Written evidence submitted by the Nottingham City Place Based Partnership Clinical Director and  its eight constituent PCN Clinical and deputy Clinical Directors  (FGP0228)

 

 

About us

 

Nottingham City is a vibrant and diverse city, but with very significant challenges and deprivation – which influence outcomes both in terms of  reduced life expectancy and healthy life expectancy.

 

It has a very strong sense of place and a long history of partnership working to try and address the inequalities challenge. Its primary care services have worked together for many years and in 2019 they formed 8 PCNs roughly aligned to local authority wards in the City .  These PCNs are the foundation of the Nottingham City Place Based Partnership  - one of four place based partnerships within the Nottingham and Nottinghamshire ICS .

 

This broad partnership which goes beyond traditional health and care is committed to supporting the PCNs and member general practices to be the centre of addressing these challenges across our communities– so it was felt important to provide a response to this call for evidence, especially  as historically general practices in deprived areas have faced particular and  long standing challenges. These include higher workload demands, delivered by fewer staff , who have lower incomes and by practices which face greater recruitment hurdles. It was also felt aspects of new PCN contract risk making this situation worse, which created an added incentive to respond.

 

Dr Hugh Porter  (GMC 3239896)

Nottingham City Place Based Partnership Clinical Director and Interim lead

Part of Nottingham and Nottinghamshire ICS

 

On behalf of the  PCN Clinical Directors in Nottingham City and their  deputies

Dr Hussain Gandhi       Dr Margaret Abbott      Dr Mike Crowe   Dr Andy Foster   Dr Heetan Patel,               Dr Jo Guha                              Dr Matt Litchfield              

Dr Katherine O’Connor   Dr Subeer  Satyam      Robana Hussain-Mills   

Dr Mark Salisbury             Dr Rashbal Ghattora   Dr Musarat Ali

Dr Tolulope Atiomo          Dr Greg Rose                Dr Fareed Khayat              

 

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

 

The main barriers can be broken down into two main themes –

 

  1. Inadequate general practice  capacity driven by

 

  1. Increasing citizen demand driven by

 

And to what extent does the  Governments and NHSE plan for improving access and supporting GP to address these :

 

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

 

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

 

 

What are the main challenges of GP in the next 5 year

 

If an health and care system ( ICS) is viewed as a building – then general practice should be considered the foundation given its key role and percentage of contacts (85%) it is responsible for 

 

Using that analogy  over the last decade the foundations have been crumbling – due to the capacity challenges and demand pressures noted above. The PCN contract was a partial response / attempt to shore up the foundations but as noted has an ideological schism running through it, and its implementation carries a host of separate challenges and issues

 

So as we move towards the formal formation of ICS with statutory ICBs are we clear what the supra-structure / building needs to look like ?

 

Increasingly we are – based on neighbourhood integrated teams  with general practice at their core, using PHM data to proactively target citizens,  working collaboratively with these citizens and their communities and maximizing the opportunities of technology to support a strength based approach reaching towards the wider determinants of health and wellbeing .  All this will be shored up by funding based on need and value in addressing inequalities, and agreed system wide  clinical best practice guidelines and thresholds with commensurate clinical governance.

 

Work needs to happen to explore this across each ICS -  to ensure all partners in each system understand and feel comfortable with this, and in principle will be willing to allow the system to pivot towards this   - this is the first challenge

 

Once this is worked through the ICS will then have a clearer mandate to work with citizens and its constituent general practices to scope out what the ‘foundations’ need to look like – accepting we aren’t starting with a blank sheet  - this may involve consideration as to whether within each neighbourhood their needs to be a hub model with increased capacity and especially increased capability, what is the estates model that will be most effective, what is the workforce / employment models that will help achieve this – especially given many younger GPs have changing views on work life balance and career expectations and aspirations – this is the second challenge

 

Then actually starting to make this happen given the system pressures – in terms of demand and finances together with regulatory inflexibility and general short-termism of central bodies is the third challenge

 

 

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

 

From the  perspective of the 8th most  deprived region in England, with many communities in the most deprived 10%, and women in Radford and Hyson Green having the 2nd lowest healthy life expectancy in England -  If the government and NHS England are genuinely committed to reducing health inequalities everything they do , and especially around general practice  it has to have that throughout its core.

 

This is especially the case when considering funding and considering targets. Without this those in our most vulnerable communities will still face through no fault of their general practices ( who are hugely committed to their patients) a lower level of service – a simple live example of this not currently happening   – practices taking on large numbers of asylum seekers from Afghanistan, who everyone accepts will be vulnerable and have very high health needs   are likely to operate in deprived areas  – and taking these citizens on  means the practice will almost certainly fail to hit  the recently introduced  childhood vaccination QoF targets and thus lose important funding for doing the right thing – compare this to  practices in leafier suburbs who wont be touched by such challenges and funding issues !!!

 

 

What part should general practice play in the prevention agenda

 

As noted above general practice both  wants to and has an absolutely  crucial part to play – especially if we succeed in  moving  towards moving PCNs being  genuine neighbourhood integrated teams, using PHM data, and acting as a resource to strengthen and co-produce with their communities . Without creating the framework and capacity for general practice to be central to the prevention agenda NHS England will be completely unable to achieve its aspirations and requirements in this domain.   

 

 

 

 

 

 

 

 

  What can be done to reduce bureaucracy and burnout and improve moral in general practice

 

The below image is a useful visual representation of what general practice does ( thanks to Dr Gandhi – PCN lead Nottingham City East PCN) . cid:image002.png@01D7EAEC.6A924030

 

In fact practices are often willing to do this work which is also often actually important to patients or the system  - but the block contract nature of general practice with burgeoning demand has meant much of this gets squeezed – or pushed into having to be done beyond core hours – In evenings and weekends. Many  colleagues ( especially but not exclusively younger ones) are rightly increasingly unwilling to accept  what is now termed ‘greedy job’  pressures – something that eats into your normal life

 

So whilst the often touted rhetoric of we will work with the profession  to reduce bureaucracy  sounds good to the public -  the reality is its  mostly unrealistic and its why it has always failed to deliver helping general practice in the past despite being regularly touted as an area of focus   – a more fundamental process needs to occur to make the working day safe and acceptable to all general practice staff – its this that will help stop burnout and likely be a core part of starting to stabilise the sector.  So NHS England needs  to  explore  safe workloads in general practice.   This has an added advantage that in turn it will then much more clearly help understand the future workforce requirements especially when thinking about employment models discussed below .

 

In  the meantime however NHSE could push for a few substantial interim changes – especially  look at sick notes in general  (does this need to be a primary care role ?)  and as an emergency measure allow self certification for at least 2/3  weeks    

 

 

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

Following the national review of the GP partnership model by Nigel Watson (  gp-partnership-review-final-report.pdf (publishing.service.gov.uk) )  in 2019 we have obviously been living through the pandemic. The review recognized the partnership model delivers many positives especially in terms of having local practices that are flexible , committed long term to their communities, invest in the business  and empirical  evidence would suggest it delivers higher quality for less cost overall – perhaps  at the cost of reduced consistency - but the increasing demand and responsibility on partners compared to the remuneration – especially when compared to other options ( salaried / locum)  means that its has an increasingly limited appeal.    Also the workforce perhaps are increasingly wishing to work in organizations with greater capacity and associated systems compared to the lower key models encountered in some smaller practices ( this is obviously a significant generalization) .

 

This question is yet to be resolved by the profession or system and  needs to be part of the future discussion around the form of general practice and its funding  – but whatever the outcome if we move to an even greater proportion of GPs working as salaried doctors it will have a significant effect on the workforce requirements – as partners especially ( but not exclusively) undertake a huge volume of hidden un-costed work – both clinically and administratively   

 

Do the current contracting and payment systems in general practice encourage proactive personalized coordinated integrated care

Overall these are inadequate and those in place have limited traction given other pressures. . There are a range of disincentives and challenges in delivering these aspirations – and  given the essentially block contract nature of primary care and situation where the GP is the easy  default last resort , there is currently limited incentives for  this at neighbourhood level beyond everyone’s professionalism and desire to do the best for patients.  It is especially worth noting the shift of work from secondary care is a major and ongoing  issue despite amendments to the national contract for acute hospitals  – and is  being accelerated  by changing  ways or working ( eg remote outpatients) and also the move essentially to block contracts for the acute sector .  As an simple current example of what this means in real life -   think about the national push ( with targets for systems)  to outpatient transformation and wide-scale adoption of PIFU ( patient initiated follow ups). In reality this will likely push even more significant work to general practice when the patient gets confused / is unable to access  PIFU / has communication difficulties   - but the incentives put in place by NHS  England (either financially or performance./ regulatory ) are for the acute trusts to adopt this at pace, and  have  no genuinely balanced incentives or genuine thought ( there maybe token mention at best) for general practice to absorb this work

 

Has the development of PCNs improved the delivery of proactive personalized, coordinated and integrated care and reduced administrative burden on GPs

Firstly one ( delivery of proactive personalized, coordinated and integrated  care) doesn’t necessarily lead to the other  (reduced admin burden on GPs) !!!

 

PCNs are still in their infancy and of course their gestation has been through the initial phases of the Covid pandemic. As noted they have the potential to be important vehicles for the delivery of proactive, personalised, coordinated and integrated care, and some of the current work they are doing is moving towards this – though they have some distance to really travel to deliver this at any scale.

 

In terms of admin burden – if anything PCNs have added to this – the ARSS roles and other requirements in the PCN DES ( beyond the Covid vaccination requirements) require significant clinician and practice  input beyond that provided by the PCN clinical director ( which is taking away clinical capacity in itself)  

 

To what extent has general practice been able to work in effective partnership with the other professions within primary care and beyond to free more GP time for patient care

Similarly to comments above on PCNs,  one ( working effectively with other professions)  doesn’t necessarily lead to the other ( free more GP time)

 

General practice is starting to work across practices and with wider partners in the neighbourhood – at differential pace – some PCNs are more developed than others. This will eventually provide long term gains for populations as it will drive both the prevention agenda as well as support strengthening communities   – but this takes years not months  

 

In terms of ARRS  roles - practices are starting to grow this workforce and looking to develop different ways of making sure they really help citizens outcomes  – but the unmet demand means that this increased capacity these staff provide  is immediately soaked up and doesn’t reduce general practice burden or free up GP time currently  – as noted  PCNs looking after this new workforce actually generates new work for general practice.   It’s worth noting that whilst better than originally outlined,  there is also still limited flexibility to ARSS roles which limits local solutions tailored to population needs , which can further limit  the benefit to general practice     

 

Dec 2021