Written evidence submitted by Dr Francis Campbell, Dr Abigail Downing and Dr Laura Smith, GP Partners at Elm Tree Surgery, Shrivenham, Swindon (FGP0226)

Introductions

Dr Francis Campbell qualified from the University of Bristol in 2009 and qualified as a GP in 2014. Following a brief period of locum work within Swindon, he became a partner at Elm Tree Surgery in 2015.

Dr Abigail Downing qualified from the University of Bristol in 2011. She trained to be a GP in Swindon and has remained here ever since. She initially worked as a salaried GP after obtaining her MRCGP qualification in 2017 before becoming a partner at the practice in November 2018.

Dr Laura Smith qualified from the University of Birmingham in 2010. She also trained to be a GP in Swindon, but worked as a salaried GP for six years, before joining Elm Tree Surgery in November 2021 as a GP partner.

We are submitting evidence because we love being GP’s, and think that primary care services form the backbone of the NHS. As we are all GP trainer’s, we want to encourage GP’s of the future to share in this rewarding career. To continue to thrive in primary care however, change must happen.

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

Specific to our Surgery

The main barriers our patients face when they access general practice is due to the lack of clinical space available for us to consult in. We have an extended team working within our practice including GP trainees, salaried Gps, nurses, midwives, Health care assistants, physiotherapists, social prescribers and more. However our building is old and not fit for the purpose of the current primary care model. We would love to take on an even more allied health professionals to help us support our patients but we simply do not have room for them. Therefore, for our patients, those who wish to see a specific doctor will wait longer to be seen.

Many of our patients wish to go back to 100% face to face appointments but due to COVID we had to convert our waiting rooms into consulting rooms to give us more scope to meet the rising demand.  We simply cannot continue in our current building for much longer. As partners, we are looking into options for other sites but this is a complex process.

Regarding General Practice as a Whole

General Practice is the default fall-back position for all work in the NHS. This creates an ever increasing amount of work for General Practice which uses up the capacity, thus becoming a barrier to accessing General Practice. For example,

• delays in hospital referrals mean patients will come back to their General Practitioner for more support / advice when unfortunately there is little extra we can do if we have already referred.
• Rejection of referrals made by General Practice to other services causes a “Merry Go Round” of more administration for the GP and uses up appointments.
• Explaining or debriefing with patients after hospital stays or even Outpatient appointments as they have no paperwork written in plain English and cannot speak with their specialist directly to clarify. Uses appointments in General Practice
• Appointments are taken up with social care concerns due to a lack of social care access
• Appointments are taken up with sick note requests where the patient has been asked to see their GP from their works occupational health department

A reduction in extra work burdens would free up time for primary care appointments for patients that primary care is best suited to deal with

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

The above plan is likely to place even more pressure on what is already a highly stressed team. We are triaging all our patients and offering face to face appointments according to need. Patients can also opt to be seen face to face when booking appointments. 100% face to face will not be safe for patients or staff in our surgery.

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

Some patients will seek help from other services such as attending A&E, calling an ambulance or attending a walk-in centre. This therefore transfers the workload to other already very busy teams. This, in turn, blocks up these services to those who need to use these services appropriately.

Some patients will choose to not seek help at all if they cannot access the GP, resulting in delay in diagnosis and often worse prognosis, e.g. in cancer cases.

Patients not being able to access General Practice in their preferred method will mean an increase in complaints. However what an individual patient would prefer is not always the right way to manage a scarce resource; most patients would prefer a GP to make a home visit and spend an hour with them for each problem, this would be amazing for patients and their GPs; but it clearly is not a safe or efficient use of resource when caring for a population. The NHS needs to be honest with patients over what is the ‘offer’ of General Practice, based on need, not want.

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?

Unfortunately the NHS has conflated having a named GP and continuity of care.

Continuity of care is a useful tool to help manage particularly complex patients. It is one of the joys of being a  GP that you really get to know the patient and their families. A named GP can be a method of providing that continuity, but most patients will be keen to receive continuous care from any GP they deem to be empathetic and effective (even if they are not the specifically named GP). Having continuity of care, results in  the patient being more likely to engage with the treatment and management of their condition. The GP is more likely to make efficient use of available resources if they can really get to know their patients. Legislation that people have to have a named GP is not helpful. Continuity of care is provided by our social prescribers and nursing team, and at times our GPs. Sending out letters to patients informing them of their named GP is a resource drain and creates multiple queries from patients.

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

1. Recruitment and retention of staff including GPs and nurses. In our practice alone 66% of our nursing staff are reaching retirement age and 25% of the GP partners. Many recruited staff do not wish to work full time due to the pressures of the job.
2. The risk from privatisation and destabilising of the whole NHS.
3. Small practices are at risk of losing out, as the NHS continues to drive working at scale. Many may have to merge or fold, if no longer financially viable.
4. Increasing workload from a more demanding population who are told to see their GP for any concern and encouraged to visit again if they are not content

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

Working at scale, may be easier to achieve in some areas of England compared to others. Rural and dispensing practices appear to have been neglected in most of the plans for primary care

As a semi-rural practice on the border of two counties, accessing the right resources for our patients can be complicated. For example health care and social care for many of our patients are commissioned by two different counties, therefore there is a lack of integration and this can lead to frustration, delays and a reduced quality of service for our patients.

What part should general practice play in the prevention agenda?

Primary care is ideally placed for helping patients to prevent illness and to encourage health promotion. Greater resources should be given to support practices to help patients take responsibility for their chronic illnesses and empower patients to take control to improve their health.

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

• Supporting practices to have access to suitable premises would help greatly.
• A media campaign to promote and support primary care, and rekindle support from the public.
• An end to the negative press and demonising of GPs which has become rife.
• Respect of General Practice and support for General Practice saying “no” to patients without fear of time consuming and morale draining complaints.
• A government who demonstrate gratitude and support for the work done in primary care, and lead by example helping the public to be receptive to the challenges faced in primary care.

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?

Yes we believe it is. Partnership encourages GPs to think about the bigger picture, and the long term outcomes for their patients. It encourages GPs to think about their patients as a whole, rather than just as individuals. Salaried GPs are an asset to our practice, but the partnership model drives the vision for the practice.

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

Possibly not. We think that paying for item of service might be a better way of paying GPs as it would be more reflective of what we actually do, day to day and would evidence those patients who require significantly more contact/intervention than others. We think that paying per item of service would encourage continuous improvement and reward practices on merit.

A massive barrier to managing care and resource is the difficulty in knowing when payments come in what they are for, quite commonly sums are lumped together, claw backs and fluctuating dates make accounting in general practice a nightmare; most managers new to General Practice are astounded by the lack of clarity we have over planning finances

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

PCNs have had some success, for example in Swindon the COVID vaccination clinic was run at scale, which has gone really well.

Additional roles within the practice have been available, for example first contact physiotherapists by sharing the staff member across other surgeries within the PCN.

Access to these team members can be limited though as they are often only available to a practice for half or one day per week.

However it appears that PCNs are starting to take on work that is not being done in other areas, our social prescribers do work that citizens advice or social care could provide if they were better resourced. Our First Contact Physiotherapists do work that used to be done by secondary care physiotherapists.

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?

Having services that patients can directly book into such as first contact physios, mental health nurses etc, allows GPs to focus on more complex patients, although care must be taken to ensure that deskilling does not occur.

Our paramedic home visiting service has been extremely useful, to try to help unwell patients present earlier in the day to secondary care should they need admission, this is funded from the practice and not through the PCN.

Summary

We remain optimistic that General Practice has a future in the NHS for many years to come.  Injecting adequate funds into Primary care, reducing bureaucracy and removing unnecessary workloads, whilst promoting the vast amounts of “good” that is done in General Practice will result in improvements across the whole NHS. If Primary care is supported, the NHS can recover and flourish once again, continuing to provide care to all, free at the point of delivery.

Dec 2021