Written evidence submitted by Wessex Local Medical Committees Ltd, Hampshire & IOW Local Medical Committee (Bath & North East Somerset, Swindon & Wiltshire (BSW) Local Medical Committee and Dorset Local Medical Committee (FGP0178)

 

The Parliamentary Health Select Committee announced the “Inquiry into General Practice” in November 2021 and has sought feedback from all areas of the NHS including individuals and organisations. LMCs are the statutory bodies which represent General Practice. The purpose of this response is to put forward the views of our elected committee members, and therefore the views of their constituent GP Practices and individual GPs.

 

Perceptions

 

General Practitioners (GPs) have always been amongst the most trusted professionals1. The perception in General Practice is that there has been a change in this sense of trust in the profession and that this has been instigated by a series of headline grabbing and often politically motivated messages. GPs are trained to form a relationship with their patients that are “birth to death”. Maintaining a relationship with a patient across their lifetime relies on a sense of trust. The undermining of this trust through the messages seen by patients has eroded GPs ability to support patients when they need us the most. Perception is affected by many areas. There are sources of media (including social media) which have a damaging and negative impact when used to tell stories of current affairs, and these sources should be held to account for their moral responsibility to ensure health and care services are not actively harmed through irresponsible reporting.

 

Honesty is a key area in which perceptions of General Practice can be shaped. There have been many promises made under political banners to support the wider NHS and more specifically Primary Care, including increasing the number of GPs both in 2015 and 2021. So far, these promises have not been fulfilled, but the perception of the general public is that GPs are being invested in. If there aren’t more GPs then who else can do the work? Open and honest communication with people will help support relationships between patients and their GPs.

 

Solutions:

 

Demand

 

Over an extended period, there has been a gradual cut in support services for patients to access. This has been across many areas of society including:

 

 

Alongside this, organisational changes have led to changes in the way Public Health is delivered. Cuts to Public Health budgets have driven Public Health work into Primary Care (obesity management, smoking cessation, addiction services, health promotion, exercise on prescription). This has taken capacity from General Practice meaning that with a similar quantity of GPs we are delivering public health policies in addition to traditional general medicine.

 

Councils have been threatened with budget cuts that have seen them slash investment in health care. The transfer of parts of health care budgets to Councils was feared due to the risk this would place on the security of these health-based services. This is now being born out as investment in Health Visiting services, School Nursing services and public health promotion is slashed. The plan from Councils is to push patients back to their GP for these services, but general practice is neither resourced nor skilled enough in these specific areas to be able to effectively provide these services.

 

Solutions:

 

Modern Medical Care

 

The benefits of modern medicine are there for all to see:

 

 

Life gains in our population comes at the price of increased demand for health care. Acknowledging how this care need will be met is critical to demand management for health services. Placing increased work burden on the same system simply means the queue gets longer. There are many innovative possibilities regarding long term condition care which will support capacity. It is however key that patients are given this message positively and honestly. General Practice cannot continue without an honest conversation with its population. Telling patients that they can have what they want is a politically motivated message, but letting patients know what they can honestly expect given the level of funding invested in their health care system is what is needed.

 

Solutions:

 

Bureaucracy

 

The NHS needs all health care professionals (including GPs) to work at the “top of their licence”. For GPs this means stripping out many of the simpler clinical issues, administrative and bureaucratic tasks. This can only be achieved if an intelligent triage system is operated to allow teams to filter out tasks that do not need a GP. We believe patients cannot simply expect to see a GP anymore just because they want to without offering some information regarding their request: “Talk before you walk” must be the normal way of accessing care.

 

Bureaucratic work has become overwhelming for most GPs with the excessive nature of managing risk in society. Few areas in society are willing to commit to providing care or products without someone else giving the go ahead first – and signing to prove it. Over the counter products and television adverts often have small print: “speak to your GP if you are unsure if you should use this product”. Companies providing services and experiences ask for GP signed fit to participate notes. This should be stripped out of General Practice workload and the consequence would be increased capacity to deliver care. This will deliver:

 

 

There are areas within the NHS business claims process where separate claims mechanisms are required in triplicate to receive a single funding stream. Payments are paid late, or not at all unless reminders are sent. Efficiencies in other areas of the system lead to exhaustive processes for managers to complete and so efficient GP Practice processes are being dragged to the speed of the slowest NHS departments. The fragmentation of funding to Primary Care has a huge administrative process consequence which could be removed. Pay General Practice for delivering General Practice – the multitudinous acronyms of additional services and payments has become a quagmire of provision and claiming.

 

Medical certification and GP assessments of fitness to work are a significant burden on General Practitioners. It is currently only Doctors who are able sign Medical Certificates (Med3’s). There are options here to consider how to minimise or remove this burden. Could an occupational health system take this work away from GPs? Should private companies who require the certificates fund this occupation health workload?

 

Solutions:

 

Transfer of Work

 

Transfer of the delivery of care into the community and out of hospitals is a laudable ambition. Patients want to be supported in their own homes in preference to hospitals if possible. In order to achieve this there needs to be acknowledgement that funding streams must follow. For a Community Nursing team to deliver the care that would previously have been given on a hospital ward requires the funding for the hospital ward team to move to the community too.  As part of the movement of work into the community, there has been a migration of other hospital work with it. This includes the chasing of hospital-initiated investigations, appointments and follow ups, writing prescriptions for hospital recommended treatments and transferring requesting duties for investigations to GPs. The rates have grown exponentially. It is clearly easier for a hospital to transfer this work to a GP than to employ another secretary. This demarcation of workload should be considered alongside hospital demand analysis to ensure the right people are able to make the patient journey as efficient as possible.

Transfer of work from Secondary care to primary care is recognised as time consuming and time inefficient way to deliver care. Secondary care teams will utilise the GP as a resource to complete work which they have started or ask a GP to start work before Secondary care will consider delivering any care. This causes barriers to care, as well as asking Primary Care teams to perform tasks they are neither paid to perform, nor skilled in delivering.

 

Solutions:

 

Workforce

 

Training a GP takes many years – 5 years of medical school, 3 plus years of post-registration junior doctor work followed by a minimum of 18 months specialist GP training. Various promises have been to the public about the number of GPs that would be delivered to increase workforce and as we have seen these have not come to fruition. There are now fewer “whole time equivalent” GPs in the NHS working than when the promise for 5000 more GPs was made in 2016. The current suggestion of 6000 more GPs to be working in 5 years is unlikely to be delivered, as referenced by the current Health Secretary in Parliament in November 2021. Simple numbers within a workforce can be unhelpful. General Practice needs the support team around it to provide care – Receptionists, Practice Managers, Nursing teams of multiple levels of skill from Advanced Nurse Practitioners to Health Care Assistants. Therefore, we need to assess the working environment of all team members to attract them into the service. The GP could be seen as a key player within the team – conducting their orchestra of professionals. This can now include our Additional Reimbursed Roles of multi-professional team born out of the PCN DES. Demonstrating to patients that being assessed by a member of the extended Primary Care Team is the same as the old fashioned “Seeing your GP”. The methods by which one might be assessed are also different and will include electronic/remote as well as face to face. This is not about Covid either – this is a direction of travel Primary Care was already heading prior to the pandemic, but one which has accelerated due to the pandemic.

 

Health care education is currently fragmented across regions and the country. Post graduate training remains variable in its accessibility to new workers. New members of a Primary Care team will often receive multitudinous training requirements from their governing bodies which removes them entirely from their ability to deliver care. We need a consistent offer of training and support for Primary Care health professionals which is simple to navigate and provides appropriate training for Primary Care. Primary Care leaders then need a simple set of requirements for all health professionals to shared and have a simple “training passport” as proof of standards being met across organisations. This would allow work force flexibility and reduce double training just because one course isn’t recognised in an area.

 

Where can we inspire a generation of GPs and multi-professional teams to enter the profession? Perhaps by giving it an inspiring leadership and voice across media platforms. When these platforms denigrate and abuse then General Practice becomes an unattractive place to work. It is rare that Doctors working in Primary Care are concerned about their potential income – they want it to be comparable with other professionals who have comparable levels of training and responsibility. Most GPs would prefer a safe working day with job satisfaction.

 

Solutions:

 

Safe Working Day

 

Workload can also be framed as “what is safe?” Most GPs across the UK currently work beyond the safe working limits recommended by their union the BMA3. This leads to inefficiency, reduced safety, decreased patient and Doctor satisfaction alongside an increased rate of errors. This is not exclusive to General Practice – this is mirrored in other professions where concentration is key to product delivery (e.g. airline industry flying safety, HGV driving hours limitation.)

 

To reach the BMA outlined target of a safe working day then there needs to be clarity of statistical assessment of requirement of health care professionals to support the traditional GP appointment. This must be alongside an improved mechanism for patient flow once safety levels are breached. Airline pilots don’t just keep flying because there’s no one else to take the helm. The plane doesn’t fly if there’s no co-pilot to take over. HGV drivers stop driving and must prove they have not driven to excess by tachometer recording systems. This is to promote public safety, and yet in Primary Care this has been overlooked.

 

So how can patients be cared for safely during periods of high demand and yet General Practice maintain a safe working day? It would be blithe to suggest that this is a simple challenge. However, GPs and their teams are trained to soak up demand during more challenging periods – this is the beauty of the model. It appears however that it is also the model’s biggest threat – demand. General Practice has been so good at meeting it’s challenges that it has reached a point of collapse without the problem being acknowledged, yet alone solved. We have previously covered the mechanisms by which extraneous “non-medical” demand could be reduced, and this would go some way to supporting the delivery of a safe working day for General Practice teams. Alongside that, the delivery of a multi-disciplinary team into general practice that is effectively (but simply) trained and is accepted as the new normal by the public would further the safe working day ideal. The consequence of delivering improved working conditions through estates, demand management and team support would once again provide an environment in which aspiring doctors in training, as well as allied team members, would want to work.

 

In itself the process of delivering these changes would (in our opinion) support future general practice for generations to come.

 

Solutions:

 

Conclusion

 

So, we know General Practice is the bedrock of the NHS – but let’s not make that a worn out cliché. Respect what General Practice brings to the NHS by investing to make it fit for the future. Strip away the layers of non-medical work which have landed on Primary Care’s doorstep because there’s nowhere else for it to go. Make General Practice a place where Doctors, Nurses, Allied Health Professionals and skilled Admin staff and Managers want to work. Give them a team to work in and trust them to care for the communities they serve in fit for purpose buildings with technological solutions that patients understand and know are good for their care when they need it. By stripping out unnecessary work, improving workforce supply and helping the public understand what General Practice is for will deliver General Practice back to its resilient and efficient best. In addition, hold to account other organisations which have directed work to Primary Care without being responsible for the consequences of their actions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References:

 

  1. Ipsos MORI Veracity Index 2020 https://www.ipsos.com/ipsos-mori/en-uk/ipsos-mori-veracity-index-2020-trust-in-professions
  2. Kingsfund publication “What’s happening to life expectancy” https://www.kingsfund.org.uk/publications/whats-happening-life-expectancy-england
  3. BMA workload control in General Practice 2018  https://www.bma.org.uk/media/1145/workload-control-general-practice-mar2018-1.pdf

 

Dec 2021