Written evidence submitted by Dr Jane Harvey (FGP0169)

 

Dr Jane Harvey MB ChB MSRH MRCGP

General Practitioner Principal and Partner - Dukinfield Medical Practice, Tameside, Greater Manchester

Primary Care Medical Educator - Tameside and Glossop GP Trainee Scheme

Clinical Director Hyde Primary Care Network

 

I have been a GP for 19 years. Before that I worked in Obstetrics and Gynaecology and Community Gynaecology. I have been qualified as a doctor for 30 years.

 

This is my personal opinion and my personal evidence from the perspective of having been a GP Partner for the last 17 years, Clinical Director of Hyde Primary Care Network for the last two years, and Hyde Neighbourhood Clinical Director from 2017 to 2020. I would like to give a brief summary of the reasons for the present General Practice crisis, answers to the specific questions posed, and my evidence of the positive contribution our Primary Care Network has made in Hyde.

 

Before we start – my analysis and summary of the current situation.

 

I am sure many offers of evidence will state the following facts that are pertinent to the recent anxiety over the purpose and performance of General Practice: our population has grown and is proportionally older and frailer; more complex clinical interventions are possible and their implementation is delegated to us in the community; the number of GPs and ability of GPs to work full time has decreased, investment in other primary care staff and structures has not kept pace with the increase in secondary care funding, and the huge increase in the number of Specialist Consultants in hospitals. There is still a belief that good health comes from shiny buildings and high-tech interventions, rather than investment in the wellness of communities and preventative health – where General Practice is naturally situated.

 

General Practice is therefore full. Every day all our appointments could be filled many times over. Access to primary care is thereby difficult. Especially as we have now opened the floodgates for everyone who has access to the internet to request an appointment within seconds of feeling things are not right. This is part of the instant access world which we all take to be normal. There are problems where speed of access is important, but for most patients, and especially for our most vulnerable, continuity with a trusted family GP is the most effective and the most valued. There will always be a tension between continuity and speed of access, and most practices put blood, sweat and tears into getting that right. In my practice a senior clinician vets every health query within hours, making sure the right person deals with the problem in the right time frame, either instantly by phone themselves, promptly by an allied health professional, later by the patient’s favoured clinician, or with NHS advice and web resources texted straight to them.

 

Obviously during the pandemic, we also had to make sure that we did not spread Covid in busy waiting rooms, traditionally full of the most vulnerable sitting next to those who are coughing.

 

Then a year ago we were asked to also be part of the national vaccination programme that needed to be rolled out at speed. Our group of 8 practices – Hyde Primary Care Network – worked tirelessly doing many extra hours under extreme intellectual and physical stress giving the Covid vaccines, delivering them to the elderly who had been shut away for a year in fear of their lives. We worked in downpours and snow at our drive-through Local Vaccine Centre in Hyde, created and staffed by myself and colleagues, for weeks on end. We now have a trusted team so don’t need to borrow many staff from Primary Care and we have delivered over 90 000 vaccines (70% of the total vaccines had by our patients) and counting. Every week the vaccination programme has given us unprecedented and often extreme challenges but we have ridden these out and are proud to have delivered a service which, all agree, has been the most effective national driver in reducing Covid transmission, hospitalisations and deaths.

 

All the above seem obvious to us in Primary Care. None of these details have been presented by the right-wing press or politicians who have been determined to publicly humiliate us. Instead they should have been defending our dedication, our managing of 90% of the consultations in the NHS throughout the pandemic, and our central involvement in the fight against the Covid by delivering the majority of the vaccines.

 

Now to the specific questions.

 

I would say that the main barrier to accessing general practice is the lack of personnel due to the lack of investment in workforce and estates. In addition, access has been made easier by the encouragement of us to provide online access.

 

Stop-start support for General Practice from the Government and NHSE with money (for example winter funding) is problematic as it encourages the premiums that locum GPs can extort, with most patients ask to see their usual GP immediately after seeing a locum anyway. Thereby disincentivising the partnership model.

 

(Support for general practice via the PCNs I completely support, and I would like to tell you about the activity of our PCN in Hyde later).

 

The impact of a young person not receiving the face to face appointment they would prefer but instead receiving a text about which creams to consult the pharmacist about for their sunburned damaged dry skin can result in a complaint taking up a lot of Primary Care time or can result in a rant about how they have rights to see a GP for whatever they deem appropriate on social media. (As has happened to our practice recently).

 

The impact of a too high proportion of our appointments being taken by younger people who can use the internet well at any time of day or night, disproportionately disadvantages those elderly or with learning disabilities who cannot access us when they are ill and need to see us. It’s very difficult to address and redress this digital advantage to those most use to demanding their entitlement.

 

As I have said above, the role of a named/favoured GP is central to our ethos in family medicine and has been proved over and over again to be the highly preferred method of patients as well as being the most efficient and effective.

 

The main challenges facing General Practice in the next five years is that the current job of a GP partner has become impossible. I go to work at 7am on a Monday morning in order to start the triaging of the requests for appointments that have come in over the weekend. There will be at least 70 waiting for us. Each GP will then do at least 8 hours of direct patient contact by phone, or video, or face to face. We will each have at least 4 hours of administration (all the complex blood tests, letters, queries, prescriptions that need an urgent clinical decision) as well. It equates to at least one complex clinical decision every few minutes, for hours and hours on end. So, a GP day, before eating, or passing water, or answering emails or considering education is at least 12 hours long. Its in the 13th hour where mistakes are made. Therefore, in order to be able to survive each working week, to continue to make safe clinical decisions, and not waste the decades of training to achieve this professional role, most GPs must limit the number of days they work as a frontline doctor. I know very few individual GPs who can work five 13-hour long days under that sort of pressure. The preferred timetable for most newly qualified GPs is two 13-hour days if also a carer, and four 13-hour days if the main breadwinner. Most four day a week GPs are now working whilst burnt out. I have heard many times - “if I was my patient, I would sign myself off sick at this point!” Add to this our recent public humiliation, which in some areas resulted in physical attacks on GPs, it is clear why it is definitely not easy to encourage the best of the newly qualified doctors into our branch of the profession. Addressing the above unmanageable workload and giving public support for our efforts would improve morale.

 

I don’t know much about regional variation in General Practice in England. I work in a post-industrial town on the edge of Manchester and the health challenges are numerous. The healthy life expectancy of our population is in the mid 50s – hence my strong views on the prevention agenda.

 

I believe we are central to the prevention agenda for several reasons, one being due to the partnership model in general practice. My experience is that once I bought into a partnership, I also professionally and emotionally bought into that community. All the strengths of the trusted, familiar, family doctor mentioned above are a positive for both parties. Most GPs also go into the profession due to a paramount interest in the overall health of an individual and the health of their family and community, rather than a fascination with the details of a particular disease.

 

I have discussed above that burnout could be reduced by having enough workforce to do the job, and a genuine public discussion around unrealistic expectations, encouragement of self-care and respect for health professionals and services. This discussion should be supported by the right-wing press and the politicians, with GPs not just scapegoated to take attention away from the way the Pandemic has been handled.

 

I believe that the development of the Primary Care Networks is crucial to address recruitment challenges, reduce the administrative burden, encourage integrated care, and prioritise proactive, personalised, coordinated care. I would like to introduce you to Hyde PCN and demonstrate how we have tackled these challenges.

 

In Hyde we already had an ethos of working together as eight practices. We had won the BMJ Primary Care Team of the Year in 2016 for our innovative social prescribing project for the over 75s (funding curtailed). We had also spent time fighting to integrate with the wider structure that determined health outcomes through becoming an integrated system in Tameside and Glossop CCG when Greater Manchester Health and Social Care was devolved.

 

Everything that we have planned in our Hyde neighbourhood (which became Hyde PCN) has then coincidentally become part of the PCN contract. We started with a few committed GPs, a few committed managers and a Community Matron. I am not embarrassed to say we knew where to start tackling the most prominent problems. We started with the enhanced care in Care Homes, leading on to social prescribing, and now to preventative work through hypertension targets. We won the BMJ Primary Care Team of the Year award again in 2020 for our Care Home project. Our plan has been to spend the maximum amount of funding that we can, in order to support our community, our population and our practices. However, our general practices are still full, they are still on their knees. It is difficult to prove that they are only 110% full rather than 150% full. I have no idea how General Practice copes in areas where the PCNs are not as supportive.

 

Our Healthy Hyde Team now consists of over 30 employees, a Care Home team, a complex housebound proactive service, a home visiting reactive service, extra surgeries staffed by first contact musculoskeletal practitioners, physician associates, paramedics, mental health nurses, a learning disability nurse, hypertension-detector nurse associates and pharmacists. A team of care co-ordinators are also trained up as reserve receptionists and health care assistants. We have started using our drive through vaccine site as a long-term condition case finding and review site when we are not giving vaccines (with outdoor spirometry – currently very difficult to perform in surgery with the risk of droplet producing procedures). We have effective partnerships with the Voluntary Service Organisation, the Mental Health Trust, Social Services and the Local Hospital. Our greatest partnership is with our patients - we have Health Champions volunteering in our practices and we are co-producing community services for the elderly, those suffering with memory problems, for disengaged youth, struggling families and the homeless. We run a monthly Healthy Memory Café, a monthly Healthy Toddler Club, an allotment, a social prescribing team and a youth outreach team.

 

I would like to encourage this approach by all PCNs. General Practices need more investment too, more staff, an estates plan and genuine vociferous support from the leaders of the NHS and the Politicians. If General Practice falls over the whole NHS will fall over. These are desperate times.

 

December 2021