Written evidence submitted by Dr Richard Trueman (FGP0264)

 

Experience: -

I have worked for the NHS for nearly thirty five years, with more than thirty of those years as a full time General Practitioner. When I started working the cost of care was often limited by what could be done. Elderly patients recalled life before the NHS and truly cherished the service. Patients presenting to us often sought advice from family or friends before accessing health care. There were usually several steps before we were consulted. This has all changed. There has always been a gap between the demand for appointments versus our supply, but since the end of lockdown, this gap has never been wider. The correlation between my perception of the desire for an appointment versus the need has widened. There are complex issues in these statements.

Model of Care: -

The model to provide GP care was stable, but there was a political drive to alter access, then Covid arrived.  General Practice demonstrated how quickly we can change when we are released from the shackles of political control.  Decisions and change were made quickly without the need for repeated review and procrastination.

There is a need for a new model for Primary Care, but our contract needs to be more flexible, or the change needs to be politically driven. A new contract providing clear priorities for the delivery of health care is needed.

What is expected of Primary Care needs to re-defined, we must keep continuity of health care at the centre but many patients who contact us, their issues are predominantly social, not physical, or psychological. Continuity of care is valued by, and required for, patients with complex conditions. Patients will be amazed, what their GP knows about them when they have been looking after them and their family for years. Secondary Care has become less holistic and more fragmented, knowing a patient gives an experienced GP a head start in every consultation. Although to do this effectively list sizes must be smaller.

Access: -

Our old model was a phone call to book an urgent or routine appointment. There was some inconvenience for a patient to attend (a factor that made them consider their need). There was less pro-active work (e.g., QOF, Safeguarding, Satisfying Regulators). Patients now have multiple ways to access our service, they can phone, call 111, they are increasingly referred from secondary care and of course can complete an e-Consult. The threshold to seek help has dropped, it is too easy, too convenient. Our need to safety-net has increased. Lower thresholds to contact and our need to explain what to do should symptoms change are both drivers that increase demand and require an increase in capacity.

Patient Education: -

Whilst there are lots of advances in health care advising a patient of what will happen (as opposed to what might happen) when they have been unwell with a temperature and vague nonspecific symptoms for less than 24 hours is not one of them. There is little doubt the move to e-Consult is affecting our workload. Many patients’ complete requests, where in the past they may have sought advice from family or friends. When they booked an appointment they could cancel, they cannot easily cancel an e-Consult. Too often we phone them to find that their problem has resolved. Appointment wasted.

Workload: -

Good General Practice works well. But I am working exhausting days. Often a long 13 + hour day. At the end I can be struggling to concentrate.  The document from NHSE partly titled “supporting General Practice” left me feeling demoralised. The General Practice service is falling over in our area. When I triage calls, converting those as required into face-to-face appointments, patients state that they are happy with our mutually agreed management plan. They do not need to be seen. Whilst individual patients have their need, I must also consider the collective need of our practice population. In our area the number of GP Partners has roughly halved over the past ~ 8 years.

Demand: -

Much of my time is spent offering reassurance for minor and social issues rather than addressing complex needs. Most issues presenting to a General Practitioner will resolve without intervention, but our reassurance is free and is too often sought, multiple times for the same problem.

My concern for the future is that patients with the loudest voice get what they want and appear to steer government policy. In General Practice we have a responsibility to ensure those with a quieter voice and especially those with no voice receive the service they need. Triage helps us to achieve this. Measuring performance by face-to-face appointments is seriously flawed. I am concerned that policy revolves around “noise” from social media and a small group of journalists. Policy should look at limited resources and plan to use them most wisely. I am doing this!

Change and Improve: -

We do need to change. We value satisfying patients’ ideas, concerns, and explanations. Patients value us addressing them. However, we need to steadily improve clinical governance. We must improve application of NICE guidance; we must improve cancer referrals and we must contribute to reducing medical errors etc. etc. Our service is far from perfect, but the solution was not published in “supporting general practice.” The solution is certainly not politicians belittling what we do.

Realism: -

We need to collectively identify the priorities for Primary Care, I will help deliver them, however when something is added, something else needs to be removed (or workforce found).  There needs to be change. Solutions need to be more than us increasing our resilience. There is an irony that there has been a drive to encourage the population to seek support for their “mental health.At the same time for employees of the health service our requirement is to become more resilient and resourceful.  It is easy to swing these issues round. Signpost the population to the resources to which we are directed!

Bureaucracy: -

Patients call us for minor problems (say nappy rash), obtaining a prescription may save the patient money but the actual cost of the appointment is highThere is an expectation that we guide patients to self-treatment. Although, please read our advice from NHSE “Conditions for which over the counter items should not routinely be prescribed in primary care: Guidance for CCGs).” [1] As prescribers we are asked to reflect local policies in our prescribing practice. Our CCG did this through sharing the document. As I prescribe, I am advised through bolt on software where patients may wish to purchase an OTC (Over the Counter) product. The cost is important, in the year up to June 2017 the NHS spent ~ £589 million on prescriptions that can be purchased OTC. [1]   However, if we request patients to buy OTC and they have a pre-paid prescription or an entitlement to free prescriptions read p5 which reminds us to maintain our clinical discretion in accordance with our professional duties and p. 12-13 which offer eleven patient groups where we must offer an NHS prescription too. Then ask yourself how does this work? What does this cost? Then add in the cost, both financial and the opportunity cost, for this work done in Primary Care. There is a need for a clear message from Politicians. The “Blacklisting” of proprietary drugs was simple, there was central guidance. Passing the issue to be solved by GPs at the coal face, whilst we answer to so many organisations and remain an advocate for our patient is a demonstration of how broken the system is.

I regularly hear that there is a drive to reduce bureaucracy, but I have no sense of this happening. The Government are paying for GP IT systems, which should be more than capable of, automatically initiating and completing the administration, drop the results into patient records and flag up concerns? Much of our work is unseen (and if its not direct patient contact it is not counted).

We answer to too many organisations HSE, CQC, NHSE, GMC, to name a few, then we need to follow guidance from NICE, RCGP, and our medical defence organisation.  Patient groups have expectations of us and foremost we answer to the patient we are treating at the time.  They all add a different emphasis upon what we should do. Due to the shortage in workforce, we have large lists (too large), patients have their expectations, and we address them but then we must add all the other bits. The task is now impossible in the time we give ourselves (10 minutes). As other professionals (nurses, physios, pharmacists, paramedics etc.) have come to help we have lost the straightforward problems where we were able to catch up, now there is more complexity.

CQC’s general view appears to be if it is not written down it is not happening. Nursing homes are tied in knots of bureaucracy. Under our contract I meet with a home weekly, there is a GP, a senior nurse from the home and multiple people from our CCG. There is no doubt multiple input helps care but five health care professionals are taking their own notes. Too much time is spent writing things down. All of this is new work for General Practice, nothing has been taken away.

We are helped by nurses, paramedics, physiotherapists, pharmacists, and social prescribers. Some of their work removes workload from the stretched GP. Some of this work is a new service provided in Primary Care. All of it is overseen by General Practitioners and the work has not left our desks, it comes back with more administrative requests and tasks.

Complexity & Quality: -

The delivery of health care through advances in research is more complex. Treatment for conditions was similar at a high level, now the subtypes of the same condition are treated in diverse ways. The expectation, rightly, is for high quality. We need better IT to guide us. It needs not to flag issues to us; it needs to think about them and process them. Within our EMIS system there is the capability but if I write complex concepts and protocols that help make decisions (e.g., applying NICE guidance), if I distribute them, they may well be defined as a medical device by the MHRA and I will be personally liable if something goes wrong. There is a lot of excellent work being done but not in a co-ordinated way and not in a way that helps us all.

Clarity: -

We are confused around our priorities. There is a lack of joined up communication. CQC advised they will stop inspections, QOF and IIF are suspended so that you can prioritise the Covid Vaccination Programme. But, at the same time, CQC are continuing their process to check up on access. QOF and IIF have not been suspended, they have been amended, in fact created more work as we need to define high risk groups and continue care here. Some may optimistically see communication to immunise a million patient a day as a challenging target. Those with a realistic outlook can see that some of the infrastructure that was around when we had our best day immunising has been dismantled, and as I write there is still need to sit for 15 minutes. On the best day ever, we were mainly immunising with Astra Zeneca, no wait necessary. I learned about this on the Sunday evening, shortly before the Prime Minister’s announcement.

We are asked to attend Safeguarding Meetings; I recognise the value where we know the patient well and we are involved in their care. CQC check our attendance and expect this. But, when I go to a meeting no one else is doing my days work, I just finish even later. Somethings need to give.

Workforce: -

There is a huge deficit in workforce planning and despite all the rhetoric from the Government there seems to be no idea how resolve recruitment. Morale is at an all-time low. Over my thirty years working in General Practice the level of respect towards General Practitioners has diminishedI have no need to be respected, the thorny issue is the level of disrespect (by a significant minority) towards the people providing a service and the lack of appreciation of the actual cost of the service they use. All we hear in the press and from politicians is a diatribe of criticism around how we need to do more and give more. We are emotionally exhausted. The first step in improvement to our morale is for our employers to start to consider their workforce, ahead of the patient, in planning the patient’s health care journey.

The biggest threat to the survival of General Practice right now is the considerable number of General Practitioners that are not ready to retire but are able to. The constant beratement by the press and politicians seems to encourage rather than minimise the chances of GPs retiring early. If you want to preserve General Practice then keep the older experienced GPs in substantive jobs (not locuming) because nothing beats experience; the patients prefer it, the younger GPs like it and the system needs it!

Solutions: -

The General Practice model locally feels very unstable.  The risk is that it starts to collapse under the strain of uncontrolled demand, an overloaded workforce that has never been more likely. When we have met across our patch there is an expectation that we need to resolve the challenges we face. The difficulty is that we have little control over the factors that have led to these problems. The job needs to become attractive again. Its not about more money, its about agreeing what a GP does, to whom they answer. We need to improve the IT. A lot of what is good governance can be built into our systems. Governance processes should be at the centre of IT system design. They should be automated. We should simplify regulation, its constantly redesigned and expanded. If CQC invested time in developing overseeing and doing some of the work that produces improvement and not, simply criticising what has been tried at a local level our service will improve. This really will keep patients safe.

We need to bridge the gap between supply and demand in a Primary Care setting. In Secondary Care this is achieved through a waiting list. A different solution is needed in Primary Care but there need to be a few steps before consulting a GP, perhaps charging for the service is the simplest solution. We pay to see a dentist or optician.

My work life balance is completely out of kilter. I am not ready to retire but I am prepared to, and able to. Please help us to help you. 

Dr Richard Trueman

 

Reference: -

  1. otc-guidance-for-ccgs.pdf (england.nhs.uk)

 

Dec 2021