Written evidence submitted by Professor Martin Roland CBE, Emeritus Professor of Health Services Research, University of Cambridge (FGP0259)

In 2015 I chaired the Primary Care Workforce Commission established by Jeremy Hunt when he was Secretary of State. We produced the report “The Future of Primary Care: Creating Teams for Tomorrow” with around 50 recommendations. The great majority of these were taken up in the NHS  General Practice Forward View in 2016 with £2.4 billion additional funding. In this evidence, I focus particularly on those parts of the General Practice Forward View that have worked, those that have not and what can be done about those that haven’t succeeded.

Is it realistic to increase the number of GPs?

The GP Forward View committed to expand the GP workforce by 5000 by 2020. Not only has this initiative failed, the number of FTE GPs has gone down during this period. This is despite record numbers of GPs in training. The problem is an increase in the number of GPs leaving the profession / working part time / retiring early. There are two potential solutions to this

Increasing the general practice multidisciplinary team

This is widely accepted as one approach to meeting demand from patients with appropriate health professional advice. Larger multi-disciplinary teams were recommended both in my report The Future of Primary Care: Creating Teams for Tomorrow and in the subsequent General Practice Forward View. Why have these recommendations not had greater impact despite considerable financial investment? In my view there are two main reasons, both of which are remediable given time:

Serious danger that current NHS re-organisation will make things worse

Under new arrangements, the main NHS management structures will be Integrated Care Systems (ICSs) serving populations of 1-3 million and – for primary care – Primary Care Networks serving populations of 50,000. Both of these risk failing in their missions because:

Assuming it is too late to turn round the ICS juggernaut, ICS performance indicators need very clearly to include the need to:

Is the GP contract outdated? Should GPs become salaried?

One of the problems of a national GP contract is that NHS management (e.g. CCGs) has been able to regard the organisation of general practice as something outside their remit. The danger of this may be increased in ICSs. It is tempting to think that primary care and especially the primary-secondary care interface could be more efficient and effective if directly managed and GPs salaried. The Committee needs to recognise major dangers in this. These include:

The Committee therefore needs to look carefully as the professionally led models of general practice currently emerging – such as those mentioned above – rather than assuming that a salaried service is the only alternative to the current GP contract.

The outdated relationship with secondary care needs to be transformed

GPs in many areas have poor access to diagnostic facilities or can only access them by referral to a specialist. Easier access to diagnostic facilities would speed up diagnosis and reduce some specialist referrals.

In the present referral system, the GP sends a letter to the hospital which gradually rises up a pile of letters until, some weeks or months later, the patient is called and sees a specialist. This system is cumbersome, ineffective and inefficient. Trials in Tower Hamlets have shown how the referral system could be radically changed to the benefit of GPs, specialists and patients. A new system would operate as follows:

  1. GP sends a letter outlining his problem to the consultant
  2. The consultant immediately takes responsibility for the patient and does one of the following:

      Phones or writes to the GP with suggestions of what to do

      Phones or has a video consultation directly with the patient

      Arranges an investigation or an alternative treatment service

      If necessary sees the patient in the outpatient clinic, prioritising as necessary

Experiments in Tower Hamlets have shown that this could dramatically reduce the need for outpatient attendance in some specialities.

The present hospital follow-up system is also grossly inefficient. Many patients have regular follow-ups for conditions where the problem could be dealt with as effectively by the specialist having a phone or video consultation with the patient. The pandemic has already started this in many places.

The relationship between primary and secondary care could also be improved greatly by each having access to the records of the other. Despite expensive failures of the past, the idea of an integrated NHS record should not be abandoned.

Focus on the wrong sort of access

Governments, including all those where Mr Hunt was Secretary of State have focused too much on access in terms of the number of people seen within a particular time (e.g. 24 or 48 hours). There has been a disappointing neglect of ensuring the right type of access and in particular access to a GP of the patient’s choice. We know from repeated rounds of the national GP Patient Survey that the majority of patients have a particular GP they prefer to see. Furthermore we know that continuity of care improves the quality of primary care, improves patient satisfaction and reduces both outpatient attendance and emergency admissions. Despite that, the GP Patient Survey shows that being able to see a doctor of their choice is the aspect of NHS performance that has declined more than any other over the last decade (from 70% to <50% for patients who have a particular GP they prefer to see). This persistent misunderstanding of the importance of continuity of care among politicians and policymakers needs to be corrected.

Two missed opportunities

In our report The Future of Primary Care: Creating Teams for Tomorrow, we made two suggestions that merit further attention.

First we could not see the logic of community nursing services being managed by separate trusts. This produces unnecessary fragmentation of services. They should either be managed by hospitals (providing vertical integration) or by primary care (providing horizontal integration). In my view, community nursing services should be managed by Primary Care Networks.

Second, we recommended training of a new cadre of ‘medical assistant’ to reduce GPs’ administrative load, a model that works well in parts of the US. We estimated that if half of the administrative work currently done by GPs were done by someone else, this would be equivalent to recruiting 1400 new full time GPs. This model should be explored more actively.

Charging patients

Charging patients, e.g. for GP appointments, A&E attendance, would likely produce a substantial decline in demand even if most (or even all) were reimbursed as occurs in some European countries. It is unlikely that any government in the near future would take the political risk of introducing charging / co-payments.

Dec 2021