Written evidence submitted by Dr. Zishan Syed Member of GPC (FGP0162)

Main barriers to accessing general practice and how can these be tackled

Lack of availability of GP appointments is due to GPs being overwhelmed with inappropriate administrative duties from secondary care to conduct investigations and test results to GPs. The situation is no longer sustainable with the effect being multiplied by consultants in secondary care conducting remote clinics and refusing face-to-face consultations with patient and asking GPs to prescribe or arrange investigations as a result of those outpatient appointments. It is not sufficient for the Government to simply state that the contract of the NHS in hospital argues that secondary care should be doing this work. Consultants in secondary care workers are not doing they are contracted workforce.

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

It has a little realistic impact that will be of tangible benefit.

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

The impact of patients not being able to access general practice when they need to are primarily abusive behaviour which has taken the form of physical as well as verbal abuse of GPs and their staff. Increasingly patients are behaving irrationally, largely due to the lack of the Government addressing the irrational & unrealistic demands of healthcare that patients are exhibiting. Any analysis of the situation in general practice requires a proper analysis of all factors and that must include patient demands no matter how upsetting patients might find this. This has resulted from NHS 111 like expectations of patients being advised with language such as ‘CONTACT PRIMARY CARE SERVICE within 1 hour or 2 hours’ going unchallenged.

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

A named GP is essential only so far as the named GP is actually involved in overseeing the care of the patient. The Government has got used to providing patients with a nominal GP who in fact might not ever have seen the patient and is simply registered by name to the GP.

What are the main challenges facing general practice in the next 5 years?

The main challenges facing general practice will involve undoing the divisive damage from schemes such as the PCN DES. This appears to be a mechanism of undermining the GP partnership model. It is deeply unpopular as witnessed in repeated LMC conferences where significant motions arguing against the DES have been passed by conferences. There is repeated abuse of the primary care network ideology by NHS England which is finding its way into discussions that have questionable relevance to primary care. We frequently find other authorities referencing primary care networks who have limited understandings of how much pressure the DES is causing general practice.

The challenges of general practice have arisen due to the dreadful leadership exhibited by the Government and questionable negotiations between NHS England and the GPC. The younger generation of doctors has lost confidence in the profession as the arguments that are often rehearsed in the media and by the Government that we should do work ‘because it is a vocation’ do not work. The vocation argument does not pay the mortgage OR the bills. Younger generations of doctors live in a difficult financial climate coming with the background of tuition fees and significant debts and mortgages to repay. Understandably younger people are ambitious and they want to earn well. They see a profession that is increasingly strangled by the Government and GPs in particular often seem to be scapegoated by the Government and media for systemic failings. This is not an attractive advert for younger generations of clinicians. They want to earn and see that the profession often is targeted unjustly for earning too much when their peers continue to an considerably more for less work. Often these revelations come late in training and this means that younger GPs leave the profession altogether to do something else. Job security is essential. You cannot work in a job where every day you are constantly worried about patient making a vexatious complaint and effectively able to end your career with very little protections available for the Dr. The GMC continues to acquire more and more powers to investigate doctors and the defence that is offered for clinicians is often very questionable

Other challenges include the peculiar request by Government to target GPs who are earning over £150,000. This is quite clearly a vindictive measure and it is very peculiar that NHS England requested this as part of negotiation for the indemnity deal. This is a good demonstration of the poor attitude exhibited by NHS England against GPs alone. By implementing hostile and possibly discriminatory requirements such as disclosing earnings in this fashion, the Government and indeed the GPC risk losing entirely the confidence of the profession in the ability of NHS England and GPC to actually negotiate a decent fair contract. There is apprehension by the Government of accepting in a capitalist economy that GPs who work hard should earn well. If the declaration of earnings goes through in April, then we can expect further acts of violence and abuse of GPs as well as retirements.

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

Each team will have its own needs for survival, for example some may need more receptionists, with good training provided, some will need more secretarial and administrative staff, some will need new phone systems, all will need high quality IT systems including rapid IT support. IT is variable with little competition and locally EMIS was given the contract when it was booted out of Wales for poor performance. Appropriate competition is needed to ensure the best IT services are available.

What part should general practice play in the prevention agenda?

If Government is serious about the prevention agenda, then tackling the social determinants of ill-health is essential.

The development of a National Occupational Health Service would stop GPs from being intertwined all too frequently with employment disputes where patients would contact such a service instead of repeatedly troubling GPs with sickness certificate requests

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

Eliminate QOF.

Pension taxation issues for General Practitioners needs to be resolved

NHSE and Government to apologise for their poor relationship with GPs and to listen and implement what we are asking for.

Scrap the PCN DES. It is frankly a disaster and saps the morale of the profession.

Clear boundaries must exist between social care and medicine. GPs are not social workers, health visitors or dieticians. If these services need the input of a clinician, they will have to employ a clinician who deals with their queries.

There is a misunderstanding that all social issues must also be tackled by GPs. In this respect the concerns are prevention of serious deterioration in the social status of the patient. Whilst it is true that social issues are intertwined with health problems, GPs find that often work that should be conducted by social services and other community bodies is being effectively dumped on them. Good examples of this includes safeguarding enquiries where frequently poorly funded work is dumped on GPs with requests for very detailed reports in short periods of time. Often social workers expect GPs to conduct home visits inappropriately in order to 'cover themselves' if they have a concern regarding the social status of the patient. By blurring the boundaries between healthcare and social care, GPs are becoming involved inappropriately in matters that are outside medicine. The GP is a doctor and not a social worker.

GPs are not health visitors either, however we see a pattern of local services involved in the prevention agenda being cut down with services such as social services and health visitors often engaging with patients and providing GPs with a list of concerns rather than engaging with the problems as they are commissioned to do so. Again, the main dilemma seems to be that all of these professionals are concerned about whether they will be blamed for a failing and purposefully involve GPs in a scapegoating fashion. As a consequence, the end result is a request for the GP to do an assessment. Another example, is the significant burden on GPs from carers. Carers frequently contact GPs simply advising they have a concern again to transfer responsibility to the GP.

Fines for secondary care and private care practitioners not conducting their own investigations and referrals whenever they dump their contracted work onto GPs. Talking/communication with these services re their inappropriate workload dumping has failed.

Investigate secondary care Consultants who are spending considerable amounts of time outside NHS work, choosing to see patients face to face in the private sector and not in the NHS simply because they receive better payment in the Private sector.

Government needs to remove home visiting requirement for GPs as this is unsafe and one visit costs a GP the assessment of 6 patients at the Practice. This does not make sense. If you want a visiting model, then employ a separate service patients can contact for this.

Adopt a no fault compensation system. The cost of NHS compensation is 83 billion. A New Zealand style system is recommended. If this is not adopted expect a bill of 168 billion in ten years time and so forth.

Stop the ability of 111 to book directly into general practice. The service itself is unfit for purpose.

How can the current model of general practice be improved to make it more sustainable in the longterm? In particular

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

Simply put going all salaried is NOT what the profession wants.

The traditional partnership model is not dead, but it has not been adequately respected in negotiations with NHS England who have slowly chipped away at the GMS contract making it extremely unfavourable. Abilities to benefit from private practice were severely restricted in 2019. 111 is able to book directly into general practice despite itself being an unfit service. GP Partners are working extraordinarily hard to support practices and have to put their assets at risk which can all go if the practice fails. A fee for service not a block contract model is urgently required.

By removing clauses from the contract that are noxious to the welfare of GP Partners, these problems can be averted. Restrictions to private practice should be removed as well and there needs to be a fee for service model adopted immediately. This latter point is critical as it is inconceivable in a capitalist economy that £93.46 is paid for each patient for an infinite number of consultations with an all-you-can-eat approach to work. The more patients you see, the more you should get paid. It is not Partnership that is failing but it is simply the fact that NHS England has a vision of forcing the GP Partnership model to fail and replacing it with an all-salaried service where it intends to have a limited number of clinicians overseeing allied health professionals and GPs accepting the liabilities and risks when things go wrong. This is unattractive for recruiting future GPs.

As already mentioned, the primary care network was perceived by GPs in conference as a Trojan horse that is destabilising general practice. It has also contributed to a lot of problems with the vaccination programme where some practices simply by virtue of the geography have been unable to participate in giving Covid vaccinations resulting in them experiencing considerable abuse. The DES is deeply unpopular with the profession and costing a lot of morale. It would be better to focus on the GMS contract.

Why during the pandemic will the Government not permit GPs to individually procure vaccines and administer them to patients? Patients are being turned away from surgeries when they want to be vaccinated? The fixation of forcing this through the PCN DES is costing the nation lives!

In respect of this I have organised a petition regarding this matter and encourage the Government to engage with GPs.

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

The present GMS contract is flawed and requires replacement.

The present system is flawed and a fee for service model remains essential.

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

Administrative work has increased significantly due to the PCN DES and there are concerns about significant financial and legal liabilities.

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?

General Practitioners ability to work in effective partnership with other professions is constrained by those professionals not working cooperatively with GPs and divesting their clinical responsibilities onto GPs by effectively using them as community house officers to do their commissioned work. Unless there is a respect of contractual boundaries, this abuse of GP will continue and ultimately will lead to a healthcare crisis as professionals will leave General Practice altogether.

Dec 2021