Written evidence submitted by Dr Margaret Reeves (FGP0236)

My name is Margaret Reeves. I am an experienced GP in my 40s. I have recently stepped down from partnership after 12 years in role. I will be taking up a new position as a  salaried GP in Shetland.I write in a personal capacity. I consider myself to have a perspective to contribue to the inquiry as a front-line clinician and someone who as reflected extensively about the place of partnership and the sustainability of the role as part of my decision to leave my practice. I have an interested in health systems and public health, as well as is in GP well-being.

To properly address the questions confronting the inquiry, it is important first to understand what it is we mean by General Practice.

What are the special characteristics of general practice?

  1.                 We are expert generalists.  Expert generalists mean that, for example, the only doctors who know more about gastroenterology problems than GPs are specialist gastroeneterologists; the only doctors who know more about cardiology than ourselves are specialist cardiologsts; and the same with every medical speciality. We have a very broad knowledge base across a wide range of medical specialities which we work hard to keep up to date.

 

  1.                 General Practitioners see undifferentiated symptoms.  Whereas other medical specialists will see patients who have defined (or system-defined) problems, for example atrial fibilliation or palpitations for cardiologists , we see patients with ‘’pain’’ or ‘’fatigue’’ or patients who are ‘’not quite right.’’ Sometimes this has an organic origin, sometimes a psychological one, sometimes a social origin - most often a combination of the above. We are alert to, and skilled in responding to presentations that might be driven by all these elements, and we are able to formulate these into an understanding for the patients and develop a management plan based on this formulation. Very often a presenting complaint is a function of multiple interacting medical problems; imagine an elderly patient who has dementia and diabetes and who is usually cared for by her daughter and by carers. When she gets a urinary tract infection, her diabetic control becomes erratic, her daughter can’t visit often enough to keep her safe and there isn’t capacity to increase carer’s visits. This becomes a problem for the GP to sort out. This is ‘’multi-morbidity and complexity’’ and is our special skill.

 

  1.                 We are experts in holding risk. We are  the point of contact and risk-managers for other agencies and professional groups. For example, that a health visitor may pass a concern to a GP about a safeguarding concern they have identified. Or an IAPT therapist may contact the GP if a patient mentions suicidal ideation during the course of an assessment. Nurses, pharmacists, physiotherapists, ANPs, paramedics will refer to the GP for decision making that carries risk beyond limits of their own role.

 

  1.                 We know patient across their life course, and we know their families. Although individual appointments may last 10 or 15 minutes, knowing patients over years means we are able to build up understandings about our patients that help in our diagnosis and management of their problems. So, for example, we may notice subtle changes in a patient’s demeanour or self-care over time.  We know our patients families. This enables us to understand stressors they may be experiencing, and to respond accordingly.

 

  1.                 As a result of the work across the life course and with families, we are trusted members of the community, often finding ourselves listening to intimate and very personal matters for our patients. Patients value a relationship in which they can place their trust. As other spaces for confidences in society have diminished (fewer people attending churches, more families separated from extended families) this role in our communities has become more significant.

 

  1.                 The central tool of our trade is the personal relationship between the doctor and the patient. Although this apparently ‘’soft’’ metric is little discussed in the public domain, there is ample evidence that continuity of care results in reduced hospital admissions, better compliance with medication, improved patient satisfaction amongst patients and better uptake of health-promoting advice ; all of which have an impact on the costs of delivery of health care within the NHS. https://www.bmj.com/content/356/bmj.j84/rr-2

 

  1.                 We are anchored in specific communities which enables us to see patterns and concerns that affect our populations. To illustrate, my former practice is in an inner-city; and area of enormous ethnic diversity, and significantly affected by the extreme cost of housing and housing lack in our area. The impact of poor housing-security played a large role in the problems patients brought to us.

 

  1.                 We work particularly with those who are vulnerable. Although (almost) everyone is registered with a GP in the UK, a small subset of patients constitute a high number of consultations or workload. In a recent review of multimorbidity, it was found that the patients who use general practice services the most are those whose problems arise from substance misuse and from mental health problems, rather than from the traditionally understood models of multimorbidity. https://bjgp.org/content/early/2021/11/15/BJGP.2021.0325

 

8. Clinical encounters are only a small part of the work of GPs. GP partners are small business owners. This means that they have budgetary and financial planning responsibilities, responsibilities for strategic planning and for ensuring that contractual obligations are fulfilled. They have HR and personnel responsibilities, and responsibilities for collaboration with other organisations - whether secondary care, other practices, the social care sector, local councils.

Common misunderstandings about general practice

In my professional experience, there are misunderstandings in policy making circles, in contract provision and in society and the media more generally about what general practice does. This mismatch between the reality of general practice and the expectations of it drives much of the current dissatisfaction within society, and disillusion amongst the profession.

  1. There is a poor understanding of the profession in the media and in the public domain. Much of the focus around access to general practice is about the timeliness of access and the resolution of single-issue acute medical problems ‘’How soon can a patient get an appointment for a bad back.’’ In fact, this reactive and acute work addressing single-problem issues is only a small part of general practice, and the part most easily delegated to other clinicians such as paramedics, ANPs, nurses and pharmacists. This focus fails to acknowledge the much more specialist and substantive work of GPs listed above, and a focus on an acute service provision agenda distorts service delivery to those patients in need of GP specialist care.

Central to the work of general practice is the patient-doctor relationship, as described above. This is not always compatible with the need to provide an urgent and immediately responsive service.

 

  1. Amongst policy makers, there appears to be a  poor understanding of the demographic profile of high users of GP services. As an illustration, whilst the focus of NHSE is on digital access, there is a danger that this further serves to disadvantage those who use general practice (and need its specialists) the most. These users are the same populations often excluded from digital access, namely the elderly, the socially vulnerable, those with English as a second language and those living in poverty. This means that general practice has to continue to meet the complex off-line demand whilst fielding the increased but usually more trivial online demand.

 

  1. General practice is not well understood even by secondary care colleagues. Even amongst hospital colleagues, there appears to be a lack of understanding as to the nature of general practice. This results in a transfer of workload which is difficult to manage in addition to the core work of general practice. Much of this work is administrative or requiring low levels of clinical skill but is time-consuming such as chasing up blood test results or changing medication.

 

  1. The financing of general practice is extremely complex and includes many perverse incentives. The core (capitation based) funding is very small. Additional funds are obtained by practices participating in additional or enhanced services. Few of these are tailored to meet local requirements or entail any local flexibility. In order to remain financially sustainable, practices are required to chase additional pots of funding, even if there is little evidence of clinical  benefit for their patients. NHS health checks are, for example, expensive to run, and yet there is limited evidence to support health benefits. Nonetheless practices participate in order to secure the income.This in turn detracts from more meaningful and valuable clinical activities.

Care for older patients and those with co-morbidities is incentivised in the funding formula. The funding formula does not capture the particular burden placed on practices by caring for patients with complex social and mental health problems (as referenced above), meaning that practices with inner city (younger but more socially disadvantaged) populations are financially disadvantaged. This in turn impacts on the ability of these practices to recruit staff with the resultant deepening of disadvantage to these populations.  

The number of funding streams and their subjectivity to change makes financial and therefore strategic planning, extremely difficult.

With these considerations in mind to set the context of my response, I will now turn to the specific questions that the inquiry wishes to address, though the limited word count precludes me from responding to them all. I have selected the most pertinent.

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

To answer this, we need to understand what we want access to be FOR, in the light of the issues raised above. It seems clear that there needs to be access to an acute and urgent, single issue service, as well as access to a service that provides continuity of care for those with complex needs and complex multi- morbidity. It is also apparent that the current provision of General Practice services cannot meet both these needs to the level of satisfaction of patients without burning out the doctors.  Fundamentally, there are not enough GPs.

There may need to be a separation of acute-on-the-day service provision  from ‘’continuity-consultations.’’ The former could be delivered by non-GP team members (administrative staff, ANP, nurses, pharmacists, first contact physios, mental health workers) - with access to a GP for reference and advice where needed. Continuity consultations would be booked with a GP. These two workstreams could be delivered at one site (the GP practice), or else the acute service could be delivered at a centralised site serving a number of GP practice. The driver for such changes in allocation of workload should be because these changes provide the best care for the needs of that patient, rather than because there is a shortfall of GPs. 

Changes provoked by the pandemic have illustrated how transformation may take place. In addition to the traditional GP face to face consultation.

There is a LIMITED role for digital access in regard to simple, usually administrative, matters which could be triaged and largely managed by non-GP pratice staff.

There is a place for telephone consultations which provide ease of access and satisfaction for patients under specific criteria, such as where the patient is well known to the doctor, and the consultation material is focussed on follow up (for example, discussing test results, or changes to medication.)

There is a place for face to face consultation with a known GP of the patient’s choice for longer-term, complex problems, for frailty, for palliative care, for multimorbidity, or for diagnostic uncertainty, and for mental health and substance misuse issues. 

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

Without doubt the main concern must be the workforce challenge. This has several elements

1. Demographic: GPs are an ageing group. NHS digital data from October 2021 reveals 38% of GPs to be over 50 (and more full time equivalent GPs represented in this group.) Many of these expect to retire in the next 5 years. There will be a loss not only of personnel, but also of experience as this group of GPs retire. There will also be a loss of partners, as once again, partner GPs are over-represented in this age group. This will result, inevitably, in changes in the partnership model of General Practice.

2. More portfolio working. As pressure mounts in the clinical domain, many GPs are choosing to use their skills in areas in which they have more control over their workload and impact- whether this is within PCNs, or in other medical areas. Choosing to limit working hours in order to respond to domestic commitments such as bringing up children is another model of portfolio working, and should be seen as thus, rather than condemned as ‘’part-time’’ working. Such portfolio work patterns should be encouraged as they enable fresh thought and new skills to be brought to bear on the clinical encounters.  Models will need to be found which enable GPs to work in this way, and to still meet the need for continuity in clinical work.

3. Challenges in recruitment. The GP workforce needs to increase, but this cannot be achieved in a hurry. Training needs to be maintained at a sufficient standard and duration to deal with the increased complexity of the work. Work in general practice is at consultant level, so training of equivalent seriousness and intensity is required to meet this end and to ensure that the profession is adequately validated.

There will be a delay before such a new workforce becomes available. The tasks of a GP cannot be met by allied health professionals as my comments above make clear. In the interim, the workload entering primary care needs to be managed differently, so the specific specialist skills of GPs (focussed on multimorbidity, complexity, risk management, and managing uncertainty) can be used where they are needed, and other work (such as the management of minor illness) can be  delivered by other members of the primary care team. 

Alongside the challenges of building a GP workforce to cover the demand are two further challenges facing general practice in the next 5 years. Responses need to be supported by NHS England rather than being led by beleaguered GPs.

The first is the restructuring of service delivery into acute and complex arms as outlined above. GPs and their managers need to be freed up to work on such service delivery models in an enabling and flexible environment tailored to local need, rather than being offered a ‘’one-size-fits-all’’ model. 

The second challenge is the revision of the partnership model of General Practice.

Comments about the partnership model

Fewer and fewer GPs wish to become partners. In my practice of 10000 patients, we were only two partners, despite a very committed team of 6 to 8 salaried doctors. No other GPs wished to consider partnership despite the high esteem in which the practice was held regionally. Partners carry unlimited personal and financial liability for their practice. This means that they are at risk of loosing their own homes in case of litigation or default. Whereas 20 years ago, these were seen as theoretical rather than real risks, the experience is now different as we live in a financially less secure and more litigious environment. In addition to carrying risk, partners are responsible for the running of their organisations. This means that shortfalls in staffing need to be assumed by the partners, resulting in 60+ hour working weeks. Partners are paid a profit share and are responsible for their own tax affairs. Meanwhile practice income is variable and difficult to plan.This makes personal financial planning precarious and insecure. In an inner city practice such as ours, there was almost no financial incentive to become a partner.  Whilst, twelve years ago, when I became a partner, an attraction of the role was the ability to shape the service to deliver what one believed to be the best service possible for one’s patients, changes in financing of general practice and an increasingly strict regulatory framework (and the complexity of practice finance), mean that this autonomy is increasingly constrained. GP partners are left with all the responsibility, and none of the previous autonomy which may have made the position attractive. I cannot see any incentive which will change this position.

As I planned my departure from the practice, our partnership took a very considered look at the alternative business models. We considered becoming a limited company. This model reduces the personal liability of partners but does nothing to address the workload. We considered mergers with neighouring practices, but dismissed this option recognising it would result in a loss of the personalised and particular character of our service. Our deliberations brought us to join a local not-for-profit, GP led federation. Under this model, the practice’s business management and contractual obligations are assumed by the federation, leaving the former partners to focus on their clinical and quality improvement responsibilities and experiencing the financial security of a salaried position. Nonetheless, the practice is protected from a profit-driven model of service provision. We consider this to be a highly satisfactory model which we would encourage others to adopt.

Comments about PCNs

The PCN DES was introduced hastily, in a one-size fits all model without adequate financing for the administrative and managerial burden of developing a new tier in primary care. When the DES was introduced, my colleague took the role of Clinical Lead in order to steer the development of the network. Over the course of the first year, it became apparent to us that the DES framework did not provide the structure and resourcing necessary to develop services for the benefits of patients without detracting significantly from the core work of the practice in delivering care to patients. At this juncture, our practice opted out of participation in the PCN DES for a year, in the hope that other practices would follow suit. Although other practices shared our concerns, none locally could contemplate the loss of income which would follow. Our partnership rejoined the PCN DES (reluctantly) the following year, as it was financially impossible not to do so. Whilst the idea of collaboration with neighbouring practices for health promoting activities is a laudable one, the DES does not provide a satisfactory vehicle for this work. The ARRS scheme is highly prescriptive, preventing recruitment of additional roles that would meet locally identified needs. Roles need to be recruited within practices as there is no legal structure within a PCN which can employ staff. All the new ARRS staff need to be line-managed and to have an organisational identity, when there is no organisation with which to identify. This is putting a near un-sustainable burden on practice managers at a time when the demands on them are already at their limit. The diversion of funding from the core NHS contract to PCN activities make network participation an imperative rather than an act of choice for many practices.

There is much I would wish to add about solutions to the ‘’crisis’’ in general practice, as well as to comment on other questions raised in the inquiry, but word contraints limit further submission. I would be delighted to elaborate these further should the committee find this helpful. I encourage you in your deliberations. Shaping the future of general practice is about shaping one of the markers of a just and civilised society and ensuring that a beacon of social good is enabled to continue to shine brightly.

Dec 2021