Written evidence submitted by Staffordshire Training Hub (FGP0294)


Staffordshire Training Hub (STH) is a work stream of Health Education England – West Midlands for Primary Care and is hosted by GP First.  STH has undergone an impressive development journey resulting in a structure that supports strong partnership working and engagement across Staffordshire and Stoke-on-Trent.


The STH team works collaboratively across the Integrated Care System (ICS) supporting 25 PCNs (152 Practices) to facilitate workforce planning (population health and training needs) and new care models/pathways.  The STH aims to build capacity for education delivery in primary care and promoting this setting as a first destination career option but also with focus on retention and reform.


Our contribution:


STH feel that we are well placed to give our views and evidence towards this enquiry as we can represent Primary Care (PC) across Staffordshire and are acutely aware and knowledgeable about how GP Practices work and the challenges they are currently facing.  It is important to note that many individual Practices may have missed this opportunity to individually comment based upon current work load and pressures.


The main barriers to accessing general practice and how they can be addressed:


Patient demand is increasing for primary care services and has been for some time.  During the pandemic, PC has embraced new ways of working that has required significant education and support for patients and healthcare staff with the use of new technologies.  There is significant health anxiety for patients and families.  Patient expectations are high for General Practice to return to previous ways of working and access.  However, there is much education and support required to enable these new ways of working to be implemented and understood by patients.  An acceptance of change is crucial.  Patient contacts throughout the pandemic have been huge in number and whilst digital technologies have needed to be embraced there has still been face to face appointment where necessary. 


Expectations are high – media perceptions have not supported primary care during the pandemic which has led to a number of issues:  Patients have been losing faith in GP Practices in some areas, but this is not a true representation of the real picture. 


Staff across the Primary Care workforce, GPs, nurses, AHP roles, non-clinical roles are burnt out, with increasing numbers leaving or retiring and the media does little to promote General Practice as an attractive career choice.   Recruitment and retention of staff is an ever challenging area to address.  Some roles are struggling to train and recruit e.g. nursing but the Additional Roles Reimbursement Scheme must be seen as additional and not “instead” of roles.  We must focus and fund where the real issues are to make an effective change to benefit General Practice and the communities we serve.


Realistic funding is required for primary care with clear career progression and opportunities with access to standardised education.



To what extent does the Government’s access plan address barriers in general practice?


In this rejected deal, General Practice feel that this funding would not have come close to supporting the needs of our practices and patients.  Funding is not sufficient.  It was felt to be very limited support and with the threat withdrawal of winter funding from struggling practices and those with a low face to face rates was demoralising to an already challenged system.  Planned ‘naming and shaming’ of Practices does nothing to improve access and serves only to lower moral further.  The demonising of Primary Care in the media has affected patients’ perceptions of their services and in some cases can have an effect on the all-important relationship that General Practice values and strives to develop and maintain, the relationship that is a cornerstone of primary care ethos. 



Consequences of patients not able to see a GP how they wish?


Complaints have risen as a result of patients feeling unable to see GPs face to face.  It should be noted that not all patients need to see a GP despite their request.  Further education is needed for the variety of primary care roles and many presentations can be safely dealt with via phone or video consultation with the option of face to face if assessed to be clinically appropriate, rather than solely according to patient demand.  We know that change can take a long time to implement usually and change has progressed at pace and been enforced in response to the pandemic and now we are seeing some negativity around that.  Realistically General Practice cannot return to the way it was as it was unsustainable.




The role of seeing named GP to continuity of care:


The concept of having a ‘named’ GP has proved to be a paper exercise and not useful at all.  Such a system can affect choice and perceptions for patients as to who they may see.  What is required however, is a clear awareness of the full primary care team and the roles within it to ensure patients see the most appropriate health care professional according to the presenting problem.



Key challenges general practice will face in the next five years:


There is a significantly ageing workforce in Primary Care – the data is evidence of this.  We are losing staff to retirement, made worse due to burnout and low morale through the pandemic, the continuing negative media has impacted on recruitment.  In addition to this, we have an ageing population with greater and more complex needs that requires primary care input.  Delays in secondary care will be problematic for Primary Care as people become more unwell as a result of the wait. 


Another concerning challenge is the lack of standardised education, opportunities for staff groups in Primary Care.  Lack of realistic investment and funding into estates is impacting on the service delivery – many Practices are operating out of small spaces, not enough rooms and premises with poor standards.


Terms and conditions across Primary Care will be a key challenge in the recruitment and retention of staff over the next 5 years and beyond.  With Agenda for Change Scales and terms optional, there is huge variety with pay and conditions which is detrimental to the stability of the workforce.  Increased working hours across primary care is unsustainable particularly in smaller teams. 


An increase in tenders being won by private companies plays an unfair hand in the delivery of services which affects service delivery, cherry picking of staff and workload, which subsequently impacts on the expectations of NHS services.



How regional variation in England will shape those challenges:


Systems can be unfair across large geographical areas with pockets of high deprivation.  There can be huge variation in funding across boundaries with real inequality in access to recruitment and education programmes.





The role of the General Practice in the prevention agenda:


This is a huge part of general practice and remit.  It is vital for population health in current and future decades.  Challenges in this area have been when crucial funding for activity such as smoking cessation and weight loss has been cut with detrimental impact on the future workload of primary care (evidence based).  In addition to the prevention agenda, health promotion is key.  The importance of family practice relations in the building of trust is key to all elements of GP practice but certainly with regard to prevention of ill health and the promotion of optimal health.



How to reduce bureaucracy, burnout and improve morale.


There needs to be less duplication of reporting, the sharing of data would support this.  There are large administrative tasks fallen to General Practice e.g. filing of covid test results (time consuming in their large quantities).  Also with secondary care being busy, many requests to generate onward referrals following a hospital attendance are frequently sent to the GP Practice to generate. 


There needs to be a much more supportive portrayal of Primary Care in the media, there needs to be more education and understanding of the work undertaken within GP Practice.  It should not be underestimated the impact this has had on morale in our teams.  Our teams have been abused and assaulted by members of the public fuelled by the media 

Little focus is provided for the wellbeing of our staff groups; work load and expectations need to be managed.  Staff should feel valued in all roles, with appropriate terms and conditions, pay scales, annual leave, maternity / paternity entitlements being equitable across the NHS. 



Making general practice more sustainable in the long term:


It is becoming more crucial to standardise:  recruitment and training opportunities, terms and conditions, supervision and support, equitable career pathways.  For example:  there is a significant workforce shortage for nursing in primary care.  General Practice is not just GPs, it is a multi-professional sector that will suffer significantly if the future of GP Nursing is not valued and secured.  The Sonnet Advisory paper describes GPNs as the “super-connectors” of General Practice.  As specialist generalists they pull together the skills and knowledge that other roles can only do part of.  Focus is needed on recruiting to a standardised education pathway for registered nurses to promotes value, excellence and competence.  This needs courage, vision and ambition to ultimately create a GPN Deanery which ensures effective education, suitable and quality supervision and this results in competent GPNs within the Primary Care workforce.  This is an area that is being developed within Staffordshire in response to the crisis already facing GP Nursing. 




The sustainability of the traditional partnership model given the workforce crisis, prioritisation of integrated care and the move towards salaried GP posts.


Partnership is a good model as it is now looking at multi-professional opportunities.  It is important that GP Practice has leadership and management skills within its structures with people who understand Primary Care and are embedded within it.  Partnership promotes a commitment to overall practice development, and it may be that the model needs to adapt to ensure opportunities for other health professionals to engage.  Historically GPs have been the automatic leaders, yet there are leaders in all professions and these need to be embraced in both individual GP Practice and Primary Care Networks. 



Whether or not current GP contracting and payment structures support ‘proactive, personalised, coordinated and integrated’ care.


This continues to be a work in progress, with a lack of infrastructure to really achieve this.  QOF is not particularly patient-centred for individual care plans although it does standardise access to care and care delivery which is evidence-based.  Unfortunately when QOF indicators are dropped, often the practice does not continue on these previously key areas as focus is placed the new indicators.



Whether or not PCNs have improved this kind of care and reduced the admin burden on GPs


GPs are generally the clinical directors and this has resulted with the same people with an increased workload.  Working at scale is improving as PCNs are able to share resources, access and workforce.



If general practice can work in effective partnerships with other job roles in primary care and beyond to free up more GP time for patients, and to what extent Secondary Care


This is what General Practice does already, and there seems to be a lack of understanding as the nature of collaboration undertaken by General Practice.  The Additional Roles brought into Primary Care free up more time for the GPs to see more complex patients.  There are two points which should be noted with regards to these roles 1) These roles are “additional” and not “instead of”. Too often it can be seen that due to the funding streams and accessibility that this might be an easier option to recruit rather than consider the investment required for example in nursing roles. 2)  All of these additional roles require ongoing support and training within primary care and this falls to the Primary Care teams already in post e.g. GPs and Nurses to undertake this. 


Developing nurse education and the general practice nursing role has been overlooked.  Roles such as the Specialist Practice in GP Nursing needs to be valued and developed to ensure GPN leadership is there for the ongoing development of nursing teams and for the benefit of patient care.  Nurses struggle to access funding and time out of Practice to commit to training needs and education and it is still frequently done in their own time.


Dec 2021