Written evidence submitted by the Hurley Group (FGP0155)

 

Introduction: who we are?

 

1)      This submission is from the Hurley Group – an NHS GP-partnership which has been in continuous service for 70 years. It is a stable partnership with doctors only leaving through retirement or death! Collectively the current partners have been working in the NHS for more than 150 years with a range of 15-40 years. We have provided continuity and multi-generational care. At present our list size is 115,000.

 

2)      Over the last 70 years we have grown from a single practice located in the bottom two storeys of a 17-story block of flats to a network of practices, urgent care centres and specialist services across London.

 

3)      We have engaged in community development, outreach work, population health and deliberately sought out hard-to-reach patients (those who do not readily walk across a practice threshold). These have included intravenous drug users through setting up an out-reach clinic in a needle exchange scheme; the homeless through working with a local charity and delivering care in homeless hostels, students in nearby halls of residences and waves of refugees and asylum seekers who have been housed in temporary accommodation in our catchment area. We set up services for the mentally ill, doctors with mental illness and gamblers.

 

4)      We led a local intermediate care centre (Lambeth Community Care Centre [LCCC]) providing care for patients in, and out-of-hours. Together with other GPs we directly admitted patients to low-threshold beds and cared for them until fit to return home. The centre had co-located physiotherapy, occupational therapy, community dentistry, social care and much more. Local hospital consultants would undertake outpatient clinics where GPs would attend with their patients to help plan care for complex patients.

 

5)      As partners we have held local and national leadership positions in several clinical areas (substance misuse, mental health, and gambling), academia (participating in several randomised controlled trials), commissioning, medical-politics, and professional areas – helping to drive improvements in primary care. We were one of the first practices to bring in professional practice management.

 

6)      We developed an innovative and ground-breaking digital consulting tool for patients (eConsult) to improve their access to care.

 

7)      We were one of the first to expand beyond our practice, initially to support a local struggling colleague, later winning tenders to provide primary care in deprived and underserved areas.

 

8)      We won awards and were lauded and respected as GPs breaking the mould of general practice.

 

 

 

 

 

 

Submission

 

9)      Our partnership epitomises the problems which general practice faces.
 

10)  As we stepped out of the consulting room to lead services we left gaps within it, with not-enough doctors in the pipeline to replace us. There has been little expansion in our workforce - between 1995-2013 the hospital workforce expanded by nearly 150% ours by barely 30%. 1

 

11)  As we learnt to take on more complex patients their numbers increased as did the expectation of what we should do as routine. Twenty years ago, 90% of all diabetic care was done in hospitals, now it’s by GPs. The same for heart failure, chronic airways diseases and other long-term illnesses and complex health problems. Our patients now challenge even the most experienced GP’s competence.

 

12)  Shared care, ostensibly a model of integrated practice, became shifted care with work passed to us, under guidelines to do what hospital practitioners neither can (due to their medical record and prescribing systems), nor want to deliver.

 

13)  Hospital doctors now expect GPs to be their ‘scribes,’ to prescribe medications which should never be part of our role – complex treatment regimens for ADHD, patients undergoing gender transition, disease modifying and cytotoxic medications and more.

 

14)  As patients were discharged from hospital (often with days of major illnesses/operations), we tried to absorb their care, often lacking essential wrap-around support (access to district nurses, community dietetics, physiotherapy, occupational health, intermediate care beds[1]) which would be standard in hospital.  This stretched our resources and again took us out of the consulting room. Instead of the acute sector adapting to care across the secondary-primary care divide we were left largely to cope alone. Now we, and our diminishing district nursing work force are asked to do more ‘hospital’ care. The list of ‘GP to do’ at the bottom of discharge letters runs into dozens of asks and has increased during covid. Simple tasks which collectively tip us over yet add only seconds to a hospital doctors work (such as issuing certifications, enough medication post discharge, conveying results, booking follow up appointments). Asking us to do their work feels disrespectful and increases our demoralisation.

 

15)  As hospitals expanded, with many having on-site shops, cafes, and restaurants, we meanwhile have had to convert our disabled lavatory into a consulting room to try and create desperately needed space.

 

16)  As we have done more, for more, to a greater degree of complexity with little increase in IT, people, premises, finance, our workload has become unsustainable. The response by NHS leaders and local Trusts has not been to provide us with the resources to do the work, instead more work has been passed our way with the mantra ‘GP is well placed’.

 

17)  We have tried to adapt to reduce workload (such as creating digital triage) but even this has become a victim of its own success with 1000% increase in e-consultations compared to before the pandemic.

 

18)  We have developed economies of scale through

 

a)      single ‘back office’. 

b)      establishing digital remote hub (acting as the conductor of all our 3,000 digital consults per week coming into our practices).

c)       increasing skill mix,

d)      allowing staff to work to the top of their licence.

 

19)  We have flexed, innovated, diversified, learnt, adapted and still we cannot deal with the workload. Our patients struggle to access us. Our staff our suffering and we, as with many practices across UK face an uncertain future.

 

20)  If general practice is to be sustainable, and to restore continuity of care and population health (our unique selling points) then the whole system needs to adapt - not just primary care.

 

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

 

22)  There are not enough GPs and other primary care staff.

 

a)      GPs are needed inside and outside the consulting room and are spread too thinly. We are required to work in ‘traditional’ general practice and other areas (such as accident and emergency, care homes, dementia services, mental health services)

b)      GPs are required to work in clinical (in and out-of-hours) and non-clinical areas (commissioning, training, supervision)

c)       There is a flat structure and no junior staff, and limited career development.

 

23)  More specific examples of what can be done. Some of these relate directly to general practice and others to the wider health system.

 

a)      Extend GP training, adapted to the local population needs and general practitioners’ future roles, as with the innovative vocational training programme set up in South London following the Tomlinson Review in the 1990’s – creating out of hospital training posts for GPs2

b)      Allow other doctors to ladder across to general practice more easily

c)       Ensure all hospital doctors train in general practice at middle grade level not F1,2

d)      Create outreach hospital teams – able to follow up patients up to one 1 month of discharge or 1 year following a new serious diagnosis.

e)      Pay primary care on a par with secondary care for training staff.

f)        Stop shifted careapply the changes made to the CCG/Hospital contract to reduce this so the work stays with the clinician with lead responsibility for the patient.

g)       Expand direct access services, allowing patients to self-refer for example, to antenatal care, physiotherapy, breast clinics, dermatology services, IVF services, talking therapies, MSK. Allow others such as optometrists, physiotherapists to make direct referrals rather than having to “go through the GP”.

h)      Community nursing needs to be strengthened with self-governing teams’ responsible patients across a geographical area able to meet the full range of a patient’s needs. 

 

24)  To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

 

25)  The government’s plan does not address the issue of demand for primary care services outstripping capacity. If anything, it makes it worse by encouraging an increase in on-demand face-to-face appointments, stretching the depleted workforce further. Practices must be allowed to determine how best to use their limited resources based on patient need, and what blend of face-to-face and remote care best suits their population. Many commentators worry about what impact of a digital offer will have on continuity, relational care and the digitally excluded. We would argue that we need a digital first offer precisely to protect our ability to maintain these elements of general practice.  

 

26)  Until NHSE and the Government rebalance resources in terms of money, IT infrastructure, manpower and premises the barriers will never be addressed. This is not just about ‘improving access’ in isolation. This has been tried in the past and the results were disappointing. For example, advanced access (do today's work today) was to the detriment of continuity and meant that those who could wait to be seen (minor self-limiting illnesses, those who could be seen by others such as pharmacy, those who were frequent attendees) took precedence over those hard-to-reach groups.

 

27)  What are the impacts when patients are unable to access general practice using their preferred method?

 

28)  What is happening at present is a false dichotomy between face-to-face vs remote. We are in a digital health revolution. Of course, patients can have choice re preferred method. But we must balance this with fairness, addressing inequalities, need and safety. We will never return to the days of a having a full surgery of patients coughing, vomiting, waiting for hours mixing with sick cancer patients or those with serious infections. We must have a way to triaging safely. There has always been a system for determining which patient should be seen by whom and to what degree of urgency and whether face to face or telephone or home visit.

 

29)  What role does have a named GP—and being able to see that GP—play in providing patients with the continuity of care they need?
 

30)  Patients are willing to balance an immediate appointment with any practitioner (access) with ‘own GP’ (continuity) depending on the problem they have.

 

31)  Working across a wider footprint (PCN/Federation level) and using digital as a triage and care navigation tool for the majority, it should enable patients to have both access and continuity. We are developing AI powered workflow to achieve this.

 

32)  On balance, all patients should be able to select a preferred GP who oversees their care and ensures continuity when required. This does not mean that this GP is responsible for all the care, always, for all conditions, rather that they have overall responsibility for certain complex patients. The GPs role will be to act as an advocate, coordinating care with the extended practice team and wider multidisciplinary team as appropriate. As the number of GPs fall there is a risk that personal lists become too big for one person to manage safely.

 

33)  For patients with more complex needs care can be provided through a separate, enhanced service, involving a wider group of specialist practitioners (including elderly care, psychiatry) providing virtual wards in the community with crisis support, care plans and step up and step-down care.

 

34)  What are the main challenges facing general practice now, and in the next 5 years?

 

35)  The challenges going forward are:

 

a)      The widening gap between continuity and access; the GPs who has an intimate and long-standing relationship with their patient, versus a production line doctor, ‘anyone, anyhow and anywhere’.

b)      The increasing distance between the GP as a clinician in their consulting room vs the GP working outside, the social entrepreneur, dealing with population health and finding solutions to the problems entering their room.

c)       Gaps in access, such that the GP is unable to meet the demand due to workload, complexity, and shift of un-resourced care to the community.

 

36)  The risk of the present trajectory is that GPs are essentially filling gaps dictated through the requirements of hospital practitioners. Instead of designing and resourcing the strongest version of primary care possible and fitting secondary care around it. We have done the opposite and are paying for it both financially and in terms of poorer health outcomes.

 

37)  How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?

 

38)  We believe it is less about regional variation and more about deprivation. Poverty exists in all parts of the country.

 

39)  Practices in deprived areas suffer multiple jeopardy of

 

a)      difficulties in recruiting GPs,

b)      having to work harder to meet health targets,

c)       increased burden of unpaid work for patients who leave their list within 3 months[1].

d)      fewer clinicians per patient

e)      struggle harder to achieve target related income for t more challenged populations with no funds to address the growing gap.

 

40)  Given the government’s ambition within the levelling up agenda, there is now a good case for new monies being targeted towards these deprived communities by reinstating the practice deprivation allowance.

 

41)  What part should general practice play in the prevention agenda?

 

42)  General practice is well placed to provide preventative care, but this needs time and resource with community-based services to support patients to improve lifestyles and make the changes needed.

 

43)  Good online resources can be used for self-directed care and signposting to local services - e.g., health coaches/social prescribers. This does not need to be GP-led and should be in conjunction with local councils and public health 

 

44)  What can be done to reduce bureaucracy and burnout, and improve morale, in general practice? 

 

45)  Strip back the multitude of micro-incentives and KPIs. It is now unreasonable to expect us to perform against the current regimen of

 

a)      QOF             

b)      enhanced services,

c)       screening

d)      monitoring of shared care requirements.

 

46)  Move to a high trust-based supportive approach using fewer more meaningful data points. Align these to priorities based on population-health-management focusing on 10-year outcomes-based measures.

 

47)  Educate other parts of the health system - for example ambulance services expecting GPs to monitor patients while waiting 3-4 hrs for an ambulance is not realistic, safe, or indeed possible. 

 

48)  General practice needs to be respected by secondary care colleagues. The lack of respect and negative narrative is making the job unattractive with new graduates looking for a road out before they even start! We have been referred to by hospital doctors as their personal assistants, ‘janitors’, junior doctors in the community’. This must stop.

 

49)  How can the current model of general practice be improved to make it more sustainable in the long term? In particular:

 

50)  It is perhaps time to re-emphasise the general practitioner as a community based specialist3 (a specialist of the medicine of general practice). Whilst using the term ‘specialist’ the notion of the generalist as the first port of call and co-ordinator of care must be retained.

 

51)  Giving the increasing complexity of care, the expanding volumes of medical knowledge required, and the increasing expectations of the public, high quality care will need to be delivered by teams with the appropriate skill and role mix. This new approach requires not only that GPs share a common skill base in generalist expertise but also that other specialist practitioners engage in generalist care in the community.  This will mean that GPs evolve from the twentieth century model where they are ‘omnicompetent’ independent doctors and will instead operate as part of a family of interconnected generalists.

 

52)  To create a sustainable financial trajectory for investment we need to unlock a mechanism to strengthen primary care. General practices are efficient small businesses. However, we preside over a system where we see little benefit from the £billions saved on the clinical decisions emanating from better use of secondary care services or better prescribing, more astute use of investigations, improvement to the quality of referrals, or reduction in the volume of unnecessary referrals or avoidable admissions. Each of these areas, represent potential resources which could be channelled back into helping PCNs mature and invigorate a wider range of primary care services. This would kick-start a virtuous cycle of both enriching the patient offer whilst building resilience. This is not an argument for Total Purchasing Budgets, but simply a way to ensure resources follow the patient.

 

53)  The skill of ICSs will be tested in how they safely defund secondary care, as the work and resources are shifted into primary care, at a lower overall cost to the NHS.

 

54)  Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

 

55)  The partnership model has served general practice well for decades, but it is no longer attractive to younger GPs given the

 

a)      responsibility for performance

b)      employing staff

c)       running buildings

d)      burgeoning workload is not outweighed by the financial package (compared to other GP roles), autonomy, and status it brings.

 

56)  Some argue that we may be better served by a wholly salaried GP workforce. This brings an ability for clinicians to contain workload, have income security and greater ability for commissioners to align system objectives. However, what we lose is the tier of leaders who develop services and provide continuity over time (often at significant personal cost). Primary care has shown its ability to innovate rapidly, transform the service model, and deliver at scale during the pandemic. Though not exclusively, much of this has been driven by the clinical entrepreneurism afforded by the partnership model.

 

57)  Transformation of the Impact Fund[2], giving GPs the ability to develop and shape local services and the resources to take on this additional work, could become a significant driver for making GP partnerships attractive again.

 

58)  Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated, and integrated care?

 

59)  The NHS is still run as it was in 1946 with dividing-lines between hospital and community care - few services straddle the divide.

 

60)  The finances are balanced towards hospital care, whereas most of the care takes place in primary care.

 

61)  The GP contract is outdated - with remuneration based on a system established more than 70 years ago - with payments for items of service, appointments/1000 population, and capitation which nowhere addresses the costs of delivering care to an increasingly complex patient population. The new contracts for practices foster fragmentation and short-termism and inhibit continuity of care.

 

62)  The primary care estate is largely not fit for purpose - with staff scrabbling for rooms, IT facilities not allowing remote consultations, lack of diagnostics, day care facilities or spaces for multidisciplinary team meetings.

 

63)  APMS contracts were introduced with higher capitation payments than GMS and PMS contracts often to take on some of the most challenging practices.  However, the drive towards equalising funding levels across contracts has brought these rates down rather than increasing the other contracts to a level where primary care had a better chance of delivering care. How then can primary care deliver when it is set up to fail from the outset?

 

64)  Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated, and integrated care and reduced the administrative burden on GPs?

 

65)  Conceptually, few disagree that PCNs could be a positive route to at-scale working. But too much has been asked of them, too soon, with too little resource. As primary care service delivery vehicles for ICSs, they could deliver proactive, personalised, and coordinated care. But they won’t unless they are made less bureaucratic, given more autonomy, and given the time, data, people, and financial resources to mature. They are the right answer executed poorly. Given they were overlaid on a network of individually underinvested practices, each of which is struggling with multitude of issues, we need support them to help primary care recover, before we expect them to deliver. However, if we do this, they will meet these objectives and deliver the healthcare dividends an optimised version of primary care brings to the NHS.     

 

66)  To what extent has general practice been able to work in effective partnerships with other professions within primary care and beyond to free more GP time for patient care?

 

67)  General practice has worked with others for decades. But this has not always freed more time for us. Instead, it has increased the demands where lines of accountability are blurred. The GP is seen as where responsibility lies as other professionals do not work as independently, holding their responsibility.

 

68)  The role of the GP positions them well to lead primary care MDTs, coordinate horizontal and vertical service integration, and oversee population health management. The reality is that implementation of effective partnership working is patchy. PCN clinical directors are fatigued, and often feel unsupported, so are starting to leave. This will improve, subject to robust delivery of the right support architecture around them.   

 

 

 

 

 

 

References

1.               In-Depth Review of the General Practitioner Work Force. Centre for Workforce Intelligence; 2014. http://www.cfwi.org.uk/

2.               Souster V, Savage B. Creating relevent SHO posts for general practice training. In: The General Practice Journey: The Future of Educational Management in Primary Care. CRC Press; 2018. https://www.google.co.uk/books/edition/The_General_Practice_Journey/On1_DwAAQBAJ?hl=en&gbpv=1&dq=slovTS&pg=PT38&printsec=frontcover

3.               Royal College of General Practitioners. The 2022 GP Compendium of Evidence.; 2013. https://www.rcgp.org.uk/~/media/Files/Policy/A-Z-policy/The-2022-GP-Compendium-of-Evidence.ashx

 


[1] The LCCC was closed to become a step-down facility for amputees.


[1] https://www.gla.ac.uk/researchinstitutes/healthwellbeing/research/generalpractice/deepend/

[2] https://www.england.nhs.uk/primary-care/primary-care-networks/network-contract-des/iif/

 

Dec 2021