Written evidence submitted by Dr Anne Woods (FGP0143)

 

My name is Dr Anne Margaret Woods, MB ChB 1996 Aberdeen, BSc Med Sci, DRCOG, DFFP. I have been a GP Partner at Old School Surgery, Great Bedwyn, Wiltshire, for just over 5 years, with PCN and CCG roles. Previously I was a GP Partner in Fife, Scotland for 14 years. The practice is a small rural practice, of approximately 3600 patients, consisting of 2 partners, 2 salaried GPs, and 2 part time practice nurses. It is a GP training practice and currently has 2 GPST’s. It also takes University of Bristol 4th and 5th year medical student on placement. Is it a dispensing practice with approximately 95% dispensing. It is part of a small PCN of just over 32K patient, consisting of 4 practices located on 6 sites, over a geographically large rural area.

 

As a small rural practice, we do not have significant problems with access. We offer both telephone and face to face routine appointments and these can be booked online at reception, or over the phone, and on the day telephone and face to face emergency appointments. Our normal wait time for a routine appointment is 3 days although this can change with staff leave. We use regular locum GPs to backfill where it is anticipated that there will be a wait for a routine appointment over 5 days. We offer a large number of emergency on the day appointments, and again will add to the end of surgery to patients are never refused the option of a phone or face to face appointment. We offer online access via DrLink, and email, and all emails are responded to within 48 hours. Patients can also send in photos via AccuRx and these will be assessed the same day. The main barrier to access is appointment availability at a time to suit the patient, for example after work or after school, and if a patient wishes to see a particular doctor who may not be available at a time that suits. The governments plan to extend access times will spread the available work force thinner as most GP’s and nurses are working at the maximum of their capacity and administrative staff are hard to recruit. Extended hours appointments were commonly filled with elderly patients who took the appointment because it was offered and could have come at any time or were left unfilled. There is no demand for them locally. They are not backed up by additional laboratory support, so patients often need to return for tests, doubling the workload.

 

Having a named GP allows the workload coming into the practice to be split fairly but I have never seen how this benefits patient care as patients will choose to see the doctor that they like and who they get on with best, regardless of whether it is their named GP. It benefits in that correspondence can go to the same GP and this provides continuity and would likely be of huge benefit in a larger practice.

 

The main challenge we face is the huge drift of all work from secondary care, who now triage and refuse many referrals, and request that GPs undertake significant amounts of work which is unfunded, such as arranging follow up scans, blood tests, medication reviews and adjustments. If every department does this moving forward primary care will be unable to cope in a very short time. In many cases we are acting out with our competency but are left with no choice. We are General Practitioners, we are not experts in Crohn’s Disease, Epilepsy, Multiple Sclerosis, yet we are being expected to be all this and more now. The main gap in our support from secondary care is Mental Health. At best a very unwell patient can expect if they are lucky a triage phone call from a Mental Health nurse then we receive a letter advising of some medication changes and a list of third sector support services. I have referred two patients to the Mental Health service in the last year and nothing additional was achieved that I could not have undertaken myself. I have over twenty years’ experience as a GP. My younger colleagues are not in this position and are taking huge amounts of responsibility for patient mental health that is not theirs to take and is a long way out with their level of competency or experience. GPs are having to take on huge amounts of diagnostic and management responsibility in all disease areas both physical and mental health that is not theirs to take. This is contributing significantly to much of the stress that is on GP’s. In addition, the referral system has become increasingly complicated. Each speciality has created a proforma for each of its diseases. This has resulted in 100’s of proformas if not more. If you accidentally use an old or out of date one your referral will be refused. Each department sends them out in different ways, so you have to have your eyes on every ball not to miss changes. Some come by email, some through the system IT. Having a locum work in the practice for a few days who is not as familiar with all local policies can result in days of work trying to fix misdirected referrals and unhappy patients. As a small practice we have some secretarial support but the GPs are responsible for most of the referrals. The introduction of proformas and templated for referrals means that it is almost impossible to delegate this work now to secretaries, and GPs now have to complete most of the referrals made themselves. Now a large number have to go through an advice and guidance route either by email or a support system such as Cinapsis or Consultant Connect in order to get agreement to even make a referral. This is huge amounts of significant additional work for GPs. In a 15 minute appointment where 2 referrals can be needed there is minus 10 minutes to complete them.

 

I have been a PCN Clinical Director for 2 years and prior to this was on the CCG Clinical Executive. I understand the reasons for the introduction of PCNs, but do not think the model can be made to successfully fit very rural practices as it currently stands. It feels like a one size fits all model is being imposed on us. Our practice is very rural and the introduction of PCN model is not likely to bring us huge benefits. We are part of a PCN with one similar sized practice, a slightly bigger one, all 3 rural, and a large town practice which is over half the list size of our PCN. Due to our location on the boundary of Wiltshire we were forced into this PCN grouping. There was no alternative for us. The three small practices come out almost every year as the top-rated practices in Wiltshire therefore we must be doing something right. Our access is good, and our patient satisfaction levels are very high. Our PCN is one of the smallest in Wiltshire yet the largest geographical area. My practice is accessed only by B roads. We have a train station with a line to Paddington, London. As a result, the practice is a mix of very elderly, who generally walk or drive a short distance to the practice, and young affluent families who have moved to the country and commute to London. Our infrastructure is poor. There is a very limited bus service, 2 or 3 a day and no direct bus to the neighbouring towns which are part of our PCN as we are on the county border. Local buses go to Berkshire. We have struggled to recruit PCN staff as the job is not appealing. They do not want to travel to 6 different bases down country roads, especially in the winter and in the dark, and we end up agreeing they can either work from home or from another base. As a small practice we get a small share. For example, we get a pharmacist from home every 2 weeks. This adds almost no value to our practice. Almost all patients despite huge efforts at education request to double check things with a GP and do not trust the pharmacist. They feel let down that they are being fobbed off by us and ask us why we do not want to look after them anymore. Long discussions regarding why are generally unfruitful. We try to split employed staff down practice lines to improve this but why then should we not be given our own budget to employ what staff we think would add value to our practice. As a PCN we struggle to recruit because we are so rural, and do not want to recruit staff where we are destabilising our local providers such as mental health services and community pharmacies. The model of the PCN is asking us to become employers for groups of staff who already have jobs, just moving them around. Any dieticians we employ already have jobs with our local provider. Why do they need to be moved into a small PCN, create additional management, employment, and training burden for us, with very little if any benefit to our practice or local community? We have very different needs from the large practice in the PCN. They have a paramedic, which is improving their services. There is no need for this in our smaller practice. There has been a reduction in GP access due to the creation of PCN’s. Partners now must spend time recruiting, managing, training, and supervising these staff and this reduces our access and availability.

 

I have always felt that the introduction of the PCN model was a back door way of amalgamating practices. I am very concerned that this is still the intended direction of travel and that small rural practices like mine will not exist in 5 years’ time. I understand the economics of having larger practices, but patients want to be able to have a relationship with their practice and GP and this is lost once a practice list size is more than 10000 patients. The government cannot have it both ways. They cannot use the press to make us look lazy and money grabbing yet at the same time call us Family Doctors, when they are trying to destroy the structure that allows us to be Family Doctors. Not being an active part of a PCN results in the loss of significant funding so this is no longer a choice. We must actively participate and take the resulting anger and frustration that we receive from patients who believe we no longer care about them or want to see them. In the 2000’s The Darci Report recommended the development of GP polyclinics and this plan was abandoned as it was too expensive. Had that model been developed we would be in a much better place with much greater resilience and sustainability. We are now being asked to do a watered-down version on a smaller scale on the cheap. 

 

General Practice can play a huge part in the prevention agenda, but we will not have the capacity to do this if we are having to deal with secondary care work. GP is the correct place for prevention, and it is something I suspect most of us feel strongly about.

 

The PCN and QOF are huge amounts of bureaucracy. In addition, dealing with the administrative queries that generate from secondary care creates stress and additional work. The feeling of being undervalued especially by the government and national press has caused a significant drop in morale. The significant increase in workload in every area has resulted in most days being 10 hours straight work, with no break for lunch, or even at times a cup of coffee. This is unsustainable. 

 

The advantage of the partnership model was that it allowed practices to recruit and run their practice with a particular ethos, and this is being destroyed by the creation of the PCN’s which impose staff on practices, and it feels especially for a small practice significantly increase administrative burden and do nothing to provide proactive, personalised, coordinated, and integrated care. If anything, it’s the very opposite. The only benefit my practice has seen has been in the access to first contact physio appointments, but even this is of limited benefit. Our patients are used to being able to call up and speak to us with ease. We are on first name terms with most of them. We know their families, attend their funerals, look after them in birth and death. Small practices like mine are likely to close soon. Our buildings are ‘not fit for purpose’ in the modern world, and we are working with CCG staff who do not understand why the whole PCN cannot be on one site. We are very rural, have an elderly population and 2 buses a day. Our provision of care has not been improved by becoming part of a PCN. Our patients feel limited if any benefit and are very upset and sad that as they see it, we don’t want to look after them anymore. All future funding will be via PCNS, practices will lose their autonomy and ability to decide what is best for their patients, and they will and are losing out.

 

Is the partnership model sustainable? The simple answer is no. Who in their right mind would want to be come a GP partner? Whilst income is higher the responsibility is significantly greater. In an average day in the practice as a partner I undertake at least 25% more work that my salaried colleagues whilst looking like I have the same number of appointments on the screen. I am the one that stays late to see emergencies, manages staff problems, deals with complaints and administrative issues. I complete reports, write supportive letters for patients, sort our referrals which have been put through incorrectly, deals with the unhappy patients whose referrals have been put through incorrectly because the system is so complicated and constantly changing. The list is extensive and long. Partnership is much more than simply a different way of being paid. It is about leadership and management. I do not think practices could exist being staffed only by salaried GP’s.

 

Most GPs became GPs because they were attracted by the culture of family practice, being able to get to know and care for patients. In the late 90s GP was a very simple career, but with Out of Hours responsibility which was becoming very challenging. The change to the GP contract to make to 8-630 responsibility made GP an attractive career again. The quality of care provided was good and the health and wellbeing of GPs matched this. Over time QOF became more intrusive and more work began to be transferred to GP. IA and EA further encroached on this balance, as it was additionality, forcing hard working GP partners to work even harder as salaried Drs did not want to take these additional shift- most are salaried for a reason- to have a work life balance and are happy with the lower income that this brings. The requirement of GPs who earn more than £150K a year to publish their earnings was a most unusual policy. This specifically highlights hard-working full-time GP partners, who often are working 8-10 sessions because they are unable to recruit. Are these not the ones that the government should want to retain within the NHS. A part time GP earning £80K for less than half the work was not going to have to publish earnings. This policy really highlighted what the government thinks of us, and thankfully on this one our voice has been heard and it has been suspended. Partners bore the brunt of this and most of the recent changes within General Practice. They bore the brunt of the cancellation of public holidays and the covid vaccination programme and the introduction of Extended Hours. Pension changes have made it more unappealing to continue as a partner. At 49, having worked full time plus for all my working carer I have nearly (as a female) reached my LTA. There is no financial incentive for me to continue. The incentives are my love of the job, and my loyalty to my patients and my staff.

 

I undertook a routine GP morning session surgery this morning. It started at 0900. Prior to this I had to check, action and file 20 pathology results. It was a mix of 10- and 15-minute phone and face to face appointments. I also had an ST2 sitting in with me who will be joining me in the practice in August 2022. I had no break and finished my last phone call at 1430, 90 minutes over the scheduled finishing time. I had to leave my surgery to assist my practice nurse with a venepuncture, and on a couple of occasions to help my current ST3 with problems which arose in her surgery. I then had to complete 20 GP tasks, mainly prescriptions. My very kind salaried GP brought me a sandwich and a cup of tea. My practice manager bought me a couple of cans of diet coke. Today is a Friday and I have a few days off next week as it is my birthday. Every time I have leave, I vow to come back and make changes. I will have a break for lunch, I will go for a walk round the block. It never happens. I can’t see how in the current climate it ever will, unless I leave, or make drastic changes. This enquiry must find a way so that for people like me, leaving is not our only option.

 

Dec 2021