Written evidence submitted by Dr Debbie Miles (FGP0355)

My name is Dr Debbie Miles.

I am a GP (Chair of the Executive committee at Coastal Medical Partnership in New Milton, Hampshire)

I have been working at this Practice for over 10 years, I left medical school in 2002.

Main barriers to accessing General Practice

-          Locally patients struggle to get through on the phone- despite us having used a cloud based system for years.

-          Our clinicians are providing far more advanced care than was the case even 10 years ago, in terms of chronic diseases, and conditions that would previously have been managed by Hospital specialists.

-          There has been a constant drive to transfer patients out of secondary care clinics, these patients still continue to need high levels of clinician input. The number of GPs has simply not increased enough to meet this level of need.

-          The quality of care that we provide in terms of long term condition management is being constantly driven forward, we are undertaking more monitoring of blood tests, BP, and clinical conditions to try and improve outcomes for patients with chronic diseases.

-          In addition to this our local population is one of the most elderly in the country. This age group has a higher need for urgent and on the day care due to conditions which are associated with age and frailty.

-          There has also been a drive for ‘admission avoidance’ which means caring for patients in their own homes, this again means that the medical needs of these patients must be met by GPs and primary care services.

-          As a result the current workforce is stretched, and we struggle to provide the level of easy access that we would want for our patients.

The current plans and developments do not answer the single biggest problem which is a lack of experienced clinicians who are capable of practising independently.

There are a number of impacts when patients are unable to access General Practice, however it is vital to consider that this situation has at times been manipulated by the mainstream media.

• The access that we provide to patients is through an uncapped ‘urgent care’ model, which means that if we feel a patient needs seeing urgently after telephone triage, we will bring them in to be seen, sometimes within half an hour.
• Not infrequently patients are shocked by this level of service as they have been fed a constant narrative by the media that it is impossible to get a GP appointment.
• I have been involved in caring for large numbers of patients who have not sought GP care because they have been told incorrectly by the media or social media that we are ‘too busy’. Some of these patients are people who have presented late with cancer, heart disease, or strokes. They had not tried to contact us, having assumed that we would not be able to help based on the portrayal of the NHS in the media.

CONTINUITY

• Is important, but more important for some patients than for others.
• We are trying to constantly achieve the correct balance of continuity with access, it is not possible to provide both with the current levels of staffing.

MAIN CHALLENGES IN THE NEXT 5 YEARS.

• Pandemic- this is going to be the single biggest issue, in terms of its wider impact.
• Longer Hospital waiting lists- these patients will inevitably seek support from Primary care whilst they are awaiting assessment and treatment.
• Chronic diseases-

-          Many patients diabetes control has slipped due to changes in diet and lifestyle due to lockdowns, self isolation and shielding.

-          Frailty- lockdowns have led to an acceleration in frailty as patients have lost dramatic muscle mass, mobility, balance

-          Social skills- have been enormously impacted

-          Respiratory conditions and cardiovascular disease- many patients have reduced their levels of exercise and this has had a catastrophic effect on obesity, blood pressure, and general wellbeing.

• REGIONAL VARIATION

-          We find that the needs of our population are not necessarily represented by the larger region- our local population has a high proportion of the very elderly which is completely different to the larger cities within our region.

-          There is a very high risk with the changes that our voice will not be heard and that our patients needs will not be met. We are already experiencing this now despite advocating strongly for our patients needs.

PREVENTION AGENDA

• Primary care is in a good position to be involved in the prevention agenda but it can only be one part of a larger drive which must span healthcare, education, workplaces, the media, social media etc.
• Prevention is something which is a personal responsibility, it is not something someone else can ‘do’ to you. Whilst there are medical aspects of preventative medicine, most of the most significant preventative steps are those that must be taken by individuals- healthier diet, increasing exercise, taking care of our own mental health and wellbeing.

BUREACRACY, BURNOUT AND MORALE

-          It is deeply demoralising to constantly read in the media how we are not doing enough.

-          GPs should only do what only GPs can do

-          Often bureaucracy (inter-hospital for example) can lead to us feeling like secretaries.

-          The tendency from Hospitals is now to send a letter with a list of jobs for us to undertake, this leads to an enormous amount of work, which should be undertaken by the Hospital teams. However, as Hospitals have been pushed to discharge patients from clinics- it is understandable that this happens.

-          We need to aim for a ‘safe working day’ so that clinicians are not working from home at 10pm at night having started at 8am, before starting at 8am the next day.

SUSTAINABILITY OF GENERAL PRACTICE

-          For us locally the Partnership model IS sustainable

-          However when we consider the financial risk that we carry as Partners, that can at times be an overwhelming concept.

-          Unfortunately my understanding is that many organisations staffed by ‘salaried’ clinicians are unhappy places to work, and this has a detrimental impact on patient care.

-          Our practice currently can only survive due to the level of commitment of its partners, and this would not be the case in a salaried model.

CONTRACTING AND PAYMENT MODELS

-          As partnerships, we know our employees, our nursing teams, healthcare teams and admin teams, and they know us. We are I think more proactive in terms of patient care as we feel that level of personal responsibility that you only get from being a part of a partnership. As a salaried GP it is far easier to leave an organisation, and I think the levels of continuity and retention of Doctors would be far less in a fully salaried model.

-          We try persistently to integrate with other local organisations, there is willingness at most levels but it is very difficult to translate that into action and true integration despite repeated attempts.

NETWORKS

-          Currently networks are not yet reducing the administrative burden on GPs.

-          We are in a very positive situation having employed quite a few members of staff through the network.

-          These members of staff are undoubtedly meeting previously unmet needs, but currently for a relatively small proportion of the population.

-          Our biggest success so far has been our covid vaccination programme. We are 3 practices which merged to form one partnership. Due to our size we are one clinical network.

-          As a result of this we were able to mobilise covid vaccinations and the booster programme at a far greater speed than many other organisations that we know of.

-          This could not have happened if we were not a Partnership as well as being a network, as it meant that complex areas such as financial negotiations, workforce supply, clinical responsibility and leadership happened seamlessly rather than requiring weeks or months of argument and negotiation.

WORKING IN PARTNERSHIP WITH OTHER PROFESSIONS

-          We have been working with – Occupational therapists, frailty practitioners, pharmacists, mental health practitioners, social prescribers, pharmacy technicians, physicians associate, paramedic.

-          There is no doubt that some patients are benefiting hugely from this, however it feels that they are meeting a previously unmet need rather than reducing GP workload to free up time for patient care.

Dec 2021