Written evidence submitted by the Avenue Surgery Warminster (FGP0195)


I am the manging partner at the Avenue Surgery in Warminster, Wiltshire. I represent the views of the partners and managers of the practice, and feel strongly compelled to submit this document owing to the situation that we now find ourselves in.


We are an 18 thousand patient training GMS practice in a market Garrison town. We support a significant elderly population including 201 care home residents. Over a quarter of our patients are aged over 65 years. As far as GP numbers are concerned, we have eight full time partners, with no salaried GPs, and are supported by an experienced management team and a staff of whom we are immeasurably proud. Historically we have followed a named patient system, with pre-booked and on the day triage, and in the last two years have expanded our workforce to include two paramedics, two pharmacists, a pharmacy technician and an extensive Living Well team including a dementia nurse, social prescribers and care co-ordinators.


Prior to the pandemic we had a traditional appointments-based system, working mainly in our main surgery but with our triage and minor illness service run at our secondary site a 5-minute walk around the corner. We had at busy times particularly a 6 to 8 week wait for those patients who wished to see a GP of their choice, but we could pre book appointments for the whole year as our annual leave was arranged and booked the previous autumn.


Since the pandemic we have had to, like every other surgery, make substantial changes. We now run an on the day triage service, have a dedicated hot hub, use eConsult and texting to an considerable extent. We still do, and always have done, see patients face to face when needed. We have continued to do vaccinations, smear tests, LARCs and other services. We have visited patients who need to be visited. We have also increased our reception capacity markedly, spending over £100,000 on employing six extra receptionists, installing an updated phone system and reconfiguring our space to accommodate the changes, in the process losing one of our two main waiting rooms.


We participated in the Covid Vaccination Programme, not an easy ask of us as we had to do all of our vaccinations at the site of our other PCN practice, at the weekends only and with a heavy GP input. To be clear, this was not a means of money making for us, we were determined to provide this service for our population.


What are the barriers to accessing General Practice?

We have a limited capacity and an increasing demand. We have expanded our workforce including the introduction of three new teams and we have absolutely run out of space to accommodate more. Workforce availability is also a challenge, two examples are first contact physiotherapists and Mental Health triage nurses. ARRS funding for the latter is limited and when Secondary Care is struggling to recruit sufficient numbers there is very little scope for General Practice to find staff. There is impact on demand from at least the following:

              The backlog for surgery or other treatments, creating a need for medication, which can then lead to side effects or other issues, or psychological support, sick notes and patient frustration.

              Increased calls from those with upper respiratory infections, sore throats or coughs. We have tried to emphasise the guidance on obtaining a PCR test when a patient has symptoms but still they call. Patients also call because they want a covid vaccination, because they want us to say they don’t need a covid vaccination or because they have reacted to their covid vaccination.

              An increased level of stress within the community. The population is weary, anxious and lacking in the basic social outlets that would normally dissipate stress.

              Misconceptions about our service, despite trying on social media, in the local press and by texting, to inform the population that our service has been ongoing. The press have been toxic, and the Government has either fuelled this deliberately or by dreadful mismanagement. The plan for improving access by NHSE was utterly misjudged. As a collective our partners and staff were appalled at the lack of understanding of what we actually are doing. The vast majority patients have been grateful for the efforts that we have made to provide them with a responsive, caring and comprehensive service, but there are those who think we have been closed, that our GPs have “had a break” or worse. The frontline for any abuse is our reception team but they inform us when it happens.


What is the impact when patients are unable to contact us by their preferred method?

They can phone us, they can do an eConsult, they can email us through the website, they can write to us and sometimes do. Age is no barrier for technology, and we have patients in their 90s happily texting us or sending us blood pressure readings online. The only technology that did not work was video consultation. We are in rural Wiltshire with debatable internet coverage and the attempt to view a rash or other complaint by video generally led to a face to face appointment.


Regarding a named GP

It is easier now to have contact with your own GP than it was pre-pandemic. As stated before we had up to an eight week waiting list before, now we have on the day triage. Patients are asked to call or eConsult on the day that their GP is in, we call our own patients as requested and if they need to or wish to be seen we see them on that day. The feedback from patients is very positive, we intend to preform a patient survey in January to confirm this and/or refine the system if needed.


Main challenges for General Practice

The challenges facing us include recruitment, patient expectation, the social care crisis and funding. There is a shortage of GPs wishing to be partners, let alone full-time partners. There is now also a shortage of GPs wishing to be salaried GPs – I have had this discussion with locums who opt for this as a preferred option to the salaried role. We are advertising to replace a retiring partner in April, plus a salaried GP and have had no response either locally or nationally and this is the picture around the UK. GP trainees see increasingly fatigued, disillusioned and overworked partners who they observe holding General Practice together at significant personal cost, and not surprisingly do not want to sign up. This exacerbates a situation where more senior GPs leave to become locums, again we have experience of this, or retire early.

Patient expectation has changed, and as one colleague says, “the speed and instantaneous requirement for resolution reflects our modern day life”. The “Supermarket Medicine” approach is helped by our technology, but we are also expected to provide adequate adjustment for those who do not wish to make use of such advances. Our administration task level has risen relentlessly, we are working through our time off and at weekends. Additional staff have helped to manage the burden but cost the practice and as stated before we have absolute building capacity restraints. Falling income, and in 20-21 our practice profit fell by £120,000, also impacts recruitment.

Social Care is beyond capacity, year on year hospital beds are blocked by patients with no relatives able or even available to look after them, no carers or no appropriate place that would meet their needs.


I cannot comment on regional variations. We have close and supportive community in a town with plenty of motivated and capable patients, and we are finding the situation challenging.


What part should General Practice play in the prevention agenda?

This is an integral part of our work and we take it seriously. Despite a blood bottle shortage, losing waiting room space, the challenges of fitting patients in for blood test appointments (especially as we are now doing bloods for Secondary Care in addition to our own) and the backlog of hospital waits we continue annual medication reviews and health checks, smoking advice, smears and vaccinations, contraception. The pandemic interrupted progress on Military Veterans support initiatives that were planned but is still part of our agenda.


What can be done to reduce burnout and improve morale?

Firstly, stop messing us around. We have put time and effort into QOF and IIF, now funding is to be taken away from us and given to those PCNs who are vaccinating. We have made a clear decision to prioritise the care and monitoring of our patients over providing a vaccination service that should and can be delivered by a National Service, not at the cost of exhausting our workforce.

Secondly, the massaging by NHSE and the Government regarding General Practice is dreadful. The press amplify anything they can, and we bear the brunt. Many feel that there is a campaign to discredit GPs, thereby making it easier to force them into various corners. It is generating significant disillusionment and has to stop.

Come and visit us. Our MP wrote to us a few years ago about waiting times, a morning spent in our surgery clarified the challenges that we were facing and the effort we put into our work. If anyone undertaking this enquiry wants to see what we are doing, the constraints that we have and the efforts that we have made to provide our service we would welcome their visit.

Make partnership more attractive, both to those who wish to leave, and those who are disinclined to join. At the very least increase ARRS funding and make the roles and recruitment more flexible.

Support with estates expansion and freeing up of space would be appreciated. Funding to digitalise all paper Lloyd George notes would be a good start. A dedicated team to assist estate planning and funding would help also.


Is the traditional model of General Practice sustainable?

There is no better alternative, and The Government should know this and do everything in it’s power to support the model. It is only by hard work, ownership of responsibility and by caring about our patients that partners hold General Practice together. This obviously is variable depending on the practice, and I speak from the view of a partnership that is strong, communicative, innovative and caring. Nonetheless partner numbers will be reducing at an alarming rate unless serious measures are taken to support them. There is no magic GP tree or secret supply of locums.


Does the payment system improve delivery of proactive and personalised care? Possibly, through QOF and initiatives such as IIF. QOF has its merits, but is designed to trip clinicians up, partly but the later change in parameters mid QOF year, partly by the hidden challenges in the QOF alerts. Only those practices with administrators and clinicians alive to the best way to extract points from QOF will make the most of it. Does it reduce the administrative burden on GPs? No.


Has the development of PCNs improved the delivery of personalised and integrated care? The original remit was commendable, and exciting. We had multiple projects, increased locality contact with our co-PCN practice, and the opportunity for all Clinical Directors around the County to meet up and develop services in Wiltshire. Our PCN projects included work with veterans, contact with local school and working with the local Geriatrician on support for the frail elderly. ARRS funded workforce has been very helpful and should continue to expand.

When the pandemic started there was mutual support to a degree and with the advent of the Covid Vaccination Programme our two practices had to and did work together. We have now however taken different routes regarding this. It is clear that using PCNs as a conduit into General Practice is considerably easier and less time consuming for NHSE, but practices are self-managed entities that have for decades operated independently. Different practices may have different approaches to patient care, staff and finance and it takes a significant amount of time and effort to achieve a co-ordinated response, especially if there is disparity in the engagement of the different parties. The PCN approach does not reduce our burden, it can be restrictive, clumsy and often frustrating.

We have an excellent working relationship with our local cancer care nurses, our district nursing team and, through our Care Homes MDT, the Social Care, Mental Health and Care of the Elderly representatives. Our CCG support has been excellent and our frustrations with the challenges that we face are shared by them. None of this frees up extra time for patient care, however, it just means that we can work together better as a team to supply the care that we wish our patients to have.


December 2021