Written evidence submitted by Society for Academic Primary Care (FGP0234)

Dear Mr Hunt,

Re: Inquiry into the Future of General Practice

Herein we, The Society for Academic Primary Care, respond to the call for evidence to support the above government inquiry. our reply is aligned to the remit of our organisation and the academic General Practice (GP) community we represent across the 44 UK medical schools. Our community is made up of clinical and non-clinical academics that support and guide the teaching of general practice in undergraduate medical programmes, as well as advancing research in GP to support the evolution of policy and practice.

We aim to provide a clear voice for academic GP in the complex and ever-changing healthcare landscape. We hope to support and improve GP by: providing a deeper understanding of Primary Care, its aims and its relevance; developing, delivering and evaluating ways of delivering Primary Care policy and practice; delivering critical commentary and evidence on how wider policy and practice impacts on the provision of Primary Care.

We work closely with other stakeholders, such as the Royal College of General Practitioners, and know that the case for general practice will well made within their response to this inquiry. Our response as SAPC aims specifically to illustrate the critical importance of academic general practice in providing the evidence-base and workforce needed to support the development of NHS general practice and  improve patient outcomes.

Key considerations:

For ease of reading, the following bullet points outline the key concerns that we, as a scholarly society, have. How these points relate to the questions outlined by the inquiry will then be expanded on, drawing on relevant evidence and literature in the sections that follow:

1.       Academic general practice is essential to the continuation of the practice of the clinical field, through contributions to teaching and research that support the training of tomorrow’s GPs, offers thought leadership and generates the distinct knowledge needed to inform policy and practice in relation to GP in the UK.

Recommendation: review and support training pathways in academic general practice, with a re-balancing of priority towards expert medical generalism in the community.

2.       Despite GPs comprising 27.5% of the total medical workforce, the UK’s 200 or so senior academic GPs comprise just 6.5% of all clinical academics. Without a strong and sustainable discipline of academic GP, the clinical field will surely flounder. It is recognised that holistic patient care delivered by expert medical generalists in the community are key to the sustainability of the NHS, and to delivery of universal healthcare for our communities. In recent years the discipline has been under serious threat due to underfunding and recruitment difficulties. As senior staff retire they are often not replaced.  If the field of academic GP is allowed to wither, there will be very serious consequence for the whole NHS and our patients.

Recommendation: scholarly bodies must realign priorities towards supporting and nurturing the pipeline of academic GP. This will need to be coupled with a review of how funding is allocated to academic GP.

3.       There are structural barriers that maintain a disparity between academic GP and other clinical academic fields. These barriers impact on the way:

• teaching undergraduate medical students is funded and supported; on the way academic GPs are recruited, trained and retained
• that senior clinical academics are valued, remunerated and rewarded compared to other clinical academic disciplines, which will have a knock-on impact on recruitment and retention.

Recommendation:              

i) To expedite the ongoing but very slow national negotiations around undergraduate medical education tariff for primary care The minimum tariff currently available for medical students placed in general practice is 20% lower than that paid for hospital placements.  This is in spite of evidence that costs are broadly the same.  In addition to setting a fair and equitable amount of payment there is urgent need to be a review of how funds are allocated to support student engagement with dispersed placements, including central programme support in medical schools, adequate funding for student travel and accommodation and support of estate development to ensure an adequate learning environment.

ii) Review of how postgraduate training posts (e.g. Foundation Year 2 and GP trainee) are funded and supported centrally. Including how estates development and maintenance is supported to provide adequate learning environments.

iii) Review of national processes that currently pose barriers to senior academics in general practice seeking clinical excellence awards (CEA) at both local and national levels. This should include a review of why there are significant disparities between general practitioners and hospital clinicians.

4.       The physical resources available to accommodate and support learners from all backgrounds (undergraduate students in medicine and other clinical fields, postgraduate trainees in GP and other fields, such as advanced nursing practice) has been a growing issue that poses a pervasive barrier to practices supporting the training and development of tomorrow’s general practice workforce.

Recommendation: GP estates need urgent investment to address the pressing need to increase clinical capacity to meet demand. This investment must also be sustained, recurring and have the capacity to flex with changing demands to meet need.

A more detailed analysis, and linkage to relevant data and evidence is outlined in the pages following this letter. We trust that this is helpful to the inquiry, and would wish to support the inquiry in any way we are able, going forward.

Yours sincerely

Professor Carolyn Chew-Graham, SAPC Chair

(Keele University)

Detailed responses

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

The most fundamental barrier facing patients trying to access general practice is capacity. We simply do not have enough GPs, advanced clinical practitioners, nurses, and other allied health and care professionals to meet demand[1].

According to most recent evidence only 11% of UK medical graduates currently intend to enter general practice at the end of their training, and only 15.3% of doctors completing foundation training are appointed to GP training programmes[2],[3].

The discipline of academic GP is charged with leading the delivery of teaching undergraduate medical students, as well as developing the scholarly base for evidence informed clinical practice. If academic GP fails, the clinical speciality would suffer, as would the wider health service and the communities it serves[4].The link between high quality, and adequate quantity, of time and teaching in GP has been linked to career intentions in medical students[5]. Therefore, undergraduate teaching is essential to the task of addressing recruitment into the speciality as outlined by the Wass Report[6]. However, recent surveys of all UK medical schools has found that on average medical students spend only 9-10% of their time based in GP surgeries and that this time has the time has declined since 2015[7].

The most common barrier to teaching, and therefore to recruitment and training of workforce, is the lack of physical space within GP surgeries across the UK[8]. Surveys undertaken by the Heads of Teaching members of SAPC have repeatedly illustrated the challenge that lack of space poses to teaching undergraduate students, as well as GP trainees and other allied professionals. . Undergraduate medical education tariff does not cover the cost of space for teaching in general practice.  However, the space provided for undergraduate teaching in hospitals is charged to medical schools (and therefore the government). Again, research by the SAPC has highlighted these unjustified inequalities between undergraduate education in hospitals and general practice. However, without intervention from Government, it is highly unlikely that these inequalities will be resolved, due to the current makeup of senior medical school personnel and their relationships to hospital senior management. Heath Education England (HEE) is also unable to support estates development and maintenances costs in postgraduate training. A review of primary care estates is underway, and the merger of HEE with NHS England & Improvement may serve as an opportunity to address this gap, by providing a sustained funding stream dedicated to supporting the growth, development and maintenance of estates in general practice to benefit direct patient access, as well as efforts to train the next generation of GP healthcare professionals. We recommend that priority is accorded to resolving this barrier as it is currently the rate-limiting factor to training health professionals in the general practice setting.   We would draw attention to the fact that the UK has one of the lowest numbers of doctors (and other healthcare professionals) per head of population in the developed (and developing) world. To address this, the MSC (Medical Schools Council) is recommending increasing the intake of medical students from 8,000 a year to 15,000 a year. To do this, general practice will need substantial investment to provide the space to do this teaching. 

A central problem reported by medical schools and highlighted by SAPC, with respect to recruiting and retaining undergraduate placements for medical students is that we still have no national tariff to pay for the time taken by general practitioners to deliver undergraduate teaching in primary care.  Payments in England are based on a minimum tariff which is still 20% below the national tariff for placements in secondary care, (where a tariff has existed for decades) and does not reflect the cost of re-providing service lost when GPs are teaching students[9].

In relation to the issues of capacity and funding of placements in GP, we wish to draw attention to a previous government review to the attention of the inquiry:

Para 172: ‘It is unacceptable that a failure to provide sufficient funding should make it more difficult for medical students to gain experience of primary care. Financial constraints which limit undergraduate exposure to primary care represent a false economy which will only generate costs elsewhere. We were, however, encouraged that Alistair Burt said that the Government is “working to develop a national payment mechanism for primary care with payments that better reflect the costs of the placements’

Para 233: ‘We recommend that the Government accelerate their work to create a payment mechanism which reflects the true cost to GP practices of teaching medical students. The objective of this work should be to ensure that reimbursement of the costs of training is not a barrier to undergraduates being able to access training in general practice. With this in mind, new proposals to replace the existing SIFT arrangements should be in place by the beginning of the 2016–17 academic year’[10]

Although some degree of progress was eventually made in 2020 by the introduction of a minimum tariff for undergraduate primary care education it is unfortunate that 5 years later neither of these recommendations has been met.  The SAPC has been negotiating for at least 10 years with Government working groups to try and resolve these inequalities after we highlighted that the costs of providing undergraduate medical education in primary and secondary care are essentially the same[11].  Negotiations are currently taking place through DHSC UMTWG (Undergraduate Medical Tariff Working Group). However, the group has been beset by delays, cancelled meetings and repeated changes of policy.  SAPC recommends that the work of this group is now brought to a swift conclusion via direct Ministerial intervention, as it reflects poorly on the efficiency of Government.

In addition to the above, it is important to note that the concerted attack of GPs and the field of general practice in the mainstream media has had an incredibly damaging impact on the morale of the professionals running and delivering these services, as well as negatively impacting on the attractiveness of careers in GP to medical students and junior doctors2,[12]. This attack has historically been disproportionately vexatious towards general practice compared to other fields of healthcare. Misinformation in the mainstream media also serves to confuse patients and undermine the relationship they have with their clinicians.

Recommendations from Key Considerations 1-4 listed above are intended to address the issues that affect issues of immediate (clinical space and clinician availability) as well as longer term (recruitment and training of next generation of clinicians) access to general practice. An additional recommendation in relation to this section would be to establish a process by which attacks in mainstream media can be fact-checked and challenged, credibly, at a national level.

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Inquiry Question: 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?

In the first instance, we would wish to draw to the attention of the inquiry, the report on relationship-based care published by the Royal College of General Practitioners[13].

Further to this, scholarly work undertaken in the field of academic general practice has elucidated the nature of the link between continuity of care by a specifically trained expert medical generalist, and positive health outcomes for patients and communities, as well as patient satisfaction[14].

We know that longer term relationships built between general practices and the communities they serve can reduce mortality from all causes and reduce acute hospital admissions, and attendance at emergency departments in the UK13,[15],[16],[17].

We also know that patients perceive the importance of continuity differentially: wishing to see a doctor who they feel knows them, for longer term conditions, and being willing to see any doctor (regardless of relationship) for more acute problems[18]. Experiencing continuity, as they see it, is also linked with increased patient satisfaction with the service, as well as increased confidence about the care received.

The work establishing this evidence clearly illustrates the pivotal role of academic general practice to fundamental aspects of healthcare policy and practice. However, under-funding and lack of career support for academic general practice is severely hampering our ability to better understand and therefore teach how the complex underlying mechanisms of continuity are enacted. This in turn hinders the professions ability to better deliver continuity.

Continuity of care can also be enhanced through, development and support of the workforce (please see previous recommendations)

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

We feel that the most pressing challenge to the future of general practice is the recruitment and retention of well-trained expert medical generalists to the field. Aspects of this have been outlined above, especially in relation to training and recruitment. We would wish to further draw to the attention of the inquiry the growing concern about retaining experienced clinicians in GP. Factors that appear to influence early retirement decisions include bureaucracy of maintaining practice, namely appraisal and revalidation[19].

In relation to this, the move to a more holistic and lighter-touch appraisal process in response to the Covid-19 pandemic pressures have been well received.

Research demonstrates 4 barriers to the application of medical generalist expertise in the whole-person management of illness. These include perceived lack of Permission to tailor care to individual needs if this is ‘beyond protocol’; failure to Prioritise the complex tasks of generalist decision making in the workload of general practice; failure to develop and maintain Professional skills and confidence in complex decision making; and the impact of Performance management which at best ignores, and at worse, criticises tailored care[20].

References:

SAPC Response to Inquiry into the Future of General Practice