Written evidence submitted by Dr Cox (FGP0126)

I’m a GP Partner in the Wyre Forest Health Partnership, which was formed in 2014 by merger of 7 former practices with the aim of providing some resilience for General Practice in North Worcestershire. I have been a GP for 20 years. We look after 72,000 patients in 5 medical centres. My practice looks after patients mainly from the lowest quintile of deprivation for semi-urban Worcestershire with high levels of disease prevalence.

I was in a leadership role for around a decade both prior and subsequent to the merger; but have now passed on those responsibilities to others. I now focus on being a GP with interests in respiratory medicine, palliative care, mens health, being a designated home visiting Dr, working some sessions on the local admission prevention unit and teaching medical students.

I am responding in an individual capacity and will address some of your points.

I became a GP because I enjoy the challenge of managing patients’ complex, multi-system problems in their early stages, frequently with vague presentations. I like working within a multidisciplinary team. GPs are uniquely placed in the NHS. Hospital doctors are specialists within a narrow clinical field, unable to manage such a range of patients with multi-morbidity. Primary care does not take up a large proportion of NHS funding.

Primary care should be the bedrock of supporting a healthy community. However, the whole-time equivalent number of GPs per patient is still falling. The aging population, more complex therapeutic and along with ongoing shift (irrespective of pandemic) of un-resourced clinical and administration work from hospitals into the community has gone beyond what is realistically possible. The culturally engrained expectation that your GP can sort everything out is not helpful with the dwindling primary care resource. Even before the pandemic it often took over 6 months for patients to be assessed by specialists in outpatients.

I accept that some of our work is helped by additional roles such as advanced nurse practitioners, pharmacists, physician associates, palliative care nurses, paramedics, physiotherapists, counsellors, lifestyle advisors and so on. However, these clinicians will generally manage only the more straightforward cases.

While I’m happy to try and manage more of my patients with complex issues, the expectation is now that GPs are managing conditions that used to be managed exclusively in secondary care. I now feel that I am a general physician, a psychiatrist and geriatrician as well as a GP.

What other job pays so well but no one wants to do? Without a shift in approach, just the total numbers of GPs in training will not equate to enthusiastic, experienced, and resilient clinicians 5 years into the future.

The Partnership model ought to allow at least minimum standards of care and access while aiming to maximise efficiency with the financial resources; but only if those resources are sufficient and there is a work force available.

It is naive to assume that temporary increasing finances to fund locums who don’t exist will help.

We started phone triage well before the pandemic. When patients can book a slot in advance it often results in the wrong patient being seen by the wrong clinician at the wrong time for a non-clinical matter. Triage allows receptionists to filter non-clinical matters and then the GP can discuss more complex clinical issues and sort an appropriate action; including a face-to-face appointment when required (usually on the day) while considering continuity of care and clinical safety. We give flexibility for patients with communication issues. A high proportion of calls from patients are for issues that the local hospital should have managed. We surveyed our patients after we had started the telephone triage service and it had more than 90% satisfaction. It also helps reduce the carbon footprint of unnecessary journeys.

We continued this process through the pandemic including in person and home visits. It is not helpful for all our patients if politicians state that insisting on a face-to-face appointment is anything but a clinical decision. However, we hope that we can expand the process of patient direct access into assessments with other clinicians such as physiotherapists.

I can and should manage a smaller number of complex patients, especially if I know them. It takes longer appointments to manage patients properly, but it is more efficient and gives a high level of job satisfaction. I can’t manage the current volume of clinical and non-clinical queries which is at least double a safe level. Our surgery with 20,000 patients sometimes has more than 2000 phone queries a day.

In summary:

• The main barriers to accessing general practice are the increased volumes of clinical and non-clinical work; both before and during the pandemic but accelerated since the pandemic since hospitals are managing even fewer of our patients who need specialist care, with primary care having a relatively smaller, more demoralised workforce
• Just throwing money at the problem won’t be helpful if there aren’t more clinical staff to spend it on but will allow some of our non-clinical staff a wage that may compete with increased supermarket hourly rates
• Hospitals to sort their own admin and clinical work and don’t expect GPs to be their junior doctors

• GPs to focus on their USP: complex patients with multiple long-term conditions
• We can continue to help patents reduce complications of their risk factors (eg managing high blood pressure to reduce stroke risk) but only if we have enough clinical time
• Train more nurse practitioners, pharmacists, physiotherapists etc to support the vast majority of more straight forward clinical cases
• Support good general practice and have another system for weeding out poor practice
• Stop the knee-jerk political and media GP bashing
• Rebalance funding from relatively well-resourced rural primary care to urban, especially in the ‘shire’ counties that have relatively less clinical need

I’m disappointed that your call to evidence made no suggestion on the potential impact of the resources needed to help primary care address the green agenda.

I would be happy to expand on any of the points I have made.

Yours faithfully,

Dr Andrew Cox

Dec 2021