Written evidence submitted by Mark Butterflied (FGP0336)

 

This is my submission and is based on evidence from my personal experiences of the General Practice model over 50 years, including in later years the care requirements of my parents – for ease, it follows the precise guidance outlined under the Terms of Reference :

GP’s have developed a resistance to face-to-face appointments following COVID claiming they are over-worked whilst conversely all the evidence suggests they are unwilling to let go of the areas they shouldn’t be dealing with

Their receptionists typically take a very dictatorial gate-keeper approach to appointments yet are not qualified in any medical way

This needs to be tackled as part of a fundamental overhaul of the whole model (see below) 

Any government/NHS plan risks being ineffective for as long as they keep caving in to the resistance put up by the profession. The whole GP model needs to change even more significantly than proposed, as it is no longer fit-for-purpose, and be forced through even if there’s some short-term pain

They don’t get what they are paying for - and entitled to - leading to resentment. The problem is, unlike almost any other service delivery available in the UK, they have no alternative. There are very few private GP’s and the profession has ensured that companies like Babylon were severely curtailed

The last time I had a ‘named’ GP in any practical sense was probably 30 years ago. Since then, I’ve rarely seen the same doctor twice. Of course, having a familiar GP who knows you personally would make a huge difference to the sense of continuity of care

Hopefully, a backlash from the public. It needs to be totally restructured as the model originally devised was designed for a totally different era, with very different healthcare issues than today - but has barely changed.

In fact, what has changed has been for the worse. One of the biggest deceits of the NHS is that the GP model is actually the most ‘private’ sector of the whole NHS, but, as a body, they portray themselves to the public as part of the NHS, presumably to maintain sympathy and support.

How could it ever have been allowed that GP’s were allowed to be the commissioners and also award the funds to their own (private) businesses ? It’s the equivalent of the Head of Marketing at GSK being given a £50m budget and then awarding all the spend to companies in which he has a personal interest…

This will always be difficult to address – same in schooling, social care etc. But the current model (see point above) exacerbates the problem as it creates inconsistencies in service delivery between practices and regions – especially as GP’s can cherry-pick the geographical areas where they work (you can’t knock them for this – why shouldn’t they, like others, have the choice over where they work)

Again, this will always be a challenge because the public have over many years been given the option to take a tablet and carry on their existing unhealthy lifestyle rather than make the changes to their lifestyle they need to. Current GPs can’t be blamed for this as it has evolved over decades and been encouraged by Pharma, but they do still tend to perpetuate it.

Part of the reason for this is that they are remunerated on the wrong basis. They are still paid bonuses for ‘cure’ elements of healthcare in preference to ‘prevention’.

I struggle to understand why many of these ‘achievement of target’ bonuses, which go towards significantly enhancing their income, are paid at all as many have the bar set so low, one would think that any self-respecting GP would (and would want to) surpass them in the course of simply doing their job

I’m sure in any public sector area, there is always huge potential to reduce unnecessary paperwork. However, I struggle to relate to these references in the press I keep hearing to burn-out and low morale – based on the GP’s I know, few seem to display these signs, and most don’t work full-time (that is, in the sense that most people work full-time i.e. 5 full days per week) – perhaps they find it more lucrative to work as locums for the other sessions ? 

It needs to be totally re-invented for the 21st century with fewer but larger practices all equipped with the latest equipment and a range of medical staff beyond just doctors – pharmacists, physios, mental health professionals etc. And to cater for those who would struggle to access these facilities, have a legal requirement for home visits.

Between the ages of 85 and 95, my parents received ONE home visit and only because my mother was so critically ill an ambulance was required). When she was admitted to a care home, she was prescribed a Fentanyl patch on release from hospital as she had been diagnosed with late colon cancer and given three weeks to live. This turned out to be a wrong diagnosis and was nothing more than a blockage. She lived in the care home for a further six years but it took me at least two years to get a doctor to finally do a medication review and be persuaded (after my own intervention) to stop the Fentanyl patch on the basis that it had been prescribed for a condition she never had, but was now causing her to suffer repeated falls.

In my experience (both my parents and myself), medication reviews are simply tick-box exercises which do not have the time and attention spent on them that they deserve (but still earn points/bonuses). These should have to be done by pharmacists who know far more about drugs than a GP ever will.

Hopefully NOT because the traditional partnership model is an anachronism in 2021. It is currently a mish-mash between a public and private model whereby the GP’s cherry-pick the optimum benefits from both to the very clear detriment to the patients whom they serve.

There should be a shift to salaried posts because for as long as the NHS is a public body, so should the GP model be – otherwise there will always be a conflict of interests, usually falling in favour of the GPs because, in the BMA, they have a very effective union and an extremely powerful voice which successive governments seem loathe to challenge.

One of my biggest issues with the current model is the actual attitude of GPs as a body. They constantly complain of being overworked with too many patients to see but absolutely insist on holding onto everything. They do not need to see someone with a cold or an ingrowing toenail so why does every first appointment have to be with a GP thus limiting those with the real need to a 5 minutes timeslot ?

Someone once likened it to the senior partner of a law firm (maybe on £1m p.a.) insisting on seeing every house-sale client the firm takes on, before allocating them to a junior conveyancing assistant on possibly £30k p.a. It simply doesn’t happen because it makes NO sense. It seems to me they are reluctant to let go (especially of patient records, but actually any element they currently ‘own’), for fear of a loss of control and therefore power, whilst maintaining that the solution can only be that more GP’s are needed.

The answer to that is emphatically NO a) because the bar on many of the payment systems is set so low that any decent GP should be achieving them anyway b) many are skewed towards what suits Pharma c) by targeting certain areas, others are completely overlooked as GP’s spend their time ‘following the money’ (who wouldn’t ?) so no time is left to focus on other areas e.g. epilepsy, mental health issues

I personally haven’t seen any improvement in co-ordinated and integrated care

I am not sufficiently close to the workings of PCN’s to really comment on this point, other than to re-iterate my earlier point about the essential ‘wrongness’ of allowing the GP’s control of the budget alongside giving them the unfettered ability to award funds to providers in which they have a personal interest.

I have personally seen evidence of some of the more forward-thinking practices taking on other professionals (e.g. pharmacists and physios), but I also know for a fact that at the levels of pay I see, from job adverts, being offered says alot about the level of esteem the partners hold for these other professionals and the value they place on them.

 

In conclusion, my overall point is that the current general practice model is fundamentally broken

a)      it has changed little since it was introduced but the whole world’s health, this nation’s healthcare needs (and the NHS itself) have all changed dramatically

 

b)      tinkering with the payment structure (starting with the reforms which ended week-end working and reduced overall hours) has undisputedly changed the focus of GPs towards money first and patients second. This is a very controversial statement to make but I have very recent evidence to support it. One is a senior ranking NHS healthcare professional whose son is a GP and he is so unhappy with the work ethic and lifestyle of his son, they have had to agree never to discuss work. The other is a female doctor who resigned her partnership as she became repulsed by the fact that well over 50% of every partnership meeting was spent discussing how they could increase the partnership’s income, with ever less time allocated to the ‘open forum’ they previously had to discuss and exchange views on any particularly challenging issues with their patients.

I would like to stress at this point, I do not think GP’s, on an individual level, are doing anything wrong as such – the system has been increasingly skewed towards incentivising them with financial reward - so they can’t be blamed for ‘taking the money’ (and as much as they can) but it is pretty evident to me that the profession itself now recognise that they are doing ‘very nicely indeed’. Evidence ? The absolute scandal that GP’s have been excused the requirement to declare their earnings this year – there can be only one reason for this and that is that they’ve risen significantly and they know it would not be a ‘good look’ – and certainly wouldn’t play well in terms of the public sentiment in the context of this review.

It’s absolutely VITAL this requirement is reintroduced early next year – and, if anything, be made far more transparent. Many of us know the only reason the figure stands at just over £100k is because so many GP’s work part-time. Full-time is way in excess of this figure – and the general public have a fundamental right to know – just as with the BBC, local councils etc etc

I sincerely hope that this government finally takes this opportunity to make the far-reaching changes to the current general practice model that are so overdue and is prepared to stand up to the profession itself in forcing them through. For too long, there’s been a reluctance to force a stand-off for fear that it might have negative repercussions with the public. My experience suggests that the blind regard the public has had for so long for the GP model has been reframed in the light of their own experiences during this pandemic and now, with less respect and goodwill for the profession among the public, is the time to implement the changes necessary. There may never be a better time…

Dec 2021