Written evidence submitted by the Future of General Practice and Access from the College of Medicine (FGP0185)

 

 

 

 

 

 

 

An outline of current challenges and solutions

 

Difficulties in GP access result from a mismatch between supply and demand.

 

On the supply side, the UK spends less on health than comparable westernised counties.  In the UK, the proportion of spending on primary care relative to hospitals has also declined over recent years.  For instance, forty years ago the number of hospital specialists was a third of the number of GPs.  Since then the former have increased threefold to now outnumber GPs, whose numbers have remained relatively static. Yet extensive research by WHO, Barbara Starfield, Sir Brian Jarman and others has shown that extra investment in primary care leads to less deaths, better health and a more cost-effective health system, while the opposite applies when extra is invested in secondary care.

 

On the demand side, there has been an exponential increase in the elderly, long term disease, patient consultation rates and patient expectation amplified by medicine becoming ever more effective and some offloading of work from hospitals on to general practice. 

 

Consequently, GPs are faced with an almost unworkable day. A woefully under resourced workforce combined with burgeoning bureaucracy and reduced autonomy have led to increasing numbers of GPs retiring, trainee GPs not becoming GPs and GPs in practice going part-time or leaving altogether.

 

These increased demands and Government emphasis on fast access per se (e.g. 48 hour access) have led to increased waiting times for booked appointments and thus a reduction in personal care and continuity between individual patient and doctor.  That in its turn has led to further reduced job satisfaction, duplication and an increased workload. 

 

Covid intervened on an already overstretched GP workforce and the emphasis on virtual access has now permanently and appropriately increased demand for virtual access, which now means a further added workload as GP practices return to routine appointments. 

 

The solution to GP access is only partly about money and the number of GPs.  It requires a radical rethink of General Practice, which starts by describing its modern purpose and function and then restores the autonomy and support that it had in the past.  Part of this rethink will require better onsite support for GPs, who have become the default point of access for an increasingly wide range of problems – particularly better in house support for mental health, musculoskeletal problems and prescribing.  Paradoxically, it will also require an extension of the GP role in self-care and improving individual health and the health of the community, which is the only long term means of containing demand on the service.  Social prescribing has provided a starting point for this but GP funding streams will need a radical revision beyond individual care to enable a new potentially crucial but historically neglected community health role for GPs.  Stemming the tide of bureaucracy and enabling local GPs and their patients and population to develop a collective vision of primary care that becomes the front door for community health and prevention and is connected to the local authority and VCSE sector will create a culture of mutual responsibility that will itself contribute to better access and restoring personal care and continuity. 

 

 

Answers to specific questions raised by the Inquiry

 

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

Lack of appointment availability is a result of GPs needing to prioritise their time tackling acute problems by phone or face to face thus leaving less time and availability for booked appointments. When waits for booked appointments run in to weeks, an increasing number of patients ask for acute same day access, which further loads the acute service and leaves less resources and time to offer booked appointments for less urgent problems.  The long-term solution requires a radical review of general practice and its funding streams.  In the short term, however, anything that reduces the burden of acute demand on a GP’s time will enable each to spend more time on book ahead appointments and the waits will become less.  Consequently, advanced nurse practitioners, prescribing physiotherapists and pharmacists and paramedics can be very helpful in this respect although recruitment can be a problem in many areas.  Mental health support for GP practices is particularly important as many acute consultations involve this clinical area. Practice attached mental health staff are a thing of the past for most GP practices with many Mental Health/Partnership Trusts tending to operate at arms length from GP practices.  If waits for routine appointments can be reduced significantly then the ability of GPs to provide personal care and continuity (see question 4 below) can be restored and this in itself will have a positive effect on access. 

 

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

 

These plans are helpful but insufficient for three reasons:-

a)      They do not address the fundamental issues (see above) of increasing demand, general practice having become an “undoable job” and clinicians feeling too frequently that they are having to short change their patients.  Many of the schemes for improving recruitment and retention have been tried before but will not produce a sustainable improvement, while the fundamental reasons why GPs and GPs in training leave the profession or work increasingly part-time are not addressed.

 

b)      Remuneration to increase the workforce is welcome but the recruitment of extra GP hours – especially from locums – is increasingly difficult and costly, when it is possible. Extra professional groups such as nurse practitioners and prescribing pharmacists and physiotherapists are equally in short supply in many areas.  Improved access to opticians, dentists and mental health would be helpful. 

 

c)       Current plans are somewhat centralist and may have lacked sufficiently wide consultation. They are seen by some as offloading responsibility for poor central planning on to GPs, inferring that GPs are not sufficiently concerned or skilled to tackle access and thus exacerbating existing issues. General practice requires support and funding that are more flexible and enable local GPs, practices and patients to determine their own priorities and produce their own often very local solutions. 

 

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

 

Failure to get appropriate access leads to less satisfied and anxious patients, sometimes late diagnosis and delayed treatment for those in most need, increased pressure on hospitals and acute services and frustrated GPs.  This mutual patient/GP frustration adds a further element of negativity to the working day.

 

 

  1. 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 beneficial to patients and GPs. Research shows that it increases patient satisfaction and quality of care as well as cost effectiveness - reducing referrals, prescriptions and patient attendances.

 

In the current situation of high levels of demand on primary care and reducing numbers of full time GP’s this presents a challenge. Primary care teams are increasingly multidisciplinary. Prescribing pharmacists, advanced nurse practitioners, prescribing physiotherapists, paramedic, mental health workers, physician associates, care navigators, social prescribers, HCAs, practice nurses, nursing associates, district nurses, health visitors and midwives are all likely to be involved in a patient’s care.  These health professionals may be much better placed to deliver elements of a patients care than their GP. It is appropriate therefore that patients will see a number of different health professionals. 

 

The only way of delivering continuity of care with such a diverse team is if the team has excellent communication. This is achieved by close proximity working and relationship development between team members.  Moving district nurses, health visitors and mental health workers out of practices has made communication more difficult and worsened patient care. Knowing your team members and having unplanned conversations over the kettle can significantly reduce workload and increasing effectiveness. It also makes the job much more fulfilling and less frustrating.

 

A good model might involve a small group of two or three GPs within a GP practice (as so many GPs are part time) working with a close team of different professionals who operate together with high levels of trust. This will provide the benefits of continuity and the benefits of a diverse skill set within a team. Thus, future patients will have a named team of which their named GP is a member. A patient could expect then to see/speak to one or two GPs within their team on any one day with the GPs in their team communicating closely together as well as with the rest of the team.

 

Small, close trusting teams are absolutely key and this cannot be achieved by outsourcing parts of care to external groups and relying on proformas and pathways to communicate.

 

 

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

The workforce crisis in general practice is unlikely to recede quickly in spite of greater recruitment in medical schools and GP training schemes because of issues already mentioned. Training will need to have a stronger focus on lifestyle and population health. Meanwhile, it will be imperative to recruit a sufficient number of nurses, physiotherapy and pharmacy prescribers, mental health workers, social prescribing link workers etc… who can support this shortfall in GP numbers. More flexible support for PCNs to recruit ``Additional Roles Reimbursement Scheme posts mapped to local community needs will alleviate the pressures on GPs and local GP practices. PCNs must be given sufficient headroom and support to improve individual and population health (see answer 7 below) as this will be the only means of reducing health service demand and enabling a financially sustainable health service.  Realigning funding streams to enable this “upstream” work will be required to avoid endless calls for further resources for our current system, which is evidently not working.

 

 

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

The provision of care and health of the population vary from region to region and deprived areas will require extra resource not only to improve access but also to reduce those inequalities.  Access and travel in rural areas are a specific issue and require revision of current funding formulary to equalise access.  In rural areas, however, the current practice model often appears to be less broken and some element of personal care and continuity maintained.  This argues for a different perspective on improving general practice and access in urban and rural areas. 

 

 

  1. What part should general practice play in the prevention agenda?

General Practice is perfectly placed to play a key role in disease prevention. Practices and PCN’s are embedded in their communities and offer a unique ability to connect with their population. This can be done through the practice site which is visited by patients and also through outreach schemes. Growing multidisciplinary teams around General Practice and PCNs will anchor primary care as the key pillar in community provision and involving local communities.

 

People generally have high levels of trust in their local practice and practice newsletters and communications are well read and responded to. 

 

A complete reversal of priority is now required. Prevention of illness should be our primary aim.  Lifestyle contributes to most diseases, in particular diseases such as diabetes, heart disease, COPD, cancers and mental illness. Even in disease which are not related to lifestyle, a patient’s lifestyle is likely to greatly affect their ability to cope with that disease. Increased isolation, reduced activity, poor diet and high levels of stress are key factors in almost all forms of morbidity and mortality.

 

Consequently, General Practice has the potential to radically reduce the amount of patients requiring hospital care and all other forms of medical care. Promoting lifestyle change requires investment in the social factors which facilitate healthy lifestyle. These may include green gyms, subsided fresh vegetables, access to social community centres and creative group-based activities.  General Practice teams are perfectly placed to promote and facilitate this messaging. A good model is the hub and spoke model whereby the Practice feeds out to community groups and activities which support radical lifestyle change.

 

General Practice should, however, extend beyond simply preventing disease and become a key element in improving individual and community health and wellbeing working alongside the local authority and VCSE sector - and thus reduce demands on the primary care team. General Practice should become the community arm of Public Health with funding flows to support this role.

 

 

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

We have replaced relationships with forms and pathways. The links between Primary Care Teams and Secondary Care Teams as well as other Community Teams have become very weak. This leads to GP’s feeling they are operating alone, filling in forms which are often rejected and trying to fit patients into strict criteria for admission to a service.

 

Good working relationships and high levels of trust between health professionals cuts the need for bureaucracy, boosts effectiveness and enhances morale. Enabling the establishment of high-quality relationships between people working in the healthcare system will transform it.

 

Lessons can be learnt from industry eg:- Google and Apple and other organisations which prioritise relationships, create a culture of valuing and caring for their staff and are thus able to motivate and retain them.

 

Over performance management and targets create a culture of fear and distrust. This leads to the cover up of difficulties and poor care and makes everyone more miserable.

 

Culture change is vital for the retention of good staff and for the improvement of patient safety. We must invest in and model a culture of support and kindness. This is essential. We must not vilify error or punish mistakes. We need to accept that error will inevitably happen and be willing to learn from it and discuss it openly and thus to minimise it. This is a big shift from the current culture. 

 

A lot of frustration comes from lack of agency.  GPs are often restricted from access to investigations or from initiating treatments they are well able to initiate. There are many instances where guidelines are imposed by local CCG’s and regulating organisations as if they were ‘Laws’. GP’s and other doctors need to regain their feeling of agency. Sensible, careful decision making is better than the rigid imposition of rules. Simple rules create complex decision making and complex rules create low level decision making.

 Our main recommendations are:-

a)      Stop the use of restrictive criteria and rigid pathways and encourage discussion and relationship building between individuals throughout the health care system. Atul Gawande writes about effective team working in his book The Checklist Manifesto. His work emphasises the importance of developing and paying attention to relationships within a team in order to improve effectiveness and safety.

 

b)      Change the culture of the whole organisation by initially changing how we deal with error. We need to shift from punitive assessment to supportive interventions. We need to encourage learning from error which first means accepting it exists. The Human Factors Group do a lot of good work on this. 

 

c)       Increase the agency of GP’s by allowing greater access to investigations and encouraging complex decision making with support from multidisciplinary teams and secondary care professionals.

 

d)      Reduce current bureaucracy such as the GP Quality Framework, the implosion of statutory learning and requirement for GPs to personally sign certificates of every kind. Restore the Cabinet Committee on GP Bureaucracy.

 

e)      Return to a system of overseeing General Practice that is hands on and supportive rather than distant and bureaucratic (i.e. similar to the Family Practitioner Committees of the past).

 

 

  1. How can the current model of general practice be improved to make it more sustainable in the long term? In particular?

a)      The traditional partnership model of general practice has historically served well and been seen as the jewel in the crown of the NHS – envied by other countries.  It appears largely broken today because of insufficient attention and support from the centre, which has found it difficult to manage the independent contractor status of GPs and seemed more comfortable with the direct accountability structures of hospitals and acute care. In some areas of the country it may be entirely broken and there is an argument for GPs becoming salaried with similar terms of service as specialist colleagues in hospital.  Establishing this in some areas could be an important experiment to see if recruitment, job satisfaction, access, personal care and continuity and cost effectiveness overall are improved.  Meanwhile, in many areas of the country the traditional partnership model simply requires greater respect and attention as it has in the past - when it has been properly supported - been able to offer personal care and continuity with connection to the community and good levels of access. 

 

b)      Current contracting and payment systems in general practice do not encourage proactive, personalised, coordinated and integrated care.  Nor do they encourage original thinking and solutions at local level.  The future (see above) needs to see payment systems that encourage general practice to take an active role in encouraging self-care, personal health, health creation within the community and a connection to all local services relevant to health.  They must also better balance the needs, wants, beliefs, culture and history of the individual patient and local community with the vagaries of national policy and priorities.  This will require mechanisms that enable a greater level of local discretionary funding balanced against national funding, which in total ensures that general practice and primary care do not lose out on their total proportion of NHS funding.

 

c)       Primary Care Networks have great potential to improve things but this has not yet been largely realised.  They need to be given greater autonomy and to connect better with individual GPs and practices as well as working at scale where this adds value.  Revised funding streams should enable and encourage them to look “upstream” to the self-care, health and community agendas.  The Westbank GP practice in Exeter, for instance, has seen a 30% reduction in appointments by engaging patients and using voluntary organisations and community services and working with local employers. Where social prescribing is advanced, it has been shown to significantly reduce the demand for GP services and future General Practice will need to build on its connections to the local community.  PCNs now need to anchor in to the health and wellbeing of local communities and become key pillars of Integrated Care Systems.

 

d)      Effective partnerships with other professions are crucial in improving general practice and its access.  Working with e.g. physiotherapists and pharmacists have been a success story in many areas, where recruitment has been possible.  More needs to be done to connect primary care with mental health and secondary care.  These connections need to be built upon if we are to ensure the right skill mix and appropriate triangulation of patient care as part of creating an economically sustainable model of future primary care. 

 

2989 Words

 

December 2021

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