Written evidence submitted by Dr John Allingham (FGP0150)

Dear MPs

I am currently a part-time salaried GP approaching retirement but I have been a partner, an LMC Chief Executive, a CCG clinical leader, a GP trainer, a Healthcare University Lecturer and a front line Army Medic during the first Gulf War.

This evidence is a reworking of an essay published on line by the Social Market Foundation.

In my 26yrs in NHS General Practice it has never been as busy or as stressful as it is now.

Patients are struggling to get the care they need and GPs and their staff are burning out trying to meet the demands.

The number of GPs and appointments is finite and there is no realistic expectation of more in the near future. It takes a minimum of 10 yrs to turn a bright 18 year old school leaver into a GP. The expansion of GP training and opening new medical schools will bring a small benefit to the service in 10 years time.

The current crisis can only be ameliorated by reducing demand and making the best use of GPs we have.

Working at the top of the licence

The NHS needs all health professionals to work at the ‘top of their licence’ as far as is possible. For GPs this means stripping out many of the simpler clinical issues, administrative and bureaucratic tasks. This can only be achieved if a triage system is operated to filter out the tasks that do not need a GP. Unfortunately patients cannot expect to book a face to face appointment without offering an explanation why their problem can only be solved by a GP.

Talk before you walk

‘Talk before you walk’ must be the normal way of accessing care. Face to face appointments should not be the default option and used when they are best way of providing care. Setting targets and producing league tables for the proportion of Face to Face appointments will not take into account population characteristics, will not improve care, will encourage gaming of how records are recorded to massage the figures and will not improve healthcare.

Pharmacy First

There are many patients with problems that can be helped by a pharmacist so ‘pharmacy first’ schemes need to be universal. Pharmacists with appropriate training can provide medication for many minor conditions that take up GP appointments. This service is currently patchy but community pharmacy is well staffed and could reduce some of the demand on GPs and A and E. It is important that the medication costs are the same to patients as with a GP prescription. Some patients attend GPs out of the financial need to get a free prescription rather than the medical need for help and advice.

A simple example is paracetamol syrup for sick children. This could be provided free by pharmacists and the cost offset against appointments generated.

Unnecessary Paperwork

Many patients attend GPs simply to get a form or certificate signed. Much of this work could be removed to provide more capacity. The Med3 or Fit note used to validate inability to work could be completely withdrawn from GPs. The DWP could police fitness to work and rely on self-declaration and the assessment of their own Doctors and Nurse Specialists. Employers could use self-declaration and specialist Occupational health teams.

A national campaign informing patients that signing forms to run marathons, get passports, make parachute jumps, be exempt from mask wearing or join a talking book club are not the responsibility of the NHS. A minimum national fee of £50 for a GP signature on all such forms with the cost being met by the organisation requiring the information or opinion rather than the patient would reduce this demand. In signing a form the GP is taking responsibility and the risk that the information and opinion given are accurate and can face sanction in the event of an error. Many patients baulk at any fee for this service and there are examples of patients lying to get an appointment and presenting a heartfelt plea for a signature in an appointment that could have been used by a patient with clinical need.

Shifting Admin

The shift of administrative tasks such as chasing appointments, results and writing prescriptions has grown exponentially as other providers try to increase throughput, do remote consultations or lack the systems to complete care. It is cheaper for a hospital to transfer work to GPs than to employ another secretary. A list of tasks that should not be transferred to GPs with a £50 fee levied for every breach would stop this and force hospital trusts to establish proper systems.

Better use of existing IT

Using the NHS app to track the status of referrals and waiting lists would enable patients to keep abreast of their treatment without having to use GP appointments to seek information and chase other providers. As waiting lists have risen the amount of GP time spent dealing with patients unable to get access to other providers has increased.

A rapid roll out of electronic prescribing (EPS) to enable hospitals to send a prescription to the patients local pharmacy rather than write to the GP who then checks the details, contacts the patient and EPSs the script.

Many of the tasks described here are ‘it will only take 5 minutes issues’. Except there are 20 or 30 of them every day.

If all the proposals outlined here were adopted it would increase access by 20-30%.

 

 

Rethink the Quality Outcomes Framework

The 2004 contract introduced the Quality Outcome Framework with a significant proportion of GP income being linked to target payments. This needs to be trimmed down to remove the transactional data recording which generates income but does not improve patient care or outcomes.

Rethink Core Funding

The current system of funding practices with a global sum capitation based system does not reflect the work conducted by GP Practices. The demand is rising with increased consultation frequencies whilst funding remains the same. The GPC has policy to seek an item of service based contract. Introducing an open well publicised system will incentivise some aspects of the contract more effectively and allow patients to see how much their healthcare is valued at. Currently patients are shocked to learn GPs receive less to provide for their annual healthcare than a pet insurance company charges for the care of a hamster.

Setting a safe maximum for patient contacts per day will improve quality and help protect against burn out in GPs. This is not achievable because the present demand is 3 or 4 times what is considered safe in other health care systems (eg USA where insurers will not fund more than 25 contacts a day).

Encourage retention of older GPs

In addition to freeing GPs from bureaucratic and low-level tasks there needs to be a campaign to preserve what we have. Older GPs need incentives not to take early retirement such as contracts with more time per patient, fixed hours and time to mentor younger GPs. The government need to rethink the pensions tax rules which force GPs to reduce hours and encourage early retirement.

Incentivise Deprived areas

Incentives to work in under-doctored areas such as 5year enhanced contracts with signing on bonuses working in modern state of the art premises might help balance the leafy suburbs versus inner city health inequality. Investing in providing new premises with the NHS as the default last tenant standing option on leases will encourage recruitment and retention to practice housed in such facilities.

What do we not want the NHS to do?

We need a grown-up conversation about what the NHS will not provide. GPs hate rationing but are warts, veruccas, headlice, threadworms and holiday advice a priority? 

GPs are not an emergency dental service. Everyone should have access to an NHS dentist stopping  the patients with dental abscesses and toothaches taking GP appointments in desperation.

Invest in Public Health

Public Health budgets have been cut in the last 10 years. The excellent preventative work in weight management, smoking cessation, drug and alcohol addiction and many other areas that help keep the population well are missing. This increases pressure for GP appointments. Investment in national health promotion schemes will increase GP capacity. A healthier population needs less care.

 

Invest in Mental Health Services

There has been an explosion in mental health problems and the poor provision of services across all age groups but most notably in child and adolescent has left GPs as the only service for too many patients. Investment in mental health services will free GP capacity.

Contractual Status

I have not mentioned the independent contractor status. If the proposals above were implemented partnership would become attractive to young GPs and the system would thrive.

Moving to a system where all GPs are salaried would reduce availability because of the effectively unpaid overtime hours worked by partners and the presenteeism which would fall if all were subject to standard employment contracts with sick pay and other benefits.

In summary.

The future of General Practice is precarious. Without the essential gatekeeper role other services will struggle. Government policy needs to focus on getting the best out of our GPs by removing unnecessary or ineffective tasks, by creating working environments that raise morale and encourage and by addressing the reasons Doctors retire early or exit the profession prematurely.

Lastly good relations between government would help retention. If the government did not appear to be colluding with the GP critics to be found in the right wing media attack dogs it would help morale.

 

Yours sincerely

Dr John Allingham FRCGP DRCOG DipSportsMedRCS (Ed) PGCME DLM

 

Dec 2021