Written evidence submitted by Dr David J Johnston (FGP0267)

I welcome the inquiry to explore the future of NHS General Practice and while this is specific for England I believe there will be findings that will be relevant for all the nations across the United Kingdom.

I would preface my comments by saying that systems rather than individuals are generally the cause of any shortcomings. It is essential that the Government play their part with robust work force planning, and maximum support in terms of recognition and resources for General Practice. Critically everything possible needs to be done to stem the loss of experienced staff in the 55 plus age group from clinical practice.

I specifically want to highlight barriers to accessing General Practice in the “Out of Hours” period.

It has been my privilege to have been a General Practitioner(GP) for almost thirty years during which time I have experienced many challenges and opportunities not only from a personal career perspective but also for General Practice as a profession. I have also been involved in organising and supporting an “Out of Hours” Urgent care service which among other things provides care when GP surgeries are closed. 

While General Practice core opening hours are defined as 8am to 6.30 pm Monday to Friday this is variable with some practices offering “extended access”, to their registered patients, of additional pre-bookable appointments outside of these hours. However, access to unscheduled or unplanned urgent primary care, provided by the patient’s own practice, can in reality be significantly less with perhaps as many as 123 hours of the 168 hours in each week being provided other than by the patient’s own practice.

Prior to the then “New GMS Contract” in 2004 GPs were entirely personally responsible for all “After hours” or “Out of Hours” (OOH) care. Subsequently following the implementation of the new contract GPs were permitted to entirely relinquished all such responsibility and unsurprisingly most did.

As so often seems to be the way we moved from one extreme to the other. Total responsibility to no responsibility. However, many GPs continued to provide OOH care by working for the various bodies that either developed anew or where reincarnations of pre-existing organisations with revised structures appropriate to the new circumstances. Although entirely voluntary GPs were initially motivated to provide OOH care for a variety of reasons which included a sense of duty, custom and practice and of course pecuniary reward. 

Over recent years fewer and fewer GPs are choosing to work in the OOH environment to a point where in some areas GP cover is almost non-existent. Again this is for a variety of reasons including life style choice, an increasing lack of familiarity with the OOH environment and perhaps even fear of the unknown. Ironically although such work generally attracts reasonable remuneration, financial considerations including concerns involving indemnity costs and pension and taxation arrangements can also be a significant deterrent. Trainee GPs are also having less exposure to OOH work and often their designated trainers do not work in the OOH environment with a resultant loss of positive role modelling of this important aspect of patient care. 

The reality is that our patients in the community get ill or need ongoing care 24 hours a day. A fact that is highlighted on the crest of the Royal College of General Practitioners with a black and white chevron representing not only the home but also day and night.

The development of partnerships which are important in so many areas of life are perhaps even more so in our Health Service if we are to ensure high quality care and safe, appropriate and effective patient journeys.

There appears to be an increasing divide between "in hours" and "out of hours" care in General Practice and perhaps even between the provision of planned, chronic and ongoing care and unplanned, unscheduled, urgent care. This is detrimental to high quality seamless patient care and can result in “pass the parcel medicine”. It can be argued that this may even account for some of the increase in attendances at hospital Emergency Departments over recent years. From the patient’s perspective to simply be passed from one challenged service to another generates distress and serves no-one’s interest.

As I have outlined in the past there was an entirely GP delivered service OOH which was of course unsustainable (although they have this in Holland with the GPs doing a compulsory 50 hours per annum OOH). We subsequently moved to a “GP led service” and I think we are now in the era of the “GP lite service”. I believe if we do not urgently address this we are at risk of sleep walking towards a “GP- less service”

I am a huge advocate of the role and value of General Practice and the literature supports that. However, if the service becomes one that functions without GPs OOH it must devalue the role in-hours and perhaps question the need for General Practice, as we understand it, all together.

At present, of course, we are all under great pressure but as we think about the post-pandemic world and the future role of General Practice, the provision of unscheduled urgent care particularly in the OOH period needs urgent consideration as it will directly impact on patient care and General Practice recruitment, retention, resilience and respect.

In my view every GP on the performers list should have an obligation to work in an approved OOH setting for 20 hours per annum to maintain their registration. Every GP contributing a small share would ensure a sustainable and resilient service as a whole in the context of a multidisciplinary response.

(This requirement could lapse at the age of 55 so it cannot be said to be encouraging early retirement.)

Such a policy is likely to be cost neutral as staff funding is already within the budgets of existing OOH organisations.

The GPs could choose when to work and could either do a booked surgery, triage calls or home visits as they preferred. There would also be the opportunity for those who wanted to do additional hours to do so and this would be within the context of a multidisciplinary service where the services offered were tightly ring-fenced to avoid inappropriate usage.

Of course there would be some initial concern from GPs and I do not expect colleagues in representative positions to be in the vanguard of promoting this.

However, in time I believe it would be accepted and even embraced.

The experience from some of the solutions that were generated to cope with the management of primary care Covid cases when, for example, GPs combined to work at district level suggests that many GPs found the opportunity to work in a dynamic and new environment outside their usual day to day experience beneficial and inspiring even. I believe that OOH work could once again be attractive for GP colleagues and many would wish to do more than their required 20 hours.  It seems likely that after the first couple of years such a commitment would simply come to be seen as part of the role and built into our work life balance.

The skills and influence that sometimes only a GP can bring to a situation contributed greatly to the patient journey and the quality of care that patients receive. This is particularly important when they are at their most vulnerable and they and their relatives need care and reassurance at difficult times that will be “bookmarks” in their family memory. Access to such care is simply what any of us would want for a family member in a similar situation.

As we reflect on the prospect of a “GP- less service” for as much as 123 hours every week recall “123GP” and reflect on what needs to be done to avoid a situation that would be detrimental to patients, the NHS as a whole and General Practice as a profession.

In the words of the song “You don’t know what you’ve got till it’s gone!”

Dec 2021