Written evidence submitted by Dr Stuart Wright (FGP0009)

Response to consultation on the future of General Practice

I am a GP partner of 25 years standing and these are my personal views

The main barriers to access are quite simple- there is more demand than capacity. While we run with more than 2000 patients per GP access will always be limited- in comparison with systems which run at 1200 patients per GP where access is much better. All manner of health outcomes possible to measure are improved by better access to primary care. ( see WHO study )However in the current system, if you put more emphasis on access any continuity is compromised. We are all aware that continuity makes a huge difference to outcomes and satisfaction for both patients and GPs but for a number of years we have pushed towards offering better access which has consistently damaged continuity. It will require significant resources directed to general Practice to allow both access and continuity- the proportion of NHS funding directed to primary care is woefully inadequate and a complete change of emphasis is needed. In years gone by we had more time with our patients and knew them and their wider circumstances much better- allowing proper continuity. We also had the time to liaise with other members of the Primary care team such as District nurses and health visitors and to provide leadership to the wider primary care team. Successive governments have failed to understand the value of this as it cannot readily be quantified and counted but is in fact very valuable.   A&E is seen as a priority to “sort out” but in reality it is just a very visible pinch point which acts as a barometer of how the rest of the system is functioning- both care before arriving in A&E and the run off afterwards.  The notion of a named GP was merely a paper exercise which changed nothing in reality.

One of the most significant challenges facing General Practice over the next 5 years in the retirement time bomb where around 25% of the GP workforce are likely to retire. In my own practice 3/9 GPs are likely to retire in this time frame. Changes to the pension scheme are certainly a significant factor in this. We can ill afford to lose this proportion of our workforce who are able to use their many years of experience to guide new GPs coming into practice. Part of the discussion at this point will need to be about the GP partner model which is unsustainable as it stands. A conscious decision is needed whether to support it or change it – to a certain extent it doesn’t matter which route you take but it does need a decision. A slow and painful death for the current model helps nobody and has helped to speed up retirement plans for many while putting off new recruits. There is also potentially a difference between practices in a larger urban area in comparison to rural practices. The urban practices are much more suited to moving to a model with salaried GPs working from larger health centres whereas rural areas are often served by smaller more independent practices who are much more invested in their communities. The current lack of investment in independent practices puts many of these smaller practices at risk of collapse. What we are setting ourselves up for is a domino effect where the collapse of one smaller practice puts unsustainable pressure on the surrounding practices which in turn collapse. Although it pains me to say it I feel that the way forward should be based on a salaried GP workforce with an overarching employer. This will mean that GPs are truly part of the NHS. At the moment when the Government wants something we are part of the NHS but when we want something we are independent contractors.

This will also greatly simplify the funding arrangements which are at best opaque and provide little security for funding going forwards. It is difficult to make a long term commitment to employ staff including GPs where we cannot see what future funding will be in place. PCNs have compounded this problem because the funding comes via a larger organisation and filters down but is not consistent or long term. The additional staff have all been non doctor clinicians – this has helped with the quality of some areas especially pharmacy and medicines management but has not increased GP availability as this work was either done in an evening after surgery or not done at all. There are also limitations to what non doctor clinicians offer- they still need overarching doctor level supervision and are good at some decision making but cannot replace GPs. There is also the loss of GP time to supervise. PCNs may make a difference in a larger urban area to integration of care but my experience in a more rural area is  that it makes little difference across a large geographical area. 

The prevention agenda. It is perhaps unclear whose remit this falls into. It could be considered to be Public Health but much of the funding has been cut for this so the prevention agenda has largely been abandoned. It could also be considered to be part of education and could be taught in schools. There are a cohort who have never acquired the skills and knowledge needed to live a healthier lifestyle so there is perhaps a place for extending schemes like the Diabetes expert programme to cover a much wider remit. I would see the role of General Practice to signpost into these other services. We do however potentially have a bigger role to play in managing age related frailty. There have been a number of services which manage admission avoidance but these largely miss the point as the crisis has already occurred by this point. Care planning can play a place in this but much earlier in time to try and prevent a crisis happening. This is time consuming and would need resourcing both in terms of GP time and also a wider team such as physiotherapy and occupational therapy.

There would also be potential for spending more time managing chronic pain – looking at the number of patients on higher dose opiates for example. It can be a time consuming process to manage these patients but ultimately worthwhile.

Nov 2021