Written evidence submitted by Carradale Futures (FGP0345)

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

Summary

Context

In the last three years, Carradale Futures has interviewed hundreds of GPs and practice staff and detailed modelling of the activities, costs and revenues of more than 20 practices throughout England. We are now working in partnership with practices in Cheshire and London and have plans to expand throughout the UK. 

Barrier one: failure to understand and communicate the true purpose and potential of general practice

This can be overcome by:

-          A practice-driven revolution in the way clinical decisions are triaged and dealt with

-          Two-way communication with practices and residents about what to reasonably expect from general practice in the 2020s

-          Elimination of a culture in general practice of ‘learned helplessness’ and dependency on NHS staff and investment

Barrier two: the lack of skills within general practice or the wider NHS to effect transformation

This can be overcome by:

-          Recognising that forcing/incentivising GPs into management roles they are neither trained for or suited to is the most obvious failure of the Lansley Reforms

-          Eliminating constraints on competition for patients to drive improvements in responsiveness to patients and better and more equal clinical outcomes

-          A recasting of the partnership model to enable rapid, expert-driven decision-making

-          These changes will drive the recruitment of partners with the required skills, networks and experience

Barrier three: over-reliance on large-scale partnerships and ‘super practices

These can be overcome by:

-          Creating the opportunities for smaller practices to grow and innovate (see above)

-          Reduce reliance on local NHS commissioners who tend to favour ‘at scale’ for reasons of culture and convenience

-          Transforming the regulatory system to

• Base ratings on objective data of improved care and patient and staff satisfaction
• Broaden the range of ratings to better guide consumer choice

Full submission

Barrier one: failure to understand and communicate the true purpose and potential of general practice

Most people assume that the purpose of general practice is to enable a consultation between a qualified GP and a patient to provide a diagnosis and/or treatment.

This focus on this one-to-one consultation as the ‘currency’ of primary care has diverted effort from transformational work and stimulated the creation of digital businesses (e.g. Babylon, PushDr, Livi, Lantum) that fuels the costly and de-stabilising market in locums.   

The actual value of general practice is to monitor, manage and prevent ill health in a local community thorough an increasingly sophisticated range of clinical and administrative responses. The ability to create tailored answers to a myriad of health needs is possible. But these answers are either not attempted or not communicated well by practices.

Personalised responses are undermined by a common perception that the role of general practice is to facilitate a consultation (usually 10-minutes long), with a GP. Yet the absence of proper preparation before this consultation means the interaction is unlikely to provide either a definitive diagnosis or treatment plan.

The BMA, RCGP and the government also appear enthralled to over-reliance on GPs in practice meaning a usually unhelpful 10-minute consultation. By this logic, the answer to increased demands on general practice is to train 6,000 more GPs. This ever-elusive objective more GPs without addressing the key issue of how to fit the appropriate clinical response to the health needs (not demands) of the local population. Analysis by Becky Malby at South Bank University suggests that 40 per cent of GP appointments pre-Covid were unnecessary, avoidable or could have been done by other staff. This suggests deeper analysis and reform is required than apparently arbitrary training and recruitment targets. 

Covid has created a particularly toxic mix. The NHS shift to telephone triage by GPs (often misleadingly called online or total triage) has not reduced GP time pressures and further frayed the relationship between people and their practice. It is difficult to understand why so many practices chose (with NHS England encouragement) unscheduled telephone calls from a GP as a means of triaging patients when planned call backs from nurses or video calls by GPs could provide a much better, safer, and more efficient alternative. 

The solution to unplanned clinical decision-making is to shift the first line of response away from inbound calls taken by overworked and undertrained reception staff. Practices need new triage systems deploying:

-          modern phone systems and websites;

-          best-of-breed triage engines that ensure patient queries are sifted according to clinical urgency, and;

-          processes to channel to the right answer which may involve diverting to other suppliers (e.g. mental health services), self-service (e.g. tracking of referrals) or the most appropriate individual clinician (nurse, doctor, pharmacist, paramedic), clinical team or administrative expert within the practice.  

These changes will only be effective if the right balance of staff is achieved, and they are prepared to operate as a team to determine – through a central triaging hub – how to respond to each clinical query. The great advantage of this team working approach is that it is certain to accelerate learning faster than any number of one-to-one unshared decisions. 

The focus of media attention and this inquiry relates to patient access to clinical resources. However, much of the time of clinicians has been eaten up with participation in, and oversight of, supporting administrative tasks. The benefits to patients and staff of the efficient despatch of these tasks – e.g. medication reviews, referral processes and coding – is difficult to see as a patient but hard to exaggerate. The only way we believe to manage, monitor and improve more than 100 of these tasks is to create, test and digitise standard operating processes. The monitoring of the data created by such a system would give regulators much greater comfort than asking – as they do now - to see proof of these SOPs’ existence

Barrier two: the lack of skills within general practice or the wider NHS to effect transformation

The skills to analyse data, recruit the right mix of clinical skills, implement technologies, and communicate better with patients are largely absent in practices. These skills are not part of training for GPs, nurses, or practice managers. Without their own expertise to test what is provided ‘for free’, practices have been easily persuaded that these skills exist in national and local NHS agencies. This has meant that poor and slow decisions about communication, technology, information governance and data analysis are routinely made on behalf of practices by Clinical Commissioning Groups and remote national agencies.

The introduction of new skills into primary care has been overlooked in favour of a fruitless and counter-productive search for more GPs. This obstacle has been reinforced by cumbersome partnership governance where many GPs seek to make collective decisions about areas of technology, finance, and people management that they do not have the experience or training to answer. 

Competitive pressure has driven most businesses to adopt digital-first approaches to manage customer demand and each local authority has been driven by lack of resources to put many more services online.

The government would need to encourage – rather than discourage – patients to switch practices to start to drive more expert and swifter decisions in general practices.

Barrier three: over-reliance on large-scale partnerships and ‘super practices

The partnership model has tended to inhibit reform by ensuring that changes can easily be blocked by partners who may soon retire. Our own findings suggest that – contrary to popular belief – the slow decision-making problems associated with larger ‘super’ practices can outweigh economies and stability of scale. There is little evidence, for example, that UK super practices transform the way care is provided to compare with improvements being offered by ‘clicks and bricks’ primary care providers in Sweden, the USA or the Indian sub-continent. NHS providers and commissioners tend to favour super practices. This is partly because they are used to (or prefer) dealing with larger bodies and because they are uncomfortable with the concept of competition.          

The answer is for NHS England to remove barriers to competition by loosening controls on patients’ ability to switch practices, on clinical wage rates and encourage and enable more direct investment in general practice by providing tech and other investment funds directly to practices. In particular, the direct purchase by NHS England of electronic patient record systems and online triage systems curtails innovation and creates a wholly unhelpful dependency culture.  

The regulatory regime (principally run by the Care Quality Commission) needs to completely overhaul its current reliance on checking for evidence of policies being adopted, training being carried out and on-the ground inspection by former employees of old-style practices. This style of inspection tends to put most (80%+) practices in the ‘good’ category when the definition cannot be described as data-driven or objective or stretching compared with international best practice (see above). 

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

The plan seems reliant on finding more locums paid through the existing bureaucratic system with little information about how the plan will happen.

The answer is for the government to cease announcing ‘investments’ in general practice that loses so much momentum on the way to its target as to make its impact undetectable. 

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

Patients have different preferences about how they would like to access their practice depending on the problem they wish solved. The failure to understand in detail those different preferences fatally undermines the effort to explain the purpose and limitations of general practice.

The solution is for general practice (supported rather than undermined by the government) to begin a conversation with its residents about what they can and cannot expect from general practice. 

• 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?

These are important to many people especially those with long-term conditions that only a GP can advise upon. But it is more important that continuity of care is provided than that it should come from a particular professional. For example, most GPs do not have the skills interest or appetite to assess the growing array of mental health services and tailor those services to the 30-40% of people who, according to the leading primary care provider of mental health navigation, come to a consultation with mental ill health as a primary symptom. 

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

Increasing demand due to covid, ageing population, more demanding patients, more patients with comorbidities and already widening health inequalities. These challenges have so far failed to be met by governments with sufficiently profound analysis or investment. The investments need to be made in the management, financial planning, resource planning, technology and processes that are vital for a practice to deliver care.

There is a great opportunity, partly driven by the urgency of these challenges, to personalise health by establishing a different relationship with residents and deploying technologies – from genetic sequencing to 21st century websites – to improve and equalise health outcomes. 

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

Variations in the underlying health of local populations and in the supply of staff are significant. However, our experience suggests that these factors are too often used to justify local inaction. For example, recruitment often fails not because there are no clinicians available but because recruitment is delegated to administrators and follows processes that do not sell the job. We have seen enthusiasm for the future of each practice and the future of primary care generally overcome the received wisdom that says you cannot hire GPs or nurses.   

Another smaller example is of one practice that believed that the poverty of their local population meant that they did not possess passports or driving licences needed for one of their communication apps. It turned out that the reason for the lack of ID was that patients were not given enough time on the app to get to the point where they could upload the documents. 

• What part should general practice play in the prevention agenda?

It is the only part of the existing system with any chance of rolling back the massive growth in unhealthy physical and mental health problems. One of the least successful policies has been the nationalisation of public health messages into generic, well-known but far from actionable advice. We all know that not smoking or drinking, eating five-a-day and exercising helps our health but these exhortations seem increasingly disconnected from the individual circumstances and local challenges. Banning smoking in public places, tax changes and screening programmes are examples of effective national action, but GPs are the only effective local public health agents. Only GPs are undertaking serious efforts to manage long-term conditions better and actively. However, this does not mean that UK general practice – with some of the worst cancer diagnosis, obesity, and diabetes rates amongst rich countries – could not achieve much more.   

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

Systematically eliminate all primary care ‘investment’ that does not go directly to practices and re-invest that money in rewarding improved and fairer clinical outcomes and enabling practices to buy technologies directly. Hundreds of GPs who have taken NHS jobs as clinical directors should be returned to their practices. 

• 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?

There is a widespread assumption that bigger practices are better than smaller ones. The difficulty with this assumption is that it encourages reinforcement of outdated practices by piling up the votes for the status quo.

The partnership model could be sustainable if people were able to easily move to better practices (see above). This would provide the incentive – like law firms or consultancies – for otherwise slow decisions to be speeded up. In the absence of such an incentive, practices should be encouraged or forced to replace equal weight voting to enable the concentration of decision-making in small teams.    

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

Basing payment on the number of people on a list should encourage a measured approach to the health of the whole population. This is reinforced by payments related to better management of long-term conditions. However, the payment system should encourage the savings that can be made in hospitals from better interventions in general practice to go back to general practice rather than be sucked up into NHS funds. The evidence from such contracts in Germany (Opti Medis) and in the USA (Medicare and Medicaid programmes) demonstrate that incentives to prevent a decline in ill health and independence reduce cost and improve life expectancy. 

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

It has a marginal effect so far because the funding is only released to pay for prescribed roles based at prescribed rates of pay. This has slowed the necessary introduction of a greater spread of clinical roles.  

A lack of investment in setting up functioning organisations often mean that PCN staff feel torn between practices rather than part of a coherent whole. Our experience suggests clinical directors are also often conflicted by their loyalty to their practice and the PCN.   

• 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?

Professional tribes have often found it difficult to work together because of snobbery. For example, GPs will often try and box pharmacists into simply signing repeat prescriptions rather than broadening their role to take on more clinical tasks and appropriate clinical risk. This has been exacerbated by the fact that most triaging and consultation is still carried out by one GP with one patient. Team-based working amongst clinicians through a single triaging hub (see above) would help break down some of these tribal divisions.

Dec 2021