Written evidence submitted by Dr Peter Davies (FGP0333)

I have the following roles but this submission is entirely personal although informed by my thirty three years of medical practice and in quality improvement and assurance as a doctor since  graduating from Leeds University in 1989 and as a GP since 1995.

 

Royal College of General Practitioners Yorkshire Faculty Representative to West Yorkshire and Harrogate Integrated Care System

Honorary Secretary, Royal College of General Practitioners Yorkshire Faculty Advisor, Clinical Advisor, Local Care Direct, West Yorkshire

GP Specialist Advisor, Care Quality Commission

GMC Expert Witness

Sessional GP, Halifax, West Yorkshire

Author of:-

The New GP’s Handbook (Radcliffe 2012)

How to Get Through Revalidation (Radcliffe 2013)

Putting Patients Last (Civitas 2009)

 

 

 

Introduction

 

Hutber’s law states that  "improvement means deterioration.” Nowhere is this more true than in UK Primary Care and General Practice over the last 30 years, and accelerating since the new GMS2 contract in 2004. John Glasspool and I predicted that the new GP contract would lead to poor outcomes for GPs and patients and we were right. (1)

The GMS2 contract betrayed the best features of UK general practice and replaced them with a morass of process measures that supposedly measured quality of care. How wrong this was can now be appreciated.

 

We lost sight of what makes primary care so valuable.

We lost sight of the fact that primary care is about relationships and long term care and not about isolated transactions and acute episodic care.

We have lost sight of the fact that relationships are a health intervention and an effective therapeutic agent in their own right and just as much as any drug or surgery is.

Relationships are personal and involve commitment on both sides. There is a cost to maintaining and developing them. The NHS in its early years supported them as did the profession and the patients.

Since the GMS2 contract the NHS has not supported them and has focused on acute reactive care delivered in transactions.

We lost sight of the fact that primary care needs to be about care throughout the 24 hours of the day, 7 days a week, 365 days a year. The division of general practice into “in hours” and “out of hours” is merely organisational. It does not reflect the evolution of disease nor the patient’s experiences of life, symptoms or respond well to their clinical needs.

 

There is abundant evidence that relationship based care between patients and a general practitioner reduces mortality (by about 30% (2-3), morbidity, and leads to more focused more use of scarce and expensive secondary care resources such as referrals and admissions. It is associated with greater patient and professional satisfaction at lower cost to the NHS system and the exchequer. (2-13)

 

We do not have a rich narrative about how relationship based care achieves good outcomes over timeframes measured across many years for patients. We have far more evidence about how best to treat isolated medical crises such as heart attacks which are definite events, with clear outcomes, which are obvious within a short time frame (minutes, hours, days)

 

Evidence based medicine is very good but has a bias towards acute definable events treated in hospital settings and has a blind spot about what works well over long periods of time. We can see a patient with a heart attack get treated and admire the technical skill that is needed for this. We dont see the skill and effort that goes into the support and rehabilitation, the return to work, the recovery from post event depression, that is provided over long time frames with less definite interventions and outcomes. There is a skill in it but it is a skill in interacting, persuading, encouraging and relating to patients, and nudging them towards better health over time. It is not necessarily about which drug or other specific intervention you prescribe. We are good at counting events, but not at appreciating processes. Processes are harder to describe and define. They are slower to show outcomes, and long term observational studies are hard to sustain and fund. Medical research funding shies away from such enterprises wanting a return on investment in under two years. Primary care relationships are barely started in such time frames.

 

This makes it hard for policy makers to see the benefit of supporting long term continuous relationships and as general practitioners we have not fully explained this point well to ourselves, patients, our secondary care colleagues and to managers and politicians. This is a failure of our speciality to justify a key part of our practice.

 

Hence, despite the evidence of the benefits of relationship based care the UK Government of whatever political colour, has pursued policies toward the NHS that have valued quantity of care and speed of care far more than the quality of care and the relationships that support care. This has led to the emergence of an overemphasis on A+E waiting times, use of 111, use of walk in centres and now urgent treatment centres. (UTC). In general practice it has led to a prioritising of same day urgent appointmentsand so to the system artefact of the rush for appointments at GP surgeries on the phone at 0800 each morning.

 

In short the government has interfered with with what was right about general practice and failed to fix what was wrong with general practice. (11) The net outcome of all this has been to put patients last. (14)

 

 

 

The Problem of Acute Reactive Medicine

 

Why did this happen?

 

It happened because for too long medicine has been dominated by the paradigm of acute reactive medicine which emphasises symptom recognition, diagnosis, treatment and hopefully cure. It sees each presentation to the NHS systems as essentially an isolated event and not part of a sequence over time. The skill of medicine is seen as residing in responding to these acute events and not in recognising the long term behaviours and patterns through time that underly them.

 

When it comes to treating acute events such as heart attacks and strokes this kind of approach works well. Speed is of the essence, and having a responsive system is more important than having a relationship with an individual caregiver. The paramedics are much better than your GP in such scenarios.

 

However it has a significant weakness as well. The tendency to see events in isolation means that patterns of attendance and trends over time are missed. So we treat one overdose and do a suicide risk assessment, but we don’t get the support and follow up into place to get the patient back to a more resourceful and flourishing place. So a few weeks later they take another overdose and another ambulance is called. The ambulance service wonder why they are so busy but we have set up a system that will inevitably generate rework and repeat business for itself because it overvalues “great saves” and fails to put in the long term support and follow up after acute events. Patients discharged from neurosurgery often find this. The head injury is reasonably treated at the time. The follow up to get back to normal function is patchy and poorly co-ordinated. They end up depressed, with chronic headaches, and often not back in work.

 

In terms of this the NHS is like the classic poorly controlled asthma patient. Such patients inhale frequently on their blue (reliever) inhaler and overuse it. They like the immediate effect it has and the relief they feel. They ignore the longer term underlying processes that are leaving them wheezy and breathless so often. They don’t take their brown (steroid, preventer inhaler). They just go back for ever more puffs on their blue inhaler. Eventually the asthma gets too bad and they end up needing a course of oral steroids or an admission to hospital. They end up with multiple acute episodes of care but won’t take the necessary long term management they need that would stop them getting so many acute episodes of problems.

 

The NHS is very like this, good at acute urgent reactions and less good at getting the long term support and rehabilitation into place that would allow them to get back to their normal life, normal work and normal function. The NHS is like a wheezy asthmatic patient looking for immediate relief but not willing to think about long term solutions. It counts “episodes of asthma care” rather than measuring effectiveness of asthma management over time.

 

In all this perhaps the most egregious example is of frail elderly people who cope reasonably at home but when their carer isn’t available they struggle and end up being admitted to hospital. The long term work of the carer keeps them at home. The absence of the carer creates a crisis that leads to what is probably an avoidable admission.

 

Acute reactive medicine is a great approach to certain issues in medicine such as heart attacks and strokes. As a general rule in medicine the speed of onset of an event is the speed with which it needs to be responded to.

 

But nearly all so called acute events have long term antecedents that could have been recognised before the problem became acute.

 

And the focus on the acute event takes away from looking at the patient, their context, their overall patterns of service use, and helping them to adapt these so that they are healthier in the future and also so they need the services less whilst living a more successful life.

 

General Practice and Primary care are the venue in which the longer term issues and management can be considered, explained, encouraged and supported. General practice needs to be the place from which the acute event can be put into context and avoided in the future.

 

General practice with its long term relationship based focus is a necessary and complementary balance to the expertise of hospitals at acute reactive medicine. It is still medicine, but it is done with a focus on long term learning, adaptation, recovery and rehabilitation as a support for the patient. It is about patients and their life context, and their function within this, not the fact that they have had a heart attack.

 

We need to regain a sense of the balance between the skills and strengths of acute reactive medicine in hospitals and the complementary strengths of GPs at managing patients in their home and life contexts and helping them to do well within those. Iona Heath described this balance superbly in her piece “Divided we fail.” (15)

 

We also need to rebalance our perception of value between “top expert specialists” and “just a GP.” We are all members of one profession and all of us want to help to patients to do better. We all manage different parts of the patient’s journey at different times and we are all different whilst being equally skilled and equally experienced and equally valuable.

 

The GP Out of Hours period.

 

We have lost sight of the fact that primary care needs to be about care throughout the 24 hours of the day, 7 days a week, 365 days a year.

We destroyed the local GP out of hours (OOH) co-operatives which were working well and allowed most GPs to manage doing some OOH work.  We replaced the GP co-operatives with large regional companies that have struggled to recruit and retain staff and deliver a timely service to patients. To illustrate this from my own direct experience when I started as a GP in 1995 it was considered impolite to take more than one hour from the time you were called by a patient to the time the patient had been seen and given relevant advice. In 2021 it is unusual for any patient to receive a call back for the regional OOH service within one hour. Many patients are waiting between one and twelve hours to receive even a telephone call.

 

In the OOH setting the progress clearly has been a deterioration in the level of service and relationship quality experienced by patients.

 

 

To answer the committee’s specific questions:-

 

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

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

Very little indeed.

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

They get frustrated. Some do go elsewhere and end up in A+E or in UTC or OOH settings.

 

        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?

It is a major role and one that needs to be revalued, redescribed and reinvigorated

 

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

 

Surface issues

Lack of staff, lack of integration with the rest of the NHS, lack of integration with local authority services including social care, safeguarding, schools. Inadequate IT.

Retention of experienced senior doctors is a key difficulty. Tax thresholds and lifetime pension allowances mean that for most GPs there is little financial incentive to work much over 55. Unlike previous generations of GPs we don’t love our work to such an extent that we don’t want to stop. Complaints risk, and a fear that complaints will not be handled fairly, is a key negative motivator for GPs. Also negative media coverage- every time the media criticise “lazy GPs” for lack of appointments ever more GPs think, “What’s the point?” and leave, so making the problem worse.

 

Deep issues

General Practice is currently experiencing a crisis of purpose. It doesn’t actually know what it is good at doing, what it should be doing and how it belongs to and relates to the patients and the wider health and social care ecosystem.

 

 

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

It is not regional variation. It is types of area variations that matter. e.g rural areas versus towns. Also we need niche general practices e.g homeless patients, asylum seekers, special allocation services, drug misuse services. The particular challenges of providing care in areas of deprivation needs specific recognition. Multi-ethnic communities and frequent use of translation services make a challenging job even harder and slower.

 

        What part should general practice play in the prevention agenda?

Potentially most hospital admissions are avoidable with better patient management and primary prevention.

 

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

Get rid of multiple IT systems. Have interoperability. Have one Caldicot guardian and Information Governance structure for the whole of health and social care.  Allow people to talk with each other rather than fill out ever longer and repetitive referral forms.

 

        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?

If I was a young doctor starting out in the speciality I would not see a partnership as being a viable business for the long term. I do not believe the independent contractor model is sustainable. I see no sign that the NHS wants to continue supporting independent contractors in general practice, opticians, pharmacies, dentistry. Poor contracts, perverse incentives, and squeezed margins do not enable good professional practice.

 

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

 

No they fail to provide any support for this. They do not appear to value this.

 

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

 

This may be a good and viable model for the future provision of services. We should in future think about how we organise primary care in an area, with general practice as part of this but with all the other parts of primary care as well. The Americans describe this a “Primary Care Home” (13) and there’s much to be said for such a concept. The focus needs to be on developing the team around the patient, not on general practice itself.

 

        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?

 

This is underdeveloped within primary care. The old model of the “primary health care team” was good one with co-location of many local services. The last twenty years have seen district nurses, health visitors and community midwives move away from general practitioners to other venues and we have moved from talking with each other to sending messages and tasks to each other. Again progress has meant deterioration.

 

Conclusion and Recommendations

 

  1. General Practice in the UK is in a poor state at present
  2. Flogging the existing staff and assets, trying to invent a faster, longer lasting and more productive horse will not work, and will likely make things worse.
  3. The potential of general practice is not appreciated by GPs, the NHS, the patients.
  4. General practice needs to be reinvigorated with a renewed sense of its purpose, mission and relationships.
  5. General Practice needs to be appreciated as an equal speciality within medicine
  6. General Practice needs to have a training equal in length to that of each hospital medical speciality. It is not easier than hospital specialities, and in fact is often harder than hospital specialisation.
  7. The relationship between primary care and secondary care services needs to be improved in terms of much deeper mutual understanding and appreciation of each other’s roles and strengths. Divided we fail as Iona Heath describes (16)
  8. The focus needs to be on developing primary care as a network of local services in each area.
  9. Primary care is much more than general practice, and future work should develop primary care.
  10. Primary care needs to focus on providing first contact advice, continuity through time and record, co-ordination of care, comprehensiveness of care.
  11. Primary care needs to see it role in terms of supporting people to live well in their communities through the combined work of many professionals working as teams around patients.
  12. Primary care goes much further than general practice and should include pharmacy, practice and district nursing, health visiting, community midwife, mental health work, much social care, care homes and their staff, hospice teams, opticians, dentists, rehabilitation services, most rheumatology, most physiotherapy, most dermatology, most geriatric medicine, most paediatric medicine, most of the follow up medicine done in secondary care at present.
  13. Many of these services do not see themselves as part of primary care at present.
  14. A+E departments, Ambulance, UTC, 111 services need to be integrated and in easy and frequent communication with primary care, not standing apart from it.
  15. There is a huge organisational development need to get the team in primary care re-established and working well around each patient.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

  1. Davies, P. and Glasspool, J. (2003) Patients and the New Contract British Medical Journal  May 24;326(7399):1099  DOI: 10.1136/bmj.326.7399.1099
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  2. Baker R, Freeman GK, Haggerty JL, Bankart MJ, Nockels KH. Primary medical care continuity and patient mortality: a systematic review. Br J Gen Pract 2020. https://bjgp.org/content/early/2020/08/10/bjgp20X712289.
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  7. Hoertel N, Limosin F, Leleu H. Poor longitudinal continuity of care is associated with an increased mortality rate among patients with mental disorders: results from the French National Health Insurance Reimbursement Database. European psychiatry. 2014 Aug;29(6):358-64.
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  10. De Maeseneer J, Hjortdahl P, Starfield B. Fix what's wrong, not what's right, with general practice in Britain. BMJ. 2000 Jun 17;320(7250):1616-7. doi: 10.1136/bmj.320.7250.1616. PMID: 10856043; PMCID: PMC1127406.
  11. WHO (2008) Primary health Care: Now More Than Ever WHO Geneva
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Dec 2021