Written evidence submitted by Dr Mark Williams (FGP0340)

 

My name is Mark Williams.  I am a GP partner at Testvale surgery in Totton Hampshire (8 yrs).  I consider myself a grass roots GP partner as I have no additional roles within the CCG or other organisation.  I am responding to the call for evidence as I am concerned for the future of general practice and feel, rather than just complaining, I should add to the conversation and at least try.

Our current barriers to accessing General Practice seem to be sheer volume of demand / need, not just for on the day urgent care but for long term condition management and more general enquiries and demands form other agencies.   Our phone lines often have over 20 calls waiting despite 6-8 receptionists answering at peak demand times.  The pressure on reception staff is immense and they often take the flack for long waits on hold.  Then there are often no remaining appointment slots, or at least not at the desired time or with the desired practitioner. 

There is limited time and capacity for any given individual health care worker – the advent of e-consults, telephone / video consults as well as handwritten notes / emails have increased demand for practitioners time as these are still consultations and take often as much time as a face to face consult.  It is possible that a return to primarily face to face consultations would ease demand as the is at least there is some effort to be made i.e a value to “seeing the doctor”.

The challenges over the next 5 years are centred around demand on time for all practice staff.  Staff recruitment and retention are a concern for both clinical and non-clinical staff.  Burn out is a real risk for all.

From my own perspective, the advent of new initiatives such as the development of PCNs  have done little to help.  This has, of course, been affected by the pandemic.  However the demands on time and headspace to navigate the complexities of contracts, income streams, division of labour, and employment issues across sometimes disparate organisation has removed a significant amount of Doctor / partner time (2-6 sessions per week in our experience for the clinical director, not including additional time given by partners to attend board meetings.   I would propose a managing director with a clinical board would be more time and economically efficient. For clarity, I am not adverse to the idea of allied health professionals in primary care at all, but I believe you would get better value for money if practices were allowed to get on with it with fewer strings attached. 

One of the great things about having general practitioners is they will see un triaged “all comers”  without the caveats often seen with additional roles practitioners.

The current appraisal system has a similar impact on time and stress ( despite valiant attempts to relieve this by the appraisal service ) It would seem more doctor time would be freed,  money would be saved and morale boosted ( and stress reduced) If this was removed.  I could perhaps be replaced with compulsory / planned attended at annual / biannual update events.  There is, of course an important role to continue significant event reporting and complaint review.

I cannot comment on regional variation as I have limited insight to this but locally our partnership model has worked well to date.  We enjoy satisfaction ratings in the 90% range and it feels like changes or outside pressure to do things and a certain way is likely to cause these ratings to fall.  I can understand the desire to level up across the board but this feels like we are being dragged down rather than other areas being brought up.  I cannot help but feel that local practices have ended up the sizes they are through evolution and manageable numbers of partners and patients. Too many partners and agreement can be difficult.  Too few and sustainability becomes the issue.  Working across networks is a good idea, and one we had been / were exploring locally but the forced PCN model has caused greater stress and division with our current situation being no one wants the clinical director job as it is felt untenable within the funding envelope.

I strongly believe in the partnership model of general practice as I think a sense of ownership and responsibility means the day job gets done.  In our own model the managing is largely left to the manager, but with clinical oversight.  I do however understand that there are those that want a more portfolio career and we have an amazing team of salaried doctors and allied staff.  We are able to ( hopefully) create an inclusive environment where people actually want to come and work and be part of and thereby perhaps give a little more  than with a larger impersonal organisation.

I struggle to see “super practices” with large number of partners being sustainable  and indeed  the same with  fewer executive partners and dependant on salaried staff leading to deeper divisions withing the workforce.

I mentioned earlier my concern re recruitment and retention. From y own experience I have reduced from 9 clinical sessions to 8 .  My reasoning was both risk of burn out ( my standard working week excluding travel and admin at home was 60hrs) and financial.  with the current pension issues and the theat of “naming and shaming if I earned too much”, It became nonsensical to continue.  This current situation really does actively discourage full time General Practice and disincentivises increasing hrs at time of high demand and need due to the additional bureaucracy involved in making it financially worthwhile in the here and now.

From the point of view of funding practices historically I have had few complaints regarding the contract with the addition of enhanced services.  No doubt the minimum practice income guarantee provided a degree of reassurance.  It has felt locally that the PCN has been a somewhat destabilising influence with significant income streams dependent upon it.  It feels, far from increasing proactive, personalised co-ordinated and integrated care The PCN has introduced another level of bureaucracy.  The success story has been the vaccination program to date, but this is in danger of crumbling with diminishing support form tired and demoralised staff.

It can often feel like we are a dumping ground or risk sink for all other agencies, having to pick up when there are issues with social care, nursing care, mental health, midwifery, ambulance service, DVLA, universal credit, hospital results and follow-up.

So what would help?

-          Free up funding to allow practices / local networks to explore their own way towards working in a more integrated way – for example allowing monies for the employment of a managing director rather than just clinical director.

-          Allowing local innovation and funding support for models that work for a locality

-          Consideration to splitting same day urgent care from long term condition management.

-          Reduce non contracted workload form other sources – perhaps patient triggerd follow up in hospital would help rather than the seeming constant see your GP / get re referred.

-          Controversially look at the patients own responsibility for their health, much time, effort and money is spent on chasing to get QOF boxes ticked. Possibly automated call and recall systems set to a national standard. 

-          Change appraisal – saving money, freeing up GP time and boosting morale ( it’s a Win, Win, Win).

-          Encouraging, incentivising workplaces to allow people to attend appointments.

-          Single universal record so care can be delivered across sites and agencies.  This would also improve resilience should practices collapse.

-          Improve publication (easy to find and usable) of local / national guidance and pathways to improve referrals.

-          Reduce additional “get a note form your doctor” burden from councils / social services / housing / DVLA / schools / exam boards, private companies or private employers. More often than not, I suspect we are merely reiterating what an individual has said to us. Or allow a commercial rate to be charged.

-          Incentivise doing additional sessions / work by sorting out pension issues and removing arbitrary penalties be they financial or bureaucratic.

-          Controversially look at wants vs needs in health care that is free to all

 

Dec 2021