Written evidence submitted by Lighthouse Medical Practice (FGP0332)

 

Introduction:

I am a GP partner at The Lighthouse Medical Practice in Eastbourne, East Sussex. I have been a partner for over 8 years since qualifying as a GP. I am the practice lead for Diabetes, the Quality and Outcomes Framework, and Workflow Management.

I am submitting this response on behalf of the practice and my partners are aware of, and support, this submission. Our practice is rated Outstanding by the CQC.

 

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

In the UK there are in the region of 28,000 full time equivalent GPs, for a population of around 65 million. Quite simply, this is nowhere near enough.

The fundamental barrier to accessing general practice is that manifest patient demand outstrips the supply of available service provision. If latent demand (unmet or hidden clinical need) is factored in, then demand outstrips supply by a large margin.

This is in no way unique to primary care. It is endemic to the whole NHS, and the COVID pandemic has brought this into very sharp focus. However, it may be more apparent in primary care and A&E as these are the open access gateways for patients to access the rest of the NHS, which is protected from direct patient access by these services. In addition, both primary care and A&E are charged with the mandate to provide an immediacy of response. Many sub-specialties can and do run up long waiting lists, some even lasting several years, as a response to demand outstripping supply. GP and A&E must respond within hours whether a patient is ill or not, if the patient themselves believe they are ill or in need of medical assistance. An appropriately rapid assessment of need and an appropriate response is a contractual and medicolegal imperative. This not infrequently results in an almost overwhelming workload on a given day and inevitably this means that patients may find it difficult to get access to a GP, via telephone, electronic or face-to-face.

There are no intrinsic barriers to patient demand on the NHS because it is free at the point of use for all UK citizens, and responsibility for determining and defining perceived need is primarily within their gift. As described above, primary care and A&E specifically have no legal or contractual protection from levels of patient demand and are not only free for all UK citizens on an unlimited basis, they are also free to use for foreign nationals visiting the UK. The NHS constitution and the contractual frameworks that reflect it, mandate the provision of theoretically unlimited access to services, whilst rightly demanding world-class standards of care and clinical governance.

On the supply side, the NHS is limited by a finite funding envelope, which is determined by historical precedent, political expediency, and economic reality. As a centrally funded and planned organisation with questionable true devolved power, it can be an incomprehensible bureaucracy even to those who have worked within it for many years. Proposed interventions for service improvement are frequently centrally driven and percolated down through the regional and local management structures, which themselves are subject to very frequent reorganisations and politically driven reform. By the time they reach the front line, usually in the form of  heavily codified policies linked to specific funding streams, necessitating the application of time-consuming bureaucratic processes to support them, they are usually met with a less than enthusiastic response from front-line clinicians who see them, at best, as an unhelpful distraction, and at worst, politically motivated interference aimed at protecting the interests of the government and placating the noisy clamour of the print media.

All this is set against a backdrop of workforce planning problems that date back to the NHS’s origins. The UK has never trained sufficient doctors to meet its own needs, for complex reasons which may relate to the UKs colonial past and financial and practical expediency in the wake of the Second World War and the attendant immediacy of need.

Clinicians working within the NHS are faced, due to the perennial demand/supply gap that is inherent to the NHSs DNA, with a very challenging and intense workload that frequently feels unsafe. They know that they are working at a pace and intensity that exceeds many international comparator nations, however due to the commitment to the NHSs values they choose to stay. However committed they may be, the impact on their personal health and wellbeing, and professional longevity is considerable.

Doctors working in the NHS are becoming harder to retain, more are retiring early or choosing to reduce their workloads by working part time or reducing their clinical responsibilities. Around half of all doctors in the UK are now women, a massive increase from the NHS’s origins, and something to be celebrated. However, the impact of increased part time working, and the impact on family life on the level of commitment that working parents can commit has not been adequately factored in to the limited workforce planning that has taken place. These and many other factors, place even greater pressure on the divide between supply and demand, whilst the mandate and clinical requirements grow ever greater with the ageing population, advancing medical technology and growing patient expectations.

According to the GMC’s workforce report published in 2019, more non-UK medical graduates took up a licence to practice than UK-trained graduates. These non-UK trained clinicians have made an epic contribution to the NHS since its foundation and are regarded as heroes, and rightly so. They have kept the NHS alive. The cost to the countries that trained them and the potential for denuding talent from those countries that need them most is not often so regularly cited. To my mind, the immeasurable value of their contribution to the NHS does not absolve us of our collective responsibility to reflect on the UKs failure to train sufficient clinicians to meet its own needs. This structural anomaly must addressed over a 15 to 20 year horizon.

The now defunct Centre for Workforce Intelligence used to produce quite detailed workforce planning reports for many different medical specialities over a 15-year horizon, before its closure in around 2016 during the tenure of Rt Hon Jeremy Hunt as Health Secretary. It is very unclear where this vital role now resides and where responsibility lies for long-term workforce planning.

 

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

Because it did not appear to address the fundamentals outlined above, and appeared politically expedient when the government was under considerable political pressure from certain sections of the print media to be seen to be doing something, it was received with scepticism and even cynicism by front line clinicians, who regarded it as a further attack on their standing, and an affront to their sacrifice. As such, it is unlikely it will make any meaningful difference to the working lives of front-line clinicians or discernibly improve the patient experience. It has dented moral just a little bit more and eaten away a little further at the lack of trust that exists between front line clinicians and the government. The lesson is that to achieve meaningful and lasting change, it is vital to take those people who will instigate that change with you.

 

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

Most practices will offer patient a timely telephone or electronic consultation to assess their needs, even where, for clinical or organisational reasons they do not allow patients to book directly into face-to-face consultations without triage. This system was endorsed and promoted by the government as part of the pandemic response. GPs, as experts in primary care and community infective illness, were reluctant to lift these measures even when under considerable political pressure to do so. The rise of the Omicron variant has borne their judgement out to be prescient, yet there has been little public recognition of this - the media and politicians have gone quiet on this subject. Should it become apparent during the telephone or electronic consultation that a face-to-face consultation is clinical necessary and the benefits outweigh the risks, I am very confident that the vast majority of practices are facilitating this.

It is worth mentioning, in response to this question, that general practice operates with a mandate to distribute its limited resources for the maximal benefit of the whole patient population. Simply giving individuals what they want, when they want it, regardless of clinical need, is not a responsible way to manage limited clinical resources on behalf of the wider population. Relying on individual patients’ perceived needs as the primary mechanism for defining how much resource allocation they should be entitled to is not likely to achieve the maximal health benefit across the population. Those patients that ‘shout the loudest’ and who probably do not have the highest level of need, are likely in such a scenario to receive a disproportionate level of access to general practice. For this reason, practices have systems and processes in place to balance the rights of the individual patient with the rights and needs of all the patients registered with them. The vast majority of GPs endeavour to maximise individual patient autonomy and exercise their right of access, within certain reasonable limits.

 

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?

I believe that continuity of care is very valuable to both the clinician, the patient and the wider NHS. Detailed knowledge of the patient’s life, personality, hopes, fears, medical history, appearance, family, job, relationships, and more, make good clinical decision-making so much easier, quicker and more satisfying. For the patient, trust is vital to the relational aspects of care, and leads to far more efficient and efficacious healthcare. Continuity of care should never be a barrier to expeditious access where the need dictates. Complete continuity of doctor is also an unachievable goal as no GP works 24/7/365 day a year for eternity. Good practices are likely to balance the need for continuity and access in a way that best matches a patients needs and their relative urgency and complexity.

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

An unsustainable workload, burnout and a recruitment and retention crisis. We need a lot more high-quality GPs and allied primary care health professionals, and fast. We need urgent recognition that primary care is swamped with reactive care, and an urgent and realistic reappraisal of the balance between reactive and proactive care. It is untenable to continually heap more proactive work on primary care when it does not have the capacity to manage current levels of reactive care.

We need society to understand the limitations of a free at the point of use service provided within a finite funding and resource envelope and try to exercise their use of it in the most responsible way possible. We need politicians to get on board with this messaging. If not, it is hard to see how primary care can regain its feet in the wake of the pandemic.

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

This is a vast topic. It is very unclear how the funding formulae take these factors into account. I work in a coastal practice. For this reason, for a given radius we have about 50% of the land area to recruit staff from compared to an inland practice. We have hidden pockets of significant coastal deprivation, which appear to be masked by adjacent affluence. I believe there is a general lack of confidence and understanding of the funding formulae, and this leads to wide variations in practice income and GP partner earnings, which don’t always appear to reflect the needs of the population nor the demands of the GP workload.

Some areas find it very difficult to attract high quality GP trainees. This has been a particular issue in our area. This potentially starves the areas that need GPs the most from accessing the talent of the next generation, driving up the price of locum cover and salaried GPs. Existing partners sometimes leave partnership realising they can earn as much or potentially more working as a locum with far less commitment or responsibility. Meanwhile popular areas may be oversubscribed with GPs. This creates a market for salaried GPs where some partners are reluctant to pass on their partnerships to the next generation as they can profit from the oversupply of salaried GPs.

What part should general practice play in the prevention agenda?

In theory it should play a pivotal role. It is ideally placed to do this, but its hands are tied by unprecedented levels of manifest patient demand. Addressing latent clinical need is a vital issue, but this cannot happen when primary care is struggling to survive with the levels of acute patient demand. Despite all the problems, primary care still handles the vast majority of preventative medicine, due to its incredible level of efficiency. The COVID and flu vaccination programmes are a case in point, but there are many other examples including the care of patients with diabetes, hypertension, heart failure, chronic kidney disease, chronic respiratory disease, learning disabilities, dementia, severe mental illness, to name but a few.

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

Define more clearly what primary care is for and what it is not for. Promote patient/public responsibility to ensure open access remains a viable model. Train enough GPs and allied health professionals to match the quality and quantity of defined service need. Stop top down reorganisation that tries to reinvent the wheel.

Implement robust long-term workforce planning over a 15-20 year horizon, without political interference, protected by law, and ensure its recommendations and funding requirements are made public, independent of politicians and political parties.

Stop politicians using the NHS and primary care as a political football.

Speak of, and treat, all those working within the NHS with the respect they deserve. Do not allow ‘clap for the NHS’ to be a long-forgotten expression of national gratitude.

 

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?

The partnership model is vital. Independent contractor status, correctly managed and regulated is an incredibly powerful driver for innovation and progressive improvement. There are countless examples from the history of general practice. It is under existential threat due to inadequate workforce planning and a contract which is not fit for purpose. The prioritisation of integrated care is best achieved via the partnership model as integrated care depends on a named clinician having an overarching, longitudinal and intimate knowledge of both individual patients’ needs and those of the local population, combined with a direct professional and financial incentive to meet them. You cannot achieve this if you degrade continuity of care, denude the primary care doctor of ownership of their patient list, put them on a salary and a work-to-rule contract and no incentive to stay in post long-term, by which I mean potentially up to 30 years, but at least 10.

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

No, however many GPs are trying desperately to achieve these things anyway, as they have always done, as this is their professional bent. The reasons they do not, are due to the many barriers outlined earlier in responses to previous questions. You cannot solve the fundamental problem of a massive mismatch in supply and demand with contractual carrots and sticks. Carrots and sticks only work if there is potential spare capacity in the system; without it, you simply rob Peter to pay Paul. What happens is that practices become dependent on financial carrots and sticks for their core funding, and there then ensues a degree of game playing and box ticking to secure the funding, which rarely serves to address the original purpose of the funding instrument.

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

In general, no. The funding envelope is too small and there is insufficient capacity on the system to have a meaningful impact. There are some practices that have effectively merged into large practices as a single PCN, however what they gain in potential capacity, they lose in personalised care. It comes down again to what you believe the purpose of primary care is. Without understanding and defining this clearly, no system designed from the top down will likely achieve its intended aims.

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 difficulty with allied health professionals taking the pressure off GPs is that there are not enough of them, the productivity cost is too high, and their level of training doesn’t really allow them to make many significant inroads into the overall workload of GPs.

GPs are so efficient with dealing with undifferentiated patient demand, that although they are more expensive per unit of time, per unit of clinical output they are probably cheaper (GP partners in particular) than other allied health professionals and the quality is probably overall higher.

The increase in paramedic practitioners has probably been the most effective partnership, but this is mainly because home visits are a very inefficient use of a GPs time, due to the dead time spent travelling to and from the patient’s home. The quality and continuity of care is not of the same standard, and because paramedics are employees on a salary, they do not have a direct incentive to manage or regulate current or future demand. This can lead to increasing supply-driven demand (another large topic in its own right).

GPs have always relied on allied health professionals. This is nothing new. Practice nurses, district nurses, advanced community nurse practitioners, palliative care staff, pharmacists and paramedics have always been part of the team. Much of the proactive work done in primary care is done by practice nurses.

The difficulty with undifferentiated clinical presentations is that only GPs are really qualified or experienced enough to manage these to a consistently high and clinically safe standard that minimises future supply-driven demand. You cannot replace 10+ years of medical training and many further years of intensive practical experience and knowledge with a significantly less intensive and in-depth training and expect the same level of service.

 

Dr Jeremy Durston

Partner

The Lighthouse Medical Practice

Ian Gow Memorial Health Centre

Dec 2021