Written evidence submitted by Dr Susie Lupton, on behalf of the partners at Norwood Medical Centre (FGP0074)

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

The barrier is chronic underinvestment in general practice over the last decades. You can look at falling spend as a percentage of NHS budget but this doesn t tell the full story. General practice is cheap, it provides most care in the NHS for a fraction of the budget but bottom line is it needs GPs. GPs take the balanced risk a publicly funded health service needs, we order less tests, manage the whole patient and join all the dots/cross the ts on a persons overall care hence reducing duplication, over investigation, cost and harm seeing multiple specialists would cause. When you see figures like it takes x number of visits to a GP to get referred for cancer tests that is because the GP is weeding out the dozens of patients who do not need referral and would break the system if they were referred, we use our expert knowledge of the whole patent and spend time with them to save them from un needed/potentially harmful tests and the system from being overburdened. Our time is our gift and skill. Our time for a good few years now has not go far enough meaning working increasingly exhausting and unsustainable days and frankly burning us out, impacting on our health and the lives of those we love. This has been further exacerbated by the pandemic and my colleagues and I have been keeping going on adrenaline for 20 months now and this is making us ill. Bottom line is patients have more disease and there are less of us and we do more before patients go near secondary care.

You can compliment primary care and offer patients better services by increasing skill mix but it is a false economy to replace a skilled GP who has a unique place within our health system. We don t want more money we want more GPs. This will prevent us burning out and leaving, believe me most of us are on the brink, there aren’t many GPs hitting 50 who are not thinking of retiring.

The other false economy of skill mix is whilst you are building these new roles in primary care and ongoing is that it actually takes the most experienced GPs out of their day job, you loose GP hours in training new roles to be able to work in the very different primary care environment and to supervise them ongoing. The experienced GP not only deals with simple problems extremely fast but also as stated is uniquely placed for the most complex. New roles consult in longer appointment times and generally deal with one problem to the extent that at times the time the GP gives up to supervise them is not made up for by the work they do. That said they definitely have a place and can improve patient care but its almost too late to introduce them when we as GPs have no time left to give them.

So the plan for improving access and supporting general practice has failed before it has started as there are simply not enough of us, we ve been shouting this for years but broken promise after broken promise and continued portrayal as whining greedy GPs has helped to accelerate the decline not growth of GPs. The plan in one fell swoop further demoralised GPs, if you were to be judged by someone in a survey about something you had no power to change I think you would agree that is bullying is it not? You cannot improve access to nothing, there is nothing more to give. All the actions suggested have already been tried/implemented or are not possible.

We are a publicly funded service and this demands value for money and needs based healthcare, patient choice was invented by government to elect politicians. It is false and plays to those who shout the loudest who ironically are often those with least needs but more money/power . There is rarely a choice, from a patient in a rural area that only has one practice it can get to, to choice of hospitals – its basically the one with the shortest wait you can actually get to and most people just want the closest anyway, to now a choice of appointment type. I am not offering a face to face appointment for a well child with chicken pox, I never have and I never will. Our practice has teetered on total triage for years, this was accelerated by the pandemic but was always on the cards. At no point during the pandemic has anyone who needed a face to face appointment been denied one. We have a cloud based telephone system (paid for by us), it doesn t grow new receptionists and extra doctors though which is what is needed. It also doesn t address the widening health inequalities my patients face which drives up demand for GP because actually we are and have been throughout the pandemic been the only service that has been fully open.

There are some greedy GPs, there are some practices who haven’t been fulfilling their contract, seek them out privately and not in the press which tars us all with the same brush and increases violence and abuse towards us further fuelling those of us who wish to leave and get their lives back. GPs are people with their own families to support and their own problems, the current pressure on us, our staff and our hospital and social care colleagues is making us ill.

Continuity of care has been impacted by changes during the pandemic, we try to counter this by regularly meeting and discussing patients, we discuss visits and have MDTs and clinical meetings. A named GP is false though, patients in normal times choose the GP that suits them best not whose name is on their record. This matters for the most complex patients but not for same day urgent demand. We feel practices should be of a size where the whole team is aware of complex patients and palliative care patients etc, we should be based within the community and not at a shiny new build a mile or 2 away and there should be more time built into our day that is not direct patient contact to enable team meetings to happen in more depth.

I believe the main challenges over the next 5 years are workforce in particular GP numbers, enough pharmacists in our area, ability to match salaries and terms/conditions for attached staff in primary care (ARRS too restrictive and practice contracts are rarely match secondary care or the private sector making recruitment hard), enough mental health workforce and no wrong door approach to patients with a history of trauma in particular, falsely raising expectations of the public so they work against us not with us, properly funding work into improving the social determinants of ill health – build back public health big.

There is a perfect storm at the moment of GP being so unattractive that those who are coming through are not prepared for it or chose to take very well defined jobs within it that do not meet the needs of the NHS or patients. The huge numbers of GP locums and salaried doctors means fewer and fewer partners who take the overall responsibility and are there on days off, holidays and late at night. I cannot blame any colleague for choosing the salaried route, the job is just too hard at the moment but it further accelerates those leaving at the top end.

My colleagues who are GP trainers also wanted me to mention the issue we have getting enough UK graduates to take up GP training, mostly I m sure because of all these problems at the moment. Whatever a doctors nationality having been through UK medical school and Foundation training makes them much better able to move into general practice training. Overseas graduates largely really struggle taking up far more GP trainer time, extending periods of training and not getting the NHS the GPs it needs quickly enough. This is more strain on GP trainers and practices. There perhaps needs to be additional pre training for overseas graduates entering GP training but we also need to attract more UK graduates.

 

Secondary care are also under immense pressure but they do still seem to daily expect us to be their junior doctors, they see far less patients face to face than we do and expect us to do their blood tests, follow up their results, issue their fit notes and prescriptions. This is all inappropriate work and it does rather annoy us that it is us that are portrayed as not seeing patients face to face when in addition to our own face to face work we do much of secondary cares.

How can the current model of GP be improved to make it more sustainable?

See above comments as well.

By this the question is really is the partnership model dead. I am part of a thriving partnership in a very deprived area in a northern city. We have 7 partners for 8000 patients none of us full time but vary between 25 and 37 hours in the practice so a fair number of hours. We actually make money from owning our building which is a huge part in enabling us to have 7 partners and provide patients with all that GP time. Our building is bursting at the seams despite 2 investments by us over the past 10 years to create 5 extra consulting rooms. None of the current schemes offered would enable us to expand further and keep the same profit needed to keep offering the same service or build further services needed. Yet another neighbouring practice can t get partners and has a disastrous building ownership problem. Another neighbouring practice has solved similar issues by being taken over by the local GP federation and is now much more sustainable. So I believe partnerships can work still, we can quickly make decisions and changes (during the pandemic practices made daily changes way ahead of government guidance) but I also believe that locally run salaried practices have a place. I do not believe ownership should be by big business or profit making companies, federations and a public owned organisation should be leading this.

Current payments are too complicated/bureaucratic and the adjustments for inequalities are ridiculously inadequate. However I maintain dealing with inequalities in the social domain is the most effective and cost effective thing in the long run but in the meantime practices in deprived areas need better allocation of funding. We have open doors and uncapped demand for largely fixed funding, nearly everywhere else is paid by work done, there is a mismatch.

PCNs and I speak from a position of knowledge as a clinical director of a PCN have done some good especially in working with other community organisations. They have also helped practices work together but I feel PCNs are loosing their way due to constant changes in what is expected of us and the continued pressure to provide covid jabs. The 1st mistake was not specifically funding management and admin time, this should have been ring fenced money in the same way that the CD money was. The pot to cover everything else was also too small for the ask PCNs have been given, look at the layers of management in other NHS organisations. The ask is too big and was totally taken over by the pandemic – due to lack of PCN infrastructure all our practices basically lost our practice managers to the vaccination campaign during phase 1 and there has been continued huge admin burden from this whether practices are opted in or out (if you are out like one of our practices then there is no funding for this admin work). I feel the PCN DES needs a total reset, it is not dead but it is going to fail and further demoralise practices without a stop and reassess. The current ask is bordering on policing of neighbouring practices and this is unacceptable at our level of scale. In addition the ARRS roles are not fully funded, in our area it is impossible to get a pharmacist within the salary window offered. PCNs are not legal entities to employ and anyone employing for us including our own practices have costs to cover. VAT is a minefield that causes sleepless nights – it is unbelievable frankly that this was not sorted our before the PCNs started and is still not sorted out, even VAT experts disagree. I could go on, lots of problems but a basic premise that is good and could be improved and succeed.

Dec 2021