Written evidence submitted by St John Livesey GP and clinical director Sheffield CCG (FGP0159)

 

I have worked as a GP since 1996, both partner and salaried. I have been involved in wider system leadership including Practice Based Commissioning and NHS Sheffield CCG for the last 15 years. These views are my own.

 

 

Executive summary.

 

 

Submission

 

  1. Of course we are demoralised. There is either no clear direction from the centre, or perhaps if there is, no one has explained it - either to the profession or the public.

 

The need for long-term vision

  1. Personally, I think that the focus on PCNs is correct, as the emphasis on populations of 30-50,000 gives us the sweet spot to develop services with economies of scale whilst remaining local and personal. It allows us to pull in all those other professionals vital to health care delivery (community nurses, physios, OTs, mental health workers, paramedics, physician associates).

 

  1. Furthermore, these populations work socially: they fit into a neighbourhood. This will allow us to develop services with social care, the VCSE and include patient co-design. However, this doesn’t only create a service that patients are more likely to use (hard-to-access services is usually a better description than hard-to-reach patients), it also gives us the chance to see more activated citizens and communities - finally developing an opportunity to create wellness rather than simply treating ill health.

 

  1. This approach is an attractive proposition to both professionals and the public - one that works with rather than against our humanity. It recognises that those that join caring professions do so to care, and that people like to have active involvement in their health and wellbeing - and are healthier if they do so.

 

  1. This vision for fully-realised PCNs makes sense when it is properly laid out. But little is heard of it, and even less is said of the reason behind it - the “why”. The primary challenge that we face is to move from a reactive service appropriate for tackling acute illness, to the planned proactive service that we need to tackle the emerging problems of living with chronic disease and caring for the frail elderly. We still need to have a service that can react to acute illness, but we need a fundamental structural change to develop the planned service that these emerging health needs require. However this “why” is ignored - leaving both the profession and the population confused about ever-changing services.

 

  1. This confusion is exacerbated by a medical leadership that appears determined to hang on to what we hold rather than design for the future, and a lack of central Government/ NHSE leadership making the case to the population.

 

  1. It is, of course, far too early to judge the effectiveness of networks. If we truly understood the reason for change, and the long-term nature of it, this question wouldn’t be posed. Networks are essential to provide the proactive, citizen-involved service that we require, but this will take years - and yet already PCNs are being judged. It is almost like asking whether a new housing estate has eased overcrowding when only the foundations have been laid. The fact that the question is being asked indicates the lack of understanding, within policy makers and the profession, of the long-term vision.

 

  1. So yes, PCN are being developed - helped in many areas by the necessity of cooperation during Covid vaccine delivery - but at present they are simply foundations. It is too early to measure their value, and they should not be expected to bear heavy loads too soon.

 

 

GP access

  1. What are the impacts when patients are unable to access their GP by their preferred method? First, it is perhaps instructive to ask why they can’t. As described above, over the last 15 years the number of patients has significantly increased in two main categories: those living with chronic illness and the frail elderly. Alongside this increase in numbers, their management has shifted out of hospitals into the community. This move is entirely justified: it’s more convenient, cheaper and often safer. However, unfortunately, the doctors have moved the other way. This reality sits alongside the fact that as a country - compared to the top 20 richest European nations - only Poland has fewer doctors per 1000 people than we do.[1]

 

  1. GPs have been encouraged, for many years, to use other staff and other methods (phone, email etc) to improve our efficiency to meet this increase in workload. But like most NHS change the reasons for this have been poorly explained to the population who in many cases, even if not clinically necessary, would prefer to see their GP face to face. And of course, so would we. A surgery full of face-to-face appointments would be bliss for a GP, but no one has told us what we should do when we are full. I remember when we could slip in 2 or 3 urgent patients as extras at the end of surgery, but this would now be 20 or 30.

 

  1. An insistence on choice inevitably means that access isn’t determined by clinical need, but by who gets up earliest to get the appointments. The rest have to wait, go to the pharmacist, or go to A+E. We should remember that, although it would be (genuinely) lovely to determine access by patient choice rather than clinical need, it necessarily makes primary care less efficient at dealing with that need, and we are already struggling due to the extra workload described above.

 

  1. Ironically, the work itself is more interesting than ever. The variety and challenge of dealing with an 88 year old taking numerous important medications who is falling at times and slightly confused, of a six month old with recurrent illness and worried parents, or a woman with abdominal pain in early pregnancy (and I could go on and on here) is simply fascinating. To my mind it remains the most interesting and rewarding branch of medicine by some distance. But there is simply too much now. We have failed to make the structural changes required to cope with the emerging needs and so, despite the attractiveness of the work itself, the job has become impossible. I find that half way through a morning I think it is the best job in the world, but by the end of an afternoon I’m spent, and simply trying to ensure that I don’t make a mistake.

 

  1. There are few practical steps that a GP can take to reduce this workload, except perhaps to attempt to shift work back to the hospital. In other words, to lower our threshold for admission and referral. So, it becomes easier to send an ambulance to a patient that has fallen, rather than visit. Regarding hospital outpatient referrals, we might see perhaps 40 patients and have 6 that we think might need a specialist opinion. With follow up, blood tests, scans etc we can reduce this to 2. But this all takes time - which we no longer have - so we refer all 6. These still look like good/ justifiably/ reasonable referrals at the hospital end (a referral management scheme would not filter them out) and after all we are still looking after 34 out of 40. But the demand on hospital outpatients triples.

 

  1. I find that my own referral practice is starting to change from those patients that I must refer to those patients that I may. The number of patients across the country that this difference describes is entirely unknown - these are the dogs who don’t bark”. Practicing this way is depressing, as it is a lesser service for the patient and I’m less of a doctor, but at least it’s safe. The effect on hospitals as more GPs do this will, I think, be huge (another depressing fact) but it’s the only way that I can see to keep my head above water. It really is simply an attempt to cope.

 

  1. To look at it another way, every other health system uses money (either the patients or the insurance companies’) to limit access to secondary care, but in this country we use a gatekeeper. In such a system, it is essential to look after them, but our gatekeepers are sinking.

 

  1. The two main statutory gatekeepers are primary care and social services (families and friends are the others), and both these services have come under increasing pressure over the last fifteen years. This pressure makes the community less able to keep people out of hospital (or indeed get them out when they are ready), overloading the hospital. But the NHS reaction to this extra pressure on secondary care is to put more resource into hospitals so that they can cope, rather than stabilise the gatekeepers - the equivalent of getting a bigger and bigger bucket as the hole in the roof gets larger

 

  1. Perhaps it would be useful to phrase it like this: it is not the hospital, but the community, that is too full.

 

  1. On occasion, we do recognise the need to stabilise the gatekeepers but we tend to move insufficient resource to do it. Social care might receive a funding boost, but usually not enough to tempt people into working as carers rather than in hospitality or supermarkets. We really would save a fortune if we used social care to hold people in the community and to get them out of hospital as soon as they are fit, to say nothing of the reduction in harm to our most vulnerable patients. But even if we see the need, we just don’t move enough money to make the difference. I’m convinced that if we found a gold mine in the desert, we would build a road three-quarters of the way there then wonder why we saw no benefit!

 

  1. So, to answer the question, I think that the increase in volume and complexity in workload in primary care, coupled (to a much lesser extent) to a drive to make practices less efficient by using choice rather than clinical need to determine access, has caused the GP threshold for referral and admission to fall. This has serious (currently unmeasured) consequences on the rest of the system, and will lead to further overcrowding in A+E, increased hospital admissions, and a worsening of the elective backlog. The difficulties in social care make this situation worse.

 

 

Partners or salaried? It’s the practice to PCN transition that counts

  1. I note the partner v salaried question with interest (I have been both), but actually I think that PCNs could work with either. A more important question is whether either of employment models creates a problem in the transition to a network service.

 

  1. The key here is about who is carrying the risk in this transition. At present it appears to be most difficult for the current GP partners that own their property - and were encouraged to do so by the government backed cost-rent scheme. It is an attractive scheme, but only if new GPs will come in to buy the property when partners retire. This is becoming rarer - fewer doctors are becoming GPs, and the idea of the same job for life is fairly foreign to many of this new generation.

 

  1. Current partners will therefore be concerned about a system that focusses entirely on networks - not only because they have had an inadequate explanation of the vision, but also because they are left holding the risk in their partnership property. Resistance to change is the inevitable consequence. (Ironically, the cost-rent scheme could be used to buy up practices and actually make money for the public purse in the same way that some property companies are now doing, but for some reason this isn’t being considered).

 

  1. The other great block is of course the lack of GPs (and other staff) as described above. But the only way to resolve this will be to create and communicate a long-term vision that recognises that although community/ family medicine is attractive, we require the change that networks make possible to make the job sustainable. Then doctors and other workers would be attracted to the service and we could start to expand the workforce.

 

Targets or Complexity

  1. Finally, a plea. Please could we understand that human systems, complex systems, are managed using principles, not targets. Targets work in those systems with negative feedback loops (like a thermostat in a central heating system or a pressure valve in a jet engine); they do not work in human systems with positive feedback loops, as the unintended consequences are detrimental. If you know you are going to be seen for your sore throat at A+E within 4 hours you go there. And then tell your friends to do the same. This positive feedback loop reinforces behaviour that is detrimental. The unintended (but entirely predictable) consequence is that there has been a big growth in minor illness presentation at A+E.

 

  1. If, however we were guided by principles - with a quality improvement approach - the unintended consequences would be advantageous. In this case the principle would be that patients at A+E are seen in the order of clinical urgency. The constant relegation of the less urgent to the back of the queue would mean that they wouldn’t come back - and would tell their friends not to do so - an unintended consequence that works to improve the system. I realise that this is fairly basic complexity theory, but it is an understanding that appears to be absent.

 

 

  1. Overall, whilst perhaps not answering all of the questions directly, I hope that this submission will contribute to some understanding around the difficulties for both patients and staff in primary care at present. I hope that it can be seen that I am still enthusiastic about family and community medicine, and that I think there is great potential in moving from the scale of individual practices to networks. There are significant barriers, but with vision, leadership and determination I do think that they can be overcome.

 

StJohn Livesey

 

 

Recommendation

The guidance for submission encourages us to submit recommendations. I ask that we start to speak to staff and patients about how difficult things are at present, and how we could develop the structural change to create a sustainable service for the future that, whilst treating illness, can also become a health service.

 

Dec 2021


[1] https://www.bma.org.uk/advice -and -support/nhs -delivery -and -workforce/workforce/medical -staffing -in -england -report