Written evidence submitted by Dr George Nurton (FGP0122)

 

Introduction.

Thank you for seeking the opinion of GPs, I do hope that something good comes of it. I am a partner in a very large semi-rural practice and have been a GP since 2003. I reduced to part-time 2 years ago, due to the unsustainable pressure which I had no means to address myself. Nothing would drag me back to full time practice in anything that resembles the current system, but I remain hopeful that the service can be valued sufficient to make my current role sustainable. At present it is not.

The starting point here is defining what is being accessed. For most patients, public, politicians and commentators this is access to a/their GP, whether or not that want is actually a need which the GP is best placed to answer. When something bad is happening in someone’s life the default advice is to ask their GP, seek a letter from their GP, seek approval from their GP, and when they have seen someone clinical, eg in a hospital, it is a typical expectation that the GP will complete the work which in any sensible system would be undertaken by the person advising it. All roads lead to the GP, even if as an incorrect diversion, and the GP is overwhelmed with the inefficiencies that then brings. GPs are so accessible that they drowning under the burden.

Adding to this is the progressive shift of what many refer to as “grey areas” into the perceived roll of general practice. For example, decades ago GPs started employing nurses to help them with their work and enabled the doctors to expand on the parts of work that only doctors could do. Pure nursing work, on the other hand, was undertaken by district nurses. On seeing nurses working in most practices, commissioners soon instructed and resourced district nurses to largely care for the house-bound, and expected practice nurses to do the nursing work for the mobile. This was funded by the GPs themselves from the same resources given to provide general medical services, took the nurses away from helping the GP do their own work, and left the GPs expected to continue to do all the original work but now with resources diverted to their nursing service. Hospitals added to this with, eg, post-operative nursing care being diverted to practice nurses. There are a few welcome funding streams now, but they are limited in scope, in a way entirely contradictory to the presumed infinite scope of general practice.

The same applies to practice support staff, again employed by the GP to help them with their own work. Additional work is generated by hospitals, commissioners, regulators, inspectors, and all of it takes them away from supporting their doctors. Even where funding has been cut and transferred centrally for provision of IT, the central service is then so poorly resourced that practices have to employ their own IT support to make up for the inadequacies – my practice now has one IT administrator for every 3-4 doctors, they are invaluable but they plug a hole left by NHSE, yet now funded by us.

I doubt that there is a practice manager in England who isn’t so overwhelmed by externally generated administrative tasks that they are seriously considering their position, and whose role in running the practice for their doctors, and the patients they care for, has been diminished beyond recognition. The doctors pay for this from the resources they have for patient care.

In summary, access must be about access to the GP for their general medical expertise and associated care. Every attempt to access the GP or the wider practice team for something else directly impacts on this. It is quite possible that this is not what the politicians and public want, but the consequences are

 

The plan appears to offer little or nothing to address the actual problem, that there aren’t nearly enough GPs to undertake what is expected of them, and to a considerable extent adds to the inflation in unrealistic expectations of the service and in particular the GP.

Most GPs were horrified by the lack of insight demonstrated in this, though remain uncertain whether it was incompetence or malign. If not already well known to those reading this, I would strongly recommend reading, with the interaction of politics/senior management (NHSE) and workers (general practice) in mind, Richard Feynman’s report on the Challenger disaster, and the not dissimilar Nut Island effect (Paul Levy). There remains a reliance on GP somehow being able to do a little bit more (often framed with “for the good of the patients”), and an ongoing reliance of goodwill, which for me and most GPs is sadly long gone – we have nothing left to give.

Patients are badly impacted by this, both in not getting what they have been told they can have, and in those who actually need their GP being barred from seeing them by all those who flood the access. Furthermore the aggressive portrayal of the service being inadequate, a misguided attempt to somehow squeeze more from the GP, merely raises the patient expectation of inadequacy. Prejudice is an integral part of medicine, the placebo effect being a prime example, if you tell patients to expect poor care then outcomes will worsen independent of the actual level of care. Bad for patients, but also bad for GPs who welcome neither poor outcomes nor the complaints that invariably follow and sap what goodwill remained to continue working in a service which values them so little.

Ivan Illich wrote a lot about this in the 1970s (Limits to Medicine), but his criticisms remain valid today. The suffering and harm created by promising something but not providing it (or it being false) is enormous. He criticised doctors for pretending they can “kill” pain, rendering any pain insufferable until relieved, whereas now we have a government and press telling people what care they should expect without considering whether the resources are even there to provide it, or whether what they promise is even reasonable. Through engineering prejudice, the government, press and legal profession have effectively become the clinical decision makers – a perverse way to try and improve medical care.

General practice is staggeringly efficient at delivering good health care, not because of clever systems but through the in-depth knowledge of their patients, and their population, across broad swathes of their lives. Continuity is essential for this and almost universally sought by GPs. The seeking to devalue the GP role, and the raising or expectations for what people should demand, leads many to now prefer expedience and their demand met rather than the waiting for the quality that their own GP might bring. They seek multiple opinions, further impairing access, and as outcomes are likely worse the demand only increases. It is immensely frustrating for GPs to be prevented from seeing their “own” patients by those seeking a quick fix or near irrelevant non-medical demand. This effect also drives a dangerous medicalisation of patients lives and expectations, with the multiple prejudiced consultations and desire to get closure resulting in diagnosis and treatment that may never have been needed if the trusted GP were allowed to offer their honest and fully informed opinion, and that be accepted.

The American report “the cost of satisfaction” demonstrated this effect, with the satisfying of patient expectations leading to greater costs and worse outcomes. This is now rife in the UK, and is the fault of the politicians, NHS leaders and the regulatory system for seeking to satisfy the demand of the public that they themselves have inflated. Seeking to demonise the GPs was pointless and likely irreversibly harmful.

There is also a troubling pressure from the regulatory and medico-legal system on this role. The ability to know our patients over years, and the continuity and good care that leads to, is now readily conflated with a presumed responsibility for all aspects of their care over the same time. Being presumed responsible for the decisions of others, be it those expected to replace the GP role or merely those seeking to transfer work/responsibility on to the GP poisons this relationship and adds no value. Individuals are responsible for their own health, clinicians are responsible for their own decisions, “naming” patients’ GPs should never have shifted this burden, nor made those unable to be fully responsible for their decisions somehow now capable of undertaking their role. It is perverse that GPs cannot de-register patients who are chronically dis-satisfied with the care they provide.

 

There will not be enough GPs to do everything that everyone wants of them. Indeed there are already not enough and have not been for some time. Quite why people keep identifying the NHS as nearing breaking point, when it is evidently already broken and simply being held together by dedicated but now broken staff is beyond me. I suspect the politicians and public feel that it cannot fail, therefore cannot have failed, hence their absolutely surprise when if mysteriously fails them. There is no valid mechanism to increase numbers, so expectations must change. Whilst many are leaving, many are simply doing what they can as well as they can and keep the rest, and the criticism, at arms length. But they will still collapse either by the relentless pressure, or when their best is declared “not good enough”.

These factors are ubiquitous so variation is less important than addressing the root causes. Areas with greater social ills will doubtless expect GP to somehow solve much of them, as already mentioned, but it would be better for the GP to be addressing the actual medical consequences. Most importantly you cannot rely on local solutions if you cannot solve the overall problem, for the supply (people) / demand (unrealistic expectation). I highlight this as I have been writing to the local CCG for the past decade asking for information to help explain to patients why the resources they seek are limited – in this context I am referring to secondary care, but the argument is actually more important for primary care. They acknowledge the truth but are clearly terrified of what NHSE or the public might say/do if they call the king out for his non-existent clothes, so instead provide me with nothing other than an offer to look in to it. Who can blame the public for demanding more if no one tells them why they can’t have it? But it is us dealing with the consequences and as with everything in medicine, if an expectation is not addressed, the outcome is poorer.

Prevention is a public health problem that general practice can support within the confines of our usual role, but should not lead on to a greater responsibility. When I see the overweight 40 year old smoker about his knee, I am there to address his knee but will point out that weight loss will help, as will smoking cessation, and that looking forward these are likely to become significant barriers to joint health and overall health. I would direct to the available resources. But the campaign about smoking, or weight loss, or activity and the resources they reflect are not part of general practice. This agenda often comes loaded with rules, plans, expectations and dogma, which whilst often thought of as part and parcel of medicine are really its ugly sisters that detract from the professionalism and patient-centred approach to general practice. The failure of public health was a political decision that does not need to be thrust on to general practice to resolve. What remains of doctor-patient trust needs to be rebuilt within the confines of that relationship, and not exploited for a population level agenda.

Largely address the points raised above. It was fascinating that at the start of the pandemic many of these factors disappeared. Whilst there was a small and unfortunate reduction in patients seeking help for medical problems there was a vast, albeit transient, reduction in the administrative burden and pressure from non-medical wants. Only NHSE persisted with ever increasing attempts to micromanage a situation they clearly had no grasp of (which is the root cause of much of this, do NHSE understand GP at all?) Several systems which sap our resources/goodwill declared themselves irrelevant and took a back seat – appraisal (now replaced with less demanding and better for it), CQC, QOF, micromanaged enhanced services to name but a few. But they could not recognise the good they did by going, and steadily started to take their piece of GP again. Even now we are being asked to justify our shift to remote/telephone consulting at the height of the pandemic, when it was both essential for public safety and mandated by NHSE/CMO/SoS. The same applied to the endless requests for “GP to do …”

 

You need to value GPs for what they are, and what they do, and trust them to maintain their professionalism and do their best. You need to identify the resource that exists, which includes recognising as in other countries what is considered a safe and appropriate workload. You need to resource practices to undertake that workload and to squeeze in no more. You need to come clean with the public what they can expect, and explain how you and they broke what they had. You need to rebuild their trust in the GP, which includes addressing the medico-legal and regulatory framework which so aggressively stacks itself against doctors and in this situation the GP. You need to allow the GP to deregister patients who do not trust them.

This is a very loaded question! These new priorities are certainly at the cost to the partnership model, but they do not have to be. I refer back to my opening statement. General practice is and always will be a system which provides GPs. It’s all in the name. We are generalists, we are medical – the complexities which this entails are vast and entirely reliant on highly experienced professionals with many years of training, further development in this, and often career-long knowledge of their population, individual patients, and themselves. We cannot expect the hospitals, the population, the politicians to understand this in full, but a starting point is to educate the public and support, not pillory, the GP into offering GP services and not something/everything else. We are better than this. The partnership model enables this. A salaried/integrated model might tick some of the right boxes, but the goose would be strangled and the golden egg would be lost or find itself elsewhere.

It should, but it doesn’t because it is abused. Less is usually more in medicine, and a fixed sum to be trusted to do our best, within the limits of what we can, is an excellent way to provide good medicine and good outcomes. The more that is squeezed, micromanaged, overregulated and exploited by shifting work and dumping inappropriate work, the less viable it becomes. It is likely now that the only way out of the mess that has been created is to fund the actual work done. This will be costly as so much work IS done, but may eventually lead to only work appropriate for the GP being their responsibility. No doubt the government are keen to not repeat their “error” of 2003/4 yet the position is similar – they did not believe what GPs said they were doing, did not value them, and were predictably surprised by the cost when some work (QOF) was actually funded, and other (out of hours) needed to be taken on and actually paid for. Yet there is no way out of this problem without acknowledging the true value GPs bring. Sadly I suspect this will never now happen as it is for government and the population to decide how to regain this value. GP can do no more.

No. Our PCN is a success in spite of what is asked of it, not because of. Every role/payment comes with so many strings attached that at face value they appear irrelevant to GP. We must seek out loopholes in them to achieve something useful. PCNs were the outcome of it being politically improper to invest in GP directly. It would have been wiser to address that taboo in Westminster / Fleet Street, and actually trust GP to do it well. Patients largely trust us, it’s only the politicians, commissioners, NHSE, CQC, GMC and the population who listen to the nonsense, who don’t.

Our hands have been hugely tied here. Every attempt to engage others appears to result in a string of problems: the engagement needs endless meetings, the others do a lot though it is often activity rather than true action and typically creates more work for the GP, the patients remain unsure if they were actually helped given their idealised view of everything GP should do and so return to GP anyway, or more commonly now write a long and aggressive complaint about the many ways in which the GP isn’t helping them/their relative. Which again brings me back to my first point, until you decide what you need GPs (who are doctors, not administrators or fall guys) for, how much is achievable with the GP resource available, and then educate public and politicians what that means (and perhaps what (how little) they have paid for), you will achieve very little and lose what was, and always has been the most effective part of UK, if not global, health care.

 

Dec 2021