Written evidence submitted by Dr Thomas Holdsworth (FGP0167)

Dr Thomas Holdsworth

GP and Primary Care Network Clinical Director

 

Executive Summary

 

Background

  1. I trained as a medical student in Edinburgh between 1998 – 2004,  completed my GP training in Sheffield in 2010 and then worked in the same practice for ten years.   I worked first as a salaried GP, then as a partner before I resigned from my partnership in December 2020.   I have been working as Primary Care Network (PCN) clinical director since the PCN contract started in July 2019, and I was working for two years prior to that as the Neighbourhood clinical lead for a local model which based on the primary care home model. 

 

 

 

  1. I have experienced life as a salaried GP and a GP partner and I wrote in September 2021 about the problems in primary care and the hopelessness the profession is struggling with in The Guardian .   My work over the last ten years has given me a perspective from the coal face at individual practice level, to the work that happens at local network level and then a city wide system level perspective.  At the age of 42 I am old enough to have significant understanding of the challenges of General Practice but I am young enough to have at least twenty years more working life in the NHS.  I am deeply invested in the need for change in General Practice for the good of the UK population as well as for my own needs as professional and as a potential patient at some point in the future.  For these reasons I have felt compelled to submit evidence to the committee.

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

Workforce

  1. The biggest challenge for General Practice is the workforce.   In 2015 the NHS Five Year Forward View promised a better health service and recognised that this would need 5,000 more GPs by 2020. However, by March 2021 there were 1,307 fewer GPs than in 2015. There is significant regional variation in GP numbers as per Nuffield Trust data in February, but even in Sheffield where the numbers of GPs are higher than in some regions, I know from my own experience and from colleagues across the city that the difficulty of recruiting GPs, especially those who want partnership, is a great problem for practices.  

 

  1. The workforce challenge extends across many of staff groups in practice.  Practice nurses have been a key part of the practice team for years and the practice cannot function properly without them.  However, nurses will often earn less working in General Practice than in other areas of the NHS, with the usual starting salary in a hospital under agenda for change band 5 being £13.15 while a practice nurse who may be extremely experienced with considerable responsibility being paid as little as £10.30 per hour.  Like GPs nursing staff are extremely difficult to recruit. 

 

  1. Ability to retain reception staff is becoming a real and immediate threat to practices managing to keep their doors open.   General Practice has been ‘under siege’ for months now with too little capacity to meet patient demand and a campaign by sectors of the press, supported by the government, that has inflamed the tensions between practices and their patients.   Reception staff bear the brunt of these frustrations while doing an often complex job trying to navigate patients who are feeling stressed and anxious, into an appropriate appointment in a system that lacks enough capacity.  The average UK pay for GP receptionists is around £9 per hour, which is the same or less than Tesco pays for a shop assistant.  It is unsurprising that many receptionists are choosing to find somewhere else to work. 

 

 

  1. Additional roles have been brought in through the PCN contract to try and help with staffing issues.  Unfortunately trained staff like pharmacists are hard to recruit with local PCNs often ending up trying to outbid each other for the small pool of staff that are available.  New roles are often not familiar with working in primary care and so need lots of training and support which is difficult given the already overburdened General Practice workforce.  The mechanisms of bringing these staff in to the network such as engaging them in employment, sharing them between practices and the newly added training roadmap are extremely complex and bureaucratic.  Overall this means that while they are a useful future investment, it is very difficult for them to add a great deal of support to core practice work in the short term.   

Estates

  1. The General Practice estate is struggling with present demands and is not fit for the future .   New roles are being brought into primary care through the network contract however we often have nowhere to put them.  There is a constant struggle to accommodate new staff to meet demand in almost all practices in the network where I work and across Sheffield.  There is no clear direction from central government or NHSE on what the solution to this will be leaving great uncertainty in networks and practices which is hampering the changes that need to happen.

 

  1. The other great challenge with estates is the partnership model that requires new partners to ‘buy in’ to the business so that a property-owning GP can retire.   The hopelessness faced by the profession means that newly qualified GPs are not keen to take up partnerships.   Even with the payment of notional rent provided by the government, owning part of a property in a partnership is a long-term investment, and to make a long-term investment you need to see a hopeful future and this is not where we are now.   With GPs unwilling to ‘buy in’ it can leave partners trapped and unable to retire, practices with retired partners still owning the building as new partners won’t buy them out and domino effects of partners leaving so that they are not left as the ‘last man standing’ with all the practice liability.  I have seen all these scenarios in my local area in Sheffield. 

Demand for care

  1. General Practice has been underinvested in and is now not able to cope with patient demand.  The proportion of money being spent in general practice has fallen, from around 9.6% of the overall NHS budget in 2005/6 to 8.1% in 2017 despite more care rightly moving out to primary care and General Practice.  The whole NHS is struggling despite recent new money, because of the underinvestment during ten years of austerity which has left it in a terrible state.   This means that other organisations struggle to help with the problems in General Practice and also leave General Practice to pick up the care they cannot provide, which makes things worse. 

 

 

 

  1. Pressure in social care, which has not been fixed with recent spending pledges, aggravates demand on general practice.  At the same time instead of finally getting to grips with the preventative work that is needed so that General Practice is not overwhelmed investment in communities and public health has also fallen leaving us with a perfect storm of overwhelming demand and not enough workforce. 

 

  1. Recommendations:  We need a proper workforce plan for the whole NHS including General Practice, investment in low paid practice staff to increase their wages, investment in estates for the future, a planned solution to the problems around property ownership, a planned approach to demand in General Practice that looks at all of the drivers to increased demand. 

 

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

  1. There is no ‘quick fix’ for General Practice but there are some things that could be done.  The bitter row during the autumn over face to face appointments that was started in the tabloid media and supported by the government was extremely difficult for many GPs.  Having been through the hardest challenges of their careers, instead of being praised as hard-working diligent professionals with a strong sense of vocation, they were vilified as lazy fat cats.  This almost certainly increased the strain between patients and practices and led at times to acts of violence.   Government, the department of health and NHSE need to start to demonstrate authentic support for practices and their staff.

 

  1. There should be some focus on ‘quick wins’ with open acknowledgment that this will not solve the problem.  This could include changes to allow patients to self-certify for longer before needing a doctors note, some recurrent increase in core funding to allow increase in wages for low paid staff such as reception, relaxing of some low value targets in QOF permanently, moving low value work away from practices, relaxation of the heavy red tape involved in the GP network contract, easing of over-regulation by NHSE of the vaccine programme, addressing pensions issue and revalidation as well as any other barriers to GPs staying on in the profession rather than retiring.

 

 

  1. Thirdly and most importantly there needs to be a hopeful vision for the future described which will attract more doctors to join the profession and stop so many from leaving.  This will mean that leaders from the BMA, Local Medical Committees and RCGP will need to show humility and an openness to change and the department of health and NHSE will need to show empathy and understanding with the profession who have served their patients often for decades.  Only with compassionate leadership on both sides can we create a brighter future.   No one is doing this at present which leaves patients and the grass roots of the profession stuck in the wilderness.  

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

  1. The traditional partnership will not be fit for the future of General Practice.   It does not allow the investment into primary care that is needed, it is no longer sustainable as GPs are less likely to want to join as a partner and it makes it more difficult for General Practice to work in a truly integrated way with the rest of the system.  In an increasingly complex health care system, significant financial risk being held by private individuals seems more and more unsuitable.   The issue of individual risk can also drive variation in services as partners balance income vs provision, as well unfairness in reward such as those is wealthier areas gaining from property value increase while those in less well-off areas might find themselves in debt due to negative equity in their building. 

 

  1. The main challenge however, is to remember that the model has served the country well for a long time with a great deal of discretional effort by GP partners.  To try to move overnight to a new model would be disastrous.  An objective and transparent debate needs to be facilitated so that all sides of the problem can be looked at and consensus reached on a reasonable way forward.  The future is likely to be integrated organisations looking after populations of 30-50000 patients and a traditional partnership is unlikely to be able to do that.  The benefits of this new vision have to be explained and a manageable transition described.   The General Practice leadership will make things more difficult if they stop this debate from happening.   The government will make things worse, and more GPs will leave, if they try and transition from the partnership model too quickly or in a way that exposes current partners to increased financial risk. 

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

  1. The GP networks were established in 2019 and have spent most of there current lifetime under the crisis conditions of the Covid19 pandemic.  Where they work well such as in Sheffield, they have facilitated the administration of the vast bulk of the Covid vaccinations with Sheffield leading other core cities.   To try and judge PCNs now on the criteria set out in the question will miss the point, especially if any judgements made at this moment are used to abandon the policy of PCNs. 

 

  1. Primary care networks have started to improve delivery of proactive personalised care.  In my network we have had very successful evaluation of an occupational therapist proactively reaching out to patients who are housebound and frail and providing holistic care.   We have been working with a paramedic for over a year with him delivering home visits across six practices.  We have been working across practice IT systems for back-office functions with the covid vaccine invites process.

 

  1. However there is still a long way to go to realise the ambitions of integrated care and improved population health.  We need to not judge emerging PCNs too quickly and we need to align the rest of the system to support them.  We also need to recognise that the PCN contract is a poor way of giving significant support to individual practices and that networks need individual practices as their foundation.  

 

  1. Recommendations:  We need longer to judge the success of the PCN contract and we need to see it as part of a journey towards a future model of care based on local populations.  We need to support individual practices in a better way than relying on the PCN contract.  We need to reduce the restrictions and red tape in the contract, give networks higher levels of trust and allow them to get on more quickly with the work. 

What part should general practice play in the prevention agenda? 

  1. General Practice absolutely must play its part in the prevention agenda, most likely through primary care networks.   It is recognised that all countries with high functioning health care systems have strong primary care and the WHO states that one of the three key aspects of primary care is: addressing the broader determinants of health through multisectoral policy and action.  It is also clear that only by working further upstream and tackling the causes of ill health can we hope to manage the increasing demands on our health services.  This need to work upstream (‘left shift’) was recognised twenty years ago by the Wanless review but we have continued to fail to do what we need to do.  We must take the opportunity now that PCNs represent. 

 

  1. General Practice will need, through PCNs, to move in to the ‘no mans land’ between statutory services and peoples every day lives.  Working in this space with patients and the voluntary sector they will need to develop activated communities that have increased control over their own health, their own lives and the services that they receive.   General Practice and Primary Care Networks will need to advocate powerfully with their patients for real change around the social determinants of health, dealing with what Sir Michael Marmot described as ‘The causes of the causes’.  Proper integration with voluntary sector and other statutory services such as social care will be needed to take action to meet the needs of underserved populations.   Population level data across PCNs will need to be used for case finding prevention work and risk stratification to facilitate new and improved models of care.  

 

 

  1. General Practice cannot afford not to be part of the prevention agenda.  However, neither can any of the health providers, social care providers or local authority in any local area.  The challenge will be greater, if anything, for hospital providers to see that it is paramount for them to get involved, in partnership with the other organisations described above, in this work.  We must start now and do this work with both impatience and with patience.  We need impatience as there is no time to lose and patience as the work will take time.

December 2021