Written evidence submitted by Dr Anna Graham PhD MRCP MRCGP (FGP0130)

Introduction

I am a GP Partner in a suburban practice in a deprived area of Bristol. I have been working as a GP since 1994 and at this practice since 2004. I have worked between 5 and 7 sessions since joining (currently 6). I am also a GP Trainer. We have been using a personal list system for more than 20 years. The practice is excellent. I love my job. I am very worried about the future of general practice and I am keen to try and help make it work better. You will see I am especially passionate about the importance of continuity to drive up quality of care as well as save lives and money.

National General Practice Profiles - Data - PHE – this link shows the practice is in the 4th most deprived decile with 90% of patients having a positive experience

GP practices are responsible for large numbers of patients with insufficient staff to manage them. This is because general practice is underfunded and the pool of staff to recruit from is reducing. This leads to there being too few appointments available for doctors or nurses.

The proportion of work done in general practice across the NHS is huge, the proportion of funding allocated to primary care is inadequate to support the work we are asked to do let alone the work we could do.

It does not. The promised 5-6000 extra GPs has not materialised. The number of GPs has reduced by 1500 full time equivalent practitioners.

Potentially patients do not get the care they need in the best place for this. For example, they do not see anyone or they seek help in Emergency Departments

We have 18,000 patients and have a ‘Personal List’ system. This means that each GP has a certain number of patients they are responsible for. This is adjusted for the number of sessions they work. The whole practice understands where the responsibility lies as do most patients. We have been auditing the proportion of a named GPs patients have contact with that named GP each month for over 12 months. We use a method called SLICC. The average patient is more likely than not to see/speak to their own GP. The all practice score is 58% with 17 list holders – only two of which are below this 50%. In some months for some GPs it can be as high as 70%. The highest monthly score was 81%.

We firmly believe this provides high quality care. We have embedded data driven policy-making in the practice to drive this improvement and will continue to do so. Recent evidence from Norway (Sandvik 2021) reveals three important benefits of continuity - reduced mortality, use of out of hours service and acute hospital admission. This showed a dose response effect with more years of continuity leading to better results. Each GP in Norway is responsible for far fewer patients compared to UK GPs.

Continuity is not financially incentivised. If it were we would save money across the health care system.

A Continuity Allowance could be paid to GPs staying in the same practice for 10, 15 or 20 years. After this many years in one practice a GP will have acquired a deep knowledge of the area, its resources and background information on a great many patients. In Personal List practices really strong patient-doctor relationships will have been established for thousands of patients with all the benefits continuity research has shown. GPs with 15 years experience are often of added value in advising new GPs in a practice.

We believe we are the largest practice in the UK achieving these continuity figures.

Continuity is very important to me professionally. I have worked at the same practice for over 17 years. I know my patients well and they know me. This works for patients – I start in the middle of the story not at the beginning each time. I understand their wider world having known them over many years. I think I make better joint decisions which can include doing nothing because of the trust I have built up over this time. For my own ability to get the job done, and get home, I find seeing the results and letters about my own patients I can do quickly because I ordered the tests and know why I made the referral. This also helps with my learning – finding out about new treatments and following this up with the same person. It is hugely satisfying as a role. If I make a mistake I apologise and the patients forgive me.

In times when work has been very stressful, such as during the pandemic, or when I have had wider difficulties in life – work or home, knowing my patients well has enabled me to carry on working – I feel a loyalty to them and they are very appreciative.

I am aware that most people sitting on this committee will, by definition, be well and not have personal experience of what it means to have GP continuity. I strongly recommend you talk to family and friends less fortunate and discuss with them the value they put on (or would do if available to them) of having a GP who knows them well over years of care. My parents are well into their 80s and are very well. They have numerous friends not as fortunate who hear about the way my practice works and wish very much this could be the case for everyone – not only the elderly but for children with complex needs and adults of working age with chronic ill health. I would argue the vast majority of people in the UK would want this personalised care.

In the practice the way we manage work is very clear. I cover my patients queries and cross cover when not in. This helps the wider team with whom to ask and where the buck stops.

Increased demand secondary to an aging population.

Inability to recruit doctors and nurses (because there are not enough of them)

Lack of retention – we have doctors leaving in their mid 60s after many years of rewarding work but we also have GPs leaving in their 30s to stop being GPs because they find the level of workload too much and struggle to combine this with childcare responsibilities

The workforce is dominated by women. Childcare is too expensive and lacks flexibility for the very long hours we work.

Medical Schools need to have 50:50 female:male intakes.

Nursing bursaries need to be reintroduced in full

Inability to recruit administrative staff (because the pay rates are not competitive with similar roles or roles that are substantially less demanding elsewhere)

General Practice could do a lot of what secondary care currently does but we cannot do this with reducing staff levels and inadequate funding

The issues above do have regional variation – I am unable to comment further on this

Part of being a GP is doing preventive work. The GP with a strong relationship with a patient can achieve some changes. This needs time as well as resources in the community to support individual change eg easy to access smoking cessation support, weight management services, support for people with mental health issues

The most significant impact is on a population level. This needs strong public health messages and changes to the way we live our lives to help individuals make the right choices eg seat belts, banning smoking in public places.

The Government needs to be brave by increasing the unit price of alcohol, making public transport affordable, safe routes to walk and cycle, so people use their cars less to reduce air pollution, ban junk food outlets near schools etc

Doctors need to do the doctoring and others need to do the box ticking which needs to be minimised

Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

Being a Partner, as I have been for 17.5y, is incredibly rewarding, working in a small institution, making change happen, as well as seeing patients. It is, however, not for everyone. More and more GPs are women with roles and responsibilities outside of work. Younger doctors do not seem to want to commit to staying in one practice over many years.

The working day, in my view, is exceptionally long and as the intensity of the work has increased it is unsustainable. A better resourced and staffed general practice would address this and enable those starting and ending their careers to do so without leaving early as well as supporting mid-career GPs who may not be able to work as long under these pressures.

The Government does not incentivise staying in one practice. This is hugely beneficial for patients and needs to be considered.

No

We are in a PCN with one other practice. We are very near each other geographically but we have very different patient demographics. In my practice we have patients in two wards – one with a life expectancy 4 years less for men and 1 year less for women than the other.

We have learnt from working together some better ways of working. I am not convinced (yet) it has improved delivery of personalised, co-ordinated and integrated care or reduced administrative burden.

It has increased administration as we have another layer of bureaucracy.

We have employed Clinical Pharmacists, Care Co-ordinators, Social Prescribers, First Contact Physiotherapists as part of the PCN project. WE are also involved in a Pharmacy First initiative. We are struggling to find rooms and find time to supervise and induct these new staff members. It may be worth it in terms of providing better quality of care to patients but it is not clear it frees up time for GPs to spend more time on patient care. It may be too early to tell.

 

My response to the Committee has been read by my GP colleagues, Business Partner as well as some staff and I am writing this on behalf of the Team at Horfield Health Centre.

I would be able to attend the Committee if helpful

Dec 2021