Written evidence submitted by Dr Lucy Davies (FGP0080)

My role:

I am a GP on the Wiltshire Hampshire borders.  I am a partner in a practice of 14000 patient practice with growing list size. We train GPs from medical students to GP registrars.  I have also worked in the local Commissioning group and then became the first Clinical Director for our Primary Care Network, stepping down in April 2021 but continuing as Clinical Lead for the vaccination programme.  Prior to working in my current practice (9years) I worked across many practices in the Hampshire and Devon region as a locum and gained a lot of experience in how different practices function.

I work 6 sessions (3 days) clinically each week.  Which with additional partnership responsibilities, primary care network work or vaccine delivery work has generally amounted to fairly consistently 60hr weeks despite the fact that statistically I would be considered ‘part-time’. 

In addressing the questions around access to general practice I would ask that some fundamental, and perhaps challengingly unpopular questions are asked first.

1)      If there a universal problem with access?

2)      What does good access look like?

Most practices have a constant discussion about the best way to manage appointment systems.  Different patient groups have different needs and priorities.  But the more you make healthcare accessible the more patients will phone with simple queries, small doubts – and flood the system.   The counter to this is that automate systems, such as online consulting, have to be very risk averse in order to pick up nuances.

Assuming there is a barrier to access the main barrier to this is work force.  I worked in Cuba as a student -  a virtually unrestricted number of doctors and you can have a Dr / patient ratio that enables continuity and on the day treatment.  This is unlikely to be cost-effective in the UK! But our workforce issues can be much improved.  Numbers of GPs and practice nurses needs to improve.  The move to recruitment of additional roles through the PCN is a good theory but many of these roles are development or training roles.  This therefore takes GP time in supervision and therefore isn’t helpful when the workforce is already in crisis.  Additional support for project management roles and time to support these roles coming in.  The Clinical Director role has been under funded but PCNs also need significant management support much of which can be done more efficiently by managers that Clinical directors.

Much emphasis is placed on patients preferred method of accessing general Practice.  I would argue that patients should be able to access services in the most appropriate way for their clinical need.  We have many patients who would like to see us face to face every week – but have no clinical need to do this.  Others who will phone and want us to manage them over the phone as they are staying 2 hours away but actually need to be seen face to face. The majority of patients choice and need corralate but the rhetoric that patient choice is the single driving force makes running a service untenable.  The COVID vaccine service is a good example.  Home visits for vaccines has been deeply challenging and very expensive.  For boosters we have had to coordinate vaccinating people in groups of 6 to ensure no wastage from vials of 6.  We have to wait for 15min with each patient’s and send 2 members of staff, one of whom is a clinician, to each one.  Therefore in reality 6 patients takes 2 members of staff a minimum of 2hr 30min. Some patients have requested home visits as they were ‘housebound’ but were then out when the team called to check.

Evidence shows that continuity improves outcomes for patients and reduces hospital admissions.  Having a named GP ensures patients have a point of contact and the ‘buck stops somewhere’.  In many practices patients can choose to see a different GP if they wish and many GPs have areas of specialism and so patients may see a different GP about a specific problem.  It is important for continuity that patients know when a particular GP is going to be in.  Working full shift systems, such as would be necessary for a full 8am-8pm 7 days a week system would make this very difficult and I would worry that for the gain of 7 day access would lead to worsening continuity.  In terms of acute care I think out of hours access to FULL GP records would make a huge difference to quality of care and is more important that patient access to their full medical records.

The next 5 years of General Practice is likely to see a further fall in GP numbers.  I was optimistic that we would see a pull of services away from hospital into community to the benefit of patients but following COVID I now worry that the next 5 years will be focused on recovery of services.  I would hope we build of learning from COVID with hospitals continuing to do some services remotely and improved partnership with general practice otherwise I see a risk of the whole system collapsing. 

Much of policy in health seems focused around what works in less rural areas and what is needed for the more mobile young populations, for whom healthcare is less immediate.  Rural populations typically have very little choice of GP or secondary care due to the geography.  Ambulance response times are challenging always.  Pharmacy opening is poor and so moves to use pharmacies to support primary care less robust. 

General Practice can support the prevention agenda but as discussed it is hugely under pressure at the moment and not best placed to address issues of prevention, health education and health inequalities – which are best addressed through public health, education and the council.  General Practice, through PCNs, are in a position to work with the council in partnership in a proactive way – but this should be driven by public health and shouldn’t be a primary part of the PCN contract.

The Partnership model is sustainable and functional.  I believe the issues with recruitment into General Practice, and partnership in particular, are more about the workload and perception given.  Constant negative press about general practice is not helpful. 

Primary Care Networks have the potential to help but have not yet had a significant impact on the day to day working of individual practices but should be given more time.  They have been functioning for 3 years – 2 of which have been COVID and practices have seen huge change in that time.  The devolution of all payments through PCNs however, has generated work for practice managers.  It would be helpful from an accountancy perspective if PCNs could set up a separate company for accounting rather than payments going to a lead practice. 

Dec 2021