Written evidence submitted by Professor Roger Jones (FGP0200)

 

Author: Professor Roger Jones 0BE MA DM FCRP FRCGP FMedSci

 

I was head of general practice at Guy’s King’s and St Thomas’, later Kings College London, School of Medicine for almost 20 years. I am an experienced researcher and educator and have written over 300 original articles. During my 30+ years as an active general practitioner I worked in five different practices in England, in rural Hampshire, Southampton city, inner city Newcastle and rural Northumberland, and central London, where I was the head of Lambeth Walk Group Practice. I have visited many other general practices in this country and across the world. I was the Editor of the British Journal of General Practice between 2010 and 2020.

 

I am submitting this evidence because I think that my experience and observations about general practice and its current difficulties will be of value to the Inquiry.

 

Introduction.

 

Although the Covid pandemic has highlighted and exacerbated difficulties faced by general practice, the problems go back much further. Key factors include long-term under-investment in general practice, leading to a substantial shortage of GPs, changing patterns of disease, with increasing numbers of people with chronic, non-communicable diseases and comorbidity, changing demography and population behaviour, with rising levels of obesity, cardiovascular risk, and socio-economic deprivation, and changing expectations, both among patients and the medical workforce. There has undoubtedly been a rise in “consumerism“, among patients and a move towards part time and “portfolio“ working amongst GPs, against a background of the “feminisation“ of the general practice workforce.

 

There now seems to be a crisis of confidence, morale, and commitment in general practice. Again, this has been brought into sharper focus by Covid, but the problems were brewing for some time before. 20 years ago, when the partnership model of general practice was prevalent, most GPs were more or less full-time, which meant that they did perhaps seven or eight clinical sessions a week, with some night-time and weekend on-call and Saturday morning surgeries. This all changed with the new GP contract, and the changes did not enhance either the reputation or the effectiveness of general practice. As salaried practice and part-time working became more established, GPs seemed to find the job progressively more difficult. The reasons for this include the effect on clinical confidence and competence that fragmentation and dilution of patient contact create. It’s worth spending a moment to understand this.

 

There is a mantra in business management that it takes 10,000 hours to become an expert. I reckon that, in full-time practice, it took me over three years, with a stable list of patients in a stable and well supported practice to become comfortable and confident with dealing with my patients. Because I was there a lot and because we knew each other, it would be perfectly possible for me to say “Sorry, we are running a bit late today but could we perhaps pick this up again later this week?”. Now, if a young GP is only doing three or four sessions a week, perhaps in more than one practice, with all the difficulties that an unfamiliar professional environment brings, this continuity and understanding of patients is completely lost, so that every patient is a new patient, every patient a new and potentially anxiety-provoking challenge. I’m not surprised that our young GP workforce feels anxious, unconfident and potentially burnt out. This is not the way that general practice was supposed to work. General practice is a difficult but enormously rewarding and potentially very enjoyable profession. It is a tragedy that some leaders of the profession have allowed us to sleepwalk into the situation where we are creating a general practice workforce which is no longer really fit for purpose.

 

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

 

Before Covid the main barrier was a simple imbalance between demand and supply. Too many patients, too many complex problems, not enough doctors and probably not enough practice nurses, administrators, receptionists, and other members of the primary care team. Years before Covid practices were experimenting with pre-consultation emails, telephone triage in many different forms and video consultations. Indeed, a research evidence base for remote consultation was gradually being built by researchers in general practice in the UK and elsewhere. Some practices had already incorporated digital consultations into their practice systems, but many had not. This is one example of the wide variation in working practices (and in standards and quality of care) that exists in general practice across the country, and which is not always acknowledged. It makes it difficult to generalise, and the truth is that there are plenty of practices where morale is high, standards are excellent and technology is fully integrated into working practices. There are many others, sadly, who have hardly begun to think about developing methods of working that would be regarded as appropriate for today’s demands on primary care.

 

Plans to increase the number of GPs, by increasing medical student numbers and the number of GP training places are, of course welcome, but these are contingent on numbers of applicants, and are not quick fixes. It seems to me that something which would generally help to raise the morale of general practice and improve access and efficiency is needed as a relatively short-term intervention. In the era of the STPs (Sustainability and Transformation Partnerships) it seemed to be almost impossible to get money quickly to practices that were facing staffing problems or needed help with premises. The size and complexity of the ICSs – Integrated Care Systems - may also prove to be a problem, and some directly targeted extra funding for general practice, perhaps a GP Technology Fund to boost or kick start practice ITC systems would be welcomed. Perhaps some carefully focussed Practice Support grants to help practices facing recruitment or service difficulties could be made directly from ICS resources? Extra funding for more nonclinical practice staff to help with triage, admin, and care navigation? Is it the right time to re-visit the old arrangements by which will-trained doctors from the “old Commonwealth” could be given automatic GMC registration and licenses to practice encouraging medium to long-term recruitment from Canada, South Africa, Australia, and New Zealand – not easy, I realise, at a time when international travel is so constrained.

 

The impacts on patients of reduced access to general practice are, naturally, substantial, all practices need to be supported as well as possible in ensuring that the historical problems of general practice, the more recent difficulties generated by the Covid pandemic and now the imperative to increase the rate of booster vaccinations do not further compromise patients’ ability to receive timely and high-quality clinical advice. Delayed diagnosis of serious disease such as cancer is, of course, high on the agenda but patients with mental health problems and a wide spectrum of other medical problems still need to be seen face-to-face whenever possible. It is very difficult to make sense of subtle, undifferentiated symptoms over the telephone or by video. Algorithms and NHS 111  are not a great help and so frequently the default advice is to see a doctor or go to A&E. This is very challenging when there aren’t enough doctors to go round. Patients should not be actively deterred from contacting the GP surgeries. Long telephone waits to speak to a receptionist or nurse could be avoided by bringing in additional staff. Skilled telephone triage could perhaps be distributed more widely across the primary care team, and greater remote monitoring/surveillance of chronic diseases such as asthma, diabetes, and hypertension could potentially free up clinical time. We’re not even thinking about community/residential care in the Inquiry, which tells a story.

 

The role of a named GP and continuity of care is a very important consideration. There is mounting research evidence that greater continuity of care is associated with better health outcomes, including lower mortality, so it is worth striving for. As mentioned above, a long-term relationship between doctors and their patients makes the job not only more efficient but more satisfying and less anxiety-provoking. Alternatives to a single named GP include a “buddy“ system where two doctors take joint responsibility for a group of patients. Continuity of care with another member of the primary care team, such as a practice nurse, may be more relevant for certain other patients. Portfolio/part-time working and split-site working are not consistent with providing this kind of continuity, and there may be opportunities within PCNs to consolidate some of these efforts.

 

The main challenges facing general practice over the next five years have largely been alluded to: funding, recruitment, retention, morale, variation in clinical standards, access and infrastructure/premises all require consideration. General practice used to be regarded as the jewel in the crown of the NHS and this is the position that the leaders of the profession need to be striving to return to – although perhaps with a transformed version of general practice.

 

Such a transformation may be brought about by realising that the small-business, quasi- partnership, gatekeeping model of general practice is unlikely to remain fit for purpose in the years ahead. The OECD league table of health outcomes shows the UK at about the mid-point, with 20 to 30 other countries above it in terms of metrics such as avoidable mortality and cancer survival. By no means all of these countries have a gatekeeping general practice sector, and almost none of them have a funding model like the NHS. The previous Chief Executive of the NHS has, with other commentators, stated that “If general practice fails, the NHS fails”. This isn’t a proposition that I would like to see tested at the moment, but I think it is important to recognise that other funding models and other models of the relationship between primary and secondary care may work to patients’ advantage. The Dutch system, which delivers excellent health outcomes, depends on a national network of primary care centres with 24-hour access and investigation/assessment facilities similar to some accident and emergency units. General practice in the Netherlands is very highly regarded – universities play a greater role in training the GPs, a substantial number of Dutch GPs go on to take higher degrees and most seem to be signed up to evidence-based medicine. We have a lot to learn, I believe, from that system, and by looking across Europe and beyond at other ways of delivering high quality care which do not necessarily depend on a formal gatekeeping system. The barriers between primary and secondary care have in many ways been the bugbear of the NHS since its formation and may need to be seriously re-evaluated in the context of the establishment of ICSs. Perhaps some really courageous ICSs could be persuaded to try our a much more integrated primary: secondary care relationship – exiting A&A departments could become primary care hubs and for acute care a shift system for part time clinicians could operate and be complemented by a mor traditional set of arrangements to provide continuity of care for those patients who need it. There is research evidence to support the re-casting of the GP role in this way, and added benefits for communication and understanding across the primary: secondary care interface

 

Regional variation is important but I suggest that smaller-area variations are even more important and maybe even more resistant to change. For many years it was a commonplace to find a very well-developed practice in one part of London, only a few hundred yards from an old-fashioned, lock-up single-handed establishment. Things have improved, but variation in standards, premises and practice remain in many areas.

 

General practice and prevention

 

There have been definite moves to recognise more clearly the public health role of general practice, beyond a general commitment to health promotion and involvement in various screening activities. This probably isn’t the best time to have this discussion, given the massive pressures on general practice to deal with acute problems and long-term, serious illness. General practice is, of course, extremely well-placed to undertake practice surveillance and screening, and to use the practice premises as a kind of well-being hub. If primary care centres like Bromley by Bow can do these kinds of things, why can’t we all? Many practices are adopting the RCGP Green Practice Tool Kit to engage with that most crucial aspect of prevention – climate change. The spirit is, I think willing, but the fabric is on the weak side.

 

Reduction in bureaucracy and burnout, increasing morale.

 

This question is framed as though bureaucracy is the main culprit here, but many other factors, some of which are discussed above, contribute to burnout, including anxiety about clinical competence and patient safety, pressures of time and patient demands and everyday stresses of work and life outside general practice. Reduction in bureaucracy would certainly help, and this needs to be done with your regard to retaining sufficient metrics for quality of care to ensure that public confidence in general practice high and which are sufficiently sensitive to identify underperformance and problem practices. Reduction in intra-practice bureaucracy is certainly possible – a recent study by the Oxford Internet Institute suggested that as much as 40% of back office” functions in general practice could be automated. Addressing this could be part of my suggested GP Technology Fund initiative.

 

Improvement in the current model/traditional partnership model

 

It’s probably a painful truth that we are seeing the last of the traditional partnership model, although we must not lose the idea of well-functioning primary-care teams working on good premises with adequate professional support delivering high quality care to a defined practice population. However, if these building blocks of good primary care are part of a larger organisational structure, such as a Primary Care Network, or other structure within an ICS, with significant economies of scale in terms of procurement, back-office functions, administration, and stuffing flexibilities then we can still retain some of the really important core functions such as comprehensiveness, coordination, and good access to personalise, continuous care. We have learnt so much about what constitutes good general practice that it should not be too difficult to ensure that new structures, notwithstanding possible changes in the porosity of the boundaries between primary and secondary care and social care in future, retain these core values.

 

Personalised, coordinated, proactive and integrated patient care?

 

The subtext to this question is that GPs never do anything for nothing. History, including the role of BMA negotiators, tell us there is some truth in this, although I still believe that the great majority of GPs want to do a good job for their patients, and just need more help in doing it. When the QOF was introduced, there was general surprise in administrative circles at how high the standards of general practice already were, before the incentive measures were announced. That said, the quality of practice care requires metrics which should be published, transparent and understandable to patients and administrators alike.

 

Working with other professionals

 

There are many examples of high-functioning primary-care teams where general practitioners work creatively and efficiently with practice nurses, nurse practitioners, physician associates, counsellors, psychologists, physiotherapists, and others. However, the interface between primary care and secondary care is often a less healthy area, with professional silos and territorial thinking at play. Consultants are dumping work on GPs; GPs are not getting a proper service from hospitals and patients are being returned either to them or to the community without being properly treated. I don’t think that working with non-GPs is a matter of freeing up time so the GPs can do more GP work – more a question of ensuring that a team is assembled which meets the needs of all patients in as cost-and clinically-effective a way was possible. Whether we will see major changes in the gatekeeping role of general practice in the future, and hence relationships between consultants and GPs, remains to be seen.

 

An absolutely key relationship, particularly at this time of integration across healthcare sectors, is the relationship between GPs and social work. For years it has been notoriously difficult to organise case conferences and meetings between primary care professionals and social work colleagues – being able to meet virtually, using high-quality video links, could turn out to be one of the real benefits of the pandemic in terms of bringing these groups together quickly and efficiently.

 

I hope these comments are helpful to the inquiry. I’d be very happy to provide any other information/views if required.

 

December 2021