Written evidence from Dr Roisin Ward (FGP0004)

 

I am a GP partner in a medium sized GP practice of 8000 patients in a rural area with lots of projected growth at a rate of 3-5%/year due to new building. I have been a partner for 11 years in the same practice having been a salaried doctor for 3 years prior to this. I also initially trained in hospital medicine before changing to general practice.

 

The main barriers for accessing general practice is multifactorial,

Perception – patients perceive only a doctor can solve their issue and no other opinion from another allied professional holds the same respect from patients.

Demand – unprecedented demand based on health anxiety with less willingness to self care without doctor opinion first flooding surgeries with unnecessary on the day demand.

Media – continual painting of GP’s as lazy, money grabbing, ineffectual is destroying morale and causing retirement age personel to bring forward plans

Workforce – depleting workforce due to retirement/isolation/resignation of newly qualified entering into GP at a time of incredible pressure and increasing work anxiety. We have had 2 newly qualified GP’s leave the profession completely due to this. Burnout is rife and continues to loom as a threat across all surgery staff.

Workload – QOF pressures and COVID immunisations alongside safe working practices whilst in a pandemic restricting flexibility of practices to direct and prioritise care of patients in ways that are essential when trying to rationalise safe patient delivery of care. Threat of loss of income to support employing staff that helps continue as a functioning practice is a real worry.

 

How to tackle this?

Morale – encourage a different vocabulary in the media about the excellent service GP provides in community based care. The public perception needs to change. Like the fuel crisis the public will self sabbotage the very service they value if they continue to abuse it in the way they are, and if it folds there is no private service or offer body that can replicate the varied and expert service we do.

Signpost – stop insisting face to face with the GP is the endpoint of good care otherwise what is the point of ploughing money into additional roles via PCN and promote and support access to GP services does not begin and end with access to a GP in all cases.

Training – increase GP training posts and promotion of it as a profession

Flexibility – give surgeries more control in a crisis phase of how they direct workforce and patient care according to their population need rather than tick boxing.

Reward – good patient care and surgeries who strive to innovate and change to deliver patient centred care and create an environment where good practice is shared and celebrated.

 

The current Government rescue package is demoralising and unsupportive showing a real lack of appreciation of the real problems GP faces so do not think it addresses any of the above.

 

Impacts of reduced access is joint GP and patient dissatisfaction. We all want to see patients face to face and give people the time they need to deliver patient care. Complaints are increasing through anger at surgeries not returning to pre- COVID format fuelled by government and media messaging, but demand is such that this would be impossible but also unnecessary with econsults and good telephone triage alongside good telemedicine that has improved with COVID reducing the need for face to face. We should harness these efficiencies to create space who truly need a doctors time.

 

A named GP has great value in delivering continuity of care in LTC, frailty, MH and EOL care as these areas of healthcare carry the greatest complexity and value in knowing the patient well. Younger patients without these is less of an issue and these patients just want to see any doctor to service their immediate needs.  There comes a point in everyones health journey where a doctor has seen them through a health scare and a trust bond is created that is valuable to that patient in future interactions so I believe there is a value to the named doctor. This also applies to family medicine with vulnerable families. Certain scenarios warrant a named doctor to manage carefully.

 

Challenges for family medicine in the next 5 years as I see it  comes down to its survival. It is at a crisis point of being understaffed, under valued and the runt of healthcare. Its failures are billed as laziness but nothing is farther from the truth. I work with dedicated, hard working exceptional colleagues who are passionate about good patient care but constrained to think about better service delivery by sheer demand.  Private companies are waiting to snap up failing surgeries who struggle with burnout and workforce and threaten to destroy the very nature of community medicine with cherry picking at contracts and centralising services. The aging population will be lost in this model.

Frailty is a huge issue in the next 5 years with good community based care needed to prevent unnecessary admission and bed blocking in hospitals but this is woefully underinvested and therefore impossible to deliver in a meaningful way. Heavy investment is needed in this.

Mental health provision needs are huge and impacting all ages of patient but worse since COVID and isolation with increasing health anxiety and depression. The volume of day to day demand for MH needs is unprecedented and impacting on sick note requests alongside a lack of resource for timely counselling and support.

Paediatric demand is another area that has hugely increased and expectation is enormous with repeated daily appointments to see through illnesses as a lack of parental confidence in dealing with typical illness.

 

We are a rural practice so our frailty and housebound demand is enormous and spread over a wide rural area. We have a large paediatric skew due to new housing and young families moving in and also a large aging population with housebound and 3 NH in our area.  This sets us apart from our other member practices in the PCN and therefore shared issues differ to immediate needs. However as a smaller practice we do not have the same volume of on the day demand as the bigger town practices but would have a greater home visit demand.

 

Regarding traditional partnership models, I think we need to be innovative and understand not just GP’s make good partners. Partners are essentially leaders who have flexible thought and problem solving skills with a knowledge of healthcare. Doctors have the additional benefit at being able to deliver the service as well and can cross into all roles within the surgery but many do not have leadership skills. Being 11 years a partner has given me a confidence and oversight that is an extra asset and independent to my work as a GP. I believe experienced GP should be moving to a mentorship role within the surgery to support junior partners/salaried staff and showcase leadership and staff development to make the career progression to a partner a more supportive one and not the solo journey I experienced in easier times. The work pressure is much more now for newly qualified GP’s such that to expect any of them to hit the floor running let alone view partnership as desirable is impossible. Create a model of support and aspiration to lead in areas of passion and there is hope of survival with some real innovation.

If the partnership model is abandoned then you have a much more work to rule mindset that is less outward and I believe will limit innovation and desire for leadership which any health care service needs. I don’t believe I would have harnessed the same passion in developing better patient centred care and hub development in cardiology and paediatrics if I didn’t have the freedom to trial this in the way a partnership allows.

 

My innovative practice has come out of developing services in my own time and in the hope the evidence attracts funding. The contract hasn’t created this space and it has been a challenge to convince fellow surgeries to follow this without clear promise of their time being paid for immediately. As previously mentioned I believe innovation and forward thinking practices should be rewarded accordingly.

PCN’s have provided a base for collaborative working and support that can only strengthen GP. More freedom should be given about how the money can be utilised if improved patient care can be demonstrated and not forced in a direction of a limited repertoire of roles that do not necessarily reduce GP workload. Breaking down working barriers between surgeries and sharing issues has only been a productive and positive development for general practice. Through the PCN we have a valued care co-ordinator managing all our health hubs with secondary care so this has helped enormously in developing an easy route to expanding hubs to include different avenues involving patients and note access across all 3 member practices.

 

The cardiology and paediatric hubs I have set up have been very successful in engaging with secondary care colleagues but reducing referrals into secondary care. It ahas also provided in house upskilling such that we are better at dealing with issues regarding these patients so effectively releasing GP time. Ongoing developments as expansion to te cardiology hub are around developing a one stop LTC clinc to concentrate appointments for complex patients who can have up to 77 appt contact /yr so effectively reducing appointments and being more time efficient for all involved alongside creating more robust care plans that should reduce admissions or improve communication between primary and secondary care if admission required.

 

In summary I am passionate about primary care and the survival of patient centred community based family medicine. GP’s are hugely underrated and underappreciated and cover the work clinically but also administratively of a multitude of individuals you would have to employ in their place if you tried to replace them. Their leadership and innovation despite enormous work pressures should be applauded and not undermined. Make the job and work life balance more palatable and less GP’s will retire early. The experienced GP is a valuable asset and should be preserved at all costs. Without them to steer and role model the next generation through this difficult time then you will have lost an opportunity for exciting and extraordinary restructuring of general practice.

 

Many thanks for the opportunity to share my thoughts

Dr Roisin Ward

 

Nov 2021