Written evidence submitted by Dr Tim Howard (FGP0104)

If you were to do a SWOT analysis of General Practice in England today, it might read something like this:

• Strengths – used to be a much loved national institution, called by Ministers ‘the jewel in the crown of the NHS’. Largely dependent on the vocational career structure of the 1950s and 60s, with a few modern additions.
• Weaknesses – in a state of dysfunction, with a dissatisfied clientele, a lack of clarity about its future, and a workforce that is disunited and demoralised. Its structure is on the cusp of major change, from a cottage-industry partnership model (think of a tweedy country solicitor) to a more structured corporate model, with just a few senior executives and a wide range of skills beneath them (think of a medium-sized corporate law firm, although this obviously cannot apply universally,  and variations will exist).  Ham-strung by top-down centrist control and direction which is often idealistic and rarely reflects patient demand or achievable workload.  Apparent absence of workforce planning.
• Opportunities – to re-create itself as the functional bedrock of the NHS, attracting the best doctors to it as a career choice, and providing an essential service that meets the needs of patients (though their needs are not necessarily the same as their wants). Without doing this, secondary care and the hospital sector will continue to be overwhelmed by minor disease, the worried well, and all the things good general practice should be screening out, but now is not. It needs emphasising that 90% of all NHS contacts take place through general practice; its present state of dysfunction has led to the public voting with their feet and going to A&E departments, which are ill-equipped to manage them.
• Threats – that unless general practice grasps the opportunities now available to it, and works collaboratively with a Dept. of Health and NHS England that truly desire to make it functional, it will dwindle and die, and the NHS and the public health will be greatly the worse for that.

So what has led to the present state of dysfunction, with patients frustrated by what they perceive to be an inaccessible service, dissatisfied doctors, overspill filling A&E departments, and morale at an all-time low? We could waste a lot of time analysing the factors that have contributed to it; they are well known.  Repeated reorganisations. Lack of status; Relative reduction in resource compared with the rest of the NHS. An overwhelming deluge of demand from a public that has been trained to think that there is a medical cure for all societal and social ills, as well as the ones caused by disease. And so on.

But we will achieve little by looking backwards at these and complaining. We are where we are, and we will only salvage general practice, especially where it is most needed, in deprived areas, by coming up with workable suggestions about how to make it function properly again. Pay is not the issue; GPs are relatively well paid. So if money isn’t the solution, let’s consider what is, or at least, might be. May I suggest  a few activities that might, just might, rekindle the flame of general practice, and make it the beacon it once was.

First, and most important, we should define what we want it to be.  General practice has become a victim of its own success, welcoming anyone and anything to come to it for a cure. So much is now defined as ‘medical’, requiring and getting a medical intervention, that the system is overwhelmed. Emotional needs, now defined as ‘mental health’, come to the GP. Homelessness comes to the GP, as does poverty, anxiety, stress, relationship problems, bereavement, unemployment, fitness to drive, ability to work, and so on and so on. Only recently the Home Secretary said that gun licencing should come to GPs, as if a general medical training gives a GP some insight into who is going to lose their temper and shoot someone. All these and a myriad of other things come to the GP. So he or she feels overwhelmed, and goes part time or retires early.   GPs are, after all, only trained in medicine. They are not trained to become the repository for all the angst of society, even though many of them feel that this is what they have become. And of course, in deprived areas with lots of societal problems, there are more of such problems that come to the GP, who feels overwhelmed sooner, and retires even earlier, leaving a void.

So (1) define what is, and what isn’t the role of the GP. And start to train the public as well as politicians who pass the buck of responsibility to them, what the limits of general practice are. There are many ways of doing this;  but that discussion is for later.

(2) Second, give them the tools so that they can do the job.   GPs are small business men who hold a franchise. They are given about £160 per head per year to provide everything – staff, premises, equipment, and a service. (That equates to the cost of 1 Starbucks coffee a week. Compare that with the cost of having a mobile phone or pet insurance).  Their pay is what is left over – the profit. So there is an inverse incentive; spend less on your staff and earn more. Buy less equipment and provide a poorer service and your take home pay increases. This is the exact opposite of common sense contractual practice. It worked for the 50 years when general practice was a lifetime vocational calling. It doesn’t now, when over half of GPs hold mobile portfolio careers and more than half are women, juggling two roles  (nb is that a sexist thing to say?).  QUAF has driven up clinical standards, despite protests from some diehard, but it needs expanding and quantifying. The principle log-jam is not quality, however, it is resource. It is not good appointing 10 more GPs to a large practice if you still only have 2 receptionists answering 4 phone lines. Patients still will not get through.

So (3), accept that the Carr-Hill formula and the global sum are archaic financial tools, and sit down with GPs and work out a method of resourcing them which permits them to deliver the service they actually should. Of course this will need more money, but you get what you pay for, and at present you, via the Government, pay peanuts. Openly explore whether the partnership model is sustainable (despite the BMA’s rigid adherence to it). My feeling is that is not.

(4) Target money at need.  If we genuinely want to tackle deprivation, incentivise GPs to work in areas of greatest need, which are only rarely nice places to live.  Like everyone, GPs want the best and nicest for themselves and their families, so accept that and work round it. The old fashioned model of GP partnership is defunct in deprived areas and in many inner cities. So work out how to get GPs to work in a portfolio way, or a more mobile way. We pay medical and dental students generously to get them to join the Armed Services for short service commissions; why not do the same for GPs?   Work for 5 years in a sink estate and we will pay off your student loans and give you an income as a student. It works in other walks of life; why not GPs?  All the big corporates do it for their interns; why not the NHS? It is irrational to think that a funding formula that supplies GPs in Kensington and Bournemouth will work in Grimsby or in the Pennines. What is it about centralised command and control that stops it being flexible and reactive?  Aldi and Tesco can make it work in both Surbiton and Hull; why not the NHS?

So (5) Break the vicious circle of top-down regulation and control; target medical resource at where localities know they are most needed, not where Whitehall thinks. Cede financial control downwards. But do not rob Peter to pay Paul. This must be new money, not just a reduction in one area to make good in another.   (This applies to all medicine, not just GPs. The law of diminishing returns is alive and well in all intensive care units in the country) Work to improve flexibility of GP service and manpower, rather than to impede it, as at present. And never forget that money talks. Incentivise GPs throughout their career to work for a while in unpopular places as well as nice ones. Allow and encourage mobility – nearly all other employers do.

(6) Do not appoint more GPs, appoint more paramedical staff. Nurse practitioners, wellness practitioners, physiotherapists, occupational therapists, pharmacist, volunteers, the whole gamut of skilled and unskilled workers who deal far better with the common presentations to general practice than the GP herself. Why see the GP with backache? The physio is far better at managing it. Very few unhappy people need antidepressants, (unhappiness, like tiredness, is part of the human condition, not a disease; yet it is presented as such), but GPs are trained in the disease model, not the life-style model. Most unhappy people presenting to GPs need a life-style or wellness advice, not a diagnosis or a pill. To medicalise all life’s vicissitudes is a sure way to overwhelm any health service, and that is what is happening now. So broaden the team, not the number of doctors.  And make a start at training the public to think in these terms; they always used to until self-reliance was overtaken by the medical model.

GPs can no longer be the repository of all medical and social wisdom, doing it all themselves;  they could and should become the leaders of teams. They will conduct an orchestra of health care professionals, just as a surgeon does, while at the same time acting as reference points, appraisers, organisers and employers. This model already exists in the UK, and it works. Its only impediment is the inertia of regulation, and the archaic strands of employment practice that lead to district nurses being employed by a different authority to practice nurses, counsellors by a different authority to psychiatrists, social workers by a different authority to care workers, and so on.  Bring them under a single roof; allow them the flexibility to work to a single common goal on a shared patient group, and give them clear leadership, and the present dysfunction can and will be iron out.  Ken Clarke tried this with Fundholding 30 years ago, with dramatic results, but predictably it was abolished for reasons of political dogma, and all the lessons were lost.

So (7) Break down the barriers between those providing services for the same patient group, allow them to work together, and recognise that their skills are often more appropriate than that of a GP.

(8) Artificial intelligence is far more effective and rapid at spotting significant change that warns of impending disease. The old ‘hunch’ of the experienced GP should superseded by the algorithm that analyses vague symptoms and inconclusive results far more quickly and effectively. A single GP may have to process 200 test results a day. To interpret these in the light of symptoms is a recipe for error. Programmes exist and are now used that do this task more quickly and more safely. They need clerical staff to input data, but the savings in doctor time, patient safety and improved outcomes show that they are the only viable way forward. AI systems should be a mandatory part of all practices, networks and hubs.  They barely exist in hospitals, where the majority of tests are checked by trainee doctors.

(9) The move from the old fashioned cradle to grave personal GP will be – has already been - replaced by the Wellbeing team. The hub will welcome all, well or ill, and direct them to the most appropriate service; dieticians for the obese, emotional care for the bereaved, psychosexual support for the impotent, a GP with special interest and training for the menopause, and so on. Only those who need genuine medical input will see the GP; most ( perhaps 60% presenting to general practice in a recent estimate) will be triaged out to a more effective practitioner or service.

(10) Learn from abroad.  Why is it that GPs in France, Germany and Scandinavia do not have the same sense of overwhelming disaster facing them, when UK GPs do?  Having looked at other systems, I can guarantee that we would learn a lot.  General Practice was designed to care for a population 70 years ago. It is hardly surprising that, without root-and-branch reorganisation since, it is now at the point of collapse, just as any business would be.

(11) Work progressively to develop this model. Do not try and impose it all at once everywhere – that is a recipe for disaster. (look at the dysfunction and cost of the Lansley reforms implementation.  Go at the pace of the quickest and most innovative, not the slowest and most luddite (and there are plenty of luddites in general practice!). Ignore the facile cries of ‘post-code lottery’, which leads to centrist control and a snail’s pace of change. This suggested model is functioning to a degree in some areas, and it is the best, perhaps the only way to drive up health inequalities. Without this holistic service, general practice will continue to collapse under the pressure of unlimited demand, the areas of most deprivation collapsing first.  Ask yourself if you can think of any provider or supply chain that is expected to deliver a service with unlimited demand and limited supply.  It is not a rational concept, yet it is what we are asking general practice to do at present.  It coped for a while with a full workload, but Covid added  3 extra work streams:  vaccination; caring for those on hospital waiting lists (the 5 million on the lists don’t just sit there waiting – someone has to care for their ongoing problems); and the tidal wave of anxiety and stress that the pandemic has generated. So the consequences were predictable. 

In conclusion,  we must stop tinkering at the fringe of an organisational structure that is long past its sell-by date. That will merely perpetuate inequality in health outcomes and lead to on-going decline. Government should not hesitate to acknowledge that significant problems exists. (the rather facile repetition of ‘we are addressing the challenges’ and ‘ x thousand more GPs or appointments’ merely irritates everyone. The public don’t like being treated like fools any more than doctors do.) Being honest with the public and with doctors that a problem exists will go a huge way to rebuilding trust and co-operative working. The practical solutions are there, as described, but there is deep inertia about facilitating them. We all know that just appointing more GPs in Middlesborough won’t cure the epidemic of obesity there, any more than appointing more bariatric surgeons will. We do know that having a lifestyle coach working with the most at-risk families may make a significant difference to their eating and smoking habits and life style. Bizarrely, we have just about abolished health visitors, the only trained health educators in primary care, and will live with the consequences of that for a generation. Why not acknowledge the need for social, not medical guidance, grasp the nettle of poverty-driven behaviour, and tackle health inequality at source - in the home and community. Start to talk about personal responsibility;  the public understands that. Use general practice as a hub or umbrella if you like, and combine it with the current confused remit of the Public Health Service, but do not, whatever you do, offer an all-encompassing medical solution for what is social and environmental malaise.

Dec 2021