Written evidence submitted by Dr Finola O’Neill (FGP0102)

 

I am a GP in North Devon, have been qualified as a doctor for 20 years, have worked for 15 years in hospital specialties (MRCP physician training, the ACEM ED training here and Australasia) then GP training, MRCGP and 6 years working in surgeries across Devon and for our out of hours GP service plus 111 (ambulance revalidation and ED first revalidation). I trained in A&E in Australia, New Zealand and the UK, and worked in two of the major ED departments in Devon.

I am a member of our Devon patient representative groups SOHS Devon and SOHS North Devon.

I was a GP partner within the Okehampton PCN before recently retiring from that GP partnership to work sessional cover for local surgeries.

 

 

The main barriers to accessing general practice and how they can be addressed:

 

1. Main barrier: lack of available GP appointment times.

a) not enough GPs; one of lowest numbers in Europe

 

b) too much GP workload;

(A) Admin work

 

-work initiated within primary care (referrals, medications, letters/medicals,)

-admin generated outside primary care; secondary care drift/dump of workload (big increase over the last 5 years, accelerated during the Pandemic;

 

(B) Clinical work:

(a) work from services outside our health service.

(i)              Dentistry; patients want dental treatment from their GP, antibiotics and pain relief (terrible lack of dentistry services especially NHS).[1]

(ii)              Education/special needs: cuts[2] mean patients seek help and referral from primary care

(iii)              Child health; cuts in sure start centres[3], health visitor services[4], school nurses[5] etc mean increased need from parents who need support in parenting/non medical childrens issues and children’s health has deteriorated.

(iv)              Childrensmental health; in Devon, my local area, these services are practically non existent and the issue is national[6]. Referrals take months to be seen, teenagers frequently just wait until they pass 18 and can access adult services before they gain meaningful input, in the meantime we are the port of call and these lead to frequent appointments. There are pitiful numbers of inpatient beds nationally.[7]

(v)              Benefits system; the structure of the benefits system (often obstructive and illogical eg patients clearly incapable of work being repeatedly assessed, etc), leads to significant time spent supporting patients with mental health deterioration related to benefits issues, med3s, letters for PIP, etc.

(B) Workload drift from other parts within our health care system:

(i)-Secondary care; due to the backlogs, patients with persisting or worsening conditions or queries about referral pathways, etc.

(ii) 111; The 111 service and urgent care are completely separate from our GP surgery systems.

111 is driven by algorithms, administered by non clinical staff. The patients are then redirected to a clinician, if deemed necessary by the algorithms. Algorithms are far less accurate regarding what care is needed, than clinicians or patients themselves and 111 has increased workload to ambulances[8] and to primary care[9].

 

2) Lack of admin (and other practice) staff and excess workload for them

Most commonly difficulty getting through to the surgery due to workload/availability of admin staff.

 

 

 

To what extent does the Governments access plan address barriers in general practice:

 

To no useful extent.

The plan requests analysis of our appointments for balance of face to face appointments but the issue is overall capacity, ie how many appointments we can offer in total. Face to face appointments take longer than telephone consults, and usually don't provide additional clinical information.

The government's plan doesn't dealt with the issues of why we are lacking in appointment capacity overall and until we have that we can't give more face to face appointments.

In fact, the plan withholds funding from those with lower availability of appointments, who are likely to be struggling most.

It looks at assessing us, in a punitive and critical way, rather than seek consultation, dialogue and cooperation.

It asks practices with problems to partner with other practices. We dont have excess time or capacity to assist each other. We all need support and it is not our job to fix each other problems with workload and staffing and we cant.

 

 

Consequences of patients not able to see a GP how they wish:

The main effect will be dissatisfaction for some patients. As we have a capacity issue, and telephone consultations are quicker on average than face to face consultations, it is safer to operate mainly through telephone triage. This increases overall capacity for appointments and ensures we can give the most timely access possible to patients seeking help. If we need a face to face in addition to the telephone consult, we book the patient in at at a time slot that is clinically appropriate.

Some patients are more satisfied and better served by the change, and some are less satisfied. I do not believe it has led to an overall decease in satisfaction, as there are patients for whom availability is now better. Telephone consultations are advantageous for groups of patients who find it harder to get to the surgery, either for practical (eg working, school, college), medical (disability, psychiatric issues) or for patients who are less likely to engage, as by phone we can more easily persist and achieve engagement.

I have had a significant reduction in DNAs (non-attendance of appointments) since we increased the proportion of appointments by phone. Because we can just keep phoning all day if we don’t catch them first time.

Many surgeries used significant amounts of telephone triage (default appointment by telephone and conversion to face to face appointment after that) prior to the Pandemic. This is neither a new method of working, or something we are not skilled and experienced in.

Some patients benefit from face to face contact re soft signs, therapeutic relationship, etc. If we had enough appointment slots and clinic times ideally we would offer the preferred mode of contact. Until then we are restricted by capacity issues and must prioritise safety at the practice patient list level.

NB E consultations, where the information is conveyed via proforma sets of questions (using algorithms), are completely different to telephone consultations and should not be conflated, as they seem to have been by NHSE and the government. Econsultations, in my opinion, have very limited use and benefit and are best reserved for specific patient queries. Targets by NHSE to promote their use are inappropriate. .

 

The role of seeing named GP to continuity of care:

 

I dont think it is generally practical to implement seeing a named GP. No GP works 5 days a week doing clinics seeing patients. (The work is too busy, stressful and rushed for many of us to find it a safe or sustainable way to work) and capacity issues can make this tricky. Some surgeries get patients to book in with their named GP when possible which works well

Following up with the same GP for the same complaint is also very useful, both for improved clinical care and to reduce duplication of workload. This is generally practical to do.

Having a named GP doing all the admin work for a list of patients is also useful.

 

Key challenges general practice will face in the next five years:

 

I believe the Health and Social Care Bill and the PCN DES will be the biggest challenge. It redirects significantly more work towards primary care, both from secondary care and from other areas of healthcare and the non healthcare domain. We would not have the sufficient workforce for this increased workload.

The Bill centres around PCNs, (local groupings of surgeries), linking in with secondary care and community care. However the direction of workload within this system appears unidirectional; towards primary care.

At present, when we refer to outpatient secondary care, that team takes over patient management for review, investigation, diagnosis and treatment. The new processes being initiated, blur the distinction between primary and secondary care and limit specialist input to remote advice (either advice and guidance systems[10] or regular MS teams meetings), leaving the patient squarely under our care (with all the corresponding clinical work and administration). We dont have the workforce to do this extra work and it is not equivalent care, either clinically or medico legally.

IN addition, as well as re allocating secondary care specialist work to primary care, the Health and Social Care Bill/PCNs (cited as the Bills major agent of change) reallocates the work of public health and local government (and community wellbeing/services) to primary care and GPs.

PCNs and surgeries are being linked to local wellbeing and community networks. We have been assigned social prescribers, as a PCN role, to signpost the patients to other support within their community.

Reassigning community health/services to the domain of healthcare (and primary care) through PCNs, doesnt integrate health care. It medicalises communities and the public. If there are services available, I can mention them myself in my patient consultation and, if they are available, the local community usually know about them in any case. Neither GPs, nor their patients,  need social prescribers and an ever increasing tendency to encourage the public to see every aspect of their health, wellbeing and community life as a medical issue, for which they need to come to their doctors surgeries. The opposite is needed. They need to be given healthy communities and opportunities to make healthy choices and lead healthy lives, capacities relying on central government and public health driven policy and local government input, the latter being dependent on their adequacy of funding.

I dont think it is helpful to require primary care to be involved with this, either in ICS board/PCN meetings or through PCN funding. Community services and nurturing communities are the domain of local government who are democratically elected. Health promotion/primary prevention is the domain of public health and central government policies. Dieticians are being assigned to PCNs as additional roles. Obesity; must be tackled by central government legislation; taxes and advertising on sugar, fat, junk/super processed food[11], etc. Once my patients are obese, neither my advice, or a dietician’s, does much, if anything to help.

 

I dont think primary care can survive this Bill and I dont think it will benefit our over medicalised society. By placing work within a health and primary care setting, where we dont have the time, power or control to make the changes needed in any case, it will massively exacerbate our workload/staff capacity crisis in primary care, and will not offer effective solutions to the major issues facing society; the obesity crisis, a mental health epidemic, a failing social care system and an overloaded NHS with severe staffing and capacity issues and a massive backlog secondary to the Pandemic.

 

Additional challenges, beyond this disastrous Bill, will be staffing levels, workload and the rising secondary care backlog.

 

How regional variation in England will shape those challenges:

I dont believe regional variation is a significant issue with these challenges. The issues I have listed are national. Workload problems, staffing shortages, workload dump/drift from other deprived services and other parts of the healthcare system are national. More socio economically deprived areas may suffer from some issues more than affluent areas, but often those patients are less demanding and have less worried well” appointments therefore our ability to provide sufficiency of appointments and care, is not in my experience, particularly different. My experience is that challenges will be subtly different in different populations, bot not greater or lesser and dont significantly affect workload and appointment capacity. Regarding population health, as explained above, I believe that is within the remit and control of central government, public health and local government.

The role of general practice in the prevention agenda

As above. I dont think primary prevention is or should be my job. I have spent twenty years practicing as a doctor. Good health starts with central government policy, public health, local community services and education. Primary care’s role is secondary prevention.

 

How to reduce bureaucracy and burnout and improve morale

IN decreasing order of importance:

-Abandon the Health and Social Care Bill.

-Give General Practice decent funding; We get 8% of NHS funding for 90% of NHS consultations. Fund for services provided not capped block funding per patient list.

-fund local government better so they can  provide more community services would help our patients and therefore us.

-Allow primary care to continue to employ additional roles, and to share them with other surgeries when needed, removing stipulations as to who those roles are or how we use them.

-minimise qof

-minimise our appraisal system/change it to a mentoring system

-get NHSE and the government to stop briefing against us to Parliament and the right wing press. It would help morale and reduce the abuse and negativity from the public if NHSE/ the government stop using primary care as a political football.

 

Making general practice more sustainable in the long term

Keep the Partnership model, fund primary care properly (ie increase it significantly, leave PCNs to function only as a management tool for surgeries to work together) and allocate the funding direct to surgeries who can then freely decide how to share funding and staff and service provision on an individual basis that suits them.

Reverse the workload drift dump from secondary care and other services, allow us the choose the balance of face to face and telephone consultations that we feel we can allow safe care.

With more funding, and lower administrative burden, primary care will find workarounds to provide the best availability we can for appointments.

Ring fence time and funding for GPs to have regular training from secondary care, re conditions we can manage to a greater extent in primary care, along with longer appointment times, to allow us to treat the widest range of issues we are able to in primary care.

We already do the vast proportion of the work for a fraction of the funding. We are clearly the most efficient part of the NHS. Extra funding to us will go a long way and help take pressure off secondary care but only if we are given what we need to do this.

 

 

The sustainability of the traditional partnership model given the workforce crisis, prioritisation of integrated care, and the move towards salaried GP posts.

If you want any hope of sustainability of general practice, the integrated care model needs to be abandoned (and with it the PCN DES) and the traditional partnership model needs to be retained and funded properly.

The reason why GPs move towards salaried posts is because partnership positions involve considerably more work, and because of consistent underfunding of primary care, salaried positions (with less work for similar pay) have been more appealing. I have been a partner for a year, I would consider partnership, but the surgery would need to be properly funded so I could be paid for the additional time I spent doing partnership work.

The only thing that is good about primary care is the partnership model; good for us; good for patient care and good for tax payers money.

It is what has kept us so productive and such good value for money. 8% of NHS budget; 90% of NHS consultations.

 

Whether or not current GP contracting and payment structures support proactive, personalised, coordinated and integratedcare

The current GP contract and funding tied to targets and the PCN DES, have exacerbated our staffing and workload crises. The ability for surgeries to work together and share staff should be retained, but the principle structure of health provision and the contracting, should be the partnership based. PCNs should be driven by their composite surgeries choosing what they need and what is appropriate, free from any targets, provisions or control. The PCN DES needs to be abandoned and the funding allocated back to surgeries, unfettered by restrictions and funding or primary care needs significant increases overall in addition.

 

Whether or not PCNs have improved this kind of care and reduced the admin burden on GPs;

PCNs have not improved this kind of care. They have been useful to provide the additional roles, who can help with some of our workload (especially physio for musculoskeletal problems, paramedics to assist with visits and pharmacists to help with medication queries and admin). However this doesnt offset the vast increase in workload drift/dump from secondary care/other services over the last few years and PCN's have also created additional work (and have opened up routes for considerably more workload dump by secondary care).

 

If general practice can work in effective partnerships with other job roles in primary care and beyond to free up more GP time for patients, and to what extent

Additional roles are useful for absorbing some parts of the workload however they are most useful for prescribed/ specific tasks, as described above. Most of the work we need to do can not be transferred. Put simply, as a GP, I specialise in undifferentiated care, the most difficult and uncertain of clinical specialities. Medical problems, psychiatric and psychological problems, social problems, life stressors and personality facets, interface and present to us as complex presentation. Within this range are purely medical problems including the acutely unwell who need an ambulance, urgent physical and psychiatric problems who need referral, chronic health problems. These all need my broad training and experience in the full range of medical and surgical specialities. Around that I have to unravel the social, behavioural, life stressor, personality and psychological factors that interface.

Quite simply, no one else, no additional role, or other professional or other specialty doctor can do my job. We do our medical training, post graduate training for 5 years in various specialities and many of us have additional experience within various specialities.  I worked in hospital specialities for 15 years before working as a GP. Nothing has stretched me academically, cognitively, emotionally or intuitively like General Practice. It is an amazing and complex skill set. And I love it. But attempts to recruit other professions to delegate our work, while trying to get us to take on leadership in public health and community services/wellbeing is a ridiculous idea. Other professions and allied roles cant do my job. Patients present with complicated intertwined issues. It is the unravelling that is the skill and until their problems are unravelled, they cant be redirected to another professional. Once their problems have been unravelled the work is largely done and there is no one to redirect them too.

For similar reasons, the current plans to train "GPs" via a parallel (and completely different) training route (opposed at the BMA AGM), will not produce equivalent care or help with workload or staffing. They will be “additional role” professionals and what we need is more fully trained and experienced GPs.

 

Dec 2021

 


[1] https://bjgp.org/content/68/677/e877

[2] https://www.theguardian.com/education/2021/sep/08/schools-in-england-forced-to-cut-support-for-special-needs-pupils

https://www.theguardian.com/education/2021/may/15/councils-in-england-facing-funding-gaps-plan-to-cut-special-needs-support

[3] https://www.bigissue.com/news/social-justice/sure-start-centres-kept-13000-teens-from-hospital-before-cuts/

[4] https://ihv.org.uk/news-and-views/news/health-visitors-fear-for-childrens-wellbeing-due-to-relentless-service-cuts/

https://www.publicsectorexecutive.com/News/cuts-to-health-visitors-could-have-irredeemable-effects-on-public-health-goals

[5] https://www.nursingtimes.net/news/children/rcn-issues-warning-ongoing-school-nurse-cuts-ahead-new-term-21-08-2019/

[6] https://www.bbc.co.uk/news/health-58565067

[7] https://www.theguardian.com/society/2021/sep/14/the-terrible-cost-of-neglecting-childrens-mental-health

[8] https://www.thenorthernecho.co.uk/news/10404227.unions-gps-say-strain-services-one-ten-calls-111-resulting-ambulance-callouts/

https://www.gponline.com/nhs-111-increases-demand-emergency-services-study-finds/article/1221047

https://www.paramedicpractice.com/features/article/paramedics-perceptions-and-experiences-of-nhs-111-in-the-south-west-of-england

[9] https://www.gponline.com/bma-claims-gp-work-nhs-111-tripled-12-months/article/1332352

[10] https://www.pulsetoday.co.uk/news/breaking-news/england-gps-demand-halt-to-mandated-advice-and-guidance-before-referrals/

https://www.pulsetoday.co.uk/analysis/referrals/advice-and-guidance-to-drive-referrals-crackdown/

[11] https://www.nationalfoodstrategy.org