Supplementary written evidence submitted by Dr Pauline Grant (FGP0397)

 

ACCESS

 

A lot was said in the session regarding access and how the general belief amongst many GPs is that you cannot have both good access and continuity. I disagree with this as in our practice until recent times, we have had both.

 

Access is a function of the number of appointments you have every week per patient.

It may be more related to the number of GP appointments you have even more specifically, as other health care professionals do not completely replace GPs, many consultations just do need a GP, or the patient’s perception is that they do.

 

I currently provide 60 appointments per week per 1000 patients and I often add extra appointments on the end of a surgery if I am very booked up early on. We prioritise access as well as continuity. 75 GP appts/1000 pt/week is considered to be best. So this is measurable. We have, however, for the first time in the last few months started to nominally cap our surgeries. I say nominally because if a patient says it is urgent they will get added but it means reception puts a bit more pressure on them to book for the following day. This is a direct result of being 2 GPs down on Cheviot side, so access will probably worsen.

 

So I think poor access is a direct function of not having enough GPs and will be worsening currently due to the recruitment crisis. Asking the remaining GPs to work harder still by seeing patients into the evening and at weekends ( the Enhanced Access DES) will be counterproductive because it will increase burn out and worsen the recruitment crisis. This in turn will worsen access rather than fixing it.

 

Continuity helps with demand because if I put some effort in to properly sorting out the patient, hopefully they will not be coming back so frequently so the number of appointments needed will be less. Also I can feed back to my patient if they are requesting appointments for inappropriate things and because we have a relationship, sometimes that works (not always if they have health anxiety). I can also feed back if they are using other parts of the health service inappropriately eg A&E.

 

The belief that you can have either access or continuity has arisen in the context of an under doctored system. When our surgery is fully doctored we have excellent access.

 

Access is a function of demand and supply.

Factors affecting demand;

 

Patients representing frequently because their problem has not been dealt with properly

Outside forces such as health scares and TV adverts eg see your GP if you have had a cough for 3 weeks

Outside organisations telling patients to see their GP, currently schools are the worse- all of a sudden they are telling parents to take their children to the GP and asking for letters due to school absence. I don’t know if some legislation or central school advice has changed?

General health anxiety in the population fuelled by the media.

 

Factors affecting supply

 

Recruitment crisis. GP needs to be more attractive – fix the pension problem the government should pay our employers contribution. This is a different subject

 

When supply of GPs is low there is a certain amount of self regulation of demand as if you cannot get an appointment for 4 weeks if the problem is minor you may give up trying (e-consult has however provided a way for the patient to circumnavigate this problem) However this is unmet need in the community and problems stored up for the future

 

 

Downsides of a Personal List System

 

 

The doctor/patient relationship in a personal list system is a bit like an arranged marriage. The patient did not choose that particular GP, and even if the don’t like them that much they are stuck with it unless they ask to change the GP. We do allow this if there seems to be a break down in the relationship but we discourage it, especially if we think the patient will have a problem with any other GP too ( eg the patient wants the GP to do something which no GP would be happy with) We prefer that they both try and work at the relationship.

 

It is possible that a GP could become complacent regarding a patients symptoms which have previously been considered medically non significant over a long period of time, but then do become significant. This can happen occasionally but mostly it works the other way round, that because the GP knows what is usual for a patient they spot the unusual. I have a patient who I have had contact with every week for 7 years and she always has a chronic bad chest because of smoking 40 cigarettes a day and quite often presents it to me as a symptom. One of these occasions I realised that she was actually unwell with pneumonia because she looked ill (she never looks healthy). She was not her usual self. And I admitted her. The reduction in mortality statistics demonstrate that it tends to work this way I believe.

 

It is possible that a GP working autonomously with their own list could get away with poor clinical practice as their patients would be seen less by other GPs.

In fact we do see quite a lot of each other’s patients as no-one works full time and so we do see the notes that our colleagues make and we do pick each other up on things from time to time. Personal lists will probably attract those GPs who might want to practice in a very individual way. We do have audits of each others work in the form of death audits. Every death in the practice is peer reviewed at a meeting and we discuss the lead up to it and diagnosis etc. We also have significant event meetings, although this relies on the doctor reporting their own significant events if a patient has not raised it.

 

Patient choice- patients are allocated to a GP and cannot choose. When they register they are allocated to the person who happens to be registering that week. We do allow a certain amount of movement eg if it is more culturally desirable for someone to have a female GP.

We also allow a patient to ask to see a female GP for a particular problem if their GP is male (and vice versa for male patients). In practices that do not have personal lists the patient can theoretically choose who they see. In practice because of current poor access they usually have to take whoever they can get.

 

We also allow a patient to ask for a second opinion if they do not agree with their own GPs diagnosis or management. So I can review a patient and sometimes will make suggestions which will hopefully improve care or, often, reinforce what the first GP has done and go over it again and reassure the patient that it was correct. This is not needed often, I think I have done about 4 in 7 years.

 

The personal list system introduces some rigidity into the days the GP can work if they have to cover the whole week. However I think job sharing will be a way forward, where 2 part time GPs cover one list (either 2 sessions each for a small list or 4 sessions each or any combination for a bigger list). They could then work any days they wanted to as long as between them they cover the week. This waters down continuity but it does allow the patient a choice of one of 2 GPs and introduces rota flexibility. It also plays into the current recruitment problems as there are GPs who want to work only 2 sessions a week, often because they have small children or other specialisms but want to keep their GP practice going. We are now trialling this due to our recruitment problems. We have had quite a few GPs interested on the basis that we are going to try to give them continuity as well as flexibility and capped sessions. This will put a strain on the remaining partners because we will have to soak up the overspill of patient demand, but if we have enough sessions of these GPs we hope to reduce this. However this could be expensive as we are effectively giving them a smaller list size ( 175 patients per session compared to our 250) in order for their capped sessions to service the list.

 

What can the government do to introduce continuity?

 

There was a discussion about how to get practices to take on board continuity and it is a complex problem.

 

There was a disagreement between the 2 panels as to whether payment would be required.

I agree that practices are fed up of jumping through hoops for their money but this is mainly due to the remuneration for the activity not being high and some of the interventions having dubious clinical value. Also these activities have to be undertaken in order to maintain a normal level of income and are a necessity.

 

Therefore, I do believe that practices would have to be incentivised to make this change but it should be a significant amount of money and it should be on top of what we currently get, not taken from elsewhere and repurposed. Every time money is removed from part of our income and directed elsewhere and the practice has to reorganise just to stand still it puts a strain on practices and leads to the feeling that we are just rearranging the deck chairs on the Titanic. However, if we have to reorganise for a significant amount of extra money it might be different. I think this has been shown by the success of PCNs. We have risen to the challenge because it is the only offer of new money we have. New money equals more staff which equals better patient care and reduced GP stress- not an increase in our personal income which is not the goal.

 

You could consider it to be enough money to fund an extra FTE GP per a number of patients (5,000- 7,000?) plus the cost of a management consultant to go into a practice and help them reorganise and prioritise continuity. GPs would also have to trust that this money would not then be taken back from elsewhere at another time (another government trick).

The money would have to be no strings attached ie could be used for existing GP (measuring additionality is fraught with difficulty) with the expectation that it would be used for an extra GP/s.

 

It could be 2 stages- lower level less money for increasing continuity in certain groups

Upper stage full personal lists.

This could then be used in research to compare the 2 types of practices and their outcomes from the point at which they decide to make the change.

 

It would be voluntary but the incentives would hopefully draw practices in. This should also be paid to those practices that are already doing it well but maybe an extra aspirational payment to those who have to set it up from scratch

 

You could make the extra GP a continuity champion therefore it would not matter if it were an existing GP because they would become the continuity champion and as part of their income they could have 1 session per week no patient facing but helping the practice to implement continuity. I think that would be an attractive job for someone and as it is centrally funded the practice would be happy for them to have the session per week to do this.

 

If continuity is less stressful for GPs as we believe then once everyone starts to see the benefits they will want to keep it.

 

The recruitment crisis in many healthcare/social care sectors is because the job is too stressful and not well paid for the hours worked.

 

If the job can be more interesting or less stressful I believe it will encourage people to come back. Also it is very difficult for people to come back at the moment after a long break

 

 

May 2022