Written evidence submitted by Herefordshire General Practice (FGP0329)





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;



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. 





  1. 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. 
  2. 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.
  3. 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. 
  4. 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.
  5. 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.

  1. 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. 
  2. 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? 



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? 



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? 



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


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


What part should general practice play in the prevention agenda? 


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


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




Dec 2021