Written evidence submitted by Ms Anne Gray (FGP0262)

I will comment on only some of the points in the Committee’s terms of reference for this inquiry, as follows:-

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

1a. To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?

In BW999- ‘Our plan for improving access and supporting general practice’ (October 2021) ICS’s are enjoined to monitor the 20% ‘worst’ practices on various indicators and take contractual action if, in extremis, these practices do not sufficiently improve. This raises two questions; firstly are the indicators sensible for all circumstances and secondly, would action against ‘failing’ practices be likely to result in something worse for patients.

One indicator is whether practices record less than 20% of appointments face to face. This is a blunt instrument. If it is true that younger, more digitally competent patients in employment often prefer phone or online consultations, as argued in the NHS Long Term Plan, it’s conceivable that some practices (for example those that have attracted mainly university students or young high-income professionals) would have a very low proportion of face to face appointments by patient preference. On the other hand the proportion of face to face appointments in a seaside town with a largely elderly population, or in a deprived area with very low rates of smartphone/computer ownership and home broadband access, might reasonably need a far higher proportion of face to face appointments than 20%. One better indicator would surely be average and maximum waiting times for face to face appointments that have been requested by patients. Another would be average time spent on hold by patients on the phone before speaking to a receptionist.

Another indicator which could give distorted results is the 20% of practices with the highest A and E attendances. This might depend partly on proximity to a hospital or UTC. It might also depend on the proportion of people who have recently moved into the area (e.g.because the local housing has a high proportion of short term rentals) and therefore haven’t got around to registering with a local GP. In some wards in Haringey for example, wards which showed amongst the highest population turnover rates in England according to the 2011 Census, this might well be a factor.

With reference to the second question, would contractual measures to remedy practice shortcomings push a practice into closure, or to its being taken over by a large corporate entity which (as I describe in point 2 below) might have different and possibly even worse outcomes for patients.

1b.What are the impacts when patients are unable to access general practice using their preferred method?

Anecdotally from members of our over 50s Forum; one 76 year old with a heart condition requiring repeat consultations was made to wait several hours to even speak to a GP about when or whether he could have a face to face checkup. One woman also in her 70s went several months struggling to get treatment for an eye infection because ‘I could never get through on the phone’. She was then given an ‘online’ consultation with an eye hospital which was ineffective for her because she needed a face to face appointment, which she could not get for several more week. She meanwhile developed a different condition about which she again ‘could not get through to the doctor on the phone’  and eventually went to her doctor’s surgery and refused to leave until promised a face to face appointment. Several other members have experienced significant delays and difficulties about getting phone access to surgeries, due to very long call waiting times and promised callbacks happening many hours later or sometimes not at all even though the patient had reported an urgent need. Our local CCG has been informed and is taking these problems on board, but clearly a rapid improvement in GPs’ phone triage and phone switchboard resources is needed and this may well apply to other geographical areas.

1c.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?

It provides some assurance that failings in the record system do not affect the quality of care. In my personal experience there are many errors in doctors’ notes which are reflected in copies of letters to hospital specialists that I have seen, about my reports of symptoms or even my age. Continuity avoids wasting precious consultation time with repetition of symptom reports or other details that the GP who knows you may remember, especially if they have seen you recently. None the less, being routed to a different person in the same practice provides an opportunity for a second opinion which can sometimes be helpful, and doctors who practice alone often have inferior practice facilities and services. Also being willing to see whichever partner is free first does speed up appointment waiting time.

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

Seen from the patients’ viewpoint:-

- excessive reliance on phone and/or online consultations is bad for elderly patients, for those with poor online access or capabilities, people reliant on PAYG mobiles, people with poor English or with hearing difficulties. Such reliance is therefore likely to increase health inequalities. I believe there is also some evidence that it leads to greater A and E admissions, according to Haringey Healthwatch. This suggests that absence of face to face contact sometimes leads to a wrong diagnosis.

- if younger, more ‘digitally literate’, employed patients take to online or phone consultations with national digital GP platforms rather than with a local practice, the traditional GP practices will be left with the more difficult and needy patients to deal with. This will adversely affect traditional GPs financially and will affect their morale, in terms of the difficulty of their workload and possibly in terms of outcomes and patient satisfaction.

- many GPs will be faced with additional workloads as colleagues retire and cannot easily be replaced.

- retirements will lead to many practices changing hands and probably being sold to large corporate undertakings which have been the subject of adverse media reports[1]. This introduces a much greater incentive for practices to make money by ‘efficiency savings’, probably offering less face to face appointments, more ‘digital’/phone ones, and/or depersonalised care delivered by several different doctors or from a distance through something like a doctors’ call centre. The profit motive is likely to be far more of a driving force for large corporates than for traditional GPs. The legally defined mission of private businesses is to make money, whereas the medical ethic calls for maximising quality and quantity of patient care.

- there is therefore a very pressing need for government to increase the supply of GPs, not only by offering more training places but by making it easier for foreign doctors to work in the UK. Measures such as fast visa routes, waiving of some visa charges and NHS treatment fees for overseas doctors and their families, and  rapid professional registration or re-qualification routes, would be helpful.

- whereas point 9 of document BW999 says that ‘participation by a practice in the COVID vaccination programme should never be at the expense of providing reasonable patient access to core GP services’ that is now exactly what is happening in the booster vaccination drive. This is unacceptable and government should call on pharmacies, the army’s medical corp, and retired doctors or nurses who can return, to avoid GPs being called off normal work to take part in the vaccination campaign.

3. What part should general practice play in the prevention agenda?

The prevention agenda surely needs to focus on at least five major risks to population health; drugs, excessive alcohol consumption, insufficient exercise, over-eating or badly chosen diet, and smoking. This invokes several other agencies and GPs should not be burdened with a leading role nor left to cope with the failings of other policies. Schools should play an important part in health education, not only of their pupils but of the pupils’ parents. Universities can reinforce their messages, particularly in relation to drugs and alcohol. It is not recognised that public service broadcasting could play a huge role in preventive health messaging, especially in relation to diet. Local authorities’ public health work is very important but underfunded.

Private companies also have an important role. Food and drink retailers are not sufficiently engaged or motivated to encourage sensible consumption and ways must be found to make them more engaged. Pubs should be encouraged to serve alcohol in smaller measures and to offer a wider range of non-alcoholic drinks, which as shown by the flourishing of new coffee bars in recent years (and in some countries juice bars) need not be unprofitable.

Air quality is also important for respiratory health and alarmingly it has now been linked to dementia and heart conditions. This is outwith the control or proper role of GPs and should be a priority for central government policy.

Damp and cold housing also affect health and may become increasingly important if many people’s overall respiratory status is compromised after they have recovered from COVID19. Regulation of landlords and financial help as well as technical advice to lower income home owners is important to deal with these problems. Government should reinstate and improve some of the offers formerly made through energy suppliers to address heating and insulation problems.

The importance of saving money for the NHS by reducing lifestyle and environmental harms cannot be over-emphasised. According to a report by NHS Wales,[2] the costs to the NHS across the UK of physical inactivity, alcohol and substance abuse, and obesity alone are huge. Figures given in the report for various dates, when roughly updated for inflation, give over  £15bn per year in current prices, or more than 8.8% of the 2022 NHS budget and much more than the £5.9bn of extra NHS funding offered by the Chancellor in October 2021. Investment in public health measures is thought to yield a social benefit of £14.30 per £1 spent, in the long run. However, many of the benefits of any investment will take more than 5 years to be realised, so that investment to reduce the future need for treatment  is not a substitute for revenue spending on current treatments and diagnoses. But both are required now. This is not really outwith the scope of the present inquiry given the question being addressed here. The point is that whatever the gains from ‘social prescribing’ and no-smoking advice, GPs can do very little else about public health and lifestyles. So other agencies need to underpin their work with appropriate policies.