Written evidence submitted by Dr Karim Adab and Dr Vish Mehra (FGP0353)

What are the main barriers to accessing General Practice and how can these be tackled?

The main barriers to accessing General Practice is a lack of capacity. Currently, demand is substantially exceeding supply for a number of reasons.

Demand

There has been a substantial shift of workload from secondary care into primary care. There are a number of factors behind this:

• Commissioning decisions to change referral pathways ensuring more work is done in primary care
• Change to hospital outpatients meaning that patients are seen remotely, and therefore examinations and investigations are being requested from General Practice
• Delays in elective care meaning that patients are re-presenting to General Practice whilst awaiting outpatient appointments or definitive management.

The effects of Covid have also placed increased demands on General Practice. This is both the acute effects of Covid (most patients with Covid do not attend hospital and are managed in the community), as well as the long-term effects of Covid including post-Covid syndrome for which patients need regular review.

Over the last couple of years, the news and public discourse has been mainly dominated by Covid. There has been a substantial change in a lot of people’s way of life including their jobs and their ability to socialise. This has meant that there has been a large increase in health anxiety, along with mental health problems brought on by these changes.  Much of this lower and moderate level mental illness health has been managed by General Practice 

The shift to online services and improved access that this has facilitated has been a double-edged sword. Although this has benefited younger, digitally-enabled patients, it has also disincentivised the necessary pursuit of self-care in managing minor illness. This ‘third way’ of access is welcome, but requires an increase in clinical capacity to maintain

Supply

Even prior to Covid, it was recognised that General Practice was struggling with a lack of workforce. The lack of sufficient staff has meant that current staff are having to work longer hours and this has led to burnout and staff leaving (including retiring early), thereby exacerbating the problem. 

There have been substantial constraints to increasing staff numbers.  As well as the lack of available trained staff to recruit, there has also been under investment in GP estates (meaning that there are insufficient consulting rooms) and there is also a lack of funding to pay for any available additional staff. Staff shortages have meant that locum rates have increased as practices compete to secure clinical capacity.

The vast majority of Covid vaccinations have been delivered by General Practice teams. This has included GPs in supervising and leading local vaccination sites, and practice nurses and healthcare assistants delivering the vaccines. 

To tackle the long-term issues, a reform to the contracting and funding modal to ensure that funding follows increases in workload would ensure that practices are able to increase their clinical capacity flexibly to manage increasing demand.

A substantial amount of the workload in General Practice could be safely and more efficiently be managed elsewhere.  This includes managing conditions that could be dealt with by self-care or by community pharmacy. Also, workload that comes out of hospital without adding clinical value (such as sickness certification, prescribing or arranging tests results).

In the short term, factors that would incentivise staff to stay on would include reform of pension arrangements, encouragement to work flexibly or from home, and healthier work environments.

Estate

There has been much public discourse about the important balance between face to face and remote consultation, but the limitation of General Practice estate has not featured heavily in the discussion. The welcome support of staff recruited under the Primary Care Network Additional Roles Reimbursement Scheme – and expansion of GP training places – threatens to be undermined by the reality that many practices do not have physical capacity to house new clinical staff. Flexible and remote working remain partial solutions, but are incompatible with the public and Government’s preference for increasing in-person consultation. To meet increasing demand and increasing responsibility and allow General Practice to thrive, significant investment in modern estate is essential.

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

Whilst additional funding is helpful, many elements of the plan may be counterproductive. The tone of the paper, along with the threats to “name and shame worst performing practices” will particularly have an adverse effect on practices who are already be struggling through no fault of their own, or who work in areas with a high ethnic mix, a deprived population or are located physically close to A&E departments.

The short-term funding that the plan delivers can be difficult to spend, and as practices are unable to make long term recruitment decisions based on short-term funding it is likely to be spent inefficiently.

Practices that are already well organised and have sufficient estate and availability of staff are most likely to be able to benefit from the fund, whereas practices who are already struggling with insufficient estate and staffing shortages will struggle to take advantage.

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

When patients are unable to access General Practice they are more likely to have late presentation of serious illness, a worsening of pre-existing illness and may end up attending other settings in order to seek medical help. However, we must be mindful of the stated direction of travel for General Practice and the expansion of the primary care team to include other disciplines and professions, the reality of which has perhaps not been made clear to the public, who are used to a doctor-first model of healthcare which is not compatible with nor desirable for a modern NHS. We would beseech the Inquiry to map out a careful and comprehensive public discussion in order to help the public understand how to access the right person, in the right place at the right time.

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?

General Practice teams include a range of clinical staff (GPs, nurses, pharmacists, physios, healthcare assistants, paramedics etc), and therefore the concept of having a “named GP” is becoming more challenging.

Whilst it can be helpful for some patients, and it undoubtedly increases job satisfaction for GPs, it is often difficult to deliver in practice. There are not nearly enough GPs to make this work as intended.

There is little point in having a named GP if that GP is unable to see the patient on a regular basis. Also, with sub-specialisation within practice teams the “named GP” may not always be the most appropriate patient to see the patient.

Continuity of care has been demonstrated to improve quality of care and save lives[1], and the therapeutic nature of an ongoing relationship with one doctor is essential for some people, such as those with long term conditions, mental illness or frailty syndromes[2]. However, equally, access to healthcare is as important to others. Addressing this balance will be the challenge for primary care over the next decade, along with helping the shift in public understanding from the current doctor-first model of primary care, to something more along the lines of the Consultant hospital firm, whereby a senior General Practitioner has oversight of a primary care team, to ensure that medical time is reserved for medically complex problems.

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

• Workload
• Shift of work from secondary to primary care
• Lack of sufficient General Practice estate
• Insufficient staffing (likely to worsen when considering the demographic of the current workforce)
• Insufficient funding

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

Inner city areas in particular have a rapidly increasing population which is putting pressure on existing primary care capacity. Poor housing and deprivation, along with poor air quality mean that this population is more likely to be unwell and suffer from chronic illness, and therefore needs more care. This is well recognised, but not sufficiently reflected in current weighted funding formulas.

What part should general practice play in the prevention agenda?

Prevention is fundamentally important to both the health of the population and the efficient running of the health service (it is cheaper to prevent illness than treat it).  It should therefore be everyone's responsibility.

Primary care is in position to coordinate some elements of the prevention agenda, however it needs the capacity to do this. Within the NHS, urgent care is often prioritised over preventative care. Therefore, when funding is pressured, preventative services tend to be decommissioned first.

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

• Substantial change in CQC including requirements, method of inspection and rating systems.
• Permanent change to appraisal to make it lighter, including reviewing patient and colleague feedback requirements.
• Increasing the overall number of staff.
• Significant investment in General Practice estate.
• Simplification of contracting, particularly for Local Enhanced Services.
• Reform to PCSE, particularly around the management of pensions and practice claims.
• Change to performance list regulations to get rid of the duplication that it offers with GMC registration requirements.
• Change to the way that forms and reports are requested and required from General Practice, including making it simpler for patients to provide electronic access to their records to third parties that may need this.
• Changes to the rules around Fitness for Work certification
• Change in the rules around Subject Access Requests including managing the workload required for the redaction of third party information.

How can the current model of general practice be improved to make it more sustainable in the long term?

Reform of the current GMS contract is probably the most important element. Currently, it is not satisfactory for either commissioning bodies or for General Practice.

There is a lack of clarity in what is “core” work for General Practice, and there are no levers to ensure that funding supports increases in workload.  The block contract based approach produces perverse incentives, and additional contracting (including LESs and DESs) create a substantial degree of complexity for both practices and commissioners.  This method of contracting is not used anywhere else in the world.

Instead, a model that retains the registered list but allocates funding based on the type, duration and number of patient contacts would better track workload, promote investment in services and allow commissioners to do away with complex bureaucracy. 

Is the traditional partnership model in general practice sustainable given recruitment challenges, the prioritisation of integrated care and the shift towards salaried GP posts?

The partnership model provides many advantages, including ensuring clinical leadership is embedded within practices, it enables accountability and drives high levels of efficiency. Most crucially, it encourages innovation and agility and creativity in terms of its structure and design[3]. The response of General Practice to the COVID-19 pandemic, in wholesale shift to remote-first consultation, and then migration to a blended model, and its central role in the vaccination and now emergency booster mission, is entirely predicated on the design of the Partnership model which promotes rapid, local decision making centred around the needs of its population.

It does need support, with improved management training (for both partners and practice managers) and there needs to be sufficient reliable investment to allow staff to be recruited without risk, and high quality services to be delivered.

Evidence from other parts of the UK suggests that moving from a partnership model to a salaried model run by local health boards reduces both efficiency and the quality of care.[4] 

We would urge the Inquiry to review the recommendations of the independent report[5] commissioned by the Chair of the Inquiry in 2019. Although many have been implemented, to some extent, more work needs to be done to mitigate the individual liability of GP Partners, review pension arrangements, and review primary care premises, which are currently one of the biggest barriers to using the full scope of the primary care team.

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

The current contracting model creates perverse incentives. From a financial perspective, a block contract rewards practices who have minimal staffing and minimal contact with their patients. Although financial security is essential to ensure medium and long term planning, 

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

Primary care networks have provided support to practices and have allowed “at-scale” primary care. They have also enabled the recruitment of new staff and have provided a platform to allow General Practice to interface with the rest of the system. They have made little change to the GP administrative burden, there has been a slight reduction of some types of meetings with an increase in others. There is opportunity to work cross-system with other organisations, but greater investment in PCN leadership structures will be required to realise this.

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?

The expansion of the General Practice team using the ARRS scheme has brought GP into closer contact with the wider primary care team, developing relationships and trust. As these relationships develop it is conceivable that some of the clinical roles may enable better delegation of time to free up scarce medical resource, but it is a project in its infancy. Certainly the integration of pharmacy and pharmacy technician colleagues into GP has led to efficiencies and quality improvement in medicines management, and enabled the further development of relationships between GP and community pharmacy, now that the discipline straddles the divide.

The Community Pharmacy Consultation Scheme has only just started. It has allowed some direction of workload into community pharmacy, but it is probably too early to consider the outcomes of this scheme. Local urgent eye services run by community opticians have also had an effect, however relatively few patients present to general Practice with eye problems. In a truly integrated system, community partners will take responsibility for the patient in front of them; the reality of the situation is that currently many are not equipped to do so and in turn refer readily back to General Practice.

Dec 2021