Evidence submitted by the Beds & Herts Local Medical Committee (FGP0287)

 

 

Beds and Herts Local Medical Committee (BHLMC) provides the representative voice of General Practice in the counties of Bedfordshire and Hertfordshire.  We support and work with GPs to ensure their views and experiences are heard across the healthcare system at local and national level. This evidence is being submitted by BHLMC on behalf of our committees, led by GPs for GPs and for the communities in which they serve.  The evidence provided below addresses three key areas:

 

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

Three main barriers to accessing General Practice are identified below.

Workforce

Issues

1.1               There is a chronic shortage of both General Practitioner (GP) and General Practice Nurse (GPN) workforce to deliver primary medical services. Government initiatives over previous years to increase workforce have failed. The solution to this has been the Additional Roles Reimbursement Scheme (ARRS) roles within the Primary Care Network (PCN) agenda – however this initiative has been too restrictive, under resourced and does not cover the roles undertaken by the traditional GP workforce.

1.2               The causes of the diminishing workforce have not been tackled systematically. General Practice is not a desirable discipline to work within – patient demand is unsustainable; career progression isn’t encouraged, and GPs are abused and scapegoated by both media and government.

 

1.3               Experienced GPs are not valued or incentivised to remain within the workforce, largely due to the phasing out of seniority payments. Changes to tax and pension contributions, escalating workloads and overly bureaucratic processes act as barriers to remaining.

 

 

Solutions

1.4               Recruitment and retention must be the priorityMedical students and specialist trainees need to be exposed to opportunities in Primary Care, portfolio working opportunities need to be expanded, and career progression needs formalising.

 

1.5               Primary Care is the bedrock of the NHS, yet the culture and attitude towards Primary Care needs to change for the workforce to feel valued. Seniority needs to be recognised, punitive pension and tax issues need to be reviewed and workload capping to safe levels should be a priority.

 

Infrastructure

Issues

 

1.6            The Covid19 pandemic has demonstrated the inadequacy of many practice buildings. The constraints of consulting room size and number, size of waiting rooms and the resources required to provide adequate back-office functions have all had an impact to the provision of patient services.

 

1.7            The rapid switch to telephone triage models highlighted the limited capacity for telephone access and the move to working from home demonstrated the need for reliable, efficient portable IT equipment and security.

 

Solutions

1.8            There needs to be a wholesale review of premises across the NHS. Primary Care premises stock is inadequate with respect to both size and quality.

 

1.9            Within the emerging ICS, there is a wide range of NHS estate provision but multiple barriers in place that prevent full utilisation which need to be tackled.

 

1.10         Risks associated with ownership or lease holding for GP premises also needs attention.

 

1.11         Capital expenditure on portable IT, telephony and software solutions need investing in for care to be provided in an agile way.

 

Workload

Issues

1.12         The current workforce can only provide so much care. Current expectations of infinite capacity from a finite workforce are unsafe, both for the workforce and patients.

 

1.13         Patient demand for care has increased due to the pandemic, but also fuelled by media and government messaging.

 

1.14         The current General Medical Services (GMS) Contract makes provision for care of patients who are ill or believe themselves to be ill. However, this core contract is so underfunded that practices are reliant on income from additional public health activities via the Quality and Outcomes Framework (QOF) and enhanced services.

 

1.15         The ability of practices to respond to requests to scale up GMS care is hampered by the financial reliance on non-GMS income. Bureaucracy suppresses the delivery of care at every level, from hours of preparation for Care Quality Commission (CQC) inspections to the inability to deliver clinical care due to lack of Patient Group Directions (PGDs), or inability to access investigations.

 

 

 

Solutions

 

1.16         Self-care needs to be a healthcare priority. People need to be empowered to self-care, supported by signposting to relevant resources, use of care navigators and interactions with the wider community care teams.

 

1.17         Consideration should be given to direct access to assessments and care for certain conditions.

 

1.18         Patient expectation must be managed, based on need rather than want. The recent huge increase in the shift of secondary care into Primary Care needs to be controlled with IT resources to enable remote care to be delivered by secondary care in a seamless way and any shift of work into Primary Care accompanied by the resources needed to deliver it.

 

1.19         The GMS contract needs to be resourced sufficiently to make services less reliant on additional contracted work and bureaucracy at all levels needs to be minimised to free up clinicians for clinical work.

 

1.20         A review is needed of the current system of 10-minute appointments. Given the complexity of needs for our aging population and treatments available, longer appointments are needed to work more efficiently, to enable true patient centred care and reduce clinician stress and risk.

 

2. To what extent does the Government and NHS England’s plan for improving access for patients and supporting General Practice address these barriers?

2.1               The plan does nothing to address the workforce crisis or address the recent vilification of the profession within the press and government messages. It is also unclear as to the timeline for implementation to make a real impact this winter.  The financial envelope to provide extra capacity is too restrictive and bureaucratic within its use and shows a lack of trust in the profession to be creative in finding local solutions.

 

2.2               The plan’s emphasis on face-to-face care is disingenuous and against the direction of travel of the past few years – there is nothing in the plan that supports the delivery of this, in fact some of the actions will reduce face-to-face delivery.

 

3. What are the impacts when patients are unable to access General Practice using their preferred method?

3.1               There are multiple routes to gain access into General Practice to provide care - telephone, email, online consultation, online appointment booking, walk-ins. It is important that people aren’t digitally excluded from access, it is vital that the human side of this interaction continues to be present.

 

3.2               It is important to define the difference between want and need. If patients don't get what they WANT, practices are subject to verbal, physical and digital abuse which is hugely detrimental to morale and staff retention. If they can't get what they NEED it increases A&E attendances, delays presentation with worsening outcomes, exacerbates mental health problems and has economic impact as patients may be unable to work due to their own health problems or caring for those with health problems.

 

4. 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?

4.1               Continuity of care is the unique selling point for General Practice, underpinned by the registered list. It has been shown to improve health outcomes, improve both clinician and patient experience and prevent unnecessary investigations and admissions to hospital.

 

4.2               Patients being able to choose and see their 'named’ GP in the current climate could be seen as a luxury but is vital for our complex, vulnerable patients.  Many issues serve to prevent the implementation of ‘named’ doctor care including lack of clinical workforce, lack of time to provide clinical care due to the increasing administrative burden and patient expectation of instant care, Amazon Prime style. 

 

4.3               The ‘named’ GP role is too simplistic for the complexities of today’s services.  If continuity of care is valued and seen as a priority it needs to be properly resourced, alternative models of delivery developed and implemented.

 

5.  What can be done to reduce bureaucracy and burnout, and improve morale, in general practice?

BHLMC have a long-established wellbeing service to support individual GPs in professional and personal difficulty.  Burnout and low morale are NOT new conditions but is currently exacerbated by a number of issues outlined below.

 

Issues:

 

5.1               A huge burden of responsibility for complex patient care has been shifted from secondary care into Primary Care and significantly onto GPs.  This has occurred due to diversion of services within hospitals and diversion of many services away from hospitals during the pandemic - without any concurrent diversion of staff or resources. With that comes a burden of professional guilt in that GPs feel that they cannot refuse or push back for fear of affecting patient care. There is no end point to this responsibility and with that comes increased personal risk for GPs and an increase in medico legal cases.

 

5.2               An increase in personal fatigue, as GPs have been the main vehicle for the covid vaccination programme and implementation.  This additional role comes with a constant rapid need to change and adapt.  This fatigue is created because GPs are providing covid vaccinations alongside seeing patients, being in Hot Hubs and looking after Care Homes etc.  GPs have suffered personal loss of family and friends, loss of patients, especially Care home residents, as well as many GPs falling ill themselves.  All this has a significant negative impact on a GP’s mental health and their ability to cope.

 

5.3               There is “system saturation” because of the work of additional covid related clinics and hubs, GP and staff sickness, and the push to return to ‘normal’.  The result of this is that practices are understaffed and have lost resilience.

 

5.4               Increased access for patients via online routes, e.g. online consultation, means that there is an increase in the administrative burden for practices without any resource attached to it.  The system gives no value to the time needed to educate and train GPs, General Practice Nurses (GPNs) and staff, despite the fact that these adaptions to new ways of working are expected at alarming speed and without adequate notice from NHSE.

 

5.5               The introduction of PCNs at the same time as Covid has resulted in PCNs focussing on Covid, rather than focussing on their constituent practices, which were supposed to benefit from creation of PCNs as a means to help to stabilise practices. There is ongoing enormous pressure on Clinical Directors (CDs) to move from a clinical GP role to a managerial business role.  Lack of support for these PCNs has meant that services already overstretched have now broken entirely.

 

5.6               There is a sense among GPs that they have no autonomy in their contracts with the NHS and that those GPs working for NHSE are unable, or decline, to understand the dire situation of General Practice.

 

5.7               Both recruitment and retention issues in General Practice were already a major concern.  The push to leave has been increased by the burden of additional work.  Experienced partners that are needed to guide, mentor, and support their practices are leaving.  New GPs have observed the tremendous stress of partners and, due to zero incentive, are not joining as partners. There is no acknowledgement of the commitment and loyalty to the NHS shown by existing GP partners, as shown by the removal of seniority payments.  The desire to remain in the system has completely disappeared.

Solutions:

5.8               Appraisals need to be streamlined and to continue as supportive vehicles.  It must be a priority to enable individual GPs to access help/support and for this they need protected time.  Just as in secondary care, protected educational time is necessary to maintain quality and should not be removed due to system saturation

 

5.9               The current expectation for return to normal with regards to locally commissioned services and the national QOF is unachievable.  The pressure to ‘tick boxes’ takes away from actual care.  Financial help through core GMS will enable practices to look at their own staffing levels.  Investment must be through core GMS and not focused on PCNs alone.  Investing money into ARRS roles in PCNs is useful but will not replace GPs and, more importantly, experienced GP partner time.

 

5.10           CQC must be re-evaluated and its purpose re analysed.  It is currently a requirement, but it should not result in such enormous pressure and burden on practices that are doing their absolute best in this difficult time.

 

6. Is the traditional partnership model in General Practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

6.1               The partnership model is the most effective model for delivering sustainable patient centred care. The introduction of other models since the contract change in 2004 has reinforced this view, as none of the other models tried have been able to match the quality of care or value for money provided by partnerships.

 

6.2               One of the key factors in this is the commitment and work ethic of GP partners. Our own research has shown that while GP Partners earn more than salaried GP per annum, when you divide these amounts by the number of hours worked by each, partner pay is not significantly higher than salaried GP pay, despite all the additional risks and liabilities held by GP partners as business owners. Moving to an exclusively salaried model would therefore remove the key efficiency driver of General Practice, the partners.

 

6.3               For Partnership to be an attractive prospect for GPs, consideration needs to be given to how the requirements and rewards of the role can be brought into balance. In the current working environment, for most, the requirements of a GP Partner (in terms of clinical and managerial risk, workload, and personal stress) outweigh the rewards of the job (autonomy, professional development, compensation), especially when compared to other available options for example, salaried roles, locum roles or relocating to another county, where the balance is better.

 

7. Do the current contracting and payment systems in General Practice encourage proactive, personalised, co-ordinated and integrated care?

7.1               Sadly not. The principles of the GMS/PMS contract are designed to deliver proactive, generalised care, with a core payment to practices calculated according to list size, geography and demographic, with practices able to use their discretion to decide how those funds are best utilised to support their local population. However, the detraction from funding the core of General Practice, in favour of a “General Practice by numbers” system moves us further and further away from addressing patient need.

 

7.2               Most new funding initiatives are poorly costed, based on national agendas and undervalue the importance of addressing local health needs. These very prescriptive funding initiatives also generate large amounts of bureaucracy, often taking time away from patient services to meet the reporting requirements of the commissioner.

 

7.3               The core payment to practices is calculated using an outdated formula which in many cases poorly reflects local needs.

 

7.4               In terms of integrating and co-ordinating care, there remains a disconnect with information sharing between providers, with different sectors working in silos. Current commissioning arrangements are disjointed, offering providers in different parts of the system misaligned incentives, causing division rather than collaboration.

 

 

8. Has the development of Primary Care Networks improved the delivery of proactive, personalised, coordinated and integrated care and reduced the administrative burden on GPs?

8.1               While some PCNs have thrived over the past two years, at least an equal number have struggled with the rigidity of the PCN DES, often being forced into unhappy marriages with practices who hold different priorities and ways of working to their own.

 

8.2               Overall, the development of PCNs has increased, rather than reduced, the administrative burden on GPs and practice managers. While there has been funding for clinical directors to take on leadership of PCNs, this has not compensated for the additional administrative burden across the individual practices.

 

8.3               The structure of the funding model, with allocation being based on total list size also disadvantages PCNs with higher numbers of practices (running a one practice 30,000 list size PCN is exponentially easier than running a seven practice 30,000 list size PCN).

 

8.4               PCNs vary in maturity, interpersonal relationships and leadership and can often consume more time. This includes having experienced clinicians being taken away from front line work and spending time in meetings, as well as the cost of additional managerial time and development.

 

8.5               The use of a national DES to set the agenda for PCNs has detracted from local variations in health needs that are the strength of individual practices. This can compromise the personalised co-ordinated care which can be provided by a local practice.

 

9. To what extent has General Practice been able to work in effective partnerships with other professions within Primary Care and beyond to free more GP time for patient care?

9.1               There has always been an excellent working relationship between GPs and other professions in Primary Care, and this tends to be in the context of a multi-disciplinary, co-ordinated, patient centred approach, rather than with the aim to generate more free time for patient care.  At present it is not clear whether bringing in additional allied healthcare professional roles releases GP time in a tangible manner, as any time freed up is often consumed supervising the new staff and building governance processes to support them.

 

9.2               One consequence of the introduction of these additional roles in General Practice is that GPs see a higher proportion of more complex patients. The lack of less complex cases to break up a busy clinic has exponentially increased the intensity of the GP working day, increasing the stress on individual clinicians and therefore the risk of burnout. 

 

9.3               The greatest return on investment of money spent in General Practice is money used to employ GPs and practice nurses.

 

Dec 2021