murphy: Yes, through the telephone system. Not everybody is able to do things via email or Skype. We have to remember that there is a large percentage of the population that is not familiar with the use of electronic devices, so we have to make it as easy as possible for them to do that.
Anna Bradley: As Katherine has said, the public think they have a huge and important part to play in this, and they recognise the scarcity of resources and want to take action themselves. They also recognise that they do not have all the tools or skills to be able to do that. They talk particularly about information and education as being something that is not readily available to them. When they talk about information, they are not talking about giving them some of the data that we already have for other purposes and saying, “Here is something that is information. Now use it.” They are talking about information about the things that they really need in order to find their way through services. It is our view that we have not yet even begun to have a conversation about what information and education the public need to play their part in this area. It is interesting that in financial services and communications we have big agendas in this space but not in health and care. Yes, it is a big challenge, I think.
Chair: We have a lot of questions to get through, so if no one has anything they want to add, can we quickly keep going through?
Q203 Maggie Throup: Moving on from that, I spent five hours in a GP’s surgery last Friday, and one of the issues they highlighted to me was the fine balance between providing good customer service and how they manage the frequent flyers. Can you expand on that?
Don Redding: First, I hate the term frequent flyers.
Maggie Throup: I know, but that is something that you can understand—
Don Redding: We should ban it along with bed blockers.
Q204 Maggie Throup: But people understand it, though. That is the issue.
Don Redding: What you might term frequent flyers are the people that I spoke about at the top of the piece—the people with multiple conditions who are going to encounter multiple challenges in managing their lives and conditions. Very often their first port of call is their family, but their first port of call with the system, rightly, will be the GP. There are various kinds of interventions that can be made as part of a planned and redesigned service that will reduce the extent to which that happens, but blaming people for coming back is not the way to do it. If you adopt a personalised care and support planning approach and you make sure that there is provision of support for people to manage their conditions as successfully as they can, which is what we should be talking about with self‑care, people’s use of the GP practice will fall. If you provide better information, people’s use of the GP practice will fall. If you provide care co‑ordination so that they have a care co‑ordinator who they can work with and who helps them to get what they need from different places, then use of the GP practice will fall; so will use of other services, particularly unplanned emergency and urgent care. That is the sort of redesign that I was speaking about at the top of the piece. For us, that is crucial to the future sustainability of services. As long as we have a mentality of blaming patients for using the service too much, we are not going to get to that.
Q205 Maggie Throup: It is as much people using it frequently as inappropriately. That is one of the concerns.
Katherine Murphy: It is to make sure that people feel able to use the most appropriate services and that people have confidence in not always having to go to the GP or use primary care services—that there are other support services in the community that they can turn to. But, for the public, it is about knowing where to go.
Anna Bradley: There is an important challenge back to primary care about the role of the GP as the gatekeeper. One thing that emerged in the deliberative work we did with the public, particularly for these people with longer‑term conditions, is that they want to be able to self‑refer. They do not want to have to keep going back to the GP every time they need something, because they know what is wrong with them and know what the mix of services is, but they cannot do it—they have to go to the GP. There is a quid pro quo here. People want to play their part, but the system needs to change and there is something quite fundamental about the power relationship that exists at the moment, which also needs to change to give people more control. That is a conversation that I do not think we hear enough about.
Q206 Maggie Throup: You mentioned earlier, Anna, about the work being done in Bradford and the fact that people’s perceptions of GPs often start with the receptionist. I am pleased that that work is ongoing. Can the other two add anything to that as to how we can make sure it is not the patient’s perception of the receptionist but the overall practice? How can we get the message out?
Katherine Murphy: It is difficult, because the receptionist is your first point of contact and the relationship with the receptionist is as important as the one you have with your healthcare professional within the practice. Receptionists also require training in many areas so that they can look after, with compassion, the people that they talk to on a daily basis. Receptionists are very often forgotten about in the primary care team and they are very important people to take care of.
Don Redding: I will make an observation about the experience of Tower Hamlets. They were one of the first areas successfully to move to care and support planning, starting with people with type 2 diabetes. They have been doing that for seven or eight years now. In the most recent period they have come round to realising that. They have had to change their appointment systems, the way people are received into the practice and the way that they handle information, so test information goes to people in advance. The corollary of changing the way you work with someone knocks on to the way you organise your systems. They have come to realise now that the people who organise the systems are particularly important in making it all work—the practice manager, the receptionists, the practice nurses who may be sitting down and doing a piece of work with a person before the care planning consultation, and so on. It is a whole‑team job.
Maggie Throup: That is a very good point.
Q207 Paula Sherriff: Katherine, you, or certainly your organisation, have previously expressed concern about patients who have not been able to access appointments within an adequate time period, but the National Audit Office has found that the vast majority of patients are satisfied in this area. Can you explain why your observations differ so much or why there appears to be such a disparity?
Katherine Murphy: At the Patients Association we have a national helpline. We also undertake many listening events around the country. Everything that we do and all our research is informed by our helpline. On the issues that we hear about on our national helpline we regularly look at undertaking a larger piece of research. At the time of that research the messages that were coming back loud and clear—and we still hear from patients and the public—were about the struggles they have in trying to get a GP appointment. Not everybody is able to access online appointments, so very often people are on the phone at half past eight in the morning, phoning for an hour, only to be told that there are no appointments left for that day or to phone back in the afternoon, and when they phone back in the afternoon the appointment has gone. This occurs day after day.
Q208 Paula Sherriff: Do you find that that is particularly affecting a certain cohort of patients? Is it restricted to the elderly, who are less likely to be so au fait with some of the various forms of communication out there, including the internet? It is not exclusively the elderly.
Katherine Murphy: The vast majority would be the elderly. However, we have heard from mothers of young children that they also struggle, and very often they will not wait until the afternoon or the next day: they will take their child to accident and emergency. I would say predominantly, yes, it is the elderly.
Q209 Paula Sherriff: Does the Patients Association record demographic information regarding people who contact you? Have you discovered any other trends in terms of complaints regarding access to appointments?
Katherine Murphy: Mental health patients find it really, really difficult, and when they do get an appointment, in the time that they are allocated, they feel they are very rushed during their consultation.
Q210 Paula Sherriff: That is during the actual consultation itself.
Katherine Murphy: In the consultation itself, yes.
Q211 Paula Sherriff: That is, largely, 10 minutes, give or take.
Katherine Murphy: Yes. If they are lucky, it is 10 minutes.
Q212 Paula Sherriff: Do you think some of these problems relating to accessing appointments are a consequence of demand outstripping supply, or is it a failure on the part of the practices themselves to make their services accessible, or is it a combination perhaps of both?
Katherine Murphy: The simple answer is that probably it is a combination of both, but certainly we at the Patients Association recognise that there is huge demand on the system. The people trying to access primary care are mostly elderly people with multiple conditions and, unfortunately, frequently they are looking for access to a general practitioner. I think the practice has some responsibility about educating or informing the local community about the other professionals who work within the organisation. It is not always necessary for people to see a GP. There should be better information from the practice about the other professionals who can manage and treat conditions the same as the GP, and in some cases probably better than the GP.
Q213 Paula Sherriff: Do you think there should be an onus upon the individual practices to offer appointments—say, not to have them all available at 8.30? For those who cannot get through, or for those who for whatever reason cannot ring or contact the surgery at 8.30, appointments should almost be filtered throughout the day so that those who cannot contact are not disadvantaged.
Katherine Murphy: I believe some practices are doing that, but it is important that practices involve their local community, as Don said earlier, in redesigning services. “What would work well for you as an individual in my practice?” It is important that patients and the public are consulted and involved.
Q214 Paula Sherriff: Through PPI forums.
Katherine Murphy: Absolutely. Some members of the public who contact us still cannot understand why some GP surgeries close for lunch for an hour and a half and sometimes GP surgeries are closed on an afternoon during the week.
Q215 Paula Sherriff: Is there a responsibility once again on individual practices to listen to the people in the area that they represent rather than going with a one‑size‑fits‑all model?
Katherine Murphy: Absolutely. For far too long it was one size fits all, but that, thankfully, is changing.
Q216 Paula Sherriff: Does anyone else have anything to add?
Don Redding: I will make a point about scale when we talk about involving local communities. An average practice with, say, 5,000 patients on its list and overburdened by current demand is going to have quite limited resource, planning time and so on to do a lot of consultation work, but across a patch—across a health economy, as people call them—in a local area it is possible to do a slightly larger‑scale consultation, or even co‑design with people. It should be possible to ensure that across the area, rather than in every individual practice, the things that people have said they want are available. Even now, some practices will have a practice nurse or nurse practitioner—I am not very good with the technical terms—who will have a special interest in, say, asthma. Patients, as Anna was saying, will be very happy, so long as they are not having regular exacerbations of the condition and they have got it within management control, to see that person. There have been attempts to have those special interest pockets available in an area that people can access from different practices. We have to be careful about loading too much expectation on a small practice to do a public consultation and make it easier by doing it across a patch.
Anna Bradley: It is important to differentiate between two things. One is systems that make it difficult for anyone to access the GP services that they need: the telephone system, where you have to ring in before half past eight to make an appointment, or whatever. Those are systems that can make it difficult for anyone. There are a number of other issues that make it particularly difficult for certain groups of the population. It is the experience of local healthwatch that, on the whole, those are people who have very particular needs, particularly complex needs or particular vulnerabilities, people with disabilities—all those groups of people who you might expect would have a particularly high need for service and particular problems in getting it. That is not because of the appointments system but because of a number of other obstacles that are in their way in some cases.
Paula Sherriff: Thank you.
Q217 Dr Whitford: That is talking about having special‑interest people within an area, but we are moving more towards people having multi-morbidity. One project happening in Govan in Glasgow was to identify the 5% of the people who generate 40% of acute care needs. They automatically always get a double appointment and are automatically seen by the GP, who looks at everything, “How is your diabetes? How is your kidney failure?” What are your thoughts on that, rather than they go there for their respiratory problem and to another practice for—
Don Redding: It is essential. If you are solely driven by pathway and guideline medicine, which works for single conditions, those people with multiple conditions are going to get suboptimal care and potentially harmful care—harmful in the sense that you are putting a huge burden of work on them to follow all those different pathways and to keep up all those different appointments. They will likely have 10 or 12 GP appointments in the year, see eight specialists, have 11 or 12 medications to manage, three episodes of urgent care, and so on. The model has to be different and work differently, and what you are describing is one way to move towards that. In Barking, Havering and Redbridge they are extracting those most complex patients from their existing practices, with consent, and moving them to a 4,000‑patient practice, as it will be, that is going to specialise in working with people with multi‑morbidities, doing it on a care and support planning model, including end-of-life care and not separating that off as it so often is. There are all kinds of ways to respond to that challenge.
Dr Whitford: Thank you very much.
Q218 Julie Cooper: Continuing the theme of access to GPs, have you come across any negative consequences for those patients who would like continuity of care, who would like to see the same GP on a regular basis, and, if so, what are those?
Anna Bradley: Certainly it has come up as an issue for the people that local healthwatch have spoken to quite frequently. The NHS Constitution says that you should be able to see the GP of your choice. Quite often that would be a GP of a particular gender perhaps. Local healthwatch has had a lot of cases brought to it by members of the public where they have not felt able to see the GP of their choice. It is a promise not being kept. I think, though, when you also have a more detailed conversation with the public about what they would like to see going forward, they would rather see someone who can help them with their problem than necessarily always see the same person. As Don was saying, there are choices here, a variety of options, and going down the path of “A single route is the right route and the only route” is probably not the best answer.
Katherine Murphy: To add to what Anna said, the relationship between the doctor and the patient is really important, and very often GPs will have a family history and the patients do see the GP sometimes as their advocate as well. That is why it is important to look at what the GP does as opposed to the services that other healthcare professionals within the team could be providing.
Q219 Julie Cooper: There is a balancing act here, is there not, I suppose? Is it between quicker access to a health professional or being prepared to wait maybe a week or more to see the preferred practitioner? Have you found that this relates to a particular group of patients? Is it the case that the elderly or people with long‑standing conditions—have you come across this—are prepared to wait a bit longer, are more tolerant of the pressures on the system, to see the person they trust and have a long‑standing relationship with? Is that somethings that has featured at all?
Katherine Murphy: I would say that, as far as possible, elderly people do like to see the same person. Also, from their point of view—again if it is somebody with multiple conditions—having to repeat the same thing to different people is quite exhausting, and you might have somebody in front of a GP who is quite stressed anyway and quite worried about their condition.
Anna Bradley: This is a very good instance of where we should not make an assumption about different categories of people in any circumstance. It is a choice I can quite easily understand and make at the point at which I want to access a GP practice. If someone says to me, “You can see your named doctor but not for a week, or you can see someone else who can advise you on this thing tomorrow,” I am capable of making that choice, and most of us are and do not object to it. That is a place where you can offer people choice. Again, when we talked with the public in the deliberative conversation about the future of primary care, they all said that they did not necessarily want a GP to be the manager of their long‑term condition; they wanted someone whom they described as a care navigator, someone who could help them to find their way through the system. They did not mind seeing five different people with different expertise as long as someone was helping them to manage the whole as a whole and it all added up. But that is a preference thing.
Chair: Thank you. Unless you have anything to add to that, we will move on to Philippa.
Q220 Dr Whitford: I think we are going to get summoned away to vote shortly, so we will try and get through the next few questions relatively compactly. Could I start with Katherine? The suggestion was, looking at seven‑day services, that your feedback was very much that patients wanted seven‑day routine services and access to general practice, and yet the Prime Minister’s Challenge Fund pilots have not shown that: 50% uptake on a Saturday; 10% or 12% on a Sunday. So some of the pilots have pulled them.
Katherine Murphy: Again, this is where it is about information and guidance for the public. The public are quite used to having a primary care service from Monday to Friday. If they do not know that the services are available, it is difficult for them to access them.
Q221 Dr Whitford: Is it your impression that where these pilots happened it was not advertised?
Katherine Murphy: It was not very well publicised. Patients and the public do not know when these are going to be, so obviously, whenever that happens, whether it is outside Monday to Friday, they need access to the most appropriate services. The vast majority of the public would prefer to be treated in the community rather than going to a hospital.
Q222 Dr Whitford: This is routine. This is not people who are feeling ill and going to an out‑of‑hours GP; this is an ordinary GP practice to go to for a routine appointment. That is what the seven‑day Prime Minister’s Challenge Fund was.
Katherine Murphy: The public would still prefer and would want to have a seven‑day service rather than having to access services on a Monday to Friday.
Q223 Dr Whitford: There are other surveys. The Royal College of GPs has just published one that shows the public would like longer opening in the evenings but they did not fancy going to their GP on a Sunday at all. Why do you think both answers are coming up so different?
Katherine Murphy: I think it is because that service has not been available to them. When the service is available to them and if the RCGP did that survey maybe in two years’ time, they might get a very different response.
Q224 Dr Whitford: The service has not been available to anybody for very long, so I am trying to understand why the different survey systems come up with such different answers.
Anna Bradley: Can I suggest a way of squaring that circle? You were alluding to the question of why people want to go and see a GP or have access. That is absolutely the critical thing. For most of us, Sundays are still a thing and we have other plans for them, so why would we want to go and see our GP for a routine meeting on a Sunday if we can get to see them on an evening, without having to take time off work? That has to be preferable. But I would much rather take my ailing child to the local GP/walk‑in centre/whatever it is in the community than spend four hours on my Sunday sitting in A&E knowing that it is the wrong place to be. To understand the difference between the surveys, you have to explore, to unpick this and understand more what it is that people want to access, because we use the term primary care as if it means all things to all people, and it does not, of course.
Q225 Dr Whitford: That is the difference. Obviously there is the GP out‑of‑hours service, which we have, and several of the pilots reported difficulty in recruiting enough GPs for that because they could sit reading the Sunday papers with only 12% of the appointments filled for far more money. So we have three things: the routine appointments, the out‑of‑hours service, which is when you or your child do not feel well, and A&E, which none of us wants to go to on a Sunday. To what degree do you think we could be utilising modern technology, such as telephone systems and Skype? A lot of GPs now run telephone consultations. What has your feedback from surveys been from patients and the carer charities? Have they found it helpful? Is there a resistance?
Katherine Murphy: There is a mixture. Some people find it really useful and very reassuring, especially mothers of young children who use Skype and telephone consultations a lot, and especially people who have had investigations and they are waiting for the results. They find it very useful. From the Patients Association’s point of view, we would say it is very valued.
Q226 Dr Whitford: Are there any particular aspects of good practice that you have come across?
Anna Bradley: The work we have done gave us a very interesting finding—slightly counterintuitive, on the first take—which was that younger people were, on the whole, less content to use Skype and other means to engage with GPs than older people. There are questions about people’s access to digital technology—that is a different matter—in terms of their comfort with digital engagement with a GP, for instance. They all see a real opportunity for digital technologies to do things differently, but young people seemed less comfortable. It emerged when we explored that a bit further that that was because these young people did not think that GPs were going to listen to them because they were young. Their experience of GPs was that they were dismissed. There was a lack of trust and confidence for these young people in their GP service. They felt that they had to sit and look at the whites of their eyes to get an honest response from their doctor. There is an important lesson in there, which is that technology can do great things for us, but unless the fundamentals of the relationships are right and the trust and confidence is there it won’t help.
Q227 Dr Whitford: Whereas the elderly person has maybe already known the doctor for years and knows that they trust them. Is there anything you would want to add?
Don Redding: We will see more use of Skype, email, telephone consultations and so on; that will come naturally. For us, the most important application in relation to supporting people to manage their conditions would be access to their full electronic record and support to make use of that, which would include associated information that you could build around it. I see Ministers claiming that 95% of patients can already access their electronic record. That needs picking apart as a statistic. By and large, GP practices are not going to their people with long‑term conditions or more complex conditions and saying, “We are going to support you to get online with us” in the way that other industries support people to get online with them.
Chair: Andrew, do you want to come in with a supplementary?
Andrew Percy: I have my debate.
Chair: Do you have time to ask your question now? We will bring your one forward.
Andrew Percy: There is about to be a Division, but I am happy to ask my question if you wish.
Chair: Yes, if you would like to, because I know you have to lead the debate.
Q228 Andrew Percy: It is on multidisciplinary practices. I think you made reference in your submission, Don, with regard to the GP’s role changing to become more of a consultant‑type position. You have advanced nurse practitioners, dietitians, physiotherapists, pharmacists and all the rest of it. I know there is some resistance to that from GPs. Can you give us your views on that and what you think patients would want from that too?
Don Redding: We would advise a number of things about the need for care co‑ordination, the potential use for co‑ordinators to help people with planned care, the fact that that can take some of the pressure away from the GP in particular, but the need then to share roles and share care with allied health professionals, pharmacists and social care, and I might also say with the local community assets, third‑sector provision and support, which can also be crucial in helping people to manage and not fall into emergency situations. The kinds of redesign that we have talked about earlier necessitate working in multidisciplinary teams to make best use of everybody’s skills and assets. How that actually happens—whether they are virtual teams, co‑located, in a single organisation or in several that have protocols to work together—is secondary.
Q229 Andrew Percy: What about GPs, though, because there does seem to be some resistance? I could not make the trip, but I believe, Chair, on your trip to Sheffield the GPs you met there were not overly enthusiastic about it. How do you think we could overcome that? Is it done from the basis of patient demand? Is there a patient expectation for this?
Katherine Murphy: There are many other healthcare professionals who need to be seen as contributors in primary care. If we recognise that there is a huge demand on GP services and that many of the people who see a GP do not need to see a GP but can be seen by one of the other healthcare professionals within the team, maybe it is about the GPs recognising that their role may have to change going forward.
Anna Bradley: Starting with what the public want is absolutely the right place to go. It is something that we do not do anywhere near enough in health and care. We start with what might be possible or with what professionals think might be the best thing. Sometimes they are right, but starting with what the public want and using that as the primary reason for change absolutely must be the way of the future. My experience is that when you ask people those questions you get some quite surprising results and they have a much more subtle understanding of the issues that the system is facing and the contribution they can make than you might otherwise expect.
Q230 Andrew Percy: Finally, how do you think patients will respond to that? In response to Philippa’s question on this, I have a practice that has been experimenting with extended hours and they say to me that the public do not use it. What comes first? It is the chicken or egg question, is it not, because clearly with expanding services a lot of people do not know they are there already? If you suddenly change the whole model—whether you have physiotherapists, pharmacists or whatever—how would the public know about that very often, particularly when from practice to practice it changes? While the vision seems great and it is what people would say they want, most people still think the GP practice is where you go and see Dr McPhee because you have always seen Dr McPhee, and that is who you want to see when you go. While the public might say they want it, how many of them practically really understand what a new model would look like?
Anna Bradley: When you have a conversation with them, they are very capable of understanding it and helping to co‑design it. Let’s not imagine that the seven‑day service was designed with patients, because it was decided on and then the pilots were run, and that was the way to find out what patients thought. If you have co‑designed something, you have arrived at a plan and then you make it available, that takes us straight to the information and education piece and the need to help people to find their way through the system. We have huge issues with that. I will give you one last example of work done by a local healthwatch in Barking and Dagenham. They did some work to find out what advice people were offering from primary care about emergency services. They discovered that people were using all the old phone numbers after they had changed, so there was poor and incorrect information. In Kirklees, in the north, they did a lot of work in relation to dentists and discovered that the information on NHS Choices about which dentists were taking on NHS patients was out of date and misleading. The information we provide people with at the moment is not good and requires a considerable amount of work.
Q231 Dr Whitford: In the Prime Minister’s Challenge Fund the idea is that there would be a different practice that would be open each weekend, or wherever it is. Do you not think that causes more confusion? If you have an out‑of‑hours service and everyone knows where it is, they know that is where you should go and that is where you take your child or where you go if you have tummy ache. You try and avoid A&E, as everybody knows you are going to wait hours and hours. If it is a Sunday afternoon, which practice is open? That is going to cause more confusion.
Don Redding: There is a lot to be said for putting in GP care at the places where people go. With all these variants of out‑of‑hours services, which people find very confusing and are not fully certain about—I am not saying that they do not necessarily trust them—people will still go to where they know, as has been said, the lights are on. They will go to the minor injuries clinic, another urgent care centre or to A&E. What has been shown to be very successful is to co‑locate out‑of‑hours GP provision at those places so that you can do a triage as people come through the door to say, “You would be better off with GP care, that is available and someone can see you here if you want to wait, or you could wait until Monday and go to your own practice.”
Q232 Chair: Are you continuing to come across ridiculous situations where people are having to leave the building and phone in again to come in under a different route?
Don Redding: I cannot speak for that.
Anna Bradley: I do not have evidence of that.
Katherine Murphy: I do not have any recent evidence of that experience.
Chair: It is something that happened in surgery last week, so I just wondered if it was something you were aware of.
Anna Bradley: I have personally, but not—
Q233 Chair: Thank you. Are there any final points any of you would like to make on behalf of the groups you represent for this Committee?
Katherine Murphy: Patients and the public are a huge asset and should be consulted with much more than they are. They should really be involved in the designing and redesigning of services. They fully accept and acknowledge that the NHS is not a bottomless pit. Sometimes patients deserve better recognition than what they currently get, but there needs to be investment in the public so that they can better understand the information that is given to them and investment in patient leadership programmes within the communities as well.
Q234 Chair: You are agreeing with Anna: start with the patient more.
Katherine Murphy: Absolutely.
Q235 Chair: Don, do you want to add anything?
Don Redding: I would agree with that. We have not had very much time to talk about models of working with community assets, whether that is social prescribing, which is now becoming increasingly used in places like Rotherham and Halton—and the Bromley by Bow centre has been doing it for a long time—or whether it is asset‑based community development or other schemes that make use of the groups and organisations that are available in local areas, which add to the picture of support and often provide vital kinds of support that people will never get from statutory services, whether that is advice on their debt, which may well be the cause of their depression, or whatever else. As we go forward and look at multidisciplinary working, that has to be not just between professionals but between professionals and communities.
Q236 Chair: Thank you. I think, Anna, it is your last time coming to give evidence to this Committee, so thank you for all the evidence you have given us over the years.
Anna Bradley: It is my pleasure, thank you.
Examination of Witnesses
Witnesses: Rosamond Roughton, National Director of Commissioning Development, NHS England, Professor Sir Bruce Keogh, National Medical Director, NHS England, Julie Wood, Chief Executive, NHS Clinical Commissioners, and Dr Steve Kell OBE, Co-chair, NHS Clinical Commissioners and Chair, NHS Bassetlaw CCG, gave evidence.
Q237 Chair: Thank you very much for coming this afternoon. Could you start by introducing yourselves to those following outside this room, starting with Rosamond?
Rosamond Roughton: Hello. I am Rosamond Roughton. I am the director of NHS Commissioning at NHS England. I have oversight of the services that we directly commission that are not specialised. That includes primary care services.
Professor Sir Bruce Keogh: I am Bruce Keogh. I am the national medical director.
Julie Wood: Hello. My name is Julie Wood. I am chief executive of NHS Clinical Commissioners, which is the membership organisation of clinical commissioning groups across England.
Dr Kell: My name is Steve Kell. I am a GP, chair of Bassetlaw CCG in Nottinghamshire and co‑chair of NHS Clinical Commissioners.
Chair: Thank you.
Q238 Mr Bradshaw: Thank you. How is co‑commissioning going? Not very well by the sounds of it.
Dr Kell: In terms of how it is going, co‑commissioning is still in the early days but there is a lot of interest in it. The whole background behind co‑commissioning was that the CCGs were keen to support primary care. We saw primary care struggling around us, and in general practice particularly we saw the opportunity to link up some of those pathways. It did not make sense that we were commissioning nursing homes—which is a good example, I think—without being able to commission general practice, which provides so much support for those patients. We have already had a significant number of CCGs in co‑commissioning with a significant amount of difference being made. We have a huge level of interest for 2016‑17—a significant increase. Over 50% of CCGs will have delegated commissioning if they are approved. It is important that we do not see this just as CCGs doing it on their own—that we are still working closely with NHS England, with our lay members and with our member practices. It has strengthened the patient engagement that we have built up in CCGs.
Q239 Mr Bradshaw: What about the CCG and NHS England perspective?
Julie Wood: It is going well. As Steve said, it is fairly early days but we are beginning to see CCGs making a real difference. We see across the country different examples where CCGs are beginning to join back-up pathways of care so that they are looking at primary care and community services and can do things differently. They can bring forward some flexibilities in how they bring resources from their wider commissioning budget to increase the level of investment in primary care, and that is a good thing too. The appetite is increasing. This year, in the first year, we saw 30% in delegated commissioning. As Steve says, we are looking at over 50% for 2016‑17, and we see examples such as where the member practice in a CCG—a neighbour to one another—in year 1 thought, “This is not for us,” and in year 2 they are saying, “This is absolutely for us. This is the way in which we can transform out‑of‑hospital care.” So I think it is going well.
Rosamond Roughton: From our perspective, we have seen three big benefits. First, it is about improved real insight about what is going on in general practice, because CCGs are just closer to the reality of general practice life than we can be, given the scale at which we operate. Secondly, to emphasise the point that Julie has made, the future for general practice is part of a much more integrated, wider set of services. Those are services that CCGs are responsible for commissioning. We can see with some of the CCGs with delegated responsibilities that they are better able to try and shape a strategy for a local place rather than having this boundary. Thirdly, it is about public involvement. We heard earlier about the strengths and the limitations of big national survey work, and some of that patient engagement and public involvement needs to happen at a local level. We can continue to build on local engagement processes that perhaps already exist, not just bespoke for general practice. Those are three things from our point of view that we think are helping to create a better system.
Q240 Mr Bradshaw: There were a couple of issues. There was the line of accountability issue, which could be seen to be blurred now as far as the patient and the public are concerned as to who is responsible for performance-managing their GPs, and the issue that was raised at the time of the Lansley legislation, which is why you were given responsibility originally, which is the conflict of interest potential. How are both of those areas being resolved in practice and are they being resolved to the satisfaction of the patient and the public?
Rosamond Roughton: I will take the conflicts of interest first. We recognise that there were heightened issues with the delegation. As a result, we published some statutory guidance on it for the first time in December. We have invested in training the lay members who sit on CCGs. We have not just left it to a piece of paper but have followed that up with training to support the lay members on CCGs in doing this. We are commissioning an independent audit so that we get some insight into how it is working in practice and be confident that we are still discharging our bit of the responsibilities adequately.
On the issue of blurred responsibilities, we have set out the things for which we do remain accountable, such as management of the list that determines whether a doctor is safe to practise in general practice—the national performers list. We have a clear distinction operationally about what we remain accountable for and what is the responsibility of CCGs. It probably is quite a technical list, but we know between us from a public point of view that we would see the CCG as the local leader on the ground and we would work with the CCGs if there were issues that were being raised by the public that they felt were not within the purview of their immediate accountabilities.
Julie Wood: Absolutely. I would add, in terms of conflicts of interests, that getting that clear was very important to our members. NHS Clinical Commissioners has worked with the BMA, the GPC and the RCGP to develop some shared principles on conflicts of interest when CCGs are commissioning from member practices. The three organisations that have a professional interest are together coming up with a single document about those important principles for how CCGs need to operate in that space.
Dr Kell: Can I come to the accountability question because it is really important? For a patient, when I see them as a GP I am accountable, and the whole reason I got involved in clinical commissioning was because I felt accountable for decisions that were made once they had walked out of my surgery door. I wanted to know that the services that got built around them were adequate, safe and sustainable and so on. That is why I got involved. The accountability technically has not changed. CCGs are there to support practices. We can do that in a much better way through co‑commissioning. Actual individual performance issues are still the responsibility of NHS England. It is helpful sometimes to have that clear separation.
Q241 Mr Bradshaw: Are you pushing amalgamation or a more federated service provision? Who would take the lead on that?
Rosamond Roughton: Just last week the Royal College of GPs and Nuffield said about two thirds of practices are now reporting that they are in some kind of network. We would very much respect that these are independent providers, but working at scale is probably one of the solutions to both some of the demographic challenges and the financial position for the NHS at the moment.
Q242 Mr Bradshaw: You are satisfied, Julie, are you, that—given the history of commissioning, not just now but under PCTs as well, which was not a particularly happy one in terms of quality—you have the capacity and the money to do it?
Julie Wood: One of the risks for CCGs in taking forward co‑commissioning was about the capacity to do it. They recognised that it was important that they did it—to join back-up care pathways—but they also recognised that they were doing it with less running costs than they had had in their predecessor PCTs and indeed less running costs than NHS England had got to support primary care co‑commissioning. They have gone ahead in spite of those risks. They are finding ways of bolstering up the management capacity to deliver things. For example, across Gloucestershire CCG they have created a team of people who are working with their localities, so very close to their member practices, who understand the issues across the different parts of Gloucestershire, to deliver that commissioning responsibility in a different way. But it has put them under stress and strain because the CCGs have not seen their running costs increase; in fact, they have seen them decrease from when they started in their first year to their second year. It was one of the factors that the CCGs had to take into account, but they felt that the improvements that they could make to the pathway for patients and the outcomes for patients outweighed the risks that were in place that they needed to cope with in taking on responsibilities.
Q243 Chair: Can I ask a supplementary on the conflict of interest? We have seen some concerns about, for example, pharmacy advisers having outside interests. What is the guidance to those who are involved as doctors commissioning—that they keep a transparent register of financial interests?
Dr Kell: This is important too. All clinical commissioning groups have a register of interests within the governing body, for example, so the GPs, lay members and everybody else who make the decisions, but then each member practice—there is quite clear guidance about this—have publicly available conflicts of interest as well.
Q244 Chair: You are happy across the board that the public can have confidence that it is transparent what those conflicts would be.
Dr Kell: Yes. The important bit is that we are assured that we have the correct processes and systems within CCGs but that we also are allowed to harness that level of innovation that is out there, to define new pathways. We are in danger of creating a system sometimes that inhibits that and how we are going to move forward. I think the processing system is key.
Q245 Chair: We have the level of not discouraging people with expertise but making it transparent what their interests are. Are you happy we have the balance right, Dr Kell?
Dr Kell: Yes. We have learned as we have gone along to become more and more used to declaring interests and leaving rooms. Sometimes it makes it more difficult to harness that innovation, but we have developed robust processing systems, overseen and authorised by NHS England.
Professor Sir Bruce Keogh: May I add two other points to that? As part of our assurance process, CCGs have to report quarterly as to where they are in terms of conflicts of interest—any that have arisen in the last quarter. They also have to update their public register and have to indicate in that quarterly self‑certification what action they have taken with respect to any conflicts that have arisen.
The second point is that, in April, we will be publishing some updated statutory guidance, which will have come out of this debate, on how we handle conflicts of interest across the commissioning system as a whole. We will be going out to consultation on that shortly.
Chair: Thank you. With the rest of the Committee’s permission, I am going to come to Philippa next because she has to leave for an all‑party group.
Q246 Dr Whitford: Thank you, Chair. We have talked about the pressure on general practice and starting to change the shape of the team. What responsibility do CCGs take to encourage the development of a true multidisciplinary team, not as some kind of second‑class primary care but able to bring a much broader range of services to the patients?
Dr Kell: One of the beauties of my job as a GP is that I am used to working as part of a team and it is really important that we see the role of the GP in primary care generally as part of a wider system. A lot of the commissioning work that I have been doing for the last three years or so has been around support for patients in the community, which in itself is support for general practice often. If I think about my most vulnerable patients who have severe dementia, in nursing homes, for example, commissioning specialist dementia nurses to support general practice—but most importantly to get better patient outcomes—has made a huge difference. We heard Don talk about social prescribing. Not everything that we see now in the GP surgery is dealt with by the NHS or by a prescription; it is dealt with by referring people to mental health counselling, to Citizens Advice or to befriending services. These things that may seem soft—they are not about referrals or numbers—are the things that are making a real difference. Co‑commissioning has enhanced and accelerated that.
Q247 Dr Whitford: Sometimes we talk about physicians’ assistants and other people as someone who can step in, whereas people like physios, counsellors and social workers are bringing in a totally different set of skills. Are there barriers to that? Is there anything that is stopping that development within commissioning?
Dr Kell: Some of it is about incentive. I have personal experience of the benefits of employing a pharmacist, which makes a huge difference both to the quality of prescribing and to workload within a practice. That has made a real difference. Physio is a good example where in a lot of areas you can now see an orthopaedic surgeon quicker than you can see a physio. That is not good for the patients or for hospital care. But the incentives are not necessarily there in the system for a practice to go out and employ a physio, because that is a completely separate budget and way of financial funding. I think there is work yet to be done around breaking down budgets, because I think the future is about multidisciplinary working.
Julie Wood: That is one of the real opportunities of co‑commissioning because you are bringing together around a place, if you have delegated commissioning, the budget for primary care with the budget for community services, and then you can look very differently at how you bring in people like clinical pharmacists, physiotherapists, OTs and all those people. GPs naturally, as leaders of local health systems, as CCGs, think in that way. It is fairly natural for them to think they can do this differently and get a broader primary healthcare team looking after the patients, who will make the very best of the skillset that you have around the place to improve care and healthcare outcomes.
Q248 Dr Whitford: Are there any other comments on that?
Rosamond Roughton: When we put the investment into the Prime Minister’s Challenge Fund about improving access, we were struck by the fact that every single one of those schemes redesigned their workforce. It has generated for the system some really powerful case studies about the contribution that the wider workforce can make. Last month we backed that with some extra investment to support a faster roll‑out of bringing clinical pharmacists into general practice. We are funding about 400 pharmacists—match funding for practices—in about 700 practices across England. That will allow us to test the kind of training and best way of making the most of that expertise. There are other things like that, but, given the nature of the population health challenge of the future, I would see the need for us to look at the primary care team and the wider extended services in the round and not just think about the medical workforce.
Chair: Julie, you had a wider point on the pharmacy issue.
Q249 Julie Cooper: Yes. Acknowledging the role of other health professionals, including pharmacists, in the primary care team I have first‑hand experience of seeing a minor ailments scheme running in the community and have heard first hand from GPs how much they valued that and how much it eased their workload. Why is this not rolled out in commissioning nationally?
Rosamond Roughton: We looked to see whether a national minor ailments service would be something we would do, but we were not able to reach an agreement with the pharmacy bodies on a price that we felt delivered good value for money for the taxpayer. Instead, we have produced some material to help CCGs negotiate our local teams a better price locally. We can see now that about a third of the country is covered by local minor ailments services.
Q250 Julie Cooper: Presumably the negotiations at local levels have been successful because pharmacies have agreed to run these schemes. I suppose it is building on that good practice and seeking to make sure that is spread nationally.
Dr Kell: This comes back to national problems but local solutions. There are very few examples where a single national solution has solved the problem in every locality. It depends very much on how many patients pay for prescriptions, the state of pharmacy locally and GP access. There are different ways of achieving the same outcome. What is really important is that we have that local knowledge. I work closely with local pharmacists, as I think CCGs do. How do we harness those relationships and see what the local problem is before we find a solution together, if that makes sense?
Julie Cooper: It does. There is a case, is there, for grouping similar areas? I take the point that, in areas where there are a lot of patients who do not pay for prescriptions, many would seek to access a GP to get a free supply of medication rather than going to the pharmacist. Maybe you could intercept that and provide cheap and effective medicines via the pharmacy. I suppose there could be some sort of encouragement for similar demographic areas to work together. If it worked in one of those, it is probably going to work in another one. Thank you for that.
Q251 Helen Whately: Over the last few weeks we have heard from other witnesses who said that primary care needs to have a greater share of NHS funding, as it used to apparently, but it has had a declining share. I would be interested to know if any of you have a particular perspective on that; and if you think the answer is, “Yes, it should have a greater share,” what that should be spent on, albeit we are tight on time, so I am not asking for an extensive answer.
Rosamond Roughton: From NHS England’s point of view, we have set out in our evidence the recognition that we think the facts are clear. In general practice, in particular, in more recent years the level of investment has not increased at the same level of hospital services at a point when we are saying strategically that we want to see greater investment in out‑of‑hospital services and potential for more to be done. If you look over the last two years, the data shows a much bigger increase. We had a 3.6% increase in 2013‑14 and a 2.7% increase in 2014‑15. This time last year, when our board was making allocations, it made a very deliberate and conscious decision that there was a 4.1% increase in allocations for primary care compared with the 3.4% uplift in CCG allocation. There is a bit of a shift towards a greater level of investment in primary care. That is why the delegation and co‑commissioning is so important. We need to try and make sure we think not just about general practice on its own but primary and wider community services together in thinking about what the balance of investment is between the different parts of the health system. We need to make that decision in light of what the local strategy is. That is why we have both made some moves towards that, but the delegation of commissioning is an important step.
Dr Kell: Co‑commissioning is an opportunity here but not the answer. We have recently held a members’ meeting for CCGs. One of their main concerns was the sustainability of general practice. It is very difficult, as a commissioner, to actively increase out‑of‑hospital care and to shift funding or support from hospitals towards community services, mental health and general practice at the moment for a number of reasons, including financial incentives, tariff and the fact that provider deficit is so high. It is very difficult to do that. It challenges within the Five Year Forward View how we meaningfully get that shift that is talked about into better support in nursing homes, which is a good example. How do we better get that shift of support, with more and more focus on hospitals, referral activity, provider deficit, four‑hour wait and so on? It is as much about focus as a real shift in funding. If we are going to go to member practices and ask them to take on more work, or work in different ways, they need that space and the funding to take on extra staff to do it.
Julie Wood: The money is absolutely important, as is the workforce. If we get the shift of the funding and if part of the solution is about more people, in terms of a broader range of people but more provider services in the community, we need to make sure they are there to pick up the additional services that are needed. For a number of our CCGs, our members will say it is not about giving them more money at this point, because even if we did they could not find the people to do the work. We need to have the workforce strategies aligned to the primary care strategies and aligned to the funding flows together to transform and improve health outcomes.
Dr Kell: I have one quick point that I forgot to make about the cycles of funding that are really important. General practice is often based on annual changes in funding or priorities. As commissioners, it is important that we work together with NHS England to create longer cycles of certainty around what our priorities are, to fund those shifts and to enable people to take staff at risk, but with a longer certainty in how our future is going to be investing in care homes, and let’s get the staff in to do it.
Q252 Helen Whately: How well does the Carr‑Hill formula allocate funding to practices, particularly those with atypical patient populations?
Rosamond Roughton: I will take that one. We think the Carr‑Hill formula, which determines the distribution of a significant proportion of money to general practice, is a little outdated now. We have begun some work with the British Medical Association to review whether it is still fit for purpose. That review is under way at the moment. In terms of atypical practices, we are having discussions about whether there are some particular population groups that no formula will ever be able to account for. For example, we may find it hard to have a national formula that sufficiently reflects the needs of a practice with a predominantly student population. We are also looking at whether there are some particular groups where, if a practice largely has that group, the national formula will not adequately reflect the needs and workload that that practice experiences.
Q253 Helen Whately: So there is a review of the formula ongoing. One answer we have heard that has been given to practices that are worried about this is that co‑commissioning will mean there are flexibilities and CCGs will be able to mitigate the impact of changes in funding, particularly for the withdrawal of PMS funding. That is the answer they have been given, but in practice they are very worried that that mitigation will not work. Do you have a view on that problem?
Rosamond Roughton: Yes. We are carrying out PMS reviews—reviews of practices that have personal medical services contracts—for two reasons. The first is that these practices get more money than a GMS practice and we want to be sure, first, that we are getting value for money for that and, secondly, that this does not mean we have one particular bit of the population benefiting and not others from whatever is on offer. Those reviews are under way, and we completely recognise that in some cases some practices are saying this has the potential to destabilise their funding.
We have set down three principles. The first is that that money must not be lost to general practice services; that is not money that is going to go into a different bit of the NHS. I think that has been really important. Secondly, it stays locally. It is not money that goes outside the local health system; we are not moving large amounts of money around the country. Thirdly, this is managed over a period of time so that, if a practice is losing money, it can prepare and think about how it adapts its business model to continue to deliver services for similar funding levels to those practices surrounding it that will have been delivering services at that funding level in the past.
I have not seen it so much with the PMS reviews but more with the removal of a minimum practice income guarantee, which was some transitional funding that was introduced over a decade ago now, but I have seen that some CCGs have taken steps to commission additional services from some practices that have been losing money through the withdrawal of the minimum practice income guarantee, which has helped stabilise those practices.
Q254 Helen Whately: As a counterbalance to providing funding, do the commissioners, whichever model they are following across the spectrum you are talking about, have the levers needed to make sure that practices are providing value for money and consistent levels of service? I say this partly reflecting on some of the things I have seen in my constituency.
Dr Kell: One of the challenges with commissioning general practice is that, apart from some outputs such as the Quality Outcomes Framework and patient satisfaction, there is relatively little known about services within general practice itself, in terms of number of consultations offered and capacity, for example. CCGs have been increasingly collecting through their member practices that level of information so that, for example, when we are planning future services, we know what the level of capacity is within practices for the week in advance and can spot surges in activity earlier. That leads to a true commissioning of general practice in a way that does not just focus on hospitals, where we look at A&E activity all the time. The intelligent commissioning of general practice will evolve, but it is about collecting the data and understanding it first before we rush in and do stuff.
Julie Wood: Through their co‑commissioning arrangements—and pre‑dating them, so some do go back to PCT days—a number of CCGs have dashboards or a range of metrics that they have developed with their member practices that help look at activity and some measures that they can then work over with their practices to help them drive forward improvement but on a comparative basis. That is being rolled out across different parts of the country in different ways, but the important thing is that it is being developed bottom‑up by the member practices within the CCG so it is seen as having the indicators that do demonstrate high-quality care and high-quality outcomes.
Dr Kell: We have those metrics running in Bassetlaw. In Liverpool, they have commissioned a certain amount of activity from general practices per 1,000 patients per week. There are different models, but it is interesting that this work is happening.
Helen Whately: That is interesting. Thank you.
Q255 Chair: Can I ask a supplementary question? When we visited Page Hall medical centre on our visit to Halifax and Sheffield, it was the degree or the scale of the shift in funding that they were going to see that they felt would have very serious implications for them. Are you seeing practices around the country expressing real concern about what they see as a cliff edge?
Julie Wood: It is interesting that we are likely to see it first as part of the PMS reviews.
Rosamond Roughton: Yes. We are about halfway through the PMS reviews. Bear in mind that none of them has been included. We are working with our local teams to understand if we are going to get that kind of cliff edge and what the mitigations are for that. Our No. 1 concern is that patients continue to get a high-quality service. If there are particular places, then I would need to follow that up.
Q256 Chair: Can you give us an indication of the number of practices that have indicated to you around England that they would be in severe financial distress as a result of the changes? Do you have an idea of the numbers?
Rosamond Roughton: No, I do not. We are doing a stock‑take at the moment about where we are with all the reviews, but we do not have that kind of data. One thing we will look at is the ratio of things like expenses to earnings and average earnings as well in taking account of to what extent, if practices think that there is a cliff edge, that is something that will impact on patients, or whether this is a practice business model issue, which is what we have seen in some places—but a very small minority, I hasten to say. It is not the majority.
Q257 Chair: It is too early for you to say.
Rosamond Roughton: Yes.
Chair: Thank you very much. We will come on to James.
Q258 Dr Davies: Representations have been made to us in terms of the benefits of GPs federating. What national support is available for GP practices that wish to federate?
Rosamond Roughton: This year at the moment and last year we have offered support to practices that were successful in bidding for money for the Prime Minister’s Challenge Fund, which was about improving access. In doing so, we set a minimum population size. That has led, in effect, to incentivising practices about coming together to work to provide a network of care. We have provided support to about 1,000 practices in the first instance in the 20 schemes and now the current 37 schemes. We have also commissioned some work from the Royal College of General Practitioners and the Nuffield Trust to support developing networks. Just last week they published their initial set of findings and the areas on which people want support. But there is also support from other bodies as well as ourselves.
Professor Sir Bruce Keogh: It might be fair to say that there are other models that are beginning to emerge other than federations. Models of single organisations with a single‑board modality in Birmingham would be an example. I would imagine that, as the new models of care programme begins to emerge, we will start to see a small but significant number of different models, some of which will have advantages over others, particularly relating to geography and demographics and so forth. We need to be careful not to get into a place where once again we start to think that one size fits all.
Dr Kell: The GP networking, or federation, has various forms, from the informal working together as joint support to a contractual or merger change. The role of commissioners is to facilitate that, to make sure it makes sense for the local population. It is also important that we have a clear narrative as to why practices would be working together. It is important that that is hopefully done in a proactive way, which improves patient quality, access and sustainability. I am more concerned when I think it is because of the financial need to do so, because then we lose some of the benefit that might happen. If it is because of changes to funding and so on that forces practices into that, we will get less benefit as commissioners. Our members as CCGs see practices working together more and more and tell us that, but they are also very worried about sustainability.
Julie Wood: The key is having a locally developed primary care strategy that underpins the future direction, but then having the enablers that get underneath that, so the business models—federations or different models of care. Also, you have to get enablers like premises, plant and IT right and operating together so that we can deliver a transformed out‑of‑hospital service in a way that makes sense to local people and local populations.
Q259 Dr Davies: If CCGs have delegated commissioning responsibilities, would they be in a position to commission a new type of care about bringing in secondary care outside the GMS contract?
Julie Wood: Yes, they would. The key thing is how that is enabled to happen and, if that requires resource shifts from secondary care to primary care, how you ensure that you are able to transact that through your various contractual responsibilities and levers through commissioning—but, yes, absolutely.
Dr Kell: I want to talk about working jointly, so I will come back to my work as a GP and working as part of a team. We are in natural health systems, so we work with community services, mental health teams, hospital providers and general practice looking at things as a whole, and that is really important. We are seeing more shift from hospitals coming out into the community, and I think that is essential. Having the whole budget to either commission jointly or commission and delegate arrangements gives us more flexibility to do that, but we have to keep the purpose right, which is improving patient care. That health system approach is crucial. We all have responsibility for the patients in our system.
Dr Davies: Thank you.
Q260 Maggie Throup: Coming back one step, I have a supplementary about federations. One barrier I have come across to federations is when you have individual practices that are obviously registered with the CQC. Then you have federations forming that perhaps want to provide the seven‑day service and they find they have to register with the CQC again. What can be done about that?
Rosamond Roughton: We have talked to the CQC about how we can make sure that its registration requirements match the developing models of care. It is very responsive to that and, certainly in the schemes that we are supporting from NHS England’s point of view, it has agreed to provide a go‑to person that can guide them through the process. We need to make sure where we are putting on these new services that we are confident that the CQC regime—the registration is there for a reason, which is around public safety—is not compromised. We think there are ways in which we could start speeding up that process. It is not just about the federations; it is also about the programme of work we have on developing new care models as part of the NHS’s Five Year Forward View. That is another area where we want to work with the regulators to ensure the regulatory regime keeps up to speed with the different ways that care is developing.
Q261 Maggie Throup: There are no more comments. That is fine. Still sticking on federations, could federations be commissioned to provide care on the basis of a capitated model of care?
Professor Sir Bruce Keogh: Yes; we are looking at that under the new models of care programme. We see that as offering quite an exciting opportunity. It is not unrelated to Dr Davies’s question.
Maggie Throup: They are connected, yes.
Dr Kell: It is a particular opportunity to improve community services and their link again with general practice. We did have this but it got lost along the way a few years ago. If you talk to a lot of GPs and district nurses—matrons—they will talk about that teamwork having been lost a few years ago; and to bring that back, which is what CCGs are doing, is crucial. Patients expect that we work together, particularly out of hospital, that we communicate, that we share records and that their pathway will be a joined‑up one, and sometimes the reality is different. Our role as commissioners, and sometimes through capitated budgets as a tool, is to bring that back together.
Q262 Maggie Throup: We are getting towards the end now. Do you anticipate that the most ambitious general practice federations will seek to develop their own MCP-type models of care?
Julie Wood: Yes.
Rosamond Roughton: That is the ultimate goal.
Professor Sir Bruce Keogh: Not just that—we would encourage it.
Q263 Chair: I have a couple of follow‑up questions. One of the barriers that we have heard about so far in our inquiry is the issue around continuing professional development for other members of the healthcare team. Is that something that you think should be commissioned by the commissioners or should we leave that to individual practices? We have heard it is sometimes not happening when individual practices have to pay for it.
Rosamond Roughton: It is not something that has been raised with me previously. My initial reaction is that in the rest of NHS services the responsibility sits with the employer for continuing professional development. That is the approach that we have been taking since the NHS’s inception with general practice. In terms of what we are trying to do about stimulating new workforce models in general practice, we are looking at some investment. When I talked about bringing pharmacists into general practice—because we are trying to kick-start some of that—we are paying for the training costs in that scheme, but that is a protected scheme at the moment. It is certainly something for us to think about.
Q264 Chair: But what about in the future, if we have physician associates and extended roles for nurses? At the moment one of the problems we have heard about is that nurses within practices often do not get access to the same continuing professional development that, say, GPs do. That is why I was asking the question whether you see that being more of an issue down the line and a case for it being commissioned more centrally.
Dr Kell: We see commissioning as being part of a health assistance system. A lot of CCGs have started to take a responsibility for education beyond the practice team. For example, nursing home nurses can often work in isolation or under great stress with low numbers and an increasingly complex caseload, so a lot of areas have brought together nursing home nurses with practice nurses and hospital nurses, often led by the hospitals on some occasions. There is that system view of, “Is it good for a hospital to improve the care within nursing homes and within general practice?” Absolutely, it is. That is the future model and that is what CCGs are working to in a lot of areas, seeing education as a whole around the system rather than educating silos of workers.
Q265 Chair: Thank you. I have one final question. Do you see the issue of devolution of health and social care—the Devo Manc model and the various other models that are being proposed around the country—as a positive thing or as something that will create more system churn just as these new models are starting to bed in?
Julie Wood: Our members very much see localism as key. Localism can be delivered in a number of ways. Devolution in its various forms is one of those, but it is not the only one. The critical thing is that there is a local conversation that goes on about what we want to have greater control of locally and who then across our place needs to lead on that. It could well be different organisations for different things, what is in the scope of us wanting greater local flexibility, and then bringing all that together. We need to be clear about the rules of the game in relation to devolution. One of the things that we are keen to understand is the devolution legislation as it develops and the existing Acts and legislation around the Health and Social Care Act: one says you can do away with public bodies and the other says you have to have them. It is important that we are clear about the implications of the devolution legislation on the footprint of local public bodies within that place.
Q266 Chair: Do other Committee members want to ask anything further? In that case, can I finish by asking if there are any questions that you have not been asked that you feel are important points you would like to make for this inquiry at all?
Dr Kell: I have one very quick thing, which is to stress the importance of workforce planning. I know you have taken some evidence on workforce, but, as a commissioner, I get increasingly concerned that we stretch things too far and that we, for example, lose part of the system that is out-of-hours, for example, in terms of GP capacity. That is a constant challenge for us, whether we are NHS England or clinical commissioning groups and I think it is something that we need to keep at the forefront of our minds when planning services.
Q267 Chair: Yes. It is certainly something that Philippa was touching on; we have heard that having dual systems is undermining out-of-hours. Is that your view?
Dr Kell: We certainly hear from a lot of our members in quite a few areas that that is a challenge.
Professor Sir Bruce Keogh: May I say something that is not really a question or anything that I necessarily would have wished you to ask? I would like to pay some credit to the people who work in primary care. It seems to me that, through a number of routes, there has been quite a lot of criticism of primary care in the recent past. There is a risk of over-criticism at our peril. Both general practitioners and their associated staff are having to deal with tricky issues of increasing demand and rising expectations, and in particular in the face of increasing complexity of the patient workload that they have to see. In my view, it is a really hard job. They have to be clinically, intellectually and emotionally strong. I can say this as a cardiac surgeon, where all our patients come to us kind of worked up. I do not want to downplay that, of course. But day in, day out, general practitioners are having to sort out the wheat from the chaff, to identify major clinical problems masquerading as minor ailments, and it is utterly relentless. It requires quite a lot of intellectual flexibility and people have to be very tolerant individuals. It is one of the hardest jobs in medicine. It is important to say that at a time when general practice is going through quite a lot of turmoil.
Chair: I am sure that will be deeply appreciated and it is a very good note to end on. Thank you very much.
Oral evidence: Primary Care, HC 408 21