Written evidence submitted by David Colin-Thomé, OBE, M.B.B.S, F.R.C.G.P, F.R.C.P, F.F.P.H, F.F.G.D.P (Honorary), FQNI (FGP0154)

Independent Healthcare Consultant,

Formerly, a GP in Castlefields, Runcorn for 36 years, National Clinical Director of Primary, Dept of Health England 2001- 10. Visiting Professor Manchester and Durham Universities.

The reason for submission to the Committee; I deeply care for general practice and have a long a varying experience of the subject material from a clinical, regional, an academic and national policy role.

 

Summary

 

General Medical Practice needs to continually meet the warranted rising expectations of their registered patients. Inadequate access is perennially an issue and of parallel concern are significant lapses in quality of care and unwarranted variations in care provision occur. All these issues are equally of concern in all healthcare services worldwide. Recently there has been specific criticism of lack of face to face patient contact in General Practice since the Covid-19 pandemic hit the UK. All NHS services are equally struggling to return to pre pandemic lockdown levels.

 

Pertaining to General Practice, to improve services all providers and funders need equally to be held to account for a service which has for years been arguably the most successful service in the NHS. I quote from the NHSE NHS 5 year Forward View - of course pre pandemic. ‘The foundation of NHS care will remain list-based primary care. GPs have one of the highest public satisfaction ratings of any public service, at over 85%, but we know improving access to primary care services is a top priority for patients. General practice is undeniably the bedrock of NHS care. General practice provides over 300 million patient consultations each year, compared to 23 million A&E visits. So if general practice fails, the NHS fails. Yet a year’s worth of GP care per patient costs less than two A&E visits, and we spend less on general practice than on hospital outpatients. For the past decade funding for hospitals has been growing around twice as fast as for family doctor services. And ‘GPs are by far the largest branch of British medicine so if anyone ten years ago had said ‘here’s what the NHS should do now- cut the share of funding for primary care and grow the number of hospital specialists three times faster than GPs’, they’d have been laughed out of court. But looking back over a decade, that’s exactly what happened. (GP Forward View. NHSE. 2016.

 

Further, previous Secretary of State Hancock referenced 75% of Covid vaccinations were delivered by General Practice. The recent agreement to cut some of the bureaucracy attached to general practice to enhance the deliver by them of the huge increase need for vaccinating to prevent or at least diminish the effects of the latest Covid variant recognising the central role of general practice

 

 

 

My plea to the Committee is given this clear evidence, wholesale changes to contracts, administrative structure and more fundamentally the service model itself are likely to negatively impact on the success reported. And generalised criticism of the service when the issue is localised is a serious demotivating factor.

 

 

Specific responses

 

 

What are the main barriers to accessing general practice and how can these be tackled?

 

Despite the huge amount of patient contact with general practice, for general practitioners specifically at 80% of all NHS clinical consultations, the public have a valid expectation of better speedier access. We have insufficient general practice services but particularly of medical consultations.

NHSE plans would address many of these issues but overturning years of relative underfunded for all community based NHS services will mean slow progress as witnessed by the continuous slow if any rise in GP recruitment. When coupled with pandemic consequences, retirements and more GPs wishing to have portfolio careers, progress will remain tortuous. Undue emphasis and by implication blame on providers for their expedient action in the face of such problems will hasten demotivation. This is inevitably a theme, while no doubt some GPs are not providing a good enough service, the majority will feel unfairly castigated. It is not by chance that GP is with community pharmacy, the most popular NHS service. And Care Quality Commission inspections confirms general practices relative success

The NHSE programme Additional Roles Reimbursement Scheme (ARRS) to provide a wider range of clinical professionals into GP is most welcome, a support that hospital medics have taken for granted for decades.

 

The vexed question of face-to-face care should not be subject to instant comments. This is a complex issue and many of us patients when appropriate welcome virtual consultations. Offering different clinical consultation modes is also the only way general practice can offer a reasonable speedy access response. GP cannot follow the hospital response of ever lengthening waiting lists. The oft used aphorism ‘never waste a crisis’, was never more appropriately utilised than in the NHS response to the pandemic.

 

During the COVID-19 outbreak, practices have had to strike a delicate balance between providing face-to-face patient care where clinically necessary and minimising the number of face-to-face patient contacts in line with national infection control protocols. In England, prior to the national lockdown in March 2020, just over 70% of GP appointments and almost 80% of appointments in general practice overall were delivered face-to-face. During the first national lockdown, these proportions changed dramatically, with data from the RCGP Research and Surveillance Centre showing that approximately 70% of GP appointments and over 65% of general practice appointments were being undertaken remotely by telephone or video. As practices have reconfigured their systems and processes to minimise risks of infection from face-to-face attendance, the mix of appointments has shifted to a more even split. By mid-March 2021 in England, telephone and video appointments accounted for 54% of total appointments, while face-to-face appointments made up 46%. That figure is now just under 60%. So continually rising and while there may be some recalcitrant practices, they should be subject to local management action.

 

General practice is a multifaceted service encompassing care, cure and health and wellbeing. Any lack of access is potentially deleterious to patients. Alternatives are inevitably of lesser value although certainly still of use. Online services outwit the NHS, GP out of hours services and various hospital urgent care services all offer very limited access to the huge amounts of people who attend general practice. Pressure induced by GP patients are claimed to overwhelm these services who inadequately cope with quite small shifts in numbers of attendees. When the GP out of hours provision was introduced in 2004, it was claimed it put huge pressure on A&E services, yet subsequent research did not support such claims.

 

General practice though not solely responsible, are key to early diagnosis so important in better patient outcomes for instance in malignant conditions but also in long term conditions, most notably in schizophrenia. Their care of vulnerable and frail patients is of manifold importance to patients and NHS alike. Recent Red Cross research figures suggest less than 1% of the population account for 16% of emergency department visits in England. There are similar figures for emergency ambulance use. This cohort of patients often respond positively to proactive case management techniques usual within or in association with their GPs. The necessary pandemic lockdown has negatively impacted on many such services where GP involvement is essential. Most of long term conditions care is delivered in general practice, augmented by QOF (Quality and Outcomes Framework) of the 2004 GP contract. The NHS high ranking by the Commonwealth Fund is largely due to general practice success in long term conditions care.

 

 

A named GP is of importance to focus on continuity of care. Patients who receive continuity of care in general practice have better health outcomes, higher satisfaction rates and the healthcare they receive is more cost effective. In 2011, the Royal College of General Practitioners published 'Promoting Continuity of Care in General Practice'

 

As general practice has in general become larger in size with more part time working and a wider range of clinical professionals to serve patients, continuity of care could become more complex and difficulty. Consequently and paradoxically continuity is more important than ever. The concept has had to be continually redefined with the increasing complexity of care delivery. Patient choice or clinician availability may prelude day by day continuity, having a named GP will give clarity and accountability to patients if the GP is the clinician they choose for their therapeutic relationship. Patients could be given a choice although the most likely is the GP for their usually wider ranging knowledge, skill and availability- the hallmark of the skilled generalist. At the least for continuity a patient in particular need should have an identified ‘their doctor’.

 

 The main and most fundamental challenge is to the role of the generalist. An essential central role in an effective healthcare system but a concept not universally accepted world wide. Given space is limited here but for strong evidence of the success of the generalist in healthcare, note the international publications of Paul Grundy, Barbara Starfield and Kurt Stange. The challenge comes from those who view healthcare from a functional, utilitarian, reductionist concept of care. Such a view may be in the ascendance despite the evidence and the importance of the generalist broader care giver is thereby diminished.

 

Other challenges are rising expectations particularly since the pandemic and a more fundamental need prevails for care giving beyond the need for cure. Covid unmasked the long existing poor health of the UK population. The consequent challenge is to expand general practice workforce, their services and extend the scope of community based care of which general practice is the main provider.

 

These challenges could affect the very survivability of general practice which until the appointment of previous NHS CEO Stevens and as previously described, suffered continuing significant disinvestment within the NHS budget

 

Regional variation of provision of care and often associated quality issues significantly affect GP services and a ‘levelling up’ is an imperative. The more fundamental variation however can also reside within regions. Despite various initiatives, the NHS since inception has underprovided general practice and indeed other cure and care services in areas of socio-economic deprivation. Poverty is the most discernible indicator of under provision and the issue that need urgent addressing, magnified by the pandemic. The previous Personal Medical Services (PMS) contracts aiming to provide more funding and support to general practice in underserved areas. A promising initiative but unaccountably became an unfocused alternative GP contract.

 

 

General Practice uniquely for an NHS provider, serves a registered population, The health of the population is a fundamental part of population responsibility which many, but not all practices accept. The GP contribution in the care of long term conditions – a significant cause of health inequalities, vaccination and indeed in advice and treatment of cigarette smoking is well described. The 2004 GP contract stimulated the preventive care offered by GPs. An under acknowledged benefit of a GP population is the facility to devolve budgets enabling enhanced local managerial responsibility and accountability. The previous fundholding policy underlined the point. General practice achievements and its further potential is internationally recognised.

 

When I joined the DH in 2001 a committee was in place to try and lessen bureaucracy in GP practice. When it became 2 committees the irony was lost! The growth of unnecessary bureaucracy is often insidious. We need to re-establish one of the successes of the pandemic response of 2020-, to organise a cross-NHS bonfire of most tick box, KPIs and targets and think anew of the need for the plethora of such. Unfortunately much of that bureaucracy is returning.

 

Morale and burnout are more difficult to address as it becomes a self perpetuating issue. A fundamental issue well beyond I believe the remit of the Select Committee is arguably the way the NHS is funded. A former Minister of Health when a service is funded through taxation it becomes a positive ethical duty to bombard the government and force or shame it into providing more money’. I believe that dependency culture goes beyond funding and inculcates an equivalent feeling of powerlessness.

 

More specifically 4 events in my working life stand out. The 1966 and 2004 GP contract rewarded many for good practice. There is a feeling that the NHS bales out underperformance without rectifying the underlying cause and gives insufficient attention to the strong performers. The Vanguard and other innovation programmes led by former CEO Stevens began to reverse that trend.

 

2 other initiatives captured the heart and minds of many GPs; The introduction of GP Fundholding despite initially much controversy, was adopted in various forms by 50% of GPs. Consequentially the fairly rapid spread of fundholding led to a burgeoning and energetic anti fundholding response, so an activation of even more GPs. And the antecedent Primary Care Home of the current policy of Primary Care Networks. The concept of the PCH originated by my self in 2009, brilliantly developed by NAPC from 2015 at the request of former CEO Stevens, within 3 years had 300 volunteers each serving 30-50k population. They produced widespread and evaluated success in care and public health provision, and equally widespread enthusiasm and reported fulfilment. This ‘bottom up’ approach became government policy. Now that it has become policy, will that enthusiasm spread to the previous non participants. Will the heavy hand of the NHS curtail energy and enthusiasm?

 

Lessons can be discerned from these successes. A suitable vehicle for innovation and commitment must be found, its development has to give providers a locus of control of their environment and service development and yet be part of NHS value. All 4 examples had different practical features of which national policy, contracts and yet an opportunity for localness and clinical and senior leadership are important features. It can be done but 100% uptake is unlikely. If a tipping point is reached, take up is more assured and tipping point evidence suggests under 50% is sufficient, but peer involvement in spread is all but mandatory.

 

 

 

The present model of general practice has for the vast majority served the patients of its registered population well, and in turn the NHS well. I repeat the words of the NHSE 5 Year Forward View. ‘The foundation of NHS Care will remain list- based primary care’. General Practice is the only NHS organisation that cares for the individual and registered population. And its strength is its localness. At a time when especially for socio-economic deprived populations services are becoming larger and more distant and inaccessible, general practice is an important part of local social capital. Do not remove or change it but support and enhance it. That was the purpose of the hugely successful and previously noted Primary Care Home. Their now national policy successor the Primary Care Network, should take on the mantle of the of its antecedent to support, nourish and enhance general practice so enhancing local community provision. Practices and Networks are co-partners.

 

In responding to these specific questions, I will expand briefly on my previous comments

The ‘traditional practice’ has been in iterative change previously, during and since my 36 years in general practice. It will continue to adapt, adopt and advance begging the question - what is traditional? Many practices have been leaders in this advance leading on quality improvements including access and responsiveness, integrated care, the prevention agenda. All part of the development of the traditional attributes of general practice previously noted; first point of contact care for many, continuous person and family focussed care, care for all common health needs, management of long term conditions, referral and coordination of specialist care, care of the health of the population as well as the individual. Recruitment particularly in areas of social deprivation as in my personal GP experience, has always been fraught but practices with help can survive. There has been a growth in other practice based clinical professionals and the largest employer of salaried GPs is list based general practice.

 

All the advances for decades has been achieved with iterations of current contracting and payment systems. They could be improved no doubt, but they are not the fundamental reason for current and indeed the many past problems faced by general practice. A fundamental problem has been the frequent lack of empathetic NHS management, exceptions always. And that lack of empathy has been also applied to all community based services. NHS management’s and indeed much of Policy’s comfort zone is focused on hospitals. Not for nothing the political slogan ‘schools and hospitals. In general, management has favoured bigness and ‘at scale’ and my observation ‘their minds are too tidy’. Human endeavour is often messy, not machine like and is relational. The stuff of humanity and hugely residing in communities-the strength of primary care in all its forms. And an over rational utilitarian policy, leadership and management will not solve the stated problems.

 

Primary Care Networks if they follow the example of their antecedent although of course voluntary Primary Care Homes, can deliver all that’s been previously described. But time to progress is the essence with an empathetic support to general practitioners and their practices. To expect big change so quickly is an NHS and Policy impediment that has led to far too much structural change over the years. Very successful organisations have often taken years to develop and have required iterations and nuanced change. Primary Care Networks are the first NHS organisations in living memory geared to support general practice and the wider primary care.

 

Another observation - I feel in choosing NHS positional leaders we focus almost solely on technical knowledge and play scant attention to the necessary behavioural attributes. And when we have the too frequent restructuring designed to elicit change and advancement, many of the chosen leaders are of the failing ‘ancien régime’.

 

General practice has always worked with others. Even the so called single-handed practice may only have a sole GP but have other members of staff. As previously noted, practices are expanding the range of clinicians within their practices, have traditionally worked closely with community nursing and co-operated with other GPs in the so called super practices and the Primary Care Homes which made up 20% of current PCNs. GPs have worked closely with other clinicians in various out of hours organisations, in academia, multi practice arrangements. When it is of mutual benefit to aid patient care, GPs co-operate.

 

 

Dec 2021