Written evidence submitted by Professor Steve Iliffe and Professor Jill Manthorpe (FGP0176)
Steve Iliffe, Emeritus Professor of Primary Care for Older People, Research Department of Primary Care & Population Health, University College London
Professor Jill Manthorpe, Director of the NIHR Policy Research Unit in Health & Social Care Workforce, King’s College London.
We are submitting evidence to the Health & Social Care committee reviewing the future of General Practice because we have carried out research and development into multidisciplinary, collaborative working in the community for over two decades. We are aware of the obstacles to the development of innovative ways of working and understand the current tensions and stresses of general practice, without exaggerating them. In this evidence submission we have applied the pragmatic thinking of Donald Berwick to the problems of general practice.
Background
The NHS is entering its third era. Era 1 was the period of noble, beneficent, self-regulating professionalism. In the compromises needed to launch the new health service in 1948, politicians conceded to the professions the authority to judge the quality of their own work, much as the professions had done previously.
Era 2 began when the variations in the quality of care, the injustices and indignities inflicted on people because of class, disability, gender and race, the profiteering and the sheer waste of Era 1, became inescapable. It is the era of management and markets, and we are still in it. Era 2 has promoted evidence-based practice and highlighted decisions about value for money in medical care but in doing so it has also fostered conflict with general practice about external determination of the GP job description.
Era 3 will struggle to resolve the conflicts generated by Era 2. Some of these conflicts already are having profound effects on general practice.
Berwick, the author of the three Era model[1], made nine proposals for helping Era 3 into being. We believe these proposals are relevant to general practice and so merit consideration in a review of its future:
- Stop excessive measurement, perhaps by reducing Care Quality Commission (CQC) scrutiny.
- Abandon complex incentives, for example by suspension of check-ups for middle-aged and older people.
- Reduce the focus on finance and refocus on outcomes (for example, the clinical outcomes in the Quality Outcome Framework (QOF).
- Reduce professional prerogative and allow the job description of general practice to evolve further but under the influence of NHS management as well as public feedback.
- Recommit to improvement science, by building continuous quality improvement into practice management.
- Embrace transparency, so we can answer the question: What do GPs actually do?
- Protect civility and reduce the criticism of general practice by specialist disciplines that is a persistent feature of medical training.
- Really listen (especially to the poor, the disadvantaged and the excluded) by tasking Patient Participation Groups to help reduce inequalities in health.
- Reject greed (it erodes trust) and make local health economies transparent and subject to public scrutiny.
We will touch on some of these recommendations in this commentary on the future of general practice that we hope will be of interest to the review’s authors.
What are the main barriers to accessing general practice and how can these be tackled?
GPs have a long-standing enthusiasm for ‘demand management’, which involves fending off work deemed outside the discipline’s remit in terms of time (out-of-hours commitment), skill and responsibility. It is possible that the GP in the vignette above did not have time to give a tetanus injection, or perhaps s/he felt that it was not his/her responsibility. GPs can define the content of their work in broad terms but they are also under contractual pressure to deliver public health tasks (primary prevention) and some aspects of specialist care (multiple long-term conditions management - secondary prevention).
The tension between easy access on-demand care and complex case management has grown during the last two decades. It has temporarily shifted in favour of complex case management during the Covid-19 pandemic, which has allowed practices (the GP organisational unit) to reduce their accessibility whilst attending more systematically to vulnerable people with complex needs. GPs can legitimately complain that they are dealing with more patients, not less, even though their work is not visible from the empty waiting room.
The NHS is promoting a swing back towards accessibility with advertisements encouraging people with worrying symptoms to seek help from their GPs – a form of supplier-induced demand. This may encourage GPs to shift their attention back to the waiting room, especially if the NHS reduces the demands made of practices to manage complex cases. A question for policy makers and practitioners is: will rebalancing the GP workload make any difference to any health outcomes, and if so for better or worse?
Mrs A is not among the ‘worried well’, she is a conscientious citizen who is not making demands on her busy hospital and expects that her primary care service will be the right place to go. In our view this should be met by a welcoming approach and a tetanus vaccine administered by the local pharmacist. The obstacle to using general practice is not only one of access (since Mrs A did get to see the receptionist who talked to a doctor) but one where some basic tasks are not being undertaken leading to patient and hospital staff’s frustration. Such problems risk undermining the trust on which general practice depends.
o To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers? The NHS is proposing a raft of initiatives to increase accessibility, including increasing the numbers of appointments by using local locum banks (professionals who are known and contactable if there is a demand for temporary labour), extending practice hours, expanding urgent treatment centres (not generally open round the clock), and increasing GP numbers (there were 1200 more GPs in summer 2021 compared with summer 2019 in England). Pharmacists will be allowed to treat minor illnesses - something nurses practitioners were once expected to do and which some have managed to sustain – and administrative burdens will be reduced.
Examples given of reduced administrative burden are not completing Fitnotes (for employment purposes) and DVLA reports (on fitness to drive), both of which could be seen as part of generalists’ biopsychosocial understanding of their patients. In our view they are no more of a ‘burden’ than documenting a consultation is. The biopsychosocial model is spoken about frequently in general practice, but it is not necessarily applied. Reducing the salience of regulation and oversight (like the Care Quality Commission’s work and other more local imperatives) and emphasising trust might be a more appropriate response (Berwick 2019)[2].
o What are the impacts when patients are unable to access general practice using their preferred method? Face-to-face consultations are important for some people, but remote communication may be preferred by others who appreciate its efficiency. We should not overstate the impact on health of either approach; lives are not immediately at stake. The common benefits of different forms of communication may be reassurance, confidence and understanding. Many citizens make effective use of digital resources when unable or unwilling to access face-to-face consultations in general practice. The take up of virtual services such as Babylon (an online GP service) demonstrated this. The impacts of not being able to see a GP or other member of the primary care team are currently visible in both mainstream and social media and reflect disappointment, frustration and a fear that important symptoms may be missed or overlooked. The lack of access to online or telephone consultations is similarly one of disappointment and frustration. We tend to think that these reflect two different groups of patients but it is likely that some people want a hybrid model of consultation. It is curious how such a hybrid model has been so slow to develop in the NHS.
o 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? Continuity of care is important for people with complex problems and their carers, whilst discontinuity may be traded off for speedy, convenient access and sometimes a different opinion (and see above). Extending continuity of care may require a change of direction in general practice development, with practices shrinking to 6,000 patients or three full-time equivalent doctors rather than continuing a steady growth in practice size. Given the long history of slow collectivisation of GPs we doubt the trend will reverse, but hub and spoke models of GP organisation might allow small sub-group working, especially within large conglomerates like Primary Care Networks. With the increase in part-time working among GPs, a model of team working may be appropriate. Such named professionals will also need to be involved in multi-disciplinary team working which is another facet of continuity of care for people with complex needs.
What are the main challenges facing general practice in the next 5 years?
How does regional variation shape the challenges facing general practice in different parts of England, including rural areas? GP services in deprived areas struggle with their workload because deprivation is so harmful to health. Deprived communities have poorer services overall (often referred to as the Inverse Care Law). Once weighted for need, GP practices serving more deprived populations receive around 7% less funding per patient than those serving more affluent populations, despite a GP in these areas being responsible for 10% more patients. Some deprived areas can be unattractive to many GPs when other options exist, although such areas may have low house prices, be close to areas of natural beauty and contribute to work-life balance. We need to consider the evidence from the new medical schools about whether their new graduates are making decisions related to such factors.
What part should general practice play in the prevention agenda? GPs can contribute to primary prevention by ‘Making Every Contact Count’, and to secondary prevention by systematic case management within a multi-disciplinary context for patients with multiple long-term conditions and psychosocial disadvantage. In effect general practice has become the clinical arm of public health medicine, at least in terms of long-term condition management and individual risk factor modification. This is not, in the main, contentious, but general practice could be criticised for not prioritising health inequalities in its preventive work.
What can be done to reduce bureaucracy and burnout, and improve morale, in general practice? ‘Bureaucracy’ (also known as management) is necessary to manage practice resources and provide systematic care, but the collection of data that is not subsequently used is a waste of energy. The NHS (and practices) need to develop a streamlined dataset that captures clinical outcomes rather than process measures. Burnout is a reified concept that means, amongst other things, job dissatisfaction. Job dissatisfaction rises in general practice whenever substantive changes are made to GP contracts, but tends to decline within a short time as practitioners become accustomed to the changes. Morale is a term that is similarly difficult to define and is often used as proxy terms for retention, satisfactory engagement with others, personal job satisfaction, and attitudes and behaviours towards patients. Professional organisations like the RCGP, and trades union bodies like the BMA, could usefully reflect on the image they create of general practice when campaigning about burnout, overload and rising stress levels. The impact of the Coronavirus pandemic on applications to medical school has been positive and indicates sustained interest in medical careers, fostered by the pandemic and possibly by articulate, personable GP commentators on the media, many of whom are from diverse communities.
How can the current model of general practice be improved to make it more sustainable in the long term? In particular:
o Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts? The independent contractor status of most GPs, and the co-operative organisational style of practices, have allowed some innovation and service development, but uptake of innovation has been slow, and many practices could be described as ‘late adopters’. The partnership model is probably sustainable for a minority of practitioners, but an alternative form of employment (e.g. employment of GPs by Trusts) may be needed to bring ‘late adopters’ up to the desired standards.
o Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care? Yes, in some practices they can do, when there is innovative leadership keen to merge income streams (see above) but full engagement of GPs in new ways of working will still require some investment. Part of the historic problem for general practice is that it has been overshadowed by acute medicine. A qualitatively different form of working will need mechanisms that route resources towards community settings and away from hospitals. This may trigger resistance from specialist services. The remaining barriers to integrated care are not technical; they are political (Berwick 2008)[3] with some long-standing problems needing attention, such as better IT and fit-for-purpose premises for practices.
o Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs? It is far too early to know; PCNs barely exist. The NHS sometimes has unrealistic expectations of the time needed for novel forms of working to become normal clinical practice. The NHS easily lapses into magical thinking. An independent evaluation of PCNs once they are out of their start-up phase would be helpful to provide an empirical evidence base for decision-making. We are after all, only just finding out how other NHS innovations such as Pioneers work in practice rather than in theory.
o 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? There is a long if variable history of multi-disciplinary working in general practice, but the belief that having more and different professionals in primary care will allow GPs to concentrate on clinical tasks is, at best, a hypothesis. More professionals may generate more work needing adjudication, review or sign-off by a GP, even if they are highly trained specialist nurses or physician associates. This question leaves out other important colleagues in practice management, ancillary staff and local NHS managers who contribute time for patient care and treatment. Sadly, engagement of GPs with social care, particularly care homes, has been very limited (and home care is even less engaged). The hypothesis that having more professionals in primary care will re-focus GPs will be tested if currently proposed changes are promoted within the new Integrated Care Systems. The NHS will need to put processes in place to evaluate innovations and learn from them.
The views expressed in this response are the authors’ alone and should not be interpreted as those of the National Institute for Health Research, the NHS, or the Department of Health and Social Care and its Arm’s Length Bodies.
Professor Jill Manthorpe, Director of the NIHR Policy Research Unit in Health & Social Care Workforce, King’s College London, Virginia Woolf Building, 22 Kingsway, London, WC2B 6LE. jill.manthorpe@kcl.ac.uk
December 2021