Written evidence submitted by National Voices (FGP0275)

Introduction

National Voices

National Voices is the leading coalition of health and social care charities in England. We have more than 190 members covering a diverse range of health conditions and communities, connecting us with the experiences of millions of people. We work together to strengthen the voice of patients, service users, carers, their families, and the voluntary organisations that work for them. Our mission is democratise, equalise and humanise health and care.

We are submitting evidence to respond to the inquiry on The future of General Practice, which aims to examine the key challenges facing general practice over the next five years as well as the biggest current and ongoing barriers to access to general practice.

Specifically, we will be answering the following questions:

  1. What are the main barriers to accessing general practice and how can these be tackled?
  2. What are the impacts when patients are unable to access general practice using their preferred method?
  3. What part should general practice play in the prevention agenda?
  4. How can the current model of general practice be improved to make it more sustainable in the long term?

 

 

 

 

  1. Main barriers to accessing general practice and how these can be overcome

1.0.1                            At National Voices, we work to make what matters to people matter in health and care. Over the past almost two years, our members have consistently told us how people living with often more than one long-term condition have faced numerous barriers to accessing general. These barriers include cancellations of services, particularly regular check ins for people with a range of long term conditions,  , lack of coherent, coherent and kind communication surrounding general practice, digital exclusion, administrative burdens and the impacts of wider inequalities, such as a failure to adapt service models to people who don’t have a fixed address, don’t speak English as a first language, have cognitive impairments or specific access needs, such a blindness or deafness.

 

“Her GP receptionist said Mum needed an online consultation to assess her Diabetes Type 2. Mum is 83, lives alone and is digital free. She said they have a few call slots a day and would call Mum the next afternoon. They didn’t”

- Interviewee, What we need now, 2021

 

1.1 Lack of access

1.1.1                            Timely access to care is now the most pressing concern of people who live ill health, disability, or impairment. Delays, waits, service disruptions and cancellations are faced not only by those waiting for elective care, but also those attempting to access general practice. Data isn’t captured in the same way, and so we don’t understand the numbers of people who give up, go elsewhere or delay seeking help in primary care. But too many people are finding it difficult or impossible to get the help and support they need in a timely manner, and the problem is now so systemic and far-reaching that it threatens the very fabric of the health system’s claim to be a ‘universal’ service. Without access, you don’t have anything else either: personalisation, quality, safety, assurance.

1.1.2                            As part of our Timely access to care: Principles for recovery we produced some recommendations for government and system leaders to work towards reinstating patients’ timely access to care and to meet their support needs while they wait.

 

1.2 Lack of coherent communication

1.2.1                            NHS E/I are currently working on multiple projects relating to the communications and messaging around access to primary care, which is welcome  But we are also concerned that where access is in fact not meeting demand, no amount of communication can solve the problem. Better communication can make a difficult situation better, but it cannot on its own solve the problem that primary care is once again being pulled into a massive and rapid vaccination drive, and that this means other healthcare will need to be paused, delayed or cancelled yet again.

1.2.2                            This against the backdrop of falling or stalling numbers of GP and growing levels of ill health, including mental ill health – partly driven by inequalities.

1.2.3                            Primary care practitioners and people using primary care services have been at the receiving end of contradictory messages from system leaders. Particularly the approach to remote vs face to face health care and the need for ongoing triage have been badly mishandled by both NHSE/I and the professional bodies, in our view, with both sets of stakeholders demanding or rejecting remote care delivery and universal triage at different times.

1.2.4                            The fallout from this unhelpful wrangling is that confidence in remote consultations as a useful tool for meeting certain types of demand for primary care has been undermined (which is even more astonishing after years of pushing a digital agenda from DHSC and wider government).

1.2.5                            We at National Voices, together with Healthwatch England, are working with NHSE and all other system leaders to develop coherent messages for what people can expect when using primary care – we welcome this opportunity. Our main concern is that whatever messages are communicated reflect what is actually the reality on the ground. Nothing will be more damaging than communicating arrangements that are then not followed through by all members of primary care teams locally.

1.2.6                            It is also clear that the new wave of Omicron infections will impact access to non-covid related primary care services significantly. We warn against a framing that requires of people and communities that they should ‘protect’ health services, when in fact health services have been created precisely to protect people and communities. Any messaging about unavoidable service pressures needs to be balanced by reinforcing that people who need help are entitled to seek it. It goes without saying, from our perspective, that any further disruption of non-Covid health and care would be easier to communicate if we were doing everything we can to reduce the spread of infections to begin with. With schools open and largely unvaccinated, large events going ahead and people being encouraged to attend Christmas Parties this is clearly not the case.

1.2.7                            Our members also highlighted the need to take particular care with the access of people who might have additional needs. The needs of people who rely on  an interpreter or advocate, or people who need to bring a carer must be fully considered. For example, patients with hearing impairments are still being offered telephone appointments. The problems only further exacerbate people’s negative experiences of accessing general practice, and prove to be an inefficient use of primary care resources. We need to signal that primary care is open, particularly for those at the sharp end of the inverse care law.

 

1.3 Inequalities

“There is nothing I can do, feel really helpless. The first wait was more manageable because I knew my care-coordinator and how to access support. I feel worthless, like I have been thrown in the dustbin”

- Interviewee, Patient Noun Adjective, 2020

 

1.3.1                            In Spring 2021, we held a four-day conference exploring how the VCSE can play a bigger role in dismantling health inequity. This conference highlighted the experiences of people facing poverty, racial injustice and digital exclusion in healthcare. People who are unable to access general practice using their preferred method describe feeling increasingly distressed, anxious, and forgotten. These patients are often those who are less able to draw on other resources, and therefore are less able to effectively self-manage or cope while waiting for personalised and inclusive care. People unable to access general practice are also more likely to lose trust in the accessibility and capability of the whole health service to meet everyone’s needs.

 

1.4 Digital Exclusion

“I could not complete an online form, I couldn’t do it, I wouldn’t know how to access the app in the first place or how to put an app on an iPad, I wouldn’t know where to start. I seem to get in a muddle but if I had to do something out the ordinary i.e. access and fill in an online form, I wouldn’t be able to do it.”

- Interviewee, Unlocking the Digital Front Door, 2021

 

1.4.1                            Rapid innovation helped general practice services transition from traditional in-person to digital models of care. While some people clearly told us that there are benefits to remote models of care, our research showed that for many of those we spoke to remote models do not provide a positive experience or high quality of care. As part of our report, Unlocking the Digital Front Door, we conducted a listening exercise highlighting why people may be digitally excluded and how this is widening the inequalities gap. People may be digitally excluded for a range of reasons, including lack of access to digital devices and infrastructure (ie. Broadband), not having adequate digital skills or low digital literacy (which can be further exacerbated by language barriers), and not feeling confident or trusting of virtual healthcare.

1.4.2                            Disseminating devices alone is not enough. Digital innovations designed to help people access healthcare online need to consider devices; installation; connection; training matched to disparate knowledge and skill level; charging; ongoing assistance and troubleshooting support and coproduction with people most at risk of exclusion, to ensure accessibility needs are met. Failing to take into account context or to provide high quality care and engagement opportunities online and offline risks excluding people from reaching out for help. The outbreak of COVID-19 meant that accessing health information from trusted sources became more important than ever, but with many in-person healthcare services no longer available, patients must be trained to accurately assess reliability of online sources. In addition, patients need to be reassured that their data (such as e-consult forms) are going to be handled with the same level of sensitivity and privacy as in-person information (eg. their consultation form is only going to be seen by doctors/nurses and not shared amongst third parties).

1.4.3                            Our work showed clearly that it doesn’t make sense to incentivise or push one delivery modus of care over another. We will need a mix. More importantly, we need to focus all service change on services becoming more inclusive and person centred, not less. This means front of house staff have an important role to play, not least in understanding access needs and responding with respect and kindness.

 

“When I phone to speak to GP, receptionist ask what the reason and she explains. Then she says the Dr will call you back. I do not know when the GP will call back. Later, when the Dr phone called, some of the things forgot. I cannot explain properly. It is very difficult.”

- Interviewee, Unlocking the Digital Front Door, 2021

 

1.5 Workforce and community capacity

1.5.1                            In addition to the recommendations above, we strongly urge the government to produce a workforce plan to recognise and address the problems brought on by extended funding cuts and poor workforce planning. There is a shortage of skilled staff and immense pressure on existing teams, both of which have not been created but  made worse by the COVID-19 pandemic.

1.5.2                            New roles have been added into the primary care team, and we are convinced they have great potential (social prescribing link workers, health coaches, pharmacists), but again, care needs to be taken that service change is developed, tested and embedded with people, and then clearly communicated.

1.5.3                            It will be a long time before we have enough primary care staff, even if we started a major recruitment drive right now. It is therefore even more important that we realise the potential of better partnership working with people and communities. Good carers support, good, funded, partnerships to provide social, and emotional support to people through community based, and community led approaches have a substantial role to play in helping people cope with mental and physical ill health, loneliness and the pressures caused by almost two years of pandemic living.

1.5.4                            I supply of clinicians will remain severely restricted for some time, we need to tackle with much more urgency the question of demand. And no amount of triage, sign posting or diverting needs will be effective if we do not also try to help people cope better, and live better. The voluntary and community sector has a massive contribution to make on this – it is extremely good value, but it is essentially not a free resource either. So primary care networks and ICS that are unable to recruit GPs or other clinical staff should consider investing directly in community provision of wellbeing services. The evidence is strong that better informed, better connected and more active people and communities use health and care services in easier to plan for, better value ways.

1.5.5                            A community based, personalised and inclusive approach is the key to ensuring a successful future of general practice – one size does not fit all. System leaders and providers must work with communities to ensure solutions are meaningful and inclusive of all accessibility and healthcare needs.

 

 

2. Role of General Practice in the prevention agenda

2.1                            There is always a risk that as services become more pressured and access more difficult, providers raise thresholds. Essentially this is how the NHS handles demand for healthcare outstripping supply. In primary care this means that people are being told that they are not distressed, anorexic, self-harming, immobile, visually impaired, pained, stressed or anxious enough to merit healthcare. This is the opposite of preventative healthcare and runs directly against central plans to charge PCNs with population health management.

2.2                            This contradiction needs to be owned by system leaders and addressed through a rethinking of the role of primary care and its partners. With the new omicron wave crashing into overstretched and demoralised primary care teams, it seems counter intuitive to talk about the need to get upstream. But it would help primary care immensely if we did.

 

“[The nurse] said, ‘Well, you’ll have to lose weight,’ and she then threw hundreds of leaflets at me, taught me how to prick my finger so I could test my blood and that was it, and I think I cried all the way home.”

-          Interviewee, Ask How I am, 2020

 

2.3                            Directly relating to the pandemic, we need to lean much more heavily on non-pharmacological interventions. We need to tackle school transmission, cultural venues, messaging around symptoms and tests, social distancing, mask wearing and office work. Only then can we keep the doors of primary care open to people who have non covid related health needs (it is easy to forget that primary care was busy before the pandemic hit).

2.4                            Much more widely, if we do not put work, housing, education and the build environment in  the service of people’s and communities’ wellbeing we will forever be facing spiralling health and care needs, and needs which are very unequally and unfairly distributed. 

2.5                            We can then also realise the power of community as it can hold and support people with health and care needs. Not so they don’t end up using healthcare, but so they don’t need to use it for reasons that are better met by befriending, social prescribing, peer support, group activities, benefit advice and advocacy services.

 

 

 

3. How the current model of General Practice can be made more sustainable

3.1                            In order to become more sustainable and fit for the future, General Practice needs to work in stronger partnership with people and communities. We need interdisciplinary teams within the NHS, where GPs can draw on the advice of experts where needed, rather than sending people ‘as referrals’ to collect that advice in a different setting. Specialists could be invited to join the team around the patient, rather than patients being referred to see someone else who then refers back, only to generate another referral and so on, with all the low value work load this generates and the time and energy this consumes for patients. Pharmacy too has a major role to play – we hear again and again how much more accessible community pharmacy feels to people at risk of exclusion than the often complicated pathways we have opened up for other parts of healthcare. The connection between the open pharmacy door and wider health services needs to be strengthened, for example by piloting pharmacy led referrals.

3.2                            But equally importantly, primary care teams should work with benefit advisors, befrienders, peer support groups, housing and education stakeholders to enable communities to live better, healthier, more connected lives. This is where the strength of the VCSE lies, and this is where we need to invest.

 

“We need to listen to families, unpaid carers, the ‘forgotten’”.

-          Participant, Our COVID Voices, 2020

 

3.3                            Once again, we express our gratitude towards primary care teams who step up to deliver a pressurised vaccination roll out. We are as dismayed as our primary care colleagues at the abuse their teams have received in recent months, with so much negative messaging about primary care coming out of parts of the media and government. But in order to put things right, we have to do more than ask for x number of new GPs (although we need those too). We need to enable and support communities to create healthier, more connected and equal ways of living.

3.4                            Our members stand ready to help with this transformation.

 

Dec 2021