Written evidence submitted by Cambridgeshire Local Medical Committee (FGP0319)


This response is from Cambridgeshire Local Medical Committee on behalf of the 90+ General Practices, 21 PCNs, and 3 GP Federations delivering the breadth of primary medical services to a population of just over 1 million patients.

We are a collective voice of the profession which includes the full gamut of general practice: from the university practices of central Cambridge to the rural surgeries of Fenland; the market towns of Huntingdonshire; and the inner-city practices of Peterborough.

With a housing stock across the county on a trajectory to increase by 100,000 by 2036, this growth and the associated need of what will be an additional quarter of a million people, is already impacting on the ability of the practices and their limited infrastructure and workforce to cope.


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


There are two clear barriers to access: excessive workload and an overburdened workforce.


Demand for general practice has never been higher which means more patients are competing for the numbers of appointments that are available. Supply continues to be outstripped at a rate that has not previously been experienced with patients directly presenting with new, ongoing, or deteriorating problems. Record numbers are awaiting treatment in secondary care, with many struggling to cope, and repeatedly seeking help from their GP. In a growth area, registrations are increasing, adding new demand and a deeper challenge for those patients already struggling to access care when they need to. Extending hours and directing patients to scaled up services for planned or urgent care mitigates an immediate pressure but cannot fully address the extent of what patients present with. Activity inevitably ends up back with the registered practice.


The burden of an uncommissioned workload also adds to this pressure. GPs are increasingly presented with long task lists from their secondary and tertiary care colleagues requiring a range of monitoring, prescribing and investigative activity that was, until recently, considered to be covered in the generous tariffs of hospital contracts. Patient expectation of what their local surgery will pick up is unhelpfully fuelled by other parts of the health service. An associated shift of resource to follow this workload has not materialised, and a dangerous norm of what specialist teams think their generalist colleagues should take on for them is establishing.


Coupling the pressure of demand with a depleted clinical and administrative workforce, exhausted by the pressures of the pandemic and able to realise equivalent or better salaries and conditions in other sectors, and the impact on patient access comes into full view.


The reduction of full time GP partners, whose business it is to manage all aspects of the contract, cannot be fully substituted by a salaried team. Remaining partners are bearing more whilst trying to ensure that they don’t become the last person standing with a name above the door, and unlimited liability. This is exacerbated by younger or newer GPs, with the weight of student debt, struggling to buy in or commit to partnership positions. General Practice needs more GPs being tempted back into the profession now – not quotes about future increased GP numbers that count those still in training.


The appeal of new roles via the Primary Care Network is quickly diluted as the reality of supporting, supervising and training this new workforce becomes apparent. The responsibility of partners that is borne for the activity delivered by roles not traditionally employed in general practice has widened and added to the layers of bureaucracy that PCN sign up has initiated.


The recent negative portrayal of the profession by the media, fed by the DHSC and NHS England, damages the ability to attract and retain a workforce, threatens the relationship with patients, and clouds the future of the service.


As an immediate measure, workload needs to feel safer, to allow the profession’s numbers to stabilise and then increase. GMS has been successively diluted with new funding going into a DES that has promised much but delivered little change on the ground. A new contract is required that could potentially focus on managing population health outcomes via excellent proactive long term condition management and care. An element of same day acute need would remain, especially for those patients in whom continuity of care was required due to complexity of multimorbid need.


A general acute on the day demand could potentially be managed and be commissioned separately via 111, or innovative PCN or Federation delivered vehicles contracted for that specific purpose. This service would be GP led, but nothing necessarily GP delivered. Commissioning may be bespoke to the needs of the local population.


Investment in premises and estates is required nationally if outpatient transformation is to be truly realised. So too should GP contractors be able to recruit and utilise specialist consultant colleagues if their experience is relevant to the population’s needs (e.g. geriatricians or diabetologists).



  1. To what extent does the Government and NHS England’s plan for improving access for patients and supporting general practice address these barriers?


It can be safely said that the Government and NHS England’s plan for improving access has only served to damage, punish, and insult General Practice. It has undermined the principles of continuity, challenging the effectiveness of the Gatekeeper role, a role which allows the NHS to live within its means. GMS offers extraordinary value for money, it is challenging to understand the DHSC and NHSE thinking behind some of the commissioning and political decisions in recent months.


The plans are unworkable and inequitable. Short term, non-recurrent investment, to be spent at breakneck speed will do little more than provide a sticking plaster to what is a much deeper set of issues. Each exercise brings a pattern of attrition to the GP and Practice Nurse workforce.


It is likely that the advance of the new covid variant will render much of the plan as redundant as the profession is called upon to accelerate the booster programme.




  1. What are the impacts when patients are unable to access general practice using their preferred method?


Experience suggests patients either seek alternative points of access to health care or delay presentation of their symptoms. Both are potentially dangerous impacts of being unable to access general practice.


Data provided by the commissioner shows a higher use of A&E or other urgent care services during core surgery hours but does little to track the subsequent care of the patients and how they end up back in the care of their registered practices.


Delayed presentations and diagnosis can lead to poorer outcomes for patients and potential medico-legal issues for clinicians involved in their care.


Complaints, bureaucracy, and punitive performance processes lead to an inequitable challenge for practices with a finite workforce and hours in the day, unsafely grappling the tsunami of demand, where public want can often be facilitated to trump clinical need.


Practices are dealing with the frustration of patients as their conditions may be worsening and their treatment is delayed. As the front door to wider services, this frustration is often levelled at practice staff but may well be about other challenges they are facing.


Patient dissatisfaction results in negative press and further undermining of the profession and the service they are providing.



  1. 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?


Whilst the principle of a named GP or GP of Choice is well understood and valued, for many practices the ability to provide this feels a distant memory. The depleting number of GPs and the current emphasis on expanding skill mix rather than concentrating on GP supply, means that the proportion of patients who can benefit from the continuity of care that this provides is also diminishing.


Having a named GP and being able to access that GP must go in tandem. Having a named GP but no access to them is no better than having no named GP at all. Achieving both is not consistently possible under current working pressures unless the debate is reframed around the GP ‘overseeing’ their care within the practice team.


At present and over the past five years, GPs have started to mitigate their exposure to unsafe working conditions. Days typically last a minimum of twelve hours, patient contacts far exceed safe levels, the OPEL state is often resting at 3-4 and lack the role lacks flexibility that younger professionals need. Consequently, shift patterns emerge of doctors and nurses working full hours across three long days, further fracturing continuity, or reducing sessions further still – or ultimately defining their own working hours by choosing to locum.


Longer consultation times, less frequently, would allow higher quality care to be delivered to those patients who need it most, to keep their care outside of hospitals. GPs need to work at the top of their license, managing the 20% of patients who fall outside the bell curve – but they need time to do this well, and safely.


  1. What are the main challenges facing general practice in the next 5 years?


The biggest challenges facing general practice include:


  • Coping with coming out of the pandemic, and what the pandemic still has to throw at society and health services, there is low morale and increasing burn-out prompting staff to leave the profession. The huge demand and post covid burden of disease will need to be managed for years to come alongside the increasing complexity of an ageing population with multi-morbidities. It is not clear where the resources and energy will come from to take this all on.


  • Attracting a GP workforce and attracting and retaining a wider support workforce. Alternative sectors can offer better wages and conditions. There is concern about the future of the partnership model. If it isn’t valued and supported then it will be lost, and there is considerable concern about what might replace it, at much greater cost and less efficiency.


  • Profession being viewed negatively and any way it responds or sets out what is needed is held against it. Patient loyalty and value of the service is undermined by an Amazon/ Just-eat culture of consumption and expected impossible timescales of responsiveness.


  • Interface with secondary care and other system providers – as delays and pressures build upstream, the fall out and redirection of patients shifts to general practice. The direct tasking of GPs by secondary and tertiary care clinicians exacerbates the problems as evidenced in our Workload Capacity Report published in November 2020, and our Demand & Capacity Survey from May 2021 with its proposed System Solutions. We would be keen to share these with the Health Select Committee.


  • Infrastructure and potential digital divide in an ageing or digitally-disenfranchised population.


  1. How does regional variation shape the challenges facing general practice in different parts of England, including rural areas?


Variation in care is not as simple as urban and rural. There are many factors that impact on deprivation, vulnerability and isolation, and many factors that impact the health of a population.

Target based payments and contract performance methods mask the different struggles that practices have to reach their patients, and many are adversely affected by the way indicators and payment models are constructed.


Local university practices have been significantly negatively impacted by the pandemic and will need to seek support through atypical funding routes. Practices that have historically fared well are experiencing a level of variation that is impacting their sustainability.


Across the East of England, recruitment is a challenge for most practices. Proximity to London, increased house prices and challenging transport routes impact on the success of practices in recruiting and retaining key members of their team.


The Carr Hill funding formula does not work across Cambridgeshire and Peterborough, it widens existing health inequalities, and the local authorities’ income falls far short of the requirements for its population. This leads to an annually growing distance to target for the finances of the ICS which then has less discretionary spend, creating a negative feedback cycle around resource, workload and workforce.


  1. What part should general practice play in the prevention agenda?


Practices are well placed to deliver preventative medicine and understand their population health. However, the culture of non-recurrent incentive schemes and the need for quick fix improvements does not support a model of care in which prevention is a core part of general practice. The longer-term benefits are not measured or valued to support the way in which this work needs to be resourced.


The necessary focus of public health teams on the pandemic has resulted in a wide range of public health prevention initiatives falling away. Expecting general practice to pick this up under current demand pressures is not realistic. Future consideration will need to be in the context of a revised contract with clear resourcing mechanisms to prioritise health promotion and disease prevention strategies at a local population level.



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


Improvements at the interface between primary care and other provider services would significantly impact on the amount of bureaucracy that practices are managing on behalf of patients.


The unlimited tasking of GPs by secondary and tertiary care clinicians has shifted unresourced administrative and clinical work into general practice, this has been exacerbated by the pandemic but was prevalent before. There needs to be an embedded culture of only passing on, what cannot be done. E.g., a fracture clinic is best placed to provide a patient with the correct MED3 for their workplace and determining how long they will need to recover. A community psychiatry team needs to monitor the blood levels of Lithium when initiating and titrating a patient’s treatment before handing their care to the GP. A Pre-admission clinic can post a kit for patients to self swab for MRSA or send off a mid stream urine pre-operatively. These tasks may seem modest in complexity, but when received in their thousands each day, they lead to frustration, inefficiencies, delay, and a lack of professional respect across the primary/secondary divide which is not in the patient’s best interest.


CQC requires a post pandemic fresh approach. Appraisal should be protected with the current pandemic simplifications. Cross nation performer’s list processes should be simplified to encourage ease of workforce transfer. The bureaucracy review committed by NHSE in contract talks with the BMA’s GPC should be honoured. We would be happy to articulate specific examples if called to provide evidence.


The PCN DES and system transformations have brought an increasing burden of meeting proliferation that detracts from direct patient care. Resources are limited and funding to attend and source backfill is non-existent. This is putting primary care – the most efficient part of the whole system, on the back-foot of the biggest reconfigurations the NHS has seen in over a decade.


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


  1. Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?


Yes, it remains the most efficient and cost-effective way to run primary care but needs adequate funding and security longer term.


Replacing with a salaried service or pursuing a Trust run vertical model would not be able to contain the activity:cost ratio in the way the partnership model does.


Salaried GPs and primary care team colleagues continue to prefer to be employed by GP partners rather than Trusts or large corporate providers.


Partnerships have provided the backbone of PCNs and the vaccination programme and without strong partnerships, Integration will be built on inadequate foundations.



  1. Do the current contracting and payment systems in general practice encourage proactive, personalised, coordinated and integrated care?


No, they stifle ingenuity and progressive practice, detracting from direct patient care and time to innovate.


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


Some areas have been improved by the creation of new roles, but the administrative burden and in some cases financial threat have increased. There appears to be a lack of flexibility at PCN level to employ what the population needs (rather than what government believes is needed). PCN funding is commissioned in a way that undermines and threatens the viability of the core contract.


Locally EEAST have insisted on VAT charges for hosting Paramedics, so there are precious few PCN paramedics. Mental health Exemplar funding has complicated the mental health worker offer, so we are no further ahead and over £1.3million of ARRS allocations remain unspent.


ARRS flexibility to be spent on GPs, nursing teams, HCAs and Practice administrators would be especially welcome.



  1. 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?


The development of first access physio has been a good example and works well. Sadly, the GPCPCS scheme only serves to create work for practices, but the introduction of clinical pharmacists has been an overwhelming success and needs to be supported to continue to realise its potential.


There are issues regarding funding re community NHS services and their roles that don’t fit into general practice especially well, such as podiatry or dietetics.


GPs still need to recruit, train and supervise additional staff, so precious little has ‘freed up’ time and indeed may have taken time away from clinical work to manage. Backfill depends upon being able to source a locum, and they are in short supply.



Dec 2021