Written evidence submitted by Covent Garden Medical Centre (FGP0014)

 

Some thoughts on solving the crisis in Primary Care

 

I am a GP of thirty-one years standing. I have worked as salaried GP, as a GP in a drugs/alcohol service, and as a GP partner ( 18 years at Fitzrovia Medical Centre and latterly 3 years at Covent Garden Medical Centre). I have also been the Medical Director of our local Federation and was PCN clinical director until recently.

 

I am not going to attempt any kind of comprehensive view here – the situation is too complex for that, but simply offer some observations that I hope will be of use.

 

  1. Demand has been rising for years. This is a combination of demographic change, vastly changed patient expectations, and the shift of significant amounts of work previously performed in secondary care. Meanwhile the proportion of the total NHS resource for Primary Care has fallen. I realize everyone will expect a GP to put resources above all! Please don’t think that I believe this the only issue – far from it - but I’ve put it first because none of those other issues will be successfully addressed unless this one is.
  2. There is an elephant in the room when it comes to the resource issue, which is the partnership model. There are two sides to this. There can be little doubt that being a partner can be very effective at getting GPs really committed to their practices and patients. On the other hand, it can be a problem for getting additional resources directly to patient care, as its tempting for GP profit sharing partners (who are of course human!) to direct additional resources into the bottom line. Closely associated with this issue is the partner- salaried divide. Whilst GP partners are often very well rewarded, salaried GPs are usually not. There are situations up and down the country where a single or small group of partners are earning very well without working excessively on the backs of frankly exploited salaried GPs. I therefore think a new model is required that will still incentivise GPs and reward hard work, innovation etc, whilst removing some of the inequity that currently exists. There are several ways this could be done, I believe. I am currently working to develop an innovative model at Covent Garden Medical Centre in collaboration with our local GP Federation. I am happy to give more detail on this if requested.
  3. As a response to the demand issue, which is widely recognised (finally!), the ARS scheme has been rolled out via the PCNs. We welcome the presence of roles such as clinical pharmacy, care navigators, and physios in our practices, and they undoubtedly improve the quality of patient care. But the idea that they  will significantly reduce the workload for GPs is flawed. Aside from the fact that they do something different from GPs, they also require supervision, managing, integrating into the team etc. Thus as well as these roles, we need additional GPs if we are to see better access and the continued move of care into the community.
  4. More GPs also allows not just better access but better continuity. Just giving someone a “named” GP achieves nothing if that GP is fully booked or doesn’t work that day. We know from lots of (often overlooked) research that continuity (even of a quite minimal level) has extraordinary effects upon measures such as hospitalisation rates. Focusing upon this, rather than the politically attractive immediate access for everything (face to face or otherwise!), would likely be a very good use of resource.
  5. This brings me onto the part time working issue. Why do so many GPs only work part time? Short answer: because current conditions, with 40, 50 or 60 patient contacts a day plus everything that goes with it, are a recipe for mental or physical health breakdown if done full time. Since continuity is (a) popular and (b) highly effective, the review I suggest above of the partnership model should also look at how to make a full-time working week more attractive to GPs. We should also look at ways of making a career in General Practice more attractive to men, as the profession is becoming increasingly feminized, and at the risk of sounding sexist this does impact upon the feasibility of full-time work.
  6. A question that may have arisen in the mind of anyone reading so far is: if Partners are usually so much better rewarded than salaried GPs, why are many partnerships currently so hard to fill? Partly, simply because GPs in general are thin on the ground. But there are other structural issues that need to be addressed. When I first started as a partner, GPs never went out of business for financial reasons. There was no CQC to come and close you down if they don’t like the look of you. Now, these risks are real. The lease on the building I signed at Fitzrovia was a 15 year full repairing lease on a grade 2 listed building in Central London. That is a risk I would be uncertain about taking today. There are many additional responsibilities that we didn’t dream of back then – information governance in the IT world, the emerging ICP model which seems to me to represent a high risk for future funding of General Practice, the entry of private sector competitors into the market who can afford to take a long- term financial view, digital only providers who can “cherry pick”, etc. Such factors mean younger GPs are wary of the risks, with many preferring to work as free -lance locums or in the private sector, where a good income with decent work-life balance can be much more easily achieved. Risk mitigation should also therefore be looked at any review of GP contracting arrangements.

 

  1. Finally, political pressure should be brought to bear upon media representation of General Practice. Criticism where it’s due is necessary and welcome, but ever since the introduction on the nGMS contract in 2003 we seem to have become the target of sustained periodic bouts of press vitriol. This is unhelpful, demoralizing, and should cease. It’s a strange society, frankly, that vents its spleen on some of its most hard working, skilled and compassionate carers. Whilst on a political level, a final point: stop interfering so much! Following the successful roll out of the PCNs, local GPs and their colleagues really are in the best position to make decisions that benefit their populations. Instead, we get lots of one-size-fits-all contracts that are often unsuitable to a particular circumstance.

 

I hope these observations are of some use. There is much more that could be said, but I have concentrated upon areas that I think are fundamental to any real change for the better. I take heart that this the review is happening, and I hope something positive emerges. General Practice in the UK, despite its current parlous state, remains a national treasure. Only when it has finally collapsed beyond recognition will many people realise just what they have lost. Hopefully the work of your committee will ensure it does not come to that.

 

Nov 2021