Written evidence submitted by Winchester Rural North and East Primary Care Network (FGP0030)
What are the main barriers to accessing general practice and how can these be tackled?
To put it simply - patient demand exceeds general practice capacity on a daily basis.
In the Western World, of the 33 OECD countries, the UK lies 22nd in terms of doctors per 1,000 patients. https://www.bmj.com/content/357/bmj.j2940
Therefore if you are spreading the workforce so thinly to care for the population the only outcome is worsening access to healthcare.
Patients struggle to get through on the phone because there are more calls than there are receptionists able to take the calls. However one cannot increase the number of receptionists for a number of reasons:
1) Estates - no extra space to house extra staff due to buildings being too small
2) No increased funding to general practice and so unable to recruit extra staff
3) Patient abuse - often high turnover of staff in this role due to patient abuse
Not enough doctors are working in day to day General Practice. The number of Whole Time Equivalent GP’s has reduced over the past 5 years despite training more GP’s than ever before. This is a sign of the profession showing it’s feelings by walking. The days have become longer (12 hour average) and more intense with increasing patient demand and no significant increase in funding to be able to recruit additional doctors into general practice. This has led to doctors retiring early, moving to places such as Australia where the work life balance is better and the remuneration higher and reducing the number of sessions they work.
To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?
Unfortunately not that much. The way General Practice is efficient and cost effective is through continuity of care with the same GP. The problem with focusing purely on same day access is that often this then reduces continuity. If I know a patient well and then have a consultation with them I am simply continuing on the story. I don’t need to spend time finding out their past medical history and family history etc because I already know it. However if I see a patient I do not know so well or have never met before it takes a good 10 minutes to gather this background information. This is where improved on the day access is not necessarily efficient or good for patients, nor for the cost effectiveness of the NHS. Continuity is key to successful, cost effective general practice.
What are the impacts when patients are unable to access general practice using their preferred method?
They may then try alternative methods such as eConsult. They may call 111 or go to A&E - neither which is useful for the NHS as a whole. It potentially leads to poor patient outcome.
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?
As discussed above. Continuity is absolutely vital to successful and sustainable General Practice.
As you lose continuity, you lose efficiency and the system then gets busier and less efficient as a result. It also leads to worse patient outcomes and increased referral rates to out of hours, and A&E. This has been proven many times in studies - most recently in a Norwegian Study by Professor Hagne Sandvik: Having the same doctor for at least 15 years slashes the risk of dying within 12 months by a quarter compared with people who have known their GP for less than a year.
Patients who had the same GP for 15 years or more were 30 per cent less likely to need out-of-hours health services and 28 per cent less likely to be admitted to hospital.
What are the main challenges facing general practice in the next 5 years?
1) Workforce: Early retirement of experienced GP’s. A lack of GP’s wanting to work in day to day General Practice because it is such an undesirable place to work at the moment is the major threat. There are huge numbers of GP’s out there but they are not working in day to day general practice; they are working in out of hours, hubs, locuming, teaching, doing appraisals etc because they can earn the same and work far less hard in those environments. If we make the General Practice day less intense through increasing funding into the core GMS contract there will be a tipping point where all of a sudden GP will become desirable again. This will then increase the workforce in a number of ways:
1) It will stop early retirement
2) Doctors will be more likely to be able to work 8 or 9 sessions per week rather than 6.
3) It will stop doctors moving oversea’s to Australia and New Zealand.
2) Patient demand and expectation. Healthcare has moved on significantly in the past 20 years. We are in an era of screening and trying to attain earlier diagnosis of health conditions - this is clearly a positive step because early detection (whether cancer, cardiovascular disease or diabetes etc) leads to better patient outcomes. However most of this work occurs in General Practice. This has led to far more patient consultations per year than 20 years ago. The model for the contract in 2004 was set at an average of 3 patient consultations per year with their GP. Over the past 17 years this has increased to an average of 7 patient consultations per year. Eg. More than double consultations but with only a few % increase in funding into core general practice.
How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?
Primary Care Networks (PCN”s) do not work well in rural area’s. They make sense in urban area’s with larger practices based geographically near one another. However my Primary Care Network covers 6 small rural practices covering well over 100 square miles. This does not make sense to be able to share staff at scale. PCN’s need more flexibility to be able to adapt to their local geography and patient needs.
What part should general practice play in the prevention agenda?
A huge part. We see 90% of NHS contacts per year compared to secondary care which only see’s 10%. Therefore we have most contact with most patients and we are embedded in local communities.
What can be done to reduce bureaucracy and burnout, and improve morale, in general practice?
Bureaucracy: This is very challenging. As GP’s we hold all the medical information for a patient. We get all secondary care letters back for the patient, their screening results, safeguarding, immunisations etc etc. This means General Practice is the “go to” for everyone - this includes insurance companies for life insurance, the DVLA, the coroners office, safeguarding, firearms licencing department.
CQC and Appraisal’s need to be stripped back. Is their evidence either of these have made a positive difference? Not to my knowledge.
Reduce Burnout and Improve Morale: The main thing is to stop the media narrative that GP’s are lazy and not working hard. This media narrative then gives patients and the public the same message. At the end of a 12+ hour day to hear you are lazy is very demoralising and leads to burnout. The public need to be made aware how hard GP’s are working and that the issues with access are not due to lazy GP’s, but are due to years of underfunding in General Practice with an inability to increase the number of GP’s combined with increasing patient demand due to multiple factors.
How can the current model of general practice be improved to make it more sustainable in the long term? In particular:
Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?
Partnership is key to sustainable and cost effective NHS General Practice. This was made abundantly clear in Nigel Watson’s GP Partnership Review in 2019. https://www.gov.uk/government/publications/gp-partnership-review-final-report
The independent contractor model works very well. A recent BMA study found you need 3 salaried GP’s to replace the work 1 GP Partner does. When it is your business you go above and beyond and put in hours upon hours of free work to ensure it succeeds. Also with partners you tend to stay longer in the same practice, this increasing patient continuity and all the benefits previously stated about this. Salaried GP’s do not do this. If you look at all the top performing GP Practices in the UK (looking at either patient health outcomes or patient satisfaction) they are all GP Partner led practices.
Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?
No.
Unfortunately the PCN ARRS scheme has not been a success. We need more money to recruit more GP’s. We do not need money that can only be spent on additional roles such as pharmacists or paramedics. These professionals are not in abundance, do not know how to ‘hit the ground running’ to work in primary care and often need huge amounts of support and ultimately increase a GP’s workload rather than decrease it. They also contribute to worse continuity of care.
What on the ground GP’s have been asking for for years is increased funding into the core GMS contract. This then gives each individual GP Practice the autonomy and ability to employ the additional staff it needs to serve it’s local population best. If you give the independent GP contractors the extra funding into their core contract they will know how best to spend it on a local level. Having centrally/nationally dictated agenda’s does not work as you cannot have a 1 size fits all approach. General Practice in inner city London is different to rural Hampshire, is different to suburban Manchester and is different to rural Cornwall. You need to trust GP’s Partners and give them the autonomy to spend money in the area’s they know will be best for their patients and
Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?
See above.
Unfortunately not. They have added to administrative burden of GP’s. The staff do not come into the roles fully trained and so often require significant supervision from GP’s. There is a huge infra-structure of management around trying to recruit these staff and all the HR which has not been accounted or funded for.
It means now a patient may see a pharmacist for their medications, a physio for their knee pains and a social prescriber for their anxiety. This reduces continuity, and as previously stated therefore leads to worse patient satisfaction and worse patient outcomes. The GP can and will deal with all the above problems in a 10-15 minute consultation. They will understand how the knee pain is impacting on their mental health and be able to adapt their medications to sort out both issues. Whereas this would take 60 minutes + of PCN ARRS role time (20 mins physio, 20 mins pharmacist and 20+ mins social prescriber). This is not efficient, not cost effective and does not make sense to me. You need more GP’s. There are lots of GP’s out there. It simply needs more core funding into General Practice to be able to recruit more GP’s to stem the tide of early GP retirement.
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?
Historically well - less well more recently. A prime example of this is our MDT (multi-disciplinary team meeting).
We used to have health visitors, school nurses, the police, social services all attend our monthly MDT’s. Unfortunately budget cuts to all these services has led to reduced workforce and 1 by 1 these professions have been unable to attend our MDT’s due to staffing shortages.
In Summary:
1) Continuity with the same GP is key
2) GP Partners and the independent contractor model is the only way NHS General Practice will survive. If General Practice fails the whole cost effectiveness of the NHS will fail.
3) There are lots of trained GP’s in the UK - but they are not working in day to day General Practice because the workload is too high.
4) Increase core funding into the GMS contract - this will give GP Partners the autonomy to employ the additional staff their practice and their patients need to provide the best care they can
5) Work with the media to change the perception of GP’s from lazy to hard working, caring and trying their best.
Nov 2021