Written evidence submitted by Dr Simon Carroll, FRCGP, Elmham Group of Practices (FGP0068)

 

Background

Elmham Group of Practices is a partnership in mid Norfolk. It has a GMS contract for its rural population and an APMS contract for an urban one. It has an MOD contract for a local army barracks. It previously had a PMS (wave 5a) contract for a Greenfield Nurse-led practice.

We have employed our own Clinical Pharmacist and Mental Health nurse before these roles became part of the Additional Roles Reimbursement Scheme (ARRS) of the Primary Care DES.

The partnership has been influenced by the model of integrated care pioneered by Professor Colin-Thome at Castlefields Health Centre, Runcorn, and we work closely with community teams and social services.

Elmham Surgery and Toftwood Medical Centre are part of the Mid Norfolk Primary Care Network (PCN).

I have been a partner for almost 25 years. I have three partners, and we employ three Salaried GPs and five Nurse Practitioners with a sixth in training.

 

A GP partnership in the pandemic

In his GP Partnership Review of 15 January 2019[1] Dr Nigel Watson reported that the partnership model was thought to be a major component of the success of English general practice’. This is also our view. We have adapted and changed during the pandemic to continue delivering high quality, evidence based , sustainable health care to our patient populations.

The ‘freedom to innovate’ and ‘relative autonomy’ that Dr Watson describes allowed all GP practices to make radical alterations to how they worked from March 2020. The adoption of remote consulting is an example of this ability to react rapidly: in 2013 Health Secretary Jeremy Hunt tried to encourage GPs to make greater use of Skype, email and phone consultations[2] and in 2019, the NHS Long Term Plan declared that in five years the NHS would offer “digital-first primary care” for every patient[3]. Within only four months of the start of pandemic working Health Secretary Matt Hancock was announcing the arrival of Zoom medicine[4].

We set up a Local Vaccination Site because of the urgent need to immunise the local population; Dr Watson is correct that partnerships are ‘part of, and accountable to, a community’1 and we were best placed to deliver this for the PCN. It was also a business opportunity and the ‘desire to succeed as business owners’1 is another strength of the partnership model.

Dr Watson had highlighted the challenge of providing ongoing care before the pandemic but more so now the ‘workload is exceeding capacity, the working day feels unmanageable, and the intensity of work and the complexity of patients has risen, with the inevitable challenges in terms of managing clinical risk1. Salaried GPs are vital, but their contractual obligation is to the partnership; as contract holders partners bear the greater risk of ensuring care continues to be provided.

It is with this experience and background that the following evidence is submitted to the enquiry:

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

Patients want both continuity of care (the ability to see the doctor of their choice) but also accessibility of general practice (to see any doctor when they choose). This was achieved in the days of the single handed GP partner, when their doctor was the only doctor available; it was also partly true before 2004 when a partnership typically had full time partners delivering care both during the day and out-of-hours, so that for patients even if their doctor was not available, they would be seen by someone they knew, who was part of the same team.

We now have accessibility in all walks of life: for those patients prioritising accessibility of health care over continuity of care, there is the NHS111 and local Walk In Centre which have evolved to offer non-urgent (and urgent) care to those patients seeking it. This is demand-led care for single episodes of need. There is no attempt to offer continuity or manage Long Term Conditions; clinicians don’t know the patient so are more inclined to escalate care or make prescribing decisions that the patient’s own GP might not make. Patients might often wait for a long time, but care is eventually delivered. This is not general practice though, but that subtlety might be lost on the patient who leaves satisfied with a met need.

With systems delivering instantly accessible care, patients have raised expectations and expect the same from their general practice. They no longer have a single health need but still expect delivery of complex general practice care: not just one ‘problem’, but several; not just the immediate one of today but the ongoing ones from last week or last year; and today’s problem must be viewed in the context of co-morbidities and polypharmacy; it might impact on their job, family members and their community; it might need coordination with other providers in the hospital or mental health care teams. Their problem might not even be a medical one, but they have nowhere else to go. They want to see their doctor; they want continuity of care.

What are the barriers to delivering this? How can general practice meet the ever increasing needs of patients who want ever greater accessibility?

1.1   Patient level barrier: Firstly the recognition that these needs can’t actually ever be met. Patients need to take responsibility for seeking help in an appropriate and timely manner; some of their initial health needs can be met with common sense and the NHS website. The default tag line to any health message [“…or go and see your GP”] should also be used more wisely. But all of this is self-evident.

 

1.2   General practice staffing barrier: GP partners should be able to deliver appropriate access in their organisation to all patients, but there needs enough staff – doctors, Nurse Practitioners, Practice Nurses, pharmacists, Receptionists and secretaries – who feel valued and appreciated by patients, by work colleagues and their employers. Existing staff are currently demoralised, overworked and underappreciated; there is a lack of suitably qualified staff to recruit from. This is also well known.

 

1.3   General practice funding barrier: There needs to be adequate funding to allow partners to recruit and retain staff and pay them appropriately, either on a nationally recognised pay scale or one that makes them feel valued and appreciated.

This is also known: Dr Watson states that ‘the current model of care in the NHS is too dependent on hospital-based care’ and ‘is not sustainable’1. ‘We cannot move forward without change that includes general practice and partnerships at its heart’1. General practice will therefore fail if not adequately resourced, with funding going to individual partnerships who are then freed up to invest in the needs of their local health economy, which they are best placed to identify and manage.

GP partners are invested in their practice and make a long term financial and emotional commitment. They are a self-selected group of doctors who enjoy both the clinical and business sides of their job. They usually work longer hours than Salaried GPs, doing both the ‘extra’ clinical work that is left over, as well as the non-clinical work that other members of the team cannot do. The reward for this responsibility and the ‘risk’ of holding the contract comes from the additional resource that is theirs: they need to ‘earn more’ than Salaried GPs who work from 8.30am to 6pm to fulfil the role of being a GP.

At PCN level patient populations differ and business values and styles of partnerships vary; funding that is channelled through PCNs therefore always risks stifling innovation and development.

If patients want general practice as it is currently is, then the GP partnership model needs to be supported: GMS contracts need to be performance managed with KPIs in place and monitored. Delivery of care used to be assessed with the Quality and Outcomes Framework, but clinical governance will always be difficult to prove given the complexity of the service.

The alternative is simply to have a radical redesign of the GMS contract.

  1. To what extent does the Government’s and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

 

Improved Access and Extended Hours have not helped improve access for patients.

 

Our impression is that both schemes were adopted locally to ensure income was maintained as funding for both was diverted from previous income streams. The GMS contract requires partners to deliver ‘medical services’ but doesn’t stipulate how to do this (or how many consultations are needed). How then to evidence improved access with no historical baseline figures? How also to provide extended hours without duplicating existing services run by NHS111? Patients and practices found it hard to define when care outside of contracted hours was ‘routine’, ‘urgent’ or an ‘emergency’; practices delivering sufficient care in-hours found it hard to fill ‘extended hours’ slots (or realised that patients simply didn’t want them).

 

Practices need to be appropriately resourced without partners having to sign up to schemes to maintain funding, without necessarily believing that patient ‘care’ is being improved by doing so.

 

2.1   What are the impacts when patients are unable to access general practice using their preferred method?

Not only do patients want the name of their GP but they also want to ‘see their GP as the preferred method of contact; they wonder why they can’t when they previously always could with the previous open-access, demand-led system of old. The increasing complexity of Primary Care however, now with greater patient expectation and a reducing workforce, means that this is unlikely to be the appropriate way to deliver care in the future. As we emerge out of the pandemic there needs to be a shift towards a supply-led system, where Primary Care controls who is seen and who they are seen by. Over the last 18 months patients as well as clinicians have become aware of how much can be achieved by remote consultation, leaving capacity for face-to-face encounters for those who most need it. We tell patients that we see 100% of patients who need to be seen” including the hard-of-hearing octogenarians with no wi-fi in a rural blackspot who can’t explain a problem over the phone…)

This is a difficult message for patients to hear and will remain so if not supported by the media and NHS England.

 

2.2   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?

It is a reassurance to patients to have a ‘named GP’; this is how general practice used to be but reinforces the view that Primary Care is doctor dependent.  The reality is not borne out in practice; care is now delivered by a team, with the Receptionist typically signposting patients to the most appropriate person to meet their needs, be it a Nurse Practitioner, pharmacist, Mental Health nurse or physiotherapist, all of whom can now be the ‘first contact’ clinician.

More GPs are choosing to work part-time so it is difficult for just one GP to be named and continuity of care is typically delivered by a team supported by the medical record. Patients anyway like to choose which clinician they see, rather than having one allocated randomly. Continuity of care is relational and reinforced if the clinical team is stable and unchanging over time; this is typical of partners, but Salaried GPs and other clinicians remain in post long term if the working environment is supportive, nurturing and remunerated. This is one reason why Elmham Group (unusually for general practice) uses the Agenda for Change pay scale for its staff: staff are a key asset to the business and are retained by rewarding them appropriately.

 

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

There is an existential threat to the partnership model of general practice.

GP morale is lower than in January 2019 and workload is higher. It is reported that 23% of GPs are aged 55 or over and expected to retire within the next few years, and 38% are 50 or over[5]. Many of these doctors will be partners in their practices or will be working as Locum GPs having already left their partnership.

It is vitally important that more experienced GPs are encouraged to stay in partnerships, and it was short sighted that the Seniority Payments that used to be paid to these doctors were phased out in 2019[6]. GP partners are the leaders and innovators within the practice and are best placed to mentor younger colleagues, both partners and Salaried GPs.

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

 

General practice varies not only from region to region, but also within localities and PCNs. Partnerships have on average 9000 patients with smaller practices in rural areas only able to survive by reinvesting their income from dispensing medication to their patients. Changes to dispensing regulations would result in a significant loss of GP practices. 

 

  1. What part should general practice play in the prevention agenda?

The example of Dr Julian Tudor Hart illustrates why general practice is the natural hub for the prevention agenda; he was seen variously as a researcher, an expert on high blood pressure, an epidemiologist, scientist, writer, political commentator, and social advocate. But at heart he was always a practising family doctor[7] and a single handed pioneering GP partner.

 

 

 

 

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

It is not surprising that morale in general practice is so low and that GPs and other clinicians in Primary Care are burning out, as the NHS experiences ‘some of the most severe pressures in its 70 year history’[8].

It need not necessarily be so. The current need to evidence the delivery of care with numbers of patients seen in face-to-face consultations is a simplistic misinterpretation of how general practice has developed during the pandemic and continues to evolve. Patients are being encouraged to demand ‘a normal appointment booking service’ when a post-pandemic world is still trying to define what the ‘new normal’ is going to be. This needs leadership at a national level that first needs to understand what general practice delivers.

 

  1. How can the current model of general practice be improved to make it more sustainable in the long term? In particular:

 

7.1   Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

The partnership model risks not being sustainable if not supported. The alternative models of large private providers running groups GP surgeries or NHS Walk In Centres delivering care does not deliver general practice.

GP partners are having to do more but with less funding. Practices need to be adequately staffed to carry out all the patient facing and back office tasks, with enough clinical staff to meet the needs of the patients. Staff need to be appropriately paid to ensure they are recruited and retained.

GPs will only want to become partners if the role is seen to be supported and sustainable in the long term. Partners need to become leaders within the organisation and this role is learnt as they are mentored by more senior partners over time. Good leadership will encourage the integrated working that improves patient care.

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

 

Funding that comes via PCNs does not encourage innovation or improve patient care. Payment systems to practices that are too tightly ‘badged’ or otherwise restricted discourages innovation and the delivery of improved care; GP partners work within their own health economy and are best placed to define and invest in the care needs of their community.

 

 

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

The PCN has not been the most efficient way of delivering the improvements in care that are needed. We understand that this is the preferred route to fund general practice but it increases bureaucracy without delivering the package of care any better than if funding had gone directly to the GP practices.

A small PCN such as Mid Norfolk’s is not big enough to have the efficiencies of scale but is large enough to lose the nimbleness of an individual GP practice. What has evolved (and which is the natural successor) is our General Practice Provider Organisation, South Norfolk Health, which represents the interests of the four PCNs in South Norfolk at CCG level; there are five GPPOs in the Norfolk and Waveney CCG working on behalf of the GP ‘providers’ of care in negotiation with the ‘commissioners’ at this higher level. PCNs have unfortunately contributed to the ‘burden’ rather than relieving partners of it.

7.4   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 has been the policy of the Elmham Group of Practices: it has proved to be an effective use of GP time and before the pandemic we were able to offer 15 minute (or longer) consultations with the doctor. Patients readily accepted being seen by other members of the team as it often allowed quicker access for care. The partners have retained their own staff as well as benefitting from the ARRS personnel that the PCN also now employs.

 

Dec 2021

 


[1]https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/770916/gp-partnership-review-final-report.pdf Accessed 23rd November 2021

[2] https://www.gov.uk/government/speeches/16-january-2013-jeremy-hunt-policy-exchange-from-notepad-to-ipad-technology-and-the-nhs Accessed 23rd November 2021

[3] https://www.england.nhs.uk/wp-content/uploads/2019/06/digital-first-primary-care-consultation.pdf Accessed 23rd November 2021

[4] https://www.gov.uk/government/speeches/the-future-of-healthcare Accessed 23rd November 2021

 

[5] https://www.theguardian.com/society/2021/oct/29/nhs-facing-mass-exodus-gps-doctors-england-experts-warn Accessed 23rd November 2021

[6] Seniority payments to end as part of GP contract changes BMJ 2013;347:f6944 Accessed 23rd November 2021

[7] www.thelancet.com Vol 397 February 27, 2021 Accessed 23rd November 2021

[8] https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressures-in-general-practice Accessed 23rd November 2021