Written evidence from Dr Nicholas Aldred (FGP0291)

The future of General Practice - Inquiry

  1. I am Dr Nicholas Aldred, a full-time GP partner working in suburban Bournemouth. I work in a practice with a high index of deprivation. Prior to my medical training I worked in the financial services industry, so have 8 years of experience working in the non-medical private sector. I have also spent time working as a GP in New Zealand where the working conditions were far more favourable.

 

  1. The challenges facing General Practice over the next 5 years are enormous and must not be underestimated. The current rhetoric in the media is unhelpful and I am disappointed that there seems to be very little if any support of any significance from central Government.

 

  1. The main barrier to accessing primary care is simple – the primary care workforce is simply insufficient in size to meet the demand. There are not enough GPs and large numbers of those currently in practice are close to retirement, so this mismatch is due to become more significant in the next few years. The promised increase in GP numbers has not been met. Training schemes are struggling to recruit candidates to train as GPs: any review which seeks to solve this must address why this is.

 

  1. In my opinion the Government and NHS England’s plan for improving access to patients and supporting general practice will do nothing to address these barriers.

 

  1. General practice is a difficult job. A common misperception amongst both the public and several outspoken medical practitioners appears to be that General Practice is an easy specialty. Many people consider themselves relative experts in what General Practice involves, as virtually everyone living in the UK has had personal contact with their GP at some point. However, the combination of medical (and legal) complexity and the sheer number of patient contacts and decisions that are made as a result of those contacts is probably unparalleled in any other professional career. Not only this, but the medical complexities and legal risks which GPs face multiple times daily are becoming increasingly and inexorably more complex and of greater as time passes.

 

  1. Primary care undertakes 90% of NHS contacts for less than 10% of the overall budget. The five year forward view states that “Overall, the NHS is one of the industrialised world’s most efficient health care systems, and substantially lower cost than other advanced European countries such as France, Germany, Sweden or Switzerland. The Germans spend 30 percent more per person on health care than we do.” Substantial increases in primary care funding would have relatively little impact on the overall budget – if primary care accounts for only 10% of the NHS budget, a 100% increase in the budget for primary care would only equate to a 10% increase in the overall NHS budget.

 

  1. The current GMS contract, which allows for a potentially infinite workload for a fixed fee is anachronistic and unfit for purpose in the climate in which we now find ourselves. In no other arena of work would any reasonable organisation either attempt to demand this or agree to such terms. The simple fact is that whilst this structure remains in place, practices are being set up to fail as they will never be able to match resources to demand within the budget they have at their disposal. Most practices already make far more use of allied health professionals than their equivalents overseas; the contract has done much to help make the UK system efficient (although a shortage of GPs has also contributed to the drive for many practices to employ non-medically trained clinicians wherever appropriate).

 

  1. Continuity of care is incredibly important in managing patient’s health and unfortunately this is something that has been eroded in recent years. However, contrary to popular opinion, this has little or nothing to do with GPs working less than full time. Instead, this is primarily driven by relentless demand on appointments and a reluctance by many patients to wait longer for an appointment with their nominated GP rather than see another doctor, sooner. Continuity problems could be improved overnight by improving the mismatch between demand and capacity.

 

  1. Health promotion is something which GPs would love to spend more time working on but is another victim of demand for acute appointments. Whilst popular and appealing in principle, the evidence base for routine health checks and screening is relatively limited. However, simply having the time to discuss health promotion proactively with patients would undoubtedly be positive in the long run. A system which enabled primary care clinicians to spend longer with fewer patients would result in more satisfactory consultations for both doctor and patient alike.

 

  1. The burden of bureaucracy is largely a function of the legal framework within which we work. There is no doubt that entries in the medical notes have changed out of recognition in the past 20 years and this is almost entirely due to the requirements of the legal system which require increasing amounts to be written for medicolegal reasons. Recent judgements have raised the bar in this regard, requiring explicit documentation of advice which is given routinely (Evie Toombes v Dr M, 2021). Many doctors feel that the medicolegal burden and the associated stress of working in such a system is a key factor in burn-out.

 

  1. The partnership model has allowed general practice to be incredibly flexible to change and enabled local solutions to be developed which address local problems. I have no doubt that abandoning the partnership model would be a grave mistake which will both increase costs and reduce patient satisfaction immeasurably.

How can the current model of General Practice be improved to make it more sustainable in the long run?

  1. The current contracting and payment systems actually encourage fragmentation of services, reducing coordination and integration. Primary Care Networks, whilst laudable in their ambition to bring local practices together, have generally served to disrupt the co-ordination and integration of many aspects of patient care. Some roles (particularly the Pharmacy team) have made a positive of difference in reducing the administrative burden of GPs, but there is no real reason why these necessarily need to be provided by a PCN structure – in fact they are increasingly working directly for individual practices.

 

  1. The current contractual obligation to try and meet unlimited demand is not fair for patients and places doctors in the unsustainable position of having to try to manage an ever-increasing burden of work. Maintaining the status quo in this regard is likely to result in practices being forced to close and hand back their contracts.

 

  1. There is a simple solution to the question of how to make General Practice sustainable: there needs to be a wholesale change to adopting a fee-for-service approach to the funding of primary care. Practices must also be allowed to offer additional services privately to patients (including those registered with the practice). This would have the following beneficial effects:

 

    1. Every appointments would be reimbursed at an agreed rate - there should be a comprehensive set of tariffs for all the services which a practice can offer as NHS services, including appointments with clinical staff and additionally for any services provided or procedures undertaken. This would enable practices to offer more appointments safely – sustained unmet demand could
    2. Practices who did not offer reasonable access to their patients (the allegation most commonly made against GPs in the media recently) would not be sustainable, whilst busy practices offering a good service would thrive.
    3. If commissioners felt that ear syringing, for example, was a valuable service which GPs could or should be providing, then GPs can choose whether to offer it (for the agreed fee) or not, in which case the patient could seek that service elsewhere. This would apply to all the procedures which the surgery provides, be that phlebotomy, ECGs, spirometry, wound care, Minor Surgery etc. Services which were not commissioned might be offered privately (including from that patient’s registered GP) – that way if the commissioners felt that ear syringing (or any other service) was not clinically valuable, but the practice felt it was a service they should offer and patients valued the service, the practice could still offer it as a private option. This transparency would mean that where patients felt strongly that certain uncommissioned services should be offered as part of the NHS offering, they would be able to lobby their commissioners directly to argue for its provision.
    4. This model would mean that where demand for services outstrips supply, practices would be empowered to employ additional staff to offer more appointments. If they were unable to meet this demand, it could be met by another provider such as a local walk-in centre or another practice.
    5. Patients should be able to easily take the funding for their appointment elsewhere. Out of hours or weekend services would naturally attract a higher rate for offering these services out of normal working hours. Moreover, this would allow and encourage practices to offer tailored health care options to better meet the needs of their population.

 

  1. This structure would not only give practices a sustainable solution to meeting demand but also to make the workload itself sustainable for their clinical staff by capping workload for individual clinicians to safe working levels and ensure that the workload is manageable. Appointment lengths could be routinely increased (e.g. to 15 minutes) to ensure that patients concerns can be more fully explored and opportunities for health promotion taken more proactively.

 

  1. The prescription charge system needs to be overhauled; I would favour a New Zealand style system where all prescriptions are subject to a prescription charge (with no exceptions save for children and palliative care), and there is a clear formulary of specific medications which are subsidised – any non-formulary items can only be prescribed privately. The prescription charge should be relatively low but should be universal. Over-the-counter medications should not be subsidised so that people are not incentivised to use medical appointments purely to obtain a prescription for a medication which they could have obtained over the counter from a pharmacy.

 

  1. Whilst the fully cost of appointments should remain predominantly subsidised, the option of introducing a fee payable at the point of care by patients to contribute towards their appointment must be open to consideration (e.g. £20 paid by the patient with the remainder of the consultation fee being paid directly to the practice by the commissioners/NHSE). Appropriate exceptions could be made for children and palliative care although beyond this, exceptions should be limited.

 

Summary

  1. General practice, which is the backbone of the NHS, is in crisis.

 

  1. The solution to this requires a significant change in approach, and the only serious solution to this is to change the system of funding entirely, to recognise the work that is being done in primary care.

 

  1. This can be done within the existing partnership model, which has shown itself to be flexible and adaptable to radical change.

 

  1. A fee-for-service approach would, at a stroke, eliminate many if not most of the problems we face in Primary Care with access to care and meeting demand.

 

  1. By making the job of a primary care physician more sustainable the whole of general practice becomes more sustainable: able to recruit and train new GPs and retain experienced GPs.

 

  1. The main unanswered question is whether the Government/NHS England are prepared to fund a model which is capable of meeting patient demand.

 

Dec 2021