Written evidence submitted by Dr David Jewell (FGP0255)

 

I have recently retired from clinical practice after nearly 40 years as a GP, with academic posts in Southampton and Bristol, and 10 years as editor of the British Journal of General Practice.  My perspective has also been informed by a project I have been involved in for the last eight years working to help improve primary care in Palestine. 

 

Given that I am no longer actively involved in day to day general practice I am not in a position to address some of these questions.  I am submitting this evidence because I can relate what is happening now to what was happening a few years before I qualified.  This provides a context of which many others are unfamiliar and which shows how a thriving primary care sector can be revived.

 

I have selected those questions that I feel qualified to answer:

 

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

It’s not clear that encouraging GPs to offer a range of methods (face to face, video consultations, phone calls, emails etc) improves access overall.  There is evidence that phone calls to discuss existing problems are useful, but those where patients present new problems often result in a face to face consultation in addition to the phone call.  In other words such approaches may counter-intuitively increase workload.  Quite obviously a video consultation may save a visit to the patient’s home but is unlikely to save time over a face to face one in the doctor’s surgery. 

Many of us feel that poor access and the current out of hours facilities increase A&E attendance.  I don’t think this has ever been proved empirically.  However the general feeling of poor access leads to frustration among patients and on a wider scale the increased anxiety will tend to increase demand for consultations.  (Here I am speaking as much as a patient as a retired doctor).  Out of hours cover is difficult.  There is the question of the efficiency of asking doctors to work overnight and still be expected to work the following day, but out of hours work had already become difficult with many doctors feeling unsafe going to patients’ homes during the night. 

Having a named doctor is an administrative task that only requires someone to bring the records up to date.  It will achieve nothing at all if it is not matched by a commitment to provide personal continuity. 

There is a mystery here about DoH policy.  The evidence is that better personal continuity of care reduces hospital referrals and admissions; reduces investigations; may reduce the death rate; is welcomed by patients; and gives GPs much more job satisfaction.  In other words it offers the NHS a set of positive outcomes.  (There are some theoretical negative outcomes but they can be allowed for).  However all the emphasis on access has been an obsession with quicker access, accompanied with financial incentives offered to practices to improve on this metric.  Generally the changes introduced as a result have reduced personal continuity.  To anyone with knowledge of the evidence it is incomprehensible, and especially incomprehensible that the DoH has not funded a well constructed controlled trial to test out whether a model that values personal continuity appropriately can offer comparable gains in normal service conditions. 

The answer here depends entirely on the nature of the particular prevention intervention.  On all immunisations the record of general practice speaks for itself, as it does for cervical cytology and various other parts of the programme.  Anything that requires specifically medical surveillance or intervention is within the capacity of general practice and there will be no controversy. However in some aspects general practice may only have a small part to play and then it would be wrong to expect it to take on full responsibility.  In the obvious areas of alcohol and drug misuse; dietary policy and obesity; exercise and transport policy it is ludicrous to expect general practice to have any impact where successive governments have failed to take any lead.  There is also difficulty with programmes that lack convincing evidence.  Here I am thinking about the current national campaign to identify and offer treatment to people identified as having so-called pre-diabetes, or the over-40s health checks for neither which there is any convincing evidence of any benefit.  Here it is unreasonable to ask GPs to participate in a programme where the opportunity costs may be high but that they can see does not good. 

 

How can the current model of general practice be improved to make it more sustainable in the long term? In particular:

It is this question that has motivated me to submit evidence. It feels as if general practice is returning to the state it was in before the contract of 1966, when it was difficult to attract doctors to enter the profession and there was serious talk of it vanishing altogether.  One of the weaknesses at that time was the existence of assistants, namely salaried doctors who were never going to become partners and who were exploited by the owners of the practices.  This has returned with a vengeance following the major change in the current payment system.  It is important to remember that from the late 1960s to early this century general practice was seen as an attractive career option very popular among doctors graduating from medical school.  Given that the traditional partnership model was so successful in the recent past, this question is the wrong one.  It should be not ‘Is this model sustainable?’ but ‘Given that the traditional partnership model seemed to ensure recruitment and retention, how can it be restored?’  The answer lies in restoring a financial model that rewards practices for taking on partners rather than salaried doctors who then have less commitment to the long term health of the practice and less incentive to stay and improve it.  A colleague referred to this as custodianship of the practice, and current financial arrangements do not reward doctors for taking it on.  Partnership has become more onerous in terms of employers’ responsibilities, but these could be shared among different practices; could be better supported; and would be tolerable if the rewards of partnership became tangible again.  Throughout the economy the advantages of small businesses are welcomed by government so there is no reason not to support the model in medicine. 

Partnership has become unattractive because it is financially less attractive and carries more responsibility.  But at the same time the increased diktats from the centre telling GPs how to run their practices and what activity they should be doing means that the previous freedom to decide what will best suit their practice has been eroded, so that GPs feel more like government functionaries than thoughtful responsible professionals.  The model of central control of GPs activities is not only an insult to their professionalism, it is also highly inefficient.  Much better to treat the system as one of distributed intelligence. 

No.  My responses above indicate my view that the current arrangements encourage fragmented and inefficient care.  For personalised and coordinated care the system should value personal continuity.  Integrated care can only be achieved with GPs who make long term commitment to practices and can develop trusting relationships with local secondary care units and specialists. 

I cannot comment.  There should be scope for some back office functions to be shared between practices, and some scope for practices to learn from each other’s initiatives.  The latter has always happened informally and it’s not clear to me that the formal arrangements have repaid the additional bureaucracy required. 

This is a rather insulting question.  The huge expansion of the role of nurses working in primary care, and the involvement of others such as pharmacists and physiotherapists all came from the initiatives taken by some practices which were then publicised and copied by others.  The question seems to be asking how GPs have managed to conform to changes imposed from outside, and that is simply not how the profession has developed.  With shortages of doctors there will be further encouragement to employ physician assistants, nurse practitioners etc.  I have no doubt that GPs will be able to work alongside any such professionals.  It’s not clear that it frees up GPs’ time, and the sharing of work means that some continuity is lost and the fragmentation leads to a lower standard of care overall. 

 

Dec 2021