Written evidence submitted by Dr Pauline Grant (FGP0024)

Evidence for the Review of General Practice

Problems in general practice

Underfunding- we do 90% of the work for 7.5% of the budget and falling. Capitation fee is derisory and so we have to jump through all sorts of hoops to make money which can take our eye off patient care
Increasing demand- more medical things have to be ‘done’ to each patient- health promotion, QOF, screening (nhs health checks), monitoring ( blood tests for medication learning disability health checks, serious mental illness health checks, vaccintions, etc etc etc) The list of what is given to primary care expands with no checks.
Transfer of care from secondary care. Consultants requesting that we prescribe their medications, do their blood tests, order their investigations and refer to other consultants, treating us as an extended member of their team. They cut corners by getting us to do the work
Imperative to keep people out of hospital and blaming GPs when they have to be admitted. Instead of looking at the under provision of hospital beds ( reduced over the years and running too close to maximum capacity)
Patient expectation- media fuelling the rhetoric that patients can have everything they want and immediately- the amazon model of healthcare despite the service not being funded sufficiently to provide this level of service- GPs being scapegoated for the poor service
Recruitment- Very stressful job- 12 hour days with no breaks and no time to do the other aspects of the job- run a business well and deal with staff issues etc. Salaried role is easier and sometimes pays just as well but without all the other roles and the open ended commitment to be at work until the day’s work is done. No GP can work full time for long without burning out. So most GPs now work ‘part time’ which is full time hours for part time pay. So the job is not attractive.
Pension -GP partners pay their own employers pension contribution as well as the employees so about 25% of my income goes into my pension ( and PCSE have lost some years of my pension and I am too busy to sort it out and too demoralised because I know it is a huge fight) So on paper it may look like I earn a lot but from my point of view it does not feel like a lot at all.
If GPs do not work above and beyond their hours they are paid for then patient access suffers- If we actually worked our proper sessions patient access would be even worse than it is. Being stressed in the day causes a mentality of having to deal with the problem (patient) in front of me as quickly as possible so I can move onto the next and get through the work load. So patients do not have all their issues tackled properly and so they come back, again and again and again. Other services that we refer to are also failing so the patient is even less satisfied so they come back to us again (we can never discharge a patient)
Contract is not fit for purpose as it is an open ended thing where we have to soak up whatever is given to us and can very rarely say no (suits everyone else who gives us things but makes very unhappy GPs)
Admin Every patient needs a letter from the GP to enable them to do things in their life, gyms, employers, sky diving, housing department. They can all speak to the patient just as well as us and we usually write ‘the patient tells me …..’ It has got to stop….
The expansion of other health care professionals can be counter productive because a patient may see 3 professionals for 3 problems (asthma check, diabetic check, and GP for their current problem) instead of one person doing all 3 things so it can be inefficient and now we are adding PCN staff to this. Although they cost less than GPs you need more of them, and the more expensive ones (eg paramedics) can cost almost as much as a GP.

Possible solutions

We run a personal list system and I think continuity is the key to a lot of the access problems and the patient and GP frustrations. We have 100% positive patient feedback from the national GP survey and it is entirely because of this system. The patient has their own GP who they see every time unless that GP is away when they can see someone else if it is urgent. That GP will deal with the urgent problem only and leave ongoing problems to the regular GP. Advantage of this system;

GP knows the patient and their history so does not have to trawl through the notes
GP has a relationship with the patient and knows their personality and how they are likely to react to things
GP knows the family and the context of the patient as we keep families with same GP
GP sees all the results and letters pertaining to that patient and can interpret them more easily and safely
Patient does not have to repeat their story every time which is very tiring
Patient trusts the GP because they have helped them in the past and not starting from a place of having to prove themselves every time
GP can educate patient re access ie when to call a doctor and how to self care etc so demand goes down (this is crucial)
GP deals with all the problems in one consultation ( even if 4 or 5) because they know if they don’t they will only have to do it another time so consultation rate goes down and patient satisfaction goes up. GP takes time to get to know all the problems- even looking for them to get them all addressed rather than the opposite so attitude changes form’ how quickly can I get you out the door’ to ‘lets deal with everything so you don’t come back for a while’ or if they do come back I know how to deal with it because I have done it before and have a headstart.
If patient access is bad the patient will moan at me as their GP- direct patient feedback and I will try to do something about it by increasing my availability so access improves

The personal list system has become unpopular because GPs have to cover the week and as we do not work every day we have to structure it carefully. Also it is a partner heavy model ( although we do have a salaried GP working the same model). But there are ways around it by having job shares- 2 GPs covering one list.

I believe continuity should be incentivised or mandated. It is better for GPs and patients.