Written evidence submitted by Herefordshire General Practice (FGP0329)

Overview

The paper is written on behalf of the LMC, GP Federation, CCG Director of Primary Care and all Clinical Directors who form the Herefordshire General Practice Leadership Group. We are passionate about General Practice and are proud of the holistic, patient-centred, proactive and urgent care we provide twenty-four hours a day, seven days a week in our county. Collectively we are one voice for Herefordshire General Practice, in and out of hours. This paper outlines the opportunities that exist for general practice to play a strong partnership role in the evolving ICS. With the right funding and contracting mechanisms to enable the right scale for the right issue, with integrated teams, the future of General practice will be sustained to influence the ICS to help lead services in the community.

Herefordshire General Practice Background

Herefordshire has a population of 195,000 , with 20 GP practices that are all part of the GP Federation: Taurus Healthcare. There are five Primary Care Networks: see link;

https://www.herefordshiregeneralpractice.co.uk/for-healthcare-professionals/primary-care-network-management

In Herefordshire, general practice has formed a Leadership group, which is the operational decision-making body for general practice and is seen as the docking point for the rest of the system to work with to provide a collaborative response. https://www.herefordshiregeneralpractice.co.uk/about/herefordshire-general-practice-leadership-team .

The group oversees the representation and co-ordination of general practice at all meetings across the system that allows for PCNs to respond in different ways according to the needs of their population and workforce demands. The group is supported by the infrastructure of the federation that employs the vast majority of ARRS roles, and provides the management infrastructure, business intelligence and quality/finance/ HR/ IT support needs.

The LMC secretary sits on the group and uses the wider LMC as the critical friend for formal sign-off of new initiatives/ contracts.

The Federation Executive and wider team represent the group at a range of meetings (including Gold and Silver command), and ensure papers and projects are developed on behalf of the group, where success of the group requires trust, but also preparation, so that the time spent together is maximised.

This approach ensured that at the start of the covid pandemic, we could mobilise quickly & collectively. Meeting seven days a week initially, we were ahead of the national decision making around PPE for General Practice teams recognising asymptomatic/ pre-symptomatic spread potential, cohorting patients with symptoms and those with the highest vulnerability to be seen in our award winning ‘supergreen’ site. Our collective approach enabled sharing of staff, estates and digital solutions with the organisational infrastructure to execute plans. Strong relationships with our system colleagues including the acute and community trust, mental health trust and council facilitated daily and then weekly discussions for have a place –based approach. This communication enabled our collective resilience, especially in moments of crisis. This weekly collaboration to integrated working has continued and strengthened.

Recommendations

The GMS contract is reviewed to take into account expectations around numbers of patient contacts that are safe to see, with the expectation that systems have plans in place to support escalation should demand be excessive- in much the same way as the system addresses approach to A&E and other parts of the system.
We encourage the shift from hospital-based care to care closer to home, in primary care. While trusts move to block contracts, patient care moves into the community so the resource to deliver this must follow, which will facilitate growth in this sector.
An Estates Strategy is developed that ensures the increasing community workforce can be co-located, relies less on estates risk being held by individual GP Partners, provides a clear process for funding new builds, supports co-location and removes the need for different parts of the system to consider cross charging.
PCN DES is continued, but the infrastructure required for general practice is considered at PCN, Place and ICS level, ensuring such funding is delivered to those where there is a commitment to a clear GP leadership and infrastructure that supports practice, PCN and at scale activities. Bolting general practice on to another organisation will result in less buy in and lose the ability to innovate.
We recognise that one-size fits all models unrealistic. Partnerships should be more creative with the wider workforce encouraged to be part of the model. Where practice partnerships are strong and thriving they should be supported to continue to deliver the GMS contract (with a plan in place to support last-man standing arrangements), and business continuity that is supported by PCN and Place leadership arrangements. Where partnerships are challenged, a salaried model with employee ownership could be developed – with a leadership culture that values and supports innovation, delivery and development of the whole workforce.

Ultimately this would take the best from a commercial model whilst being at the heart of the NHS family.

Better collection of integrated data (including General Practice) in system dashboards, to demonstrate demand and capacity so that we have an evidence-based approach to workforce, estates and models of delivery including signposting.
A public national narrative that celebrates the flexible, adaptable and high-quality care General Practice provides, recognising it as a critical and necessary partner for the future of the NHS.

Key questions

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

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

Barriers	How to tackle
Access to General Practice is seen as a General Practice issue to resolve	Improving access for patients needs to be considered as a system, that supports continuity of care for complex patients, but allows for an at scale response where there are access pressures. Currently patients get a different response from different parts of the system (111, pharmacy, general practice, A&E). The challenge is to ensure patients trust the opinion they are given so they are managed quickly and safely, without increasing health anxieties. Often this is a risk-based discussion, where algorithms and non-clinical staff may often struggle. The GP team are experts at assessing and managing this risk, and increasingly need to be seen as the conductors of patient care, directing patients to the right place at the right time. This will require a number of initiatives.
Lack of meaningful data around general practice demand, capacity, unmet need and integrated data sets to build PCN, place and ICS solutions	We need system data to understand demand and capacity and the infrastructure to collect, analyse and deliver models of care to reflect this.
Small practice-based teams struggle to deal with the day-to-day variation in numbers of people requiring support	Have clear expectations of numbers of patients that it is safe for practices to deal with, and make this explicit in the GMS contract, above which local systems need to have arrangements in place to support (see below) Encourage a local place-based system that is the vehicle for support in the event of increased demand or reduced workforce. This may be virtual GP practice that supports the duty doctor team of each practice and works in conjunction with 111 (ie becomes a part of the clinical assessment service of 111). Ideally this should be grown from local at scale providers but could work with other providers as long as they integrate with local services. Patients would then ring their own surgery and have an option to access the place-based service (for conditions that do not require continuity of care) Align algorithms and clinical response of 111 and GP surgeries plus A&E that allows all services to manage risk in the same way, without creating unrealistic expectations for patients but still remain safe.
There has been a shift of work into the community (diabetic care, heart failure, complex multi-morbidity, mental health) but without the resource that follows. General Practice workforce numbers have remained fairly static (until the ARRS roles) whilst secondary care numbers have risen	The funding of General Practice needs to recognise the increase in workforce needed to meet the new models of care. Consideration needs to be given to allow growth by measuring and remunerating activity
National drive to strengthen the workforce with additional roles is not matched with a change in the national language, creating a mismatch of patient expectation.	We need to change the “see your GP” mantra – to embrace active signposting to enable you to see the appropriate member of the primary care team Telephone triage, active signposting and digital solutions need to assist people to see the right person in the right place at the right time.
Social, cultural and technological changes seem to mean people are less able to self-manage simple ailments than previously. The pandemic and lock downs have resulted in a new generation of less supported, more anxious parents. General Practice is the go-to place for a plethora of non-health issues, including social care, housing, financial difficulties	Education of the public to reduce the unnecessary flow to General Practice (and ED) Local digital apps to support self-care and local signposting to PCN and place-based interventions Establishment and emphasis on community support outside of health, including health visitors, parenting groups, social activities, use of social prescribers and children’s care coordinators Adequately resourced community services A localised CAS of 111 (where the hub supports the region when busy but leads on their local area where feasible), would ensure 111 still has the support it requires, will allow for patients to be advised on local access arrangements including optometry and pharmacy. Over time this will build trust between 111 and GP Practices, so that the end state could be a trusted 111 service that has local ownership triages patients to all parts of the system.
An aging and increasingly complex population creates new demands and work that is not visible to the public nor remunerated in contracts	Our county statistics show that over the coming 10 years a significant % of patients will be over 80. Frailty, medical and social complexity requires a generalist system to support health needs But it also needs an integrated approach to avoid over medicalising and to reduce the need for a GP to be the solution to many problems. The GP becomes the conductor of an orchestra of multi-disciplinary roles who can provide wider access to care and promote prevention with public health colleagues. The left shift and the change in population demographics mean there is submerged work – for example medicine optimisation and implementing one-stop outpatient attendance treatment escalations falls to general practice.

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

It is hard for patients to navigate the health system and access the right person in the right place. We need care navigation with senior clinician triage that can add huge value but is limited by capacity.
Care sought in the wrong place is less effective and more expensive (unnecessary tests) and duplicates work for the system.
Walk in centres often deal with the immediate need but often do not provide the trusted clinical opinion sought and evidence often demonstrates duplication. It is far more cost effective to triage, care navigate and then use resources to meet unmet need rather than deploy resources to meet unmet want.
Patients are given different answers in different parts of the system in terms of urgency, investigations required and too many parts of the system put a sticking plaster on with all roads back to general practice.
Poor access also results in a challenge for the personalised care agenda. Care is best delivered which is person centred, with interventions appropriate to that person. An integrated care record with patient portal will help address this and avoid system duplication.
Those unable to access care in their preferred way create a negative narrative that is impacting on morale in the workforce. Workforce would like to offer more capacity but are limited by funding and the current workforce crisis.
We also need to manage the expectation around patient choice. The NHS is free for those with need – not necessarily for those that want without need. Patient expectations need to be managed – the offer cannot be unlimited – and the system is set up as General Practice as the gatekeeper. This needs to be respected and preserved in the national narrative not used to create a negative narrative.

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?

Continuity of care for an episode of illness or condition is part of the historic strength and value of General Practice. It is good for patients and for workforce morale.
However, we cannot have a named GP for all – with an increasingly complex aging population and less GPs, this model needs to change. Indeed named professional would be more appropriate.
To preserve the best of this for certain patients this continuity is vital – complex mental health, palliative care.
However, a named team is more realistic: a PCN member or a nurse, but also may be a GP with an interest in a certain area.
For others, and for acute issues, access is more important than continuity and this should be enabled.

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

Our key challenge is that as the work shifts into general practice from hospital settings, the resource to deliver needs to flow with it. Funding mechanisms in General Practice prevent us from expanding workforce in preparation for the change in workload now and ahead. Hospitals are moving onto block contracts but were previously on activity-based contracts. This enables resource to increase as demand does. It is now time to reverse this model.
Workforce. We have a workforce crisis and our solution is to expand the team with additional roles which enrich the primary care offer. But the public expectation and the narrative has to change with this so they understand the strength of this offer. This also involves GPs moving to a conductor role – and overseeing teams. This needs to be built into GP training and those in post need support in a new way of working.
Data to understand General practice - we need the resource to be able to collect and analyse our data to be able to best shape a model fit for the future. We have 90% of the contacts, but 90% of the data feels secondary care orientated.
Organisational Development: General Practice wants to own and shape the way it develops to be part of this system.
Representation: The future model needs to be clinically led and driven from the front line. We need the time and resource of having those delivering services also leading and directing them.
The right size: General Practice needs to be big when it needs to be – back-office function, county wide services – and small when it needs to be – practice continuity, PCN delivery teams. Getting this right is key to our success.
Estates: many not fit for purpose, and many not big enough to house integrated teams.
Prevention: the prevention agenda is critical for our country’s health. But unless resources and funding are ring-fenced, General Practice is constantly brought into fire-fighting acute care and proactive care suffers.
Patient expectation and the public narrative. General Practice has to change and develop to fit our aging population, a digital culture and a shift in the way secondary care is delivered. The public need to be helped to understand this the media need to champion General Practice as a fundamental, necessary and celebrated NHS partner. The negative press is detrimental to morale and is resulting in a worsening of the workforce crisis: people leaving and less people joining.

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

Contracts often designed to deliver care in larger city conurbation
Rurality often under resourced as finance follows patient population - and does not consider the extra cost of delivering across a larger sparser geography.
Transport infrastructure more challenging - more expensive in rural area to resolve
Digital infrastructure issues with poor connectivity.
Rural poverty - isolated populations, especially the elderly who are transport rather than housebound but decondition quickly – increasing the dependence they have on care. Local Authorities have increased care to deliver, their workforce must be able to drive, travel is expensive in time and money and yet their income too is proportionate to wealth of local business and population size.
Deprivation under-reported and often hidden in rural areas.

What part should general practice play in the prevention agenda?

General Practice is key to the prevention agenda but needs to utilise the wider network teams and partnerships with other providers to strengthen this.
General Practice data set is ideally placed to understand prevention. The professionals are in the privileged and influential position with patients to make a difference.
We need to move to GPs as the conductor of the multidisciplinary team identifying patients to work with social prescribers, health and wellbeing coaches and wider member of the PCN role to address inequality
We must not forget that social determinants of health are not all resting on the shoulders of health care. Society and many other services have a role here and a collaborative approach is needed. Closer working with health visitors, school nurses, community services in network teams can support this agenda and prevent over-medicalisation.
Prevention care needs to be ring-fenced. When we are pulled into system crises, or when acute care needs escalate, prevention falls off the agenda and this means we face short- and medium-term priorities for longer. Without ring fenced resource this is a vicious cycle. Formalising approach to resources between primary care at scale and local authorities could facilitate a higher profile and delivery of prevention.
NHS General Practice role in prevention needs to be recognised. We do more than deliver to the immediate needs of patients. Private health care is entirely driven by patient want and this is not financially sustainable for a publicly funded system with a duty of care to the population as well as the individual.

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

A change in the national narrative and media perception of General Practice to recognise, champion and celebrate the high-quality enormous volume of care we deliver for patients both proactively and reactively despite being the least funded part of the system.
Less reliance on the GP to sign multiple forms (insurance, death certificates, passports, DVLA, social services forms or the default for other organisations) - to articulate the qualifications of other roles and then utilise these releasing GPs to do the work only their training enables.
Infrastructure to allow us to work at scale – our covid response was enabled by our place-based infrastructure.
OD resource that lets us own the development/ evolvement of this infrastructure - being “done-to” by other parts of the system will reduce morale and increase those leaving. General Practice will be more efficient to run itself in the ICS space – rather than others in the system running general practice. Give us the remit to make it more efficient.
Recognition of clinical leadership in practice, PCN, Place and ICS- the system pays for management, but expects clinicians to do it as part of their job- CD funding is insufficient for this. Funding should reflect general practice leadership at PCN, Place and ICS so that systems can use according to their local arrangements, and are linked to general practice identifying a common voice and leadership structure

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

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

There is no one size fits all model of General Practice employment right now. Our leadership group celebrate all types of employment- salaried, partners, full time, flexible. Leadership and ownership of our service is not determined by how we are paid.
Where partnerships work and are stable and delivering good care – do not undermine this, otherwise our most experienced GPs will retire early. Where this model is time limited, ensure transitioning is easy.
Let's be more creative about what a partnership is – to be more reflective of the teams we are now building.
In areas where a salaried model is needed – look at the John Lewis model of employee ownership and review the leadership culture to ensure every employee feels a valid part of the team and does their best in the role. Empower your workforce however they are employed. This still needs general practice voice and ownership, so the generalist, conductor role, can influence the system.
Do not confuse partnership and contracts. Whilst currently GP contracts are co-terminus with partnerships, they do not need to be. Teams can be partners but work in a contract over a different scale. The network contracts in New Zealand Model are an example of this. Partnership at practice level can work within integrated care systems but needs general practice to join up across place so that leadership is clear, and at scale infrastructure can support wider workforce developments
Partnership creates ownership and pride of the services delivered but the right leadership can do this too .Flexible working can also help with recruitment and retention, recognising different roles suit people at different parts of their life and being sympathetic to life's challenges.

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

The PCN DES does indeed promote collective approach across practices and with other providers/ communities for population health approach. However, general practice needs an infrastructure to allow it to participate as a peer, ensure new workforce are supported, with other functions such as finance, quality, IT and HR all required- this is currently supplemented by federations where they exist, and in other areas is often a struggle.
However, the GMS contract creates an exponential demand on general practice that risks being over burdened with subsequent concerns on safety. There is an increasing workload that is moved from other providers such as acute trusts that general practice picks up without additional resource, although we are fully supportive of this left shift in activity as it is the right thing for patient care.
Personalised care is vital for good patient outcomes but it takes time. This needs to be supported with additional roles, digital solutions for shared care records and patient portals but also the workforce training to change the way we consult with patients.

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

The intentions of PCNs are good and we fully support. However, PCNs are NOT general practice (which is confused by all including national teams)- to deliver proactive, personalised care, requires significant organisational development of general practice, so that time can be spent on creating the right culture of inter-practice and cross organisational working. This requires both time and expertise/ infrastructure- much as one sees as a core part of any trust. To behave like a trust, general practice needs to be resourced like one- then we can help lead the agenda and build on the positive holistic role that general practice must play if the ICS and PCN mechanisms are to be a success.
We have seen the benefit of admin and additional roles working with patients to ascertain patient goals and empowering clinicians and patients to have better conversations about care.

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 ARRS roles have been and will continue to be a success, as workforce is the key challenge in the system. However, the public and politicians need to understand the philosophy of seeing the right person at the right time - reliance on ‘see your GP’ as a mantra needs to change to ‘see a member of your PCN. Care navigate to direct access to specialise. ’a
To maximise efficiency from ARRS roles they need to feel and own the pressures and responsibilities felt at practice level. At scale employment and shared, managed contractual targets would help this and there is a case for moving the contract to the largest scale with which general practice feels comfortable.

Dec 2021