Written evidence submitted by Dr Lara Shemtob, Dr Martha Martin, Dr Connie Junghans, Dr Annabelle Painter, Dr Dipesh Gopal and Dr Mohammad Razai (FGP0222)

 

Lara Shemtob

GPST3 and Academic Clinical Fellow in General Practice, Imperial College London

 

Martha Martin

GPST2 and Academic Clinical Fellow in General Practice, Imperial College London

 

Connie Junghans

GP and Senior Clinical Fellow, Imperial College London

 

Annabelle Painter

GPST2 at Imperial College London and AI and Workforce Fellow at HEE and NHSx

 

Dipesh Gopal

GP and NIHR In-Practice Fellow, Queen Mary University of London

 

Mohammad Razai

GP and NIHR In-Practice Fellow, St George’s University of London

 

We are a group of Academic General Practitioners and Academic Clinical Fellows in General Practice/ GP Trainees. We all work in General Practice alongside conducting research in Primary Care and Public Health. Therefore, we are invested in the future of General Practice for our patients, the communities, and the populations we work with. We have chosen to work in this speciality and realise that changes to General Practice will affect our future.

 

There are two main arguments to support an increase in general practice funding and resources:

 

        Moral argument: if demand outstrips supply then this has negative effects on patient trust in their healthcare system and negatively impacts on healthcare staff morale and retention perpetuating the problems of access to general practice.


 

        Financial argument: effective primary care is associated with decreased overall healthcare costs


 

General practice and community services are struggling to meet demand. Many of the questions asked by the inquiry discuss access to general practice. A focus on patient access ignores that those that need access to healthcare are often not the same group that would like access to healthcare: the so-called inverse-care rule. This is particularly concerning given widening health outcomes between the richest and poorest which span almost a difference in life expectancy of almost 10 years. Increasing access alone without understanding these complexities can increase this difference in life expectancy.

 

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

 

        Factors such as language barriers, written or health literacy, mistrust in the system, cultural differences, disability and access to or understanding of technology can act as barriers to accessing General Practice. There needs to be increased funding for measuring and solving these problems to work towards health equity. Examples of solutions include clear and consistent messaging; a dedicated freephone number for vulnerable patients; a triage system that prioritises their needs; and face-to-face, longer appointments.

        Patients book GP appointments when they don’t need to see a GP. As a result, appointments become full and those with more urgent concerns are not able to book to see a GP. GP expertise and skill is not being used optimally, many GP complaints could be managed by allied health care professionals (AHPs) or non-medical staff such as administrative teams or social prescribers. Much of this stems from a lack of triage of patient requests to see a GP. Triage tools will be a valuable mechanism to improve access and appropriate use of GP multi-disciplinary team (MDT) services.

        GP appointments get filled with minor ailments that could be better reviewed elsewhere, such by community-based prescribing pharmacists using clear guidance to advise when GP input is needed.

        Traditional access model with landline phone lines restricts calling times and volumes. This can result in long waiting times to speak to a receptionist and excludes patients who are not able to call at specific times of the day. Moving to cloud-based telephony is part of the solution in dealing with high call volumes at busy times of the day.

        Perceptions by patients as to how quickly they should be seen and by who in a General Practice setting can lead to poor perceived access. A patient might perceive that their problem needs to be dealt with immediately, rather than wait to be seen for the next available appointment, giving them the perception that their access is poorer than it is. Working with the public on self-care initiatives, increasing health literacy and managing expectations of health systems are potential solutions to these problems.

 

 

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

        The winter access plan appears limited in placing the burden of accurate appointments data onto practices without financial compensation: diverting practice team resources away from patient care to data quality. Although we advocate collecting accurate appointment data, to do this well and without detracting from patient care, practices need adequate additional funding and expertise for example through hiring well-trained data analysts.

        Patient-reported ‘access ratings’ will be of limited value and challenging to interpret. Robust, objective data on primary care access is needed. Primary care electronic health records (EHRs) are not designed to collect this kind of appointment data and traditional models of primary care do not collect information on unmet demand. Practices require financial investment, staff and training to implement systems to improve data collection and quality. Structured data quality (DQ) in the primary care EHR has barely progressed in twenty years because primary care teams entering data do not have the time or incentives to prioritise DQ. This limits the use of the EHR for research and service planning, such as the under-coding of long-COVID in the GP EHR.

        It is unclear where the ‘bottom 20%’ threshold of face-to-face appointments has come from in the winter access plan or the evidence base for this.

        Lots of activity in practice is ‘invisible’ such as administration activity and contacting patients prompted by communications from secondary care. It may help understanding practice team workload if this activity was ‘visible’ and acknowledged, rather than focussing on appointments in isolation.

        Patient complexity and demands from each individual consultation have increased in recent years making ‘satisfactory’ access challenging in 10-15 minutes, regardless of consultation mode.

        People living in poorer areas report poorer experience and poorer access to care, which is alarming given the greater health burden in areas of deprivation. To really improve access in these areas there actively needs to be more recognition and investment in these under-doctored under-funded areas, both in terms of health and the drivers or social determinants of health, such as well-paid jobs or access to affordable unprocessed food for example.

        Efficiencies gained through remote consulting are helping improve access through volume, reduced wait times and flexibility.

        However, remote consulting is not appropriate for all patient groups. For example, people who find it hard to express themselves verbally or those who under-report physical symptoms and are seen remotely may then require additional face to face appointments. Though this can lead to more appointments or more clinical time being used, clinicians and practice teams are trained and able to listen to patients and identify where remote consultations are not appropriate.

 

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

        Patient dissatisfaction/frustration, a lack of trust and confidence in the General Practice system and team, leading to decreased access and worsening health problems and sometimes resulting in verbal and physical aggression towards primary care teams.

        Patients may simply go to the Emergency Department where they will get a quick and on-the-day answer to their health problem.

 

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?

        The named GP scheme does not always guarantee that the patient has access to a GP whom they can rely on.

        In most practices, patients can request the next available appointment with their preferred clinician and can consult with them according to practice policy. This can be helpful for people living with complex health and social issues and prevents repeated history taking so appointments can be more efficient. It can also help the doctor-patient relationship, holistic care and the supportive role of general practitioners, via improved trust and relationship-based care.

        It can result in dependence on individual doctors which can limit care for other patients in some cases.

 

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

        Increasing demand and patient complexity- due to an ageing population, increased prevalence of multiple comorbidities including a huge burden of non-communicable diseases such as type 2 diabetes mellitus and obesity, and an increasing burden of mental illness coupled with higher expectations from health service

        The staffing crisis across all professionals throughout the health service.  Most newly qualified GPs feel working full time in practice is unsustainable as the stress and workload is too high. A full clinical day is eight hours on paper but can span 12-15 hours in reality so many GPs can easily work a 40 hour week in three calendar days. Therefore, GPs are increasingly working less-than-full-time and retiring early, worsening the cycle of poor retention. This is true across other disciplines including the additional roles in General Practice like Pharmacists and Social Prescribers, as well as resulting in a high turnover of administrative staff.

        Almost half of NHS staff reported feeling unwell from work-related stress in the 2021 staff survey. Mental illness accounts for the largest burden of sickness absence in the NHS workforce, surpassing COVID-19 related reasons for sickness absence in all but two months of the pandemic. Around 30% of the time someone an NHS worker is off sick it will be due to mental ill-health, whereas mental illness accounts for around 15% of sickness absence nationally.

 

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

        There is widening inequality in society with shorter life expectancy and poorer health outcomes in the most deprived areas of the country alongside reduced resource investment in these areas.

        This results in the health burden being higher in areas of deprivation despite there being reduced or inadequate resources available. This needs to change through actively increasing resources, particularly in these areas, to work towards health equity. This is evident in recent research data showing better staffing in less deprived areas compared to more deprived areas.

 

What part should general practice play in the prevention agenda?

        Prescription of services and tools to promote health and disease prevention including exercise, nutrition, occupational health and digital therapeutics.

        Being part of working across society to address the social determinants of health, for example by adopting new models of holistic care and increased collaboration between General Practice and Public health and acting as an anchor institution within the local community.

        Though General Practice is well-placed to be a part of the prevention agenda, prevention is difficult to tackle ‘incidentally’ with patients presenting with their own agendas, both from a resource and consultation management perspective in 10 minutes. Some innovative practices are creating internal data dashboards to guide a separate chronic disease management/ prevention workstream, and this is only possible with adequate financial resources and staff. Ideally, there would be the time and the resource to tackle prevention opportunistically in each consultation but it seems unlikely given the current demands.

 

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

        Ensure media representation of GP is fair and balanced, rather than anecdotal. In the most recent GP patient survey 83% of respondents describe the experience of their general practice as good vs 7% describing it as poor. Despite this perspective,the overall picture is often lost in negative media reporting of individual patient stories. Prior to and since the pandemic, media representations of general practice have been negative. This has led to concern from RCGP and the BMA that the recent public criticism directed at primary care is having a dangerous impact on the relationships between staff and patients and the wellbeing of primary care staff.

        Health and Safety Executive management standards – reduce demand, improve control over workload, make boundaries of GP role clear.

        Either communicate the limitations of what can be achieved in a ten minute consultation clear and ubiquitous to all patients to help manage their expectations of their GP appointment, or lengthen standard appointment time. The latter would be much more popular as some “issues” can take a very short period of time whilst others can take much longer.

        Lower the threshold of zero-tolerance policies to crack down on abuse from patients.

        Encourage GP autonomy over workload in their practices and empower GPs and practices to decide how best to serve patient populations with different appointment modes.

        Facilitate and normalise a culture of flexible working for GPs and primary care teams.

        Encourage innovation within primary care giving GPs agency and input in improving care delivery.

        Use technology to automate time-intensive administrative tasks such as communications with primary care, referrals, and reviewing letters.

        Work with the public to change perception and expectations for example, that non-urgent issues may be able to wait to be seen.

 

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

        GP partners are a lynchpin of primary healthcare and undertake a large workload that is unlikely to be absorbed by Integrated Care System (ICS) managers/ salaried GPs. 

        Many newly qualified GPs value the autonomy and different ways of working in different practices afforded by partnerships. 

        However, it appears unsustainable unless the demands on GP partners are reduced to become more realistic and more manageable. For example, it should not be a GP partners’ responsibility to inform patients about the GP Data for Planning and Research as well as encourage patients to be vaccinated alongside catch up care and running their practices and far fewer GP trainees are wanting to pursue a partnership in 10 years time.

        Homogenising the healthcare landscape and being salaried to an ICS may be less appealing for healthcare professionals who are united in teams by practice partnerships.

 

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

        Primary Care Networks (PCNs) have helped collaboration between practices and have improved use of AHP in primary care, with benefits for patients. PCNs have helped primary and secondary care integration although the administrative burden has increased.

 

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?

        AHP are working alongside GPs in primary care to great effect and appear essential for the future of General Practice. However, retention of staff is problematic and can lead to more administrative burden for partners in having to persistently advertise, recruit and train new staff. The additional roles reimbursement scheme needs to become a more attractive offer to better retain staff. 

        Dividing the workload between different professionals in primary care leaves GPs vulnerable to a heavier workload because of the degree of complexity left to them which may not be attractive to some GPs who enjoy the variety and range in case complexity. However, if appointment times increase and the administrative burden decreases this may well be attractive for others. 

 

December 2021