Written evidence submitted by Dr Laura Edwards (FGP0352)

 

I am Dr Laura Edwards, a GP and also work as a Medical Director of an LMC. I am answering this as an individual and not representing either employer in this response.

 

 

If they can’t access using their preferred method they try one of the other multiple methods or they try other parts of our confused NHS system – 111, walk in centres, urgent treatment centres or Emergency Departments. Although the cost to the system is vastly different from using these other options there are no disincentives for patients using other access points even if it is inappropriate for their clinical need.

Expectations are also high. We see 40% of patients on the day they ask to be seen. This is very good despite dire circumstances we face. And yet patients think this isn’t good. They can sometimes become very frustrated and angry. They don’t seem to realise the system is broken. They are paying a ‘Wowcher price’ for a five star hotel and then complaining it isn’t the penthouse. Again there needs to be a reset of actually what the NHS can realistically provide. That anger spills onto our receptionists, our nurses, the GPs. It makes our consultations harder and less satisfying. National communications around this needs to be done. Making patients angry through government stoked false expectations is not fair on anyone.

Nothing. This is a technical fallacy. Continuity is cost saving, safer and the bedrock of quality, satisfying care for patients and clinicians. However the lack of workforce means that this is no longer possible for everyone in a long term way. GPs love continuity. GPs love seeing and caring for their patients. We absolutely try to pick out and provide continuity for those who need it. For the vast majority the best we can aim for is continuity for an episode of care. Placing a tick box exercise like the ‘named GP’ for everyone when it isn’t actually possible is farcical. It also flies in the face of the drive to multidisciplinary care. If that is the direction we want to go then these professionals need to be accountable too and the system needs to let them take that accountability.

Again if we move to very large organisations then we may well lose this ability to give continuity. With complex patients this means every consultation takes longer and you are likely to practice defensively. I once sat in with a colleague. We saw a patient he knew well. They started off the consultation saying they had come for a medication review but did just want to mention their chest pain. They rubbed the left side of their chest. I instantly thought – oh they will need a referral, perhaps even an ambulance and went into cardiac emergency mode. My colleague however calmly said – this is the same chest pain that you have had for 5 years, that we have sent you to cardiology and respiratory and gastroenterology and that you have had numerous and extensive investigations for and everything was normal and you are ok – that chest pain. Yes they replied. That took him 30 seconds. If that patient had seen me it would have taken me 30 minutes to take her history and then look through all the notes and letters and I may well have called an ambulance because I may have felt compelled to make a decision faster than that. This would have been a poor outcome for the patient (lost time, investgiations, pain, worry) and for the NHS (cost, time, other patients having to wait). There was no recognition for him of that cost saving, that amazing recollection of her history and of his risk taking (because there is a tiny chance he might be wrong (he wasn’t). I saw it. I recognised it as one professional watching another and was deeply impressed. That patient was safe and cared for by an excellent doctor. But like watching a skilled pilot – you just can’t tell how difficult it is until you have a go yourself or watch someone unskilled do it. We really need to value GPs and their AMAZING skill set more.

We need secondary clinicians and managers to understand primary care. I think funded days (with funding for both sides) experiencing primary care would be good. The funding needs to be generous at the present time as having someone for the day when you are overwhelmed is a big ask.

 

Lack of GP workforce.

Public perception and understanding of what General Practice does. Expectations of the public and politicians.

Media and the effect on morale – GP bashing seems to have become a national past time – one of my family said to me recently ‘ In my day GPs were respected’ – after all I have sacrificed to be where I am and give everything to patients that I do - that really hurt.

The demand of patients – both true clinical need of our aging and increasingly complex population – a patient with a headache who has a past history of cancer is a completely different risk category to a patient with no history of cancer. With increasing survival rates we see more of the first patient but with no extra time to really carefully assess them. So whilst we are doing wonderful cutting edge things in secondary care the government through the meagre GP contract are not allocating the correct resources and time to the basic care processes. We are rushing them or missing them as we simply do not have the time or workforce to dedicate to them.

There are also rising needs due to an increasingly fragmented and stressed society – some are real, some are due to misplaced rising expectations of what medicine will achieve when it is due to societal ills – loneliness, poor housing, drinking etc

We expect General Practice to be all things to all people. We have a dwindling workforce. We cannot do it.

We are used to doing everything but perhaps the time has come, like other countries, to take patient sections of our work out eg paediatrics, care home residents, the most frail patients, mental health, women’s health and give them a separately funded dedicated service. We also perhaps need to consider whether General Practice can really cover both urgent care/ emergencies and chronic ongoing care. Perhaps these need to be split as well. It is not ideal for doctors or patients but perhaps it is the only thing to be done in this state of emergency we now face. We actually are deeply struggling to provide both at the moment.

 

What part should general practice play in the prevention agenda?

It could play a lot. Not as much as councils can with housing, social fabric, town design, movement. If this is to be done it may need to be separate from General Practice or simply funded better. At the moment everything is piled in to already overcrowded 10 minute consultations.

GPs are hugely affected by what is in the media. Myself and many of my colleagues have stories of patients sat in our consultation room having a face to face consultation with us and asking when we are going to start seeing patients face to face again. This is the influence of the media. It is making our patients more confrontational. It is making them angry. It is not helping us to have kind, thoughtful, safe consultations with our patients. GPs tell me they are tired before they go into work because they have been told that despite working a 14 hour day with no breaks they are lazy. There absolutely needs to be an end to the culture of blame than emanates from the centre. It is toxic and self defeating. Instead the media needs to celebrate the amazing service our GPs provide – before they are all gone…

At the end of every media story of something being ‘missed’ we are usually told that GPs need more education. We are expected by the NHS, our professional regulators and the public to know about every disease and every drug – and yet we get the least amount of study leave ie time to learn than any other doctor in the NHS. How can that be? We need protected learning time to keep up to date, reflect, learn and explore what we need to know from our patients and learn with colleagues. Again ultimately patients lose out because we don’t do this and GPs burn out.

We really need other parts of the health system to play their part. Currently inefficiencies in hospitals and the community services spill over into primary care and processes to progress technological development eg electronic prescribing, access to General Practice records seem very slow.
I think that GP records should be opened up to the NHS family. It would largely be done on consent but it would make a huge difference if hospital clinicians would prescribe the drugs they recommend rather than writing a letter or sending a discharge summary with a plan that has to be typed into our system. The duplication is so wasteful. We need to say that other parts of the establishment eg education, the DVLA, the DWP need to go elsewhere for medical support and not send requests to primary care for help.

We need to think about whether the current contract is fit for purpose. Again we have proved time and again we can do anything but we can’t do everything. The current contract includes no safety limits on workload or demand. This is dangerous for clinicians and dangerous for patients. We tightly regulate air traffic control who also make life and death decisions for hundreds of people per day. But those who do it in health care – no limit no regulation and then we blame them when they make a mistake. It is an impossible pressure cooker. We need to find a system that keeps doctors and patients safe, that rewards continuity and personalised care rather than simply volume; a system that gives both doctors and patients time to be heard and time to care and make complex decisions carefully but that does not drown them in bureaucracy or invoicing.

I think we should take fit notes out of General Practice. Due to the importance of the long term relationship with the practice then I do not think we are objective about sickness and certification. The system wants us to be gatekeepers but realistically we are conflicted and it is not therefore effective. It creates huge work that could easily be done by someone else. I think non doctors should be able to do this work. If employers really want a medical opinion then they should approach occupational health. There is still great confusion over the use of General Practice for this and this needs to be addressed. Significant time and appointments are wasted in General Practice by patients approaching us for help with employment matters – often sent by their employers so they get caught in the middle. Again once the appointment is made and the request uncovered then the appointment slot has been wasted.

We need to get patients to understand that they need to share the reason for their appointment before they attend. We do not have a workforce large enough that they can pick and choose which professional they want to see. We are in a depleted system where choice has to be based on clinical need not patient desire. Politicians need to be mindful of this and honest with the public. Then the NHS nationally needs to support General Practice in saying that.

 

I think we lose the partnership model at our peril. We have witnessed the amazing fleet footedness of the GP partnership model with our vaccination programme where the vast hospital network and mass vaccination centres have barely scratched the surface in numbers. We need to make the whole career of General Practice more attractive. Both salaried roles and partnership.

We need to place safety limits on the work that can be safely done both for clinicians and for patients

No. I don’t think they do. They could do but the current resource attached to the current demands and requirements do not match at all. All the planning resources I have seen around personalised care have utterly underestimated the resource required to undertake it for example the RCGP kit suggests it is cost and time neutral but misses out the costs and time of the most expensive part – the multidisciplinary team meeting where the case is discussed.  We need to have some serious conversations around whether we have the realistic prospect of doing personalised care with the workforce that we have. I don’t think we currently do.

No. There are some wonderful professionals coming in as part of this initiative. However feedback from practices is that they are nowhere near as efficient as GPs. They are very selective over which patients and conditions they can see and cannot deal with mixed complexity eg a fungal nail infection and a sore knee – this would be dealt with easily by a GP but no allied health care professional would deal with both in a single (even though it would be longer!) consultation – they would need to refer… to a GP. From a cost perspective they are not cost efficient. The workload expected from them in primary care is vastly higher than they are used to elsewhere. The complexity is also higher. They are not trained for this and require significant supervision and input to make them safe with patients and feel safe themselves with the large clinical risk that is expected when you work in primary care.

I don’t think this has really taken off at all. General Practice is overwhelmed and unable to commit time to developing partnerships. Other parts of the NHS don’t really understand what we do and cannot offer support in a meaningful way a) because of the lack of understanding b) regulation of professionals eg the Performer List and c) because they are already overwhelmed with demand themselves.

Dec 2021