Written evidence submitted by Julia Dudd (FGP0132)

My name is Julia Judd, I am a registered nurse who qualified in 1989. I have worked in General Practice since 1993, initially as a Practice Nurse before moving across to advanced practice and Nurse Practitioner role in 2004 to include Nurse Prescribing in 2010. I have completed a master’s PGCE qualification in Nurse education and split my work time between Clinical Practice and teaching a post graduate General Practice Nursing Course via Bournemouth University. I also run my own training company J2S Training Ltd since 2011, providing skills-based training for nurses and HCAs in Primary and Community Care. Based on the themes raised in the Call for Evidence enquiry I attach my feedback within these themes.

Perception of General Practice

Pressure was evident ‘pre Covid’; with reduced capacity, a deficit of GPs (through retirement and retention) and increasing service demands. Following the National Lockdown in March 2020 there has been greater reduced capacity to access GP services with a screening system of e consultations / telephone Triage and email correspondence. This was introduced overnight, no staff training and no administrative support to manage the burden. Surgery doors are shut and entry is only via appointment, limiting face to face interaction and access to consultation appointments.

This has been heavily swayed in the direction of the GPs – Advanced practitioners and treatment room nurses have continued working at the same level as pre covid. Patient perception, however, is that General Practice is shut. Further encouraged by the media narrative that showed daily updates of ITU/Critical Care hospital settings without one reference to the part that has been played by Primary Care.

Patient charter gives them the right to demand whatever they want from the NHS, from minor illness treatment, through to X ray, Ultrasound, consultant referral – often without any validity to the request – yet the medically trained practitioner has absolutely no rights to defend their practice, seen as ignorant or denying human rights.

Demand

Demand has grown exponentially.

Statistically the population is living longer with more complex health needs. The social care burden is phenomenal, with NOWHERE to refer the vulnerable, the elderly frail or those with complex mental health needs. There is no service, there is no infrastructure. A risk to health, or a social need may be identified – but there is nothing else that can be done.

Family dynamic means that there are many single parents, young people and elderly people who are both isolated, with limited support network and limited capacity to self-care. The GP is seen as the panacea for every query – regardless of health or social care needs.

Media

Horrendous – I am embarrassed to say that I work in a General Practice for the barrage of insult that will follow. The Media narrative has reinforced the closed surgery perception – salute the NHS (secondary care), scapegoat the General Practice (primary Care). Social network platforms such as Face Book reinforce the inability to see, diagnose and treat – highlighting GP ‘failings’ daily. Local neighbourhood forums are highjacked by the disenchanted key board warriors who know nothing of the truthful representation of Primary Care. This fuels the flames and adds to the negative connotation of ‘GP’s doing nothing’, behind closed doors.

Workforce

The model of GP care being ‘owned’ and a private business sitting outside the NHS doesn’t work, it has never worked since the inception of the NHS. Look at the timeline, The Collings Report, Alma Alta declaration, GP Contract, GP fund holding. There are very few GP partners in practice now, more choose to be salaried whereby the T&Cs of employment are slightly better. The service is predominantly female lead – this often means part- time working and childcare. Leadership in care doesn’t equate to leadership in business. Two very different strains pulling in opposite directions. Health care will never make profit and those GPs who once saw the job as an attractive option are leaving in their droves.

Moving on to the clinical staff employed by the GP – compared to their colleagues in secondary care, they have none of the employment benefits that are offered by the NHS organisations. Salary is independently negotiated and can range from £10 -30, with no consideration of qualifications/skills experience and no gateway pay rises like Agenda for Change. Equally annual leave calculation can range from 4-5 weeks, rarely more (AfC is 7 weeks + bank Holiday entitlement). Some staff are on zero hours contracts, some receive no sick pay, some are not paid when isolating for Covid, whilst others are. Such disparity means that failing practices continue to fail – staff leave and high staff turnover pursues.

Following the Five Year Forward paper, money has been thrown at General Practice to try and plug the gaps – this has resulted in a plethora of skill mix and a dilution in quality. Working backwards from the GP there are Physicians Assistants, Advanced Clinical Practitioners, Nurse Practitioners, Practice Nurses, Associate Practitioners, Nursing Associates, HCAs. Neither the patient or the practice manager can decide who does what and consultations become meaningless, bounced from one clinician to another. Whilst I will never belittle my clinical peers, (there are some excellent nurse practitioners). We are governed by the NMC and our scope of practice – which means that ultimately a GP cannot be replaced in certain situations and this mix of disciplines just muddies the waters (albeit at a far cheaper rate).  

Workload

Drowning under paperwork is an understatement. Referral pathways are complex and tedious, with hoop jumping criteria to fit referral pathways. For every piece of paperwork that is processed, another three appear in their place. Audit and QoF drive up the demand to review notes and bring patients through the service. Whilst in principle, QoF works well, in reality it is driven by finance and ‘tick box’ stats with no quality attached to it. Again, this work is being delegated down to the HCAs – those least qualified, on the lowest salary, capturing data and stats. No expectation that they will need to interpret them, therefore not appreciating the value of them for the patient living with a long-term condition. Therefore, no benefit to the patient and health promotion becomes meaningless, overlooked or ignored; reactive rather than proactive.

Covid has stripped out any resources that we had, with the burden of care focused on acute management. General Practice is not the place to provide Covid vaccinations – send the patients to the organised Hubs and scale up the resources there. Every time we are expected to jump into mass vaccinating, another nurse/GP/HCA is pulled out of their workload. In their absence, who provides routine baby vaccinations, cervical cytology, wound care, leg ulcer management, LTC assessment and review, sexual health and well woman clinics, medication reviews, diagnostics, blood tests, cancer care, end of life care, flu, pneumonia and shingles vaccinations? – WE DO! Its an unnecessary diversion of our essential core care and again, is driven by finances, with GPs trying to claw back any profit where they can.

In my own Practice – a successful, well-respected organisation, we have gone from a team of 8 full time Partner GPs to 3 Part time Partner GPs and 5 part time salaried GPs. Retirement, resignation and one GP off with Long Covid for over a year, we have a permanent advert out to replace posts, without one single application. We are decimated and rely on locums (quadruple the price and have no knowledge of the patients that they consult). Our patient population is nearing 16,000 and we have had to close our books to new registrations.

I have been a nurse since 1986 and worked in Primary Care since 1993, sadly I have never experienced anything quite as bad as the situation that General Practice is currently languishing in. I am proud of my profession and have worked with the most dedicated staff, without exception. We are a breed of our own who roll up our sleeves, approach challenges head on and knuckle down to see a job through. Millions of hours of unpaid overtime, studying and learning in our evenings and weekends. Compromising our home life as we go above and beyond to provide the best care we can with the limited resources available to us. We are now compromising care and we are now failing patients. As I write this evidence, I have taken a call from my practice manager asking if I have any capacity to work tomorrow as they are ‘desperate’ with another nurse now off sick ?Covid and awaiting a PCR. So, I am going in to work tomorrow on my day off to help out my colleagues. Desperate times call for desperate measures. 

Dec 2021