Written evidence submitted by Midsomer Norton and Clinical Director of 3 Valleys Health PCN (FGP0205)

Submitted by Dr Elizabeth Hersch, GP Partner St Chads Surgery, Midsomer Norton and Clinical Director of 3 Valleys Health PCN

3 Valleys Health is a 9 practice PCN in Bath and North East Somerset with a population of 67 thousand people. Our CCG is BANES, Swindon and Wiltshire.

These are my own observations based on numerous conversations with colleagues. I have been a GP since 1997 and a partner at St Chads Surgery since 2001. I have been clinical director since 2019 and previously had leadership roles in the CCG and PCT. 

I am passionate about ensuring the future of general practice is bright and sustainable for many years to come and believe that PCN’s supporting individual practices are a major part of the solution to thriving primary care.


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

Getting through to the practice on the phone, lack of confidence using IT ( eg e consultations, online prescription ordering) , lack of trust in automated services eg Accubook and Healthcare Apps eg GetUBetter, confusion regarding which service to use and when , unwillingness to use other parts of the health service eg community pharmacies, reluctance to speak to other non- GP clinicians eg ARRS staff, perception that phone consultations are inferior to face to face consultations and appointments at inconvenient times.  Covid IP&C requirements also reduce capacity. Long waiting times to see a specialist and get investigations mean these complex patients need to be ‘held in primary care’ longer.

Main issue is lack of staffing capacity to match rising demand. Most of our PCN practices are already on cloud- based telephony systems but the problem is insufficient reception staff to answer phone lines and deal with requests. Many practices have been unable to manage a large surge in demand from e consultations.  PCN care coordinators help our vulnerable patients access care and we encourage on- line prescription ordering at every opportunity. Public campaigns are required to encourage people to use community pharmacies and see other clinical staff in the practice team. Whilst the ARRS scheme is welcomed it is too rigid and does not cover the substantial management and supervision costs and time incurred. With workforce challenges evening and weekend working is very unpopular with staff who need to recover from ongoing high and unsustainable workloads.  Tools such as Cinapsis to connect with specialists are very helpful but avoiding a referral often takes longer than referring to another service.


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

It is helpful to postpone Improving Access, have a zero tolerance to staff abuse and continue to reduce bureaucracy. There are also opportunities in using data from cloud based telephony systems,  having digital locum pools, updating websites and primary care hubs. However the plans did not allow for local innovative solutions and there were too many performance measures and heavy handed consequences. Primary care needs to be trusted and given autonomy to do what is right for our populations.

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

My practice has a number of examples of delayed serious diagnoses , increased number of complaints involving our local MP, increase in A&E attendances and NHS 111 calls and unprecedented abuse to staff from frustrated and angry patients. This feeds into reducing staff morale.  Our observation is that if patients call NHS 111 rather than their own practice then this service has a lower threshold for calling the ambulance service or advising an A&E attendance. This is understandable given the use of Pathways algorithms, lack of access to medical notes and stretched clinical hubs trying to validate these calls.

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? Our experience (backed up by evidence) is that continuity of care is good for patients and clinicians. It results in better care and reduced healthcare costs. Modern day continuity of care is not about just having a named GP but needs a MDT approach . Our PCN wants to adopt the RCGP continuity of care toolkit.

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

Rising demand and costs, recruitment and retainment of staff (especially clinical), excessive and dangerous workloads for GP’s , continuity of care with part time and MDT working, partnership model and inadequate premises.

How does regional variation shape the challenges facing general practice in different parts of England, including rural areas? My PCN is mainly rural. The reduction in dispensing income means some village practices and branch surgeries may need to close. There is little or no public transport for people to use to get to appointments. We have a high number of care homes which require a great deal of support. There are many new housing developments with very little increase in local resources to match the population increase.

What part should general practice play in the prevention agenda?

This should be a big part as we are good at delivering successful immunisation and vaccination campaigns and hitting high screening targets. We do need more resource and support from public health at neighbourhood level to focus on population health management and inequalities, early intervention and addressing the wider determinants of health.

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

Referral processes are too complex and choice is a distraction. Bids for small pots of non- recurrent funding are seldom helpful but devolved budgets with a few key outcome performance  measures are better . QOF and IIF are too complicated and difficult to manage without the right tools eg real time PCN dashboard. Guidance keeps changing and it is very hard to keep up with it. Primary care is over- regulated and professionals need to be given more autonomy to do the right thing for those they care for.

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


Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

I have been a GP partner for over 20 years and I still believe the partnership model has a place in the future. Our practice manager is a partner and we would consider others eg a clinical pharmacist also to become partners. Partners tend to invest in a practice over the long term and are key to continuity of care. It is good to have partnership as part of career choice and progression but continue with salaried options and more flexible retainer schemes. Partnership Liability needs to be limited and golden hello’s help.


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

No. These are not fit for purpose. Systems are complex and confusing, not aligned with other parts of the system and do not reflect actual work done. Primary care has insufficient resource allocation and much of the money for the NHS never reaches the frontline. We calculated that it costs £155 per patient per year which was less than a colleague pays for veterinary care for her cat.

Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?

Our PCN is working well collaboratively but we are not yet mature. I believe with the right support and resources that PCN’s will deliver this vision. PCN’s projects such as aligning CQC policies should help reduce this burden but many PCN processes are very inefficient and increase this burden eg claims for ARRS staff. We need to be ‘governance light but watertight’ as shown during the pandemic.

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?

This is an important priority for our PCN eg our clinical pharmacists are working with the community pharmacists, we are working closely with the voluntary sector and community teams via our care coordinators and SPLW. As clinical director I work closely with the local acute hospital and mental health teams.  We also meet our school leaders and public health colleagues.

Many thanks for taking the time to read this.


December 2021