Written evidence submitted by Dr Jacob Lee MRCGP (FGP0254)

I am 39 years old

GP Partner Horfield Health Centre, Lockleaze, Bristol BS7 9RR an inner-city Bristol practice providing care to over 17000 patients.

I have previously worked as a Locum Gp, for the local out of hours service and for the previous 4 years working as the Medical Director for One Care (BNSSG) ltd, this is the local general practice federation covering 1 million patients across Bristol, North Somerset and South Gloucestershire.

I am providing evidence to the committee of the importance of Continuity of Care for patient’s General practice. Improving continuity will directly improve quality of patient care, provide better cost-effective care for our population, improve the satisfaction GPs have in the work place, improve recruitment and retention within General Practice.

Continuity of Care reduces hospital admissions and emergency department attendances. Improvement in is achievable by all practices. The government can enable this by committing to prioritising Continuity in a similar way as it has with access previously through such measures as providing organisational and managerial support, increased GP numbers and financially supporting practices to undertake the transformation. If we are able to achieve this it will enable the NHS to continue to provide sustainable, high-quality, person-centred care for future generations.

General practice is an amazing place to work, I believe this is because of the dedicated partnership and wider practice team I work with and the satisfaction I get from providing care to my personal list of patients. As a practice we provide a personal list care to over 17000 patients. We provide monthly measurement of continuity to the whole practice; an anonymised example is provided. This information is easily available and extracted from within our practice computer system.

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Fig 1 – Horfield health centre Monthly Slicc* measure of continuity. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6478463/

These measures can be easily replicated for other practices at a local and national scale.

I have previously worked within other practices that do not value or strive to achieve continuity of care. Working there left me demoralised and frustrated that most of my time was spent endlessly searching through notes to find out the patient’s history whilst also trying to hold a conversation with the patient. Every consultation felt difficult and largely unrewarding.

Providing care to a personal list of patients I am now able to understand my patients within a wider context including their family and social context. I no longer feel that my actions are isolated contacts, I am supporting my patients lives, my interactions are easier not having to start at the beginning of every consultation knowing nothing about the patient. I hold a sense of responsibility to the longer-term care of my patients that makes me want to take the time to discuss prevention and self-care as I know we will both see the benefit.

For patients that have complex multi-morbidity prioritising care and deciding on appropriate treatment and escalation becomes even more important. Having built up knowledge and a relationship with the patient over time I am more able to have difficult conversations that ensures escalation of care is appropriate, avoiding over medicalisation and if needed end of life planning takes place in a timely manner.

As a practice we have not faced the difficulties other practices have in retaining and recruiting GP both salaried and Partners. I believe this is due to our strong ethos to providing personalised care through a personal list system. The sense of reward and responsibility in providing this helps boost and maintain morale even during a difficult time such as the last 18 months.

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?

Having a named GP allocated is the first step to trying to develop continuity, although having a named GP within a computer record will not improve continuity on its own. It is the processes that the practice has in place that supports patients to see the GP as the preferred clinician that is important.

Wider delivery of continuity

I was the lead GP for one of the Health Foundation ‘Continuity of Care’ programme sites How well do I know and trust my doctor? (health.org.uk) it was a privilege to be able to work with 23 practices covering 400,000 patients who, when given the opportunity and support, actively wanted to be part of the project and were able to improve the level of continuity of care they provided to their patients.

Within the project we worked with a wide number of practices of varying size and patient demographic. Many operated pooled lists (patients are able to see any available GP) during the project they identified groups of patients who they felt were more likely to benefit from continuity. These included, palliative care, frequent attenders, and patients with Learning Disability. Once identified the practices put systems in place to encourage continuity. They all saw improvement in the level of continuity they provided. It is noteworthy that these practices also saw improvement in continuity figures for the wider practice population outside of the target groups.

A number of practices already used a personal list system (this is seen as the gold standard method of providing continuity) in these practices improvements were gained through increased training of frontline staff, use of patient participation groups and improved messaging with patients to help them understand the importance and value of continuity.

Given the right motivation, tools to measure and operational resources General practice can adapt its way of working to provide greater continuity of care. There are many varying ways to achieve this and each practice was able to find the method most suitable for its staff and for its practice population.


Challenges to continuity

Not all clinical presentations need to see a GP and with current workforce pressures many practices rely on or have adapted the care model they provide through using an expanding workforce including pharmacy, social prescribing, nurse practitioners, mental health workers and physios it is increasingly important to start to identify patients who due to complexity/multimorbidity would still gain greater benefit from an appointment with their GP rather an allied health professional. The GP is a highly skilled clinician that can deal with and prioritise many problems in one appointment and manage a level of complexity and risk that other staff are not able to. Whilst GP resources are limited further research will be helpful to understand which patient groups are likely to benefit the most from continuity with their GP.

The majority of the GP workforce working less than 5 days per week it is important to address the challenge of speed of access v continuity. Whilst it is accepted that some clinical conditions require urgent assessment in a time frame that does not enable them to see their named GP Patients need to be part of this conversation and there needs to be practice level and national support to enable patients to understand the benefits that continuity brings so they are able to make an informed decision. The benefits include:

 

Practical steps that would support continuity

              Making continuity part of the national agenda and a priority area

              Developing national and practice level metrics to measure continuity

Promoting continuity to patients through media and health promotion campaigns

Providing operational and financial support to encourage and incentivise practices

Providing training in the benefits of continuity within the GP training scheme.

 

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

The Partnership model of general practice is not broken and there are many examples of practices delivering excellent care by high performing and motivated teams. External pressures on practices with increasing life expectancy, rising workload, and higher patient consultation rates compounded by lack of workforce planning and insufficient investment over the last 15 years has meant general practice is under huge pressure however these external factors would be present in any model of general practice provision. It is the underlying problems that need to be addressed rather than the operational model.

Underpinning each partnership are groups of GP working as a team providing the commitment, clinical leadership and drive to provide excellent care to the communities they serve. Within the partnership review carried out by Nigel Watson autonomy, flexibility and being able to implement change rapidly were repeatedly seen to be key motivating factors in all of the many differing partnership models.

The partnership model will shape itself to best meet the needs of the practices and patients. This may be as 30 practice super partnerships or small 2-3 Partner practices. The ability to rapidly change in this way enables General practice to continue to provide localised patient focussed care. Partnerships go hand in hand with a longer-term commitment to a practice which is key to supports the provision of continuity of care to the practice population

Partnerships need to be supported in both retaining long standing senior GP Partners who act as experienced voices and mentors to more junior staff within a practice.

Incentivising GPs to remain in one practice for longer periods (10 years +) of time would be beneficial for the practice and patients.

Supporting new partners through education of partnerships in GP training and first 5 years after becoming a GP training, continuing the new partner financial incentives and considering introducing practice incentives to take on new partners would be beneficial.

Review of partnership estates and the financial risk holding of estates within partnerships is key as this is often seen as a barrier for new partners particularly in those practices that have older estates.

 

Dec 2021