Written evidence submitted by Hurley Clinical Partnership (FGP0219)

 

The Committee invites written submissions addressing any, or all, of the following points: 

 

  1. Introduction

 

  1. I am currently Chief Executive of The Hurley Group (an at-scale NHS GP Partnership).  My previous career comprised nursing, practice management and primary care commissioning within London. This is a management response, separate to that of the partners’ and aims to bring a wider breadth of information to the points raised.  

 

  1. Many responses are complex and interlinked thus applicable to multiple sections.

 

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

 

  1. Workforce: There are insufficient GPs, nurses, allied health professionals, experienced managers, and non-clinical staff to undertake an increasing workload.  Solutions include:

 

  1. Increasing training placements in all disciplines a long-term solution

 

  1. Recognising the need for, and fund, on-site supervisors who will reduce their caseload freeing up time for training and support of new staff.

 

  1. Developing career pathways for all staff

 

  1. Stop GPs leaving to take on locum roles (more money and less individual responsibility) soon after qualification, without developing their skills in a partnership like they used to; extend training / requirement for post qualification (MRCGP) experience.

 

  1. Include general practice placements for secondary care doctors at a senior point in training.  This would deliver additional capacity that works independently with support in general practice thus gaining understanding of its complexity.

 

  1. Out-dated ‘Contract’ (GMS/PMS/APMS) : The delivery of sufficient appointments to meet ‘reasonable need’, purchased through the Contract, historically barely sufficed to meet patient need and never met patient demand.  This has worsened with the increasing shift of workload into general practice, without adequate resources, yet the contractual expectations such as patients rights to ‘see’ a GP of ‘their choice’ within 48 hours” continue. Lack of GPs, insufficient appointments, and an unsustainable workload make many contractual expectations unachievable. Solutions include:

 

  1. Updating contractual requirements to accurately reflect the situation. Currently contracts (or KPIs) focus on number / length of appointments, the care provider and mode of delivery e.g.  face-to-face (f2f) or remote.

 

  1. Understanding the majority of f2f appointments now involve complex issues occupying longer than ten minutes as new models including triage, digital and self-help account for simpler needs.  Home visits occupy an hour and bureaucratic, time consuming,  requirements e.g., case reviews are not considered appointments.

 

  1. Resourcing and promoting acceptance of new models of care e.g., triage, eConsultations and self-help options thus empowering patients to take greater responsibility.

 

  1. Reassuring patients unable to access the new models of the continued availability of f2f consultations and continuity of care in addition to the new models.

 

  1. Focus on fast access: Too much focus on fast access and not fast access based on clinical need  e.g., we must get the potential cancer patient into the system quickly, and effective triage can achieve this.  Multiple points of entry for those with low acuity issues result in unnecessary duplication of work and wasted capacity e.g., patient completes an eConsultation, response time 24-48 hours (much better than the 2+week wait for appointments previously)  eConsult  automatically triages based on symptoms and if urgent, diverts to a different point of entry.  However, the patient decides to ask for a telephone consultation instead and there is a 24hour wait so they go to the urgent treatment centre or A&E. Frequently the eConsultation is completed and  the appointment isn’t cancelled.  Solutions include:

 

  1. Ensure that patients are empowered to self-manage their condition

 

  1. Understand triage  - the fact that symptoms are reviewed and a clinically safe decision taken about the speed with which a response is required which informs the next step i.e., it is safe to wait. 

 

  1. Increasing workload, complexity, and associated administration: Key system changes such as care closer to home, shorter hospital admissions, cost pressures resulting in service cessation e.g., interpreting, welfare rights and increased patient expectations have impacted on general practice workload. Acting as gatekeeper for referrals, undertaking tests prior to referral and monitoring following discharge is not adequately recognised or resourced. Post-pandemic general practice is required to action requests for changes in treatment and monitoring linked to ongoing virtual out-patient appointments and handle anxiety about delays in hospital treatment.  Solutions include:

 

  1. Ensuring workload shift is appropriately resourced.

 

  1. Understanding, acknowledging, and respecting how different parts of the system operate and not just passing workload on.

 

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

 

  1. Previous promises to deliver more GPs and nurses have materialised but are still needed. There is limited transparent statistical information about future training commitments or workforce statistics. Yet we are required to provide detailed, time consuming to collect, information about our workforce quarterly.

 

  1. The introduction of allied health professional (ARRS) roles linked to Primary Care Networks (PCN) is positive but it must be accompanied by:

 

  1. Messaging to the patients that these are professionals who will work within their competency i.e., they will only deal with conditions that they have been trained in – they are not second best to a GP.

 

  1. Supervision and training -  not currently resourced in time or money.

 

  1. Most practices do not have the space for this new workforce.

 

  1. The push for PCNs and ICSs to develop locally focussed valuable services is positive and has already resulted in the return of social prescribing (lost previously).

 

  1. However, there is one pool of general practice staff - new initiatives result in staff moving around but unless the overall workforce is increasing another part of the system will be depleted by the changes – most frequently direct patient care as staff relish new challenges.

 

  1. Recent examples using brief snapshots of unverified and non-standardised data to ‘call out’ general practice is flawed, unhelpful and demoralising especially when applied to professional groups such as GPs who work in an evidence based setting.  Examples include:

 

  1. The annual patient survey where patient satisfaction results directly impact on practice earnings.  Between 400- 500 questionnaires are sent out to patients on a practice list annually (whatever the list size). No more than 20% of these are returned and there is no guarantee that these patients have been into the surgery within the past year. These results do not constitute a representative sample.

 

  1. Numbers of patients being seen f2f in general practice were apparently based on one month’s data during the summer period.

 

  1. Practices were criticised, despite major advertising directing patients to use 111 online or telephone services, if a high number of patients accessed 111 services i.e., it was considered an indicator that insufficient appointments were being provided.

 

  1. Recent government guidance acknowledged increasingly high numbers of complaints and violent incidents in general practice.  Whilst the zero tolerance policy has been promoted nationally there is no recognition that centralised raising expectations and negative messaging exaggerates this behaviour.

 

  1. We all need to have a shared understanding of what ‘improving access’ means and how it is monitored  e.g. Is it: seeing one of a number of professionals (not only the GP); accessing care that meets clinical needs; seeing a GP when their condition needs it; achieving continuity of care with a team or individuals; often with a case manager in more complex cases but not always a GP, or making self-help, digital, planned care available?

 

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

 

  1. Negative impact on their health - For more complex patients and those needing f2f treatment for other reasons ,the inability to access f2f services may negatively impact their health. Although a relatively small cohort, meeting their needs has to be a priority for general practice.

 

  1. Duplication – attending multiple servicessee elsewhere

 

  1. Patients get very angry, complaints and violent incidents increase see elsewhere. Results in staff hours spent responding to complaints, increase in staff sickness and reduction in morale (see below)

 

  1. Staff experience loss of morale, confidence, enthusiasm for their work – many consider leaving rather than fail to deliver the high quality services they strive towards.

 

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?

 

  1. What does ‘named GP’ mean to a service user? The someone the patient phones when ill, or the person providing clinical leadership to the team supporting the most complex patients?  Realistically what’s needed is how to contact the team that looks after them.  

 

  1. For minor concerns there is no need for a named GP and it may stop patients thinking self-help first’ or that discussions with a pharmacist is acceptable

 

  1. Practically as the number of practices reduces, list sizes get bigger and GPs work fewer clinical sessions, the option of a named GP for all loses credibility even if the aim is that they oversee, along with a team of professionals, a personalised list.

 

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

 

  1. Workforce – see elsewhere plus:

 

  1. For nurses and other allied health professionals accessible training is needed to ensure that experienced staff from one discipline can move into another e.g., between general practice, secondary care, community care etc. 

 

  1. GPs:  The number of GPs and the number of sessions they work has dropped significantly – we are currently undertaking a survey to ascertain why!

 

  1. Increasing administrative workload

 

  1. Improved IT systems and interconnected systems could significantly reduce administrative workloads.  IT support in general practice has not kept pace with change and doesn’t deliver in a timely fashion.  Solutions include:

 

  1. Increase support for remote working and ‘new digital’ equipment e.g., laptops and effective Wi-Fi.

 

  1. Clinical IT kit needs to include cameras, dual screens, and industrial scanners.

 

  1. Securing accessible storage for those working remotely with patient identifiable information is currently limited.

 

  1. Systems need to be slicker and adequate training provided

 

  1. IT programmes that join up systems need to be supported.  If clinical system providers obstruct this they should be strongly challenged.

 

  1. All medical records digitised thus saving countless hours spent printing and forwarding on.

 

  1. Electronic transfer of data should be acceptable between parts of the system

 

  1. Update contractual messages and monitoring – see elsewhere

 

  1. Financial remuneration

 

  1. Increasing financial commitments, especially in such a labour-intensive profession, are jeopardising the financial viability of small businesses such as practices. Solutions include:

 

  1. Ensuring national insurance and pension increases, impact of IR35 and new risks e.g., rise in utility bills, are clearly recognised in contractual payments. (A massive risk from April 2022)

 

  1. Acknowledge the unfunded financial liability incurred setting up PCNs and employing ARRS roles - legal and accountancy fees, supervision costs and increasing redundancy, sickness, and maternity costs.

 

  1. Financial information should be accurate and understandable – not always the case e.g., practice list size has not been available to APMS contract holders since 1.4.21 and most payments are based on this.

 

  1. Address concerns about pensions and lifetime allowance.

 

  1. Support organisations able to work at scale as they mitigate some risks and increase sustainability. Current difficulties include:

 

  1. Continued insistence returns are submitted on individual forms i.e., 11 times rather than a combined form

 

  1. Staff work across sites fulfilling broader roles but reporting systems don’t recognise this.

 

  1. Not using one approach for claiming simple things

 

  1. Stop setting up systems that require ++ administration to claim where payments are so small it is impractical.

 

  1. Do not publish individual GP earnings – they cannot be standardised where practice partners are involved in different opportunities and may prompt backlash against GPs where it is impossible to provide detailed clarity alongside a blunt figure.

 

  1. Premises

 

  1. Access to premises improvement grants is inconsistently available, costly, and administratively cumbersome

 

  1. Stamp duty and the responsibility for taking responsibility for an FRI lease should be reimbursed as per premises directions.

 

  1. The District Valuer should be involved in valuations on market rates to ensure practices don’t face risk of a shortfall in reimbursement.

 

 

 

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

 

  1. The regional variations existing in the ability to attract workforce, local differences in population needs , scale, turnover etc are not adequately recognised.

 

  1. Insufficient recognition is given to deprivation generally in the payment model

 

  1. In addition to improving recognition of deprivation generally there needs to be consideration of concentration of deprivation to postcode areas that can majorly impact on practices ability to cope with their workload and deliver required services.  E.g., a large tower block filled with young families – vaccinations, ante-natal and post-natal care, health visiting, depression, poverty, unemployment etc may impact just one or two practices. Previous deprivation models were not sophisticated enough to reflect these issues.

 

  1. High turnover, recognised in part within the capitation payment, is negated totally if patients register for a short time.  Onerous work is undertaken initially – then they move on.   Sometimes a practice will not receive even a quarter of the annual capitation payment (approx. £100 per patient per year) as they will have joined and left before the first payment is received.  The same may apply in nursing homes if patients die. 

 

What part should general practice play in the prevention agenda?

 

  1. General practice is heavily involved in the prevention agenda e.g., call recall public health programmes.

 

  1. The trust between patients and the general practice team often influences patients when engaging with the prevention agenda and clinical IT systems reflect this purpose. However, joint working with local authority Directors of Public Health, health visitors, school nurses, social workers is essential but has reduced in recent years for financial reasons.  Challenges to delivering the prevention agenda include:

 

  1. We need to ensure practices receive commensurate remuneration.  Where payment is based on achieving targets e.g., % of women undergoing cytology, it fails to reflect efforts made to achieve compliance, or as in this example failure to recognise procedures undertaken overseas but not considered as meeting UK quality requirements.

 

  1. We talk about not having sufficient resources to meet the needs of the sick.  This agenda focuses on well patients so the risk is it becomes a lower priority.

 

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

 

  1. Provide time for reflection, support, supervision and learning during the working week and allow practices to close for at least a 4 hour period on a monthly basis.  The expectation that learning is ‘fitted in’ whilst services remain open is unrealistic.

 

  1. Stop shifting work into general practice without the resources to fulfil it – e.g., relocation of ECG services requires purchasing equipment, allocating space and reception services, for which reimbursements are inadequate

 

  1. Curtail negative messaging (media and government) when not justified, achievable or correct. Listen to those who understand the complexities of general practice – often managers working in the service daily.

 

  1. Staff within the health service spend their time finding solutions (often life and death), managing risk, and trying to get everything right. Unjust negative media undermines their confidence, willingness, and ability to continue, as evidenced by increased numbers of staff presenting to Practitioner Health services and those leaving the profession. 

 

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?

 

  1. Without the traditional partnership model continuing it will not be possible to deliver the level of care required within the resources available.  The model depends on teams led by partners who take responsibility for the care of the registered patients and who will flex their working hours to achieve this. 

 

  1. Salaried GP models are based on set sessions worked, maximum numbers of appointments, documents, prescriptions within an agreed period of time and this will not deliver the capacity required to meet patients’ needs. Salaries commanded by these roles are often more than that of a partner. 

 

  1. The new to partnership scheme brings an incentive to continue to build partnerships and this is positive.

 

  1. Creating a career path for GPs and altering length of training (see elsewhere) could turn this round.

 

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

 

  1. No.

 

  1. Levelling income across ‘Contract types’ has significantly reduced the innovation previously possible through higher paid APMS Contracts.

 

  1. Active list cleansing massively destabilises practices only for the majority of patients to re-register.

 

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

 

  1. It has begun to deliver this care on a small scale but it has created increased and different administrative burdens including:

 

  1. Getting agreement from members within the PCN often means more meetings, negotiation, patience

 

  1. Financial remuneration arrangements that are complex, time consuming and increase concern that practice income is vulnerable (dependent on others’ achievements)

 

  1. Limited ability to remove financial barriers to cross boundary working – e.g., Idea - give flu vaccines at the same time as Covid vaccinations. Flu is purchased by practices who earn an administration fee. Vaccination centres see patients from anywhere - difficult to make the finances work.  However, the government could have purchased the vaccines from practices and allocated the administration fee to the PCN thus ensuring the practice didn’t lose out and less appointments would have been required across the system .

 

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?

 

  1. The expectation is that GPs need to be involved in the setting up of these partnerships and there are many. From experience taking on external activities appeals to many GPs and tends to lead towards taking more time out of the practice rather than reverting to delivering more clinical sessions.

 

December 2021