Written evidence submitted by Dr J Lees Millais (FGP0354)

 

Introduction

I have been a Portfolio GP of 40 years experience ; currently I am a Locum GP, an

Expert member of  Medical Ethics Research Committee for the Royal Free Hospital (Hampstead) , and a vice-Chair of the BSW section of the Wessex LMCs. I am speaking for myself here, as I have not had time to formally ballot my constituents or committees.

I love General Practice ; it is the best job in the world, but currently it is in great difficulty .

I have worked at surgeries in Bedfordshire,Bucks, Oxon, Berkshire and Wiltshire, so I have seen at close hand many surgeries, large and small and the different problems they face .

I am so frustrated at being unable to work to the full benefit of my patients right now.

There is  great potential for good in the new Bill; but please don’t throw out the baby with the bathwater . The baby will be very helpful to you if you look after it well.

Thank you .

 

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

It is obvious that the main problem involved in accessing general practice is the general lack of GPs, nurses and ancillary staff compared with the enormous recent increase in demand from the general population.

 

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

I’m not sure which government and NHS England plan is meant here, probably the recent plan about access ? There are just not enough staff in General Practice ,the Out Of Hours units or anywhere else . All the meat on the bone is gone .

 

3.What are the impacts when patients are unable to access general practice ..etcetera?

I do not know as we have worked full time throughout the entire pandemic and all our patients have been pleased to be able to access us in many ways. ‘Impacts’ is a word carrying many meanings so it is not particularly helpful in this context. There are undoubtedly surgeries that do not provide as good care as others. Therefore some patients may come to harm but I have no evidence of this .

 

  1. 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?

I think it is important to state that many patients do not need continuity of care particularly those who are young , relatively well and have confidence dealing with electronic communication.

However for those who are mentally unwell and for those whose history is long and complex it is very important to have continuity and to be able to recognise the GP that they know. However having a good IT system and good doctors in the whole team makes an enormous difference as any doctor is able to catch up on what is happening with to the patient at that time. However in a large practice of 10,000 patients there absolutely cannot be continuity of practitioner as so many practitioners have to work part time now due to burnout and fatigue. Having worked for many years in a single-handed practice of 2,500 patients, the difference is striking as every patient sees the doctor that they know and the doctor is able to get the information they need from their IT system.

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

 

(a) Loss of GPs and experienced nurses, occurring due to burnout, boredom and frustration. There is much optimistic expectation in government discourse about training thousands more doctors and health practitioners but there is very little discussion about retention and its causes.

(B) there seems to be a significant loss of very young GPs , abandoning this career completely. Some is due to poor selection by medical schools and some of it may be due to a perception of a better life elsewhere. This area needs research including exit polls .

 

6.How does Regional variation across England shape the challenges facing general practice in different parts of England , including rural areas? .

 

There are many reasons for large variations in the shape of practices ; one area may have more psychologists because it has a University offering this topic while another area has few community physiotherapists because the reverse is true, and trainees like to be near training  until they are confident .One area has many frail elderly, another is pulsating with mother and baby units and another has a high proportion of recently traumatised refugees.

It’s not the geography of the country ,it’s the type of people who live there and the institutions which service the area that make a difference to general practice.  Insufficient local specialities clinics (eg cardiology )for referral into make a very big difference to waiting lists. One patient travels miles to access a memory clinic, another has to wait many months to see a single rheumatologist,(who although close to that patient’s general practice) is a single operator in a population which needs four rheumatologists. Both of these problems will have long waiting lists that GPs cannot expedite or reduce the hidden extra costs  to the NHS;  for repeat prescriptions, repeat consultations, distress, and fatigue on part of both patient, family and GP.

 

 

 

7. what part should General Practice play in the prevention agenda?

Very little. I believe that this is a public education area and GPs cannot do it well without significant training and reduction of consultation time. This is better done using good PR and specialised health practitioners interested in the area.

 

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

 

The obvious inspirations of GPs are often (i) scientific and (ii) relational. Other drivers of enthusiasm include (iii)professional pride and (iv) constructive refreshment (v) national representation (vi) visible reduction in bureaucracy. Government does not seem to address these issues in its discourse about GPs, but it ignores them at its peril ; a good percentage of the 5,000 anticipated newly qualified GPs will also leave, work part tIme and look around for other occupations as they become burnt out, bored, disenchanted and dishonoured.

 

(i)We are scientists, we want to know the answers to this puzzle? What does it mean? How does it affect the person in front of me? Do I need to go and look this up and learn more about it ? Intelligent people generally enjoy and like to learn more about their subject .The excitement of a good diagnosis , using ones’ skills and knowledge is very satisfying and fun to exchange with other doctors. It takes time and effort.

 

(ii)We are relational; investing in relationships with patients and their families; working  with a patient “ what can I do for you?”, “how would you like to move move forward here”, “how are your family taking this news?”

would you like to come back with your children when you are ready?

This kindness of practice and knowledge is satisfying for both GP and patient, requiring time sometimes spent in silence with the patient, interpreting small signs and expressions of emotional significance. This above all takes time and TEN MINUTES WILL NOT DO

 

Of course there are other reasons why people become doctors but if these two central issues are not addressed , there is reduced satisfaction, the doctor becomes bored ,frustrated and seeks interest elsewhere.

 

(iii) How ridiculous that GPs employ consultant nurses and consultant physiotherapists while not being called consultants ourselves. As occurs in hospitals, after 10 or 15 years’ service , we should be offered the title of Consultant GP after 10 or 15 years’ practice.

 

(iv) it should be easier for GPs to grow a wider professional life, e.g. become involved in research, take clinical sabbaticals every 5 to 7 years ,practice in third world countries, invent new gadgets, thereby refreshing themselves and acquiring new skills and interests to prevent becoming stale. Some of these things are already available but difficult to access in various ways.

 

(v)National representation of GPs, and morale

 

The BMA is NOT a representative body for GPs. It is a trade union for all doctors who purchase membership. The general practice committee (GPC) is the negotiating arm of the BMA. The BMA therefore functions under industrial trade union law. Many GPs are not members of the BMA, because they understand this.

The only bodies recognised in statute to represent GPs and utterly loyal to and helpful of GP’s interests are the Local Medical Committees.

These committees are locally based ,so currently they lack an English or national focus eg a National LMC to represent GPs.

 

GPs are extremely angry about being left out of the new Health and Social Care Bill 2021. General practice should be at the heart of this bill and encouraging involvement of the LMCs in this new bill could raise GP morale considerably.

 

(vii) bureaucracy? The wasted forms

Doctors are some of the most intelligent people in the NHS ; yet they are given almost insultingly poor algorithms for patient care, and asked to fill out incompetent forms that we cannot honestly answer (eg gun licenses ,DVLA forms, disability benefits etc)– after all, I don’t really know how he drives or whether she takes medication properly. But GPs go on filling these forms out, losing time from real practice.

 

Example 1.Prior Approval (or  Soviet-style madness)

GPs fill out long forms for simple operations, eg removal of varicose veins,small facial deformities, eyelid corrections (enabling old people to see clearly, carpal tunnel release) and many more, but these requests are routinely turned down as too expensive. So GPs fill out more and more of these forms ; by the third approach, the permission is granted. This charade uses up at least 4 patient consultations, many telephone calls and begging letters for expedition, all of which must be organised ,replied to and filed.

It’s certainly proactive, personalised and exhausting. How much did this process really cost compared to the cost of the small intervention?

 

 

If these unnecessary activities were removed from practice (and institutions organised their own doctors to check the information remotely,) this would free up about 8% of our workload immediately.

 

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

 

(i)A massive increase not only in doctors and nurses but in allied professions to integrate with, refer to, and to share care as appropriate

 

(ii) substantial reduction in unnecessary patient demand for consultation ;

 

This could be achieved pre-consultation using public education and use of more qualified nurses on 111, use of better algorithms so that triage nurses are allowed to triage appropriately directly to  community physiotherapy.

 

Every case of anxiety could be referred immediately from pre-consultation to appropriate psychological counselling and help,

Just these 2 interventions would free up about 10 % of general practice workload.

 

(iii) proper salaried posts of allied professionals-community physios, psychologists, community nurses, and support nurses, not the short- term , often model contracts currently being used. This short -termism ensures that many really good candidates do not apply for GP positions or community work - they have mortgages to pay.

 

 

 

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

 

I do believe that the partnership model is sustainable, if enough GPs are involved in integrated care  management , to help guide their practices towards useful functional integration with all services .

 

There are very few GPs or groups of GPs and managers who have acquired requisite skills or experience of handling large budgets and complexities associated with running practices of 200,000 +patients.

However, the working heart of the ICS will be far from its core activity of human health, unless steps are taken to encourage more GPs  into management and finance. There are many GPs who would like to do this, and even those who might go back into General Practice.

 

Integrated Care Systems will need GPs to be publicly involved at all levels of change , not merely to function but to lend authority and authenticity. The involvement of partnerships, practices and all types of 

GPs are imperative  for any practical integration to succeed . They are the lynchpin of change.

 

Salaried GP posts may seem like a good idea but as in section 6(iii) many GPs are rejecting poorly paid and badly drawn up, amateur model contracts.. Current GP trainees emerge after three years specialised training , like surgeons, ready to go and their wages should reflect this.

Until this occurs, many will go from being salaried to being locums. Locum work is sufficiently well-paid now to be a realistic life option for many years. Given the huge increase in demand for GP consultations it is just not physically possible to work full-time or even half time . Why undertake the hassle of partnership when you can have a good long-term career as a locum and control of your work-life balance?

Portfolio GPs are also not mentioned in the new Health and Social Care Bill- they may have medico-political interests, be educators,writers, accountants, etc, etc, but they will be unlikely to ever go back to fulltime GP work- it’s just too unpleasant and physically demanding at present .

 

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

 

The current system of payment in which a monopoly monopsony (the NHS) pays practices for certain items, -while not at precisely a fee for service arrangement -nevertheless encourages chasing the dollar rather than proactive and personalised care. There  is an inherent conflict of interest which patients are becoming critical about .Care should be taken of this aspect of General Practice

 

We already have too many algorithms to fill out and control points to manoeuvre in order to get paid. Asking for and managing a personalised computer care plan for several thousand elderly patients is hardly what is meant by the term proactive and personalised. Who will be paid for producing these plans and implementing them at scale? there will have to be further levels of probably non-medical care managers for this.

 

Coordinated and integrated - fine words but unless backed up by enough properly employed social workers, mental health practitioners, and other important clinicians, then there is no integration but huge waiting lists of patients , because there is simply not enough care available to refer any of  them.

Example of a payment system in the NHS preventing proactive personalised coordinated care

Our re-ablement team – the team who get patients with complex needs out of hospital and into the community quickly and efficiently – has shut down due to lack of staff . They cannot recruit because of short term contracts but the costs of these needy people staying in hospital is vast. We needed the team to help keep them in their own homes for longer. Dr Mark Luciani, Clinical Director for Frailty in Swindon is desperate to improve the situation , but all he can do is wait for what the ICS have to offer in the next few months

 

 

12Has the development of Primary Care Networks improved the delivery of proactive personalised coordinated and integrated care and reduced administrative burden on GPs?

 

Very little at present. Due to the pandemic we have lost two years of PCN development. This has prevented the coordination and implementation of expected change. There have been significantly fewer staff to integrate or coordinate with and it is really too early to ask this question. We desperately need more mental health practitioners, child and adult psychologists, physiotherapists and accessory therapies such as re-ablement to get people out of hospital.

There is no point in saying that you are being proactive and personal when you can’t refer a post-operative patient for physio at home because there is no one in post.

 

13. 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?

 

GPs are not currently able to work in effective partnerships, as so many service providers are simply not there or inadequately funded . Of course there are a few- we have 3 part-time community physios in our primary care network. However that is nothing like enough for the workload and we only seem to have 10 appointments per fortnight for each of three practices of 7-10,000 patients .

 

So far, I have not yet had any more time freed up for patient care at all .

 

Thank you for offering us GPs a voice at last

 

Dec 2021

 

 

 

 

 

 

 

 

 

 

 

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