Written evidence submitted by Anonymous (FGP0149)

 

 

My experience inside general practice is that I have never felt as accessible or available as I do now.  Long gone are the days of working in practices where access was only through turning up at the practice (often in some places queuing on a first-come-first-served basis, and often in places then in a waiting area sealed off from the GPs consulting rooms) or by telephone.  Now I can have patients submitting eConsults at all times of the day, or emailing, or texting, or Online Messaging through their online access to their GP records, or accessing me by an App which loads queries directly to and from our clinical system.  The labyrinthine process of getting to a hospital doctor is not even remotely comparable!

I also think a distinction needs to be drawn between access based on need and access based on want.  For example, I think the total triage model that we were advised by NHSE and government to move to during the Covid pandemic does at least mean that we have been better able to identify and prioritise patients we need to see more quickly than if relying as in the past on the lottery of who shouts loudest/ has the sharpest elbows.

But the main barriers to accessing general practice in the way that everyone would like are to do with demand (both in terms of volume and immediacy) far outstripping supply.

I have never worked in any general practice (and I have worked in many over the past 14 years, in England and in Wales, and across very varied settings and populations) where the number of GPs/ clinicians and appointments is anywhere near enough to meet the demands placed upon it.

Demand is continuously stoked by media campaigns (like the Daily Mail’s earlier this year), government advice, and a creeping and pervasive “Amazon Prime” mentality of getting what you want now.  The general fall back for any health or social issue in any sector seems to be “see your GP”, whether or not there is a GP to be seen, or that GP has training and resources to be able to deal with that problem, or that GP has any levers whatsoever to effect any solutions, or is able to request the help/ support/ test etc that is expected.

 

To the extent that I understand these, they fall woefully short, being imposed from above on GPs rather than developed from the ground up with and by GPs.  There is a general failure to accept and communicate to the wider public that primary care is and always be a finite resource, which like any finite resource needs to be used responsibly and sustainably.

A really helpful plan would take more workload off GPs, increase the number of GPs more quickly, and develop support services like independent vaccination centres, timely access to talking therapies as a realistic alternative to anti-depressant prescribing, and timely and more comprehensive access to mental health support for children and young people for all mental health problems, not just the most serious, ongoing follow-up of patients by secondary care post-admissions and with outpatient clinics, rather than being discharged to care of GP at first opportunity, often asking us to chase things up for them, prescribing pharmacists with good indemnity, home-visiting services, walk-in centres, 111 services for acute care, and other forms of support for patients to choose from.  And removing (rather than continuously erecting) barriers to GPs from accessing investigations like CTs and MRIs, simplifying referral forms and processes, direct avenues to all specialties at all times, sharing of clinical records between primary and secondary care, and ensuring that all hospital doctors have to have spent a decent chunk of their training working in primary care to gain some understanding of what it’s really like.

 

Delayed presentations/ increased morbidity/ mortality may result, as may over-prescribing/ over-investigation/ over-referral.  As well as patients feeling let down or abandoned/ alone to face, increased health anxiety, increased inappropriate use of emergency services, increased patient frustration/ dissatisfaction, verbal and physical abuse towards staff, complaints and time and stress dealing with these, increased litigation risks.

 

This of course presupposes that continuity of care with a named GP is an uncontested “good”, whereas I would suggest that timeliness of care with the clinician best-placed through training/ experience etc to deal with a particular problem should trump simply seeing the same person.

This is not in any way to suggest that there are not advantages to continuity of care, both to patients and GPs, which are that knowing a doctor and knowing a patient, and developing a longitudinal relationship of trust between them, has clear advantages in terms of things like spotting changes, putting problems in wider context, reduced delayed presentations and clear trails of progress and responsibility.

The disadvantages are that you may wait longer to see a particular GP as they will only have a finite amount of time to deal with you, which may be deleterious in some health problems, that there might be a breakdown or dysfunction in that relationship, that it may foster dependence on the “doctor as drug”, and that it may increase stress and burnout for GPs stuck with particularly difficult or demanding patients without help from colleagues.

 

Not being possibly able to provide the quality of care to patients that we went into the profession for in the first place.  Not able to meet ever increasing expectations and demands heaped upon us from all sides.  Working ever harder, ever more hours, ever more aspects of NHS provision with ever more tying of hands behind backs, and ever fewer colleagues/ resources/ direct access to diagnostics and treatments and specialists.  Ever worsening fatigue, stress, burnout, demoralisation, being continuously scapegoated and attacked by some in secondary care, media, government and wider public, workload, erosion of any work-life balance, early retirement, recruitment to salaried/ partnership roles as locum-working is more attractive and more lucrative, lack of quality junior doctors choosing general practice as seen as increasingly unattractive and unworthy and undervalued career option in medicine.

 

Recruitment and retention, and therefore supply to meet demand, is likely to be more challenging in less attractive areas to live and work. 

The ‘one-size-fits-all’ reforms to primary care creating PCNs has added pressure and workload and financial liabilties to more geographically separated rural practices that cannot merge or work together as seamlessly as urban settings might.

 

It depends on what workload is removed from GPs to allow resources of time and expenditure on prevention.  Ideally, I would like this to be larger part of my work, but we lack capacity to do so because at the same time we are expected to deliver so many other services.  I would prefer to take on a certain amount of time per week delivering prevention services as a separate role in a portfolio career, rather than try and shoehorn it into already over-burdened GP workload (where it will inevitably lose out against more immediate/ pressing/ more within my power considerations.  I think prevention services should be separate to, but embedded and/ or where possible co-located in, primary care, and never have GPs as gatekeeper but allow self-referral/ as few barriers as possible.  Public Health should be part of NHS, not local government, and should be better funded to deliver public health interventions alongside and integrated within primary care and local authorities.

 

Firstly, consistent and supportive messaging about primary care from the NHS, media and government.  No GP can possibly be anything other than intelligent enough to get into medical school and complete years of post-graduate training and exams, and caring about other people, to choose general practice.  Colleagues I have worked with have been without exception amongst the most conscientious, kind, reasonable people I know, and all the time are continually abused and denigrated from all sides.

Simplifying contracts would be a good start, also: reducing box-ticking exercises/ simplifying QOF (or abandoning it until pandemic conditions gone); increasing direct access to diagnostics like CTs and MRIs; and to specialists, without having to go through hoops like referral management centres, advice and guidance first, FIT tests even if meeting fast track criteria for bowel cancer, blood tests before fast track referrals; direct access to all specialists through email/ messaging; shared health records between primary and secondary care.

Also increasing to 15 minutes GP appointment times, and capping number of appointments to an agreed “safe” maximum, with development of other services to take up the overflow.

 

 

No, I do not believe it is at all sustainable.  Personally, my preference would be what I think many people outside the health service imagine is already the case: namely, one seamless NHS organisation, with GPs employed on a salary by the NHS. 

I would envisage GPs individually contracted and employed as consultants (in primary care), and like consultants, over time develop sub-specialty consultants in primary care (e.g. primary care prevention, acute primary care, older people primary care, etc) and all GP surgeries and their staff to be managed and employed within the NHS, not by GP partners.  Primary care consultants could work in hospital settings where necessary, e.g. alongside A&E departments, and secondary care consultants could work in general practice/ community settings/ hubs where applicable e.g. some outpatient clinics, minor surgery etc.

Although I cannot see how the government or NHS could possibly afford this, as I believe the current model is much, much cheaper for them.  Perhaps this would require a state-backed insurance model of funding, rather than from general taxation, or tax-hypothecation for NHS services?

 

No, I do not believe they do at all, but I think a model such as I have outlined above might.  Although if GPs were employed and had the rights of employees, they might not be so ready to work quite so much outside their contracted hours.

 

Not in our experience at least.  The opposite effects have largely been apparent, of increasing bureaucracy and workload.  I think that the PCN model is not fit for purpose, certainly not in our area, and that the whole move from PCTs to CCGs was a mistake in the first place, which PCNs have simply confounded.  Remove PCNs, and replace CCGs with PCT type organisations, but with direct accountability to member practices would be the way I think, to remove workload from GPs that is not clinical.  Given the nature of the typical doctor who chooses to train as a GP, if you free up and trust GPs to do clinical work with patients, the freer and more supported we are to do so, we would tend to deliver care in this way as that is what we trained for, and how we would wish to practise if only we could.

 

Within primary care, my experience has been of effective partnerships with community nurses and community palliative care and community rehab teams, and often with social services.

Beyond primary care, not nearly well enough, but not for lack of effort or wish on our side I think.  I feel my colleagues and I go out of our way to involve and contact other professions within and beyond primary care, but often face many barriers to doing so, and many negative perceptions, but at the same time unrealistic and excessive expectations of us from those colleagues.  All medical colleagues outside primary care should spend a significant part of their training working in primary care, as all GPs have to spend a significant period of their training working in secondary care.  Investigations, onward referrals, and prescriptions by secondary colleagues should be followed up/ done directly by themselves. 

Dec 2021