Written evidence submitted by Stockport Local Medical Committee (FGP0253)

Introduction

Stockport Local Medical Committee (LMC) represents GP practices within the footprint of Stockport Clinical Commissioning Group (CCG). This comprises of 36 Practices serving a population of over 300,000 registered patients. Stockport CCG is part of the Greater Manchester Health and Social Care Partnership.

Stockport is an industrial town on the edge of the urban area of Greater Manchester and borders the more rural areas of Cheshire East, Derbyshire, and Tameside and Glossop. The population is varied and includes some areas of significant deprivation, areas of wealth and is broadly urban or suburban with some semi-rural demographics around the edges.

We responded to the call for evidence by polling our constituent GPs and practices to gather some qualitive data from front line teams and asked the LMC committee members, who are all GPs themselves and each represent an area of Stockport, to review and support the writing of the submission with the aim of giving a balanced and representative piece of evidence from frontline General Practice in Stockport.

 

Evidence Submission

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

The themes here are around infrastructure, capacity and demand that mean patients are struggling to make appointments with their GP as the services are overwhelmed. GP practices are frequently reporting demand far exceeding any previously experienced levels. This is from patients directly presenting with new or ongoing problems, some of whom are waiting for secondary care appointments and are struggling to cope with, or seeing a worsening, of their problem. Other issues that are absorbing GP time and degrading access for patients include a significant increase in inappropriate workload transfers from secondary and tertiary care as they send ‘instructions’ for tasks to the GP that they should be completing within their own services sometimes because they are not seeing patients face to face but only by phone and sometimes even if the patient has been into hospital to see them.

Patient expectation, that has been driven by government and media narratives for some time now, builds barriers to access as patients with minor symptoms (lasting only a matter of hours at times) will often book appointments to speak to a GP about it and in doing so block access for the more vulnerable and/or needful patients. One respondent describes how the open-ended nature of GP access, and the GP contract that describes no limitations on access, paradoxically worsens access for patients who need to see a GP. Their access is limited by patients who do not need to be seeking GP contact at all or are even sent from a wide range of other sources such as pharmacies and hospitals who should know better, and gyms and other private companies, and even other public bodies who use NHS GPs as a risk dump by telling their clients to see their GP before they will work with them.

To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

There is a clear sense that the improving access plans are unworkable and rely on essentially squeezing an already burnt-out workforce harder. None of the respondents to our enquiries felt that there was anything in the Governments plan that has potential to improve access for patients to general practice usefully or sustainably. One PCN Clinical Director advised us that his PCN had assessed their workforce options and very few GPs had anything else to give and of these most were only able to give ad-hoc and short-term assistance which would not provide any sustainable solution to access.

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

The evidence in the numbers that our CCG present to us, is that patients are driven to other services such as out of hours, and the Emergency Departments.

However, the practices and their patients also must deal with a more emotional and potentially dangerous impact. Patients who struggle to access practices can become angry and upset. Most practices are reporting one impact of this as a rise in complaints which take time and emotional energy to address, and in some cases violence and threatening behaviour has been suffered by practice teams. One practice recently had a patient storm the back office and had to be removed by police. This further impacts on the function of the practice and may cause patients waiting to suffer distress themselves or delayed care due to the practice having to manage the threat.

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?

There is strong feedback that a consistent GP can bring a significant advantage to patient care. This is best described, however as a GP of choice’ rather than a ‘named GP’ as patents may see one GP for one problem and another for a different problem but the longitudinal care through a patient journey can add significant benefit to the patient and the health economy. One GP tells us of a patient who he has successfully kept out of hospital for many years due to the ongoing and consistent Dr-patient relationship he has with them when they would undoubtably have endured multiple admissions should their care have been fragmented. The trust and understanding that is built up over time is a cornerstone of General Practice care for a vast number of patients – even when presenting with seemingly minor problems the consultations usually are more effective and faster and lead to fewer re-presentations when with a GP who is known and trusted by the patient.

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

There is a clear steer from practices that a significant challenge is low morale and burnout, poor resourcing into the core, and the flood of workload transfer from secondary care.

This demoralised workforce is facing a steady and inextricable rise in the number of patients suffering from multiple and complex morbidities both physical such as diabetes, and psychological such as stress and depression. There is also a growing burden of work and pressure from the complex conditions that are being more commonly recognised and diagnosed such as Hyperactivity, and Autistic Spectrum Disorders and the exceedingly complex and specialist needs of Trans people. All this increasingly complex and specialist workload is not matched by the commissioning of proper specialist care so that GPs are finding themselves increasingly being asked to deal with pathologies, problems and issues that are outside of any reasonably expected competence range of General Practitioners. This poses a significant risk for both the professionals and, of course, the patients who need better care than can be provided within Core General Practice.

A further challenge is premises. Stockport General Practice premises have seen woeful levels of investment over the last 15 – 20 years resulting in a premises estate that is, in its present position, inadequate for existing levels of service delivery. The problem is compounded by two major priorities: the need to house ARRS staff and the desire to engage in the training of tomorrow’s clinical staff

All these factors are likely to precipitate a net loss of experienced Partners both locally and nationally within this period. Unless there is a significant and well publicised change in direction from the current policy of the undermining of the partnership model at every turn, then this loss of partners will lead to the eventual collapse of General Practice with the predictable consequences to the wider health care system. By continuing to overlook the benefits of the Partnership model this scenario is much more likely to come to pass and the subsequent Primary Care ‘offer’ will look vastly different to patients in the future, and this is something that would take a huge re-adjustment on behalf of the electorate.

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

The variation in care is not just regional, or urban vs rural, but is apparent between practices within towns and boroughs.

The resourcing challenges described above are notably impacted by changes to the target-based payment mechanism of the Quality Outcomes Framework which can be incredibly dependent of the demographics of the patient population. For example, one practice in a very deprived area has seen a sizeable chunk of their finances cut due to the retirement of an indicator with a large baseline population (that increases the value of the target) while at the same time some newer indicators such as child immunisations are significantly harder to achieve with their particular patient population who have a low health literacy. The consequent amount of additional work can be extraordinarily high yet the points and therefore the income to fund that work, may remain out of reach.

What part should general practice play in the prevention agenda?

There is a strong feeling that General Practice is well placed to play a significant part in the prevention agenda as part of the Cradle to Grave holistic care that is a core part of general practice but that the reality is that it is a time-consuming task, and a population-based approach is required so it would be an exceedingly difficult ask of General Practice in the current situation.

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

Many of these issues are already highlighted. The drivers to burnout can be broken down into organisational level and practitioner/staff level.

At the organisational level practices are hugely impacted by the complicated structure of the contracting and funding processes and the poor performance of PCSE (Primary Care Support England). The stresses that are applied by CQC (Care Quality Commission) and Appraisal are particularly seen as disproportionate and arduous for both practices and practitioners.

At the practitioner (and other staff) level there is enormous pressure generated by the low level but countless administrative and clinical requirements of various systems and agencies. As described elsewhere in this document GPs and their practice teams are inundated with asks, tasks and demands from all directions that individually may seem insignificant but when taken as a whole the effect is well described by the phrase “death by a thousand cuts. The majority of these asks are not even part of GPs role or contract although this is often misconceived by the requestor. Challenging this inappropriate workload can be time consuming and emotionally draining.

The damaged morale would be well addressed in the first instance by a recognition and reversal of the negative spin that GP has been subjected to in increasing levels from multiple political and media sources. A clear and effective look is needed at what NHS GP is actually resourced to do, with a well backed publicity campaign to describe this and adjust expectations to reverse this negative swing in public opinion and the resultant emotional, professional, and sadly too frequent physical attack, that has been levied against GP teams.

In addition, there is need for an unambiguous directive to agencies and organisations outside of GP (Both NHS and others) about their roles and responsibilities to discharge their own duties without transferring that into GP. Alongside this should be an effective mechanism for GPs to report such behaviours that result in feedback, change and if necessary, censure of the originator.

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?

There are concerns that this question feels loaded. The clear and recognised opinion from the front line is that the recruitment challenges and a shift towards Salaried posts are caused by the lack of support into General Practice and the consequent pressures on practices and partners as described above; it is not an inherent change in how General Practice care is delivered that then puts the partnership model at risk.

The ICS (Integrated Care System) and integrated care approach may have many positive aspects, but they fail to provide any mechanism that matches the partnership model to provide the personalised and consistent care that has been explored above. In the words of one constituent GP the Partnership model is not only sustainable but key to the long-term survival of primary care. The consistent message around this is GP Partnership must be financially and professionally rewarding to ensure it remains an attractive proposition for GPs entering the profession. A purely salaried model is almost guaranteed to undermine the consistency and efficiency of care. It is recognised that Partners perform a great deal of work both clinical and non-clinical outside of the hours and expectations that could be delivered through a salaried contract; a change to such a model would lead to a significant degradation of the volume and quality of work being performed or a sizable increase in staffing costs to achieve the same outcomes. To avoid this the ‘rights and responsibilities’ see-saw for Partners needs to be re-balanced in order that confidence returns to those entering a career in General Practice.

Another theme around sustainability is that of trainees and training. GP trainees are usually trained by partners or within partnerships who recognise trainees as the potential partners of the future. This leads to a training and working environment that tends to encourage teamwork and ownership of the work and the job. This ‘expert apprentice approach encourages recruitment and development at the bottom end of the career ladder. The partnership model is seen as a strong driver of this, and a less personalised and more diffused training structure is considered less likely to be as effective in these respects.

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

There is a mixed response to this. The problem with the systems generally is that they are often very convoluted and inconsistent and the payment mechanisms can be hard to fathom and stressful to complete. This encourages a more ‘tick box’ approach as the only way to deliver on the contract. In contrast to this there is also a feeling that there is great strength in some contracted schemes to provide truly effective and personalised care for patients of the practices. In particular the more ‘light touch’ approach to contracting where Practices have been given access to funds that can be deployed to best serve patients, as they see fit and are not burdened with excessive and overly detailed targets or outcome measures. This type of contract has allowed practices to concentrate on delivering the best value on the contract and importantly the best care for patients by tailoring the deployment of the contract to their specific needs.

One clear barrier to the integration agenda is the way that commissioning of services can be spread across multiple organisations or agencies; each of which will have their own agendas and frameworks which can be at odds with the integration agenda. This is detailed more specifically in the final section below.

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

This is another area with gains and losses. The recent increased flexibility within the ARRS (Additional Roles reimbursement Scheme) budget is a good example of how care can be improved by Practices and PCNs being able to recruit to roles to meet specific needs of patients and practices. One example is the recruitment of safeguarding care co-ordinators that have helped practice in the more deprived areas of the locality where this workload is disproportionally higher and often more complex.

However, the administrative burden is far from reduced by PCNs and co-ordinated care. In fact, they are often seen as drains on practices, and it seems that managing the various elements of the schemes can cause greater administrative burden on GPs not less. More meetings and more reports, more expectations and queries from other agencies and more time taken away from direct patient care.

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

Effective partnership with other professions has been hugely limited by the resourcing and contractual issues previously mentioned. As alluded to above other organisations that form key parts of the care team can put up barriers to decision making. Small and flexible partner owned practices are able to make executive decisions almost instantly in many cases while the larger and more cumbersome organisations cannot or do not empower the staff in the PCN leadership teams to make decisions. They instead throttle the development of effective and personalised care delivery plans through the application of the complex governance structures in the management heavy organisations; or they simply don’t engage with the issues at the PCN level as it may not align with their other agendas. In Stockport, the Community Health Services have been commissioned to the secondary care provider who have these complex and obstructive organisational structures. These services include key components of frontline practice and PCN care delivery, such as the District Nursing team and the community physiotherapy service. Sadly, this has essentially ground innovation, personalisation, and the improvement of care to a halt. Only a new commissioning process centring the community services on practices and PCNs and ultimately localised to patient needs would solve this impasse.

 

Submitted on behalf of Stockport Local Medical Committee

 

Dr Howard Sunderland

Honorary Secretary

www.stockportlmc.org

 

Dec 2021