Written evidence submitted by the Cheshire Local Medical Committee Limited (FGP0179)

1 Introduction to Cheshire LMC

1.1 We are writing in response the inquiry that has been launched into the future of general practice, as a local body of elected GP representatives covering over 600 GPs of all contract types.


1.2 Cheshire LMC is a member- based organisation, independently funded by its 79 GP member practices. It is the only GP representative voice in the local NHS that is recognised by statute (NHS Act 2006 S.97). LMCs were originally established in 1913.


2 Executive Summary

2.1 Doctors enter general practice to provide direct patient care with continuity of care a given priority to provide quality patient centred care. New ways of online access and working that have been deployed in line with NHSE wishes during the pandemic to provide opportunities to improve access and direct patients to the right person or services with an appropriate degree of urgency. The importance of direct patient and service knowledge to underpin correct and cost-effective decisions cannot be underestimated. This is fundamental to the GP gatekeeper role.

2.2 A lack of supportive central infrastructure and positive workforce planning have caused operational barriers to accessing care as operational changes have not kept pace with the direction of NHSE planning (e.g., NHS Long Term Plan). The response to the pandemic has, however, reinforced just how flexible, adept and cost-efficient general practice is if given time and the right support for the current partnership model. The partnership model, with defined patient lists, and with a stable clinical workforce working as a team has served the NHS well.

2.3 To state the obvious general practice in England is under significant pressure, with a rising workload that is becoming more complex and intense. At the same time, funding has not been growing at the same rate as demand and the number of GPs has been declining. Practices are therefore under increasing pressure both to work more productively and to work in different ways.

3 Evidence

The Practice (Partnership) as the Core Delivery Unit of Patient Centred Care

3.1There is a great deal of published work on demand in general practice and recommendations on how this might be addressed in the future. The Kings Fund in particular has published documents on understanding the pressure in general practice. In 2016 they published an analysis if the crisis in practice. The report analysed 30 million patient contacts from 177 practices and includes extensive research with GP practices and trainees.

3.2 As well as a growth in the number of consultations, it shows that general practice’s workload had become more complex and intense.

3.3 Understanding Pressures in General Practice (Kings Fund) https://www.kingsfund.org.uk/sites/default/files/field/field_publication_file/Understanding-GP-pressures-Kings-Fund-May-2016.pdf


3.4 This and other Kings Fund reports underlined the scale of the recruitment and retention crisis facing the profession, finding that fewer GPs were choosing full-time clinical work – this is true of both male and female GPs. New research for the report found that five years after qualifying, only 1 in 10 new GP trainees planned to be working full time seeing patients in general practice. GPs were also retiring earlier and in greater numbers: between 2009 and 2014, 46 per cent of GPs leaving the profession were under 50; between 2005 and 2014 the proportion of GPs aged between 55 and 64 leaving doubled. These trends have all continued since publication of the report and recent NHS data figures prove this.

3.5 In 2018 the BMA published a report on ‘Workload Control in General Practice’ https://www.bma.org.uk/media/1145/workload-control-general-practice-mar2018-1.pdf?utm_source=The%20British%20Medical%20Association&utm_medium=email&utm_campaign=12741476_GP%20ENEWSLETTER%202


3.6 This report provided a series of practical recommendations to address many of the issues impacting safe workload levels in practices.


3.7 Whilst we believe that the partnership model of general practice works well in delivering a patient centred and cost-effective basis general practice has been quick to adopt ‘at scale’ opportunities when funded.


3.8 Dr Nigel Watson’s review of the partnership model was a nationally well-received and respected exercise with some pragmatic recommendations which could go a long way to overcoming some of the key issues impacting the GP workforce and infrastructure issues.



General Practice Services ‘at Scale’

3.9 The Primary Care Home model which was used by NHS as a basis for Primary care Networks (PCNs). These retain the practice as the core ‘local independent delivery unit’ but facilitate a wider population / ‘at scale’ delivery option where appropriate.


3.10 Participating in the PCN contract ‘add on’ (Directed Enhanced Service) has strengthened inter-professional working between GPs and other health professionals, and stimulated new services and ways of working tailored to the needs of different patient groups – for example, through targeting frail patients at risk of hospital admission. Policy-makers must, however, accept that these new working relationships will take time to establish, as widespread service change requires support from people at all levels and across organisational boundaries.


3.11 Developing the PCN model needs significant investment in time, money and support to enable change. Additional funding for core general practice will need to be balanced with investment in the kinds of at-scale multidisciplinary work envisioned in the NHS Long Term Plan.


3.12 Good quality data – and the ability to use it – are essential for future evaluations of the PCN care models. The lack of joined-up data between different parts of the NHS and social care could further impede progress. 


3.13 PCNs are not the only ‘at scale’ models operating and there are many case studies on the subject including ones by The Nuffield Trust. The case studies demonstrate some common characteristics that have enabled successful transformation of general practices. However, a culture change is needed in practices which are used to NHS funding for organisational development. Many of these models aim to balance the benefits of small and local organisations with the scale and capacity to improve quality and deliver a wider range of services. The models include:

‘Super-partnerships’: Large-scale single partnerships created through list growth and formal partnership mergers;

‘Multi-practices’: Small-scale GP partnerships managing multiple practices and services;

‘GP Federations’: Collaborations between multiple practices through informal linkages (networks) or formal legal contracts (federations).

3.14 Many of these grew organically and were driven from the individual partnerships rather than a top down imposed central model. This helped develop a real ‘change culture’ at their heart.

New models of primary care: practical lessons | The Nuffield Trust

Wider NHS Organisational Change Impacting Delivery of General Practice


3.15 The complex external context in which PCNs are emerging – particularly with the implications of the current Government proposals to change the NHS system e.g., Integrated Care Boards/Integrated Care Partnerships/ Place Based Commissioning – could help or hinder their development. Sites will need local commissioners to buy in to both the individual practice and the PCN vision and fully fund new services, which may be difficult with regional priorities restricting their clout to support enthusiastic local PCNs. There is a danger of a one size fits all approach by some ICBs is a real danger to progress in primary care.


3.16 One key issue about future role of general practice (and primary care as a whole) concerns the degree to which, in the current changing NHS environment, gatekeeping is a sufficient tool to manage access to secondary and tertiary health services. NHS structures have been in constant flex since the late 1980s. Perhaps these continued centrally imposed changes have been a barrier to how general practice has developed since it is delivered by (in effect) non-NHS businesses (general practitioners). The impact of ongoing organisational changes in the way that the wider primary care is delivered may have eroded the GPs gatekeeping role, which in the past may have kept overall NHS costs down.

3.17 Increased points of entry for patients can create dilemmas in terms of co-ordination issues. Other examples of growing organisational pressure include establishing a single patient record that can follow a patient through the system, and the decreased likelihood that patients may not know the treating GP in larger practices or in health centres, particularly if there are part-time physicians or other professionals working in the practice or PCN. Continuity of care is vital and often the cause of patient complaints about services. Having a ‘registered’ GP list or named GP can assist in minimising problems.

Credibility of General Practice as a Profession

3.18 A key element of the concept of credibility, as viewed from the perspective of trust and power, is that it reflects not the imposition of control upon patients, but rather the acceptance by patients of that control as both clinically appropriate and socially legitimate. There have been a number of efforts over the last 30 years to try to raise the overall position of general practitioners within the health sector. There have been educational efforts, programmes to create training rotations for GPs within hospital clinics, and to give GPs wider control of funding (GP Fundholding and Practice Based Commissioning). Some of the later have suffered from short termism by the Department of Health/NHSE and so have been cancelled before benefits have been identified.

3.19 There have been widespread initiatives to create specialisations in general practise and family medicine, as well as to introduce a process of continuing education. There have also been concerted financial efforts in some other countries, including the introduction of higher incomes (at one point in the late 1980s in Finland, a primary care doctor in a rural area could earn a higher salary than a cardiac surgeon in a public hospital in Helsinki).

3.20 More needs to be done to elevate the public and NHS organisational acknowledgement that GPs could be recognised as Consultants in General Practice for example.

3.21 Gatekeeping is a traditional role within UK general practice, along with registered patient lists, both of which have sometimes been utilised (for example in Spain and in Sweden) to try to increase the status and role of general practice and make it more appealing to newly qualified doctors, as an alternative to hospital work.

4 Recommendations

4.1 What are the main barriers to accessing general practice and how can these be tackled?


4.2 To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

4.3 What are the impacts when patients are unable to access general practice using their preferred method?

4.4 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?

4.5 What are the main challenges facing general practice in the next 5 years?

4.6 How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?

4.7 What part should general practice play in the prevention agenda?

4.8 What can be done to reduce bureaucracy and burnout, and improve morale, in general practice?

4.9 How can the current model of general practice be improved to make it more sustainable in the long term?


4.10 Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

4.11 Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?

4.12 Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?

4.13 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?

William Greenwood

Chief Executive and Company Secretary

Submitted on behalf of Cheshire Local Medical Committee

December 2021


December 2021