Written evidence submitted by Dr James Findlay (FGP0201)

 

Table of Contents

Introduction

Historical Context

What lessons can we learn?

An option appraisal

Five-Together model

Discussion

Summary

 

Introduction

 

I am a Northamptonshire GP who provides clinical service and pathway redesign advice to our Clinical Commissioning Group as their Clinical Pathway lead. I am also a Named Safeguarding GP for Northamptonshire. The evidence I am submitting is my based on my experience of working in the NHS since 1982.

 

Historical Context

 

General Practice as the first and single point of contact (access) for patients has in general proved a successful model of healthcare delivery throughout the 20th century but over the last couple of decades the strain has been showing with a growing number of patients defaulting to A/E to meet their health needs. The demographic and cultural changes driving these health-seeking behaviours have been written about and are likely to operate for the foreseeable future therefore primary care itself needs to adapt and change. Modern healthcare has seen the steady expansion of medical knowledge and know-how with an ever-increasing number of treatment options. The ‘success of science’ is perversely a challenge for health delivery systems which must ensure that interventions are affordable and offered based on need. There is also the impact of an ageing population with associated multimorbidity and a greater need for integration of health and social care to help maintain independence and quality of life experience for all. Finally, there are the expectations of the individual, as a consumer, to have prompt access to care with good outcomes.

 

The impact of these societal changes on primary care has been the subject of ongoing discussion within CCGs and NHS England and there is broad agreement that General Practice needs to work at greater scale whilst still retaining its traditional values of accessibility and continuity of care. As a steppingstone towards this aspiration there has been the introduction of Primary Care Networks (PCNs) whose ‘place’ is the local neighbourhood. PCNs are at an early stage in their evolution and their focus since inception has been expansion of the practice workforce to include a wider range of health and care professionals such as pharmacists, physiotherapists, social prescribers, and care coordinators.

 

What lessons can we learn?

 

When contemplating the future evolution of primary care in England it is helpful to consider the merits and limitations of healthcare systems provided by other countries. For example, if we focus on the issue of access and look to countries where primary care has no gatekeeper role with patients choosing the specialist who they feel best meets their needs. Comparative data shows that this is a relatively expensive way to provide healthcare for a population and funding usually involves a private insurance-based system with the user making co-payments at the point of care. Other important disadvantages of this model relate to continuity and personalisation of care. The significant and rapid advance in the knowledge base of medicine has given rise to the saying that “increasingly generalists know less about more whilst specialists know more about less. The risk of a ‘direct to specialist’ model is that the doctor consulted will focus on what they know and might not see the bigger picture potentially leading to a delay in providing the most appropriate intervention or in a worst-case scenario, providing unnecessary interventions including surgical treatments which cannot be undone. On the other side, the jeopardy for the generalist is not being aware of treatment options or the best practice care of patients with less common conditions or sometimes common conditions which are presenting in a more challenging way.

 

In the UK, GPs can refer patients for a specialist opinion and advice on treatment. Outpatient Care, a system which has run alongside General Practice since the inception of the NHS, has its own intrinsic limitations. Inefficiencies arise from several factors, for example, difficulties in administration, waiting lists, duplication of effort, uncertainty over whether primary or secondary care is taking the lead, pathways that reflect the speciality rather than the patients presentation, for example, a heart or chest clinic instead of a breathlessness clinic.

 

Before going on to discuss potential solutions, I would just like to emphasise a common shared understanding amongst NHS workers, and that is; whilst individual healthcare professionals consult’ to define need, it is healthcare teams that deliver effective outcomes. Based on this accepted wisdom, it follows that increased scale should not come at the expense of team working because this would be a recipe for a dysfunctional NHS.

 

An option appraisal

 

So, if a single point of patient access is under strain and multiple points of entry has its limitations then what does good look like. From a mathematical modelling perspective, one can consider any key system quality marker that correlates with effective care and evaluate the impact of that factor (on the y-axis) against the number of points of access (on the x-axis) to end up with an optimisation curve. If you then combine all these plots into a single composite curve this will show you the number of points of access which has the best overall trade-off. Evidence through research tells us that the following system quality markers are important:

 

In the illustration below I have considered the advantages and disadvantages of one, several and many points of access to healthcare. I have used my own experience of working in the NHS to rate each generic model in terms of how they (might) deliver against each of the key system quality markers described above.

 

Effective Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Higher

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intermediate

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lower

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Care attribute

C

A

E

S

T

C

A

E

S

T

C

A

E

S

T

Access points

ONE

SEVERAL

MANY

Model

Traditional General Practice

Possible future model

 

 

 

Direct to specialist

 

 

The above analysis supports the ‘several points of access model’ with limited differentiation (subspecialisation) of primary care at place within a neighbourhood (Primary Care Network). This would have the following advantages over the current system of primary care:

 

Five-Together model

 

Subspecialisation of primary care within a neighbourhood invites a plethora of models. My instinct tells me that between 4 and 6 centres delivering different aspects of care but working closely together would be the optimal solution. The specific model described below has 5 centres, hence the Five-Together model. For avoidance of doubt, I am not suggesting that this model is definitive only that it has definite advantages over the current primary care system.

 

The Five-Together model comprises the following autonomous healthcare centres, which collaborate and interact with one another and together form a neighbourhood hub that subsumes the previous functions of primary and community care.

  1. Acute Care (same day) centre
  2. Medical Care centre
  3. Restorative Care centre
  4. Wellbeing centre
  5. Family Care centre

 

Centres

Acute Care

Medical Care

Restorative Care

Wellbeing

Family Care

Cohort

All ages

Adults

All ages

Adults

All ages

 

Key areas

of

healthcare
provision

 

Same-day centre for acute presentations including

infective exacerbations, undiagnosed illness etc.

 

The care of long-term conditions:

- Cardiology
- Respiratory

- Gastroenterology

- Diabetes 

- Endocrine

- Renal

 

Musculoskeletal
Rheumatology

Neurology

Head and Neck

Rehabilitation

Frailty
Memory services

 

 

Mental health

Neurodiversity

Dermatology

Palliative care

 

Child health

Paediatrics

Immunisations

Family planning
Sexual health

Antenatal care
Postnatal care

 

Key goals

 

  • Reduction of harm from acute illness
  • Reduced A/E footfall

 

  • Primary prevention
  • Secondary prevention
  • Promote self-management

 

  • Preserve function
  • Promote independence

 

  • Improve wellbeing
  • Promote resilience

 

  • Safeguard children
  • Promote family wellbeing

 


Key Components of Model

 

The following is a summary of the overarching purposes of each centre:
 

  1. The Acute Care centre has the function of managing acute illness irrespective of whether the cause is known or has yet to be determined. The centre also sees patients with minor injuries. Patients are seen on a same-day basis and can present as walk-ins or be referred by NHS 111. The centre can adjust its capacity to cope with times of higher (surge) demand thus protecting and leaving the local A/E department to concentrate on serious emergencies and trauma. Patients are reviewed as necessary until the acute illness has resolved. The centre follows clear risk-based management protocols ensuring that serious or deteriorating conditions are identified early and referred on to secondary care for further management. The centre has appropriate near-patient diagnostic facilities.

 

  1. The role of the Medical Care centre is to provide care for adults who have or are at risk of developing, long-term conditions affecting any of the body’s major organs, namely the heart, lung, liver, digestive tract, renal and endocrine system. The centre would therefore manage patients with conditions like diabetes, COPD, and ischaemic heart disease. Local specialists would provide support and expertise with the aim of reducing the need for medical outpatient care and savings reinvested back into primary care.

 

  1. The role of the Restorative Care centre is to focus on the maintenance and restoration of function and the promotion of independence. There would be a multidisciplinary approach to care so that problems are managed in a holistic rather than a procedural way. Local specialists from the appropriate disciplines along with physiotherapists, podiatrists, occupational therapists, nurses, and GPs would support the centre.

 

  1. The Wellbeing centre would seek to improve the mental health of adults by offering proven low level interventions using evidence based psychosocial approaches. The team would focus on what is preventing the person from enjoying good health and wellbeing rather than providing diagnostic labels. The centre aims to promote good mental health and personal resilience whilst reducing any perceived stigma. The team will include psychiatrists, psychologists, therapists, and primary care clinicians with a special interest in mental health. The current community mental health team will be subsumed into this centre.

 

  1. The Family Care centre would be responsible for the care of children with long-term health conditions and developmental disorders. The emotional wellbeing of children and young people will be paramount. The centre will also manage the reproductive and sexual health of adults and young people. Local family planning services would come together to provide a single point of access for high quality advice. Community midwives and health visitors will work alongside primary care clinicians with a special interest in child health. Acute and community paediatricians will also be important members of the team. The centre will have input from child social services with a focus on ‘think family’.

 

For any Primary Care Network, the numbers of each type of centre will depend on the location and distribution of NHS buildings (including existing surgeries), population density/demographics and other local factors. For example, in a PCN neighbourhood serving 50,000 people, there may be 2 or 3 Family Care centres but only a single Acute Care centre.

 

 

 

Discussion

 

The following discussion considers the questions posed in the enquiry’s terms of reference.

 

  1. What are the main barriers to accessing general practice and how can these be tackled?
     
  1. To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?
  2. What are the impacts when patients are unable to access general practice using their preferred method?
  3. 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?

 

There is no doubt that continuity of care is a vital ingredient for an effective NHS, both in terms of cost and outcomes. The question is how to maintain continuity in the face of adverse factors, for example, a move to part-time/portfolio working and the expansion of medical knowledge and health interventions. I believe that vesting continuity of care in a team rather than a specific type of health professional, is the way forward. This approach has been shown to be effective in the hospital treatment of cancer and the community provision of palliative care. It is for this reason that I have advocated limited subspecialisation of primary care within a PCN neighbourhood as described above. Each team involved with a patient can decide on a case-by-case basis, who is best placed to advocate for that individual, and this person could be a GP, nurse, therapist, or care coordinator, as appropriate to the person’s needs at that point in time. A team involved in the care of a patient’s asthma might choose a nurse, whilst a team involved in the patient’s rehabilitation following joint surgery, might choose a physiotherapist. I don't believe that there are enough GPs, nor can they have the necessary breadth of knowledge and experience, to advocate for every person across all their different health needs.

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

The overarching challenge faced by the NHS over the next 5 years will be its ability to recruit and retain a workforce which is sufficient in size and diversity of skills, to meet the health needs of our population. Changes in structure and/or new models of care will not on their own be sufficient. Retention of existing workforce must run alongside training new entrants to the NHS. To retain GPs and allied health professionals, there needs to be a step-improvement in the working environment currently experienced by clinicians and their staff. The subspecialisation model discussed above is compatible with portfolio working and supports the creation of purposeful teams, whose role and actions are closely aligned to clear health objectives. This clarity of role and purpose will improve teamwork and the sense of worth experienced by individual members of a team.

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

When considering variation, one must remember that human biology dictates that there is more that unites us, than divides us. Whilst recognising and acknowledging diversity is important in terms of understanding the patient’s perspective and life journey, there are overarching outcomes that usually transcend a person’s background, for example the desire for independence, existential meaning, social integration, and emotional wellbeing/resilience. Clearly there are geographical challenges posed by metropolitan areas with high population density and rural areas with low population density. Both settings would benefit from the availability of video-consulting and telemonitoring to improve access to healthcare. Areas of deprivation make additional demands on primary care and this needs to be recognised through the allocation of resources, so that clinicians ‘have time to care’.

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

Primary care provides a great setting for opportunistic prevention. People are more likely to change their lifestyle for the better if advice is provided by a person they trust at a time when they are emotionally ready to act on it. For example, a person undergoing treatment for a chest infection is more likely to be receptive to advice on smoking cessation. It is therefore important not to dilute the efficacy of contextual health promotion by mandating poorly thought-out one-size fits all population health interventions, such as requiring GPs to routinely ask about weight to achieve a quality performance measure. Population health promotion is better addressed by other methods such as social media campaigns.

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

GPs are a great source of knowledge and soft intelligence which is why partner agencies increasingly seek their views when there are safeguarding concerns. GPs are required to share information within the legislative framework of GDPR and redact 3rd party references and this process places an administrative burden on practices. This is just one example of why GPs spend an increasing proportion of their time on non-patient facing work which in turn results in longer working hours and/or reduced availability of patient appointments. The bottom line is that working more than 8 hours per day is not sustainable and has caused many GPs to reduce their sessional commitment to the NHS and is one of the main reasons for the decline in the partnership model of General Practice. Improving the flow of information in safeguarding situations without having an excessive impact on clinical time will release time for direct patient care and improve the morale of the GP workforce.

  1. How can the current model of general practice be improved to make it more sustainable in the long term? In particular:
    1. Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?
    2. Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated, and integrated care?
    3. 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. 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?

The Five-Together model described on pages 3 & 4 supports portfolio careers and whilst the model is not incompatible with a partner-led primary care, it does not require it and would perhaps be better without it.
The GP partner-led model has served the NHS well since its inception, but the challenges of this century make it less sustainable, as evidenced by the gradual reduction in GP partners and increase in salaried and locum doctors. With the shift to a locum GP workforce comes an increase in work-place mobility and a reduction in the continuity of care, organisational memory, and cohesiveness of teamwork. Although the partnership model has the benefit of being a clinician led service, unfortunately current recruitment issues mean that there are not enough GPs to meet both the clinical and managerial needs of a modern General Practice.

 

With respect to Primary Care Networks (PCNs), it is important to remember that these are very early in their evolution, and this means that GPs are having to invest a significant amount of time and energy to support their development at a time when the pandemic is also making its demands on primary care. Therefore, I would suggest that we need to avoid judging PCNs as successful or otherwise at this moment in time but instead keep the faith in their purpose and the reason why they were brought into existence. My other concern is that policy makers focus overly on PCNs as a vehicle for improving efficiency and capacity within secondary care which may have the unintended consequence of delaying their maturation and possibly reduce their potential to support primary care.

 

The move to allow allied professionals to take on work traditionally carried out by GPs is welcome but needs to be managed carefully. GPs are very effective risk managers whilst other health professionals by virtue of their training are more risk adverse when it comes to care decisions. Hence if other professionals are to provide added value in an extended primary care, they will need appropriate training and ongoing supervision, both of which will make calls on a GPs time. To optimise the value and safety of a blended team it will be important to make use of decision support software, especially expert systems, otherwise known as narrow AI. Full learning-systems offer less value to primary care since the evidence-based guidelines for best practice already exist and the challenge is in their implementation. Funding should therefore be targeted to support the development of expert systems for the management of common long-term conditions such as hypertension and diabetes which will support nurses and pharmacists to take on this work, thus freeing up GP time for patient care.

 

 

Summary

 

In the UK, the binary healthcare system of primary and secondary care has been broadly successful since the inception of the NHS, however, in the last 2 decades there has been increasing strain on the NHS due to cultural/societal factors and scientific developments. These challenges are not amenable to change, nor would we want to stop innovation in healthcare therefore the delivery system itself must change. Historically, experience of service redesign has served to highlight the importance of access, teams, and continuity of care. The NHS has also witnessed the unintended consequences of making unilateral changes to primary care which impacts adversely on secondary care and vice versa. The parliamentary enquiry is asking for evidence to inform the development of primary care and perhaps this is also the time to consider how primary and secondary care can better solve each other’s problems by working more closely together. Another important consideration informing this debate is the need to bring the cultures of social care, the third sector and healthcare closer to best serve the needs of the individual and society.

 

In my submission I have looked at access to primary care, comparing the single point of access (traditional General Practice) with multiple points of access (direct to specialist) and then considered the benefits of several points of access with limited subspecialisation of primary care within the footprint of a Primary Care Network. It is the last of these generic models which I feel provides the best opportunity for more integrated healthcare, where a degree of scale is achieved but without primary care teams losing the qualities that patients value in traditional General Practice. To illustrate the positive attributes of the ‘several points of access’ approach I have described the eponymous Five-Together model of primary care. No model of healthcare can ever be definitive and as such the Five-Together model is an example of doing things differently in a way that I believe addresses some of the main challenges that our current NHS faces whilst offering an opportunity for greater integration between primary care and other providers of health and social care, for the benefit of the service-user (patient).

 

As an NHS doctor for almost 40 years and a GP who cares greatly about our wonderful NHS, I thank our constitution for allowing me to share my personal thoughts on a public service which is important to us all.

 

December 2021