Written evidence submitted by Dr Rachel Warrington (FGP0241)

 

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

The main issue is that demand completely outweighs capacity.

Reasons for no capacity:

There are no GPs to recruit. Lots of GPs are leaving or retiring early as the job is so unsustainable with high levels of burnout. The description of GP and working hours needs to be completely overhauled. The current description is misleading and unhelpful and it has likely contributed to the negative rhetoric in the media and abuse against GPs.

A ‘session’ is defined as 4 hours 10 minutes so a part time GP at 6 sessions would be working 25 hours on paper. In reality a 6 session GP does 12-14 hours a day 3 days a week, they are working at least 36 to 42 hours and often more. On paper these GPs are seen as part time, whereas in reality, they are working at full time hours and above. There is no capacity for these ‘part time’ GPs to increase their hours.

The working day that GPs undertake are intense, with 6-8 hours a day of clinical consultations, and 4-5 hours a day of an ‘iceberg’ of unseen paperwork that needs to be completed. This unseen paperwork is also contributing to the inability for GPs to have any slack in the system to increase capacity. (I have detailed this more in the bureaucracy terms of reference)

The staff that the government have tried to recruit to increase capacity are very good as part of a team, but are not a substitute for GPs, and a lot of work that is undertaken by the allied team members often filters back to GPs. There is also a huge amount of work that can only be done by GPs.

Reasons for high demand:

Patients are living longer with complex needs and so consultations are longer and more complicated. We have an elderly population and along with this comes the multiple co-morbidities, poly -pharmacy and social issues that arise in this age group. This, coupled with conditions like dementia and trying to find the time to work in multi-disciplinary teams to care for these patients, and already one can see that 10 minutes is no longer appropriate, or safe, to address patients in this cohort.

There has to be an honest conversation about misuse of the system by certain parts of the public. Some people access the NHS services at an inappropriately high rate at times, they access for inappropriate reasons, and they access for medical reasons that really should be dealt with by self-care. There are a finite number of appointments and if they are booked inappropriately, of if longer is needed to manage the more complex patients, then it is easy to see that this also decreases the capacity of appointments remaining.

How to tackle the issue

Completely overhaul how GPs working hours are calculated. GPs do not work sessions anymore. The continued use of this term leads to misinformation on the hours GPs are actually working and also leads to abuse from the media and certain members of public.

Recognition is needed for all the unseen work GPs undertake.  Time needs to be allocated in the day so there is dedicated time to undertake this necessary work. It is incredibly stressful for GPs trying to squeeze important clinical paperwork into the only time left when the surgery has shut, and if done at the end of a 12-hour day, it can also be unsafe. Just by recognising the paperwork/unseen paperwork, and allowing dedicated time for this, would increase morale which in turn would improve recruitment. Hospital consultants have recognised time set aside for paperwork and GPs should have this also.

For complex patients clearly 10 minutes is not long enough. Appointments need to be adapted to the needs of the patients to practice medicine safely. Generic 10-minute appointments do not work anymore, it leads to stress for the GP as they cannot deliver the standard of medicine they would like, and frustration for the patient.

There has to be a huge drive on patient education. Self-care, health and healthy living should all start at school age. Education should also involve what accessing the NHS costs for their care so they can see the price of the interventions they are having. The knowledge of the price may generate some respect back for the NHS in certain sectors of society.

 

 

 

 

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

There is an iceberg of unseen work, which needs to be recognised, to understand the problem of burnout, low morale and capacity issues. An average day for a GP is probably made up of 6-8 hours of patient clinical contact and consultations. This is the work that the public sees GPs to be doing, and thinks that this is the only work undertaken.

There is then the 4-5 hours of paperwork that goes along side this, each and every day.

There is the time pressured clinical paperwork that consists of reviewing blood results, processing prescriptions, reviewing letters from consultants of patients that have recent important diagnoses or that need medication changes, the referrals we have generated ourselves that day or discussing with other specialists if we are worried about a patient.

Then there is the non-urgent paperwork:  e-mails (too many, which often causes information fatigue), DVLA, life insurance, MOD fitness forms, firearms, universal credit, safeguarding, sick note requests, adoption medicals... the list seems endless.

Attending meetings with other primary care team clinicians which are important and include district nurses, dementia team, health visitors, palliative care team. Sometimes there will be emergency meetings held if safeguarding issues arise for a patient.

Work also exists which has a non-clinical element: CQC compliance, PCN meetings, reviewing QoF, financial meetings and reviewing funding streams (as the funding is unnecessarily complicated and often micromanaged from a higher level) and reviewing the accounts, all this to make sure the surgery is compliant and fit to run, both to deliver a safe service, but also to be financially buoyant and to avoid being one of the many surgeries that are closing annually.

This paperwork is important. The processing of the clinical paperwork (eg: results and prescriptions), is all part of delivering a good standard of safe clinical care.

Other doctors eg: hospital consultants, are given dedicated time to complete paperwork and it is factored into their day, as it is recognised as being important for good clinical care. However, GPs do not have any time set aside, and so GPs are trying to cram the 4-5 hours of paperwork into the end of the day after the surgery has shut. This is increasing burnout, decreasing morale and is not safe when done at the end of a long intense day. Hence GPs are working 12–14-hour days and taking no breaks with high burnout levels. This is contributing to the huge current recruitment crisis that we currently have.

Just by recognising the paperwork/unseen paperwork, and allowing dedicated time for this, would increase morale overnight which in turn would improve recruitment.

 

 

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

No, not at all.

Lots of GP practices were effectively forced into becoming members of PCNs. If Practices did not join then they would have lost a huge amount of funding.

The PCNs consist of member practices, often with a different ethos, who try and work together. GPs from the surgeries are taken away from patient care even more, as they attend PCN meetings and try and plan a way forward on how to work as a PCN. Money that was given to practices is now diverted into the PCNs, so personalised care is even less. Instead of it coming to the individual surgery directly where you could personalise care, it is now given to the PCN where the care delivered is less likely to be personalised for a particular surgery.

The money comes with caveats attached, and so the micromanagement continues. One example is the money to be spent on Additional Roles Reimbursement Scheme (AARS scheme), which is to employ allied professionals, but money is not allowed to be used to employ ANPs. Why is that? This completely takes away practice autonomy and depersonalises the care for the patients at the surgery.

How to tackle the issue:

Completely overhaul the funding system. Don’t make GPs continuously jump through hoops to get small amounts of funding numerous times to make up the annual funding. The constant micromanagement is a false economy, it takes money away from direct patient care and is centred on trying to collect the data to get the funding earned. This is ridiculous.

Disband PCNS, they are yet another level of bureaucracy that takes GPs away from clinical care and which depersonalises care even more.

Dec 2021