Terms of reference

Response

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

The principal barrier is too few GPs.  Compared to other developed countries, we have fewer GPs (or indeed doctors of any sort) per head of population.

Moving GPs into ever larger groupings in health centres and encouraging online access make it more difficult for vulnerable patients as the vulnerable often find it more difficult to travel longer distances and are less likely to have online access.

Online access tends to encourage more trivial questions to be asked, taking GP time away from those who most need it.

Emphasis on speed of access can degrade the value of the appointment. It is usually better to wait a little and be attended to by the right person (who may not always be a GP).  The right person should usually be the person who knows the patient, to provide continuity.

Patients are encouraged by all sorts of people, including government to "see your GP". They do not say "see the most appropriate allied health professional (AHP)", but the PCN DES does not allow us more GPs, only more AHP.  When patients see an AHP they perceive that they have not access to a GP.

The plethora of targets and projects that GPs are supposed to complete also takes GPs away from direct patient care - see all the complicated contracts: GMS, QOF, PCN DES, IIF ....

Apart from vaccinations and cervical screening, GPs did not traditionally do much preventative work.  Now we are supposed to be intervening earlier and to manage population health (which used to be the remit of public health specialists). Organising all this further takes GPs away from direct patient care.

As more work is moved out from the hospitals to General Practice, the complexity of the work increases meaning that patients with long term conditions (LTC) either need longer consultations or more consultations.  There is evidence to show that both are happening. This puts further pressure on access to appointments.

Cuts in other services eg sexual health, substance misuse; or other services being closed eg dentists closed in pandemic, (or general lack of NHS dentists which is a chronic problem) - all drive people to GP because we are open and relatively more accessible.  Also when they are referred to hospital services nowadays there are very long waiting lists, which means they keep on contacting us when by definition we cannot help or we would not have referred them... all these add to pressure on GP appointments.

More senior GPs tend to be more efficient clinicians, but increasingly they are called upon to run not only their own practices but PCNs too, to supervise not only medical students and trainee GPs but physiotherapists, pharmacists, social prescribers...this all takes time, so there is less time for seeing patients.

NHS111 does not always help, as it tends to be risk averse and advise patients to contact a GP, perhaps urgently, when a more experienced clinician would not deem it necessary.

 

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

Not at all - the above issues are not addressed

 

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

Mostly patients will try again, or try other methods, until they get what they want. Some will access advice from other providers (pharmacy, 111) and a few will end up in A&E. In my personal experience, those who actually contact us but go to A&E are usually quite sick and it is appropriate.  There is another group who go to A&E claiming they could not access the GP, but we have no evidence that they tried to contact us.

 

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?

It depends on how it is used. It can be used to encourage patients to consult with the same doctor or other HCP, but there are other ways this can be done too. Continuity of care has been shown to improve both patient satisfaction and clinical outcomes and should be promoted.  It should be more important than speed of access.

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

Too few GPs

Too many different demands on GP time, which take away from patient facing activity.

Inadequate/insufficient estate from which to run services.

Inadequate IT and IT support.

Too many short-term funding streams which do not allow for proper planning and development. It is a full-time job for someone to simply keep track of them all. Many of them are also tied to certain targets or prespecified goals, which may not align with the local needs, and are always more administratively onerous. This means the money cannot be spent efficiently.

 

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

Rural areas do have a particular problem of travel, but the biggest variation between areas is that of deprivation. More deprived populations develop LTC at an earlier age and consult GPs more often.  If consultations require an interpreter, then they take twice as long and again put pressure on appointments. Such areas tend to be relatively under-doctored, which compounds the problem. The funding formula does not adequately account for the increased costs of looking after such populations.

When you look at so-called "unwarranted variation" between different surgeries it usually comes down to the differing practice populations.  Sometimes it is not a real variation at all, but a coding problem. The second most common reason for real variation is that there are such a huge number of metrics applied to general practice that it is not possible to focus on all of them at once; when we improve one thing then something else slips.

 

What part should general practice play in the prevention agenda?

Given the sheer number of patient contacts, general practice must have a role in the prevention of ill-health BUT (I) GPs are not public health doctors, they do not have the training nor the skills nor the time to replace the public health workforce which has been so disastrously cut (ii) the most effective public health and preventative interventions are those applied to the whole population, such as banning of smoking, fluoridation of water etc.  Advice to individuals does make a difference, but it is marginal.

 

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

More GPs

Stop GP bashing - it is not the fault of GPs that we are in short supply. When there was a shortage of HGV drivers, we sought more drivers.  We do not want tired drivers at the wheel of an HGV. We do not want tired GPs making decisions about a patient's health. We live in fear of making mistakes, and we know they are more likely if we are tired.  We already carry more clinical risk than secondary care doctors do, this is one of the reasons GP are relatively cheap. The GP patient survey shows that over 80% of patients are actually happy with their GPs, but a vocal minority, aided and abetted by some in government, are making the environment so toxic that GPs are walking away.  The job is already emotionally draining, we do not need this abuse too.

Fewer targets and tick boxes.

More long-term funding streams.

Fewer other agencies demanding that GPs do their work for them eg in assessing housing needs, educational needs, social needs, mental health needs.  Secondary care to do their own tests and chasing up.

Proper funded occupational health service for GPs and their staff.

Reverse the requirement for non-clinical staff to be vaccinated against coronavirus.  This will lead to the loss of experienced administrative staff.

 

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

See above, noting that retaining existing experienced GPs is a much quicker fix that training new ones (though training new ones is obviously necessary for the long term).

 

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

No model will work if it is under-resourced, particularly if there are too few GPs.  Moving to a wholly salaried workforce will be more expensive, as was discovered when OOH provision moved to hourly payments after 2004, and has also been rediscovered in setting up NHS111.  As with OOH and 111 care, it is also likely to promote algorithmic care, and reduce continuity, relationships, flexibility and entrepreneurial practice.

 

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

No, too many payments are short term and fragmented, with tick boxes for BP, smoking, weight etc which makes it difficult to see a patient as a whole person.  IT systems are inadequate for integrating with other services. Some areas have put targets on GPs NOT to refer to and involve other services.

 

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

No - the reverse. There are now MORE targets, MORE short term fragmented and/or conditional funding, MORE meetings go to, MORE time spent supervising physios and other who were provided and supervised by other services in the past.  For many of these PCN staff, the requirement to work over multiple sites makes for an unsatisfactory work experience, it is harder to feel part of the team, and they are less likely to stay in post than our practice staff, which means the time and effort invested in them is not recouped.

PCN funding is for allied roles, not for GPs or Nurses, but patients usually want to consult a GP or nurse - it can be hard work to get them to see one of the allied roles, and government rhetoric really does not help.  How many MPs get complaints that their constituents cannot get to see a social prescriber?

 

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 only other professional group who have made any sustained and consistent improvement to GP workload are pharmacists. But again, practice-based pharmacists tend to stay longer and our investment in them is repaid in the time they save us once they are trained up. PCN pharmacists are less likely to stay long enough to repay the effort of training them in the ways of GP.