Written evidence submitted by H&F Partnership (FGP0174)

 

Response to Health Select Committee call for evidence – the future of primary care

https://committees.parliament.uk/call-for-evidence/632/

 

 

About us

We are a single partnership of 24 GPs (see header and footer), employing 150 staff, and with a registered list of 69,000 patients in the borough of Hammersmith & Fulham in London. More information available at www.hfpmedical.com

 

Our response

 

General Practice is the main gateway to the NHS for patients. The notion of a registered list enables patients to access care through a single local team and allows GP practices to support and manage long term conditions as well as deal with acute medical problems. GPs are the primary physicians in the NHS with a generalist training that is essential for an effective “first point of contact”. Secondary care provides the specialty expertise to complement the ongoing clinical relationship and holistic approach of GPs. Primary care adds value by managing clinical risk and uncertainty. Healthcare resources in the rest of the system are finite and so GP clinical investigation and referral needs to reflect this.

 

Access to primary care has multiple drivers. There are practical considerations such as the level of funding (which drives clinical capacity), and organisational capability (we believe that there are advantages to working at scale which is why our five surgeries merged before the Primary Care Network (“PCN”) programme was established). There are policy considerations such as the balance between what patients need and what they want, and what the scope of the NHS is and where the edges are. And there are communication and marketing factors which affect how, when, and to what extent, patients access NHS services.

 

The practical considerations are what mainly concern GP practices and we believe that the following components are key to optimising access, clinical quality, and efficiency:

  1. Working at scale. GP practices need to work at least at PCN level. By doing this, we have found that we can better manage our resourcing, enhance our recruitment and retention, and improve our resilience when issues occur. We were one of the first Covid Assessment Hubs to go live in NW London before Easter 2020, and we were a Wave 1 vaccination centre from December 2020. Working at scale enabled us to move very fast
  2. Better infrastructure support. GP practices deal with a myriad of administrative tasks. This includes clinical administration, navigating the IT systems and processes of secondary care, as well as responding to non-clinical administration requests from the local NHS, regulatory bodies, and NHS England. Additionally, GP practices deal with all issues relating to premises, supply chain, governance compliance, and telephone systems. As small organisations, this is a challenge to do effectively and efficiently. Accessing and funding HR advice, training and professional development for staff, and organisational development is also time consuming and challenging. Our merger received some financial support at the time which funded the five-way TUPE transfer and post-merger support in terms of pay and terms harmonisation. GP practices and PCNs need infrastructure support to implement their improvement plans.

 

  1. System integration. We are implementing a new clinical model which promotes integration with the rest of the NHS and social care system for four groups of patients whose needs often span the whole system and are complicated to manage: long term mental health, frailty, complex children and families, and patients with multiple long term medical conditions. Each of our surgeries has mini teams focused on these four areas and there is much work to be done building relationships with the people in all the other services around us: geriatrics in hospital, social services, community nurses, mental health services, voluntary and cultural networks. Improved coordination of planning and action across all the interfaces improves the overall care package, supports better outcomes, and reduces waste and duplication. GP practices are right in the middle of this integration work – we see the benefits when it works, and we see the chaos when it doesn’t. This integration must be effective both at a medical level as well as a social/wellbeing level. The generalist medical expertise of the GP needs to be backed up by the specialist expertise of the care of the elderly consultant or psychiatrist so that we can perform the core function of holding and managing clinical risk. At a social level, the largest long-term drivers of health and morbidity are non-medical. Social connection is critical. It improves mental wellbeing, provides purpose, encourages physical exercise, and provides group support between family and friends. Many NHS reports include case studies about the person who couldn’t pay their heating bill that ends up in hospital. No amount of medical care from the NHS can solve this.

 

Most patients, most of the time, see “the NHS” as being their GP practice, their local hospital (including A&E), and the ambulance service accessed via 999. Whilst patients also access 111 and the NHS digital assets via the national website and app, these tend to be secondary considerations at the point of care being needed. When patients can’t access general practice in the way that they want, when they want, they become frustrated, and they may try other access routes. Self help is not used as extensively as it could be and people’s thresholds beyond which they seek help vary enormously. Demand growth, across the NHS, probably outstrips population growth and changes in morbidity. Traditional concepts of health maintenance, like a family medicine cabinet, or “wait and see if it gets better”, have fallen by the wayside with a consequent increase in demand.

 

In relation to continuity of care (named GP), this adds a lot of value in some circumstances (for example, in the four complex cohorts described earlier), and it adds relatively little value in other circumstances. At an individual patient level, there may be times when a patient will benefit greatly from GP continuity, or vice versa, but then their situation changes.

 

 

Continuity is needed for both short term transactional issues and long-term continuity, but this is different to the ability to choose your clinician and also different to having a named GP for all care. The primary care workforce no longer works in a way that can provide this (60% are part-time, and 50% of the clinical team is non-GP) but the external drivers to increase same day capacity consumes resource and causes collateral limitations on our ability to provide continuity. This dichotomy is then further exacerbated by the overall resource deficit in primary care. Continuity is a clinical tool, and the ability to use it is being eroded as we are increasingly forced to concentrate more and more time on same day care and less on providing the follow up and continuity required following an assessment. The only way to manage this is at GP practice level. That allows for dynamic response to individual patient needs and workforce availability to enable sensible choices and prioritisation.

The main challenges facing general practice in the next 5 years can be split between strategic and operational.

 

Strategic

 

Operational

 

Our specific comments in relation to regional variation are because population composition and healthcare assets differ widely between localities, and this drives different patterns of behaviour and need. The dynamics in a West London locality are going to be very different to Cumbria. Healthcare utilisation in a system free at the point of service is affected by proximity and accessibility which means that the urgent care strategy (including primary care, A&E, and 111) will need to be localised. National funding formulas take account of age and disease burden, but do not take account of language. In multi-ethnic areas, the length of consultations is increased, even when a translator is present, but this is not factored into the funding.

Additionally, there is no factor in the funding to account for the support that some refugees/asylum seekers need who have complex medical needs, even at young ages, in combination with both the language barrier and, understandably, little knowledge about the difference between boundaries of care setting in the UK (primary versus secondary care, urgent versus planned care). Published evidence (here)suggests that deprivation is not effectively reflected in the Carr-Hill Formula.  There were indications that this was to be addressed in 2018 but it hasn’t been.  In the context of the evidence of how deprivation and COVID mortality are linked, the need for this is more prescient than ever.  We see similar issues in the lack of differential funding for residents in nursing homes (high medical need) versus residential homes (relatively low medical need).  The PCN contract at least recognised the increased cost of providing effective care to both of these settings but not the difference between them.

Preventive care is a core part of general practice, and it adds value. For example, we have been supported in NW London by specific funding for diabetes and pre-diabetes and before the pandemic there were demonstrable improvements in population clinical measures such as blood pressure control, blood sugar and blood cholesterol levels. Unfortunately, this has gone backwards somewhat in the last 18 months since the start of the pandemic. Long term conditions are a burden for individuals, for society, for the economy, and for the health service – around 80% of the whole NHS budget is spent on long term conditions and the consequences of poor maintenance. There is more that can be done, but the benefits are often long term and subtle, and so the conversations about improvement get squeezed out by the short-term priorities of waiting lists and budget balancing. Primary care is core to disease management and prevention but, understandably in the current circumstances, it is not a top priority across the NHS.

 

In relation to morale and burn out, we have the following observations:

 

 

For us, the partnership model remains strong. Since merging the five practices in 2017 and 2018, we have appointed nine new partners, eight of which were already working with us as salaried GPs. Six partners have retired or moved away. We are stronger as a group because of the diversity and resilience. A business where all the owners actively work in it week in week out is also going to be more agile – the partners get feedback from patients and staff every day, and they are intimately involved in clinical care, quality, and safety. The national “golden hello incentive has been helpful in our efforts to attract new partners.  However, the process for claiming the funding has been unnecessarily bureaucratic.

 

Payment mechanisms, funding, and contracting, overall are neutral in relation to quality of care, convenience, and access. Some aspects help, and some aspects hinder. A reduction in the overall bureaucratic burden would be welcome. PCNs are an opportunity to work differently, but ultimately it comes down to the people involved in each PCN. Organisational politics exist everywhere, but as a single partnership PCN we have sidestepped various operational complexities associated with working at scale – employment, deployment, which services each practice delivers, financial stability, and shared leadership.

 

Our own efforts to work collaboratively across the system are at a very early stage. The NHS is typically dominated at local level by the large acute, community, and mental health Trusts and the agenda is largely set through that lens. It sometimes feels to primary care that our voice is crowded out, or an afterthought. We know that’s not intentional, but with constant operational priorities “back at the ranch”, it affects GPs’ appetite to invest their energy into system development, and that’s a lost opportunity.

 

December 2021