Written evidence submitted by Leeds Local Medical Committee (FGP0053)

Summary

General practice is the foundation on which healthcare services in the UK are delivered and on which the NHS is built. Despite the current significant pressures practices remain very accessible to their patients but funding provided does not match the workload, leading to an overburdened and demoralised workforce. The historic failure to prioritise general practice has led to the problems we now face, with insufficient workforce or space in premises to properly respond to the needs of an increasing population, an ageing population with more complex needs and the shift in work from secondary to primary care. Long term commitment to increased investment in the workforce and premises is essential, as well as reducing bureaucracy and contractual micromanagement. This should build on the partnership model which has clearly demonstrated its flexibility, responsiveness and ability to innovate over the last few years. The increased multidisciplinary team being developed through PCNs is a positive change, but they need to be embedded in practices to be most effective.

What are the main barriers to accessing general practice and how can these be tackled?

General Practice, despite the many challenges facing the service, is extremely accessible, and with 83% of patients reporting in the 2021 national GP Patient Survey that their overall experience of general practice was good, the service continues to deliver high standards of primary care for the population. Over a million patients access the service every day and the majority of those have a consultation the same day.  Patients can access GP services 24 hours a day, seven days a week. This has been the case throughout the pandemic.  There is also no limit to the number of times individual patients can access their GP practice and as a result many patients are seen repeatedly, with consultation rates being higher than many other similar healthcare systems. The introduction of e-consultations has both increased accessibility but also added to the workload burden practices have to manage.

When many parts of the NHS are placing limits on access to their services, and set referral criteria that make it more difficult for referred patients to be accepted, general practice continues to be open to all patients. This has also meant that a lot of activity once done in other sectors has been passed to general practice to deliver, often without the transfer of funding to support this workload shift. Much of the care for patients with long term conditions that was once done in hospitals is now delivered by GPs and their teams.

However this accessibility comes at a price, and is increasingly leading to workforce and workload pressures, a demoralised workforce and a growing number of individuals suffering stress and burnout.  As members of the team leave or reduce their working hours it adds more pressure on to the remaining members of the workforce to respond to an unchanged workload.

The fundamental problem facing general practice has been a historic lack of investment and prioritisation.  Funding and workforce have not matched the growth in the population and the increased age profile of the population, increasing numbers of whom are living with more complex long term conditions that require more frequent GP practice care. The proportion of NHS investment in to general practice fell from 9.6% in 2006/7 to 7.4% in 2014/15 and has only risen to 8.1% by 2019/20. The NHS Long Term Plan committed to preferentially invest in primary and community care but with the funding changes during the pandemic this aspiration may not have been delivered. During the same time the number of FTE GPs has fallen whilst the number of hospital consultants has risen significantly. This suggests successive governments and NHS systems have prioritised secondary care services ahead of primary care, and the growing but still limited number of medical students trained in the UK continue to be encouraged to choose secondary care careers rather than ones in general practice, yet international evidence produced by Barbara Starfield and others suggests that investment in primary care delivers more healthcare gain than in hospital services.

The lack of prioritisation of general practice by government and the NHS feeds in to and does not challenge historical negative stereotypes about GPs and general practice.  Medical students are questioned if they express an interest in choosing general practice as a career “Why do you want to be just a GP?” The media repeatedly questions the value and skills of GPs but rarely if ever does the same for consultants. GP academics are few in number compared with other specialties and do not have the same terms and conditions of employment. GPs are still seen as those doctors not clever enough to be consultants. All of this must fundamentally change to properly address the workforce recruitment and retention crisis and therefore further improve patient access.

The NHSEI plan to improve access for patients and support general practice has so far failed to do either.  Resources have not yet been made available to practices or wider general practice to either support practices or improve access, and the concern is that even if they are there remains a limited workforce to call on to do additional work. The narrow and misguided focus on face to face consultations misses the important point that many patients have valued improved accessibility to practices through telephone and digital consultations, and that practices have used these methods to help manage the rise in workload pressures, as well as keeping patients and the workforce safe from contracting COVID-19 from overcrowded and poorly ventilated waiting rooms.

Practices will always offer and indeed encourage face to face appointments when it is clinically necessary to do so. Whilst patients’ preferences should be taken in to account, it should not be possible for individuals to insist on a particular mode of consultation as the practice has to balance and individual’s wishes with the needs of all their patients, and this is made more difficult with some practices having very limited waiting room space. No customer could insist on a table at a restaurant when all the places are full. Practices would be held accountable if patients left with an infection they did not come to the practice with.  The historic lack of investment in to general practice premises is now a major limiting factor.

Continuity of care is important and many patients and clinicians will try to ensure this is delivered through their regular contact with particular patients for specific episodes of care.  Increasingly it is  delivered though a small team rather than a specific individual. The system of having a named GP has not worked and has just created an added administrative burden. It is not practical with an increasing multidisciplinary workforce. Moreover there should be less pressure to work harder and more quickly, which often leads to burnout and ultimately poorer efficiency and wasted resources.  Instead we need to work smarter with a focus on skilled and careful triage - ensuring the first contact is with the right healthcare professional, offering the necessary length of appointment for the patient’s needs rather than assuming a rigid appointment structure, and therefore preventing duplication of work and appointment wastage.

What are the main challenges facing general practice in the next 5 years?

Funding, workforce and workload are all interlinked and must all be addressed. The workload pressures resulting from an increasing population, many of whom have more complex needs, are not being matched by an increase in funding or workforce which in turn impacts on the wellbeing of the existing workforce, and thus makes the problems worse.

It is therefore imperative that much more is done to recruit, and crucially to retain, the whole general practice workforce – GPs, nurses, practice managers, reception and support staff and the increasingly wider multidisciplinary team, such as pharmacists, paramedics, physiotherapists, physicians associates, mental health practitioners, social prescribers and many others.  Alongside this much needed expansion in the workforce, investment is vital for practice premises development, as there is little point recruiting an expanded workforce if they have nowhere to work from or see patients.  It is not acceptable to suggest newly recruited primary care workers can deliver care away from the practices they work for, simply because of lack of space in practice premises, as this will not enable them to feel part of the general practice team, or to fully learn and understand how general practice works.

It is good to see an increase in the number of GPs in training, although this is largely being achieved through international recruitment. However there is not the same emphasis on practice nurse training, nor support to do this as with GP trainees, and yet many practices struggle to recruit sufficient numbers of practice nurses. Similarly there is no significant support for practice manager training, and investment in this could make a big difference to the organisation and development of practices. Training and development have also not been included in the funding for the PCN ARRS workforce and needs to be urgently resolved.

Much more needs to be done to address workforce retention.  The workforce must be valued far more than they are. The disincentives of pension annual allowance and life time allowance must be removed. The bureaucracy and targets that can feel like a burden to many in the workforce need to be removed in England as they have been removed elsewhere in the UK. The annual requirement for “mandatory training” in a wide range of areas can also feel burdensome and unnecessary, and was a rate limiting factor for doctors who wished to return to work during the pandemic. Penalising GPs (but noticeably not other doctors) for working hard by naming and shaming them in the media should they earn more than £150,000 is just the latest encouragement to reduce clinical commitment or leave the profession altogether.

How does regional variation shape the challenges face general practice in different parts of England, including rural areas?

There is a shortage of general practice workforce for the whole country but this is worse in areas of deprivation, and some rural and coastal areas. Professionals often have partners who are also professionals and the availability of work for a GP’s partner is an important factor in where they both are able to live and work. The opening of medical schools in areas where workforce recruitment is particularly difficult is an important development.  Targeted payment schemes to attract GPs to specific areas have also been helpful and could be broadened to include areas of deprivation, but nothing has been done to introduce similar schemes for other healthcare professionals, and this has therefore impacted the successful recruitment of staff by some practices and PCNs. The recent cuts to dispensing fees may make this situation worse for some practices in rural areas.

What part does general practice play in the prevention agenda?

GPs and their teams spend a lot of their time focused on prevention. It forms a part of many consultations. GPs and their teams have also played a leading part in the COVID-19 vaccination programme and delivered the biggest flu campaign. However with workload pressures as they are, there is rarely sufficient time to focus on wider population health issues. The recruitment of additional healthcare workers through the ARRS PCN scheme may help but they are also needed to support practices with their current workload pressure and need to focus on this as a top priority. In addition, many public health services have been cut back and the services practices refer to help with prevention, are also extremely stretched and often have long waiting lists.

What can be done to reduce bureaucracy and burnout and improve morale in general practice?

It’s imperative that the repeated abuse directed at GPs and general practice is stopped. This comes sections of the national media but has recently been fuelled by comments from government and NHSEI. It then feeds in to daily abuse reception staff and others are receiving from patients and often goes unchallenged by senior healthcare managers.

More has been done elsewhere in the UK to tackle unnecessary bureaucracy. In Scotland QOF was discontinued and replaced with a more professionally appropriate focus in quality improvement. In Northern Ireland QOF has not been restarted in April 2021 as it has been in England.  Healthcare workers are also expected to do a large range of “mandatory training” often annual, when the evidence to support this need or frequency is lacking. The reform to annual appraisal to focus on wellbeing rather than gathering large amounts of evidence to demonstrate educational activity has been welcomed but there remains concern that this will be reversed.

Changing the regulations relating to who can complete fit notes may not make much difference to practice workload as they would still need to be completed by someone with the necessary skills, and the default would often be to the GP. Extending the period of self certification from 7 to 14 days could be helpful.

Reducing unfunded shifted work from secondary to primary care could make a big difference to practice workload. Despite changes to secondary care contracts, fit notes are rarely provided at the time of hospital discharge and practice staff have to be employed to code information provided in hospital letters rather than this being automatically added to the electronic record.

General practice has the flexibility to offer a wide range of opportunities for skills development. Encouragement and facilitation should be done for GPs to develop a special interest areas, alongside their generalist role, and could boost morale, reduce burnout and help with retention.

Ultimately burnout will only be addressed when there is sufficient workforce to cope with the workload.  Investment in community nursing teams, who are also under significant pressure, and in community diagnostic centres, could also help reduce practice workload e.g. doing complex leg ulcer management, providing spirometry and phlebotomy services.

How can the current model of general practice be improved to make it more sustainable in the long term?  Is the traditional partnership model in general practice sustainable given the recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

The partnership model has demonstrated it’s flexibility in the way practices rapidly responded to the pandemic, changing the way they worked to both protect patients and the workforce, and at the same time delivering the COVID-19 vaccination campaign. General Practice partners, including both GPs and practice managers, commit to a local population for the long-term, have a direct incentive in delivering the best possible services with the available resources to their patients, and can have the flexibility to develop personal skills and practice services when properly supported by commissioners. Partnerships can offer more flexible working arrangements than commonly available to employed doctors, which can help to recruit and retain GPs and other staff, and such arrangements need to be promoted and encouraged. Whilst many GPs choose salaried roles at particular stages of their career, in part to have a more defined workload level, they often report that they would rather be employed by GP partnerships rather than a Trust or private provider.

The DHSC commissioned Partnership Review in 2019 highlighted many of the benefits of the partnership model, but government have not implemented many of the recommendations. More needs to be done to reduce the liabilities GP partners carry, particularly relating to premises ownership or lease holding. Greater investment in practice managers could help to reduce the need for GP partners to be involved in day-to-day practice management.

The introduction of the Partnership Premium scheme in England was a good initiative but the application process is overly bureaucratic and only 1000 GPs have successfully applied for it. A similar scheme in Wales in more generous and simpler. However neither compensates for the previous seniority scheme which has now been removed from the contract.

Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?

The current contract and payment arrangements are unnecessarily complex and fragmentated both in general practice and secondary care. Practices should be provided with the necessary overall resource for their practice population without the need to achieve multiple targets and indicators and the level of micromanagement that this leads to. Practices should be trusted to deliver for their patients and provided with the necessary information to benchmark what they are doing compared with peers, without this being linked to financial payments.

The increased focus on integrated care should lead to commissioners encouraging greater development of community based services, but this needs the necessary resources to be made available to make them sustainable. In areas such as Leeds there is a long history of community based specialist services, with consultants working alongside GPs and other clinicians with a special interest. The current barriers between primary and secondary care need to be removed, not with a focus on all being employed by a single organisation, but by creating a common feeling of one team working together for the benefit of our shared patients.  This also means secondary care services being much more flexible in shared care arrangements, and moving away from the tradition of accepting and discharging referrals.

Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?

In Leeds practices have been working well together in PCNs. This follows a long history of working in communities through PCGs, practice based commissioning and other initiatives. The support of Leeds CCG and Leeds GP Confederation has also been valuable, not least as the resources to support the organisation and infrastructure of PCNs has been insufficient. Practices working in PCNs have played an important role inf the successful roll-out of the vaccination programme. However the requirement to return to focus on QOF in April 2021 has meant fewer practices and therefore PCNs being able to do this.

PCNs have been successful in recruiting a greater multidisciplinary workforce and they are a welcome addition to the workforce, however it is too early yet to see the full benefit of this. For instance, many of the pharmacists recruited cannot yet prescribe, so limiting their role in practices. Some PCNs have struggled to recruit mental health practitioners, in part because of the national lack of this group of professionals, but also because of the rigidity of the national arrangements and requirement for the mental health Trust to be involved which has slowed progress.

PCNs have not reduced the administrative burden on GPs, and if anything have added to it. A greater national focus needs to be placed on PCNs doing this and directly supporting and reducing the existing practice workload rather than on delivering against service specifications and achieving the Investment and Impact Fund targets.

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?

This is starting to happen in some areas but not yet as consistently as it should. In some practices PCN recruited staff are starting to take on some of the tasks previously done by GPs, including prescribing reviews, audits, some QOF related long-term condition reviews and home visits. Where this is happening it is often linked to the new workforce working in the practice and therefore alongside existing practice staff and developing a greater understanding of how general practice works as well as creating a stronger sense of being one team which improves morale. PCN recruited healthcare professionals have also played an important role in supporting the vaccination programme, so freeing up existing staff to focus on other areas of care.

However work is regularly shifted from other NHS services under pressure, and who are able to set firmer boundaries, on to general practice. This has become worse during the pandemic as other services moved to remote consultations, and yet asking patients to attend their GP surgery to have blood tests, obtain prescriptions or receive results. Secondary care access to e-prescribing with community dispensing could help resolve some of this. Other services have tightened their criteria and no longer accept referrals as they did, e.g. nail care by podiatry.

Dec 2021