Written evidence submitted by The Simpson Centre and Penn Surgery (FGP0250)

 

We are a GP partnership of 8 partners and 5 salaried GPs. We are a large practice working across two sites with a list size of 18,500 patients. We are a member of ARC PCN, a group of 6 practices in South Bucks covering a total of 80,000 patients.

 

The evidence we present is based on our experience of working in the NHS on a daily basis, and the challenges we have faced over the past 5 years in particular.

 

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

-Doctors

We have been fortunate to replace our retiring GPs with other doctors. We are a training practice and many of our current registrars are not looking for full time work but plan a portfolio career or locum/salaried roles. Current low morale is not encouraging GPs to want to commit long term to a practice.

-Nurses

We have struggled to recruit nurses to assist us particularly with long term conditions management, and those we have recruited have required significant training time and several have not stayed beyond their training.

-Support staff

We have a paramedic working with us for minor illness clinics and home visiting. With the introduction of PCNs there is a shortage of supply of Paramedics, Pharmacists and Physicians Associates and attracting these staff to us and then retaining them is a challenge. Our PCN has been unable to recruit the pharmacist hours needed.

-Increasing ageing population and multiple comorbidities. This makes consultations more complex, multiple conditions and issues to be tackled. The traditional 10min consultation is no longer appropriate in a lot of cases.

-Patient expectations

The ‘Tesco culture’ 24hr health care on demand. Busy working lives, failure of employers to give time off for routine medical care, long term condition work.

The place for telephone and online consulting.

Example.

In April we introduced Klinik. This in an online platform which allows patients via our website to fill in a document with their medical complaint and request an appointment or advise. It has an AI (artificial intelligence) to identify the degree of urgency of the problem and will ask the patient to call an ambulance if it is recognised to be an emergency.

We were overwhelmed with requests.

The AI was not helpful. It inappropriately asked patients to call an ambulance and was unable to identify all the urgent cases. We persevered for 5 months but have been unable to continue due to the volume of work and concerns about safety of the system.

General practice is severely underfunded compared to our secondary care colleagues. We are picking up increasing amounts of secondary care work and receiving minimal funding for doing so. For example: we now care for all our type 2 diabetics in general practice with two specialist GPs. We initiate insulin and other injectable medications. All this work would previously have been done by secondary care, but we have seen hardly any transfer of funding, we are just expected to absorb this into our daily work. Another example. For our QOF payments we now must do FENO testing and spirometry for diagnosis of asthma. We have had to purchase these machines ourselves. We no longer have any nurses who are trained to do spirometry and no funding for this service. We are now having to refer all our patients to secondary care for this and waiting lists are very long (made worse by covid).

 

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 a recent survey of our patients by our PPG (Patient Participation Group) post Covid and the introduction of our new online appointment system the biggest two complaints that were raised were the lack of face to face appointments and the desire for continuity of care, the ability to choose their GP and to have the same person each time.

As a GP this is very valuable to us too. Having had a number of contacts with a patient means the next consultation will potentially take less time, you can pick up where you left off. If reviewing results, you know why you did the tests and your plan for management with the results. You may get to know the social circumstances of a patient, they may attend with a family member one time who can fill in a lot of detail that may not be available on every visit. For a young healthy person with a sore throat this may be less important, but for our older patients or those with chronic conditions continuity improves patient satisfaction, trust and compliance with treatment, and time efficiency for the GP. There is also potentially a safety element to continuity. If this is the third time you have seen someone with a minor complaint you might start to wonder what else is going on and pick up on potential early warning symptoms of a more serious condition, or social concerns such as neglect/abuse.

 

 

What part should General Practice Play in the Prevention Agenda?

General practice is ideally placed.

Challenges are in recruitment of staff to support in this.

GPs telling a patient to lose weight or stop smoking are powerful in encouraging them to start to take action, but we need the support staff to follow up on this.

Currently our LWSW (Live Well Stay Well) service has a very long wait and support is largely by telephone or online which many patients do not engage well with.

 

 

 

 

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

Causes of low morale in the last 2 years.

  1. Communication, communication, communication

There have been numerous examples of the past year of a complete lack of understanding over how announcements made on national TV will impact on the NHS and increase workload unnecessarily.

One example: Last night 12/12/21 It was announced that general practice was going to be involved in a huge increase to the vaccination programme to vaccinate all people over 18 by the end of December. We are told this with the general population, no prior warning. Apparently, we will be able to reduce some of our routine appointments to free up time for this.

So, Monday morning we are bombarded with patients wanting to know what is happening and whether we are cancelling the appointment they have booked with us, when we know no more than they do. Some thought over the messages being relayed, understanding the likely consequences please. You could tell everyone at the time. A good start might be: “Your doctors are learning about this now. Do not call them, give them a day or two to set his up, they will call you”

  1. Covid              huge increase in workload with onset of the Pandemic. Move to online and telephone consulting /video consulting overnight, as per NHS England advise, requiring setting up of new systems, training of all staff on new systems. Daily briefing e mails with changes updated requiring action. Large numbers of staff working from home with children isolating/ themselves isolating. Shielding staff working from home. Coping with staff off sick. Family members sick. Multiple sick patients, managing care home outbreak via video calls. Care home vaccinations during a covid outbreak at the home. Multiple patient deaths. Long covid.

Covid vaccinations: setting up and running vaccine clinics with our PCN. Providing vaccinators, runners and admin support to clinics from our existing workforce many working their days off.

Housebound covid vaccinations

Flu vaccinations last yr. and this yr. with increased cohort.

  1. Long working hours

We are often working 12-14 hours a day in practice non-stop, with no lunch breaks, and high patient demand. Multiple patient contacts, often with complex patients with multiple problems. Large amounts of administration. This includes dealing with hospital letters, prescriptions with many outstanding medication reviews that have been delayed by Covid and more recently a shortage of blood bottles. We have had a huge number of queries regarding covid vaccinations. Examples include patients who need a third dose (due to being immunosuppressed) rather than a booster dose. There is great confusion about who is making this decision and vaccine centres have been sending patients back to their GP because their consultant hadn’t given them a letter. Many patients have had vaccinations abroad and these were not recognised by the nhs app. (including those who had a vaccine in Wales or Scotland). Whenever anyone cannot answer the patient’s question (at 111, or the vaccine booking service 119) the default is always to ‘just ask your GP’.

 

Many of us are working our days off, working locum shifts and at weekends at vaccination clinics, covering our absent colleagues.

Our contract is open ended. There is no limit to the work that comes our way, we cannot turn patients away we just have to encourage patients to call back if their problem is not urgent for today and if it is just keep going until the work is done.

 

Our registrars in training watch what we do. They are protected in the hours they are contracted to work while in training. Why would they want to join a practice and put themselves through the intensity of work and stress that they see us doing? Many of them choose to do locum work, or work in salaried roles where they can better control their hours and volume of work.

 

  1. Press coverage

PRESS REPORTS THAT GP SURGERIES HAVE BEEN CLOSED AND NOT SEEING ANY FACE TO FACE PATIENTS WHEN THIS WAS THE NHS ENGLAND ADVICE, WITH NO ATTEMPT TO COUNTER THESE REPORTS, BY THE GOVERNMENT PROVIDING ZERO SUPPORT TO THE GP WORKFORCE AND INFLAMMING PATIENT ANTAGONISM AND ANGER THAT IS ALREADY A PROBLEM AS WE TRY TO RECOVER FROM THE PANDEMIC IMPACT ON THE HEALTH SERVICE. SEEMING TO SUPPORT PRIVATE PROVIDERS EG PHARMACISTS WITH NATIONAL BOOKING SYSTEMS FOR COVID VACCIINATION EARLIER IN THE YEAR. NO APPRECIATION OF HOW MANY THOUSANDS OF HOURS WENT INTO CALLING IN PATIENTS FOR THE FIRST AND SECOND PHASES BY OUR TEAMS WHILST CARRYING ON WITH EVERYTHING ELSE.

 

 

To improve morale

  1. Recognise the role of General Practice as the backbone of the health service. Support GPs in the media. Tell the population that we matter, that we have an important role to play, that we are working hard, that we have played a huge role in the past year. Change the rhetoric.

Explain to the public that the waiting lists are long as we have made thousands of referrals through this period. We have managed thousands of patients and have checked thousands of prescriptions. We were mandated by NHSE to move to teleconsultation first, to close our waiting rooms. We have still been working very hard for our patients by telephone, video links and face to face when required. There has been no effort from the government to explain this. Our teams have been left exhausted, feeling abused, and very demoralised.

  1. Increase the number of GPs and support staff in training and increase funding to encourage retired and lapsed staff back in to work. We need additional staff coming through the system to provide increasing numbers of staff for the future.
  2. Work across parties to work towards a long term 20-year plan for the health service. Take politics out of health. Can we have an independent advisory body like the Bank of England? We need a plan that we can work to that does not get rewritten and changed every 5 years. Drs who have been working for 20-30 years are very weary of constant change.

 

 

 

How can the current model of General practice be improved to make it more sustainable in the long term?

Is the current Partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

The partnership model has been invaluable in the last 2 years as we have coped with a pandemic, as has the existence of a National Health Service that can work together to implement standard procedures for care.

The Covid vaccinations is one area that has demonstrated this. We were able as partners within our PCN to rapidly work together to staff and manage a local vaccination site, contact all our eligible patients, and invite them in a timely manner to the site and arrange clinics for our vulnerable care home and housebound patients. At a local level we know these people personally and are invested in the desire to care for them and put in the extra time required to do so, working days off and weekends to complete the task.

 

The current contract is open ended. When demand outstrips supply, we have nowhere else to ask our patients to go. If they choose to go to a&e or call 111, we are blamed for this. We need more honesty at a national/ government level about what can be achieved with our current level of resources, staffing and funding, and the expectation that patients cannot always expect instant care for non-urgent conditions.

 

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

No. it is a tick box exercise!

There is no doubt that the introduction of QOF (Quality Outcome Framework) payments, in 2004, improved standards. This helped to bring all practices in line to a recognised standard. Certain disease conditions have been focused on with this such as hypertension, cardiovascular disease and stroke, and have therefore been focussed on more than others.

We have reached a plateau with this now. There needs to be thought into what should come next.

 

Has the development of PCNs improved the delivery of proactive, personalised, coordinated, and integrated care and reduced the admin burden on GPs.

We have a PCN which is expanding, and we have social prescribers, care coordinators, pharmacists, physicians associate, a paramedic and health coach.

It has taken a significant amount of time for certain GPs within the practices to recruit and support these staff and our PCN is funding locum cover for 5 sessions per week to free Dr time to support the team.

Recruitment is a problem. We have found it difficult to recruit pharmacists, in particular. There is an issue with space for these new teams to work and none of our surgeries have enough rooms for them, so they are having to work from home some days in the week.

The teams have set up multidisciplinary team meetings with social services, housing and health which has significantly improved our links and coordination with social services.

The team are proactively following up patients post discharge from hospital and care home residents, as well as referrals from GPs and nurses in the community. It is unclear whether this has yet had an impact on admissions/ a&e visits etc.

 

They have played a huge and vital role in supporting the vaccination clinics, attending every clinic, pharmacists have helped with diluting of Pfizer vaccines, our care coordinators and social prescribers have helped as runners and admin support and our physicians associate and paramedic as observers of patients post vaccination, treating any reactions /feinting etc.

There is a lot more that these teams can potentially offer but we need to be able to recruit the staff, provide the space and equipment for them to work from and the time to embed their role (not keep changing it each April!)

 

To what extent has GP been able to work in effective partnerships with other profession within primary care and beyond to free more GP time for patient care?

 

Allied professionals working with us all need support, supervision, and training.

We need to recruit to roles, invest time to train staff in the roles and then stabilise the workforce and be able to keep and use these members of staff over the longer term. So far it seems we have invested more time than we have been able to save in recruiting, managing, and supporting these staff members.

We need a period of stability for these teams to allow consolidation of their roles and develop their expertise so they can safely and successfully take on more of the traditional clinical work and free up GP time.

 

 

Conclusion:

GENERAL PRACTICE IS IN CRISIS, and we have felt it vital to contribute to any efforts that government is making to help us to address the issues we are facing. This information is brief as we have had limited time to put it together, but it represents the views of all our partners, and we hope it goes some way to explain some of the issues we are facing on the ground in our individual practice: some of the good results we have achieved working with our PCN and new support staff, the huge amount of effort that has been made by all our staff, Doctors, Nurses, paramedic, pcn team and all our reception and admin staff to continue to support our patients throughout this period and particularly with the vaccination programme. But also the challenges: working through the pandemic with constant daily change, uncertainty and flux and a political attitude that seems to fail to notice any of the good work we have been doing and indeed at times actively suggests we have been doing otherwise.

Before the pandemic we were struggling but now we have reached a crisis point. The demand on our services is far exceeding the capacity we have to provide and we urgently need change.

 

We look forward to hearing some positive outcomes from the inquiry.

 

Yours Sincerely

 

 

The Simpson Centre and Penn Surgery

 

 

Dec 2021