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.

a 13 per cent growth in face-to-face consultations and a 63 per cent growth in telephone consultations, contributing to stressful and highly pressurised working days for GPs
the biggest increase in consultations were among the over-85 age group (up 28 per cent), who are more likely to have more than one chronic condition
using other members of the primary care team to triage and manage minor illness means that the patients GPs do see tend to be the most complex cases, who often require more than a 10-minute appointment
the move to transfer care closer to patients’ homes had not been coupled with the equivalent transfer of resources to primary care, again increasing the pressure on GPs.

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.

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/770916/gp-partnership-review-final-report.pdf

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?

Current and future workforce. We need incentives (financial and work/life balance) to attract many more doctors to become GPs.
Define (and properly cost) general practice role, define what is primary and secondary care for patients so they understand roles, and define capacity/cap on safe practice/daily consultations. Stop ‘bucket’ style approach to commissioning.

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?

Not greatly. Workload is a major factor and the current problems with recruitment and retention clearly impacts on this. A range of areas need to be examined including the impact of regulatory change; access to support services; identifying administrative tasks that do not need to be completed by a GP; focus on disease prevention; more self-care and self-management; and the use of technology to support patients.

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

We need an ongoing campaign to promote the new ways of consultations in the NHS, with new clinician types and explaining the benefits to patients and try to remove the distrust of new roles.

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?

this has worked well in the past but with an increase in workload it is not always possible to book in with a certain doctor for an urgent appointment. Educating patients, that every clinician, has access to patient full records, and that it is reasonable to expect patients to see the next available clinician If the matter is urgent may help.

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

The need to increase GP numbers is critical. The core aims of making general practice a better place to work; making partnership more attractive than being a locum; expanding the multi-professional team working with and supporting GPs; creating primary care networks that will support practices; and use more of the existing resources to deliver frontline care.
Demand will continue to increase. Unless the workforce increases the demands and pressures will continue to rise. We need an education agenda for patients on how to the support they need: and to promote the new clinical staff types,explaining their benefits.
The NHS workers deserve better than being continually criticised, we have so much to be proud off.

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

Variation may not be a negative concept. We need to agree the principles behind high quality patient services and safe working. We need to undertake further work to specify precise safe limits to workload in practice settings. (Expressed in appointments, time or list size). We also need to endorse locality approaches which supports local population needs.

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

With greater capacity GPs (and their expanded teams) could engage local communities via practices and PCN structures. We need a bigger GP workforce capacity and financial resource to allow time to have the time to engage in face to face and ‘management’ tasks. PCNs could help deliver but need more local flexibility to work with communities.

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

Implement recommendations in BMA report @Saving General Practice 2017 bma-saving-general-practice-report-nov-2017.pdf

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

we not only need practices to be stable and resilient; we also need to have community based care delivered at scale supporting individual practices and the natural communities of care.

There are important benefits of the current model and in particular the ability to change, adapt, and innovate expeditiously, as independent contractors, separate from quite the same levels of bureaucracy as often afflicts other parts of the NHS. Other benefits include being part of a local community; the desire to succeed as business owners; and delivering value for money. The current contract needs a major reset.

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?

It’s fragile but not dead! It requires encouragement by better infrastructure resourcing and personal risk reduction within contracting mechanisms. It is vital that the risks associated with the GP Partnership model are reduced. A key issue is property ownership/ liabilities. Doing nothing is not an option.

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

We need to create an agreed (DHSC/BMA) measure of general practice effectiveness which would then serve as part of a formula for a more standard measurement of productivity: by dividing this ‘output’ (which combines quality and activity) by the ‘input’ of financial expenditure or some other measure of resource use.

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?

PCNs were ‘sold’ as bringing sustainability to general practice. Many would say PCNs are being used by the system for other purposes for which they are not funded or have capacity at present. We need to redefine what PCNs are/ are not and agree a longer lead-in time for their development than at present.
PCNs need more local freedom to innovate. The current system is too command and control.

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?

We need to explore issues such as the status enjoyed by GPs and how GPs can become part of the health system’s senior leadership. These are complex issues that clearly go beyond any regulatory, process driven or legal remedy. In summary general practice needs to be valued: it is vital to the future of the NHS and rests on the partnership model.

William Greenwood

Chief Executive and Company Secretary

Submitted on behalf of Cheshire Local Medical Committee

December 2021