Written evidence submitted by Dr Alison Hobbs (FGP0140)

 

I have worked as a GP in an inner-city practice in Sheffield for 20+ years. I am the managing partner. We have 15000 patients and 6 partners (3.75 WTE) The views expressed are my own.

Our practice boundary largely covers a ward in the lowest decile for deprivation. 65% of our practice population don’t have English as their first language and many hail from cultures where there was no recognised, functioning primary care. We have high rates for everything: nursing and residential care beds; learning disability accommodation; mother & baby unit for assessment of parents’ abilities to keep children; severe enduring mental illness (3x national rate) to name a few

It has always been an incredibly tough place to be a GP, but we have prided ourselves over the years in providing gold standard access and quality of care, with continuity at the heart of it. Over 4 years ago we moved away from the traditional ‘fastest finger first’ access to adopt a ‘doctor first’ approach. In a nutshell all requests for appointments are triaged by a clinician (usually a GP) first and allocated to the most appropriate individual (who may not be a GP) to deal with. This may then be dealt with remotely or in person depending on a number of factors including the nature of the problem, the experience of the clinician and the wish of the patient. The covid-19 pandemic has driven an increase in remote working which has been generally well accepted by our patients who were already used to this concept and many have welcomed the fact they can be dealt with without having to come into the surgery building.

However, we now find ourselves in a perfect storm and can no longer safely manage this system. There has been a sustained increase in demand for GP appointments over the past 15m. We have a consistently reduced capacity due to staff sickness (stress/ burnout; long covid; isolating) and staff leaving. We are unable to recruit clinicians and even locums are hard to come by and in reality, the majority cost double and achieve less than a salaried GP.

My partners are choosing to restrict access to try to manage this and we are in danger of reverting to the ‘fastest finger first’ approach where those who are most persistent/ shout the loudest can access the system. This is making me desperately sad as it contravenes all that we have stood for over the past decades.

We use an online platform (askmyGP) which was open 24/7 until November 2020. Since then, we have cut it back: firstly, closing for the weekends; then each afternoon and onwards to the point where it is now only open for 1 hr a day Mon-Fri. This is a deliberate attempt to make it difficult for patients to access us as we are unable to cope otherwise.

This has inevitably driven up complaints. I suspect we will see worse patient outcomes.

So, in fact we are putting barriers up because we cannot manage the sheer numbers of people trying to access us. We do not have enough staff

This has been compounded by an obvious sense of entitlement we now see/ hear from our patients driven by rhetoric from various elements of the media and government. The recent focus on number of face-to-face appointments has been incredibly unhelpful as we know we can be much more efficient when we choose how people are dealt with. Stories of ‘lazy GPs hiding behind screens’ have significantly damaged patient confidence in the service and are driving up demand and abuse of our staff.

I wholeheartedly believe in continuity of care in general practice and have always actively promoted a named GP approach however this is being eroded by a vocal minority of my partners who believe it promotes dependence.

 

 

 

It’s difficult to see the NHS still functioning in 5 years time. The slow dismantling of the system seems to have ramped up over the last few months as is now seen by the current crises, most obvious in ED & ambulance waits but these are just a symptom of a system that is failing fast

The workforce crisis in primary care cannot be overstated.

Primary care needs more investment – back to 10-11% of the NHS budget to start with. We can no longer be the dumping ground for anything and everything that isn’t dealt with elsewhere (not simply secondary care but many of the failings in society come our way too)

Regarding regional variation, I can only speak from my own experience but the variation in life expectancy across the city of Sheffield is horrifying – as much as 10 years between the patients registered with me and those in practices in the west of the city less than 5 miles away. Current funding models do not adequately reimburse practices in areas of high deprivation. And the current workforce crisis is now putting us at huge risk – why would anyone choose to work with us when there is a plethora of jobs elsewhere in the city offering an ‘easier life’ This is being made worse by the advent of ‘moral distress’ – whereby doctors are unable to reconcile their principles/ raison d’etre with the current situation and feeling that they are failing themselves and their patients. This is putting off people who would ordinarily choose to work in a practice like ours; indeed, only this week one salaried doctor, who qualified as a GP less than 12 months ago, tendered her resignation and will almost certainly leave the profession altogether.

There is much bureaucracy and ‘box-ticking’ that certainly make the job less rewarding. However, for me the biggest boost to morale would be to have enough staff to do our job properly. We need an army of allied professionals to pick up the slack (minor illness, prescriptions, MSK, some mental health) to allow GPs to do what they are good at – managing people from cradle to grave in all their complexities. We need more of us too! And as part of our role, we would love to be involved in the public health/ health promotion/ prevention work. It is this that is going by the wayside at the moment.

 

 

 

Funding is a key issue here. The current state of play in the modern NHS, whereby secondary care trusts can claim a fee for activity whereas primary care get a flat rate regardless of it, is frankly unfair. We are expected to be everything to everyone for less than the cost of insuring a guinea pig for a year!

I don’t believe the partnership model is at fault. To be honest it is partners like me who are propping up a failing system. Salaried GPs are much more likely to work to rule and jump ship when the going gets tough.

I’m blessed to be in a well-functioning PCN and would be supportive of the concept of locally driven and managed services.

My final comments would be around the future of the NHS and primary care within it. It’s unrealistic to think there is a magic GP (& all the other people we need) tree and I personally think we need to have a national conversation about the purpose of the NHS. Sadly, much of our time is taken up managing people who have become entitled and demanding. People wake up feeling unwell and believe it is their unbridled right to an in-person appointment that morning. There is stark contrast between generations – broadly speaking the older generation are more grateful and less demanding, often waiting a lot longer to contact us and reluctant to take up our time. It feels that they come from an age that understands just how precious a ‘free at the point of delivery’ health service is. Unless the rest of the population are taught this, I don’t think the NHS is salvageable in its current state. This makes me incredibly sad.

Dec 2021