Written evidence submitted by Professor John L Campbell MBE MD FRCGP, University of Exeter Medical School (FGP0325)
 

 

Brief Bio

 

Summary

In presenting this evidence, I am commenting on the status and contribution of the clinical academic base supporting, underpinning, and informing service general practice – the discipline of academic general practice and primary care.

Access

General practitioners provide front-end care to the UK population which is continuous, comprehensive, coordinated, and highly cost-effective. GPs, of all professional groups in the UK, are still held in the highest regard across the population

There is a need to retain the mixed economy of consulting modes

The Plan (6) refers to providing 50 million more appointments - what is needed is not more appointments, but smarter consulting arrangements

Research evidence suggests that face to face consultations should still be regarded as a gold standard for access

Introducing telephone triage by GPs or nurses is associated with a substantial increase in overall primary care workload - supplier induced demand. Caution is required when introducing new technologies, especially where major system constraints exist in respect of GP and primary care workforce.

Innovative approaches are required in respect of continuity, an area with a large evidence base. Whilst patients may prefer continuity of care, not all patients achieve that continuity.

The national GP patient survey, focusing, as it does, on patient experience of care, remains an important baseline monitor for access to GP based primary care. It needs to be seen as a tool to help support and improve general practice. One way to achieve this would be to ensure targeted financial support for practices wishing to act in response to GPPS findings.

New models of care should consider the potential unintended consequences for patient experience of the widespread introduction of multidisciplinary teams in general practice.

Referral Management Centres are bureaucratic exercises, fundamentally undermining the clinical skill and decision making of experienced, astute GPs.

Status

The perception and status of general practice is terrible at the moment, resulting in severe demoralisation and adverse knock on effects on the clinical service and academic GP workforce.

Political statements lauding the filling of GP training places are misplaced. General practice is not currently seen as an attractive career option for UK trained undergraduates.

Some clinical academic mid-career posts (academic clinical lecturers) are unequally distributed across the UK. A review of the provision and funding of these posts is needed.

Of fundamental importance is the disadvantage of academic GP as a clinical academic discipline, evidenced by the lack of access to local clinical excellence awards for senior academic GPs.

Workforce

Our NIHR funded REGROUP study identified the perilous state of the GP workforce in 2017. That situation has continued, and worsened.

The GP workforce problems are compounded by gender issues in resourcing the future GP workforce. It is essentially necessary to train around two GPs to fill one GP service post.

Given the already-difficult data referred to above on the attractiveness of GP as a career destination for UK graduates, a fundamental review of the reasons why UK undergraduates, especially men, are making these career decisions is required. Many relevant earlier, authoritative recommendations from national reports have gone unheeded and unactioned.

UK primary care healthcare spend

The UK spends approximately the same as western-economy averages on healthcare, However, 2017 data identified a reduction in investment in primary care from 2005/6 levels (9.6% of NHS budget) to 8.1%; against these modest amounts , GPs and their teams deliver around 90% of contacts with the NHS in England.

Successive governments have failed to invest in the NHS – that is why we have fewer doctors per capita (UK 280 per 100000 popn) than France (310) and Germany (400).

‘Protecting the NHS against COVID’ is a key aim in COVID control. However, the fundamental issue is the failure of successive governments to invest sufficiently in the forward planning problems of a modern NHS, thus creating the core problem and exposing the whole UK economy to potential disaster.

General practice based primary care – building the evidence base, sustaining the clinical discipline

Every major clinical discipline has, at its heart, a core of related clinical academics delivering high quality undergraduate and postgraduate education and research which builds, informs, and sustain NHS service delivery and patient care. Academic GPs also deliver large volumes of direct patient care in NHS service practice settings. They oversee and deliver an extensive portfolio of clinical, organisational, health-services focused, and educational research, attracting funding from all UKRI and NIHR funding streams as well as major research charities.

The National Institute for Health Research funds the School for Primary Care Research, bringing together the nine leading departments of academic GP/Primary Care in England. This is a critically important and welcomed national initiative.

NIHR funds many opportunities for primary care academic careers for clinicians and scientists and these are enormously welcomed.

But UK clinical research is plagued by excessive bureaucracy.

‘Urgent Public Health’ badging in the pandemic destroyed and undermined many millions of pounds of nationally funded primary care clinical and organisational research in a reaction to COVID. The processes used to allocate COVID research funds were questionable, focussing on just a few centres to the detriment of many other centres carrying out priority, nationally funded research in many other areas.

As in the case of service general practice, attracting bright young doctors to a career in academic GP is a challenge. Major uncertainties exist for any individuals embarking on such a career, with insecurity, uncertainty, and limited opportunities at every step of the way. Undergraduate experience of academic primary care may be variable. Many primary care departments within HEIs have a disadvantageous fracturing and separation of GP based education and research.

Core training opportunities for junior doctors considering a GP academic career are challenged, with a limited pool of more senior colleagues to support career development. Salaries for early career clinical academics are lower than their service counterparts.

Mid-career clinical lecturer posts are no longer tenured, are extremely limited in number, and are competed for with many other specialties when funded through NIHR/HEE. Geographical inequalities are widespread.

Lack of access to local clinical excellence awards deprives early-senior academic GPs of an important income stream compared with hospital based clinical academics, and also deprives them of a platform from which to bid for national clinical excellence awards.

Core service development must be matched by equivalent development and support of the academic base for this large clinical discipline. Equivalence of status for GPs and for academic GPs is fundamental. Without high quality general practice, NHS care will collapse; without motivated and vibrant academic general practice, UK primary care and NHS operation and delivery will be neutered, ill informed, and of reduced effectiveness.


Key issues:

Access

General practitioners provide front-end care to the UK population which is continuous, comprehensive, coordinated, and highly cost-effective. GPs, of all professional groups in the UK, are still held in the highest regard across the population

There is a need to retain the mixed economy of consulting modes whose implementation in primary care has been accelerated in primary care during the pandemic; GPs and their teams continue to see many patients face to face, and the increased remote access (econsulting, telephone triage, small amounts of video consulting supplemented by use of digital media) has provided improved access for some patient groups.

The Plan (6) refers to providing 50 million more appointments – this is exactly the kind of approach which undermines and demoralises GPs and their teams; what is needed is not more appointments, but smarter consulting arrangements where GPs are recognised with clear Consultant status, and able to manage their multi-disciplinary teams effectively.

Research evidence suggests that face to face consultations should still be regarded as a gold standard for access[1], but that other approaches as mentioned above have an important contribution in facilitating access to primary care.

Our NIHR funded ESTEEM trial[2] (42000 patients,22 practices, 4 areas, 2015, £1.8m) identified that introducing telephone triage by GPs or nurses was associated with a substantial increase in overall primary care workload as measured by numbers of contacts. Caution is therefore necessary in respect of supplier induced demand, especially where major system constraints exist in respect of GP and primary care workforce.

Innovative approaches are required in respect of continuity, and the ability to provide dedicated, named personal continuity in the present environment of workforce constraint and increasing complexity of primary care presentation. Continuity of information (e-records, managed data) and team based care have important potential in ensuring optimal patient experience of care. Many patients prefer continuity of care[3], most notably older people, people with long term or mental health conditions, or those seeking non-urgent care. Patients less likely to achieve continuity include women, patients of larger practices, and individuals from ethnic minorities. Researchers have highlighted the importance of continuity, suggesting it is (literally) a matter of life and death[4].

The national GP patient survey, focusing, as it does, on patient experience of care, remains an important baseline monitor for access to GP based primary care. Our team jointly developed the survey (in conjunction with University of Cambridge and IPSOS MORI), but GPPS is important, and too susceptible to political interference. It is one of the largest such datasets anywhere in the world, but it now has inadequate academic representation supporting its further development and use. It needs to be seen as a tool to help support and improve general practice, rather than acting as a basis for disciplining and over-managing GPs and their teams. One way to achieve this would be to ensure targeted financial support for practices wishing to act in response to GPPS findings. In addition, the move to an annual survey means that the survey is less granular and useful than in its earliest stages of delivery, when the survey was administered several times each year – data could easily be presented as rolling averages.

Preferred method of access

Our research[5] identified that patients’ evaluation of their care is worse if they do not receive the type of consultation they expect, especially if they prefer a doctor but are unable to see one (or want a face to face consultation but receive an alternative). We advised that new models of care should consider the potential unintended consequences for patient experience of the widespread introduction of multidisciplinary teams in general practice.

Referral Management Centres

Such centres are bureaucratic exercises, fundamentally undermining the clinical skill and decision making of experienced, astute GPs. Typical is staffing by relatively inexperienced clinicians passing judgement on GP referrals, and frequently delaying and obfuscating patient care on account of minor bureaucratic issues.

 

Status

The perception and status of general practice is terrible at the moment (December 2021), resulting in severe demoralisation and adverse knock on effects on the service and academic GP workforce. Key issues need to be addressed urgently. Political statements lauding the filling of GP training places are misplaced – the only reason GP training places are full is on account of incoming international graduates (47% of GP training places are currently filled by international medical graduates (Professor Simon Gregory, HEE, 2021)fortunately, as otherwise we would be facing an immediate major, and severe national crisis). But this data highlights that general practice is not currently seen as an attractive career option for UK trained undergraduates. The reason are complex, but in part relate to the serious devaluation of GP training for undergraduates. This is evidenced (for example) by the NHSEI proposed delay in introducing tariff-equivalence for GP undergraduate placements – academic GPs had to fight for this in the Undergraduate Tariff Working Group chaired by Prof Liz Hughes (HEE). This is unacceptable, and highlights the disdain held by central planning in relation to primary care education. That situation is further complicated by the failure of NHSE to fund accommodation and travel costs to allow undergraduates to easily undertake high-quality placements in a variety of settings in England – again, undermining the overall status and vitality of General Practice as an undergraduate training option.

When Service Increments for Training were originally introduced, important non-tariff payments were also made to many HEI to support the development of the discipline of academic General Practice. However, these non-tariff payments are unequally distributed, with some HEI having (eg) clinical lecturer posts funded by this mechanism; many other HEIs have no such arrangements meaning that clinical academic trainees in some settings are deprived of career progression opportunities. What is needed is a review of middle grade clinical academic careers for GPs – the NIHR School for Primary Care does provide important training opportunities, but not at clinical lecturer level, thus undermining the clinical academic training pipeline in England.

Of fundamental importance is the disadvantage of academic GP as a clinical academic discipline, evidenced by the lack of access to local clinical excellence awards for senior academic GPs – unlike every other clinical academic discipline in England. Senior Academic GPs (academic GPs at senior lecturer or above) hold a substantive academic contract with a University, and an honorary contract (consultant equivalent, recognised as creating eligibility for national-level clinical excellence awards) with NHSEI. I have led negotiations at every level of NHS and DH over 10 years in an attempt to resolve this issue, including meetings with the national Medical Director of NHS (eg Keogh, with NHS Executive representation on some occasions), NHSE Directors and Deputy Directors of Primary Care, BMA, ACCEA, AMRC, RCGP, UCEA, NHS Employers, and Medical Schools Council. The failure to see this issue resolved reflects widely and negatively on academic GP as a viable career option. Academic GPs have a career and income trajectory similar to all other Consultants in the NHS – this being the basis for their already-established eligibility for National Clinical Excellence Awards (a process in which they have had considerable success and to which they have made a significant contribution in England). Unlike service GPs, senior academic GPs are not independent contractors, and are usually not profit sharing partners in GP practices, having a share in practice premises or being eligible for the tax advantages associated with GP partner status. In addition, they do not undertake private service practice, although all continue to deliver direct NHS patient care as a requirement of their Honorary Contract with the NHS. The failure to address and resolve this issue is a blight on the NHS, who collude in discriminatory practice against this small group of individuals (c 230 fte), thus undermining the status and potential of senior academic GPs in England. NHS employers almost resolved the issue with the support of NHS Executive in 2017 when they produced a draft outline for a local CEA awards scheme for SAGPs. But a change in personnel at Skipton House resulted in cessation of progress that had been negotiated over several preceding years. That situation needs urgently addressed to gain the confidence of senior academic GPs in England – who are responsible for many hundreds of millions of pounds of research underpinning the primary care evidence base for clinical and operational research in the UK as well as delivering around 15-20% of the clinical undergraduate teaching curriculum and providing deep-level support for many areas of NHS policy and practice (for example, in my own case, developing the research for the GMC round revalidation using patient and colleague feedback in multisource feedback for all UK doctors in all clinical specialties and settings; developing the national GP patient survey (now used by c 25 million respondents); developing the evidence base for the routine working of all ACCEA regional subcommittees; undertaking and publishing leading research informing GP workforce planning; leading academic primary care nationally and in the southwest; leading the evidence base round non face to face consultations (e-consultations, phone, video); and many other areas of local, regional, and national activity relating to the support and development of my clinical academic discipline. My situation is typical of my other SAGP colleagues in England.)

Workforce

Our NIHR funded REGROUP study[6][7][8] identified the perilous state of the GP workforce in 2017. GPs reported that they felt they were the last stop in healthcare, shouldering the responsibility for access to NHS care and managing complex clinical cases in a risk-prone environment; they felt vulnerable and unsupported in delivering such care – to the point that attitudes to risk, and the related sense of medico-legal and clinical vulnerability were major contributing factors in many deciding or considering leaving primary care. We identified many practical areas where action might be taken to support GP recruitment and retention (Appendix).

The GP workforce problems (current deficit of 7000 trained GPs against an estimated workforce of c 35k individuals (fte) is compounded by gender issues which are straightforward but usually unvoiced. The simple fact is that around 55% of medical undergraduates in the UK are women, and around 75% of GP trainees are women. Given that many women will take career breaks, these figures make it clear that it is essentially necessary to train around two GPs to fill one GP service post. Given the already-difficult data referred to above on the attractiveness of GP as a career destination for UK graduates, this is a toxic situation that requires a fundamental review of the reasons why UK undergraduates, especially men, are making these career decisions. (Quite apart from other considerations, there is a concern that men may have difficulty accessing a male GP for medical problems in the future, should they wish to do so; the majority of GPs have been women since 2014). Those fundamental issues need urgently addressed – many of the solutions were outlined in the Wass Report (By Choice – not by chance, MSC 2016), the Centre for Workforce Intelligence report and In-depth review of GP workforce (2014) and the Roland report (The future primary care workforce; GP workforce Commission 2015), many of whose recommendations have gone unheeded and unactioned.

UK primary care healthcare spend

The UK spends approximately the same as western-economy averages on healthcare, with an average per capita spend of around $US 4500 pa per citizen (range amongst high income economies Switzerland $10000 to Poland $1000), and c 10.2% of GDP spent on healthcare (Switzerland 12.1%, Kazakhstan 3.4%)[9]. Around 80% of UK healthcare spend is derived from public sources, with an additional 17% deriving from out of pocket expenditure. WHO have called ‘on countries to allocate an extra 1% of gross domestic product to primary health care as a cost-effective way of speeding up progress towards universal health coverage. Public investment in primary health care offers the potential to improve access to services in middle-income countries, to enhance the quality and efficiency of people-centred services in high-income countries and to improve financial protection in all countries, especially if accompanied by efforts to strengthen coverage policy’. 2017 data identified a reduction in investment in primary care from 2005/6 levels (9.6% of NHS budget) to 8.1% - this against a call for 11% from RCGP and BMA; against these modest amounts , GPs and their teams deliver around 90% of contacts with the NHS in England.

The response to COVID highlights the problem. Successive governments have failed to invest in the NHS – that is why we have fewer doctors per capita[10] (UK 280 per 100000 popn) than France (310) and Germany (400):

File:Practising physicians, 2013 and 2018 (per 100 000 inhabitants) Health20.png

 

‘Protecting the NHS against COVID’ is a key aim in COVID control – However, the fundamental issue is the failure of successive governments to invest sufficiently in the forward planning problems of a modern NHS, thus creating the core problem and exposing the whole UK economy to potential disaster.

 

General practice based primary care – building the evidence base, sustaining the clinical discipline

Every major clinical discipline has, at its heart, a core of related clinical academics delivering high quality undergraduate and postgraduate education and research which builds, informs, and sustain NHS service delivery and patient care[11]. Academic GPs also deliver large volumes of direct patient care in NHS service practice settings. They oversee and deliver an extensive portfolio of clinical, organisational, health-services focused, and educational research, attracting funding from all UKRI and NIHR funding streams as well as major research charities.

The National Institute for Health Research funds the School for Primary Care Research, bringing together the nine leading departments of academic GP/Primary Care in England to develop and deliver a major programme of research and to build primary care academic capacity. Beyond its £32 million core funding, SPCR also leads on other programmes of research, for example into mental health (£10 million) and dementia (£3 million). SPCR works in conjunction with the NIHR Academy and the other two national schools for research (public health, social care). NIHR funds many opportunities for primary care academic careers for clinicians and scientists and these are enormously welcomed.

But UK clinical research is plagued – I choose the word carefully – by excessive bureaucracy. Fundamental lack of understanding of research risk and poor risk stratification underpins the processes of MHRA ethics approval. Studies which are low risk to patients are interrogated, investigated, and managed in the same way as major early-phase clinical trials of drugs which carry much greater potential risk, thus incurring huge amounts of bureaucracy, time delays, and unnecessary expense. The NIHR Clinical Research Network focuses their (primary care) activity on selected practices rather than providing access to research support for all practices and for all studies, thus undermining the science of primary care observational research and potentially of many clinical trials which are thus targeted on non-representative practices, populations, and patients. Variable CRN working patterns and arrangements between regions are emerging. Many examples are available. The processes and requirements for ‘Urgent Public Health’ badging in the pandemic destroyed and undermined many millions of pounds of nationally funded primary care clinical and organisational research in a questionable reaction to COVID. The processes used to allocate COVID research funds resulted in focusing activity on just a few centres – Oxford, UCL, Imperial – to the detriment of many other centres carrying out priority, nationally funded clinical and organisational research in many other areas. The approach adopted was also to the detriment of many studies, including our BRACE study[12] which has major philanthropic funding (c £12million), but which failed to attract NIHR funding support, failed to secure Urgent Public Health status, and consequently failed to secure early CRN support thus creating difficulties in securing UK ethics clearance for a study which already had global ethics clearance in Australia and Europe (and later in South America), and undermining the roll-out of the study in the UK. The decision-making round COVID research in the early stages of the pandemic was fundamentally flawed and partisan. Time will (shortly) tell whether the BRACE intervention (BCG vaccination) is effective in mitigating the risk of acquiring COVID – if indeed that proved to be the case, the UK failed to see the opportunity and was prepared to sacrifice potential benefit for millions of people in favour of narrow, bureaucratic, and partisan decision-making.

As in the case of service general practice, attracting bright young doctors to a career in academic GP is a challenge. Major uncertainties exist for any individuals embarking on such a career, with insecurity, uncertainty, and limited opportunities at every step of the way. Undergraduate experience of academic primary care may be variable. Primary care departments within many HEIs are now fragmented, with a disadvantageous fracturing and separation of GP based education and research. Core training opportunities for junior doctors considering a GP academic career are challenged, with a limited pool of more senior colleagues to support career development. Salaries for early career clinical academics are lower than their service counterparts. Mid-career clinical lecturer posts are no longer tenured, are extremely limited in number, and are competed for with many other specialties when funded through NIHR/HEE. Geographical inequalities are widespread. Of vital importance, lack of access to local clinical excellence awards deprives early-senior academic GPs of an important income stream compared with hospital based clinical academics, and also deprives them of a platform from which to bid for national clinical excellence awards. Should they achieve success with a national award, unlike all other Consultants in England, they have no safety net should they have problems renewing that award, with major financial implications resulting.

Core service development must be matched by equivalent development and support of the academic base for this large clinical discipline. Equivalence of status for GPs and for academic GPs is fundamental. Without high quality general practice, NHS care will collapse; without motivated and vibrant academic general practice, UK primary care and NHS operation and delivery will be neutered, ill informed, and of reduced effectiveness.


Appendix