Written evidence submitted by Dr Jon Tuppen (FGP0168)

Sirs,

I write this as a recently retired GP principle, aged 60, having worked exclusively for the NHS for 37 years in senior roles. I refer you to my email to the chair (14.10.21 11:32 replied 9.12.21).

The NHS must solve recruitment and retention issues and openly calculate REAL staffing need. All other issues are secondary to this.

The NHS must solve the conundrum of how the perception of General Practice has changed so much. In 1989 when I became a partner it was an exciting stimulating rewarding career with 60-100 applicants per advert. The job held many opportunities. Compare this to the current state of relentless, bureaucratic driven pressure where clinical need is over-ridden by superficial “wants”.  Recruitment and retention figures are abysmal – and this I have predicted and communicated to all levels for the past 20+ years. Morale is at ground zero, with survival only on Maslow’s hierarchy.

I will try and analyse the reasons, before offering suggestions.

  1. Political short-termism
  2. General Practice was established for office hours with care for emergencies only beyond this. Over the last 15 years there have been relentless directives pushing access way beyond this, but without proper business planning, workforce analysis and commissioning. This has stretched the human resource thinner and thinner causing exhaustion and stress. Meanwhile, the public have been led to believe that access is now near 24/7, even to the point of adverts telling people to book appointments over Christmas bank holidays.
  3. Honesty about critical issues and support of pragmatic surgery level solutions is absent, whilst bureaucratic flogging dressed up as safety by CQC, NHSE etc  is commissioned and supported. This misses the critical point that the safety of the individual is far more at risk by system failure and fatigue.
  4. The political default to perceived lack of performance / productivity is to reorganise far too regularly resulting in bloated management and confusion/obfuscation masking reality from staff and public – perhaps even intentionally.
  5. Malignant NHS management culture
  6. The norm is blame, the reaction often saying one thing but doing the other. Endless enquiries have proved this. Fear is the common denominator. At senior level there is fundamentally kowtowing  to political masters rather than support of a distressed system and recognition of the impact on patient safety.
  7. 2 examples both where central “masters” chose to confront rather than listen to concerns.
  8. Take the 98% vote of 76.2 % turnout of junior doctors in 2016 and subsequent strike.- this had little to do pay per se, rather much more to do with the culture of the NHS managers and imposition of nonsensical process which threatened patient and workforce safety.
  9. The current BMA actions in reaction to the plain stupid rescue package” of money that can buy nothing from empty shelves, when demand management and the start of a conversation about consumer use  is needed in the short to medium term.
  10. A domestic abuse project in Duluth MN USA came up with a wheel to show how power and control is exerted on (usually) the woman in an abusive relationship. It is frightening how few words need to be changed to alter this into the wheel of control and power wielded by NHS England and similar.  Is this a sensible way to treat the workforce?

 

  1. http://lutheransettlement.org/wp-content/uploads/2013/08/ViolenceControlWheel.gif
  2. Lack of Trust level management for Primary Care
  3. All providers other than Primary Care have large corporate management  bodies to look after their interests and negotiate fresh resource. Primary Care was set up as individual practices and has never moved beyond cottage industry corporacy. In the days of PCGs and before the provider – commissioner split of PCTs there was some attempt and success but any advance was lost once PCTs became commissioners.
  4. As a result, no-one “bats” for primary care at the same level as other providers and this is completely reflected in the woeful predictable workforce figures and declining share of NHS budget in Primary Care. Various recovery plans such as the 5 Year Forward View or the NHS Long term plan have missed primary care targets massively . True recovery can only happen with both resource and a powerful corporate advocate. PCNs are NOT set up or resourced as such, and are too small to compete equally with secondary care Trusts. GPC/LMCs are trade union bodies.
  5. The same deficiency has probably meant that earlier warning of the workforce crisis has been missed. Primary care are not included in system workforce opinion surveys.
  6. Lack of workforce planning
  7. It has been known for 20 years that there was going to be a bulge of retiring GPs. Even to stand still workforce planning was needed. Add in the ever increasing complexity of medicine, population growth , attempts to expand access, Increased consultation rates at all age groups and increased expectations and it is clear that workforce planning has been wholly inadequate. Further add in declining retention and you reach the current crisis. Many of us have been shouting this for years. NHSE has chosen to ignore us.
  8. The lack of openness and accountability of managers is a deficiency. Managemnet ownership of this crisis is needed
  9. The recent loss of a parliamentary vote on an independent body for workforce planning is lamentable. I would urge the Scrutiny committee to maintain pressure for this entity.
  10. FTE is now a meaningless measure
  11. Issues

21.1.                      The reduction in workforce numbers both crudely and especially linked to population numbers ,

21.2.                      the swap to very largely a female GP workforce,

21.3.                      expanded office hours for General Practice,

21.4.                      increased administration and bureaucracy and

21.5.                       

21.6.                      increasingly portfolio careers has stretched the work covered by all primary HCPs enormously.

21.7.                      The “FTE” lacks any linkage with a true measurable unit of time. Meanwhile NHSE and workforce audits have declared that 1 FTE = 38 hours/ week .

  1. There has been enormous recent hostility by media and politicians to the part-time nature of GPs, without any acknowledgement that most GPS work the equivalent 50+ hours per week. Instead of persisting with attempts to cover up the workforce crisis a simple explanation and recognition would have improved morale and allowed genuine workforce need for planning.
  2. Lack of System ownership for changes in the style of General Practice
  3. Over the last 20 years General Practice has moved from a “personal doctor” model with continuity and responsibility of care to a fragmented and increasingly disorganised hotchpotch of professionals who frequently actively disown responsibility. This has been a strategic course set by NHSE who have hoped shared electronic records would suffice and have evidenced the superficial responses in surveys saying that speed rather than who is most important. This fails as soon as serious illness hits.
  4. As patient numbers have escalated from c. 1800 per GP to 3000 the old model couldn’t work so patients were no longer allocated to a doctor list but to a practice list and now a PCN. Accountability and responsibility plummets.
  5. NHSE / political insistence of stretching access without manpower resource to make political headlines has simply exacerbated the situation after a short illusionary period. This has fuelled so called solutions such as our local GP+ - ( set up using Prime Minister’s Challenge Fund. Suffolk GP+ provides extra doctors appointments in the evenings, at weekends and Bank Holidays). The cost of setting up new services is large compared with the cost of traditional general practice. Staff working for these services have better pay, length of appointments and no admin. They refer and order tests but all responsibility falls on the further depleted staff back at the real surgery. This expensive short-term fix further fragments care and further destroys efficiency. It poaches locums and staff from the core service.
  6. I am absolutely sure that efficiency in health care comes from teamwork. A well functioning extended primary care team who know ( and grow) each other, with knowledge of the patient should be central. Corridor chats save hours. This model needs time to develop the team and to bond. It improves care outcomes and staff morale.
  7. Teamwork extends to referrals into secondary care sectors. Knowing the specialist improves communication and care. Instead we have false administrative barriers set up as referral centres who refuse referral because tick boxes have not been completed or the provider wants primary care to do work which is beyond GMS, not funded and sometimes beyond a comfortable level of competence. These nameless centres and inability to make bespoke referrals to individual specialists does not use each others skills and gives enormous voids for patients to fall between.  
  8. I fully support a very multi-disciplinary team
  9. However non-medical staff want to work within set perimeters and are frightened of extending roles by regulators and registers. They want to refer to doctors for support. This is logical and necessary but can only perform a fraction to assist doctors with workload. To be effective considerable time for mutual support and development is needed. Providing this from a shrinking number of partners or committed GPs needs recognition.
  10. Patient expectation and demand drivers
  11. Over the past 30 years average patient contacts per year have risen from 3.2 to 7.5. This is not purely LTC and complexities. It is across all age ranges.
  12. The balance between helping people access healthcare v demand management is difficult. However, many contacts in primary care could, and in my view should, be managed at self-help level before entry into higher tiers. As the mismatch between increased demand and reduced senior professional workforce widens, unfortunately tighter demand management is necessary. The situation has no short to medium term solution. What does have to happen is honesty from the system and politicians to start the process of readjusting expectation, total support for GPs to be able to say No to unneeded demand and support to the workforce when pressure of work will inevitably increase errors through fatigue and stress. 

 

  1. The whole system must be consistent in the message to the public. 111 and regulators must be realistic, and this needs them to adjust higher their tolerance of risk. My suggestion would be to utilise the very good and very usable “when to contact ….” information on NHS choices under a lot of everyday conditions. Application of these guidelines as criteria for access would be possible with HCP discretion.

 

  1. Predictability
  2. None of the current situation is unexpected to me. - see 
  3. BMJ. 1996 Jun 1;312(7043):1422.The nature of general practice. Service is abused because it is perceived as being free. Tuppen J.
  4. However, particularly with the culture of NHS management (Dido Harding, NHS Improvement: “I’m shocked at the lack of basic people management skills in the NHS” BMJ 2018; 361 doi: https://doi.org/10.1136/bmj.k2657 (Published 18 June 2018NHS leaders self-select those they listen too to get the answer they want.
  5. The NHS needs to listen more  widely.
  6. Regulators and appraisal/accreditation.
  7. Regulators currently act in a high handed critical manner. In reality a lot of the clinical assessors have left the coal face of patient contact as they struggled to cope .Regulators offer far more blame, and decline to help or advise. The interaction is fearful and dysfunctional.
  8. Careful use of available outcome data, death rates, prescribing data, primary care IT system data and the like could well be used to focus critical scrutiny at sites of need.
  9. Other interaction should be much more like utilising an organisational development consultant.
  10. Appraisal should be an early warning device for staff fatigue, early retirement etc and should inform the commissioning cycle for primary care
  11. Adequate time for relevant mandatory training and ongoing PDP with assessment needs to be allowed for in a new calculation of staff numbers.
  12. This should be financed by the NHS, not left to the individual.

Your questions

47)  Education/ teambuilding  needs to be fun not a chore. What are the main barriers to accessing general practice and how can these be tackled?

a)      Staffing levels and morale

b)      Common criteria for the level of need to access GP not purely patient led “wants”

c)       Properly re-commissioned and resourced model dependent on true “needs analysis” to fit desired model

d)      15 years of stability to stabilise and mature the system

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

a)      Very little as there is so little congruence on NHSE v surgery level assessment of the issues

b)      Lack of mutual understanding

c)       The NHS must pay equal attention to  staff welfare in primary care as to patient need.  Without the former the later Cannot be delivered.

d)      The latest rescue plan based on money demonstrates the gap and was an insulting own-goal by NHSE

e)      Demand management must be a short to medium term solution.

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

a)      The fragmentation of services confuses patients.

b)      The traditional model of primary care worked as people knew where to go for help

c)       If there is a resourced common service efficiency improves and choice naturally follows.

d)      At present different parts eg 111 cf practices work on different models.

50)  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)      Depart from named GPs to consistent known teams of people patients can learn to trust and respect

b)      GPs should be directors of care with autonomy to work with a team of other HCPs

c)       Continuity of care is in everyones interest but reversing the direction of travel and combining disparate resource will take years of carefully directed work.

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

a)      Survival

b)      Staff recruitment / retention (staff retention attempts are a joke- for example I would willingly dip in and out should I be permitted to triage and managwe demand and use 37 years of experience.  Similarly to how older drivers have reduced accidents, experienced doctors could be offered re-accreditation lite for 5 years.

c)       Staff morale

d)      The NHS is confused by Independent Contractor status to the point that after 37 years NOONE outside my practice has thanked me for my years of commitment!

e)      I advise accepting there is no quick fix, spend time building mutual rapport and respect, performing a modernised and updated true (ie not based on FTE) needs assessment of workforce, estate, support etc.then agreeing an updated contractual agreement.

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

a)      The biggest issue remains inverse care law .

b)      Incentives to encourage workforce to areas of need.

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

a)      Some areas such as mammography, FIT testing in screening can be outside GP. However, good prevention needs a holistic assessment and explanation of individual risk. Primary care should do this

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

a)      Have cycles of QOF with years without. Perhaps 3 years on, 3 years off with those years being focused on continuity of care, relationship building across the broader service (ICS/PCN development)

b)      Autonomy and the fun of practice has completely eroded. Fear and bullying replaces it. Trust at surgery level is needed with air cover by the system . There is no time for anything other than the relentless patient contact/ admin

c)       The situation has no short to medium term solution. What does have to happen is  honesty from the system and leaders like you to start the process of readjusting expectation, total support for GPs to be able to say No to unneeded demand and support to the workforce when pressure of work will inevitably increase errors through fatigue and stress. 

d)      Public NHSE/political acceptance that current working conditions and workload within primary care has reached the point where safety of both patient and professional health is seriously compromised to the point where mistakes and erosion of quality of provision are inevitable. As such the system should own vicarious responsibility

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

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

a)      This model has demonstrated that it is capable of very cost effective nimble care over decades. The current decline in partner numbers is largely related to workforce issues. Salaried GPs work to contracted hours. Partners pick up responsibility for all gaps. As gaps increase attractiveness plummets. I would advise modernisation of the model – underwriting of estate, staffing costs etc by NHSE would make a huge difference Local demand management needs embracing by NHSE rather than fighting. Until workforce / patient numbers have improved to mutually negotiated safe levels local autonomy is needed.

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

a)      No, I refer you to previous comments on the need for a fresh start with modernised new negotiated contract based on a new needs assessment.

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

a)      No and it will not until time and true resource and development is allocated. The time scale should be a decade given available workforce.

b)      Local subsidiarity in decision making is needed at ICS level to allow PCNs to assess need and to decide where to deploy resource. Others will scream “workforce planning”. I scream we are in this mess as a result of the skills in plnning!

59)  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?

a)      See 27, 29 and 30, and 50 a,b,c

December 2021