Written evidence submitted by Dr Marc Rowland (FGP0177)

 

 

 

Summary Points:

 

 

 

 

It is impossible to separate General Practice from the health and Social Care services but in deference to the ‘call for evidence’. I will start with brief notes on General Practice then move to Health and Social Care.

 

General Practice

 

GPs are now a mixture of very small and medium sized practices, national ‘super partnerships’ with up to 500,000 patients and over 100 partners e.g. Modality, very large practices with few partners e.g. The Hurley and other forms of practice run by nurses, hospitals and other variations. All practices are at present very stressed trying to deliver effective services. Many, especially smaller practices, are especially struggling to keep up with the requirements of patient care and running the GP business, CQC etc..

 

Not having Community Services like nursing, physiotherapy and Mental Health Services integrated with GPs has always lead to less efficient care. To the patients, it’s all one service.

 

Primary Care Networks (PCNs) have been brought in to link GPs together locally and get them to work better with Community Services.

 

The idea for PCNs is largely based on a mature, successful model in Tower Hamlets. This was slowly grown locally and well funded. PCNs are at present mainly neither. Some are working due to local previous experience of shared working, goodwill and good practices with management experience. These tend to be larger practices that have the experience of changing working ways and the ability to dedicate staff to it.

There is a large national variation in PCN development; the most successful are often those consisting of one large partnership group.

Partners at present are generally doing well financially, often relatively independent of the quality of service given. NHSE, over the years, has been ineffective at removing poor practices and this is only now happening mainly by retirement and a few occasional, notable examples by CQC. Some partners are effectively, legitimately selling the practice goodwill to an incoming practice by being given a very generous year or two in partnership with the incoming practice before eventually retiring.

 

With COVID19, many practices have shown excellent innovation and changes in working. Some have been slower to change and others have been keen on extra funding to support this, as one might expect from independent contractors with inbuilt conflict of interests of workload and income. The overall position has yet to emerge.

 

Workload overall is a major problem. Pressure on practice staff derives largely from a lack of overview as to the modern function of Primary Care. To be effective it need to be the focus of all but very specialist care, e.g. repositioning outpatient care in primary care needs adequate funding.

 

Patients must feel confident that Practices can provide all their reasonable health needs or direct people to such services in order to prevent them attending multiple access points causing patients confusion and causing massive over investigating, over referring and duplication from attendances at A&E, 111, out of hours, private clinics etc.

 

GPs must be integrated fully into the NHS. The current independent contractor status is an historical anomaly and needs changing. Consultants and other professionals work very effectively as salaried doctors and the conflict of interest inherent in running a private business and delivering NHS care is too great. It can work well and be superficially more efficient but overall the COI is too high. GPs are neither fully part of the system nor fully independent with the agility but risks that brings. It is a rigged market with the worst of both systems.

 

Primary care has changed. Patients are often initially assessed by an AI programme (with face-to-face consultations for those who can’t use the AI systems). They are then directed to online or face-to-face consultations, administration, pharmacy, counsellors, physicians assistants, nurses, district nurses, physiotherapists, 1ry care paramedics, 1ry care mental health nurses, counsellors, social care etc. as needed. Current AI systems are quite good and they will get better. They will allow assessment/treatment by the most appropriate staff or system, and, if set up well, can, when appropriate, encourage continuity of care, with it’s proved efficiencies.

 

AI can be used to enhance or degrade patient care depending on how it is deployed and perceived by clinicians, management and patients. It can be used just to save money, or to allow flexibility and increased choice for patients. If the former, then the world-rated ‘old fashioned UK GP’ will either go private or wither away into the very expensive direct to secondary service that exist in many other countries.

 

Hospitals should have effective systems (like Consultant Connect) in place now for when primary care clinicians need to ask for advice as this can stop the need for a 2ry care referral. Unlike the present, this must be a wholly local service as 1ry and 2ry look after the same patients in a locality and should be viewed as one unit. Increasing communication between them is essential. COVID19 has started the change and it must be continued.

 

Primary Care working to the top of it’s licence can contain a lot of work. Time and support are the keys to unlock this.

 

Funding systems need frequent reviews and updating to stop gaming e.g. payment for advice and then also recommending seeing the patients, Pharmacists asking GPs for all of a patient’s repeat prescriptions not just the one the patient asked them for, etc.

 

The key integration for the future NHS is GPs working closely with their local hospitals and Community services in whatever ways are possible. All staff in all organisations care for the same population. Funding must reflect any shift in work but it is more likely that efficient services, following the patient’s needs, will reduce the workload to all and improve patient satisfaction.

 

NHS 111 has been changed to a national system during COVID19 and seems to work much better. Are there other parts of the system that could work this way to give equity of services nationally? It should remove the need for expensive systems like Babylon and Push Doctor, which lead to unnecessary queue jumping with arbitrary imposed time limits for minor as well as more serious conditions.

 

The COVID19 crisis gives us a unique chance to push through radical changes. Let’s seize it.

 

 

What would ideal Health and Social Care look like?

 

We need a national, single organisation working as one delivering health and social care. ?’NH&SCS’. It must be flexible and agile with as few points of entry as possible and seeing the patient as a whole person at all times. From ‘cradle to grave’.

 

Politicians must stop being afraid to say what everybody know, that the NHS can’t do everything. The language must change to look to an honest, realistic service. Some changes I have outline, effectively done, could provide a better service for the same funding in health; from my experience, this is unlikely in social care.

 

This organisation should be as deeply grounded in communities as possible but still allowing it to be an equitable, national organisation.

 

It should be centrally funded by direct taxation, as this is shown to be the most efficient funding method. It needs to be capable of using any appropriate organisation to help it deliver effective services, all responsible to the ’NH&SCS’ with transparent funding arrangements not hidden under commercial confidentiality clauses. It is public money.

 

All systems would share data and use it maximally, appropriately and legally.

 

The internal market will be allowed to continue it’s decline to it’s natural end.

 

There should be much more effective management than at present, especially in the NHS. No scapegoating of good managers in underfunded organisations and removal of poor managers, not shuffling them around.

 

Flexibility and sensitivity should be built in at all levels by allowing patient and staff input to clinical and management decisions and close links with Local Authorities (LAs)

 

 

Pre-COVID19

 

Health and social care were starting to work together, largely driven by austerity. Means testing, political control and other major differences make changes difficult.

 

There are well recognised, major differences between the health and social care systems in England in funding and political control. Without addressing them, it is impossible to provide an integrated health and social care system.

 

Health care was getting more fragmented following the Lansley reforms of 2012 and increasing outsourcing.

 

Health care in England is centrally funded and largely run on a command and control basis by NHSE, which runs Trusts and primary care and is funded from central taxation via the department of Health and Social Care. It makes policy and disseminates it for implementation. It has even managed to largely control the independently contracted GPs through changes in their contracts. It remains to be seen whether Integrated Care Systems (ICS) will make any difference to this. The membership of Integrated Care Boards must be non political.

 

There is an ‘N in the NHS’. It cannot be locally different or you have an even larger ‘postcode lottery’. Despite this, there has always been inequality in care and, because the Lansley reforms and stopping deprivation payments with more emphasis on age and other funding changes, inequalities have increased. An average 70 year old’s health in a wealthy area is equivalent to an average 60 year old’s in a deprived area.

 

Command and control means NHS change is usually slow and lacks local refinement. All major change e.g. hospital realignments/closures, GP practice changes etc. have lengthy public consultations. The NHS also has a ‘culture’ specific to it. However bad, something/someone is, ‘magic money eventually appears or people get moved sideways, very rarely sacked. Pressure to change anything is usually resisted.

 

Health in general is understandably concerned about working with LAs because of the culture difference and any possible responsibility to local politicians.

 

Social care is largely delivered through LAs with a high degree of outsourcing. It is means tested to varying degrees e.g. if nursing or other care is not deemed an essential health need, it will cost individuals/families money or lead to reduction in quality or choice of care.

 

Ineffective social care costs a lot. When it fails people are hospitalised and that can make them ill, as we have found with COVID19. Usually hospitals are the worst place possible for any except acutely ill older people, but they are the default place of care if social care is not speedy and effective. If you are lonely and/or have poor social circumstances a hospital feels safe with kind people around you all the time. Respite care needs rethinking as it saves money for physical and mental health care if done properly.

 

LA delivery of social care means it will reflect local politics e.g. differences in emphasis between keeping council tax as low as possible or delivering better social care. This local leadership does mean that, in contrast to the NHS, when change is needed, it can happen very quickly. The LA can allocate or cut money with a vote, within legal restrictions.

 

Because of the above, the culture is different too. It is more sensitive to local feelings and Politics, with the good and bad that brings. LA managers and politicians are very concerned about working with the NHS as they think decisions take forever and change on the whim of a senior manager or politician in Whitehall.

 

 

 

Post COVID19

 

People in organisations working with the NHS express surprise that it is very fragmented to deal with, ‘like relating to many organisations not one.' This has always been the case but this worsened after the 2012 changes.

 

Much of outsourcing has been unsuccessful. PFIs will cost future generations a lot. Capita and similar organisations have delivered expensive, poor services, which with Capita, specifically damaged GPs efficiency for time with slow and inaccurate payments. Part privatisation of hospitals, such as Hitchinbrook, failed. Careful evaluation of any future outsourcing is needed to see if it does deliver value for money and there should be penalties for poor service.

 

To avoid this the NHS must integrate further internally. The separation of Community Services, GP, 2ry and 3ry care is artificial. Patients don’t understand or want it. At the start of the NHS in 1948, as a way to push it through against medical opposition, the consultants were ‘given the hospitalsand the GPs given the lists of patients. This ‘ownership ended long ago.  Consultants don’t run the hospitals any more, managers do. GPs have kept the patient lists and remain ‘Independent Contractors’ but now much more uneasily and they are far more under the ‘command and control’ of NHSE.

 

Hospitals say they invented the new COVID19 ways of working using telephones, Skype, teleconferencing, emails, photographs and working closer with GPs to avoid outpatient attendances. GPs and others have been being urging them to adopt these ways of working for at least 10 years but old ways, and old funding systems have blocked it. These changes must not be lost. They need to be further developed nationally and locally but with careful thought for people unable or initially unwell to adapt.

 

Care should follow the patient’s needs as this reduces unnecessary contacts with health and care providers, makes patients much happier and saves money overall. There is evidence if a population knows it can access services quickly and efficiently they feel safer and it reduces demand.

 

 

 

Social Care

 

Every government in the last 20 years has come to power saying it will look at social care reform and produce a policy statement on this within 6 months of taking power. After initial work they all realise the political and financial implications of such a review, freeze the work, and no coherent policy plans have appeared.

 

This government is now trying to effect change. I hope for the best and will not discuss that here.

 

The current care system is totally unacceptable and now has been further exposed by COVID19. The discharging of infected patients to care homes, lack of PPE and initial lack of insight to the problem increased deaths in the UKs pandemic. The current funding level for care homes is inadequate to keep standards satisfactory and many were closing even before COVID19. Contracts must be clear, public and equitable.

 

Conclusion - and see page one

 

Further work must be carried out as soon as possible on health and social care funding and integration with analysis of what works best, relevant international comparisons and clear plans for what could work for England.

 

Local government must have strong input to the newly developed, integrated service to reflect local differences, maintain flexibility and keep as much decision making as possible local. Some central control is essential to ensure equality in this National Service.

 

1ry, 2ry, 3ry NHS services, and Social Care do not work in silos.

 

 

 

We must use the deaths, social and economic upheaval that have come from COVID19 to deliver a much better and more robust health and social care system for the future.

 

December 2021

 

 

 

 

 

 

 

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