Written evidence submitted by Dr Imogen Staveley (FGP0211)

Introduction

I am a salaried GP in North Warwickshire.  I work part time in an urban practice with ~20,000 patients.  Most of my patients are from a low socio-economic background.  I felt passionate to submit evidence because I care deeply about my patients and want to sustain a high-quality general practice which is free to access and which strives to reduce health inequalities.

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

Barriers to access:

• Increasing demand due to:
• Patient behaviour – ‘Amazon prime’ generation – want everything now
• Patients having long waits for secondary care so GPs managing in short term
• Increased mental health issues following pandemic
• Growing population particularly in certain geographies
• More complex patients, increase in frailty
• Patients have ‘saved up’ problems that they did not come for during the pandemic
• Patients using GP when other services fail them e.g. social services
• Patients using GP as signposting service because other service access unclear or ineffective
• Lack of workforce due to:
• Insufficient numbers being trained
• Increase in part time working/portfolio careers
• Many leaving the profession prematurely
• Competing priorities:
• General practice now does so much – complex care, acute, care, prevention, COVID vaccinations, medicals, reports and more

How can barriers be tackled:

• Genuine engagement and consultation with staff working in the health and social care system and the public about what the future of general practice should be.
• Practices need to be supported to take a quality improvement (QI) approach to determine how to provide access.
• National bodies need to provide guidance, resource, tools and sharing of good practice to facilitate local QI approaches.
• It would be detrimental to go back to pre-pandemic ways of working but what isn’t clear is the right approach for each practice going forward. 
• Workforce planning – this needs a strategic approach for the next ten years to consider what roles need to be trained up and how different roles should work together.
• Workforce retention – again, a strategic approach is required.  Useful resources to guide this include: Michael West’s Caring For Doctors Caring for Patients https://www.gmc-uk.org/-/media/documents/caring-for-doctors-caring-for-patients_pdf-80706341.pdf  and the IHI’s Framework for Improving Joy in work http://www.ihi.org/resources/Pages/IHIWhitePapers/Framework-Improving-Joy-in-Work.aspx.
• Support with technology – for many, technology to support access is poor and not only is the hardware and software outdated but the IT support on a day to day basis is not fit for purpose. 
• Communications with the public and media to honestly reflect the situation in primary care and build trust between patients and their primary care services. 
• Strategically think about how to enable patients to self-manage and find support for their health in the right place first time. 

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

• The plan did not address the very real and difficult discussion that needs to be had with the public about what type of general practice we need and what can we manage with the resources we have. 
• The plan promoted face-to-face care with a GP being superior to other types of primary care access with no rationale as to why. 
• By recommending publishing of earnings it also terrified many staff who believed that this would lead to more targeted abuse by the public and even violence.  Although part of the document mentioned measures to defend practices against abuse, this was an afterthought and not sufficient. 
• Unfortunately, the plan added fuel to the fire of the press who were able to continue to pit patients against general practice. 

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

• This question is complex.  ‘Access’ needs breaking down – does it mean access to a clinician or access to some sort of signposting service at the surgery be that a receptionist or an online portal or an automated telephone?  ‘Access’ means different things to different people.  
• More research is required into what patients deem as appropriate access and a conversation is required with the public about what is reasonable access to expect in general practice.
• ‘Access’ has an impact on patient experience and may also have one on their clinical outcome.  Patients want this concern dealt with at the right time and in the right place. 
• The NHS has a responsibility to ensure that access routes are clear for patients and that patients are given confidence in the services they are accessing.  Part of building confidence is making it clear to patients how different staff members and organisations within a system work together to ensure a patient receives joined up care. 
• Access must be equal to all and not increase health inequalities. 

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 pivotal for many.  However, how that continuity is achieved is what is important.  We must be realistic; GPs do not work 24/7.  Therefore, it is about teams of GPs and other staff working together to ensure a patient receives seamless care. 
• Having a named GP does not always solve this problem: the GP may not be available when the patient needs them; the patient may not have a good relationship with their named GP; a GP may not be best placed to coordinate their care.
• Further discussion on what continuity of care means and positive case studies on how it is achieved would be welcome in the GP community.  This needs debate, engagement, co-design and communication with patients.  A QI approach is required when re-thinking access.
• Technology and data sharing need to be optimised to support teamworking and continuity of care.  For example, safety net systems need to be strengthened.

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

1. Workforce recruitment and retention
2. Patient expectations – general practice must deal with ‘wants’ as well as ‘needs’
3. Estates – primary care estates not suitable for modern needs
4. Must find a voice in integrated care systems
5. Making the most of primary care networks
6. IT – not only is technology outdated but the support around it is very poor in many areas of the country
7. The new generation of GPs are choosing to work differently, and this requires re-thinking of how general practice moves forward
8. Patients’ needs are changing, patients are ever more complex, and many have co-existing mental and physical health problems
9. Balancing providing an acute service with prevention and managing complex patients
10. Balancing general practice with taking part in the COVID vaccination campaign

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

Regions do vary.  Therefore, support for localised approaches is key.  Integrated care boards (ICBs) must set strategy but support a bottom-up place-based approach in the main.  ICBs must have reducing health inequalities core to their strategy.

What part should general practice play in the prevention agenda?

• This question needs to be considered in the wider context of what the general practice of the future should be delivering on.
• General practice is well placed to play an active role in the prevention agenda.  Staff in primary care can role model and they also know their population and can target prevention initiatives appropriately. 
• To do this well, they must have appropriate services to signpost patients too.  For example, if they advise to stop smoking but there is no smoking cessation service available then it is ineffective. 
• Also, they need time and resource to do it. 
• Finally, the way it is done needs a rethink.  In the past, when seeing the majority of patients face-to-face, doctors, nurses and healthcare assistants would do a blood pressure opportunistically and then manage it.  Now, if a patient is seen virtually, opportunistic checks are harder to do.  Furthermore, there are now additional roles in general practice and their role in prevention and coordination with other clinicians needs considering.
• Prevention must be done increasingly collaboratively between general practice and other organisations such as: workplaces, religious venues, pharmacies and schools.  These organisations could provide health ‘pods’, where self-diagnosis and management is promoted, and self-referral lifestyle service information.  Furthermore, non-clinical people such as carers and social workers should also be able to directly refer to lifestyle services.  General practice can then be involved in those requiring medical management. 

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

• Reduce bureaucracy
• Use of AI to manage documents
• Training of administrators and physicians’ associates/pharmacists/medical assistants to support with managing bureaucracy
• Improve technology to support referrals – currently digital systems, like DXS, are used which are clunky and outdated.  Primary care needs a single place where localised evidence-based pathways are available, with hyperlinks to referral forms with embedded patient details.
• As much as possible we need single points of access both for routine referrals but also for acute referrals.  In Warwickshire, GPs call a liaison nurse at UHCW, if they need to do an acute referral – she can signpost a patient to the right service for them. 
• Reduce burnout and improve morale
• GP surgeries need support in uniformly improving HR processes to ensure that there is appropriate workforce planning mapped to demand and staff members need time for appropriate training and wellbeing to ensure they can work well in a sustainable way. 
• Surgeries also need support to work out who is the best person to do each task so that people work at the top of their license and as efficiently and effectively as possible.  There also needs to be sufficient time and space for training – medicine is a vocational career so people cannot always work at the top of their license – they need time to become competent and confident in their role.
• See Michael West’s “Caring for Doctors, Caring for Patients” document and the IHI’s Framework for Improving Joy in work.

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

• A discussion is required as to what the future of general practice should be both nationally but also in regions and integrated care systems.
• We need to think radically differently about workforce retention – I don’t think the question should be partnership or not, I think people need to work out what is right for their system.  Alternatives are numerous, one example would be including rotational posts at a PCN level for core staff.  Another would be trainees being hosted by a training practice but spending part of their week in another practice in their local system.  This would increase the experience of the trainee, enable sharing of learning and help provide workforce in practices who might be finding it hard to recruit.  This would provide a portfolio experience for the GP and improve care for patients. 

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?

• There are pros and cons to the partnership model.  The pros are that partners go above and beyond their sessional hours to deliver quality care to their patients.  Also, as it’s their business they care deeply about the service they provide and work hard (often into the night and weekends) to provide the best care possible.  This should not be underestimated.  The cost of replacing partners with salaried GPs is likely to be incredibly high.  The partnership model also supports localisation of care for patients.  GP partners are also more likely to be retained due to the autonomy they have.
• However, the partnership model is not without problems.  Firstly, GPs are not trained in business and some find the dual role of running a business and providing medical care to their patients challenging, particularly if they are unable to recruit and retain a strong practice manager.  HR processes in practices fall short and this can be part of the problem with retaining staff.   However, arguably the much larger problem is the ever increasing and uncontrollable workload that GPs face.  Another problem is that GP partners take home pay is linked to the money they receive to improve quality of care for their patients – this can be uncomfortable and even abused in a small number of cases. 
• Primary Care Networks (PCNs) and Federations provide vehicles for both strengthening the partnership model and facilitating integrated care. 
• PCNs allow resources to be pooled and for employment of roles that a practice individually might not be able to afford.  However, PCNs need time to evolve and work and they will not be the solution for all. 
• Federations enable groups of surgeries to work together to provide care to patients close to home.  This may also provide options for the workforce that are appealing – for example, if the federation runs a frailty service, this may provide a GP an opportunity to do a few sessions a week as a frailty GP to balance their work in general practice.  We know the new GP workforce is keen to have a portfolio career. 
• Clinical leads from federations and PCNs will be able to deliver a respected responsive primary care voice at the integrated care system table.   
• Sufficient research has not been done into why the new generation of GPs are not choosing partnership.  People make assumptions about it.  It might be that if the partnership model was strengthened, the new generation would choose to be partners.  The younger generation are entering in at a time where their peers are joining high profile new companies such as Google which have prioritised measures to ensure the wellbeing of their workforce is prioritised to not only ensure they are effective when at work but also that they are retained.  The new generation of GPs want this too in order to provide excellent quality care to their patients over a sustained working life. 
• The option for removing the partnership model is drastic and would require a lot of evidence that an alternative solution that would be better.  I am not clear that there is anything better out there.  But do feel that we need to strengthen the current partnership model and do need to be better at targeting practices that are providing substandard care with the right support to ensure their patients get equal care to others.  There must not be a postcode lottery to the primary care offer you can receive as a patient. 

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

In a word no!  The NHS should be using outcome-based contracts and value-based commissioning.  We need to segment the population and work collectively across organisational boundaries in each integrated care system.  To achieve this the NHS needs ambition and sensitivity.

One of the barriers to this is that it is easier to track process measures than outcomes measures because outcome measures have many factors impacting on them and in some cases cannot be measured for years after the intervention was made. However, we cannot use this as an excuse for evermore because we do have proxies we can use and research is helping us work out the best of those to use.  Outcomes Based Healthcare https://outcomesbasedhealthcare.com/ is pioneering in this regard.

Many more people need training in values-based healthcare.  It is crucial for our patients that we embrace this now. 

Furthermore, clinicians must be involved in choosing measures linked to contracts.  In the past, QOF markers have directly gone against the most up to date guidance on how to manage patients which is at best frustrating and at worst dangerous.  One example of this was around atrial fibrillation management – practices were incentivised for prescribing aspirin long after it was clear this was poor practice.  

Along with payment, practices also need tools to enable them to monitor outcomes effectively and support segmentation.  They also need to be supported to work with others in their PCN and ICS on this – they cannot work in a silo to be effective. 

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

• Yes and no.  There are some excellent examples of where it has but this is not across the board.  But also, arguably PCNs haven’t been given a chance.  It is still early days.  The NHS is often too quick to change structures without providing the current one with the resource and time to work.  All new structures/organisations/groups need to go through the forming, storming, norming phases before they can perform.  It has not helped that they have been brought into political debate and have been setting up 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 question isn’t entirely clear.  Is it referring to the ARRS coming into primary care currently or with others such as community pharmacists working alongside?
• GPs have worked effectively with practice nurses and healthcare assistants for years.  GPs are now adapting to the additional roles joining primary care.  There is feedback that training these professionals into the world of primary care has been time consuming and that finding physical space for them to work has been really tough, as the estates of general practice are not fit for purpose in many places.  However, this can be worked through but needs time and resource.  The problems are real and need taking seriously but I think most in primary care are optimistic about it as long as they are supported to get over the hurdles to it working. 
• No one solution alone will work to stem the tide of increasing patient demand and finite resource in general practice. 

December 2021