Written evidence submitted by Dr Ben Burville (FGP0297)

The problem is mainly one of patient demand outstripping capacity – typically access will be by telephoning into surgeries, and this leads to an inevitable rush between 08:00-09:30. In many practices by 08:45 all the appointments have gone, and demand has already exceeded capacity.

(as per Point 6 on NHS plan)

Online access to appointments can help some but often not the patients in greatest need who may be frail, elderly and with limited IT access or skills.

Other barriers include GP being a default solution for even minor ailments and the excessive reliance on GP by a relatively small number of patients (Pareto principle 80:20 in action)

A sustained campaign using media (TV/Media/Radio/Newspapers) to encourage a "pharmacy first" approach may help.

Increased capacity at GP sites would obviously be a huge benefit with, of course, adequate estate and appropriate phone lines/reception / care navigation staff to answer the calls.

This question is, in fact, key and the issue of a small number of patients generating a disproportionate amount of work is significant.

Identifying frail patients in the community, especially those who have multiple co-morbidities and are housebound then commissioning a bespoke community frailty service (frailty nurses with a community care of the elderly physician) integral to a practice (or group of practices) would be very helpful.

These teams would need to complement GP sites and become integral to the workforce – they would not delegate to the GPs – they would provide care instead of the GPs. Freeing up GP time to help with capacity problems and improve access.


The plan ( Coronavirus » Our plan for improving access for patients and supporting general practice (england.nhs.uk) ) seems to support patients being entitled to select a F2F appointment when, in reality, GP time is a valuable resource.

A patient may well "want" a F2F review for fungal nail infection but it may not be an appropriate use of a F2F slot.

The plan should be more focused on what patients "need" rather than what they "want". (Point 7 NHS plan)

Point 9 of the plan has been written as though GP has accepted this approach when in fact many GPs struggle with this model.

(In our hospitals, the consultant leads a multidisciplinary team of different professionals. That model is rightly becoming the new norm in general practice, with the GP expert generalist supported by a much wider array of clinical professionals.)

In fact, I think this model has significant potential and as a GP trainer who has helped oversee the training of medical students, physician assistants, ANPs, F2 doctors and of course GP registrars it makes a lot of sense.

The model does, however, encourage the GP to take more of a "trainers" role, supporting, coaching and mentoring as required and this narrative has not been "sold" to the majority of GPs yet.

In fact, some will find it quite intimidating.

With regards to the new £250m Winter Access Fund (page 6) – this has genuine benefits for patients when a healthy proportion of the money filters down to GP sites to pay for additional bodies (be that locums or extra sessions for employed clinicians). However, by way of an example, in Northumberland the amount of money available for practices to claim against for extra sessions/ appointment provision is approximately just over £1 per patient registered and has only just be clarified – compared to the £4.60/patient that the Winter Fund equates to.

This means for a practice of 12,000 patients, like my own, we can get an extra 10 days ANP locum/ month at c. £430/day for the period Jan-end March.

Point 17 page 8 – highlights the need for the promised 6000 WTE additional GPs.

The key factor then is that practices are funded adequately to employ these extra GPs. We could employ additional GPs right now if we had the funding.

Point 28 page 10 – "secondary care providers must assess and address certain processes that generate avoidable administrative burdens for GPs. "

This is an ongoing problem that is getting worse.

The latest trends from CCGs/Trust actually reinforce the opposite – a clear example being the inappropriate use of "Advice & Guidance" as a barrier to patient referral.

I can provide personal examples of referrals being undermined and delayed by secondary care providing unnecessary and unrequested "Advice & Guidance" that has ignored the fact that tests had already been arranged.  Indeed A&G can result in considerable "work dump" on GP sites.

B.Address variation and encourage good practice Page 12

I trained as faculty for NHS IQ (Improving Quality) and am a great supporter of the concept of reducing variation and encouraging the sharing of good practice – some of the goals are laudable but the data being used to identify sites in the bottom 20% is inaccurate.  In addition this approach has further impacted negatively on GP morale. The narrative surrounding the Point 42 page 14 was not highlighted as a quality improvement activity but rather a "name and shame" exercise.

In an area where overall GP practice performance is considered "good" , there will still be a bottom 20%.

Point 47 (iv) page 16 needs to be considered in the context of "Actions available to GPs when the Duty GP has reached a "safe capacity" "

Where do people go?

Point 50 page 16 "NHS England will work with the BMA GPC, the RCGP and patient groups such as Healthwatch and National Voices to develop communications tools that can help people to understand how they can access the care they need, in general practice"

NHSE needs to agree a joint comms message with BMA/RCGP to help convey a clear set of messages to patients. To date the comms have been conflicting and at times inflammatory. This needs to change.

This can lead to abuse and patient dissatisfaction.

Patients with easy access to alternative NHS provision – e.g. minor injury units, A&E may well simply seek access there.

Occasionally patients may then delay seeking help if their initial attempt to access care via GP was difficult and this can obviously have serious repercussions.

An interesting question! I am a great believer in continuity of care for a condition / problem more than continuity of care per se.

Having a named GP is often a paper exercise more than a practical process.

Continuity of care has significant benefits for certain groups (multi-morbidity/ elderly)

Staff! Simply not enough funding to employ enough staff to see patients and attempt to meet the growing demand & public expectations.

Estate is also a major factor.

Perhaps NHS Property Services could be refocused to become an organisation tasked with rapidly delivering appropriate estate to ensure clinicians have a room to actually see patients?

Covid has had a major impact and moving forward there will need to be robust plans in place to incorporate annual Covid/Flu boosters in the business as usual (BAU) model for GPs.

I can elaborate with suggestions as needed.

In North Northumberland rurality plays a significant role.

e.g. Patients may be happy to travel 10 miles to a Mass Vaccination site in a urban area but a round trip from Berwick to the nearest Mass Vaccination site in Newcastle is 130 miles. In these circumstances patients are more dependant on GP run vaccination sites.

Recruitment (to PCN roles) in a rural areas can also be challenging.

GP should be a local "Beacon of good health provision and advice"

The "prevention agenda" is a broad concept!

GPs should play a major role in prevention, for example post heart attacks or for those with a high risk of diabetes detected on blood tests. When adequately resourced they can also play a significant role in obesity management and even prevention but this must be part of a well-co-ordinated Public health campaign.

Increase core funding as a higher % of NHS expenditure and invest in adequate staffing. This may involve both short- and long-term staffing plans.

Media campaigns from the Government & NHSE to help support the incredible efforts of a huge number of GPs and GP staff to care for patients who help as at least GPs would feel acknowledged.

Understanding of the concept of "safe capacity" in GP – both for NHSE and indeed GPs as a group needs to be outlined with adequate provision of care pathways once a "safe capacity" is reached.

How can the current model of general practice be improved to make it more sustainable in the long term? In particular:

Yes, it can still work and has some benefits. As a well-established training  practice we are lucky to have no problems with recruitment- including that of partners, but nationally it is a major issue.


No – it has been a challenge to integrate PCN workforce fully into practice teams and all too often practices have a very small share of the PCN clinicians working week.

Until we reach a point where there are significantly more GPs available, then primary care provision must involve the integration of a range of clinicians to simply provide enough "bums on seats" to go anywhere towards meeting patient demand. We have been able to engage in this process but there is a long way to go till the model outlined in Point 9 of the NHS access plan has been adequately explained and "sold" to GPs nationwide.

Dec 2021