Written evidence from Daniel Moore (FGP0003)

 

Dear Committee,

 

Thank you for the opportunity to respond to your call for evidence

 

Personal details :-

 

I am a full time GP working for the NHS. I qualified as a doctor in 1990 and as a GP in 1996. I have been at my current practice for almost 25 years and am the senior partner in a practice caring for almost 14,000 patients in south east England. I also work as a GP appraiser, GP trainer and PCN Clinical Director and in the past have served on the boards of local CCGs and community trust. I have also worked abroad.

As such I have experienced the NHS through many structural reforms right back to the Clarke reforms in 1990, the purchaser/provider split, fundholding, PCGs, the various iterations of PCTs, the various iterations of CCGs and now PCNs and ICPs.

Throughout this there have been few constants with such a pace of managerial change but they include the GP-patient relationship and consultation and the GP practice.

 

Response to the call for evidence

 

 

What are the main barriers to accessing general practice and how can these be tackled?

The fundamental limitation on access to general practice is the number of GPs.

As yet there has been no meaningful government action that is likely to reverse the continuing decline in GP numbers.  Attempts to recruit GPs from abroad have largely failed because the workload of UK GPs is far greater than most countries, both in the number of patients seen and the degree of responsibility taken on by GPs across the range of medical specialties (for example, in France GPs would not treat all paediatric patients). With the ongoing shortage of capacity in the NHS secondary sector this is unlikely to change and the expressed desire to move work from the secondary to primary care sector is likely to increase this workload in the future.

The volume of bureaucracy, which has been increasing year on year also takes away a larger portion of GP time making them less available to patients. GPs are now having to spend large amounts of time on managerial tasks generated by NHSE, CCGs, ICPs, PCNs, the CQC, the appraisal system and the demands of the NHS internal ‘market’ that has increased paperwork for even the simplest of referrals. When I started 25 years ago we had about 3 or 4 referral forms. This has increased to over 200 and includes, paper forms, bespoke e-portals, electronic referral forms to name but a few. Most of these require the GP to fill these in rather than be able to delegate them to an admin staff member or dictating an appropriate letter using secretarial staff. Appraisal takes over a week of GP time from every GP annually, longer if one includes the GP appraiser time. CQC inspections are often based on hospital criteria creating a greater workload than if they were tailored to primary care. The funding demands on social services results in many patients calling their GP when they are left without access to care, all children in need seem to require up to 4 reports a year from their GP rather than the ad hoc process of years gone by, increased bureaucracy from many industries requires more forms to be completed by GPs. GPs have been promised a bonfire of bureaucracy in the past but this has not materialised.

Ancillary staff, often touted as reducing the workload for GPs (nurse practitioners, community matrons, clinical pharmacists et al) rarely do so and often increase the workload of GPs due to the lower levels of training and certainty these staff have, leading them to require some form of oversight from a GP.  Good evidence for this can be found in figures showing a rapid rise in the number of primary care consultations with non-GPs over the past 20 years, but still an increasing workload for GPs. It begs the question how much value are those no-medical consultations bringing to patients if patient demand  and GP workload is now higher, despite this, with no major shifts in health outcomes either?

Pay for GPs has not kept up with inflation, making  the role even less attractive from a financial perspective. This has been known by parliament for many years and not reversed. Funding for GMS work barley covers the costs and the only way GPs have managed to increase income is by doing less GP work and more work outside general practice. This leads to further pressure on GP appointments. Pay for GPs in other Anglophone countries is significantly higher for the workloads. Of the 10 GP trainees on my GP trainee scheme 6 of them now work abroad. I have worked in Australia and Canada and only issues with obtaining the correct visa and family issues have kept me in the NHS. I am now a GP trainer and have seen many GPs that I have trained leave the NHS or even medicine completely, including those that had secured work as salaried GPs or GP partners in the NHS. The workload and bureaucracy, as well as the poor pay are the usually cited reasons. In recent years with many more  GP trainees emerging from minority backgrounds I have now even started to see many new GPs emigrate to non-anglophone countries.

Previous reports to parliament have highlighted pretty much all of these issues (  https://publications.parliament.uk/pa/cm201516/cmselect/cmhealth/408/408.pdf ) but the reports have either been rejected (either wholly or in parts) or seemingly  ignored.

If I were to recommend one single course of action to reverse the decline in general practice, and the NHS in general, I would suggest abandoning the purchaser provider split. All the benefits touted by the introduction (increased efficiency, freeing up of resources et al) have simply not come to pass in any meaningful way. Certainly any benefits cannot possibly be justified by the army of management that has grown to consume some estimated 15% of the entire NHS budget and the inefficiencies created by the enormous burden of bureaucracy that has been placed on clinicians. I genuinely believe that PCNs, ICPs, CCGs and NHSE itself have not proven their worth and should be replaced by a more centralised and efficient command and control system, thereby releasing tens of billions of pounds for the improvement of patient care, including stimulating a growth in GP number.

To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

I am afraid the current plan is doomed to failure. It seems to have been produced with no real understanding of the way general practice works in parts of it.

Examples include the presumption that remote consultations, including e-consultations, emails , telephone or video consultations, can somehow improve efficiency. This is a clear fallacy as the fundamental unit of GP consultation is a single GP dealing with a single patient in an average of 10 minutes, and the patient’s problem cannot be safely reduced to a smaller timeframe even with the use of a different method of communication. In fact the consultations may be longer, for example a telephone consultation may take longer as there will need to be longer verbal communication to replace the nonverbal communication in a face to face consultation, a written electronic communication may not contain sufficient details to practice safely and so often requires further follow up communications to gather all the essential data.

Centralised disease-specific hubs are even more inefficient as the hubs cannot deal with the whole patient with the same depth of knowledge as the patient’s GP and so a single consultation with a hub will never replace one with a GP, thus the number of consultations will rise in total but the number of consultations with the GP may not fall. This does not even take into account the requirement for the GP to digest any communication from such hubs, act on their recommendations and communicate back to such hubs.

PCNs have introduced yet another layer of management which has taken up much GP time needlessly. Most of the ARRS roles and the DES actually add work to general practice that would not previously have been done at all but was carried out by other providers. They have done the opposite of freeing up GP time to see patients. The absence of any legal structure for a PCN has made them worse than useless as they cannot employ anyone, cannot hold a contract or even open a bank account, yet work is being commissioned on a PCN basis. This has necessitated GPs to either abandon PCNs or try and create new business structures to carry out the work. The model of practice based provision is by far more efficient.

     What role does having a named GP—and being able to see that GP—play in providing patients    with the continuity of care they need?

Pretty much every study over the decades has demonstrated the great value of having a personal GP attending to patients, to patients themselves, to the GPs caring for them and the NHS as a whole. It is one of  the great strengths of the NHS and allows greater understanding of patients as  whole individuals. The decades long relationship with individual patients and their families allows nuances of understanding that improve diagnosis, improve patient concordance with treatments plans and reduces referral rates. To lose this would significantly damage the NHS as an organisation as well as damaging patient care.

Primarily the continued policy of allowing GMS to wither on the vine. As has already happened this policy has led to fewer and fewer GPs, even to the closing of practices in many areas with the well publicised near collapse of all NHS GP services in some towns. If it continues there will be increasing numbers of people with no access to GPs at all with the inevitable consequences that will have on public health. The current difficulties of access are really a reflection of that day approaching as GPs become scarcer. For GPs themselves the options are increasingly to leave the NHS or do less NHS GP work to supplement income from elsewhere. The current plans to make GPs publish their incomes may be intended to deny this reality as it does not differentiate income gained by GPs from providing GP services and income gained from taking on other, better paid, roles.

The loss of the rural practice allowance has been a challenge for some practices. For patients the push to centralise general practice is making access increasingly difficult in rural areas.

As above, you need to abolish the internal market and its associated bureaucracy and have a professionally led NHS with a central command structure. In Australia all hospital directors are required to have both managerial and medical degrees to allow them to see both the clinical and organisational sides of running hospitals in tandem. This would be a great improvement on the divide between clinicians and managers that we have in the NHS. Certainly it would seem likely to avoid disasters such as the Mid Staffordshire scandl.

The problems in general practice are not caused by the partnership model. In fact the partnership model is a positive force for recruitment and standards as it allows support from other GPs as well as triangulation of professional standards and behaviour. Further, it allows for innovation and efficiency as each GP in the partnership strives to make it more successful. Compare that to a salaried model in which a GP would essentially ‘clock on and clock off’ and have no responsibility for the provision of GP services to cover things like sick leave or maternity leave. A salaried model would also stifle the innovation of GPs and changes in the practice would be left to those with a lesser understanding of the issues concerning staff and patients, thus losing the input of an important and skilled member of staff. In reality purely salaried practices that I have seen do very poorly with low levels of patient satisfaction and often no GP on site or available elsewhere at times, something that no partnership would allow. The level of income is also likely to be less making such posts unattractive. Fundamentally, moving to a salaried GP model would see a vast swathe of GPs leave the NHS practically overnight, myself included. I do not believe NHS general practice would survive such a change and I do not think that the rest of the NHS could survive without an effective general practice service. Some evidence for the efficiency of general practice consultations  will be found in a cost analysis of consultations with NHS 111 compared with the cost of a consultation in general practice and the percentages of those consultations that are completed without any onward referral in both of those situations.

              Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?

I think the GMS contract does to an extent but much of the primary care team has been fragmented with the introduction of community trusts and the funding shortfalls for other services, making it far less efficient. No longer do GPs have regular personal contact with district nurses, health visitors, social workers or community psychiatric nurses as we did in the past and this has made it far more difficult to coordinate patient care. Even increased funding for hospice care has had some unintended consequences in that GPs are now largely sidelined when it comes to palliative care and makes communication more onerous.

              Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?

Completely the opposite. I have commented on the negative effects of PCNs in the first section but they really need to be rethought or abolished. I do not think I have come across a more ill-conceived management reorganisation ever in my time in the NHS. Either make them genuine legal entities or get rid of them. They may have some use in areas with many single handed GPs but that is no longer the geography of general practice in much of the country and they provide more of a barrier to contracting directly with large practices than a conduit.

              To what extent has general practice been able to work in effective partnerships with other professions within primary care and beyond to free more GP time for patient care?

The fragmentation of other services as part of the purchaser provider split has made this far harder than 20 years ago. As such the extra time required to communicate with multiple different organisations in multiple different ways has made coordination of patient care harder. Perhaps GPs may one day be allowed to provide the other community services and bring them back under one roof but CCGs have seemed reluctant to allow this to happen to date.

 

Nov 2021