Written evidence submitted by Harptree and Cameley Surgeries (FGP0085)

I hereby submit evidence for the Health and Social Care Select Committee Inquiry into the future of General Practice by the Government. I am a General Practitioner, a GP Partner, and I represent the views of my fellow partners and GPs at the Surgery.

Access to General Practice: The main barrier to accessing general practice is the high demand for appointments from patients. The massive impact of the pandemic has meant that thousands of patients who would have had routine and elective operations have not had this treatment. The impact of this is that a patient who has hip osteoarthritis who should have had a hip replacement 18 months ago now has increased pain and decreased mobility and is seeking social care and general practice input to manage this. They need pain relief, physiotherapy and want help chasing their secondary care appointments and operations. Each of these requests for contact with the GP means that another patient cannot get through with a new problem. If this was just one patient then there would be no problem, but as this affects thousands upon thousands of patients across the United Kingdom this issue is replicated every day in every GP Surgery. The impact on this for general practice has been massive and sustained, in the last six months particularly. As the waiting list for routine care is pushed further back, not least because of the expected winter pressures combined with the ongoing pandemic, the situation can only worsen.

NHS England's plan to clear the backlog of routine secondary care operations will ease some of this pressure, as long as it works. The concern is that surgeons in the NHS are already working at capacity and there are not extra surgical sessions or time available to clear this backlog. Additional infection control measures required due to the pandemic slows the rate of operations and access to imaging within the NHS, making it even harder to clear a backlog. Sustained demand staff to work extra hours and long hours mean that more doctors and nurses are retiring or leaving the profession, and the same goes for administrative staff, who do not wish to take constant abuse from patients for a problem they cannot control.

Patients want to see their GP; they trust GPs and understand how the GP system works, and find it helpful, reassuring, and effective. If they are unable to get an appointment and are forced to resort to phoning 111, visiting walk in centres or attending minor injuries units when they know that the GP is the best person for them to see, they become frustrated. They take this anger out on the receptionists and other staff at the GP Surgery. As a result we have seen a vast increase in the abuse aimed at our staff in the last 12 months, with a patient even going to local news outlets to complain about access to GPs. What the public – and Government/DoH/NHSE – do not seem to understand is that there are only so many appointments in a day. GPs can only treat a limited number of patients per day; an ever-expanding list of patients to treat each day becomes unsafe for the patients and risks the GP making clinical errors. It also makes each consultation rushed, leading to poor patient satisfaction, poor clinician satisfaction (knowing they have not been able to do their best for the patient), and makes it likely that the patient forgets to raise an important symptom that the GP may take seriously, and risks the GP leaving their job.

Named GPs: Having named GPs and being able to see that GP is helpful for some patients. What is more useful is each patient being able to see or speak to the same doctor each time about their current clinical problem. It may be that a patient wants to see one doctor about one clinical problem and a different doctor about another problem and we should support that. In these instances, having a named GP is not particularly helpful. In our practice we have trained the receptionists to try to ensure continuity of care for the particular episode of care, without binding the patient to seeing one doctor. We do know that the GP knowing the patient leads to better clinical outcomes, but patients should still have a choice. Other surgeries work in different ways and make use of personal lists of patients and this does work for some populations – each Surgery is different, as is each patient.

The next five years, and PCNs: The main challenges facing general practice in the next five years will depend on the outcome of the pandemic, on the NHS’ ability to clear the backlog of operations, and on staff retention and recruitment. The current government seems not to value general practice, nor to trust general practitioners to do what is best for their patients. Increased bureaucracy and the diverting of funding from practices into primary care networks (PCNs) has meant that surgeries are forced to collaborate with other organisations whether it’s best for them or not, simply to tick the boxes to access the funding they need to run the Surgery and provide good clinical care.

The PCN system appears to be designed to allow the privatisation of general practice. The large groupings of practices are attractive to corporate organisations, and as primary care provision becomes unsustainable over time, surgeries will collapse and allow for corporate takeover – this has already happened in London, and is on the horizon in the South West, where a particular group of practices are taking on more and more failing surgeries with the aim of selling off the whole large business privately. The government aim appears to be to make general practice bigger and bigger rather than focusing on the individual nature of each population. We know as general practitioners that we are best placed to help our population; the issues our group of patients have to face will not be the same as those of the surgery in the next village. Therefore, to force collaboration by only allowing access to funding through the PCNs shifts our focus away from providing the right care for our patients and onto providing what the government thinks all populations should have. This is not the best way to help our patients. It is not the way to run good healthcare provision. It is not the way to run a business. The recent BMA ballot on industrial action for general practice shows our commitment to providing our core contractual obligations; that is, to provide excellent clinical care to our populations, without the bureaucratic approach to care provision that PCNs lead to. The ballot results demonstrate our desire to do our jobs better, so we can help our patients.

Partnership: The traditional partnership model is an effective way to run GP surgeries. Our surgery is run as a partnership with salaried GPs alongside the partners. It is understood that the partners take on more complex clinical work as well as liaising with PCNs, CCGs, CQC, and managing staff. As business owners as well as clinicians, we also have an eye on the future as well as the clinical care of our patients. For example, it has become apparent that our surgery no longer has the physical space to cope with a growing population and a growing staff roster. We are proactively re-arranging the surgery, building more clinical rooms, and moving to a hub and spoke dispensary model to future-proof the business. This would not happen without a partnership model. As dispensing practises, we are also responsible for our own purchasing of medication and will therefore prescribe responsibly and cost effectively, thereby benefiting the NHS. Having this personal responsibility for running the business saves the NHS thousands per year, as we monitor everything from the cost of electricity to the cost of medications.

Freeing GP time: There has been a drive to introduce more allied healthcare professionals to the general practice environment. This includes paramedics, social prescribers, pharmacists, pharmacy technicians, physiotherapists and care-coordinators. The aim is laudable. The aim is to ease the pressure on GPs to allow us to see the more complex patients. However, much of what these allied healthcare professional do is protocol driven, and is therefore limited – patients often sit outside of these protocols. Each patient that is too complex has to be referred back to the GP, and it retrospect it would have been quicker and more satisfying for the patient had the GP managed the situation from the start. Each allied healthcare professional also must be supervised by a senior clinician, that is, by a GP, so any time saved is taken up with supervision. There are some areas of the country where recruitment and retention of GPs is challenging, and here the allied healthcare professional team can be invaluable. But they are not, nor will they ever be, an effective replacement for the specialist care provided by a highly qualified family medicine specialist, the GP.

Morale: Morale in primary care is at an all time low. We are haemorrhaging staff, from receptionists to nurses to doctors. Part of this is the denigration of general practice by the healthcare secretary. the government is working against us not with us, and is painting GPs as lazy and unwilling to see patients. This erodes the trust that our patients place in us, and deepens the feeling of ‘them and us’ between doctors and the government. It will lead to industrial action. NHS England needs to listen to the BMA and the GPC – organisations put in place to tell the government what we need on the ground; we know that the GPC and BMA have been ignored. If you wish to improve morale, listen to what our representatives say, and do as they ask. As an example of this, NHS England this week announced that GPs will be freed from some of their requirements to monitor health conditions in order to better engage with the COVID booster programme. We do not want to be freed from the most important aspects of our jobs, that is, to treat chronic health conditions, diagnose chronic health conditions, and improve the health of our population. The national protocol for the booster programme makes it extremely difficult for healthcare assistants in GP surgeries to give COVID boosters and forces reliance on GPs to give these jabs. This is a complete waste of our skills and further deepens the dissatisfaction of patients, who have even less access to GP appointments as the GPs are busy vaccinating. This government intervention in who can give vaccinations is one of many examples of bureaucratic red tape, imposed by people who are not involved in healthcare and who do not understand what they are doing. We are all happier in our jobs when we are able to do the job we trained for. We feel that morale in general practice would be far better if we were allowed to be GPs, and to spend less time fulfilling the requirements of government pen-pushers and data gatherers.

We all recited the Hippocratic Oath at our medical school graduation. Perhaps, in considering the future of general practice and the NHS, Parliament should consider what we trained and swore to do: “may I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help”.

Dr Jim Robinson, GP Partner, on behalf of the partners and staff at Harptree and Cameley Surgeries.

Dec 2021